危重症病人肠内与肠外营养支持的对比观察

目的:对比研究危重症病人EN与PN支持的效果.方法:将48例危重症病人随机分为EN组和PN组,对比观察营养支持后两组病人的Hb、PA、血清总蛋白(TP)、ALB等营养指标以及腹泻、腹胀、胃肠道出血、肝功能损害、高血糖等并发症的发生率.结果:经EN支持后,病人的Hb、TP和PA明显升高(P<0.05);而PN组与营养支持前比较,病人各指标无显著性差异.PN组并发症的发生率高于EN组.结论:EN支持可较好地改善病人的营养状况,并发症少,是危重症病人较好的营养支持方式.     

Tolerability and efficacy of a low-volume enteral supplement containing key nutrients in the critically ill

Background & aims

To compare early supplementation with antioxidants and glutamine using a low-volume enteral supplement containing key nutrients to an energy adjusted standard elementary diet and to investigate its effect on clinical efficacy and tolerability in critically ill patients with sepsis/SIRS. The primary endpoints were length of stay in the ICU and sufficient enteral feed.

Methods

This was a randomized, prospective, single-blind, controlled study in 58 critically ill patients (56.9% male, mean age 46.7 years, mean APACHE II score 21.6). They received either a low-volume enteral supplement containing key nutrients or a diluted standard nutrition solution. After 10 or 14 days inflammatory parameters, catecholamine need, and maximal enteral delivery were determined.

Results

Patients receiving a low-volume enteral supplement containing key nutrients did not reach sufficient enteral feed more often than controls (76 vs. 62%, respectively, p = 0.17). The difference in vitamin E and selenium uptake was higher in the treatment group than controls (12.4 vs. 3.7 and 54.7 vs. 16.3, respectively, p ≤ 0.011). Parameters such as fever, antibiotic treatment, artificial ventilation, and death were comparable. This was also true for days of ICU or hospital stay (33 ± 23 and 49 ± 34 days, respectively).

Conclusions

The low-volume enteral supplement containing key nutrients was well tolerated and led to a better vitamin E and selenium supply. However, it did not affect length of ICU or hospital stay. Further studies are necessary to determine which disease-specific subgroups may benefit from this supplementation or which group may be harmed.     

补充含有谷氨酰胺的肠外营养对危重病人

作为人体内最丰富的氨基酸,谷氨酰胺(Gln)具有许多重要的代谢作用,能够维持和改善组织的完整性和促进机体的免疫功能.危重病人的血浆和组织中的谷氨酰胺都是下降的,说明这些病人对谷氨酰胺的需要量超过了内源性谷氨酰胺的供给量.目的危重病人谷氨酰胺的相对缺乏将会影响到病人的恢复和延长疾病的时间并可能增加病人后期死亡率.本研究将检验这个假说.方法在本研究中,我们采用前瞻、块随机和双盲设计,研究与传统的等氮、等热卡的肠外营养相比,观察给予含有谷氨酰胺的肠外营养是否影响病人的预后,研究指标采用6个月的患病率、死亡率和费用情况.在同一个普通的ICU进行研究,保证治疗和处理的一致性.84例危重成年病人进入研究,他们的APACHE评分＞10,因为他们有肠内营养的禁忌症或肠内营养不成功,他们都接受肠外营养.结果接受含谷氨酰胺肠外营养组病人的6个月存活率明显改善(24/42比14/42,P=0.049).需要接受不含谷氨酰胺的肠外营养超过10天的病人死亡数明显较多(P=0.03).对照组病人死亡多发生在疾病后期,病人在给予治疗后住ICU时间明显较长(P=0.012).接受谷氨酰胺的病人,每例存活者总的ICU费用和总住院费用下降50%.结论对不能接受肠内营养的ICU危重病人,给予含谷氨酰胺的肠外营养可以改善6个月的生存率和降低每个存活者的住院费用.     

营养支持治疗在老年危重患者救治中的应用

目的探讨不同营养支持方式在老年危重患者救治中的作用。方法选择老年危重患者98例,根据不同营养支持方式分为肠外营养(PN)组30例,肠内营养(EN)组32例,PN+EN组36例。摄入同等总热量和同等氮量,营养支持治疗时间14 d。治疗0 d和连续营养支持治疗14 d后,检测血清白蛋白(Alb)、前白蛋白(PA)、血红蛋白(Hb)、淋巴细胞总数(TLC)、免疫球蛋白(IgA、IgG、IgM)值并进行回顾性对比分析。结果 3组患者Hb均较治疗前增高。EN+PN组患者Alb、PA较PN组及EN组治疗后增高。营养支持治疗后,3组患者TLC明显增高。EN组IgA、IgM,EN+PN组IgA、IgG、IgM均较PN组增高。PN+EN组并发症低于PN组及EN组。结论老年危重患者救治中应根据老年人特点及疾病不同情况合理选择营养支持方式,PN+EN联合应用更有利于改善老年危重患者营养状况及免疫功能,减少并发症发生,促进疾病的康复。     

营养支持治疗在神经外科危重病人中的合理应用

目的 :探讨神经外科危重病人营养支持的方法。　方法 :对 2 8例神经外科危重病人早期 (发病后 4 8～ 72h)即开始实施肠内营养 ,并逐渐加量 ,不足部分以肠外营养补充 ;应激期 (发病后 7天内 )注意适当减少葡萄糖的供给。　结果 :本组治愈 2 3例 ,死亡 5例 ;治疗过程中未出现明显的糖、脂代谢异常和肝酶谱变化的代谢性并发症。肠内营养期间无严重腹泻、腹胀等并发症。使用呼吸机支持者均一次脱机成功 ,　结论 :早期即行肠内营养 ,逐渐过渡到完全肠内营养 ;应激期适当减少葡萄糖的供给 ,可提高脑外科危重病人的救治成功率 ,降低并发症和病死率     

肠内与肠外两种营养支持疗法在重症监护病房危重症患者综合治疗中的应用比较

目的 比较肠内与肠外两种营养支持疗法在重症监护病房（ICU）危重症患者综合治疗中的疗效.方法 选择ICU危重症患者114例,按随机数字表法分为肠内营养组（57例）和肠外营养组（57例）,治疗2周后比较两组血红蛋白、总蛋白、白蛋白、前清蛋白等营养指标及并发症发生情况.结果 两组患者治疗2周后各营养指标均有所升高,且肠内营养组比肠外营养组升高更明显[血红蛋白：（120.47±22.46） g/L比（114.83±23.86） g/L,总蛋白：（78.21±8.42） g/L比（70.48±8.21） g/L,白蛋白：（38.21±5.03） g/L比（33.87±5.62） g/L,前清蛋白：（245.57±44.61） mg/L比（182.24±42.73） mg/L],差异有统计学意义（P＜0.05）.肠内营养组腹胀腹泻、呕吐恶心、感染、肝肾功能损伤发生率均明显低于肠外营养组[14.04％（8/57）比26.32％ （15/57）,12.28％（7/57）比17.54％（10/57）,3.51％（2/57）比8.77％（5/57）,1.75％（1/57）比5.26％ （3/57）],差异均有统计学意义（P＜0.05）.结论 营养支持对于危重症患者的营养状况和机体免疫力都有提升作用,且肠内营养效果更加明显,可更好地提高预后,可能成为危重症患者更佳的营养支持疗法.     

胃肠道手术后规范化序贯肠内肠外营养支持疗法与肠外营养支持的临床随机对照研究

目的 比较胃肠道手术后规范化序贯肠内肠外营养支持疗法与肠外营养支持的临床疗效.方法 采用随机数字表法,将126例拟行开腹胃肠道手术的患者随机分为早期肠内肠外营养支持疗法组(EEN+PN组,n=62)和肠外营养支持组(PN组,n=64),分别于手术前,手术后第3、7天监测患者的体重、体重指数、血清白蛋白、前白蛋白、血脂、血生化、血淋巴细胞计数、血C反应蛋白变化情况,比较两组患者术后胃肠道功能恢复时间、手术并发症、营养支持相关费用及住院天数.结果 术前两组患者的营养相关指标、血生化指标和炎症及免疫指标差异均无统计学意义(P>0.05);术后第3天,EEN+PN组患者前白蛋白水平显著高于PN组[(160.3±23.0)g/L比(137.0±28.7)g/L,P=0.000];术后第7天,EEN+PN组患者前白蛋白[(210.6±34.6)g/L比(154.8±36.9)g/L,P=0.000]、白蛋白[(33.6±3.8)g/L比(31.8±4.7)g/L,P=0.042]、淋巴细胞计数[(2.33±0.53)×109/L比(1.04±0.36)×109/L,P=0.046]水平均显著高于PN组,血γ-谷氨酰转肽酶[(48.12±33.84)U/L比(71.54±34.00)U/L,P=0.048]、C反应蛋白[(31.15±19.00)mmol/L比(45.90±23.21)mmol/L,P=0.042]、总胆固醇[(3.09±0.83)mmol/L比(3.29±0.91)mmoL/L,P=0.045]、低密度脂蛋白[(2.01±0.39)mmoi/L比(2.31±0.72)mmol/L,P=0.049]水平显著低于PN组.EEN+PN组患者术后胃肠道功能恢复时间显著短于PN组[(65.7±15.6)h比(75.1±27.0)h,P=0.036],围手术营养支持疗法总费用显著低于PN组[(2634.5±1306.8)元比(3058.6±1216.0)元,P=0.046].结论 胃肠道手术后早期规范化序贯肠内肠外营养支持疗法可以改善机体术后前白蛋白水平,有益于术后患者免疫功能和组织损伤水平的恢复,促进早期胃肠道功能恢复,降低营养支持疗法相关费用.

Abstract：

Objective To compare the clinical efficacy between standard sequential early enteral nutrition (EEN) plus parenteral nutrition (PN) and PN alone in patients undergoing gastrointestinal surgery. Methods Werandomly divided 126 patients who underwent laparotomy gastrointestinal surgery into EEN + PN group (n = 62) and PN group (n = 64). The levels of blood nutrition-related indicators, biochemical indicators, and inflammatory indicators were determined before surgery and 3 and 7 days after surgery, and the gastrointestinal function recovery time, complications, nutritional support cost, and length of hospital stay were compared between two groups. Results The preoperative nutrition-related indicators, biochemical indicators, and inflammatory indicators showed no significant differences between two groups (P >0. 05). Three days after operation, however, the levels of prealbumin in EEN + PN group were significantly higher than those in PN group [(160. 3 ±23. 0) g/L vs. (137.0±28.7) g/L, P=0.000]. Seven days after operation, the levels of albumin [(33.6±3.8) g/L vs. (31.8±4.7) g/L, P = 0.042], prealbumin [(210.6±34.6) g/L vs. (154.8 ±36.9) g/L, P=0.000], and lymphocyte cell count [(2.33±0.53) x 109/L vs. (1.04±0.36) × 109/L, P = 0. 046] in EEN + PN group were significantly higher than those in PN group, and the levels of serum γ-glutamyltransferase [(48. 12 ± 33.84) U/L vs. (71.54±34.00)U/L, P=0.048], C-reactive protein [(31.15 ± 19.00) mmol/L vs. (45.90 ± 23.21) mmol/L, P=0.042], total cholesterol [(3.09±0.83) mmol/L vs. (3.29±0.91) mmol/L, P = 0. 045] and low density lipoprotein [(2.01 ± 0. 39) mmol/L vs. (2. 31 ± 0. 72 ) mmol/L, P = 0. 049] were significantly lower than those in PN group. The postoperative gastrointestinal function recovery time in EEN + PN group was significantly shorter than that in PN group [(65. 7 ± 15. 6) hours vs. (75. 1 ± 27. 0) hours, P = 0. 036], and the total cost of perioperative nutrition in EEN + PN group was also significantly lower than in PN [(2634. 5 ±1306. 8) RMB vs. (3058. 6 ± 1216. 0) RMB, P= 0.046]. Conclusion Standard sequential EEN plus PN can increase the post-operative prealbumin level, improve the immune function, promote the recovery of gastrointestinal function, and decrease the cost of nutritional support.     

早期肠内营养在危重症病人营养支持中的临床价值

目的:通过对危重症病人行早期肠内营养(EEN),观察病人的临床转归和评价EEN的应用价值.方法:将46例危重症病人随机分为治疗组和对照组.治疗组病人在入住ICU的24～48 h内行EN,对照组病人在入ICU的48 h后开始EN.比较两组病人对营养支持的耐受性、营养指标、肝功能、EN可耐受的起始时间、达EN目标喂养点所需...     

胃肠癌肿术后围化疗期肠外营养的临床研究

目的：研究胃肠外营养在胃癌、结肠癌术后围化疗期的临床疗效。方法：80例胃癌、结肠癌术后病人采用自身前后交叉对比的方法随机分为两组。一组为单纯化疗者,另一组在接受化疗的同时给予胃肠外营养,结果：胃肠外营养能增强病人的食欲,改善病人的营养状况,提高机体免疫力,使病人如期接受化疗,组能减轻化疗药物的不良反应。结论：胃肠癌术后围化疗期有必要给予胃肠外营养。     

重症监护患者营养风险筛查2002和营养支持实况调查

目的 调查重症监护患者营养风险筛查2002(NRS 2002)和营养支持的应用现状.方法 采用定点连续抽样方法,选取2011年9月至12月在北京市某三甲医院重症医学科(ICU)住院≥3 d的内外科成年危重患者172例,记录患者进入ICU后的营养支持应用状况,评估患者入院24 h内的营养风险状况(根据NRS 2002)、营养状况(根据体重指数,BMI)和疾病严重程度(根据急性生理和慢性健康状况评分Ⅱ,APACHEⅡ).结果 营养支持率在入ICU首日最低(39.5％),至第7日达67.9％,肠外营养(PN)应用比例(33.6％～39.5％)高于肠内营养(EN)应用比例(4.1％ ～ 16.0％).NRS 2002、APACHEⅡ评分及BMI显示160例(93.0％)患者应当接受营养支持,但仅对其中103例(64.4％)给予了营养支持,在这些患者中,92例(89.3％)的营养支持开始于入ICU 3 d内.结论 危重患者的营养支持率不足,多数危重患者的营养支持开始得较为及时.危重患者的营养支持途径以PN为主.     

Quality control of parenteral nutrition in hospitalized patients

ObjectiveFor hospitalized patients requiring parenteral nutrition (PN), adequate nutritional support has a profound effect on hospital length of stay, morbidity, mortality, and complication rates. Inappropriate or inadequate nutritional therapy may worsen clinical outcome. The aim of this study was to investigate the compliance with nutritional guidelines for PN in a university hospital setting.MethodsOver a 6-mo period, this monocentric study prospectively recruited 107 (41 women, 66 men) hospitalized medical and surgical patients requiring PN. Data on nutritional support were collected before nutritional counseling. Nutritional requirements were estimated on the basis of the European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines for Adult Parenteral Nutrition (2009).ResultsThe mean patient age was 65 ± 1.4 y and the mean body mass index was 23.2 ± 0.5 kg/m². Only 75% of the caloric requirement was met. Multivitamin supplementation was adequate in only 37%, and for vitamin K in only 6% of cases. Trace element supplementation was adequate in only 35%. PN in complete agreement with the ESPEN guidelines was achieved in none of the patients.ConclusionsIn routine hospital practice, PN is generally not provided in compliance with established guidelines. To improve the quality of nutritional therapy, a nutritional support team should be established. Furthermore, there should be periodical training sessions in nutrition for medical and nursing staff, as well as in standard operating procedures.     

Practicalities of nutrition support in the intensive care unit: the usefulness of gastric residual volume and prokinetic agents with enteral nutrition

The provision of early nutrition therapy to critically ill patients is established as the standard of care in most intensive care units around the world. Despite the known benefits, tolerance of enteral nutrition in the critically ill varies and delivery is often interrupted. Observational research has demonstrated that clinicians deliver little more than half of the enteral nutrition they plan to provide. The main clinical tool for assessing gastric tolerance is gastric residual volume; however, its usefulness in this setting is debated. There are several strategies employed to improve the tolerance and hence adequacy of enteral nutrition delivery in the critically ill. One of the most widely used strategies is that of prokinetic drug administration, most commonly metoclopramide and erythromycin. Although there are new agents being investigated, none are ready for routine application in the critically ill and the benefits are still being established. This review investigates current practice and considers the literature on assessment of enteral tolerance and optimization of enteral nutrition in the critically ill.     

肝切除患者围手术期营养支持的护理作用

目的 评述肝切除患者围手术期营养支持的护理作用.方法 146例接受肝切除手术的患者人院后进行营养风险筛查,术前给予肠内营养,术后进行肠外和肠内营养支持,围绕术后营养指标变化、临床部分结局指标,就诊治过程中的各种护理方法进行总结.结果 146例患者营养风险筛查评分≥3分者91例,＜3分者55例;接受肠外肠内营养支持者118例,平均肠内营养支持时间9.6 d,平均肠外营养支持时间5.4d;术后平均肛门排气时间(70.7±17.1)h;死亡3例,术后感染15例次,其他并发症13例,中位住院习25.5 d.结论 肝切除患者人院后应进行营养风险筛查,围手术期营养支持以肠内营养为主,术后需要联合肠外营养,强化护理作用是实施营养支持的保障.     

胃肠恶性肿瘤合并糖尿病围手术期的肠外营养支持探讨

目的:探讨糖尿病围手术期肠外营养支持及安全控制血糖的方法. 方法:对28例胃肠恶性肿瘤合并糖尿病的病人,围手术期的肠外营养支持进行回顾性分析. 结果:在糖尿病病人围手术期肠外营养支持期间,血、尿糖可调控在安全范围内,血脂无升高,术后尿素氮增加,体重下降,血浆蛋白减少. 结论:糖尿病病人围手术期肠外营养支持是必要的、切实可行的措施,正确、及时应用胰岛素调控血糖、尿糖是肠外营养支持的关键步骤.营养支持只能达到保护和支持器官的结构和功能,减轻葡萄糖代谢障碍和糖原、脂肪、蛋白质的分解,推动各种代谢通路,能使病人顺利度过围手术期的目的.     

肠外营养对老年胃癌病人术后的作用

目的：观察肠外营养（PN）对老年胃癌病人术后的营养支持作用。方法：选择20例术后应用PN治疗的老年胃癌病人作为PN组，并与同期未行PN治疗的20例老年胃癌病人作对照。结果：①PN组术后并发症发生率为15％（3／20），无死亡；对照组为45％（9／20），病死率为5％（1／20）。②PN组与对照相比，体重、肌酐－身高指数、血清白蛋白、转铁蛋白、血清尿素氮、氮平衡等均有显著差异（P＜0．01）。③PN组血糖、三酰甘油、SGPT、AKP、γ－GT等与对照组比均有显著升高。结论：PN可改善老年胃癌病人术后氮平衡和营养状况，降低蛋白质分解，减少术后并发症，但应掌握能量供给要适当的原则。