间断喂养与持续喂养对行机械通气患者耐受性、营养指标及预后的影响

doi:10.3969/j.issn.1004-583X.2023.10.008

摘要/Abstract

摘要： 目的比较间断喂养与持续喂养对行机械通气的危重患者耐受性、营养指标及预后的影响。方法选取2021年6月至2022年6月于邯郸市中心医院接受机械通气的危重患者100例,并随机分为持续喂养组和间断喂养组,每组各50例。比较两组喂养目标达标情况、喂养耐受情况、机械通气时间及营养指标的差异。营养指标包括前白蛋白(prealbumin, PA)、白蛋白(albumin,ALB)、总蛋白(total protein, TP)、血红蛋白(hemoglobin, Hb)。结果两组喂养第1~6天目标达标率比较, 差异无统计学意义(P>0.05);喂养第7天,间断组目标达标率高于持续组(P<0.05);两组喂养耐受性情况和机械通气时间比较,差异无统计学意义(P>0.05);喂养第1天及第7天,两组ALB、PA、Hb水平比较,差异无统计学意义(P>0.05);予肠内营养支持后,第7天两组ALB及Hb均较前升高(P<0.05)。结论机械通气的危重患者早期间断喂养与持续喂养效果相当,提高喂养耐受性是提高喂养效果的关键。

关键词: 呼吸, 人工, 肠道营养, 营养支持, 喂养耐受性

Abstract: Objective To compare the effects of intermittent feeding versus continuous feeding on the tolerance, nutritional indexes and prognosis of critically ill patients undergoing mechanical ventilation. Methods A total of 100 critically ill patients receiving mechanical ventilation in the Handan Central Hospital from June 2021 to June 2022 were recruited. They were randomly divided into continuous feeding group (50 cases) and intermittent feeding group (50 cases). The compliance rate of nutrition calories, feeding tolerance, mechanical ventilation time and nutritional indexes were compared between the two groups. Nutritional indexes included prealbumin (PA), albumin (ALB), total protein (TP), and hemoglobin (Hb). Results There was no significant difference in the compliance rate of nutrition calories from the 1st to 6th day of feeding (P>0.05). On the 7th day of feeding, the compliance rate of nutrition calories was significantly higher in patients of intermittent feeding group than that of continuous feeding group (P<0.05). There were no significant differences in feeding tolerance and mechanical ventilation time between the two groups (P>0.05). There were no significant difference in ALB, PA and Hb levels on the 1st and 7th day of feeding between the two groups (P>0.05). After enteral nutrition support, ALB and Hb on the 7th day of feeding were significantly enhanced in both groups (P<0.05). Conclusion Early intermittent feeding provides a comparable effect with continuous feeding on critically ill patients with mechanical ventilation. Improving feeding tolerance is the key to improve the feeding effect.

Key words: respiration, artificial, enteral nutrition, nutritional support, tolerance

中图分类号:

R605.973

未培轩, 兰晓敬, 吴亭亭, 史俊峰, 薛延英, 王景梅. 间断喂养与持续喂养对行机械通气患者耐受性、营养指标及预后的影响[J]. 临床荟萃, 2023, 38(10): 907-911.

Wei Peixuan, Lan Xiaojing, Wu Tingting, Shi Junfeng, Xue Yanying, Wang Jingmei. Effects of intermittent feeding versus continuous feeding on tolerance, nutritional indexes, and prognosis in critically ill patients undergoing mechanical ventilation[J]. Clinical Focus, 2023, 38(10): 907-911.

导出引用管理器 EndNote|Ris|BibTeX

链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.10.008

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I10/907

图/表 6

表1 肠内营养耐受性评分表(分)[9]

Tab. 1 Enteral nutrition tolerance scale (score) [9]

评价内容	计分标准
评价内容	0	1	2	5
腹胀/腹痛	无	轻度腹胀/无腹痛	明显腹胀或腹痛自行缓解或腹内压15~20 mmHg	严重腹胀或腹痛不能自行缓解或腹内压>20 mmHg
恶心/呕吐	无或持续胃肠减压无症状	恶心但无呕吐	恶心呕吐,不需胃肠减压或250 ml<胃残余量(gastric residual volume,GRV)<500 ml	呕吐,且需胃肠减压或GRV>500 ml
腹泻	无	稀便3~5次/d,且量<500 ml	稀便>5次/d,且量500~1500 ml	稀便>5次/d且量>1500 ml

表2 两组基线资料比较($\bar{x}$±s)

Tab. 2 Comparison of baseline data between groups ($\bar{x}$±s)

组别	例数 (男/女)	年龄 (岁)	BMI (kg/m²)	疾病类型(例)			APACHEII 评分(分)	mNUTRIC (分)	AGI分级(例)
组别	例数 (男/女)	年龄 (岁)	BMI (kg/m²)	神经系统疾病	多发外伤	其他	APACHEII 评分(分)	mNUTRIC (分)	Ⅰ	Ⅱ	Ⅲ
间断组	50(31/19)	62.780±11.132	24.000±3.674	28	8	14	26.40±2.821	8.18±1.792	19	21	2
持续组	50(29/21)	61.660±12.077	24.520±4.159	23	10	17	26.28±2.603	8.40±1.784	25	23	2
统计值	χ²=0.167	$t$ =0.482	$t$ =0.653	χ²=1.003			$t$ =0.221	$t$ =0.615	$Z$ =1.139
$P$ 值	0.683	0.631	0.515	0.606			0.826	0.540	0.164

表2 两组基线资料比较($\bar{x}$±s)

Tab. 2 Comparison of baseline data between groups ($\bar{x}$±s)

组别	例数 (男/女)	年龄 (岁)	BMI (kg/m²)	疾病类型(例)			APACHEII 评分(分)	mNUTRIC (分)	AGI分级(例)
组别	例数 (男/女)	年龄 (岁)	BMI (kg/m²)	神经系统疾病	多发外伤	其他	APACHEII 评分(分)	mNUTRIC (分)	Ⅰ	Ⅱ	Ⅲ
间断组	50(31/19)	62.780±11.132	24.000±3.674	28	8	14	26.40±2.821	8.18±1.792	19	21	2
持续组	50(29/21)	61.660±12.077	24.520±4.159	23	10	17	26.28±2.603	8.40±1.784	25	23	2
统计值	χ²=0.167	$t$ =0.482	$t$ =0.653	χ²=1.003			$t$ =0.221	$t$ =0.615	$Z$ =1.139
$P$ 值	0.683	0.631	0.515	0.606			0.826	0.540	0.164

表3 两组肠内营养耐受性比较(例)

Tab. 3 Comparison of enteral nutrition tolerance between groups (n)

组别	例数	耐受等级	第1天	第2天	第3天	第4天	第5天	第6天	第7天
间断组	50	良	44	34	30	22	35	41	42
		中	4	12	12	18	11	6	5
		差	2	4	8	10	4	3	3
持续组	50	良	43	36	32	30	40	35	42
		中	5	11	15	12	9	10	6
		差	2	3	3	8	2	5	2
$Z$ 值			-0.283	-0.464	-0.737	-1.425	-1.019	-1.386	-0.043
$P$ 值			0.777	0.643	0.461	0.154	0.308	0.166	0.965

表3 两组肠内营养耐受性比较(例)

Tab. 3 Comparison of enteral nutrition tolerance between groups (n)

组别	例数	耐受等级	第1天	第2天	第3天	第4天	第5天	第6天	第7天
间断组	50	良	44	34	30	22	35	41	42
		中	4	12	12	18	11	6	5
		差	2	4	8	10	4	3	3
持续组	50	良	43	36	32	30	40	35	42
		中	5	11	15	12	9	10	6
		差	2	3	3	8	2	5	2
$Z$ 值			-0.283	-0.464	-0.737	-1.425	-1.019	-1.386	-0.043
$P$ 值			0.777	0.643	0.461	0.154	0.308	0.166	0.965

表4 两组每日喂养目标达标情况比较(例)

Tab. 4 Comparison of daily compliance rate of nutrition calories between groups (n)

组别	例数	第1天	第2天	第3天	第4天	第5天	第6天	第7天
间断组	50	43	43	25	18	15	20	23
持续组	50	40	35	20	15	10	12	15
χ²值		0.638	3.730	1.010	0.407	1.333	2.941	5.319
$P$ 值		0.424	0.053	0.053	0.523	0.248	0.086	0.021

表4 两组每日喂养目标达标情况比较(例)

Tab. 4 Comparison of daily compliance rate of nutrition calories between groups (n)

组别	例数	第1天	第2天	第3天	第4天	第5天	第6天	第7天
间断组	50	43	43	25	18	15	20	23
持续组	50	40	35	20	15	10	12	15
χ²值		0.638	3.730	1.010	0.407	1.333	2.941	5.319
$P$ 值		0.424	0.053	0.053	0.523	0.248	0.086	0.021

表5 两组第1、7天各项营养指标比较($\bar{x}$±s,g/L)

Tab. 5 Comparison of nutritional indicators on the 1st and 7th day of feeding between groups ($\bar{x}$±s, g/L)

组别	例数	ALB		PA		Hb
组别	例数	第1天	第7天	第1天	第7天	第1天	第7天
间断组	50	30.560±3.580	32.040±2.610^*	0.191±0.050	0.202±0.080	118.800±14.360	123.860±10.300^*
持续组	50	30.740±3.430	32.600±2.220^*	0.195±0.060	0.203±0.023	116.060±10.840	125.220±6.210^*
$t$ 值		0.256	1.153	0.307	0.108	1.076	0.799
$P$ 值		0.798	0.252	0.759	0.914	0.285	0.425

表5 两组第1、7天各项营养指标比较($\bar{x}$±s,g/L)

Tab. 5 Comparison of nutritional indicators on the 1st and 7th day of feeding between groups ($\bar{x}$±s, g/L)

组别	例数	ALB		PA		Hb
组别	例数	第1天	第7天	第1天	第7天	第1天	第7天
间断组	50	30.560±3.580	32.040±2.610^*	0.191±0.050	0.202±0.080	118.800±14.360	123.860±10.300^*
持续组	50	30.740±3.430	32.600±2.220^*	0.195±0.060	0.203±0.023	116.060±10.840	125.220±6.210^*
$t$ 值		0.256	1.153	0.307	0.108	1.076	0.799
$P$ 值		0.798	0.252	0.759	0.914	0.285	0.425

表6 两组机械通气时间比较($\bar{x}$±s)

Tab. 6 Comparison of mechanical ventilation time between groups ($\bar{x}$±s)

组别	例数	机械通气时间(d)
间断组	50	11.14±2.33
持续组	50	10.84±1.82
$t$ 值		0.717
$P$ 值		0.475

表6 两组机械通气时间比较($\bar{x}$±s)

Tab. 6 Comparison of mechanical ventilation time between groups ($\bar{x}$±s)

组别	例数	机械通气时间(d)
间断组	50	11.14±2.33
持续组	50	10.84±1.82
$t$ 值		0.717
$P$ 值		0.475

参考文献 18

[1]	Sharma K, Mogensen KM, Robinson MK. Pathophysiology of critical Il iness and role of nutrition[J]. Nutr Clin Pract, 2019, 34(1):12-22. doi: 10.1002/ncp.2019.34.issue-1 URL
[2]	Al-Dorzi HM, Arabi YM. Nutrition support for critically ill patients[J]. JPEN J Parenter Enteral Nutr, 2021, 45(S2):47-59. doi: 10.1002/jpen.2228 pmid: 34897737
[3]	王丽娜, 詹英, 陈军, 等. 机械通气患者早期肠内营养与胃黏膜pH值监测的临床应用[J]. 中国危重病急救医学, 2009, 21(7):409-411.
[4]	Wang K, McIlroy K, Plank LD, et al. Prevalence, outcomes, and management of enteral tube feeding intolerance: A retrospective cohort study in a tertiary center[J]. JPEN J Parenter Enteral Nutr, 2017, 41(6):959-967. doi: 10.1177/0148607115627142 pmid: 26850741
[5]	刘明月, 顾艳, 杨伟伟. 持续与间断肠内营养支持方式对颅脑损伤病人肠内营养耐受性的影响[J]. 全科护理, 2019, 17(22):2766-2768.
[6]	Knaus WA, Draper EA, Wagner DP, et al. APACHE II: A severity of disease classification system[J]. Crit Care Med, 1985, 13(10):818-829. pmid: 3928249
[7]	Rahman A, Hasan RM, Agarwala R, et al. Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the “modified NUTRIC” nutritional risk assessment tool[J]. Clin Nutr, 2016, 35(1):158-162. doi: S0261-5614(15)00037-0 pmid: 25698099
[8]	Reintam BA, Malbrain ML, Starkopf J, et al. Gastrointestinal function in intensive care patients: Terminology, definitions and management. recommendations of the ESICM working group on abdominal problems[J]. Intensive Care Med, 2012, 38(3):384-394. doi: 10.1007/s00134-011-2459-y pmid: 22310869
[9]	Martindale RG, McClave SA, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of critical care medicine and american society for parenteral and enteral nutrition:executive summary[J]. Crit Care Med, 2009, 37(5):1757-1761. doi: 10.1097/CCM.0b013e3181a40116 pmid: 19373044
[10]	Reintam BA, Starkopf L, Deane AM, et al. Comparison of different definitions of feeding intolerance: A retrospective observational study[J]. Clin Nutr, 2015, 34(5):956-961. doi: 10.1016/j.clnu.2014.10.006 pmid: 25467878
[11]	Heyland DK, Ortiz A, Stoppe C, et al. Incidence, risk factors, and clinical consequence of enteral feeding intolerance in the mechanically ventilated critically Ill: An analysis of a multicenter, multiyear database[J]. Crit Care Med, 2021, 49(1):49-59. doi: 10.1097/CCM.0000000000004712 pmid: 33148950
[12]	尹立国, 张锐利, 张小章, 等. 早期低剂量肠内营养对重症颅脑损伤患者肠黏膜屏障功能的保护作用[J]. 临床合理用药杂志, 2015, 8(10):144-145.
[13]	万燕, 李子轶, 冯霁, 等. 早期滋养型肠内营养在神经外科中老年重症患者中的临床效果[J]. 中国老年学杂志, 2022, 42(5):1134-1137.
[14]	董敬之, 刘睿, 李璐, 等. 间断喂养与持续喂养对危重症患者肌肉萎缩和营养状态的影响[J]. 中华危重病急救医学, 2021, 33(7):844-848.
[15]	马晨, 李力, 李雯, 等. 基于喂养泵的持续性与间断性肠内喂养对脑卒中患者营养达标率的影响[J]. 中华临床营养杂志, 2017, 25(3):153-158.
[16]	Kittiskulnam P, Banjongjit A, Metta K, et al. The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: A prospective randomized controlled trial[J]. Sci Rep, 2022, 12(1):4529. doi: 10.1038/s41598-022-08726-8 pmid: 35296793
[17]	须晋, 赵娜, 马士程, 等. 危重患者间断喂养和持续喂养有效性和耐受性比较[J]. 中国急救医学, 2022, 42(6):481-486.
[18]	Liu R, Paz M, Siraj L, et al. Feeding intolerance in critically ill patients with COVID-19[J]. Clin Nutr, 2022, 41(12):3069-3076. doi: 10.1016/j.clnu.2021.03.033 URL