肠内营养不耐受标准化流程管理对重症肺炎机械通气患者血糖控制及预后的影响
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摘要
目的探讨在重症肺炎有创机械通气患者中采取早期肠内营养(EN)不耐受标准化流程管理对患者血糖控制作用及相关预后的影响。方法 54例重症肺炎有创机械通气患者分为两组,两组患者均给予常规治疗并于入院24～48 h内开始早期经鼻肠管肠内营养治疗。在肠内营养治疗期间,实验组实行肠内营养不耐受标准化流程管理,对照组实行常规管理。比较两组营养支持指标、血糖变异性指标、氧合指数、肺泡动脉血氧分压差、预后相关指标。结果经过肠内营养不耐受标准化流程管理,患者首次排便时间、达目标喂养量时间明显提前,实验组患者7 d EN/EN+PN比值、7 d鼻肠管达标比例明显高于对照组患者(t分别=27.81、20.64,χ~2分别=36.22、38.33,P均<0.05)。实验组患者整体血糖变异程度(血糖变异系数、最高血糖值、最低血糖值)均明显优于对照组(t分别=21.86、18.62、10.73,P均<0.05),实验组患者高血糖发生率明显低于对照组(χ~2=41.86,P<0.05)。自病程第9天起,实验组患者氧合指数明显优于对照组(t分别=16.69、18.32,P均<0.05),自病程第7天起,实验组肺泡-动脉血氧分压差明显低于对照组(t分别=14.87、16.26、8.34、6.26,P均<0.05);实验组患者多器官功能障碍综合征(MODS)发生率、有创机械通气时长明显低于对照组(χ~2=26.62,t=6.86,P均<0.05);但两组患者28 d病死率、入住ICU时间比较,差异无统计学意义(χ~2分别=5.62,t=3.34,P均>0.05)。结论对重症肺炎有创机械通气患者进行EN不耐受标准化流程管理可改善营养状况,降低血糖波动水平,改善预后。
Objective To explore the effect of the early enteral nutrition(EN)intolerance standardized process management on blood glucose control and prognosis in patients of severe pneumonia with mechanical ventilation. Methods Totally 54 patients of severe pneumonia with mechanical ventilation were selected and divided into the experimental group(28 cases)and the control group(26 cases).Patients were all received routine treatment and early enteral nutrition through nasointestinal tube within 24 to 48 hours after admission. Patients in the experimental group were given standardized management of enteral nutrition intolerance,while the control group were given routine management.The nutritional support parameters,the blood glucose variability parameters,the respiratory function related parameters,and the prognostic indicators were compared between the two groups. Results After the early enteral nutrition(EN)intolerance standardized process management,the first defecation time,the time of completing target feeding,the 7-day EN/PN ratio,and the 7-day nasal bowel arrival rate were significantly improved(t= 27.81,20.64,χ~2=36.22,38.33,P<0.05).The blood glucose coefficient of variation,the highest and the minimum levels of blood glucose of the experimental group were significantly better than those of the control group(t= 21.86,18.62,10.73,P<0.05).The incidence of hyperglycemia was significantly lower than that of the control group(χ~2= 41.86,P<0.05).From the 9th day of the disease course,the oxygenation index of the experimental group was significantly better than that of the control group(t=16.69,18.32,P<0.05),and from the7 th day of the disease course,the alveolar-arterial oxygen pressure difference of the experimental group was significantly lower than that of the control group(t=14.87,16.26,8.34,6.26,P<0.05).The incidence of MODS and the time of invasive mechanical ventilation of the experimental group were significantly lower than those of the control group(χ~2=26.62,t=6.86,P<0.05).However,there was no significant difference in the 28-day hospital mortality and the ICU stay time between the two groups(χ~2= 5.62,t= 3.34,P>0.05). Conclusions The EN intolerance standardized process management may improve the nutritional status of the patients of severe pneumonia with mechanical ventilation,lower blood sugar fluctuations,and improve the prognosis.
Objective To explore the effect of the early enteral nutrition(EN)intolerance standardized process management on blood glucose control and prognosis in patients of severe pneumonia with mechanical ventilation. Methods Totally 54 patients of severe pneumonia with mechanical ventilation were selected and divided into the experimental group(28 cases)and the control group(26 cases).Patients were all received routine treatment and early enteral nutrition through nasointestinal tube within 24 to 48 hours after admission. Patients in the experimental group were given standardized management of enteral nutrition intolerance,while the control group were given routine management.The nutritional support parameters,the blood glucose variability parameters,the respiratory function related parameters,and the prognostic indicators were compared between the two groups. Results After the early enteral nutrition(EN)intolerance standardized process management,the first defecation time,the time of completing target feeding,the 7-day EN/PN ratio,and the 7-day nasal bowel arrival rate were significantly improved(t= 27.81,20.64,χ~2=36.22,38.33,P<0.05).The blood glucose coefficient of variation,the highest and the minimum levels of blood glucose of the experimental group were significantly better than those of the control group(t= 21.86,18.62,10.73,P<0.05).The incidence of hyperglycemia was significantly lower than that of the control group(χ~2= 41.86,P<0.05).From the 9th day of the disease course,the oxygenation index of the experimental group was significantly better than that of the control group(t=16.69,18.32,P<0.05),and from the7 th day of the disease course,the alveolar-arterial oxygen pressure difference of the experimental group was significantly lower than that of the control group(t=14.87,16.26,8.34,6.26,P<0.05).The incidence of MODS and the time of invasive mechanical ventilation of the experimental group were significantly lower than those of the control group(χ~2=26.62,t=6.86,P<0.05).However,there was no significant difference in the 28-day hospital mortality and the ICU stay time between the two groups(χ~2= 5.62,t= 3.34,P>0.05). Conclusions The EN intolerance standardized process management may improve the nutritional status of the patients of severe pneumonia with mechanical ventilation,lower blood sugar fluctuations,and improve the prognosis.
引文
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6 有创-无创序贯机械通气多中心研究协作组.以肺部感染控制窗为切换点行有创与无创序贯机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的随机对照研究[J].中华结核和呼吸杂志,2006,29(1):14-18.
7 Taylor BE,McClave SA,Martindale RG,et al.Guidelines for the provision and assessment of nutrition support therapy in the adult criticallyⅢpatient:society of critical care medicine(SCCM)and American society for parenteral and enteral nutrition(A.S.P.E.N.)[J].Critical Care Medi,2016,44(2):391-438.
8 中国医师协会急诊医师分会.中国重症肺炎临床实践专家共识[J].中国急救医学,2016,36(2):97-106.
9 章黎,王新颖,黎介寿.综合评价危重症病人营养支持和重症监护的措施——介绍一种助记法“CAN WE FEED”[J].肠外与肠内营养,2012,19(4):250-252.
10 华晨,刘励军.早期肠内营养在危重症病人营养支持中的临床价值[J].肠外与肠内营养,2011,18(1):12-14.
11 柳梅,范学朋.含缓释淀粉的肠内营养制剂对危重症病人血糖及预后的影响[J].肠外与肠内营养,2015,22(3):140-142.
12 Gianchandani RY,Esfandiari NH,Haft JW,et al.Diabetes and stress hyperglycemia in the intensive care unit:outcomes after cardiac surgery[J]. Hosp Pract,2012,40(2):22-30.
13 Hovver HC Jr,Ryan JA,Anderson EJ,et al. Nutritional benefits of immediate postoperative jejunal feeding of an elemantal diet[J].Am Surg,1980,139(1):153-159.
14 Nguyen N,Ching K,Fraser R,et al.The relationship between blood glucose control and intolerance to enteral feeding during critical illness[J].Int Care Med,2007,33(12):2085-2092.
15 蒋洋洋.肠内营养病人喂养不耐受相关因素的研究进展[J].肠外与肠内营养,2011,18(1):46-49.
2 El-Osta A,Brasacchio D,Yao D,et al. Transient high glucose causes persistent epigenetic changes and altered gene expression during subsequent normoglycemia[J].Exp Med,2008,205(10):2409-2417.
3 Lim WS,Baudouin SV,George RC,et al.BTS gudelines for the management of community aqcuired pneumonia in adults:update 2009[J].Thorax,2009,64(Suppl3):1-55.
4 刘大为,邱海波,严静,等.中国重症医学专科资质培训教材[M].北京:人民卫生出版社,2013.141-142.
5 Mackenzie SL,Zygun DA,Whitmore BL,et al.Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit[J].JPEN,2005,29(2):74.
6 有创-无创序贯机械通气多中心研究协作组.以肺部感染控制窗为切换点行有创与无创序贯机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的随机对照研究[J].中华结核和呼吸杂志,2006,29(1):14-18.
7 Taylor BE,McClave SA,Martindale RG,et al.Guidelines for the provision and assessment of nutrition support therapy in the adult criticallyⅢpatient:society of critical care medicine(SCCM)and American society for parenteral and enteral nutrition(A.S.P.E.N.)[J].Critical Care Medi,2016,44(2):391-438.
8 中国医师协会急诊医师分会.中国重症肺炎临床实践专家共识[J].中国急救医学,2016,36(2):97-106.
9 章黎,王新颖,黎介寿.综合评价危重症病人营养支持和重症监护的措施——介绍一种助记法“CAN WE FEED”[J].肠外与肠内营养,2012,19(4):250-252.
10 华晨,刘励军.早期肠内营养在危重症病人营养支持中的临床价值[J].肠外与肠内营养,2011,18(1):12-14.
11 柳梅,范学朋.含缓释淀粉的肠内营养制剂对危重症病人血糖及预后的影响[J].肠外与肠内营养,2015,22(3):140-142.
12 Gianchandani RY,Esfandiari NH,Haft JW,et al.Diabetes and stress hyperglycemia in the intensive care unit:outcomes after cardiac surgery[J]. Hosp Pract,2012,40(2):22-30.
13 Hovver HC Jr,Ryan JA,Anderson EJ,et al. Nutritional benefits of immediate postoperative jejunal feeding of an elemantal diet[J].Am Surg,1980,139(1):153-159.
14 Nguyen N,Ching K,Fraser R,et al.The relationship between blood glucose control and intolerance to enteral feeding during critical illness[J].Int Care Med,2007,33(12):2085-2092.
15 蒋洋洋.肠内营养病人喂养不耐受相关因素的研究进展[J].肠外与肠内营养,2011,18(1):46-49.
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