内镜下放置小肠营养管治疗慢性呼吸衰竭伴营养不良患者20例护理体会

目的观察内镜下放置小肠营养管对改善呼吸衰竭患者的营养状况及临床症状改善的疗效。方法选择40例在我院住院的慢性呼吸衰竭伴营养不良患者．通过口胃肠道和小肠营养管两种途径予以营养干预，经过精心护理21天后评估临床症状及体征的改善情况．进行人体测量学测量、血清蛋白数值等检测以及血气分析，观察营养干预的效果。结果经过21天的营养干预治疗和护理发现小肠营养管组的效果明显优于口胃肠组。结论两种营养干预方式对慢性呼吸衰竭伴营养不良患者的营养状况均有不同程度的改善，但内镜下放置小肠营养管疗效更显著，具有实用性和可行性，值得临床选用。     

床边盲视法放置鼻肠营养管在危重症患者中的应用

目的　探讨在一定辅助方法下床边放置鼻肠营养管在危重症患者应用中的安全性和有效性。方法　2013 年 9 月 1 日至 2015年9月10日安徽医科大学第二附属医院重症医学科不能经口及经胃进食的危重症患者，按本科执行的床边放置鼻肠营养管操作规范，根据病情特点选择辅助方法，行床边放置鼻肠管，记录操作时间、营养管位置和相关并发症等，并对资料进行回顾性分析。 结果　共有 21 例不能经口及经胃进食患者，床边放置鼻肠管23例次，营养管头端跨幽门成功率为913%（21/23），将营养管头端送达Treitz 韧带以下     

X线辅助超滑导丝法放置经鼻小肠营养管在危重症患者中的应用

营养支持治疗是危重症患者重要的临床治疗措施之一,由于肠内营养具有更多的优越性而广泛应用于临床[1].但有相当一部分危重症患者,经鼻胃管喂养可能出现胃潴留,尤其伴有胃动力障碍的患者更为严重,为减少并发症常需要行经鼻小肠营养.但常规放置小肠营养管需要内窥镜引导或行空肠造瘘,对危重症患者影响较大.我院于2008年4-10月,共采用X线辅助超滑导丝法放置经鼻小肠营养管30例,取得较好的疗效,现报道如下.     

鼻空肠管与鼻胃管在危重患者早期肠内营养的应用比较

目的比较危重患者经鼻空肠管与经鼻胃管实施早期肠内营养的临床应用效果,选择一条更有效的肠内营养途径。方法对37例危重患者采用经鼻空肠管早期肠内营养,观察开始实施时间、达到预计能量需要时间以及并发症等,并与经鼻胃管进行比较,评价经鼻空肠管早期肠内营养的有效性和安全性。结果危重患者早期肠内营养的开始时间及达到预计能量所需时间与营养管途径有关,经鼻空肠管肠内营养的开始时间与鼻胃管比较U=4.497,P<0.01;达到预计能量所需时间比较U=4.040,P<0.01,差异均有统计学意义;并发症比较χ2=5.572,P<0.05,差异有统计学意义。结论危重患者早期肠内营养经鼻空肠管途径比经鼻胃管更为安全有效,并能将实施肠内营养的时间显著提前。     

床边X线下经胃镜引导鼻肠营养管放置术的临床应用

目的评价床边X线监视下经胃镜引导鼻空肠营养管放置术的临床应用价值。方法对病情危重不易搬动或昏迷的患者在床边经胃镜引导放置鼻空肠营养管,同时经床边X线摄片及CR机监视,观察营养管放置是否到位。结果床边X线监视下经胃镜引导可以将空肠营养管放置至空肠屈氏韧带以远30 cm以上,置管成功率100%,置管时间15~40(20±4.5)m in。置管后营养管在位良好,喂养过程顺利。结论床边X线下经胃镜引导放置鼻空肠营养管是一种操作简便快捷、安全可靠、实用有效的空肠营养管放置术。     

上消化道手术术后空肠营养管的应用

近年来,肠内营养（enteral nutrition EN）由于具有经济简便、安全有效、符合生理需要等特点,被临床作为首选的营养支持方法,尤其对危重患者而言,常常是治疗的必要组成部分。因此,本院2006年～2008年在上消化道手术术后常规放置空肠营养管,取得了良好的效果。     

经鼻超细胃镜引导放置空肠营养管

目的观察经鼻超细胃镜在空肠营养管置入中的作用。方法对20例危重需肠内营养的患者应用FujinonEG-530N经鼻超细电子胃镜引导放置导丝至空肠，退出胃镜，沿导丝送入空肠营养管至合适位置，从另一侧鼻腔进镜，观察空肠营养管深度及是否折回。结果16例1次置管成功，4例折回，重新放置均成功。置管时间为10～45min，平均操作时间22min。平均置管深度105cm，平均留管时间14～100d。其中1例有少量鼻出血，余未出现并发症。结论经鼻超细胃镜引导放置空肠营养管较其他方法简捷、安全、实用、有效。     

鼻空肠管与鼻胃管在危重患者早期肠内营养的应用比较

目的比较危重患者经鼻空肠管与经鼻胃管实施早期肠内营养的临床应用效果，选择一条更有效的肠内营养途径。方法对37例危重患者采用经鼻空肠管早期肠内营养，观察开始实施时间、达到预计能量需要时间以及并发症等，并与经鼻胃管进行比较，评价经鼻空肠管早期肠内营养的有效性和安全性。结果危重患者早期肠内营养的开始时间及达到预计能量所需时间与营养管途径有关，经鼻空肠管肠内营养的开始时间与鼻胃管比较U=4．497，P〈0．01；达到预计能量所需时间比较U=4．040，P〈0．01，差异均有统计学意义；并发症比较χ^2=5．572，P〈0．05，差异有统计学意义。结论危重患者早期肠内营养经鼻空肠管途径比经鼻胃管更为安全有效。并能将实施肠内营养的时间显著提前。     

ICU危重患者肠内营养的护理

目的观察肠内营养护理对防止危重患者肠道并发症的临床效果。方法对ICU危重患者实施肠内营养护理并观察肠道并发症的发生情况。结果颅脑损伤并发症:腹泻22.4%,呕吐10%,消化道出血7.1%,误吸3.1%,脱管4.1%,堵管5.1%。胸外伤并发症:腹泻11.2%,呕吐4.1%,消化道出血6.1%,误吸2.0%,脱管2.0%,堵管2.0%。脊髓损伤并发症:泻8.16%,呕吐5.1%,消化道出血4.1%,误吸2.0%,脱管1.0%,堵管1.0%。腹泻等并发症发生低于不给予肠内营养支持的患者。结论 ICU危重患者实施肠内营养护理对防止胃肠道并发症有重要的临床意义。     

基于PubMed数据库的危重患者肠内营养研究热点共词聚类分析

目的:分析PubMed数据库中2011至2020年危重患者肠内营养研究的热点,了解该领域的研究现状及发展趋势。方法:通过PubMed检索2011至2020年发表的危重患者肠内营养文献,运用Biocomb软件和gCLUTO软件对主题词进行词频及图形聚类分析。结果:共纳入5 686篇危重患者肠内营养研究文献,主要来自于美国...     

Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel?

Although the enteral route of enteral feeding is the preferred method of nutrition support for critically ill patients, this important therapeutic strategy is not without risk. In human subjects, the digestion and absorption of nutrients induce typical hemodynamic changes, consisting of an increase in mesenteric blood flow at the expense of reduced systemic blood pressure. On rare occasion when providing aggressive enteral nutrition to critically ill patients, common symptoms of gastrointestinal intolerance may progress to a syndrome of abdominal distention, hypotension, and shock, with the development of small bowel ischemia or necrosis. Although the incidence of small bowel ischemia secondary to enteral feeding is low, the overall clinical outcome is still poor and carries a high mortality rate. Enteral feeding is well tolerated and is probably beneficial in most critically ill patients before and after a period of hypotension. Although enteral nutrition may be used with caution during the period of hypotension, evidence of poor gastrointestinal function (increased nasogastric tube output, unexplained abdominal pain, and abdominal distention), or development of dilated loops of bowel or intramural gas (pneumatosis intestinalis) on radiographic studies should be interpreted as potential indicators of gut ischemia. With progress in our understanding of the pathophysiology, diagnosis, and prevention of ischemic injury to the intestinal mucosa, the strategy of aggressive enteral feeding for critically ill patients may result in a reduction in this major complication and enhanced functional recovery from severe illness.     

Biomarqueurs entérocytaires et nutrition artificielle en réanimation

Early initiation of nutrition is required among critically ill patients hospitalized in the ICU. Enteral nutrition (EN) is the preferred route when the gut is presumed to be functioning but EN is associated with a risk of digestive intolerance which occurs in one half of the patients and which is associated with a poor prognosis. Evaluation of the small bowel function of critically ill patients hospitalized in the ICU is difficult. Plasma citrulline is a marker of functional enterocyte mass and plasma I-FABP is a marker of enterocyte damage. Plasma citrulline concentration is a validated biomarker of enterocyte mass among patients presenting with short bowel syndrome or with villous atrophy-associated diseases. I-FABP appears to be a promising biomarker of acute mesenteric ischemia. There is evidence that both biomarkers could be of interest among critically ill patients for the identification of small bowel damage or dysfunction. There is a two-way connection between enterocyte biomarkers and the route of nutrition. On the one hand, in the context of short bowel syndrome, plasma citrulline concentration appears to be a promising indicator for the evaluation of the tolerance of the enteral route and the possibility to wean parenteral nutrition. On the other hand, among critically ill patients, there is evidence that the route of nutrition modify the evolution of enterocyte biomarkers. Globally, it seems that, comparatively to PN, EN is associated with a more rapid increase of plasma citrulline concentration. This raises the question of a possible beneficial effect of EN over PN on the trophicity of the small bowel mucosa.     

Establishing Early Enteral Nutrition With the Use of Self‐Advancing Postpyloric Feeding Tube in Critically Ill Children

Introduction: Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%?80%. The authors report on their experience with a 14Fr polyurethane self‐advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors’ knowledge, there have been no reports of its use in the pediatric age group. Case Series: The authors present 7 critically ill patients 8–19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. Conclusion: The self‐advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.     

Percutaneous Endoscopic Gastrostomy in the Open Abdomen Patient

Nutrition support of critically ill patients is an integral element to their multimodal care. We describe the placement of a percutaneous endoscopic gastrostomy (PEG) for long‐term enteral access in a patient with an open abdomen. To our knowledge, this is the third successfully reported case that demonstrates the viability of PEG in this uncommon population. In critically ill and malnourished surgical patients with contraindications for immediate abdominal closure, PEG should be strongly considered as a procedure for enteral feedings.     

危重病人早期肠内营养的临床应用分析

目的:分析早期肠内营养在危重病人中的临床应用状况. 方法:回顾3年半中住ICU>10天的278例病人资料,分析各类病种及各种途径早期肠内营养的实施情况,观察开始时间、达到营养目标点时间、并发症等. 结果:87.1%的危重病人可早期给予肠内营养,早期肠内营养开始时间、达到营养目标点时间与营养途径有关. 结论:早期肠内营养在危重病人中可以实施,并可能有助于降低病死率.     

Meta-analyses: what they can and cannot tell us about clinical research

PURPOSE OF REVIEW: The number of published clinical trials has increased exponentially over the past few decades. The majority of clinical research questions has been addressed by several small or moderately sized trials. Statisticians have developed guidelines for meta-analyses, which provide objective quantitative reviews to lighten the burden of clinicians who seek to keep themselves current in one or more areas of clinical investigation. The purpose of this review is to illustrate how to read critically a meta-analysis of nutrition support in critically ill patients. RECENT FINDINGS: Summary evidence based on a meta-analysis is observational, even though the individual elements of the meta-analysis are clinical trials. The level of evidence from a meta-analysis is thus similar to that derived from a case series or a cohort, with the stipulation that the 'subjects' are clinical trials instead of individuals. The effects of the combination of parenteral and enteral nutrition on mortality and infection rates in critically ill patients have been compared with enteral nutrition alone. Meta-analysis results show non-significant reductions in mortality and infectious complications favoring enteral nutrition. In patients with acute pancreatitis, the summary effects of parenteral versus enteral nutrition on the infection rate indicate a significant reduction in risk favoring enteral nutrition. SUMMARY: An interpretation of meta-analysis summary results is put in perspective with underlying medical assumptions. This critical review indicates what issues a meta-analysis can and cannot address.     

Enteral feeding

In this review, topics with scientific strength, topical interest, and controversy were selected. Over the past 50 years, malnutrition has become increasingly recognized as a cause of increased morbidity and mortality in hospital patients. From 1970 to 1980, parenteral nutrition was advocated as the most appropriate form of nutritional therapy for hospital patients. Since then, parenteral nutrition has been replaced by enteral nutrition as the best way of delivering nutrients to hospital patients. The timing of enteral nutrition has been debated. Should it be instituted early, within the first 24 hours? In addition, enteral nutrition containing immune-enhancing nutrients such as arginine, omega-3 fatty acids, glutamine, and nucleotides has been advocated for critically ill patients. The relative merits of enteral versus total parenteral nutrition continue to be debated. Questions about possible complications related to enteral nutrition have been raised. Patients are at risk of nosocomial pneumonia from aspiration and at risk of bowel ischemia because enteral nutrition increases intestinal oxygen consumption. Steroids are often used to treat Crohn disease, but because of undesirable side effects, various techniques have been used to reduce steroid dependency. Enteral nutrition has been advocated as a way of reducing steroid dependency. Finally, enteral nutrition is routinely used to feed demented patients and those in a vegetative state. It is not clear whether this practice alters outcome or quality of life.     

Placement of nasoenteral feeding tubes using external magnetic guidance

BACKGROUND: Enteral feeding is preferred over parenteral methods, and feeding into the duodenum is preferred over gastric feeding in certain groups of critically ill patients. However, with current techniques, feeding tubes often coil in the stomach, exposing patients to the risk of aspiration. This study investigated whether a nasoenteral feeding tube can be guided beyond the pyloric sphincter, using external magnetic guidance. METHODS: This is a case series of 288 critically ill patients who needed placement of an enteral feeding tube, carried out in the intensive care units and wards of a university-affiliated community hospital. A 12-French polyurethane nasoduodenal feeding tube was modified by placing a small magnet in the distal tip. After inserting the tube through the nares into the esophagus, an external magnet was used to draw the tube tip beyond the pyloric sphincter and further into the duodenum or jejunum. Placement was verified by plain abdominal x-ray, and the depth of insertion (stomach, proximal duodenum, distal duodenum, or jejunum) was recorded. RESULTS: Three hundred twenty-nine intubations were performed in 288 patients (mean procedure time 15 minutes). In 293 cases (89.1%), the tube was placed beyond the pyloric sphincter. In 139 insertions (42.2%), the tube tip was in the distal portion of the duodenum or the jejunum. There were no significant complications. CONCLUSIONS: This case series demonstrates that external magnetic guidance achieves transpyloric placement of an enteral feeding tube in 89.1% of cases. This reliable bedside technique is superior to other methods described in the literature.     

The patient with circulatory shock: to feed or not to feed?

Controversy continues to surround the appropriate form and timing of nutrition support for the patient with circulatory shock. Clinical studies have demonstrated improvements in outcome with the administration of enteral nutrition to critically ill patients; however, the provision of enteral nutrition to critically ill patients with ongoing shock remains controversial. This article reviews gut perfusion during normal states and during circulatory shock as well as alterations in perfusion when enteral feeding is provided. Pharmaconutrients studied during ischemia and reperfusion are discussed.