早期肠内营养对静脉一动脉体外膜肺氧合患者预后的影响

Effect of early enteral nutrition on prognosis of patients during veno-arterial extracorporeal membrane oxygenation

目的观察静脉-动脉体外膜肺氧合(VA-ECMO)患者早期肠内营养(EEN)的可行性及相关的临床结果。方法选择2012年1月至2017年12月入住宁波市医疗中心李惠利医院重症医学科(ICU)使用VA-ECMO治疗的34例患者作为研究对象。所有患者均在排除禁忌证后积极实施EEN,按照104.65kJ·kg^-1·d^-1(25kcal·kg^-1·d^-1)计算目标热卡量,按照1.2g·kg^-1·d^-1计算目标蛋白量,以1周内是否达到上述目标量的80%将患者分为达标组和非达标组,观察两组患者入ICU时急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、多器官功能障碍综合征(MODS)评分、ECMO治疗至开始EN的时间、EN达标时间、VA-ECMO持续时间、ICU住院时间,总住院时间及住院病死率,并记录EN中断的原因,分析VA-ECMO患者EEN对预后的影响。结果非达标组入ICU时APACHEⅡ评分、MODS评分均高于达标组〔APACHEⅡ评分(分):25.50±5.62比19.91±8.53,MODS评分(分):11.08±3.26比6.73±2.05,均P<0.05〕,且达标组的住院病死率更低〔40.9%(9/22)比83.3%(10/12),P<0.05〕。两组ECMO治疗至开始EN时间、EN达标时间、VA-ECMO治疗时间、ICU住院时间、总住院时间比较差异无统计学意义(均P>0.05)。高胃残余量是喂养中断最主要的原因。结论接受VA-ECMO的危重患者能否在1周内达到目标喂养量,与疾病的危重程度相关,疾病危重者较难达到目标喂养量,进而可能影响患者的预后。

Objective To observe the feasibility of early enteral nutrition (EEN) in adult patients during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and its related clinical results. Methods Thirtyfour patients admitted to the Intensive Care Unit (ICU) of Ningbo Medical Center Li Huili Hospital from January 2012 to December 2017 to receive VA-ECMO treatment were selected as the study objects. All patients received EEN after exclusion of contraindications; the target calories were calculated by using 104.65 kJ·kg^-1 ·d^-1 (25 kcal·kg^-1 ·d^-1 ) and according to 1.2 g·kg^-1 ·d^-1 , the target protein requirements were calculated. Within one week of EN energetic treatment, if the feeding amount reached 80% or over of the above calculated targets, the EN administration was fulfilling the standard, thus the patients were divided into a standard group and a non-standard group, After ICU admission, the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, multiple organ dysfunction syndrome (MODS) score, the time from the beginning of ECMO to the start of EN, time reaching feeding standard, VA-ECMO persistent days, ICU days of stay, total hospitalization days, hospital mortality, and reasons for feeding interruptions were recorded, and the effects of EEN on prognosis of patients during VA-ECMO were analyzed in the two groups. Results The APACHE Ⅱ score and MODS score of the non-standard group were higher than those of the standard group on admission of ICU (APACHE Ⅱ score: 25.50±5.62 vs. 19.91±8.53, MODS score: 11.08±3.26 vs. 6.73±2.05, both P < 0.05), and the hospital mortality was lower in the standard group than that in non-standard group [40.9% (9/22) vs. 83.3% (10/12), P < 0.05]. The comparisons of differences in time from the beginning of ECMO to the start of EN, time of reaching feeding standard, VA-ECMO treatment days, ICU days of stay, hospitalization days between the two groups were of no statistical significance (all P > 0.05). The most common reason for interruption of feeding was high gastric residual volume (GRV). Conclusion Whether a critically ill patient receiving VA-ECMO can reach the target feeding amount in a week or not is related to the degree of disease severity; it is difficult for a seriously ill patient to reach the target amount of feeding, that may affect their prognosis.