早期肠内营养在重型颅脑损伤患者急性胃肠损伤中的应用

Function of early enteral nutrition in patients with acute gastrointestinal injury and severe craniocere- bral injury

目的观察急性胃肠损伤在重型颅脑损伤患者中的发生及其相关因素，急性胃肠损伤后喂养的可行性，并探讨临床结局与肠道喂养之间的关系。方法收集患者的临床资料，包括性别、年龄、有无急性胃肠损伤及急性胃肠损伤分级、急性生理与慢性健康状态（APACHE）Ⅱ评分、格拉斯哥昏迷量表（GCS）评分、死亡率、24h喂养率及7d热量达标率等。根据急性胃肠损伤分级将患者分为Ⅰ、Ⅱ、Ⅲ、Ⅳ级4组，对性别、年龄、APACHEⅡ评分、GCS评分、死亡率，24h喂养率及7d热量达标率进行观察。根据临床结局对患者进行死亡与存活分组，对GCS评分、24h喂养率及7d热量达标率结果进行观察。结果重型颅脑损伤患者86例均发生急性胃肠损伤，其中Ⅰ级30例、Ⅱ级26例、Ⅲ级21例、Ⅳ级9例。根据急性胃肠损伤分级，4组间APACHEⅡ评分、GCS评分及死亡率差异有统计学意义（均P〈0．05或P〈0．01），随胃肠道功能障碍越重，患者APACHEⅡ评分越高、GCS评分越低及死亡率越高。4组间患者24h喂养率和7d热量达标率比较差异有统计学意义（P〈0．01），随胃肠道功能障碍加重，患者24h喂养率及7d热量达标率呈下降趋势。根据不同临床结局分组，死亡组24h喂养率、7dg量达标率和GCS评分明显低于存活组（P〈0．01）。死亡率与24h喂养率（r=-0．478，P〈0．01）及7d热量达标率（r=-0．795，P〈0．01）和GCS评分（r=-0．638，P〈0．01）呈负相关。结论急性胃肠损伤与重型颅脑损伤密切相关，颅脑损伤、特别是重型颅脑损伤的患者，应根据患者的胃肠功能状态进行评估，尽快采取切实有效的营养支持措施，纠正代谢紊乱，改善负氮平衡状态，促进伤者康复。

Objective To observe the occurrence and related factors of acute gastrointestinal injury （AGI） in patients with severe craniocerebral injury, to discuss the feasibility of early enteral nutrition （EN） af- ter AGI, and to explore the relationship between clinical outcome and early EN. Methods We collected the clinical data of 86 patients with severe craniocerebral injury, including gender, age, presence and grading of AGI, Acute Physiology and Chronic Health Evaluation （APACHE） Ⅱ score, Glasgow coma scale （GCS）, mortality, the rate of EN within 24 hours, and 7-day standard energy intake rate. The patients were divided into four groups according to AGI grading, i. e. grade Ⅰ、Ⅱ、Ⅲ and Ⅳ, and compared in terms of gender, age, APACHE I1 score, GCS, mortality, 24-hour EN rate, and 7-day standard energy intake rate. The pa- tients were divided into two groups according to the clinical outcome （ death or survival）, and compared in terms of GCS, 24-hour EN rate, and 7-day standard energy intake rate. Results AGI occurred in all the 86 patients with severe craniocerebral injury, and the number of patients in grade I , I1 , In, IV were 30, 26, 21, 9, respectively. Among the four groups according to AGI grading, there were statistical differences in APACHE II score, GCS, and mortality （P 〈0. 05 or P 〈0. 01 ）. The more severe the gastrointestinal dysfunc- tion, the higher the APACHE I1 score and mortality, and the lower the GCS score. There were statistical differ- ences in the rate of 24-hour EN and 7-day standard energy intake rate among the four groups of AGI grading （P 〈 0. 01 ）, with both rates decreasing with more severe gastrointestinal dysfunction. Among the two groups according to different clinical outcome, the rate of 24-hour EN, 7-day standard energy intake rate and GCS score were significantly lower in the death group than in the survival group （ all P 〈 0. 01 ）. Correlation analysis showed that there was a negative correlation between mortality and the rate of 24-hour EN （r = - 0. 478, P 〈 0. 01 ）, 7-day standard energy intake （r = - 0. 795, P 〈 0. 01 ）, and GCS score （r = - 0. 638, P 〈 0. 01 ）. Condtmion AGI may be closely associated with severe craniocerebral injury. For patients with craniocerebral injury, especially severe injury, the gastrointestinal function should be estimated for timely application of effective nutrition support to improve patient outcome through correcting metabolic disturbance and negative nitrogen balance.