- 學位論文
中鏈脂肪酸及長鏈脂肪酸對於使用全靜脈營養治療之重症病患臨床應用評估
The assessment of medium chain triglyceride vs long chain triglyceride on critically ill patients with total parenteral nutrition therapy
摘要
中文摘要 本研究旨在探討加護病房中使用全靜脈營養治療大於一週以上的重症病患之病歷資料所做之回溯性研究。研究樣本取自中部某醫學中心，自西元2007年7月至2008年6月間加護病房之重症病患。將病患依其使用中鏈脂肪酸(MCT)與長鏈脂肪酸(LCT)不同的脂肪乳劑，分為Lipofundin® (MCT : LCT = 50% : 50%)的MCT/LCT組及使用Intrafat® (LCT 100%)的LCT組，分別於MCT/LCT組及LCT組各選取50位病患，將其病歷資料整理分析評估兩種不同脂肪乳劑在臨床應用上之差異。 分析結果顯示，MCT/LCT組在治療前後的前白蛋白檢驗值(治療前0.103±0.008 g/L、治療後0.153±0. 009 g/L, p<0.05)有統計上顯著的差異，在治療前後的運鐵蛋白檢驗值(治療前1.287±0.081 g/L、治療後1.368±0.082 g/L, p<0.05)也有統計上顯著的差異。而在LCT組則在治療前後的SGOT檢驗值(治療前41.7±8.0 U/L、治療後69.1±8.3 U/L, p<0.05)也有統計上顯著的差異。將兩組以白血球高低與血糖高低再續分為四個次組，互相比較在不同病況下其檢驗值的變化，除了在MCT/LCT組中除了前白蛋白檢驗值與運鐵蛋白檢驗值皆出現明顯差異外，在較嚴重組中的前白蛋白檢驗值也有差異出現（治療前0.106±0.011 g/L、治療後0.132±0.009 g/L, p<0.05)。在LCT組中的較不嚴重組Ι之SGPT有出現差異，但平均值仍在正常範圍內（分別為51.5±8.2 U/L, p<0.05, 40.3±5.2 U/L, p<0.05)，而較嚴重組的SGOT與SGPT雖未出現差異，但平均值已高於正常值（分別為89.5±21.6 U/L, p<0.192, 57.5±19.8 U/L, p<0.656)。以往的研究顯示MCT與脂蛋白脂解酵素(lipoprotein lipase)的親和力較強，在血中被清除的速率較LCT快，不會造成血脂過高，另外MCT的輸入有節省蛋白質的作用，故被認為對一些會引起血脂代謝異常或異化性的疾病有利。由 於其脂肪酸的碳鏈短，在肝臟中可快速完全氧化，立即提供能量，不會造成肝臟脂肪堆積。一些體外的實驗顯示LCT會使白血球的趨化和移動性受損而降低白血球的活性，也會抑制免疫球蛋白的合成和吞噬細胞腫瘤壞死因子之產生。最近的研究顯示MCT輸入可促進吞噬細胞的噬菌能力，動物實驗也顯示，由於MCT輸入可減輕肝脾網狀內皮系統的負擔，因而有較好的清除細菌的能力，可降低感染率。MCT相較於LCT有較佳的氮平衡。含MCT的脂肪乳劑在本研究顯示對重症患者有良好的耐受性，對於患者的營養狀態恢復顯現較好的影響。因此本研究可提供醫師、營養師於臨床選用脂肪乳劑供給使用全靜脈營養重症病患之參考。
並列摘要
Abstract The purpose of this study was to investigate the use of an intravenous lipid emulsion containing medium chain tryglycerides (MCTs) with TPN more than one week in critically ill patients during Jul 2007 and Jun. 2008 and compared the effects with those of a conventional long chain triglyceride (LCT) preparation. We separated patients into two group: MCT/LCT Group with Lipofundin® (MCT:LCT = 50%:50%) (n=50) and LCT Group with Intrafat® (LCT 100%)(n=50) and evaluate the treatment differences of both emulsion. The analysis result presented prealbumin in MCT/LCT Group (Before treated: 0.103±0.008 g/L、After treated: 0.153±0.009 mg/dL, p<0.05)and transferrin in MCT/LCT Group (Before treated: 1.287±0.081 g/L、After treated: 1.368±0.082 g/L, p<0.05) . The SGOT of LCT Group presented statistically significant difference (Before treated: 41.7±8.0 U/L、After treated: 69.1±8.3 U/L, p<0.05). We separated the two groups further into four sub-groups by treating with values of white counts and glucose. Not only the MCT/LCT Group showed a significant change of the values of pre-albumin and transferrin but also the transferrin of the Serious group (Before treated: 0.106±0.011 m/L、After treated: 0.132±0.009 g/L, p<0.05). In the LCT group, SGOT and SGPT in Not-serious group showed difference but the mean was in normal range (SGOT: 51.5±8.2 U/L, p<0.05, SGPT: 40.3±5.2 U/L, p<0.05)and SGOT and SGPT in Serious group showed no difference but the mean was higher than normal range (SGOT: 89.5±21.6 U/L, p=0.192, SGPT: 57.5±19.8 U/L, p=0.656), Previous studies have shown that MCTs are metabolized faster than LCTs. MCT enter the mitochondria relatively independently of carnitine, the carrier required for LCT. Moreover, MCTs are rapidly hydrolysed and oxidised to fatty acids and ketones which can be readily utilized and storage is very limited. MCT/LCT emulsions do not impair liver function, which may reduce interference with organ function and immunity and no reticuloendothelial system function compromise, and do not interfere with pulmonary hemodynamics or gas exchange. This study indicates that MCT are safe in critically ill patients and may have advantages over LCT. With this result, we can provide physician and dietician a clinically option of using fat emulsion during parenteral therapy with critically ill patients.