有创机械通气腹内压与肠内营养支持期间喂养不耐受的相关性研究

目的探讨有创机械通气腹内压与肠内营养支持期间喂养不耐受的相关性。方法选取2017年7月至2019年7月我科收治的气管插管的机械通气患者70例作为研究对象,于肠内营养前和肠内营养后3 d测量腹内压,记录腹泻、肠鸣音减弱或消失、呕吐/反流、便秘、胃肠道出血的肠内营养过程中喂养不耐受情况,分析腹内压与喂养不耐受的相关性。结果患者中发生喂养不耐受51(72.86%)例,其中肠鸣音减弱或消失和腹泻占比分别为52.86%,45.71%;相关性分析显示,腹内压与喂养不耐受呈正相关(P<0.05)。结论气管插管机械通气患者腹内压与早期肠内营养不耐受存在正相关。当肠内营养前3 d腹内压≥11 mmHg时,护理人员应警惕即将发生喂养不耐受,并针对性给予相应预防干预措施,保证胃肠道营养。     

ICU机械通气患者腹内压与肠内营养喂养不耐受的相关性

目的 探究ICU机械通气患者腹内压与肠内营养(EN)喂养不耐受的相关性.方法 选择2019年2—12月医院ICU机械通气患者80例为研究对象,在患者EN之前与EN后测量患者腹内压,评估患者营养期间是否有肠内营养不耐受现象发生.结果 80例患者的肠内营养喂养不耐受发生率为75％,其中肠鸣音消失或减弱的发生率为55％,腹泻...     

重型颅脑外伤患者早期肠内营养不耐受的多因素分析

目的探讨影响重型颅脑外伤患者早期肠内营养不耐受的常见危险因素。方法回顾性分析2009年6月～2011年6月年收治的354例重型颅脑外伤并行早期肠内营养患者的临床资料,分别对年龄、GCS评分、APA-CHEII评分、机械通气、幽门后喂养等17项危险因素进行单因素分析,并进行Logistic回归分析。结果152例患者发生肠内营养不耐受(42.94%),单因素分析示GCS评分、APACHEII评分、机械通气、幽门后喂养、血清白蛋白、质子泵抑制剂、镇静剂、儿茶酚胺类药物、专科护士护理与肠内营养不耐受发生相关。多因素Logistic回归分析示APACHEII评分(OR=6.787,P=0.01)、机械通气(OR=7.072,P=0.007)、镇静剂(OR=7.298,P=0.005)为肠内营养不耐受的独立危险因素,幽门后喂养(OR=0.157,P<0.01)和专科护士护理(OR=0.07,P<0.01)为保护性因素。结论APACHEII评分越高、使用机械通气和镇静剂患者容易发生肠内营养不耐受,通过幽门后喂养及专科护士护理能有效降低肠内营养不耐受发生率。     

重症胰腺炎患者肠内营养喂养不耐受发生的相关影响因素

目的探讨重症胰腺炎患者肠内营养喂养不耐受发生的相关影响因素。方法选取2017年11月至2019年11月淄矿集团中心医院收治的重症胰腺炎患者88例为研究对象,通过回顾性问卷调查方式,对入选对象的一般资料进行收集。采用单因素和多因素Logistic回归分析法对重症胰腺炎患者肠内营养喂养不耐受发生的相关危险因素进行分析。结果在88例重症胰腺炎患者中有51例(57.95%)发生肠内营养喂养不耐受情况。镇静剂使用情况、肠内营养实施时间、急慢性生理健康评分、治疗前白蛋白水平、腹内压、中心静脉压、血钾浓度、腹腔穿刺、机械通气情况及膳食纤维添加均为重症胰腺炎患者肠内营养喂养不耐受发生的相关影响因素(P<0.05);肠内营养实施时间、急慢性生理健康评分、腹内压及中心静脉压均为重症胰腺炎患者肠内营养喂养不耐受发生的独立危险因素(P<0.05),而膳食纤维添加是重症胰腺炎患者肠内营养喂养不耐受发生的保护性因素(P<0.05)。结论肠内营养实施时间、急慢性生理健康评分、腹内压及中心静脉压均为重症胰腺炎患者肠内营养喂养不耐受发生的独立危险因素,而膳食纤维添加是重症胰腺炎患者肠内营养喂养不耐受发生的保护性因素。     

营养风险评估对特重度烧伤患者早期肠内营养不耐受的影响

目的 探讨营养风险评估对特重度烧伤患者早期肠内营养不耐受的影响。方法 选取2021年1月-6月我科收治的28例特重度烧伤患者为对照组,采用常规营养支持护理。选取2021年7月-12月收治的32例特重度烧伤患者为观察组,对其评估肠内营养不耐受的风险,制定营养管理方案。比较两组肠内营养不耐受发生率、营养指标、免疫指标等。结果 观察组营养支持2周后血清白蛋白、血清前白蛋白水平高于对照组(P<0.05)。观察组营养支持2周后hs-CRP、内毒素水平低于对照组,CD4+/CD8水平高于对照组,负氮平衡恢复时间短于对照组,营养不耐受发生率低于对照组(P<0.05)。结论 营养不耐受风险评估能够减少特重度烧伤患者早期肠内不耐受的发生,改善营养及免疫状况。     

重症急性胰腺炎患者肠内营养喂养不耐受状况及其影响因素研究

目的探讨重症急性胰腺炎患者发生肠内营养喂养不耐受的现状及其影响因素。方法对2012年10月—2015年10月期间入住某三级甲等医院实施肠内营养的重症急性胰腺炎患者的病历资料进行回顾性分析,统计研究对象实施肠内营养期间喂养不耐受的发生情况,并分析其影响因素。结果 92例患者中,54例发生了肠内营养喂养不耐受。急性生理与慢性健康状况评分、腹内压和中心静脉压过高是引起重症急性胰腺炎患者发生肠内营养喂养不耐受的独立危险因素,肠内营养中添加膳食纤维是保护性因素。结论重症急性胰腺炎患者急性生理与慢性健康状况评分、腹内压和中心静脉压越高,其发生肠内营养喂养不耐受的风险越大,在肠内营养中添加膳食纤维有助于减少喂养不耐受的发生。     

腹内压监测在ICU病人早期肠内营养中的应用效果

目的:探讨腹内压监测在重症监护病房（ICU）病人早期肠内营养中的应用效果。方法:采用便利抽样法，选取2020年11月—2021年9月太原市某三级甲等医院综合ICU病人为研究对象。采用随机数字表法将病人分为试验组和对照组。试验组采用腹内压监测指导肠内营养，对照组采用空针抽吸法监测胃残余量指导肠内营养。评价两组病人喂养不耐受发生率、7 d内目标喂养量达成率、额外护理时长、额外费用。结果:研究过程中，试验组、对照组各有1例病人因病情变化停止肠内营养，予以剔除，最终试验组纳入66例，对照组纳入46例。试验组喂养不耐受发生率为27.76%，低于对照组（54.17%）；试验组7 d内目标喂养量达成率为80.30%，高于对照组（56.52%）；试验组额外护理时长为0.00(90.00)min，短于对照组[100.00(300.00)min]；试验组额外费用为0.00(105.00)元，低于对照组[95.00(275.00)元]，差异均有统计学意义（P<0.05）。结论:根据腹内压调整营养液泵入，能够指导危重症病人早期肠内营养治疗，降低喂养不耐受发生率，提高早期肠内营养达标率，减轻护士工作量，降...     

腹内压监测在ICU重症患者肠内营养管理中的应用

目的: 探讨腹内压监测在指导ICU重症患者早期肠内营养（EN）的应用效果。方法: 将2018年1至12月236例入住ICU并实施EN的危重患者,随机分成对照组和观察组。对照组采用ICU常规的护理方法。观察组在对照组基础上采用自制一次性膀胱内压测量器监测腹内压,并根据腹内压情况给予相应的对症治疗。比较两组患者喂养不耐受并发症的发生率和7 d喂养达标率。结果: 观察组患者腹泻、胃残余量增加、呕吐/返流、便秘等喂养不耐受并发症低于对照组,7 d喂养达标率高于对照组,差异有统计学意义（P<0.05）,两组患者在肠鸣音减弱上差异无统计学意义（P>0.01）。结论: 使用自制一次性膀胱内压测量器监测腹内压能减少ICU危重患者早期EN的并发症发生。     

重症胰腺炎患者发生肠内喂养不耐受的相关危险因素分析

目的分析重症胰腺炎患者发生肠内喂养不耐受的相关危险因素。方法选取医院2020年1月至2022年5月收治的重症胰腺炎患者77例,根据患者治疗期间是否发生肠内喂养不耐受将其分为耐受组与不耐受组。采用自制基线资料调查问卷记录两组患者临床资料并比较,找出影响重症胰腺炎患者发生肠内喂养不耐受的相关危险因素。结果77例重症胰腺炎患者中,共发生43例(54.43%)肠内喂养不耐受;两组腹内压、肠内营养时间、APACHEⅡ评分、膳食纤维添加比较,差异有统计学意义(P<0.05);经多项logistic回归分析结果显示,腹内压高、肠内营养时间长、APACHEⅡ评分高、未添加膳食纤维是影响重症胰腺炎患者发生肠内喂养不耐受的危险因素(OR>1,P<0.05)。结论重症胰腺炎患者肠内喂养期间不耐受发生率较高,可能受到腹内压高、肠内营养时间长、APACHEⅡ评分高、未添加膳食纤维等危险因素的影响。     

危重症患者肠内营养不耐受预防及管理的最佳证据总结

目的 检索并获取危重症患者肠内营养喂养不耐受预防及管理的相关证据,为临床提供参考。方法 应用循证护理的方法,针对成人危重症患者肠内营养喂养不耐受预防及管理提出问题,按照“6S”模型检索文献,采用澳大利亚JBI循证卫生保健中心的文献评价标准和证据分级系统（2014版）对各类研究进行文献质量评价及证据级别评定。 结果 结合专业人员的判断,汇总出22条危重症患者肠内营养喂养不耐受预防及管理的证据,包括喂养不耐受性评估、喂养不耐受危险因素、营养制剂配方管理、肠内营养喂养策略（喂养的途径、速度、温度）、体位管理、胃残余量监测、药物应用、腹内压监测与管理和中医疗法等9个方面。 结论 本研究总结了目前关于危重症患者肠内营养喂养不耐受预防及管理的最佳证据,为规范ICU护士实施肠内营养支持护理行为提供循证依据,以科学的护理方法来管理危重症患者肠内营养喂养不耐受的问题,提升护理质量。     

急性呼吸窘迫综合征患者俯卧位通气时肠内营养的回顾性分析

目的分析急性呼吸窘迫综合征（ARDS）患者俯卧位通气（PPV）期间肠内营养（EN）的耐受情况。 方法收集2013年2月至2017年10月期间广州医科大学附属第一医院重症医学科60例ARDS患者的临床资料。根据患者每次PPV前后分为PPV前组及PPV组;经喂养方式分为胃管组及幽门后组;胃管组PPV期间EN速度相比每次PPV前的营养速度分为减速组及非减速组;PPV时间≥12 h为高强度PPV,根据PPV时间分为≥12 h组和≥16 h组。回顾分析各组患者行PPV治疗期间EN的情况。 结果60例ARDS患者共行321次PPV治疗,胃管组有274次,幽门后组有47次。非减速组为122次,PPV时间≥12 h有89次（72.95%）,PPV时间≥16 h有65次（53.28%）;减速组152次,PPV时间≥12 h有77次（50.66%）,PPV时间≥16 h有63次（41.45%）。胃管组在PPV治疗期间的胃残留量（GRV）、呕吐、口鼻腔可见食物残渣率和PPV前比较差异均无统计学意义（P>0.05）,即使减慢PPV期间EN速度、应用高强度PPV所得结果相近;胃管组和幽门后组的呕吐、口鼻腔可见食物差异无统计学意义（P>0.05）,但热卡摄入量低于幽门后组。 结论ARDS患者行PPV并不增加胃潴留及EN反流的风险。PPV期间不需特别减慢EN速度;对于有胃潴留或EN不达标的ARDS患者需要行PPV治疗,幽门后置管喂养是选择。     

Early enteral nutrition in mechanically ventilated patients in the prone position

OBJECTIVE: To assess the tolerance of early enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position. DESIGN: Prospective, comparative study. SETTING: General intensive care unit in a university-affiliated hospital. PATIENTS: A total of 71 consecutive patients receiving invasive mechanical ventilation with early nasogastric enteral nutrition were studied for 5 days while being treated continuously in the supine position (supine position group, n = 37) or with intermittent prone positioning for severe hypoxemia (prone position group, n = 34). INTERVENTIONS: Inclusion occurred within 24 hrs of mechanical ventilation initiation. Daily 18-hr enteral nutrition via a 14F gastric tube was initiated. Prone position patients were turned every 6 hrs as long as PaO2/FiO2 remained at <150, with a FiO2 of 0.6 and positive end-expiratory pressure of 10; the head was slightly elevated. When supine, patients in both groups were semirecumbent. Residual gastric volume was measured every 6 hrs, and enteral nutrition was discontinued if it exceeded 250 mL or vomiting occurred. MEASUREMENTS AND MAIN RESULTS: The groups were similar for age, sex, Simplified Acute Physiology Score II, mortality, and risk factors for enteral nutrition intolerance. At baseline, PaO2/FiO2 was lower in prone position patients than in supine position patients (127 +/- 55 vs. 228 +/- 102; p <.001). As compared with supine position patients, prone position patients had significantly greater residual gastric volumes on days 1, 2, and 4 and experienced more vomiting episodes (median, 1 [interquartile range, 0-2] vs. 0 [interquartile range, 0-1]; p <.05). Enteral nutrition was stopped in 82% of prone position patients and 49% of supine position patients (p <.01) so that daily enteral nutrition volumes were lower with prone position patients. In the prone position group, vomiting occurred more frequently in the prone than in the supine position (relative risk, 2.5; 95% confidence interval, 1.5-4.0; p <.001). CONCLUSION: In critically ill patients receiving invasive mechanical ventilation in the prone position, early enteral nutrition is poorly tolerated. Prokinetic agents or transpyloric feeding and semirecumbency should be considered to enhance gastric emptying and to prevent vomiting in patients receiving mechanical ventilation in the prone position.     

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial

ObjectiveTo compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.Materials and MethodsWe conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).ResultsThe success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.ConclusionThis modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.     

Nutrition intervention in pediatric patients with thermal injuries who require laparotomy

Increased intra-abdominal pressure is a complication of thermal injuries that is most commonly noted during burn shock or sepsis. Severely elevated intra-abdominal pressure requires surgical treatment by laparotomy to avert cardiac, respiratory, and renal compromise. The purpose of this retrospective study was to examine the manipulation of the nutrition program and outcomes in response to such a procedure. Open laparotomy for increased intra-abdominal pressure was necessary for 6 patients admitted to a pediatric burn facility from March 1993 to April 1999. One patient was excluded from the review because he died 2 days after the burn injury (1 day after the laparotomy) and nutrition intervention was not initiated. Four of the five remaining patients received parenteral nutrition within 48 hours of surgery. One patient did not receive parenteral nutrition because the enteral regimen was at the goal by 5 days after the laparotomy. Trophic enteral feedings were initiated in all 5 patients within 48 hours of the operations. Tube feedings were gradually increased and the parenteral nutrition rate was decreased in accordance with gastrointestinal tolerance (abdominal girth, bowel motility). Enteral nutrition was started before abdomen closure in all of the patients. No mechanical, infectious, or mortality-related complications related to the initiation of enteral nutrition after open laparotomies were noted. Surgical intervention by open laparotomy interrupts the postburn nutrition regimen but does not preclude the safe postoperative delivery and advancement of enteral feedings.     

A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study

Objective To assess a novel method, adapted from already published literature, for bedside placement of nasojejunal feeding tubes using erythromycin, air insufflation of the stomach and continuous ECG guidance.Design and setting Prospective study in a tertiary teaching hospital.Patients and participants 40 consecutive patients who required enteral nutrition and mechanical ventilation for at least 48 h.Interventions Erythromycin (200 mg) was administered intravenously 30 min prior to the insertion of the feeding tube. The post-pyloric feeding tube was then inserted into the stomach and 500 ml air insufflated. Stomach ECG was performed, and during further insertion of the tube the QRS complex was continuously monitored for a change in polarity, suggesting passage across the midline through the pylorus. At the end of the procedure aspirate was obtained from the feeding tube and checked for alkaline pH. Exact tube position was determined by abdominal radiography.Measurements and results In 88% of cases the feeding tubes were post-pyloric, with a median time to insertion of 15 min (range 7–75). No major complications were seen in 52 attempts. Change in QRS polarity had 94% sensitivity in predicting post-pyloric tip placement. Of the 32 alkaline pH aspirates 31 were post-pyloric.Conclusions This procedure is safe, effective and could be performed in a short time period within the confines of the intensive care unit without endoscopic assistance.     

Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus

Objective To evaluate a blind ‘active’ technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus. Design and setting An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital. Patients 20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route. Interventions Previously described insertion technique—the Corpak 10-10-10 protocol—for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening. Measurements and results A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3–55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage. Conclusions The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.     

Bedside post-pyloric tube placement using direct visualisation in mechanically ventilated patients: A single centre case series

IntroductionPost-pyloric feeding tubes are used for intensive care patients unable to tolerate gastric feeding. The Kangaroo Feeding Tube with IRIS Technology (‘IRIS’) uses real-time visualisation of anatomical markers to guide bedside placement, however limited studies currently explore post-pyloric insertions in mechanically ventilated patients. We describe a case series of ‘IRIS’ post-pyloric placements performed by trained intensivists and dietitians.MethodsThis was a prospective, single-centred clinical effectiveness study of mechanically ventilated adults referred for bedside post-pyloric tube placement between May 2020 and May 2021. The feasibility, success rates, anatomical visualisation using ‘IRIS’ and nutritional outcomes were documented.ResultsTwelve patients were included in total. The primary indication for post-pyloric placement was gastric feeding intolerance, with a median of 3.5 (IQR 0–6) days with inadequate nutrition prior to placement. All tubes were inserted within 24 h of referral as there was always a trained clinician available. Post-pyloric placement was successful for 9/12 patients (75%), as identified on the ‘IRIS’ console and X-ray confirmation. Only 3 (25%) patients required parenteral nutrition (mean duration 4 [SD 1] days). Respiratory misplacement occurred in 1 patient (8%) and was clearly differentiated from gastrointestinal anatomy, permitting early removal. Although duodenal placement was possible, no tubes reached the jejunum solely using the ‘IRIS’ method.ConclusionPost-pyloric tube placement using ‘IRIS’ in mechanically ventilated patients was feasible, successful and safe, resulting in reduced durations with inadequate enteral nutrition. Further, larger-scale studies are required to confirm these findings and explore the effectiveness of ‘IRIS’ in achieving deep small-intestinal placement.