Влијание на калорискиот внес врз клиничките резултати во акутната фаза кај критично болни политрауматизирани пациенти

Abstract

Introduction: Nutrition is the integral part of the therapy in the intensive care units, and it is particularly important in the first week of the critical illness. In spite of the fact that many studies have examined the influence of different nutritional protocols on the clinical results, the optimal nutritional dose during the acute phase of the critical illness still remains unknown. Aim: The aim of our study was to determine the influence of different calorie intake during the acute phase of critically ill polytrauma patients on their clinical results. Material and methods: This prospective randomized double-blind study included 75 patients, older than 18 years, with polytrauma, hospitalized in the Intensive Care Unit of the University Clinic for Anesthesiology, Reanimation and Intensive Care. Patients were divided into three groups: Group 1 (T) - 21 patients who received enteral nutrition with calorie intake up to 25% of the calculated energy requirements; Group 2 (E) - 23 patients who received enteral nutrition with calorie intake from 40% to 60% of the calculated energy requirements; Group 3 (P) - 31 patients who had enteral nutrition with calorie intake from 40% to 60% of the calculated requirements, but supplemented with parenteral nutrition up to 100% of the calculated energy requirements. Protein intake in groups 2 and 3 patients was 1.2 g/kg/day. Nutrition was initiated on the first day of hospitalization with gradual increase in the volume and calories until the target values were reached on the third day of nutrition. Nutrition was administered according to the examined protocol in the first 7 days of hospitalization. Assessment of the disease severity was made by using APACHE II and ISS score. Nutritional status and eventual risk of malnutrition were assessed with the score for Subjective Global Assessment (SGA) and Nutrition Risk in Critically Ill score (NUTRIC). The influence of different calorie intake on several parameters was evaluated including mortality, days on mechanical ventilation, length of hospital treatment and onset of infectious complications and gastrointestinal intolerance. The scope of care for the examined patients in the groups with different nutritional protocol was calculated with TISS-28 score, and the effect on the severity of the disease with SOFA score. Anthropometric measurements made on the first and seventh day of admission were used for determination of: forearm circumference, skinfold thickness, midarm muscle circumference, thickness of m. adductor pollicis, lower limb circumference, and ultrasonography of m. quadrices femoris. Biochemical examinations were made on the first, third and seventh day of admission and comprised the basic biochemical analysis, and serum proteins and inflammatory markers were determined on the first and seventh day. In addition, the influence of age and body mass index was analyzed for each group separately. Results: The average daily calorie intake was 6.98 ± 1.4 kcal/kg/day in group T; it was 13.67 ± 5.6 kcal/kg/day in group E and 21.41 ± 2.99 kcal/kg/day in group P. The results showed that different calorie intake had no significant influence on mortality. Patients in group P had a significantly longer hospital stay and were on mechanical ventilation for a longer period than those in group T (p=0.00076 and p=0.0044, respectively). Infections with a confirmed microbiological result were most common in group P patients (64.55%). Also, these patients had the highest body temperature (37.31 ± 0.7). Gastrointestinal complications appeared in 2 patients of group E and in 5 patients of group P. Regarding the anthropometric measurements, the average lower limb circumference on the dominant side was significantly reduced (p=0.019) in group T patients on the seventh day of admission whereas in groups E and P thickness of m. quadriceps on the dominant and non-dominant side was reduced (p=0.022, p=0.008 for the dominant side, and p=0.002, p=0.011 for the non-dominant side, respectively). With reference to the biochemical analysis on the seventh day of admission, only patients in group P had significantly more often increased serum concentrations of ALT (p=0.045) and significantly higher average levels of cholesterol compared to the initial levels (p=0.003). They had a significantly higher glycemia on the third day of admission compared to patients in groups E and T (p=0.016). The workload in the intensive care units was measured with TISS-29 and it was significantly increased on the third and seventh day in group P patients (p=0.0016, p=0.000005). Body mass index was within the normal range in 47.8% of group E patients, in 45.2% of group P patients and in 80.95% of group T patients, and the remaining patients were either overweight or obese. Patients in group P and overweight patients had the longest duration of mechanical ventilation and the longest hospital stay. In our study, there was decrease in the muscle mass in all overweight patients but there was no statistical significance of the decrease in quadriceps mass both on the dominant and non-dominant leg in group P patients. Normocaloric diet had a beneficial effect in patients with normal body weight and with body mass index less than 25, which was observed by increase in the quadriceps body mass. Conclusion: In our study the best clinical results were obtained in patients who had trophic feeding and the worst results in those with normocaloric diet. It is evident that the phase of the critical illness, the critical illness itself and individual factors such as the existing risk of malnutrition, body mass index and age are factors that determine the choice of nutritional support. According to the results obtained in our research, hypocaloric nutrition (under 70% of calculated requirements) should be preferred over isocaloric nutrition, especially within the first week of critical illness in patients with smaller nutritional risk and NUTRIC score less than 5 as well as in overweight patients with body mass index greater than 25. In the end, we have to adhere to the postulate of the nutritional therapy administered in all critically ill patients that says progressive implementation of nutrition is necessary until calorie maximum is achieved.