早期肠内营养支持对接受机械通气治疗的急危重症患者的效果

目的 探讨早期肠内营养（enteral nutrition, EN）支持对接受机械通气治疗的急危重症患者的效果。方法 将急危重症患者70例,随机分为A组35例和B组35例。两组均进行常规治疗,A组给予早期肠内营养支持,B组于入院48 h后给予肠内营养支持。对治疗后的营养学指标、免疫学指标、营养不良发生率、呼吸机相关肺炎（VAP）发生率、机械通气时间及住院时间进行比较。结果 两组治疗后血红蛋白、血清清蛋白均较治疗前高,A组较B组高（P＜0.05）。两组治疗后血清总蛋白均较治疗前低,A组较B组低（P＜0.05）。两组治疗后免疫功能指标均显著改善（P＜0.05）。A组免疫功能指标中的CD3+、CD4+、CD4/CD8水平均高于B组,CD8+水平低于B组（P＜0.05）。治疗后A组营养不良发生率（8.57%）、VAP发生率（2.86%）均较B组不良反应发生率（42.86%）、VAP发生率（28.57%）低（P＜0.05）。A组治疗后的机械通气时间和住院时间均较B组短（P＜0.05）。结论 为有效预防机械通气治疗中急危重症患者发生营养不良,在常规药物治疗的基础上给予早期肠内营养支持具有较为显著的临床效果。     

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。     

肠内营养对危重病机械通气患者临床疗效观察

目的观察肠内营养对危重病机械通气患者的临床疗效。方法78例需机械通气患者，肠内营养组42例，予以能全力（荷兰Nutrieia公司）每日1000ml鼻饲；对照组36例，予以普通流质每日1000ml鼻饲（250ml，每日4次）。观察治疗前和治疗后3、7、14d2组患者血清总蛋白、白蛋白、肌酐身高指数、免疫球蛋白、淋巴细胞计数、氮平衡、氧合指数（PaO2／FiO2）、呼吸机参数、血常规以及APACHEⅡ评分、呼吸机相关性肺炎发病率、28d存活率、脱机成功率和平均住院天数等临床指标的变化。结果与治疗前比较，肠内营养组治疗3d时差异无统计学意义，治疗7和14d后各指标差异均有统计学意义（P〈0．05或0．01）；对照组治疗前、后差异均无统计学意义（均P〉0．05）。2组患者呼吸机相关性肺炎发病率、28d存活率、脱机成功率和平均住院天数比较差异均有统计学意义（均P〈0．05）。结论鼻饲肠内营养可以改善危重病机械通气患者营养状况，促进蛋白质合成，纠正负氮平衡，改善机体免疫机能，增强呼吸肌功能，缩短机械通气时间，减少并发症的发生率，降低平均住院天数。     

Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill patients receiving mechanical ventilation: a prospective,multi-centre,observational study

Introduction  

The primary aim was to measure the amount of nutrients required, prescribed and actually administered in critically ill patients. Secondary aims were to assess adherence to clinical practice guidelines, and investigate factors leading to non-adherence.     

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。     

Evaluation of pain severity in critically ill patients on mechanical ventilation

ObjectivesTo elucidate how patients’ illness severity, respiratory status, or haemodynamics are associated with the pain score of critically ill patients.MethodsThis was an observational study of patients on mechanical ventilation after surgeries. At rest and on turning, patient pain was evaluated using the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). Related factors were collected from medical records and analysed.FindingsMultiple logistic regression analysis was performed using data on 127 scenarios. An increase of >2 in BPS score on turning was affected by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR] = 0.864), systolic blood pressure at rest (OR = 1.032), BPS at rest (OR = 0.638), heart rate difference (OR = 1.124), and tidal volume difference (OR = 0.548). An increase of >2 in CPOT on turning score was associated with the APACHE II score (OR = 0.894), Sequential Organ Failure Assessment score (OR = 1.248), systolic blood pressure at rest (OR = 1.025), heart rate difference (OR = 1.096), and tidal volume difference (OR = 0.578).ConclusionThe Behavioural Pain Scale and the Critical-Care Pain Observation Tools were associated with illness severity and haemodynamics. A reduction in tidal volume may be useful in assessing pain.     

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。     

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     

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,     

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.     

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。     

机械通气患者肠内营养支持的临床应用研究

目的探讨机械通气患者肠内营养支持的临床应用效果。方法重症监护病房的机械通气患者84例,分为肠外营养支持组（PN组）与肠内营养支持组（EN组）,各42例。PN组通过中心静脉途径给予能量,EN组经鼻胃管给予能量。观察2组患者治疗前后的营养指标、免疫指标、病情转归指标、并发症情况。结果 EN组治疗后营养指标和免疫指标均明显高于PN组治疗后,机械通气时间和入住ICU时间明显少于PN组,病死率和并发症明显低于PN组。结论肠内营养支持可以改善机械通气危重症患者的营养状况和免疫功能,促进患者康复。     

机械通气患者肠内营养的临床应用

对 12例机械通气患者采用肠内营养支持治疗 ,效果满意 ,总结如下。1　病例与方法1.1　病例 :选择我院 2 0 0 1年 11月—2 0 0 2年 8月期间收入呼吸监护病房的机械通气患者 2 2例 ,按照随机排列表法将患者分为 2组 :肠内营养组 (治疗组 )12例与静脉营养组 (对照组 ) 10例。治疗组中慢性阻塞性肺疾病 (COPD)、哮喘、慢性支气管炎 6例 ,慢性充血性心力衰竭并发呼吸衰竭 3例 ,中毒 2例 ,急性呼吸窘迫综合征 (ARDS) 1例 ;其中男 5例 ,女 7例 ;年龄 31～ 78岁 ,平均 (6 2 .5±11.1)岁。对照组 COPD、哮喘、慢性支气管炎 5例 ,慢性充血性心力…     

2种肠内营养途径及护理在老年ICU机械通气患者中的应用

目的：比较2种肠内营养途径在老年ICU机械通气患者中的应用效果,为此类患者实施肠内营养支持提供依据。方法采用病例对照研究,使用鼻胃管和鼻肠管2种肠内营养支持途径及护理措施,各选取25例老年ICU机械通气患者,对比分析2组目标营养剂量达到时间,第2、3、4周患者营养改善情况,以及并发症发生率。结果鼻肠管喂养组达到目标营养剂量的时间短于鼻胃管喂养组,两组比较差异具有统计学意义（P＜0．05）;喂养后4周后2组患者总蛋白、血清前白蛋白、转铁蛋白量均有改善,且鼻肠管组改善结果显著优于鼻胃管组（P＜0．05）;鼻肠管组喂养相关并发症发生率显著低于鼻胃管组（P＜0．05）。结论老年ICU机械通气患者进行鼻肠管喂养并采取有效护理措施,更易达到目标营养剂量,且发生腹胀、误吸等并发症的概率较低。     

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。     

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.

     

Famotidine versus pantoprazole for preventing bleeding in the upper gastrointestinal tract of critically ill patients receiving mechanical ventilation.

BACKGROUND: Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. Proton pump inhibitors, although they are more potent and longer acting inhibitors of gastric acid production than are histamine(2) antagonists, also are generally more expensive. Data comparing the 2 types of agents for preventing gastrointestinal bleeding in critically ill patients are limited. OBJECTIVES: To compare the effectiveness of famotidine (a histamine(2) antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation. METHODS: Data were collected from the Project Impact database. All patients who received mechanical ventilation for more than 48 hours from November 2002 to June 2006 and were treated with either drug were included. Patients receiving other drugs or with known bleeding in the upper part of the gastrointestinal tract, thrombocytopenia, or coagulopathy were excluded. RESULTS: A total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03). Although scores on the Acute Physiology and Chronic Health Evaluation II were higher in patients who received pantoprazole (P= .01), other outcome measures did not differ significantly between groups. Bleeding in the upper part of the gastrointestinal tract was more frequent among dialysis patients receiving pantoprazole than among those receiving famotidine. CONCLUSIONS: Famotidine and pantoprazole are similarly effective for preventing bleeding in the upper part of the gastrointestinal tract in patients receiving mechanical ventilation.     

改良鼻饲法在危重症病人肠内营养中的应用

为探讨胃肠内营养更有效的鼻饲方法,对2008年9月-2009年1月我院60例危重症病人采取两种不同的鼻饲方法,观察比较其胃肠内营养并发症情况.现报告如下.