危重患者早期肠内营养相关并发症分析

目的 观察综合性ICU危重症患者早期肠内营养支持中，相关并发症的发生及其相关因素。方法 119例入住ICU接受早期肠内营养支持患者，入ICU后根据24小时内各项监护指标及血常规、血气分析及肝肾功能检查，进行APACHE-Ⅱ评分。观察肠内营养量、速度、血清白蛋白(Alb)及肠内营养的耐受情况。总结各种肠内营养并发症的发生率。结果 随APACHE-Ⅱ评分的增加，肠内营养耐受的最大维持量降低、达最大维持量的时间延长、相关并发症的发生率增加。腹泻发生与Alb水平呈负相关，与APACHE-Ⅱ评分呈正相关。肠内营养并发症中以腹泻最为常见。结论 肠内营养相关并发症与疾病严重程度、血清蛋白水平等因素相关，一些危重患者无法过渡到完全肠内营养(TEN)，而需以静脉营养(PN) 肠内营养(EN)形式实现营养支持。     

改良鼻饲法在危重症病人肠内营养中的应用

为探讨胃肠内营养更有效的鼻饲方法,对2008年9月-2009年1月我院60例危重症病人采取两种不同的鼻饲方法,观察比较其胃肠内营养并发症情况.现报告如下.     

An evaluation of enteral feeding practices in critically ill children

Background: Establishing and sustaining enteral feeding in critically ill children is challenging and has met with many problems. Aims and objectives: The aim of this study was to investigate (a) how actual calorie intake compared with estimated caloric requirements and (b) whether feeding guideline adherence resulted in improved nutritional intake. Design and methods: A prospective observational study was undertaken over 1 month in a tertiary referral paediatric intensive care unit (PICU) in the northwest of England. Results: Forty‐seven children were studied, with a wide range of diagnoses in a 1‐month period. Only 47% of the children had enteral feeds started within our 6 h post‐admission target. Over half (55%) of the children received less than half of their estimated calorie requirements, but if feeding guidelines were followed, this resulted in a significantly higher (p = 0·004) delivery of the child's estimated requirements. Conclusions: This study found that many children are not receiving adequate nutrition in PICU and that the use of feeding guidelines significantly improves calorie delivery in PICU patients. Relevance to clinical practice: This paper highlights the dearth of research related to enteral feeding in critically ill children. We found that the use of feeding guidelines improved calorie delivery and so units should be encouraged to develop their own guidelines based on the best evidence available.     

Common complications in critically ill patients

Patients in intensive care units (ICUs) are subject to many complications connected with the advanced therapy required for their serious illnesses. Complications of ventilatory support include problems associated with short-term and long-term intubation, barotrauma, gastrointestinal tract bleeding, and weaning errors. Cardiac tachyarrhythmias can arise from a patient's intrinsic cardiac disease, as well as from drug therapy itself. Hemodynamic monitoring is crucial to careful patient management, but it is associated with technical complications during insertion such as pneumothorax, as well as interpretive errors such as those caused by positive end-inspiratory pressure. Acute renal failure can develop as a result both of therapy with drugs such as aminoglycosides and hypotension of many etiologies, as well as the use of contrast media. Nosocomial infection, which is a dreaded complication in ICU patients, usually arises from sources in the urinary tract, bloodstream, or lung. Complications frequently can arise if the interactions of drugs commonly used in the ICU are not recognized. Further, the ICU patient is subject to nutritional complications, acid base problems, and psychological disturbances. This monograph deals with the frequency, etiology, and prevention of these common ICU complications.     

Impact of abdominal massage on enteral nutrition complications in adult critically ill patients: A systematic review and meta-analysis

BackgroundAdult critically ill patients are prone to complications when receiving enteral nutrition, including feeding intolerance. Although abdominal massage is an effective intervention, its effects on enteral nutrition complications in adult critically ill patients are controversial.ObjectiveTo summarize and evaluate the effect of abdominal massage on enteral nutrition complications in adult critically ill patients.MethodsWe searched databases (e.g., PubMed, the Cochrane Library, Embase, and Web of Science) from inception until November 2020 for relevant studies published in English. The methodological quality of selected studies was assessed with the Cochrane Risk of Bias 2.0 tool. And we used of PRISMA 2020 guidelines. The meta-analysis results were reported as mean difference (MD) and events, and the heterogeneity of the studies was evaluated using I².ResultsSeven studies including 472 participants (aged≥18 years) met the inclusion criteria. The mean gastric residual volume (GRV) (MD=−42.41, 95% confidence interval [CI]: −71.43, −13.39; P = 0.004) and incidence of abdominal distension (odds ratio [OR]=0.08, 95%CI: 0.03, 0.19; P < 0.00001) were significantly lower in the massage therapy group compared with controls. The incidence of vomiting (OR=0.09, 95%CI: 0.01, 0.72; P = 0.02) and ventilator-associated pneumonia (VAP) (OR=0.20, 95%CI: 0.05, 0.77; P = 0.02) were statistically significantly lower in the abdominal massage group compared with controls.ConclusionAbdominal massage reduces GRV, vomiting, abdominal distension, and VAP in adult critically ill patients. Given the limited number of reviewed studies, small number of patients examined, and short intervention periods, further randomized controlled trials are needed that use accurate methodology, longer interventions, and larger sample sizes to confirm the effect of abdominal massage on feeding intolerance in adult critically ill patients.     

肠内营养支持在危重病中的应用研究

目的：观察肠内营养在危重病中的支持效果。方法：将ＩＣＵ中２６例危重患者随机分为肠内营养支持组（１４例）和肠外营养支持组（１２例）,在营养支持前１日及营养支持第１０日测量三头肌皱厚度,上臂肌围,血清白蛋白及血红蛋白,每日计算氮平衡并观察相关并发症情况。     

万古霉素在成人危重症患者中的应用进展

万古霉素是糖肽类杀菌剂,主要用于治疗耐药金黄色葡萄球菌和肠球菌等革兰氏阳性菌引起的严重感染。重症患者由于生理屏障被破坏,感染发生率高,而且常常合并耐药菌感染,但危重症患者因为毛细血管渗漏和器官功能障碍等使得药物在体内的药动学发生极大的改变,因此万古霉素在重症患者中的使用还需要结合具体实际情况。现就在重症患者中正确合理使用万古霉素作一综述,为优化特殊人群给药提供新思路。     

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。     

成人重症患者床旁超声引导鼻肠管置入的证据总结

目的 检索、评价并总结成人重症患者床旁超声引导鼻肠管置入的最佳证据,为完善超声引导鼻肠管置入规范提供依据。方法 计算机检索UpToDate、BMJ Best Practice、全球各指南网站、澳大利亚乔安娜布里格斯研究所循证卫生保健中心数据库、Cochrane Library等中英文相关数据库以及重症医学、营养协会网站关于成人重症患者床旁超声引导鼻肠管置入的相关文献,包括临床指南、专家共识、团体标准、临床决策、证据总结、系统评价等。检索时限为建库至2022年6月。由2名循证护理研究者对文献质量进行评价,并结合临床情境,提取相关证据。结果 共纳入22篇文献。其中指南5篇,专家共识6篇,团体标准1篇,临床决策2篇,证据总结3篇,系统评价5篇。从临床场景、评估、准备、置管要点、护理等5个方面汇总了26条证据。结论 该研究总结了成人重症患者床旁超声引导鼻肠管置入的最佳证据,为床旁开展超声引导鼻肠管置入提供借鉴,保证患者安全。     

危重症患者早期肠内营养供给量的研究进展

对危重症患者而言,早期启用肠内营养（EN）不仅是补充营养,更重要的是发挥其在维持肠道功能和肠道微生态中的特殊重要作用。任何药物治疗产生的效果都与剂量相关,营养治疗亦是如此。理想的EN目标在于供给的量与质能够带给危重症患者最大获益与最小伤害,而充分营养供给并避免医源性营养不良是最终的理想目标。但是,早期EN的不耐受是危重症患者常面临的困难与挑战,不恰当的供给将会产生不良影响,甚至危害。认识这些可能的风险并予以规避是ICU医护人员需要重视与了解的必要知识。在一些严重的或特殊疾病状态下,及时评估及调整EN治疗方案才可能实现其理想目标,使患者最大获益。     

早期肠内营养对危重患者的影响

目的通过对危重患者入院24～48h内早期肠内营养支持的研究，了解其对危重患者的影响。方法选择我院综合性ICU中的危重患者，随机分为实验组和对照组。实验组在入院24～48h内开始肠内营养；对照组在入院48h后开始肠内营养。检测两组患者的营养指标、感染发生率、机械通气时间。结果共有206例危重患者进入实验。实验组的热量摄入、氮平衡优于对照组，感染发生率降低。结论早期肠内营养能更好地改善危重患者的营养摄入，降低感染发生率。     

Screening and risk factors of exocrine pancreatic insufficiency in critically ill adult patients receiving enteral nutrition

Introduction

Malnutrition is a frequent problem associated with detrimental clinical outcomes in critically ill patients. To avoid malnutrition, most studies focus on the prevention of inadequate nutrition delivery, whereas little attention is paid to the potential role of exocrine pancreatic insufficiency (EPI). In this trial, we aim to evaluate the prevalence of EPI and identify its potential risk factors in critically ill adult patients without preexisting pancreatic diseases.

Methods

In this prospective cross-sectional study, we recruited 563 adult patients with critical illnesses. All details of the patients were documented, stool samples were collected three to five days following the initiation of enteral nutrition, and faecal elastase 1 (FE-1) concentrations were assayed using an enzyme-linked immunosorbent assay kit. Blood samples were also taken to determine serum amylase and lipase activity.

Results

The percentages of recruited patients with EPI (FE-1 concentration <200 μg/g) and severe EPI (FE-1 concentration <100 μg/g) were 52.2% and 18.3%, respectively. The incidences of steatorrhea were significantly different (P < 0.05) among the patients without EPI, with moderate EPI (FE-1 concentration = 100 to 200 μg/g) and severe EPI (FE-1 concentration < 100 μg/g). Both multivariate logistic regression analysis and z-tests indicated that the occurrence of EPI was closely associated with shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis.

Conclusions

More than 50% of critically ill adult patients without primary pancreatic diseases had EPI, and nearly one-fifth of them had severe EPI. The risk factors for EPI included shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis.

Trial registration

{"type":"clinical-trial","attrs":{"text":"NCT01753024","term_id":"NCT01753024"}}NCT01753024     

Bioavailability of gatifloxacin by gastric tube administration with and without concomitant enteral feeding in critically ill patients

OBJECTIVE: Sequential intravenous-to-oral antimicrobial therapy with highly bioavailable antiinfective agents such as the fluoroquinolones may improve patient safety and decrease cost of infection management. However, physiologic changes associated with critical illness may alter drug absorption, distribution, and clearance, and concomitant enteral feeding may decrease fluoroquinolone bioavailability. We evaluated the effect of critical illness and concomitant gastric tube feeding on gatifloxacin bioavailability. DESIGN: Prospective, randomized, single-dose, two-way crossover, pharmacokinetic study.SETTINGA tertiary, level-one, trauma center. PATIENTS: Sixteen critically ill patients (baseline Acute Physiology and Chronic Health Evaluation II score >or=16) tolerating enteral nutrition administered by gastric tube (NG) for >or=12 hrs were randomized to receive gatifloxacin concurrently with continuous tube feeding or with interrupted tube feeds. Patients with renal insufficiency or those receiving concomitant fluoroquinolone therapy or postpyloric feeding were excluded. Patients received gatifloxacin 400 mg either by the intravenous or NG route followed by the alternative dosage form after a 72-hr washout period. MEASUREMENTS AND MAIN RESULTS: Serial serum gatifloxacin concentrations (from 5 mins to 24 hrs) were analyzed using a validated high-performance liquid chromatography method. Bioavailability was determined as the ratio of NG/intravenous area under the concentration-time curve (AUC infinity ) measured by the trapezoidal method. Although there was no difference in the bioavailability between NG (AUC infinity : 38.0 [range 20.1 to 48.5] microg x h/mL) and intravenous (AUC infinity : 39.5 [range 24.1 to 63.1] microg x h/mL, p =.60) gatifloxacin (bioavailability: 98.5% [range 61.1% to 119.7%]), a wide variability was observed in three of eight patients (>30% reduction in bioavailability). Concomitant gastric tube feeding did not affect gatifloxacin bioavailability (interrupted tube feeds: 98.5% [range 61.1% to 119.7%]; continuous tube feeding: 109.0% [range 86.2% to 142.1%]; p =.42). Neither a period nor differential carryover effect was observed. CONCLUSIONS: Although concomitant tube feeding did not affect gatifloxacin bioavailability, critical illness resulted in significant variability that may complicate the role of gatifloxacin in sequential intravenous-to-oral therapy. More research is needed to identify those patients in whom gatifloxacin bioavailability is reduced and for whom an empirical increase in gatifloxacin dose should be considered.