HEYLAND DK, DHALIWALR, DROVER JW, et al.Canadian clinical practice guidelines for nutrition support in mechanically ventilated,critically ill adult patients[J].JPEN J Parenter Enteral Nutr, 2003, 27(5):355-373.
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BALDONADOA,NAQVI MA,GARLANDA,et al.Evidence based practice strategy: increasing nutrition in mechanically ventilated trauma surgical patients[J].Dimens Crit Care Nurs,2011,30(6):346-355.
Abstract Malnutrition is common in the intensive care unit (ICU) and is related to higher incidence of morbidity and mortality among seriously ill patients. Achieving a quality nutritional care plan is a challenge to critical care practitioners and dietitians worldwide. The multifaceted and advanced therapies in the ICU historically take priority over nutritional assessments and interventions and may cause delay in achieving quality nutritional care. The initiation of nutrition in mechanically ventilated adult trauma patients is inconsistent in some hospitals. The implementation plan in this early nutrition project involved an algorithm, physicians order set, and nurse advocacy plan. Early nutritional support will likely be associated with improved clinical outcomes.
KATTELMANN KK,HISEM,RUSSELLM,et al.Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients[J].J Am Diet Assoc,2006,106(8):1226-1241.
The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically ill patients. The data sources consisted of an intensive literature review from five databases, using standardized search terms. Randomized controlled clinical trials, meta-analyses, consensus statements, reviews, US Food and Drug Administration alerts, and case reports were selected for study. Research reports were abstracted in detail and evaluated for research quality using the criteria developed by the American Dietetic Association. Consensus statements regarding the influence of specific enteral feeding methods on key clinical outcomes (ie, infectious complications, cost, length of hospital stay, and mortality) were developed and graded based on the quality of the available evidence. The data support the use of enteral over parenteral nutrition to reduce infectious complications and cost, and the initiation of enteral feedings within 24 to 48 hours of injury or admission to an intensive care unit to reduce infectious complications and length of hospital stay in head injury and trauma patients. Postpyloric tube placement is associated with reduced gastric residual volume and reflux, but adequately powered trials are not available to support prevention of aspiration pneumonia. Acceptance of gastric residual volumes of up to 250 mL may increase volume of formula delivered. Promotility agents are associated with reduced gastric residual volume. Feeding patients in the semirecumbent rather than supine position is associated with reduced aspiration pneumonia and pharyngoesophageal formula reflux. Actual delivery of 14 to 18 kcal/kg/day or 60% to 70% of goal is associated with improved outcomes, whereas greater intake may not be in some populations. Blue food coloring should not be used with enteral feedings due to its limited sensitivity for aspiration and some risk of mortality. Well-designed, adequately powered, randomized controlled clinical trials are needed to evaluate any benefit of tube tip position on aspiration pneumonia or mortality, and of early enteral feedings on mortality.
HEIGHES PT,DOIG GS,SWEETMAN EA,et al.An overview of evidence from systematic reviews evaluating early enteral nutrition in critically ill patients: more convincing evidence is needed[J].Anaesth Intens Care,2010, 38(1):167-174.
International quality improvement initiatives such as Fast-Hug bring a focus on improving the delivery of early enteral nutrition to critically ill patients, however surveys demonstrate current practice remains variable. One way to reduce variability in practice is to provide strong evidence to convince clinicians to change. The purpose of this overview was to identify current best evidence supporting the delivery of early enteral nutrition in critical illness. We sought high-quality evidence in the form of systematic reviews containing meta-analyses of randomised controlled trials. Two authors independently identified studies and assessed methodological quality. Data sources included Medline, EMBASE and hand-searching of guideline reference lists. The literature search identified five systematic reviews that summarised 30 clinical trials. These systematic reviews focused on acutely hospitalised patients, critical illness, burns, elective intestinal surgery and pancreatitis. Early enteral nutrition significantly reduced mortality in elective intestinal surgery patients (relative risk 0.41, 95% confidence interval 0.18 to 0.93, P = 0.03, I2 = 0.0%) and significantly reduced infectious complications in acutely ill hospitalised patients (relative risk 0.45, 95% confidence interval 0.3 to 0.66, P = 0.00006, heterogeneity P = 0.049). Four of five identified systematic reviews had key methodological quality deficiencies. The results of this overview highlight the variability in the evidence regarding the benefits of early enteral nutrition in critically ill patient populations. The inconsistent delivery to critically ill patients may be explained by the lack of convincing evidence. Better evidence may be needed to reduce the irregularity in the provision of early enteral nutrition to critically ill patients.
目的探讨肠内营养支持治疗对老年重症肺炎的疗效。方法选择58例老年重症肺炎患者分成2组,肠内营养组29例,肠外营养组29例,比较治疗前后肱三头肌皮褶厚度、上臂肌围、血红蛋白、血清白蛋白、相关并发症发生及治疗前1 d,治疗后第5、10 d血清IgA、IgG、IgM的变化。结果肠内营养组治疗后血红蛋白及白蛋白水平显著提高,明显高于肠外营养组治疗后的水平(P0.05),但在比较肱三头肌皮褶厚度、上臂肌围中差异无统计学意义(P0.05);肠内营养组治疗后血清免疫球蛋白IgA、IgG、IgM均显著增加[(IgA(2.30±0.25)与(1.78±0.21)]g/L;IgG(10.32±1.78)与(8.51±1.21)g/L、IgM(1.78±0.20)与(1.34±0.19)g/L,P0.05)],而肠外营养组增加不显著;肠内营养组治疗后第10 d 3种免疫球蛋白水平与肠外营养组比较差异均有统计学意义(P0.05);2组并发症发生的比较差异无统计学意义(P0.05)。结论老年重症肺炎治疗中运用肠内营养支持,对促进患者康复有益。
, 龚晨
