外科重症监护病房早期肠内营养充足与炎症较少和临床结局改善相关

　　重症患者全身炎症往往影响其恢复，肠内营养（EN）可能通过肠道淋巴组织的作用减轻炎症反应，改善重症患者的结局。中性粒细胞-淋巴细胞计数比（NLR）可以反映系统性炎症反应状况。

　　美国麻省总医院回顾性纳入2012～2015年接受EN的外科重症患者293例，分析早期充足营养供给EN后NLR及临床结局之间的关系。

　　结果发现，EN支持3天内充足的蛋白质和能量供给与低NLR相关，证实了早期充足EN供给可改善系统性炎症。同时发现，基线的NLR与外科重症患者的临床结局无关，但是EN支持后3～5天的低水平NLR提示此类患者结局良好，如总住院时间、ICU入住时间、机械通气时间缩短以及死亡率降低。

JPEN J Parenter Enteral Nutr. 2017;41(2):273-274.

Early enteral adequacy in the surgical ICU is correlated with less inflammation and improved clinical outcomes.

Luis A. Ortiz; Yuchiao Chang; Sadeq A. Quraishi; Haytham M. A. Kaafarani; Marc de Moya; David R. King; Peter Fagenholz; George Velmahos; D. Dante Yeh.

Massachusetts General Hospital, Boston, Massachusetts, USA.

PURPOSE: Neutrophil-lymphocyte ratio (NLR) is a measure of the host inflammatory response, and higher NLR has been associated with worse clinical outcomes in critically ill patients. Enteral nutrition (EN) may mitigate inflammation through interaction with gut-associated lymphoid tissue. The aim of this study was to analyze the relationship between nutrition adequacy, NLR after 3-5 days of EN, and clinical outcomes in surgical intensive care unit (ICU) patients. We hypothesized that improved early nutrition adequacy is associated with lower NLR, which is in turn associated with better clinical outcomes.

METHODS: Adult critically ill surgical patients receiving EN admitted between 2012 and 2015 were included in this retrospective analysis. Data collected included age, weight, body mass index (BMI), Acute Physiology and Chronic Health Evaluation (APACHE II), Charlson Comorbidity Index, serum albumin, NLR ratio (absolute neutrophil count/absolute lymphocyte count) at baseline ICU admission and on the first 5 EN days, cumulative deficit of calories and proteins, initial nutrition status, parenteral nutrition, hospital length of stay (LOS), ICU LOS, 28-day ventilator-free days (28-VFD), discharge disposition, and hospital mortality. Tertile groups were created for day 3 protein deficit and NLR after 3-5 days of EN, and comparisons were made between the highest (H) and lowest (L) tertile groups. Categorical variables were compared using Fisher’s exact test/χ² tests while continuous variables were compared using t tests/Wilcoxon tests. Regression analyses were performed to control for the effect of age, sex, and APACHE II.

RESULTS: The cohort included 293 subjects. The median [interquartile range] NLR change from baseline was a decrease of 1.4 [-9.2 to 3.5] for patients in the lowest day 3 protein deficit tertile, but an increase of 1.6 [-11.5 to 8.5] for patients in the highest day 3 protein deficit tertile. The difference between the 2 groups remained significant in the regression model (P = .044). Compared with patients in the H-NLR tertile, patients in the L-NLR tertile were younger, had lower severity of illness, and had received significantly more daily protein. While hospital LOS, ICU LOS, 28-VFD, and mortality rates were similar when comparing baseline L-NLR and H-NLR tertile groups (data not shown), clinical outcomes were significantly improved in the L-NLR compared with the H-NLR tertile group and remained significant in the regression models controlling for age, sex, and APACHE II.

CONCLUSIONS: In critically ill surgical patients receiving EN, greater protein delivery in the first 3 days of EN is correlated with lower NLR. A similar trend was seen with caloric delivery. While NLR at baseline did not predict clinical outcomes, a lower NLR after 3-5 days of EN was associated with shorter hospital LOS, ICU LOS, more ventilator-free days, and lower mortality rates. Though mechanistically plausible, it remains to be proven whether early EN adequacy is causally linked to decreased inflammation and improved clinical outcomes.

DOI: 10.1177/0148607116686023