Helicobacter pylori infection: a risk factor for upper gastrointestinal bleeding after cardiac surgery?

OBJECTIVE: To determine the prevalence of Helicobacter pylori (H. pylori) in critically ill patients who develop upper gastrointestinal bleeding after cardiac surgery in relation to other risk factors. DESIGN: Prospective, single center, cohort study. SETTING: Surgical intensive care unit in a university hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over a 1-yr period, all consecutive patients with upper gastrointestinal hemorrhage from the stomach or duodenum were studied for H. pylori infection by serology. Additionally, the need for mechanical ventilation over 48 hrs, the duration cardiopulmonary bypass, and the aortic cross-clamp time were analyzed. For control, 229 patients with no evidence of gastrointestinal hemorrhage after cardiac surgery were studied. All patients received stress ulcer prophylaxis with ranitidine. Operations were performed on 2,956 patients during the study period. The incidence of upper gastrointestinal bleeding was 0.9%. Twenty (77%) of the 26 patients with upper gastrointestinal bleeding and 145 (63%) patients of the control group had serologic evidence for H. pylori infection (odds ratio, 1.9; 95% confidence interval 0.7-5.0; p = .2). Patients who required prolonged mechanical ventilation had a significantly greater risk for upper gastrointestinal bleeding (odds ratio, 22.1; 95% confidence interval 8.6-56.7; p<.001). Patients with upper gastrointestinal bleeding also had a significantly longer duration of cardiopulmonary bypass and aortic cross-clamp time (p<.001) CONCLUSIONS: H. pylori is not associated with upper gastrointestinal bleeding in critically ill patients who receive stress ulcer prophylaxis, whereas patients who require prolonged mechanical ventilation are at high risk. A prophylactic eradication of H. pylori is not justified.     

危重病患者早期肠内营养应激性溃疡的预防及护理

目的 :验证早期肠内营养对重症患者应激性溃疡的预防作用 ,并总结临床护理经验。方法 :随机将入院ICU的危重患者 77例分成早期肠内营养组 (4 2例 )和延迟肠内营养组 (35例 ) ,分别监测每例患者不同时间段的胃液及粪便的隐血情况 ,并对监测结果进行统计学处理。结果 :早期肠内营养组与延迟肠内营养组上消化道出血发生分别为 4 / 4 2和 15 / 35 (P <0 0 0 1)。结论 :早期肠内营养对危重患者应激性溃疡的发生有一定的预防作用。     

危重病患者早期肠内营养预防应激性溃疡的观察及护理

目的 :验证早期肠内营养对重症患者应激性溃疡的预防作用 ,并对这类患者的护理注意事项进行探讨。方法 :对 77例进ICU的危重患者随机分成早期肠内营养组 (42例 )和延迟肠内营养组 (35例 ) ,分别对每例患者的胃液及粪便进行不同时间段的隐血情况监测 ,并对监测结果进行统计学处理。结果 :早期肠内营养组与延迟肠内营养组上消化道出血发生分别为 4 / 4 2和 15 / 35例 (P <0 .0 0 1)。结论 :早期肠内营养对危重患者应激性溃疡的发生有一定的预防作用。     

Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients

The incidence of upper gastrointestinal (GI) bleeding in mechanically ventilated ICU patients receiving enteral alimentation was reviewed and compared to bleeding occurring in ventilated patients receiving prophylactic antacids or cimetidine. Of 250 patients admitted to our ICU during a 1-yr time period, 43 ventilated patients were studied. Patients in each group were comparable with respect to age, respiratory diagnosis, number of GI hemorrhage risk factors, and number of ventilator, ICU, and hospital days. Twenty-one patients had evidence of GI bleeding. Fourteen of 20 patients receiving antacids and 7 of 9 patients receiving cimetidine had evidence of GI bleeding. No bleeding occurred in 14 patients receiving enteral alimentation. Complications of enteral alimentation were few and none required discontinuation of enteral alimentation. Our preliminary data suggest the role of enteral alimentation in critically ill patients may include not only protection against malnutrition but also protection against GI bleeding.     

Histamine 2 receptor antagonists vs intravenous proton pump inhibitors in a pediatric intensive care unit: a comparison of gastric pH

Purpose

The aim of this study was to assess gastric pH in critically ill pediatric patients receiving intravenous stress ulcer medication.

Materials and Methods

A prospective study was done in 48 patients with a gastric tube in place who were receiving either ranitidine or a proton pump inhibitor and no enteral nutrition. Daily peak and trough gastric pHs were measured.

Results

The median age was 7 years 5 months (range, 1 month to 19 years), the median weight was 31 kg (range, 3-130 kg), and the median pediatric risk of mortality 2 (PRISM2) score was 12.5 (range, 0-31). All patients were intubated and 8 received dialysis. The average trough pH was 4.4 ± 1.6 in the ranitidine group, 4.9 ± 1.8 in the once daily proton pump inhibitor group, and 5.0 ± 1.2 in the twice daily proton pump inhibitor group (P = .16). The average peak pH was 5.3 ± 1.8 in the ranitidine group, 5.9 ± 1.6 in the once daily proton pump inhibitor group, and 6.0 ± 1.0 in the twice daily proton pump inhibitor group (P = .06). Three (10%) of 28 trough pH measurements in the twice daily proton pump inhibitor group were more acidic than 4 vs 24 (40%) of 60 in the ranitidine group, and 22 (40%) of 56 in the once daily proton pump inhibitor group (P = .02). One (4%) of 27 peak pH measurements in the twice daily proton pump inhibitor group were more acidic than 4 vs 13 (20%) of 61 in the ranitidine group, and 9 (16%) of 56 in the once daily proton pump inhibitor group (P = .12). Three patients (6%; 95% confidence interval, 0.51%-16%) developed upper gastrointestinal bleeding, and 4 patients (8%; 95% confidence interval, 0%-13%) developed ventilator-acquired pneumonia.

Conclusions

Many critically ill pediatric patients receiving stress ulcer prophylaxis have a trough or peak gastric pH more acidic than 4.     

Incidence and risk factors of gastrointestinal bleeding in mechanically ventilated patients

BACKGROUND:

The widespread use of gastrointestinal bleeding prophylaxis in critically ill patients was one of the most controversial issues. Since few studies reported the incidence of gastrointestinal bleeding in mechanically ventilated patients, this study aimed to identify the incidence and risk factors related to gastrointestinal bleeding in patients undergoing mechanical ventilation for more than 48 hours.

METHODS:

A total of 283 ICU patients who had received mechanical ventilation for longer than 48 hours at a provincial hospital affiliated to Shandong University from January 1, 2007 to December 31, 2009 were analyzed retrospectively. Those were excluded from the study if they had a history of gastrointestinal bleeding or ulceration, recent gastrointestinal surgery, brain death and active bleeding from the nose or throat. Demographic data of the patients included patient age, diagnosis on admission, duration of ICU stay, duration of ventilation, patterns and parameters of ventilation, ICU mortality, APACHE II score, multiple organ dysfunction, and indexes of biochemistry, kidney function, liver function and coagulation function. Risk factors of gastrointestinal bleeding were analyzed by univariate analysis and multiple logistic regression analysis.

RESULTS:

In the 242 patients who were given mechanical ventilation longer than 48 hours, the incidence of gastrointestinal bleeding was 46.7%. The bleeding in 3.3% of the patients was clinically significant. Significant risk factors were peak inspiratory pressure ≥30cmH₂O, renal failure, liver failure, PLT count<50×10⁹/L and prolonged APTT. Enteral nutrition had a beneficial effect on gastrointestinal bleeding. However, the multiple logistic regression analysis revealed that the independent risk factors of gastrointestinal bleeding were as follows: high pressure ventilator setting ≥ 30cmH₂O(RR=3.478, 95%CI=2.208-10.733), renal failure(RR=1.687, 95%CI = 1.098-3.482), PLT count<50×1 0⁹/L (RR=3.762, 95%CI=2.346-14.685), and prolonged APTT(RR=5.368, 95%CI=2.487-11.266). Enteral nutrition(RR=0.436, 95%CI= 0.346-0.764) was the independent protective factor.

CONCLUSIONS:

The incidence of gastrointestinal bleeding was high in the patients who received mechanical ventilation, and bleeding usually occurred within the first 48 hours. High pressure ventilator setting, renal failure, decreased PLT count and prolonged APTT were the significant risk factors of gastrointestinal bleeding. However, enteral nutrition was the independent protective factor.KEY WORDS: Mechanical ventilation, Gastrointestinal bleeding, Risk factors     

Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis

Stress-related mucosal disease is a typical complication of critically ill patients in the intensive care unit (ICU). It poses a risk of clinically relevant upper gastrointestinal (GI) bleeding. Therefore, stress ulcer prophylaxis (SUP) is recommended in high-risk patients, especially those mechanically ventilated > 48 h and those with a manifest coagulopathy. Proton pump inhibitors (PPI) and, less effectively, histamine 2 receptor antagonists (H2RA) prevent GI bleeding in critically ill patients in the ICU. However, the routine use of pharmacological SUP does not reduce overall mortality in ICU patients. Moreover, recent studies revealed that SUP in the ICU might be associated with potential harm such as an increased risk of infectious complications, especially nosocomial pneumonia and Clostridium difficile-associated diarrhea. Additionally, special populations such as patients with liver cirrhosis may even have an increased mortality rate if treated with PPI. Likewise, PPI can be toxic for both the liver and the bone marrow, and some PPI show clinically relevant interactions with important other drugs like clopidogrel. Therefore, the agent of choice, the specific balance of risks and benefits for individual patients as well as the possible dose of PPI has to be chosen carefully. Alternatives to PPI prophylaxis include H2RA and/or sucralfate. Instead of routine SUP, further trials should investigate risk-adjusted algorithms, balancing benefits and threats of SUP medication in the ICU.     

机械通气患者消化道出血的高危因素分析

目的 具有保护作用.Logistic多元回归分析表明气道峰压≥30 cmH2O(RR=3.73,95%CI=1.59～9.46)、肾功能衰竭(RR=1.16,95%CI=1.02～2.32)、血小板计数<50×109L-1(RR=2.67,95%CI=1.32～15.78)、APTT延长(RR=4.58,95%CI=2.32～12.96)是机械通气患者发生消化道出血的独立危险因素,而肠内营养(RR=0.30,95%CI=0.13～0.67)则是独立保护因素.结论 持续机械通气超过48 h的ICU患者消化道出血发生率较高,且大多发生于接受机械通气最初48 h内;高气道峰压,肾功能衰竭,血小板计数<50×109L-1和APTT延长是机械通气患者发生消化道出血的独立危险因素,肠内营养则是独立保护因素.     

Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients

OBJECTIVE: To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults. DATA SOURCES: Computerized biomedical literature search of MEDLINE (1966-June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts. DATA SYNTHESIS: Traditional medications used for stress ulcer prophylaxis include antacids, histamine(2) receptor antagonists (H(2)RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH > or =4.0. PPIs are safe and seem to be as efficacious as H(2)RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies. CONCLUSIONS: Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H(2)RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.     

Impaired gastrointestinal transit and its associated morbidity in the intensive care unit

Purpose

To determine the proportion of critically ill adults developing impaired gastrointestinal transit (IGT) using a clinically pragmatic definition, its associated morbidity and risk factors.

Materials and Methods

Critically ill adult patients receiving enteral nutrition for ≥ 72 hours and mechanically ventilated for ≥ 48 hours were prospectively identified. IGT was defined as absence of a bowel movement for ≥ 3 days, treatment for constipation, and one of the following: (1) radiologic confirmed ileus, (2) feed intolerance, (3) abdominal distention, or (4) gastric decompression.

Results

One thousand patients were screened, and 248 were included for analysis. Fifty patients (20.1%; 95% confidence interval, 15.1-25.6%) developed IGT persisting for 6.5 ± 2.5 days. Patients with IGT had longer lengths of intensive care unit stay and were less likely to reach nutrition targets compared to patients without IGT or traditional definitions of constipation. Daily opioid use and pharmacological constipation prophylaxis were identified risk factors for IGT.

Conclusion

Traditional definitions of constipation or ileus in intensive care unit patients are simplistic and lack clinical relevance. Pragmatically defined IGT is a common complication of critical illness and is associated with significant morbidity. Future interventional studies for IGT in critically ill adults should use a more clinically relevant definition and evaluate energy deficits and lengths of stay as clinically relevant outcomes.     

Gastrointestinal failure score in critically ill patients: a prospective observational study

Introduction

There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality. The prognostic value of the GIF score alone and in combination with the Sequential Organ Failure Assessment (SOFA) score is evaluated, and the incidence and outcome of gastrointestinal failure is described relative to the GIF score.

Methods

A total of 264 subsequently hospitalized patients, who were mechanically ventilated on admission and stayed in the intensive care unit (ICU) for longer than 24 hours, were prospectively studied. GIF score was documented daily as follows: 0 = normal gastrointestinal function; 1 = enteral feeding with under 50% of calculated needs or no feeding 3 days after abdominal surgery; 2 = FI or IAH; 3 = FI and IAH; and 4 = abdominal compartment syndrome (ACS). Admission parameters and mean GIF and SOFA scores for the first 3 days were used to predict ICU outcome.

Results

FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factor for mortality (odds ratio = 3.02, 95% confidence interval = 1.63 to 5.59; P < 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P < 0.001). The development of gastrointestinal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality.

Conclusion

The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development of gastrointestinal failure is associated with significantly impaired outcome.     

Frequency and prophylaxis of upper gastrointestinal hemorrhage in critically ill children: a prospective study comparing the efficacy of almagate, ranitidine, and sucralfate. The Gastrointestinal Hemorrhage Study Group.

OBJECTIVE: To determine the occurrence of upper gastrointestinal hemorrhage in critically ill children, and the efficacy of prophylaxis with almagate (antacid), ranitidine, and sucralfate. DESIGN: Prospective, randomized, controlled trial. SETTING: Pediatric ICU of a tertiary care pediatric hospital. PATIENTS: During a 2-yr study period, 165 patients with one or more upper gastrointestinal hemorrhage risk factors were randomized into one of four groups. Twenty-five patients were excluded because of protocol violations. A total of 140 patients completed the study, with 35 patients in each group. INTERVENTIONS: Patients received no treatment in the control group. The antacid group received almagate 0.25 to 0.5 mL/kg every 2 hrs by nasogastric tube. The ranitidine group received 1.5 mg/kg every 6 hrs iv. The sucralfate group received 0.5 to 1 g every 6 hrs by nasogastric tube. METHODS: Gastric pH and macroscopic bleeding were determined every 2 hrs in all patients until the end of the study. Macroscopic bleeding was classified as nonhemorrhage, slight, or important. Microscopic gastric bleeding was researched with guaiac testing in 72 patients (680 samples). The severity of illness was evaluated by using the Therapeutic Intervention Scoring System, Physiologic Stability Index, and the Multiorgan System Failure scores. The risk of upper gastrointestinal hemorrhage was evaluated by the Zinner and Tryba indices, and was modified for children. MEASUREMENTS AND MAIN RESULTS: The occurrence rate of important upper gastrointestinal hemorrhage was higher (by 20%) in the control group than in the rest of the groups (5.7%), p less than .01. There were no differences between the other groups (almagate 5.7%, ranitidine 8.5%, and sucralfate 2.8%). There was a statistically significant correlation between the occurrence rate of important upper gastrointestinal hemorrhage, the scores of severity of illness indices (Therapeutic Intervention Scoring System, Physiologic Stability Index, and the Multiorgan System Failure scoring system), the risk of upper gastrointestinal hemorrhage indices (Zinner and Tryba), and mortality rate. The Zinner index better classified the patients in relation to the onset of important upper gastrointestinal hemorrhage (sensitivity 76.9%, specificity 85.8%). CONCLUSIONS: Upper gastrointestinal hemorrhage is an important complication in critically ill children. Prophylaxis with almagate, ranitidine, or sucralfate reduces the occurrence rate of clinically important gastrointestinal hemorrhage.     

The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients

Objective  

To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients.     

Low seroprevalence of Helicobacter pylori infection in patients with stress ulcer bleeding

OBJECTIVE: The pathogenesis of stress ulceration in seriously ill patients is uncertain and the pathogenic role of Helicobacter pylori infection is unknown. We therefore assessed the seroprevalence of patients of a cardiosurgical intensive care unit (ICU) with clinically important stress ulcer bleeding. We compared this prevalence with a control group matched for this kind of surgical intervention, missing history of peptic ulcer disease, age and gender. DESIGN: Prospective survey. SETTING: Cardiosurgical ICU in a university teaching hospital. Patients and participants: Two thousand five hundred seventy cardiosurgical patients with intravenous ranitidine stress ulcer prophylaxis were screened for clinically important stress ulcer bleeding. Helicobacter pylori seropositivity was measured in all patients with a clinically important bleeding and in a control group of 245 consecutive cardiosurgical patients, matched for the kind of cardiosurgical intervention, age and gender. RESULTS: In 56 of 2,570 (2.1%) patients signs of clinically important bleeding were seen. Endoscopical examination revealed stress ulcer bleeding in 42 cases. The incidence of stress ulcer bleeding was 1.6%. The seropositivity of the group with ulcer bleeding was 45.2 % whereas 62.4 % of the patients in the control group were Helicobacter pylori positive (p = 0.08). CONCLUSIONS: Our results suggest that the Helicobacter pylori infection does not play a pathogenic role in stress ulcer bleeding. Prophylactic cure of Helicobacter pylori can not be recommended in this setting.     

Prospective endoscopic study of stress erosions and ulcers in critically ill neurosurgical patients: current incidence and effect of acid-reducing prophylaxis

We studied prospectively 40 critically ill neurosurgical patients who required prolonged mechanical ventilation to determine the current incidence of stress-related gastroduodenal erosions and ulcers, and to assess endoscopically the efficacy of acid-reducing prophylactic treatment. Nineteen patients were randomized to receive ranitidine plus antacids if necessary to maintain gastric pH at greater than or equal to 4. The remaining 21 patients were given no drug prophylaxis. Gastric pH was significantly (p less than .001) higher in the treated group: 78% of pH readings were at greater than or equal to 4 as compared to 32% in the control group. However, after five study days, incidence and severity of stress lesions were similar in the two groups: nine patients in each group had more than five erosions, one treated patient had a gastric ulcer, and one control patient had duodenal ulcerations. No patient experienced clinically relevant upper GI bleeding. The lack of severe stress bleeding and the low ulcer rate contrast with results from earlier reports on similar patient populations. Furthermore, drug prophylaxis had no detectable benefit, as assessed endoscopically. These findings suggest that routine stress lesion prophylaxis may not be necessary in critically ill patients with comparable risk factors.     

胃残留量监测对重症患者肠内营养并发症的效果观察

目的 比较采用持续经泵滴注进行肠内营养(Enteral Nutrition,EN)的机械通气病人.是否监测胃残留量,观察其胃肠道并发症的发生情况.方法 选择ICU内接受机械通气、需肠内营养支持的危重患者90例,随机分成观察组48例、对照组42例.对照组采用传统持续经泵滴注方法;观察组采用2006年危重患者营养支持指导意见(草案)提出的持续经泵滴注方法,观察患者鼻饲期间有无胃肠道并发症发生.结果 观察组胃肠道并发症的发生率明显少于对照组.结论 2006年危重患者营养支持指导意见(草案)提出的EN方法,是适合危重症监护病房(ICU)危重病人肠内营养支持的最佳方法,值得在临床上推广使用.     

危重症患者应激性溃疡发生的危险因素分析

目的：分析危重症患者发生应激性溃疡的危险因素,为危重症患者应激性溃疡的合理预防提供理论依据。方法：回顾性分析2011-01-2013-12入住我院急诊重症监护病房患者的病例资料,以是否发生应激性溃疡将患者分为两组,以机械通气、凝血功能障碍、低血压、颅脑损伤、肝功能衰竭、肾功能衰竭、肠内营养、糖皮质激素的应用、创伤、饮酒史、消化道溃疡病史为变量,分析上述变量在两组患者中的差别,采用Logistic回归分析方法确定应激性溃疡发生的危险因素。结果：两组患者在机械通气、凝血功能障碍、低血压、颅脑损伤、肝功能衰竭和创伤方面存在差异（P〈0.05）,机械通气、凝血功能障碍、低血压和颅脑损伤是危重症患者应激性溃疡发生的危险因素。结论：当危重症患者并发存在机械通气、凝血功能障碍、低血压和颅脑损伤时应加强应激性溃疡的预防治疗。     

Ventilator-associated pneumonia and upper airway colonisation with Gram negative bacilli: the role of stress ulcer prophylaxis in children

OBJECTIVE: To assess the risk of ventilator-associated pneumonia (VAP) and the incidence of upper airway colonisation related to the use of stress ulcer prophylaxis in critically ill children. DESIGN: Retrospective study. SETTING: Paediatric intensive care unit (PICU) of a tertiary care centre. PATIENTS: All children who were mechanically ventilated for more than 48 h. INTERVENTIONS: None. RESULTS: A total of 54 patients were given ranitidine, 53 patients were given sucralfate and 48 patients were given no stress ulcer prophylaxis. Thirteen (8.4%) patients developed VAP: 6 (11.1%) patients in the ranitidine group, 4 (7.5%) in the sucralfate group and 3 (6.2%) in the group without prophylaxis. The rate of upper airway colonisation with Gram negative bacilli was 25.9% (14/54) in the ranitidine group, 22.6% (12/53) in the sucralfate group and 37.5% (18/48) in the group without prophylaxis. The differences among the groups were not significant. CONCLUSIONS: In contrast to findings in adults, we found that, in children, sucralfate does not decrease the incidence of VAP or the incidence of upper airway colonisation with Gram negative bacilli as compared to ranitidine or no stress ulcer prophylaxis. However, the small sample size and study design substantially limit our conclusions.     

胃肠电图评价ICU内肠内营养患者胃肠动力水平的临床价值

目的探讨胃肠电图对ICU肠内营养(EN)患者胃肠动力水平评价中的临床价值。方法对92例入住ICU进行肠内营养的危重病人及28例健康体检者进行胃肠电图、胃肠激素水平的检测,比较肠内营养前后的变化,并分析各参数与危重病评分(APACHEⅡ)、GCS评分、主要疾病诊断、机械通气、胃肠耐受情况的相互关系。结果观察组餐前和餐后胃肠电节律紊乱高于对照组(P<0.01),观察组餐前的正常慢波百分比低于对照组(P<0.01),观察组胆囊收缩素(CCK)和血管活性肠肽(VIP)水平高于对照组(P<0.05);APACHEⅡ<20分组(B组)的VIP水平显著低于APACHEⅡ≥20分组(A组)(P<0.05),两组的幅值、主频、胃肠电节律紊乱、正常慢波百分比、餐前/餐后功率比、胃动素(MTL)、CCK、EN耐受性无显著差异。结论胃肠电图中的胃肠电节律紊乱升高及餐前的正常慢波百分比降低与胃肠激素CCK、VIP提示的胃肠功能障碍是一致的,可以应用胃肠电图评估ICU患者肠内营养,指导肠内营养的个体化实施。     

Use of enteral nutrition for stress ulcer prophylaxis.

OBJECTIVE: To review the controversies involving the use of enteral nutrition support for stress ulcer prophylaxis and formulate recommendations. DATA SOURCES: A MEDLINE search (1966-December 2000) was conducted using the MeSH of nutrition, ulcer, critical care, and acid to identify relevant articles. References of selected articles were reviewed, and relevant abstracts from critical care or gastrointestinal journals identified. DATA EXTRACTION: Animal and human data from prospective studies, retrospective studies, and case series were evaluated for the effects of enteral nutrition on gastric pH, intramucosal pH, gastrointestinal blood flow, development of macroscopic mucosal erosions, and hemorrhage. DATA SYNTHESIS: Intragastric administration of enteral nutrition has variable effects on gastric pH, enhances regional distribution of gastrointestinal blood flow, and may lower intramucosal pH. All substrates (carbohydrate, lipid, amino acid), when administered into the stomach, reduce the occurrence of mucosal erosions but do not entirely prevent their development. Few studies of stress ulcer prophylaxis regimens have reported use of enteral nutrition. Limited retrospective data suggest enteral nutrition support may be effective for preventing gastrointestinal hemorrhage, but the results of prospective studies are confounded by poor study design. CONCLUSIONS: Definitive recommendations regarding the role of enteral nutrition for stress ulcer prophylaxis are not possible due to the lack of prospective, randomized studies. Therefore, the use of enteral nutrition as the only therapeutic agent for stress ulcer prophylaxis should be discouraged until definitive data are available. Initiation and discontinuation of pharmacologic stress ulcer prophylaxis should be independent of enteral nutrition.