超声导向的胃肠内营养在神经重症患者中的实施

Implementation of ultrasound-guided gastrointestinal nutrition in critically ill neurological patients

目的使用改良B超胃窦单切面法检测胃窦运动指数(motility index,MI)来指导神经重症患者的经胃营养,避免空肠营养的副作用,同时最大限度减少反流误吸的不良后果。方法选取格拉斯哥昏迷评分(Glasgow coma scale,GCS)<8分的神经重症患者18例作为研究组实施经胃营养,使用B超每日行胃窦单切面法测定空腹MI,确定当天的营养计划。同期选取19例GCS评分<8分的神经重症患者实施经空肠营养作为对照组,营养计划由主管医师根据经验制定,肠内营养实施期间,根据患者的胃残余量与胃肠道耐受性调整肠内营养(enteral nutrition,EN)速度与量。比较两组患者的一般情况、EN实施情况及并发症、预后相关指标等。结果研究组患者EN起始速度[(52.0±14.5)ml/h]高于对照组[(35.0±12.5)ml/h,P=0.045)];达全量营养(total enteral nutrition,TEN)的时间[(3.2±0.8)天)短于对照组[(5.2±0.9)天,P=0.048)];研究组的反流、新发肺炎、呕吐、腹泻及腹胀等并发症的发生率以及感染发生率、呼吸机使用时间及住ICU时间与对照组相比差异无统计学意义。结论使用超声导向的肠内营养方案指导经胃营养在神经重症患者中实施效果良好,不会增加感染及胃肠道不耐受等的发生率,是维护胃肠道结构功能完整性、最符合生理的肠内营养支持方式,可避免长期空肠喂养的副作用。

Objective To guide the gastric nutrition in critically ill neurological patients and to avoid the side effects of jejunum nutrition and minimize the adverse effects of aspiration and regurgitation using the antral motility index（MI） detected by modified single transverse section of gastric antrum measurement with ultrasonography. Methods Eighteen critically ill neurological patients with Glasgow Coma Scale（GCS） score lower than 8 points were enrolled in the study group and gastric nutrition was implemented in this group. Single transverse section of gastric antrum measurement was used to detect the MI of the patients every day and their daily nutrition plans were determined afterwards. During the same period of time, 19 cases of critically ill neurological patients with GCS score lower than 8 points were selected as the control group to implement jejunum nutrition, and their daily nutrition plan were developed by the physicians in charge based on their clinical experience. During the implementation of enteral nutrition, the amount and speed of enteral nutrition（EN） were adjusted according to the patients＇ gastric residual volume（GAV） and gastrointestinal tolerance. The two groups＇ general situation, EN implementation and related complications as well as prognostic indicators etc. were compared. Results The initial speed of EN in the study group was higher than that in the control group（52±14.5 ml/h v.s 35±12.5 ml/h, P=0.045）. The time of the study group reaching total enteral nutrition（TEN） was shorter than that of the control group（3.2±0.75 d v.s 5.2±0.92 d, P=0.048）. The differences in incidence of complications such as reflux, new onset of pneumonia, vomiting, diarrhea and abdominal distension as well as the incidence of infection, duration of mechanical ventilation and ICU stay were not statistically significant between the two groups. Conclusion Using ultrasound-guided enteral nutrition program to guide the implementation of gastric nutrition in critically ill neurological patients had shown good results. The incidence of infection and gastrointestinal intolerance will not increase. Therefore, ultrasound-guided gastric nutrition is an ideal physiological nutrition support method to maintain the structural integrity of the gastrointestinal tract, which can avoid the side effects of long-term jejuna feeding.