重症患者肠内喂养不足的危险因素分析

Risk Factors Analysis for Inadequate Enteral Nutrition in Critically Ill Patients

目的了解重症医学科(ICU)内重症患者肠内喂养不足的发生率、主要原因和导致喂养不足的危险因素。方法采用前瞻性单中心研究,选择2013年10月至2013年12月广州医科大学附属第一医院重症医学科收治的需要肠内营养的患者。患者入组后记录性别、年龄以及入组时急性生理学和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分。其后以每天为观察单位,记录患者当日的计划肠内喂养量和实际完成肠内喂养量,以实际完成肠内喂养量/计划肠内喂养量≥65%为界,将患者当日分为肠内喂养完成组(≥65%)和肠内喂养不足组(<65%)。分别记录患者是否需要机械通气、意识水平、去甲肾上腺素使用量、镇静药物使用量、镇痛药物使用量,并记录患者肠内营养中断的原因。结果总共入组符合合标准行肠内喂养天数302 d,来源于31例患者。分为肠内喂养完成组(≥65%)249 d和肠内喂养不足组(<65%)53 d。肠内喂养不足组营养喂养中断的主要原因为腹胀(38.1%),胃潴留(26.4%),医疗操作或检查(17.3%),呕吐(11.4%),消化道出血(9.2%),鼻饲管障碍(5.8%),新出现循环动力学不稳定(4.3%),腹痛(1.4%)。两组间进行单因素比较发现喂养成功组去甲肾上腺素、丙泊酚、瑞芬太尼使用量小于喂养不足组,两组间比较有显著差异(P<0.05),将以上指标进行Logistic多因素分析发现以上三者均为肠内喂养不足的独立危险因素(P<0.05)。结论 ICU内重症患者仍存在肠内喂养不足的现象,去甲肾上腺素、丙泊酚、瑞芬太尼的使用是导致喂养不足的独立危险因素。

Objective To determine the incidence rate,main causes and risk factors of inadequate enteral nutrition in critically ill patients in intensive care unit（ICU）. Methods A single-center prospective cohort study was conducted. Critically ill patients who need enteral nutrition in ICU of the First Affiliated Hospital of Guangzhou Medical University from October 2013 to December 2013 were enrolled. Each patient＇s demographic and clinical characteristics （gender, age, APACHE ]] score）, the need for ventilatory support,the level of consciousness,the use and dosage of medications, and the causes for cessation of enteral nutrition were recorded. The daily evaluation of nutrition intake was executed. Enteral nutrition was considered adequate if the patient received at least 65% of the recommended calories （complete group ~〉 65% and insufficient group 〈65% ）. Results A total of 302 daily evaluations were done in 31 patients. They were divided into an enteral nutrition complete group （249 cases） and an enteral nutrition insufficient group （ 53 cases ）. The main reasons for insufficient enteral nutrition were ventosity （ 38.1% ）, reflux （26. 4% ）, medical procedure and examination （ 17.3% ）, vomiting （ 11.4% ）, gastrointestinal bleeding （9. 2% ）, problems with the enteral nutrition tube （5.8%）, hemodynamic instability （4. 3 % ）, and abdominal pain（ 1.4% ）. Univariate analysis revealed that the dosage of norepinephrine, propofol and remifentanil were significantly lower in the enteral nutrition complete group compared with the enteral nutrition insufficient group（P 〈 0.05 ）. Logistic analysis revealed that the dosage of norepinephrine, propofol and remifentanil were independent risk factors for inadequate enteral nutrition （ P 〈 0. 05 ）. Conclusion Achievement of daily enteral nutrition goals is inadequate in critically ill patients, and the main risk factors associated with this failure are the use and dosage of norepinephrine, propofol and remifentanil.