临床营养支持方式对机械通气效果的影响

Influence of clinical nutritional support on the effects of mechanical ventilation

目的 探讨临床营养支持方式对机械通气（MV）效果的影响，寻找MV患者撤机结果的影响因素。方法 采用病例对照研究方法，回顾性分析2015年1月至2017年6月浙江省立同德医院重症医学科（ICU）收治的235例MV患者的临床资料。按照7 d内是否成功撤机分为两组，收集两组患者的性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、基础疾病、营养指标、营养支持方式及并发症发生情况等。以7 d内撤机结果为应变量，以观察指标为自变量进行Logistic回归分析，筛选7 d内撤机结果的影响因素。结果 235例MV患者均纳入分析，7 d内撤机成功128例，撤机失败107例。与撤机成功组比较，撤机失败组患者年龄更大，APACHEⅡ评分更高，白蛋白（Alb）、血红蛋白（Hb）水平更低，内科基础疾病及接受肠外营养（PN）和混合营养的患者更多，且继发感染、呕吐、腹胀、肠鸣音异常、胃潴留、腹泻的发生率更高；但两组性别构成差异无统计学意义。将单因素分析中有统计学意义的变量纳入多因素分析模型，结果显示，年龄〔优势比（OR）=1.269，95%可信区间（95%CI）=1.119~1.439，P〈0.001〕、APACHEⅡ评分（OR=1.643，95%CI=1.423~1.897，P〈0.001）、内科基础疾病（OR=6.298，95%CI=4.012~9.887，P〈0.001）、继发感染（OR=8.323，95%CI=2.568~26.975，P〈0.001）、腹胀（OR=3.368，95%CI=1.586~7.152，P=0.002）、肠鸣音异常（OR=2.856，95%CI=1.215~6.713，P=0.017）、胃潴留（OR=1.996，95%CI=1.183~3.368，P=0.010）、腹泻（OR=3.035，95%CI=1.337~6.890，P=0.008）等是7 d内撤机失败的危险因素；相对于PN，肠内营养（OR=0.191，95%CI=0.098~0.372，P〈0.001）和混合营养（OR=0.375，95%CI=0.150~0.938，P=0.037）是撤机成功的保护因素。而性别、MV前后Alb和Hb水平、呕吐、消化道出血则与7 d内撤机结果无关。结论 高龄、APACHEⅡ评分较高、内科基础疾病，或发生继发感染、腹胀、肠鸣音异常、胃潴留、腹泻等并发症是MV患者7 d内撤机失败的危险因素；相对于PN，EN和混合营养是撤机成功的保护因素。对于MV患者，在充分复苏、血流动力学稳定、严重代谢紊乱已纠正的情况下，应早期进行EN。

Objective To study the influence of clinical nutritional support on the effects of mechanical ventilation （MV）, and to find the factors affecting the outcome of patients undergoing MV.Methods A case-control study was conducted. The clinical data of 235 patients undergoing MV admitted to intensive care unit （ICU） of Tongde Hospital of Zhejiang Province from January 2015 to June 2017 were retrospectively analyzed. The patients were divided into two groups according to whether weaning successfully within 7 days. The clinical data of patients in the two groups were collected including gender, age, acute physiology and chronic health evaluation Ⅱ （APACHEⅡ） score, underlying disease, nutritional indicators, nutritional support, and complications. The outcome of withdrawal within 7 days was served as a dependent variable, all observed indicators were served as independent variables, and Logistic regression analysis was carried out to screen the influencing factors of the weaning results within 7 days.Results 235 patients undergoing MV were enrolled, 128 patients were successfully withdrawn within 7 days, and 107 were unsuccessfully withdrawn. Compared with the successful weaning group, the patients of weaning failure group were older, and had higher APACHEⅡ score and lower albumin （Alb） and hemoglobin （Hb）, more patients with internal medical underlying diseases and receiving parenteral nutrition （PN） and mixed nutrition, and the incidences of secondary infection, vomiting, abdominal distension, abnormal bowel sound, gastric retention, and diarrhea were higher. However, there was no statistical significance in gender between the two groups. The variables of statistical significance in univariate analysis were enrolled in the multifactor analysis model showing that age [odds ratio （OR） = 1.269, 95% confidence interval （95%CI） = 1.119-1.439, P 〈 0.001], APACHEⅡ score （OR = 1.643, 95%CI = 1.423-1.897, P 〈 0.001）, internal medical underlying diseases （OR = 6.298, 95%CI = 4.012-9.887, P 〈 0.001）, secondary infection （OR = 8.323, 95%CI = 2.568-26.975, P 〈 0.001）, abdominal distension （OR = 3.368, 95%CI = 1.586-7.152, P = 0.002）, abnormal bowel sounds （OR = 2.856, 95%CI = 1.215-6.713, P = 0.017）, gastric retention （OR = 1.996, 95%CI = 1.183-3.368, P = 0.010）, diarrhea （OR = 3.035, 95%CI = 1.337-6.890, P = 0.008） were risk factors for unsuccessful weaning, and compared with PN, enteral nutrition （EN; OR = 0.191, 95%CI = 0.098-0.372, P 〈 0.001） and mixed nutrition （OR = 0.375, 95%CI = 0.150-0.938, P = 0.037） were protective factors of successful weaning. The gender, Alb and Hb before and after MV, vomiting, gastrointestinal hemorrhage were not associated with weaning outcome within 7 days.Conclusions Elder, high APACHEⅡ score, internal medical underlying diseases, or secondary infection, abdominal distension, abnormal bowel sounds, gastric retention, diarrhea were risk factors of weaning failure within 7 days in patients undergoing MV. Compared with PN, EN and mixed nutrition were protective factors for successful weaning. For patients undergoing MV, EN should be performed early in the case of full recovery, hemodynamic stability, and serious metabolic disorders.