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。     

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     

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。     

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。     

肠内营养不耐受的危险因素研究

介绍了肠内营养的两个常见不耐受情况腹泻、腹胀的危险因素,以及肠内营养的护理研究进展。     

肠内营养不耐受的危险因素研究

介绍了肠内营养的两个常见不耐受情况腹泻、腹胀的危险因素,以及肠内营养的护理研究进展。     

Ventilator-associated pneumonia in critically ill stroke patients: frequency, risk factors, and outcomes

Purpose

Our main objective was to assess incidence, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients.

Materials and Methods

After obtaining approval from the Human Studies Committee, we reviewed the electronic records from our intensive care unit database of 111 stroke patients on mechanical ventilation for more than 48 hours. Thirty-six risk factors related to disease and general health status, and 8 related to care—all assigned a priori—were collected and analyzed. Selected factors with univariate statistical significance (P < .05) were then analyzed with multivariate logistic regression.

Results

Thirty-one patients developed pneumonia (28%). Methicillin-resistant Staphylococcus aureus (n = 12) and methicillin-sensitive S aureus (n = 7) were the most common pathogenic bacteria. Chronic lung disease, neurological status at admission as assessed by the National Institutes of Health Stroke Scale, and hemorrhagic transformation were the independent risk factors contributing to VAP. Worsening oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) and proton pump inhibitor use for ulcer prophylaxis were other potentially important factors.

Conclusions

Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit stay gets significantly prolonged by VAP, but it does not affect mortality.     

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。     

Preventing common enteral feeding complications in critically ill adult patients

Nutritional support provides critically ill patients with energy and nutrients required to face the demands of their illness and stress. For those unable to ingest orally, enteral feeding rather than parenteral feeding is recommended, as the former better preserves gut integrity, reduces risk of infection, and costs less. Early enteral feeding in critically ill patients is also associated with decreased disease severity, reduced complications, and shortened length of stay. Risks associated with enteral feeding include aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. This article reviews current knowledge on enteral feeding and addresses correct feeding tube placement, proper feeding sites, assessing and managing gastric residual volume, and preventing feeding tube occultation. We also review information related to identifying and controlling risk factors for enteral feeding complications such as aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. Nurses can use this information to provide high quality care for enteral feeding patients and develop institutional protocols, guidelines, and standards of care for such patients in intensive care units.     

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Purpose

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

Methods

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

Results

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

Conclusions

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

     

危重症病人肠内营养并发症及其预防护理的研究进展

综述危重症病人肠内营养常见并发症及其预防护理的研究进展,指出肠内营养易发生胃食管反流、误吸、声音嘶哑、腹泻等并发症。通过正确的营养剂的选择和输注,妥善固定导管,加强导管的护理和病人的监测等措施能减少导管相关并发症的发生,保障危重病人的营养供给。     

Parenteral with enteral nutrition in the critically ill

Objective: To determine whether nutrient intake by early enteral nutrition with parenteral nutrition improves levels of retinol-binding protein and prealbumin (primary endpoint) and reduce morbidity and mortality (secondary endpoint) in ICU patients. Design: Prospective, double-blind, and randomized, placebo-controlled study. Setting: Two intensive care units in a tertiary institution. Patients and participants: 120 patients in two groups of 60.¶Interventions: Patients received either enteral plus parenteral nutrition (treatment group) or enteral nutrition plus placebo (placebo group) for 4–7 days after initiation of nutritional support. Measurements and results: Retinol-binding protein (P = 0.0496) and prealbumin (P = 0.0369) increased significantly in the treatment group from day 0 to day 7. There was no reduction in morbidity in ICU. There was no difference in OMEGA score (263 vs. 244) and length of stay in the ICU (16.9 vs. 17.3), but a reduction in length of stay at hospital (31.2 ± 18.5 vs. 33.7 ± 27.7, P = 0.0022). Mortality on day 90 (17 vs. 18) and after 2 years (24 vs. 24) was identical. Conclusions: Although it enhances nutrient intake and corrects nutritional parameters such as RBP and prealbumin more rapidly, within 1 week, supplemental parenteral nutrition has no clinically relevant effect on outcome in ICU patients at the early phase of nutritional support.     

ICU危重病人肠内营养的护理

营养支持是危重病人的重要治疗手段之一。随着临床营养的研究和发展,人们逐步认识到肠内营养比肠外营养有更多的优点[1]。肠内营养作为一种方便、安全、有效的营养支持方式在临床得到广泛的应用[2]。我科危重病人进行肠内营养支持过程中,采取了有效的护理措施,取得较好的临床效果。1资料与方法1.1临床资料2009年10月—2010年10月我院ICU危重病人62例,均采用鼻胃管给予肠内营养,其中男32例,女30例,     

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.     

合并腹腔高压重症患者肠内营养期间误吸预防的证据总结

目的:评价并整合合并腹腔高压的重症患者肠内营养期间预防误吸的证据。方法:检索BMJBestPractice、UpToDate、国际指南协作网(GIN)、美国国立指南库(NGC)、CochraneLibrary、PubMed、WebofScience、中国知网、万方、维普等数据库关于重症患者合并腹腔高压期间肠内营养误吸预防的所有证据,包括指南、证据总结、临床决策、专家共识、系统评价及原始研究。由两名研究者对纳入的文献进行质量评析,并对提取的证据级别进行评定。结果:共纳入文章17篇,其中系统评价8篇,指南3篇,最佳证据总结2篇,临床决策4篇。总结出20条误吸预防的证据,包括腹腔高压及误吸的危险因素的识别、肠内营养的管理、腹腔高压的管理、气道的管理、药物管理以及临床监测等。结论:建议在使用此证据时还应结合科室患者的具体情况进行个体化调整,并且此证据在临床使用过程中,若发现问题应及时改进,以提升护理质量,保证安全,提高患者满意度。     

重症脑卒中患者肠内营养的护理

目的探讨重症脑卒中患者经鼻胃管肠内营养的护理效果。方法对118例NICU的重症脑卒中患者进行经鼻胃管肠内营养治疗,并配合做好护理,比较营养支持前后患者血清白蛋白的变化。结果经鼻胃管肠内营养支持后,患者的血清白蛋白较未行肠内营养支持前明显升高(均P<0.05),差别有统计学意义。结论肠内营养对重症脑卒中患者有良好的营养支持作用。     

危重症患儿肠内营养研究进展

文章归纳了危重症患儿肠内营养治疗时的关键问题,指出了危重症患儿需早期开展肠内营养,减少肠内营养治疗的中断,并对肠内营养实施的途径及输注方式的研究进展进行了综述。