不同镇痛镇静方案对危重症患者肠内营养实施的影响

The effects of different analgesic and sedative regimens on the implementation of enteral nutrition in critically ill patients

目的观察不同镇痛镇静方案对危重患者肠内营养实施的影响。方法收集北京大学人民医院2014年2月至2017年1月危重症患者210例,随机分为芬太尼组(芬太尼镇痛+咪达唑仑镇静,70例)、瑞芬太尼组(瑞芬太尼镇痛+咪达唑仑镇静,70例)、对照组(单纯使用咪达唑仑镇静,70例),3组中使用肠内营养患者分别有37例、37例和30例。比较3组患者性别、年龄、体质量、急性生理学与慢性健康状况评分Ⅱ(APACHE Ⅱ)、肠内营养使用率、镇痛镇静药物用量、首次肠内营养时间、肠内营养量、肠内营养使用天数/重症监护病房(ICU)住院天数、中断喂养次数、肠鸣音恢复时间、腹胀发生率、胃潴留量、大便次数、大便量、28 d生存率的差异。结果3组患者的性别、年龄、体质量、APACHE Ⅱ评分及肠内营养使用率比较差异均无统计学意义(均P>0.05)。芬太尼组和瑞芬太尼组咪达唑仑用量明显少于对照组(mg/d:144.9±31.8、164.4±31.7比181.9±42.0,P<0.05)。芬太尼组首次肠内营养使用时间明显晚于瑞芬太尼组和对照组(d:10.7±6.5比5.4±2.9、6.1±4.7,均P<0.05),但瑞芬太尼组与对照组比较差异无统计学意义(P>0.05);芬太尼组中断喂养次数多于瑞芬太尼组和对照组(次:1.50±1.20比0.70±0.39、0.70±0.27,均P<0.05),但瑞芬太尼组与对照组比较差异无统计学意义(P>0.05);3组患者肠内营养量及使用天数比较差异无统计学意义(均P>0.05);芬太尼组肠鸣音恢复时间较瑞芬太尼组与对照组最慢(10.5±6.5比5.0±3.3、6.5±4.0,均P<0.05),但瑞芬太尼组与对照组比较差异无统计学意义(P>0.05);3组患者腹胀发生率、胃潴留量、大便次数、大便量比较差异均无统计学意义(均P>0.05)。瑞芬太尼组患者28 d生存率与芬太尼组均略好于对照组,但差异无统计学意义(91.9%、91.9%比86.7%,P>0.05),但瑞芬太尼组存活天数总体好于芬太尼组。结论在镇静基础上应用芬太尼和瑞芬太尼镇痛的镇痛镇静方案对于肠内营养的实施均有一定的影响,其中芬太尼易导致危重患者胃肠道功能障碍,可明显延缓胃肠道功能的恢复,影响肠内营养的实施,而瑞芬太尼的影响较小。

Objective To observe the effects of different analgesic and sedative regimens on the implementation of enteral nutrition in critically ill patients.Methods 210 critically ill patients(February 2014-January 2017)from Peking University People's Hospital were collected and randomly divided into fentanyl group(fentanyl analgesia+midazolam sedation,70 cases),remifentanil group(remifentanil analgesia+midazolam sedation,70 cases),and control group(only used midazolam sedation,70 cases).There were 37,37,and 30 patients who used enteral nutrition in the three groups,respectively.The difference of gender,age,body mass,acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ),the enteral nutrition utilization rate,the dosage of analgesic and sedative drugs,time of first use of enteral nutrition,the dosage of enteral nutrition,the days of enteral nutrition use/the days in intensive care unit(ICU),the times of feeding interruptions,the recovery time of intestinal sounds,the incidence of abdominal distention,the amount of stomach retention,frequency of defecation,the stool volume and the 28-day survival rates were compared among the three groups.Results There were no significant differences in gender,age,body mass,APACHE Ⅱ score,and the enteral nutrition utilization rate among the three groups(all P>0.05).The dosage of midazolam in the fentanyl and remifentanil groups was significantly lower than that in the control group(mg/d:144.9±31.8,164.4±31.7 vs.181.9±42.0,P<0.05).The first time of enteral nutrition use in fentanyl group was significantly later than that in remifentanil group and control group(days:10.7±6.5 vs.5.4±2.9,6.1±4.7,both P<0.05),but there was no significant difference between remifentanil group and control group(P>0.05);the times of feeding interruptions in the fentanyl group was significantly more than that in the remifentanil group and the control group(times:1.50±1.20 vs.0.70±0.39,0.70±0.27,both P<0.05),but there was no statistically significant difference between the remifentanil group and the control group(P>0.05);there were no significant differences in the dosage of enteral nutrition and the use days among the three groups(all P>0.05).The recovery time of bowel sounds in the fentanyl group was significantly slower compared to the remifentanil group and the control group(10.5±6.5 vs.5.0±3.3,6.5±4.0,both P<0.05),but there was no statistically significant difference between the remifentanil group and the control group(P>0.05);there were no significant differences in the incidence of abdominal distention,the amount of gastric retention,frequency of defecation and stool volume among the three groups(all P>0.05).The 28-day survival rates of patients in the remifentanil group and the fentanyl group were slightly better than those in the control group,but the difference was not statistically significant(91.9%,91.9%vs.86.7%,P>0.05),however,the overall survival days in the remifentanil group were better than those in the fentanyl group.Conclusions Analgesic and sedative regimen of using fentanyl and remifentanil for analgesia based on sedation have a certain impact on the implementation of enteral nutrition,among them,fentanyl is prone to cause gastrointestinal dysfunction in critically ill patients,which can significantly delay the recovery of gastrointestinal function and affect the implementation of enteral nutrition,while the impact of remifentanil is small.