早期肠内营养标准化治疗流程管理对ARDS机械通气患者血糖变化及预后的影响

Effect of early enteral nutrition standardized treatment on blood glucose and prognosis in acute respiratory distress syndrome patients with mechanical ventilation

目的探讨早期肠内营养（EN）标准化治疗流程管理对急性呼吸窘迫综合征（ARDS）机械通气患者血糖控制的优化作用及对预后的影响。方法选择2015年4月至2017年3月浙江省湖州市第一人民医院收治的42例ARDS机械通气患者。以2016年4月1日开展EN标准化治疗流程管理为时间节点，将2015年4月1日至2016年3月31日收治的20例患者纳入对照组，2016年4月1日至2017年3月31日收治的22例患者纳入试验组。在常规治疗基础上，试验组于入院24-48 h内停止胃肠减压，开始早期经鼻肠管EN；对照组则于入院48 h后行常规EN。比较两组营养支持指标、血糖指标、血糖变异性指标以及预后指标的差异。结果与对照组比较，经过早期EN标准化治疗流程管理的试验组EN可耐受起始时间、首次排便时间、达目标喂养量时间均明显提前〔EN可耐受起始时间（h）：106.82±42.84比157.29±56.76，首次排便时间（h）：71.29±23.43比104.69±26.94，达目标喂养量时间（d）：6.24±1.25比9.86±2.36〕，7 d EN与EN＋肠外营养（PN）的比例（EN/EN＋PN）和7 d鼻肠管达标比例均明显升高〔EN/EN＋PN比例：98.69%比78.69%，鼻肠管达标比例：68.18%（15/22）比45.00%（9/20）〕；平均血糖（GLUave）、最高血糖（GLUmax）、血糖标准差（GLUsd）、血糖变异系数（GLUcv）、高血糖发生率、多器官功能障碍综合征（MODS）发生率、28 d病死率均明显降低〔GLUave（mmol/L）：9.4±2.6比11.5±3.9，GLUmax（mmol/L）：14.19±2.36比16.26±4.89，GLUsd（mmol/L）：4.86±1.27比6.87±2.46，GLUcv：（49.86±6.32）%比（59.95±5.81）%，高血糖发生率：59.09%（13/22）比80.00%（16/20），MODS发生率：59.09%（13/22）比80.00%（16/20），28 d病死率：36.36%（8/22）比45.00%（9/20）〕，最低血糖（GLUmin）明显升高（mmol/L：5.86±2.32比4.18±1.86）；有创机械通气时间明显缩短（h：156.82±26.84比169.93±32.34）；上述各指标比较差异均有统计学意义（均P〈0.05）。早期EN还可以改善患者的肺氧合功能，从病程9 d起，试验组氧合指数（PaO2/FiO2）明显高于对照组〔mmHg（1 mmHg=0.133 kPa）：256.97±18.63比239.82±21.72，P〈0.05〕，但ICU住院时间比较差异无统计学意义（d：13.9±3.6比14.8±3.4，P=0.068）。结论对ARDS机械通气患者进行早期EN标准化治疗流程管理可改善营养状况，降低血糖波动水平，进而有利于预后的改善。

ObjectiveTo study the effect of early entreat nutrition （EN） standardized treatment on optimization of blood glucose control and prognosis in acute respiratory distress syndrome （ARDS） patients with mechanical ventilation （MV）.MethodsForty-two patients with MV of ARDS admitted to Huzhou First Municipal People＇s Hospital from April 2015 to March 2017 were enrolled. April 1st, 2016 was taken as the time node, the patients treated from April 1st, 2015 to March 31st, 2016 were assigned in the control group （n = 20）, while the patients treated from April 1st, 2016 to March 31st, 2017 were included in the experimental group （n = 22）. The patients in experimental group were given conventional treatment, in 24-48 hours after admission gastrointestinal decompression was stopped and early EN was begun through a nasointestinal tube; the patients in control group received conventional treatment and routine EN （given 48 hours after admission）. The differences in nutritional support indexes, the blood glucose variability indexes and the prognostic related indicators were compared between the two groups.ResultsCompared with the control group, the initiation time for EN tolerance, first defecation time, time of reaching target feeding amount were significantly earlier in the early EN standardized treatment process management [time of initial EN tolerance （hours）： 106.82±42.84 vs. 157.29±56.76, first defecation time （hours）： 71.29±23.43 vs. 104.69±26.94, time of reaching target feeding amount （days）： 6.24±1.25 vs. 9.86±2.36], the proportions of EN/EN＋parenteral nutrition （PN） and the nasointestinal tube feeding reaching the standard on 7 days in experimental group were significantly increased [the proportion of EN/EN＋PN： 98.69% vs. 78.69%, the nasointestinal tube feeding reaching standard： 68.18% （15/22） vs. 45.00% （9/20）], average level of blood glucose （GLUave）, maximum value of blood glucose （GLUmax）, standard deviation of blood glucose （GLUsd）, coefficient of variation of blood glucose （GLUcv）, hyperglycemia incidence, incidence of multiple organ dysfunction syndrome （MODS）, 28-day mortality were significantly decreased [GLUave （mmol/L）： 9.4±2.6 vs. 11.5±3.9, GLUmax （mmol/L）： 14.19±2.36 vs. 16.26±4.89, GLUsd （mmol/L）： 4.86±1.27 vs. 6.87±2.46, GLUcv： （49.86±6.32）% vs. （59.95±5.81）%, hyperglycemia incidence： 59.09% （13/22） vs. 80.00% （16/20）, incidence of MODS： 59.09% （13/22） vs. 80.00% （16/20）, 28-day mortality： 36.36% （8/22） vs. 45.00% （9/20）], minimum value of blood glucose （GLUmin） was significantly increased （mmol/L： 5.86±2.32 vs. 4.18±1.86）, invasive MV time was significantly shorted （hours： 156.82±26.84 vs. 169.93±32.34） with statistically significant differences （all P 〈 0.05）. Early EN could also improve the patient＇s pulmonary oxygenation function. Since 9 days of disease course, the oxygenation index （PaO2/FiO2） in the experimental group was significantly higher than that of the control group [mmHg （1 mmHg = 0.133 kPa）： 256.97±18.63 vs. 239.82±21.72, P = 0.068], but there was no significant difference in the length of ICU stay （days： 13.9±3.6 vs. 14.8±3.4, P 〉 0.05）.ConclusionThe early EN standardized treatment process management can improve the nutritional status, decrease blood sugar fluctuations, and further benefit the improvement of the prognosis of ARDS patients with MV.