内镜下放置鼻空肠管在危重病人的应用

目的:总结危重病人内镜辅助下床边放置鼻空肠管的经验,探讨内镜置管的具体方法及其在危重病人中的应用.方法:1997年1月至2005年1月间共107例重症病人接受内镜辅助下放置鼻空肠管,观察置管的时间、成功率、并发症及留置时间.结果:置管时间为(12.3±7.8)min,成功率为98.1%,未发生置管相关并发症,置管后并发症发生率为2.8%(3/107).导管留置时间为(20.7±8.4)d.结论:内镜辅助放置鼻空肠管具有简单、快捷、安全,易于护理、病人痛苦小和易于耐受等优点,尤其适于危重病人使用.     

Hypocaloric enteral tube feeding in critically ill obese patients

OBJECTIVE: We respectively compared the nutritional and clinical efficacies of eucaloric and hypocaloric enteral feedings in 40 critically ill, obese patients admitted to the trauma or surgical intensive care unit. METHODS: Adult patients, 18 to 69 years old, with weights greater than 125% of ideal body weight, normal renal and hepatic functions, and who received at least 7 d of enteral tube feeding were studied. Patients were stratified according to feeding group: eucaloric feeding (>or=20 kcal/kg of adjusted weight per day; n = 12) or hypocaloric feeding (<20 kcal/kg of adjusted weight per day; n = 28). The goal protein intake for both groups was approximately 2 g/kg of ideal body weight per day. Clinical events and nutrition data were recorded for 4 wk. RESULTS: Patients were similar according to sex, age, weight, body mass index, Second Acute Physiology and Chronic Health Evaluation score, Trauma score, and Injury Severity Score. The hypocaloric feeding group received significantly fewer calories than the eucaloric group (P相似文献   

Hypocaloric feeding of the critically ill.

During critical illness, the stress response causes accelerated gluconeogenesis and lipolysis, leading to hyperglycemia and elevated serum triglyceride levels. The traditional nutrition support strategy of meeting or exceeding calorie requirements may compound the metabolic alterations of the stress response. Hypocaloric nutrition support has the potential to provide nutrition support without exacerbating the stress response. Studies have shown hypocaloric nutrition support to be safe and to achieve nitrogen balance comparable with traditional regimens. Benefits shown include improved glycemic control, decreased intensive care unit (ICU) length of stay (LOS), and decreased ventilator days and infection rate; however, not all studies have produced identical results. Providing adequate dietary protein has emerged as an important factor in efficacy of the hypocaloric regimen. Although it is inconclusive, currently available research suggests that a nutrition support goal of 10-20 kcal/kg of ideal or adjusted weight and 1.5-2 g/kg ideal weight of protein may be beneficial during the acute stress response. Well-designed, randomized, controlled studies with adequate sample size that evaluate relevant clinical outcomes such as mortality, ICU LOS, and infection while controlling for factors such as glycemic control, severity of illness, incorporation of calories from all sources, in addition to feeding regimens, are needed to definitively determine the effects of hypocaloric nutrition support.     

Comparison of formulaic equations to determine energy expenditure in the critically ill patient

OBJECTIVE: Inappropriate energy intake can negatively affect patient outcome during critical illness. Measuring energy expenditure via indirect calorimetry (IC) is the most accurate method of determining needs. Often predictive equations are used because IC is not available at all institutions or for all populations. METHODS: This study compared 24-h IC measures with five previously published formulaic equations and nomograms using kilocalorie per kilogram of body weight to determine their accuracy in predicting energy needs in critically ill adults receiving nutrition support. Two different weight categories were analyzed: body mass indexes below 25 kg/m(2) and below 30 kg/m(2). RESULTS: The Harris-Benedict equation using adjusted body weight multiplied by a stress factor of 1.6 and the Swinamer equation predicted measured energy expenditure (MEE) within 20% of IC values 80% of the time for the entire population studied. For those individuals at the lower weight range, the Harris-Benedict equation using actual weight reference weight via the Hamwi equation and via adjusted weight times a stress factor of 1.6 and the Swinamer equation predicted MEE within 20% of IC values 89% of the time. The Frankenfield equation overestimated MEE; whereas the Penn State and Ireton-Jones equations underestimated energy needs in the population studied. CONCLUSIONS: Predictive equations such as the Harris-Benedict equation multiplied by a stress factor of 1.6 and the Swinamer equation may be accurate enough for short-term nutrition support of critically ill patients when IC is unavailable.     

Post‐pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian dietitians

Aim

To determine whether the placement of a post‐pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian.

Methods

This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post‐pyloric intubation by the dietitian. The 10 ‘learning’ attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine ‘consolidation’ attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X‐ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice.

Results

A total of 19 post‐pyloric tube placements were attempted in 18 patients (52 (23–70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9–27.1 minutes).

Conclusions

A dietitian can be trained to safely and successfully place PPFT in critically ill patients.     

Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location

Background: An electromagnetic tube placement device (ETPD) monitors tip position of feeding tubes (FT) during placement in the digestive tract. It helps to avoid airway misplacement and permits positioning into the small bowel (SB). This study compares the overall agreement between FT tip location as determined by an ETPD vs an abdominal radiograph of the kidneys, ureter, and bladder (KUB). Methods: Using an ETPD, A nurse placed postpyloric FTs in ICU patients. We included all patients in whom the ETPD was used for FT placement. Data were prospectively recorded for 255 days on the rate of successful postpyloric placement, ETPD estimated tip location, and KUB location. Results: 860 tubes were placed in 616 patients, 719 (83.6%) of which recorded for ETPD and KUB. According to the KUB, 81% of tubes were in the SB; however, ETPD suggested 89% were beyond the pylorus. There was moderate agreement beyond what could be attributed to chance between KUB and ETPD tip locations (475 [66.1%], κ score 0.62 [95% confidence interval 0.58–0.67]). More tubes by KUB were distal (134[18.6%]) vs proximal (110[15.3%]) to the suspected location by ETPD (P < .0001. Tubes in or distal to the second half of the duodenum, according to ETPD were rarely in the stomach (<1%). No tubes were proximal to the stomach or placed into the airway. Conclusions: The strong agreement between KUB and ETPD, when tubes were believed to be in the second part of the duodenum or beyond, suggests that KUB is necessary only when the FT tip is suspected to be in the proximal duodenum.     

A randomized controlled trial comparing three different techniques of nasojejunal feeding tube placement in critically ill children

BACKGROUND: The goal of this study was to compare 3 different techniques used to place nasojejunal (NJ) feeding tubes in the critically ill or injured pediatric patients. This was a randomized, prospective trial in a university-affiliated 12-bed pediatric intensive care unit. Patients were critically ill children requiring placement of an NJ feeding tube. Patient age, weight, medications, use of mechanical ventilation, and patient tolerance were recorded. An abdominal radiograph obtained immediately after the placement determined correct placement. The final placement was recorded, as was the number of placement attempts. METHODS: Patients were randomized to 1 of 3 groups: standard technique, standard technique facilitated with gastric insufflation, and standard technique facilitated with the use of preinsertion erythromycin. To ensure equal distribution, all patients were stratified by weight (<10 kg vs > or =10 kg) before randomization. All NJ tubes were placed by one of the investigators. If unsuccessful, a second attempt by the same investigator was allowed. Successful placement of the NJ tube was defined by confirmation of the tip of the tube in the first part of the duodenum or beyond by a pediatric radiologist blinded to the treatment groups. RESULTS: Seventy-five pediatric patients were enrolled in the study; 94.6% (71/75) of tubes were passed successfully into the small bowel on the first or second attempt. Evaluation of the data revealed no significant association with a specific technique and successful placement (p = .1999). CONCLUSIONS: When placed by a core group of experienced operators, the majority of NJ feeding tubes can be placed in critically ill or injured children on the first or second attempt, regardless of the technique used.     

床旁空肠营养管徒手置入技术在危重症病人营养治疗中的应用研究

目的:探讨床旁空肠营养管徒手置入技术在危重症病人肠内营养(EN)治疗中的安全性、有效性和实用性. 方法:鼻空肠管组病人采用美国CORPAK公司CORFLO导管置入行鼻空肠营养29例.鼻胃管组采用普通胃管置入行EN支持30例.观察鼻空肠管组置管成功率,置管时间和不良反应.对比观察两组病人血清清蛋白(ALB)、前清蛋白(PA)、血红蛋白(Hb)、APACHEⅡ评分、入住ICU时间、置管费用和ICU总费用等指标的变化,以及反流、腹胀、腹泻、应激性溃疡和吸入性肺炎等并发症的发生率. 结果:床旁经鼻空肠营养管徒手置入成功率为93.1％,置管时间为(19.3-6.8) min,无不良反应.鼻空肠管组病人营养指标和APACHEⅡ评分改善明显,且入住ICU时间、ICU总费用和并发症的发生率均低于对照组. 结论:床旁空肠营养管徒手置入技术在危重症病人EN支持治疗中,具有操作简单、安全、置管成功率高、并发症低、病人营养状况改善明显的优点.     

Percutaneous radiologic gastrostomy versus nasogastric tube in critically ill patients

AIMS: To examine the feasibility of percutaneous radiologic gastrostomy in critically ill patients and to assess the rates of complications, esophagitis and gastroesophageal reflux when compared with nasogastric tube. METHOD: Sixty patients admitted to a medical intensive care unit and who were supposed to require gastric tubing for at least 14 days were randomized to have a nasogastric tube or a percutaneous radiologic gastrostomy. Patients with gastrostomy contraindication or gastric tubing for more than 2 days were excluded. RESULTS: No major complication requiring invasive treatment was observed. The nasogastric tube was more prone to failure as defined by the impossibility to place or to replace the allocated tube (P = 0.04) and to tube dysfunction (P<0.001), whereas gastrostomy was associated with increased incidence of minor local complications (P<0.001). Ten days after allocation, the rates of esophagitis (15%) and gastroesophageal reflux (24%) were not significantly different between the two groups. CONCLUSION: In selected critically ill patients, percutaneous radiologic gastrostomy carried a low risk of severe complication but we found no benefit in terms of esophagitis and gastroesphageal reflux between early performed gastrostomy and the nasogastric tube.     

血清降钙素原在危重患者感染诊断中的应用

目的 探讨血清降钙素原(PCT)对危重患者细菌感染的临床意义,分析PCT对患者预后评估价值.方法 选取ICU中69例细菌感染患者,将其分为一般感染组37例、重症感染组32例,并以30例非感染者作为非感染组,应用电化学发光法测定其血清PCT,荧光流式细胞计数法测定外周血白细胞(WBC)计数和透射比浊法测定C反应蛋白(CRP)水平,结果作统计分析.结果 一般感染组PCT、CRP、WBC阳性率分别为89.1％、91.9％、75.7％,明显低于重症感染组的96.9％、100.0％、87.5％(P＜0.05);一般感染组、重症感染组分别与非感染组比较PCT浓度有显著增高(P＜0.05),一般感染组和重症感染组患者的血清PCT水平均显著高于非感染组患者(P＜0.05);重症感染组患者的血清PCT水平显著高于一般感染组患者(P＜0.05);CRP、WBC在重症感染组与一般感染症组之间比较差异均无统计学意义,当感染得到控制后PCT浓度也随之下降.结论 血清PCT检测作为全身细菌感染早期诊断指标,在危重患者细菌感染诊断和预后临床治疗中具有较高的特异性和敏感性.     

Metabolic effects of arginine addition to the enteral feeding of critically ill patients.

BACKGROUND: Some studies have suggested that the addition of arginine to enteral feeding solutions may improve outcome in critically ill patients, but the mechanism is incompletely explained. In particular, the availability and utilization of arginine administered enterally is not well defined. METHODS: This prospective, randomized, double-blind, placebo-controlled study performed in a Department of Medicosurgical Intensive Care included 51 patients likely requiring long-term enteral feeding. Thirty-seven patients (57 +/- 7 years, SAPS II 33 +/- 6) completed the 7-day study, of whom 20 received the formula enriched with free arginine (6.3 g/L) and 17 received an isocaloric and isonitrogenous control solution. Arginine absorption was assessed from plasma arginine concentrations in serial samples. Three pathways of arginine utilization were explored: (1) the production of nitric oxide, assessed by the plasma concentration of nitrite/nitrate (NOx) and citrulline, and 24-hour urinary excretion of NOx; (2) the protein turnover, estimated by the phenylalanine concentrations; and (3) the activity of arginase, reflected by the ornithine concentration. RESULTS: The plasma concentrations of arginine and ornithine increased in the group fed with the enriched formula (from 55 +/- 9 micromol/L to 102 +/- 9 micromol/L and from 57 +/- 7 to 135 +/- 11 micromol/L, respectively, p < .05), but not with the control formula. There was no difference between groups in either NO production or phenylalanine concentration. CONCLUSIONS: Supplemental arginine in enteral feeding is readily absorbed, and mainly metabolized into ornithine, presumably by the arginase enzyme.     

Adequate feeding and the usefulness of the respiratory quotient in critically ill children

OBJECTIVE: We determined incidences of underfeeding and overfeeding in children who were admitted to a multidisciplinary tertiary pediatric intensive care and evaluated the usefulness of the respiratory quotient (RQ) obtained from indirect calorimetry to assess feeding adequacy. METHODS: Children 18 y and younger who fulfilled the criteria for indirect calorimetry entered our prospective, observational study and were studied until day 14. Actual energy intake was recorded, compared with required energy intake (measured energy expenditure plus 10%), and classified as underfeeding (<90% of required), adequate feeding (90% to 110% of required), or overfeeding (>110% of required). We also evaluated the adequacy of a measured RQ lower than 0.85 to identify underfeeding, and an RQ higher than 1.0 to identify overfeeding. RESULTS: Ninety-eight children underwent 195 calorimetric measurements. Underfeeding, adequate feeding, and overfeeding occurred on 21%, 10%, and 69% of days, respectively. An RQ lower than 0.85 to identify underfeeding showed low sensitivity (63%), high specificity (89%), and high negative predictive value (90%). An RQ higher than 1.0 to indicate overfeeding showed poor sensitivity (21%), but a high specificity (97%) and a high positive predictive value (93%). Food composition, notably high-carbohydrate intake, was responsible for an RQ exceeding 1.0 in the overfed group. CONCLUSION: Children admitted to the intensive care unit receive adequate feeding on only 10% of measurement days during the first 2 wk of admission. The usefulness of RQ to monitor feeding adequacy is limited to identifying (carbohydrate) overfeeding and excluding underfeeding.     

Gastrointestinal hormone concentrations associated with gastric feeding in critically ill patients

Background: Altered concentrations of ghrelin, motilin, and cholecystokinin (CCK) may contribute to gastric hypomotility. The aims of this study were to evaluate the concentrations of these hormones in patients tolerant and intolerant to gastric nutrition, assess the influence of prokinetic therapy on these hormone concentrations, determine the associations between these mediators and gastric emptying, and evaluate whether inflammation influences their concentrations. Methods: Post hoc analyses of 2 prospective studies that enrolled 20 critically ill patients with an aspirated gastric residual (GR) >150 mL while receiving gastric enteral nutrition (intolerant group) and 10 critically ill patients with minimal GR (tolerant group). Patients with intolerance were also assessed 1 day after prokinetic therapy. Fasting serum concentrations of total ghrelin, acyl ghrelin (active), des‐acyl ghrelin (inactive), motilin, CCK, and tumor necrosis factor (TNF)?α were determined. Gastric emptying was assessed concurrently using the acetaminophen absorption method. Results: Compared to the tolerant group, the intolerant group had higher total ghrelin (1324.8 ± 1204.6 vs 285.1 ± 132.5 pg/mL; P < .001), lower acyl ghrelin (70.5 ± 65.4 vs 208.5 ± 186.9 pg/mL; P < .05), and lower acyl ghrelin to des‐acyl ghrelin ratio (1.11 ± 1.35 vs 3.47 ± 3.21 pg/mL; P < .05). Concentrations of other hormones and TNF‐α were similar. Despite accelerated gastric emptying after prokinetic therapy, concentrations of all hormones and TNF‐α were similar to baseline values. Hormone concentrations were not associated with gastric emptying or TNF‐α. Conclusion: Patients intolerant to gastric nutrition generate less acyl ghrelin, which may contribute to gastric hypomotility. Intolerance is not associated with altered concentrations of other hormones. Hormone concentrations are not influenced by prokinetic therapy.     

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     

Tube feeding in mechanically ventilated critically ill patients: a prospective clinical audit.

BACKGROUND: When and whether early enteral nutrition (EN) benefits critically ill patients is debatable. This prospective clinical audit aimed to evaluate the feasibility of an early EN protocol and to identify factors that may hinder EN delivery in critically ill patients. METHODS: Thirty-six medical patients with severe respiratory failure under invasive ventilation and scheduled to receive early EN, with a length of ICU stay >72 hours, were included. As asserted by the Society of Critical Care Medicine, 8% of patients were priority 1, 72% priority 2, and 20% priority 3 for intensive therapeutic and vital support interventions. RESULTS: Overall, because of gastrointestinal complications, only 39% of the prescribed EN was administered; only 8 (22%) patients did tolerate EN within the first 48 hours after admission and did achieve their minimum nutritional requirements. The most frequent complication (78%) was high volume of gastric residuals followed by abdominal distention (61%), both associated with hemodynamic instability (HI). Gastrointestinal dysfunction was associated with high Acute Physiologic and Chronic Health Evaluation II score (p = .01), total calorie intake (p = .02), total carbohydrate intake (p = .02), HI (p = .03), malnutrition (p = .04), volume of IV saline (p = .04), and concurrent vasoactive drug administration (p = .05). CONCLUSIONS: This audit in extremely severe intensive care patients identified several factors that impair gastrointestinal function and preclude EN at any stage, namely early EN. Nutrition management must take into account concurrent therapies, given their potential interference with nutrition and organ function.