经皮胃空肠造瘘术对重型颅脑损伤患者营养摄入及预后的影响

Effects of percutaneous gastrojejunostomy on nutritional intake and prognosis in severe brain injury patients

目的探讨重型颅脑损伤患者早期通过经皮胃空肠造瘘管进行肠内营养支持后能量摄人的变化以及对预后的影响。方法选取2013年1月至2016年12月入住常熟市第一人民医院重症监护病房（ICU）的重型颅脑损伤患者，按随机数字表法分为经胃管喂养组（对照组）和经经皮胃空肠造瘘管（PEG-J）喂养组（治疗组）。根据胃残余量或反流呕吐发生情况调整鼻饲速度。比较两组患者前7d肠内营养摄人情况，治疗后患者免疫、内分泌功能及营养状况，28d病死率、28d日常生活活动能力量表（Barthel指数）评分、住院时间、感染及其他并发症的发生率。结果共87例患者纳入研究，对照组45例，治疗组42例。治疗组自第4天起靶能量达标率明显高于对照组（P=0．001，〈0．01，0．024），第7天时治疗组外周血清CD4^＋水平、CD4^＋CD8^＋比值高于对照组（P=0．03，0．01），促甲状腺激素、游离T3及游离T4水平高于对照组（P=0．036，0013，0．025），皮质醇浓度低于对照组（P=0．004），28d时两组患者白蛋白水平、前白蛋白水平、胰岛素用量等差异无统计学意义，28d病死率、新发器官功能不全情况相似，治疗组28d Barthel指数评分高于对照组（P=0．049），机械通气时间及住ICU时间缩短（P=0．044，0．048），呕吐反流发生率及呼吸机相关性肺炎发生率下降（P=0．013,0．037）。结论重型颅脑损伤患者早期通过经皮胃空肠造瘘管实施肠内营养，可以提高能量摄人，改善早期免疫及内分泌功能，促进后期生活能力的恢复，缩短机械通气时间及ICU时间，降低呼吸机相关性肺炎的发生。

Objective To evaluate the effects on nutritional intakes and clinical outcomes of severe brain injury patients receiving percutaneous gastrojejunostomy （PEG-J） feedings. Methods The severe brain injury patients treated in ICU of Changshu No. 1 Hospital from Jan 2013 to Dec 2016 were enrolled in the study. Patients were randomized into： control group, patients received nasoduodenal feedings and treatment group, patients received PEG-J feedings. The feeding speed was adjusted according to the amount of gastric residual or reflux vomiting. The daily dose of enteral nutrition in the first week, endocrine function, immune function, nutritional states and clinical outcomes were recorded. Results Totally 87 patients were enrolled in this study, 45 patients in the control group and 42 patients in the treatment group. The daily dose of enteral nutrition of the treatment group were significantly more than the control group from the fourth to the seventh days （P= 0.001, （0.01, 0.024）, the CD4^＋T-lymphocyte percentage and CD4^＋/CD8^＋ ratio were significantly higher in the treatment group on day 7 （P=0.03, 0.01）, levels of thyroidstimulating hormone, free triiodothyronine and free thyroxine of the treatment group were higher （P=0.036, 0.013, 0.025）, and the level of hormonal was lower in the treatment group （P=0.004）.The levels of albumin, prealbumin and insulin dosage were not significantly different between the two groups, neither did mortality, rates of organ failures. But the treatment group has a higher Barthel index scores （P=0.049）, shorter length of mechanical ventilation and stay ICU （P=0.044, 0.048）, and the lower incidence of vomiting and ventilator associated pneumonia （P=0.013, 0.037）. Conclusions PEG-J could increase energy intake, improve immunity and endocrine function, promote the recovery of life ability, reduce the incidence of VAP, shorten mechanical ventilation time and ICU stay in severe brain injury patients.