红霉素联合甲氧氯普胺治疗重症监护病房机械通气患者肠内喂养失败的临床研究

目的观察红霉素或甲氧氯普胺对重症监护病房（ICU）肠内喂养失败的机械通气患者胃排空障碍的治疗效果，以及红霉素联合甲氧氯普胺补救治疗单药治疗失败病例的效果，并筛选影响红霉素或甲氧氯普胺作用的独立危险因素。方法收集2007年6月至2010年6月肠内喂养失败的机械通气患者72例，肠内喂养失败后第1天10：00进行肠道营养。患者随机分为红霉素组和甲氧氯普胺组，共治疗6d。各组第1次给药均在第1天8：00，给药24h后，开始记录每日10：00，16：00，22：00和次日4：00胃液潴留量、患者基本情况和治疗前24h的胃液潴留量。比较每日胃液潴留量及肠内喂养成功率。对于单药治疗失败者，直接纳入联合治疗组，联合治疗时间6d，治疗24h后开始记录联合治疗组每日胃液潴留量及肠内喂养成功率。结果ICU机械通气患者肠内喂养失败的情况下，红霉素组每日平均胃液潴留量较甲氧氯普胺组少d2：（75±19）1）S（130-4-23）ml；d3：（72±16）w（120±21）ml；d4：（71±22）VS（125±18）ml；P〈0．05】；红霉素组的喂养成功率较甲氧氯普胺组高d2：65．7％US37．8％；d3：51．4％VS27．0％；d4：45．7％VS18．9％；d5：40．0％IJS16．2％；P〈0．05]；在单药治疗失败后，红霉素联合甲氧氯普胺补救治疗效果更佳，在第5天的喂养成功率高达64．3％，明显高于红霉素组（40％）和甲氧氯普胺组（16．2％）；治疗前24h的胃液潴留量、血糖水平、入组时急性病生理学和长期健康评价（APACHEI／）评分、是否存在休克与喂养失败显著相关。结论在ICU机械通气患者肠内喂养失败的情况下，小剂量红霉素治疗胃排空障碍效果较甲氧氯普胺为佳；在单药治疗失败后，红霉素联合甲氧氯普胺补救治疗效果更佳；治疗前24h的胃液潴留量、高血糖水平、入组时高APACHEII评分、休克为喂养失败的独立危险因素。

Erythromycin and metoclopramide for treatment of feed failure in mechanically ventilated patients in intensive care unit

Objective To compare the effect of erythromycin or metoclopramide on feed failure of mechanically ventilated patients in intensive care unit; to observe the effect of ＂rescue＂ combination therapy using both erythromycin and metoclopramide after monotherapy failure; to screen out the factors associated with a poor response to prokinetic therapy. Methods Seventy-two mechanically ventilated patients with feed failure in ICU from June 2007 to June 2010 were collected. Enteral nutrition was given at 10：00 on the first day after feed failure. The subjects were randomly divided into erythromycin group and metoclopramide group. The first erythromycin or metoclopramide injection was given at 8：00 on the first day. After 24 hours, gastric residual volume was aspirated and measured every day at 10：00, 16：00, 22：00 and 04：00 on next day. At the same time, we recorded the general condition and pretreatment 24-hour gastric residual volume of the subjects. The mean gastric residual volume and the successful feeding rate were compared every day. Six days later, the patients who failed the monotherapy received the rescue combination therapy directly for another 6 days. Twenty-four hours later, daily gastric residual volume and the successful feeding rate were recorded. Results For mechanically ventilated patients with feed failure, the daily gastric residual volume in erythromycin group was smaller than that in metoclopramide groupday 2：（75±19） vs （130± 23） ml; day 3：（72± 16） vs （120± 21） ml; day 4：（71 ±22） vs （125±18） ml; P 〈 0.05]. The successful feeding rate in erythromycin group was higher than that in metoclopramide group（day 2：65.7% vs 37.8%; day3： 51.4% vs 27.0%; day 4： 45.7% vs 18.9%; day 5：40.0% vs 16.2%; P〈 0.05）. In patients who failed monotherapy, the ＂rescue＂ combination therapy using erythromycin and metoclopramide had higher successful feeding rate（64.3% on day 5） than erythromycin（40%） or metoclopramide （16.2%）. Factors that were associated with a poor response to prokinetic therapy included high pretreatment 24-hour gastric residual volume, high blood sugar, a high Acute Physiology and Chronic Health Evaluation II （APACHE 1I ） score on inclusion day and the existence of any kinds of shock. Conclusion For mechanically ventilated patients with feed failure in ICU, erythromycin is more effective than metoclopramide; in patients who failed monotherapy, ＂rescue＂ combination therapy using erythromycin and metoclopramide is highly effective. High pretreatment 24-hour gastric residual volume, high blood sugar, a high APACHE 1I score on inclusion day and existence of any kinds of shock are independent risk factors of a poor response to prokinetic therapy.