早期肠内营养对静脉-动脉体外膜肺氧合患者预后的影响

摘要

目的 观察静脉-动脉体外膜肺氧合(VA-ECMO)患者早期肠内营养(EEN)的可行性及相关的临床结果.方法 选择2012年1月至2017年12月入住宁波市医疗中心李惠利医院重症医学科(ICU)使用VA-ECMO治疗的34例患者作为研究对象.所有患者均在排除禁忌证后积极实施EEN,按照104.65 kJ·kg-1·d-1(25 kcal·kg-1·d-1)计算目标热卡量,按照1.2 g·kg-1·d-1计算目标蛋白量,以1周内是否达到上述目标量的80%将患者分为达标组和非达标组,观察两组患者入ICU时急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、多器官功能障碍综合征(MODS)评分、ECMO治疗至开始EN的时间、EN达标时间、VA-ECMO持续时间、ICU住院时间,总住院时间及住院病死率,并记录EN中断的原因,分析VA-ECMO患者EEN对预后的影响.结果 非达标组入ICU时APACHEⅡ评分、MODS评分均高于达标组〔APACHEⅡ评分(分):25.50±5.62比19.91±8.53,MODS评分(分):11.08±3.26比6.73±2.05,均P＜0.05〕,且达标组的住院病死率更低〔40.9%(9/22)比83.3%(10/12),P＜0.05〕.两组ECMO治疗至开始EN时间、EN达标时间、VA-ECMO治疗时间、ICU住院时间、总住院时间比较差异无统计学意义(均P＞0.05).高胃残余量是喂养中断最主要的原因.结论 接受VA-ECMO的危重患者能否在1周内达到目标喂养量,与疾病的危重程度相关,疾病危重者较难达到目标喂养量,进而可能影响患者的预后.%Objective To observe the feasibility of early enteral nutrition (EEN) in adult patients during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and its related clinical results. Methods Thirty-four patients admitted to the Intensive Care Unit (ICU) of Ningbo Medical Center Li Huili Hospital from January 2012 to December 2017 to receive VA-ECMO treatment were selected as the study objects. All patients received EEN after exclusion of contraindications; the target calories were calculated by using 104.65 kJ·kg-1·d-1(25 kcal·kg-1·d-1) and according to 1.2 g·kg-1·d-1, the target protein requirements were calculated. Within one week of EN energetic treatment, if the feeding amount reached 80% or over of the above calculated targets, the EN administration was fulfilling the standard, thus the patients were divided into a standard group and a non-standard group, After ICU admission, the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, multiple organ dysfunction syndrome (MODS) score, the time from the beginning of ECMO to the start of EN, time reaching feeding standard, VA-ECMO persistent days, ICU days of stay, total hospitalization days, hospital mortality, and reasons for feeding interruptions were recorded, and the effects of EEN on prognosis of patients during VA-ECMO were analyzed in the two groups. Results The APACHE Ⅱ score and MODS score of the non-standard group were higher than those of the standard group on admission of ICU (APACHE Ⅱscore: 25.50±5.62 vs. 19.91±8.53, MODS score: 11.08±3.26 vs. 6.73±2.05, both P < 0.05), and the hospital mortality was lower in the standard group than that in non-standard group [40.9% (9/22) vs. 83.3% (10/12), P < 0.05]. The comparisons of differences in time from the beginning of ECMO to the start of EN, time of reaching feeding standard, VA-ECMO treatment days, ICU days of stay, hospitalization days between the two groups were of no statistical significance (all P > 0.05). The most common reason for interruption of feeding was high gastric residual volume (GRV). Conclusion Whether a critically ill patient receiving VA-ECMO can reach the target feeding amount in a week or not is related to the degree of disease severity; it is difficult for a seriously ill patient to reach the target amount of feeding, that may affect their prognosis.