臺灣博碩士論文加值系統

本研究目的為探討全身性發炎反應對外科重症病患能量消耗、尿素氮排泄及氮平衡之影響。研究對象為外科加護中心的病患共56位，依是否發生全身性發炎反應及有無感染分為三組：無全身性發炎反應組(Non-SIRS)12位、非敗血性全身性發炎反應組(Nonseptic SIRS)17位及敗血症組(SEPSIS)27位。於研究當日留取病患的24小時尿液，以測量尿液中尿素氮含量，並記錄其能量及蛋白質攝取量，能量消耗則以新陳代謝測量儀來測量。Nonseptic SIRS與SEPSIS組的能量消耗顯著高於Non-SIRS組，但Nonseptic SIRS與SEPSIS組的能量消耗間無統計差異。Nonseptic SIRS組尿素氮的排出量顯著高於Non-SIRS組，但SEPSIS組與Nonseptic SIRS組及Non-SIRS組間的尿素氮的排出量均無顯著差異。以Harris-Benedict Equation來估計重症病患的基礎能量消耗時，會低估Nonseptic SIRS及SEPSIS患者的基礎能量消耗，高估Non-SIRS患者的基礎能量消耗。本研究中三組病患均呈現負氮平衡現象。出現全身性發炎反應（Nonseptic SIRS與SEPSIS組）的病患能量消耗量與氮平衡呈顯著負相關，能量攝取、能量攝取/實測能量消耗比值與蛋白質攝取量和氮平衡呈顯著正相關；但Non-SIRS組患者的上述各項指標與氮平衡間均無相關。顯示外科重症病患均呈高度蛋白質異化狀況。因感染或非感染傷害引起的全身性發炎反應是造成外科加護中心病患能量消耗顯著上升的主要機轉。氮平衡可幫助評估病患的能量代謝與需求。

The purpose of this study was to examine the effect of systemic inflammatory response on energy expenditure and nitrogen balance of surgical critically ill patients. In respect to the existence of systemic inflammatory response syndrome (SIRS) or infection, fifty-six patients were classified into three groups: Non-SIRS, Nonseptic SIRS and SEPSIS. The resting energy expenditure (REE) was determined by indirect calorimetry. On the day of the energy measurement, the 24-hour urine samples were collected and the dietary intake was recorded. Nonseptic SIRS and SEPSIS groups had significantly higher REE than the Non-SIRS group. However, the REE between the Nonseptic SIRS and SEPSIS groups was not significantly different. The estimated basal energy expenditure (EBEE) calculated by using Harris-Benedict equation was greater than the REE in the Non-SIRS group. In contrast, the EBEE was lower than the REE in both Nonseptic SIRS and SEPSIS groups. Negative nitrogen balance was observed in all three groups despite of comparable amount of energy supply, indicating these patients were in the hypermetabolic state. The REE was negatively correlated with nitrogen balance, whereas the energy intake, the ratio of energy intake to REE and protein intake were positively correlated with nitrogen balance in all SIRS patients with or without infection. No such correlations were found in the Non-SIRS group. Results of the present study suggest that systemic inflammatory response is responsible for the higher REE observed in the Nonseptic SIRS and SEPSIS groups. Nitrogen balance is a valuable index in evaluating the energy metabolism and demands of surgical critically ill patients.

目 錄
頁次
第壹章 緒論…………………………………………………. .1
第一節 研究動機…………………………………………………… .1
第二節 研究重要性………………………………………………… .3
第貳章 文獻查證……………………………………………. .5
第一節 全身性發炎反應…………………………………………… .5
第二節 外科重症病人的代謝……………………………………… .6
第三節 重症病人的能量消耗……………………………………… . 8
第四節 重症病人的氮平衡………………………………………… .10
第五節 重症病患疾病嚴重度與能量消耗………………………… .11
第六節 全身性發炎反應病人的能量消耗及氮平衡……………… .13
第叁章 研究架構……………………………………………. .17
第一節 研究概念架構……………………………………………… .17
第二節 研究目的…………………………………………………… .18
第三節 名詞定義…………………………………………………… .18
第肆章 研究方法……………………………………………. .20
第一節 研究設計…………………………………………………… .20
第二節 研究對象及場所…………………………………………… .20
第三節 研究測量工具……………………………………………… .21
第四節 資料收集方法及過程……………………………………… .22
第五節 資料的統計分析…………………………………………… .23
第六節 倫理考量…………………………………………………… .24
第七節 研究中注意事項…………………………………………… .25
第伍章 研究結果……………………………………………. .26
第一節 研究對象之基本屬性……………………………………… .26
第二節 能量消耗…………………………………………………… .31
第三節 尿素氮、氮平衡與能量供應……………………………… .36
第陸章 討論…………………………………………………. .41
第柒章 結論…………………………………………………. .53
第捌章 研究的限制及建議…………………………………. .54
參考文獻 ……………………………………………………… .55
附錄一 研究同意書…………………………………………. .63
附錄二 研究資料收集表……………………………………. .64
圖表目錄
圖一. 研究架構…………………………………………………. .17
表一. 病患基本資料…………………………………………… .27
表二. 病患臨床狀況、分類及營養供應方式………………… .28
表三. Non-SIRS, Nonseptic SIRS及SEPSIS病患基本資料…… .30
表四. Non-SIRS, Nonseptic SIRS及SEPSIS病患的CO2產生量、O2消耗量、呼吸商及能量消耗…………………. … ……
.32
表五. 病患的體溫、心跳、平均血壓、APACHE Ⅱ分數、昏迷指數與實測能量消耗的相關………………………….
.35
表六. Non-SIRS, Nonseptic SIRS及SEPSIS病患的尿素氮排泄量、氮平衡、能量及能量營養素攝取量………………
.37
表七. 病患的實測能量消耗、能量攝取、蛋白質攝取、能量攝取/實測能量消耗與氮平衡間的相關性………………
.40
表八. 病患能量供給與能量需要差值大小對氮平衡的影響…. .52

李寧遠•（1979）•有關人體蛋白質需要量問題之研究•國立台灣大學博士論文。
邱艷芬•（1995）•重症期間之代謝變化與護理•護理雜誌，42（2），7-13。
楊泮池•（1999）•Acute phase response, systemic inflammatory response syndrome and multiple organ failure•內科新知，2（2）， 18-25。
謝善德•（1995）•多重器官功能障礙症候群•內科學誌，6， 212-217。
American college of chest physicians/ Society of critical care medicine consensus conference committee（1992）. American college of chest physicians/ Society of critical care medicine consensus conference： Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Critical Care Medicine, 20（6）, 864-874.
Arnold, J., Shipley, K. A., Scott, N. A., Little, R. A.,＆ Irving, M. H.(1991). Lipid infusion increases oxygen consumption similarly in septic and nonseptic patients. American Journal of Clinical Nutrition, 53（1）, 143-148.
Barton, R. G.(1994). Nutrition support in critical illness. Nutrition in Clinical Practice, 9, 127-139.
Berry, J. K.,＆ Braunschweig, C. A.(1998). Nutritional assessment of the critically ill patient. Critical Care Nursing Quarterly, 21（3）, 33-46.
Bitzani, M., Matamis, D., Nalbandi, V., Vakalos, A., Karasakalides, A.,＆Riggos, D.(1999). Resting energy expenditure in brain death. Intensive Care Medicine, 25（9）, 970-976.
Bone, R. C.（1995）. Sepsis, sepsis syndrome, and systemic inflammatory response syndrome：Gulliver in Laputa. The Journal of the American Medical Association, 273（2）, 155-156.
Briassoulis, G., Venkataraman, S.,＆ Thompson, A. E. (2000). Energy expenditure in critically ill children. Critical Care Medicine, 28（4）, 1166-1172.
Brown, P. E., McClave, S. A., Hoy, N. W., Short, A. F., Sexton, L. K., ＆Meyer, K. L.（1993）. The acute physiology and chronic health evaluation Ⅱ classification system is A valid marker for physiologic stress in the critically ill patient. Critical Care Medicine, 21（3）, 363-367.
Carlstedt F., Lind, L.,＆ Lindahl, B.（1997）. Proinflammatory cytokines, measured in a mixed population on arrival in the emergency department, are related to mortality and severity of disease. Journal of Internal Medicine, 242（5）, 361-365.
Chai, J., Sheng, Z.,＆ Gao, J.(2001).The effects of extensive excision of massive invasive infected burn wound on the REE of burn patients with sepsis. Zhonghua Shao Shang Za Zhi, 17(2), 96-98.
Coss-Bu, J. A., Jefferson, L. S., Walding, D., David, Y.,Smith, E. O.,＆ Klish, W. J.（1998）. Resting energy expenditure in children in A pediatric intensive care unit： Comparison of Harris-Benedict and Talbot predictions with indirect calorimetry values. American Journal of Clinical Nutrition, 67, 74-80.
Coss-Bu, J. A., Jefferson, L. S., Walding, D., David, Y.,Smith, E. O.,＆ Klish, W. J.（1998）. Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation. Nutrition, 14(9), 649-652.
Coss-Bu, J. A., Klish, W. J., Walding, D., Stein, F., Smith, E. O.,＆ Jefferson, L. S.(2001). Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. American Journal of Clinical Nutrition, 74(5), 664-669.
DeBoisblanc, B. P., McClarity, E.,＆ Lord, K.（1998）. Oxygen consumption in the intensive care unit： Indirect calorimetry is the way to go, but where？ Critical Care Medicine, 26（7）, 1153-1154.
Flancbaum, L., Choban, P. S., Sambucco, S., Verducci, J.,＆ Burge, J. C.（1999）. Comparison of indirect calorimetry, the Fick method, and prediction equations in estimating the energy requirements of critically ill patients. American Journal of Clinical Nutrition, 69, 461-466.
Frankenfield, D. C., Smith, J. S., Cooney, R. N., Blosser, S. A.,＆ Sarson, G. Y.（1997）. Relative association of fever and injury with hypermetabolism in critically ill patients. Injury, 28（9-10）, 617-621.
Frankenfield, D. C., Wiles, C. E., Bagley, S.,＆ Siegel, J. H.（1994）. Relationships between resting and total energy expenditure in injured and septic patients. Critical Care Medicine, 22（11）,1796-1804.
Giovannini, I., Boldrini, G., Castagneto, M., Sganga, G., Nanni, G., Pittiruti, M.,＆ Castiglioni, G.（1983）. Respiratory quotient and patterns of substrate utilization in human sepsis and trauma. Journal of Parenteral ＆ Enteral Nutrition, 7（3）,2226-230.
Hasselgren, P. O.＆ Fischer, J. E.(1998). Sepsis: stimulation of energy-dependent protein breakdown resulting in protein loss in skeletal muscle. World Journal of Surgery, 22(2), 203-208.
Hwang, T. L., Huang, S. L.,＆ Chen, M. F.（1993）. The use of indirect calorimetry in critically ill patients- the relationship of measured energy expenditure to Injury Severity Score, Septic Severity Score, and APACHE Ⅱ Score. Journal of Trauma-Injury Infection＆ Critical Care, 34（2）, 247-251.
Hume, D. M.,＆ Egdahl, R. H.(1959). The importance of the brain in the endocrine response to injury . Annal of Surgery, 10(5), 679-701.
Ishibashi, N., Plank, L. D., Sando, K.,＆ Hill, G. L.(1998). Optimal protein requirements during the first 2 weeks after the onset of critical illness . Critical Care Medicine, 26(9), 1529-1535.
Kinney, J. M.（1995）. Metabolic responses of the critically ill patient. Critical Care Clinics,11（3）, 569-585.
Klein, C. J., Stanek, G. S.,＆ Wiles, C. E.（1998）. Overfeeding maronutrients to critically ill adults： metabolic complications. Journal of the American Dietetic Association,98（7）,795-806.
Koea, J. B., Wolfe, R. R.,＆ Shaw, J. H.(1995). Total energy expenditure during total parenteral nutrition: ambulatory patients at home versus patients with sepsis in surgical intensive care. Surgery, 118(1), 54-62.
Kreymann, G., Grosser, S. Buggisch, P., Gottschall, C., Matthaei, S.,＆ Greten, H.（1993）. Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic shock. Critical Care Medicine, 21（7）, 1012-1019.
Lakshman, K.,＆ Blackburn, G. L.（1986）. Monitoring nutritional status in the critically ill adult. Journal of Clinical Monitoring, 2（2）, 114-120.
Monk, D. N., Plank, L. D., Franch-Arcas, G., Finn, P. J., Streat, S. J.,＆ Hill, G. L.（1996）. Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma. Annals of Surgery, 223（4）,395-405.
Moriyama, S., Okamoto, K., Tabira, Y., KiKuta, k., Kukita, I.,Hamaguchi, M.,＆ Kitamura, N.（1999）. Evaluation of oxygen consumption and resting energy expenditure in critically ill patients with systemic inflammatory syndrome. Critical Care Medicine, 27（10）, 2133-2136.
Mrozek, J. D., Georgieff, M. K., Blazar, B. R., Mammel, M. C.,＆ Schwarzenberg, S. J.(2000). Effect of sepsis syndrome on neonatal protein and energy metabolism. Journal of Perinatology, 20(2), 96-100.
Muller,T. F., Muller, A., Bachem, M. G.,＆ Lange, H.(1995). Immediate metabolic effects of different nutritional regimens in critically ill medical patients. Intensive Care Medicine, 21(7), 561-566.
Pittet, D., Rangel-Frausto, S., Li, N., Tarara, D., Coatigan, M., Rempe, L., Jebson, P.,＆ Wenzel, R. P.（1995）. Systemic inflammatory response syndrome, Sepsis, Severe sepsis and septic shock：incidence, morbidities and outcomes in surgical ICU patients. Intensive Care Medicine, 21, 302-309.
Plank,L.,＆ Hill, G. L.（2000）. Sequential metabolic changes following induction of systemic inflammatory response in patients with severe sepsis or major blunt trauma. World Journal of Surgery, 24, 630-638.
Porter, C.,＆ Cohen, N. H.（1996）. Indirect calorimetry in critically ill patients： Role of the clinical dietitian in interpreting results. Journal of the American Dietetic Association,96（1）, 49-557.
Rangel-Frausto, M. S., Pittet, D., Costigan, M., Hwang, T., Davis, C. S.,＆ Wenzel, R. P.（1995）. The natural history of the systemic inflammatory response syndrome: A prospective study. The Journal of the American Medical Association, 273（2）, 117-123.
Robben, J. H., Zaal, M. D., Hallebeek, J. M.,＆ Beynen, A. C.（1999）. Enteral nutritional support for critically ill patients. Tijdschrift Voor Diergeneeskunde, 124（16）, 468-471.
Sherman, M. S.（1994）. A predictive equation for determination of resting energy expenditure in mechanically ventilated patients. Chest, 105, 544-549.
Smail, N., Messiah, A., Edouard, A., Descorps-Declere, A., Duranteau, J., Vigue, B., Mimoz, O.,＆ Smail, K.（1995）. Role of systemic inflammatory response syndrome and infection in the occurrence of early multiple organ dysfunction syndrome following severe trauma. Intensive Care Medicine, 21, 813-816.
Swinamer, D. L., Grace, M. G., Hamilton, S. M., Jones,R.L., Roberts, P.,＆ King, E. G.（1990）. Predictive equation for assessing energy expenditure in mechanically ventilated critically ill patients. Critical Care Medicine, 18（6）, 657-661.
Tierney, A. J.（1996）. Undernutrition and elderly hospital patients：A review. Journal of Advanced Nursing, 23（2）, 228-236.
Turi, R. A., Petros, A. J., Fasoli, L., Poeis, M., Basu, R., Spitz, L.,＆ Pierro, A.（2001）. Energy metabolism of infants and children with systemic inflammatory response syndrome and sepsis. Annals of Surgery, 233（4）,581-587.
Uehara, M., Plank, L. D.,＆ Hill, G. L.（1999）. Components of energy expenditure in patients with severe sepsis and major trauma：A basis for clinical care. Critical Care Medicine, 27（7）, 1295-1302.
Vermeij, C. G., Feenstra, B. W. A., van Lanschot, J. J. B.,＆ Bruining, H. A.（1989）. Day-to-day variability of energy expenditure in critically ill surgical patients. Critical Care Medicine, 17（7）, 623-626.
Weissman, C., Kemper, M.（1995）. Metabolic measurements in the critically ill. Critical Care Clinics,11（1）, 169-197.
Weissman, C., Kemper, M. S., Askanazi, J., Hyman, A. I.,＆ Kinney, J. M.（1986）. Day-to-day variation in the resting metabolic rate of mechanically ventilated critically ill patients. Critical Care Medicine, 14（4）, 408.
Whitney, J. D.,＆ Heitkemper, M. M.（1999）. Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds. Heart Lung, 28（2）, 123-133.
Zauner, C., Schuster, B. I.,＆ Schneeuseiss, B.（2001）. Similar metabolic responses to standardized total parenteral nutrition of septic and nonseptic critically ill patients. American Journal of Clinical Nutrition,74（2）,265-270.
Zell, R., Geck, P., Werdan, K.,＆ Boekstegers, P.（1997）. TNF-alpha and IL-1 aipha inhibit both pyruvate dehydrogenase activity and mitochondrial function in cardiomyocytes： evidence for primary impairment of mitochondrial function. Mol Cell Biochem, 177, 61-67.