靜脈營養的脂肪酸型式對重症病人發炎反應及血糖濃度之影響

The effects of emulsion type of parenteral nutrition on inflammatory responses and blood glucose in critically ill patients.

李沛融(Pei-Rong Li)

指導教授 ： 黃怡嘉

中山醫學大學/健康管理學院/營養學系碩士班/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00109

摘要

重症病人處於高度疾病壓力及異化狀態下，會持續分泌促發炎細胞激素而造成全身性發炎反應，嚴重者甚至造成敗血症及多重器官衰竭；也會經由糖質新生及肝醣分解造成胰島素阻抗而造成壓力型高血糖。研究發現不同的脂肪酸型式之脂肪乳劑對重症病人的發炎反應及血糖濃度的影響不同，惟此方面的研究並未有定論。因此本研究目的為探討不同的脂肪酸型式之脂肪乳劑及營養支持時間對重症病人的發炎指標及血糖濃度之影響。本研究為回溯性觀察型研究。資料回溯時間自2010年1月份起至2013年1月底止，對象為童綜合醫療社團法人童綜合醫院外科加護病房之重症病人。依據病人進外科加護病房後使用靜脈營養之脂肪乳劑型式，區分為三組：控制組 (n = 58)、ω-3脂肪酸組 (n = 30) 及ω-6脂肪酸組 (n = 27)。紀錄病人臨床資料、進入外科加護病房第一天之疾病嚴重度，住加護病房第一、四、七及十天的臨床生化值、發炎反應指標（C-反應蛋白）及血糖值。結果顯示三組間的年齡、性別、疾病嚴重度及臨床結果（加護病房住院天數、總住院天數、14天死亡率、28天死亡率）沒有顯著差異。ω-3脂肪酸組的第十天C-反應蛋白顯著低於控制組，但ω-6脂肪酸組則顯著高於控制組。血糖濃度在3組間的任何時間點都無顯著差異。C-反應蛋白顯著受到脂肪酸型式、治療時間及脂肪酸型式和治療時間之交互作用的影響。但是，血糖濃度則不受脂肪酸型式、治療時間、或兩者交互作用之影響。外科重症病人接受不同的靜脈營養脂肪酸型式會顯著影響其發炎反應（C-反應蛋白濃度），但對血糖濃度則無影響。重症病人營養支持過程需給予脂肪乳劑時，建議優先選擇ω-3脂肪酸之脂肪乳劑以改善發炎反應。

關鍵字

脂肪乳劑 ； 發炎反應 ； C-反應蛋白 ； 血糖 ； 靜脈營養 ； 重症病人

並列摘要

Critically ill patients are susceptible to severe stress of illness and under the catabolism condition, which may lead to systemic inflammatory response syndrome (SIRS) through the secretion of proinflammatory cytokines, and even cause severe sepsis and multiple organ failure. Critically ill patients may also suffer stress-induced hyperglycemia caused by insulin resistance via gluconeogenesis and glycogenolysis. Previous studies indicated that various emulsion types had the different effects on inflammatory responses and blood glucose values in critically ill patients; however, the results of research have not been certained yet. This study aimed to evaluate the effect of different emulsion types and the period of nutritional support on the inflammatory marker and blood glucose concentration in critically ill patients. This was a retrospective observational study. The medical records of all patients receiving TPN at the surgical intensive care unit (SICU) of Tung’s Taichung MetroHarbor Hospital between Jan. 1, 2010 and Jan. 31, 2013 were reviewed. Patients were allocated into three groups, control group (n = 58), ω-3 fatty acid group (n = 30) or ω-6 fatty acid group (n= 27), based on the type of emulsion they received at admission to the SICU. Patients' disease severity (APACHE II), length of ICU stay, length of hospital stay, 14 day mortality, 28 day mortality, anthropometric values, hematological values, inflammatory indicator (C- reactive protein, CRP), blood glucose values were recorded at the 1st d, 4th d, 7th d and 10th d of admission to the SICU. The results showed that there were no significant differences in age, gender, severity of illness (APACHE II) and clinical outcomes (length of ICU stay, length of hospital stay, 14 day mortality and 28 day mortality) among three groups. The mean CRP values on day 10 were significantly lower in the ω-3 fatty acid group significantly higher in the ω-6 group when compared to the control group. There were no significant differences in blood glucose value at any time point among the three groups. The value of CRP was significantly affected by the type of emulsion, the period of nutritional support and the interaction of emulsion type and the period of nutritional support. However, blood glucose was not significantly affected by the type of emulsion, the period of nutritional support and the interaction of emulsion type and the period of nutritional support period. The different types of emulsion used in the parenteral nutrition may have significantly effect on inflammatory responses (C-reactive protein) but not blood glucose in critically ill surgical patients. The ω-3 fatty acid lipid emulsion could be a priority choice for improving inflammatory responses when critically ill patients received parenteral nutritional support.

並列關鍵字

emulsion ； inflammatory responses ； C-reactive protein ； blood glucose ； parenteral nutrition ； critically ill patients

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