A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness
A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness
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DOI：
10.1097/ccm.0b013e318255d87e
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发表时间：
2012-08-01
影响因子：
8.8
通讯作者：
Heyland, Daren K.
中科院分区：
文献类型：
--
作者：
Davies, Andrew R.;Morrison, Siouxzy S.;Heyland, Daren K.
目的：目前的指南建议危重成人进行肠内营养，然而，胃动力不良往往阻碍营养目标的实现。我们假设早期鼻空肠营养将改善肠内营养的输送。设计：前瞻性、随机、对照试验。背景：澳大利亚的17个多学科、封闭的内外科重症监护病房。患者：181名在重症监护病房入院后72小时内胃残留量增加的机械通气成人。干预：患者被随机分配到接受早期鼻空肠营养的患者中，这些患者通过自发迁移的摩擦鼻空肠管或持续鼻胃营养。测量和主要结果：主要结果是标准化估计的能量需求作为肠内营养提供的比例。次要结果包括呼吸机相关性肺炎、胃肠道出血和住院死亡率。92例患者分为早期鼻空肠营养组和持续鼻胃营养组。基线特征相似。79例(87%)早期鼻空肠营养患者在中位时间15(四分位数范围7-32)小时后被证实将鼻空肠管放置到小肠。早期鼻空肠营养提供的目标能量比例为72%，鼻胃营养为71%(平均差值为1%，95%可信区间为-3%~5%，p=.66)。呼吸机相关性肺炎的发生率(20%比21%，p=.94)、呕吐、目击误吸、腹泻和死亡率相似。早期鼻空肠营养组胃肠道出血较常见(12例[13%]vs.3例[3%]，p=0.02)。结论：在已接受鼻胃营养的机械通气患者中，早期鼻空肠营养不能增加能量供应，也不能减少肺炎的发生率。轻度上消化道出血率升高。对于此类患者，不推荐常规放置鼻空肠管。(Crit Care Med 2012；40：2342-2348)
Objective: Current guidelines recommend enteral nutrition in critically ill adults; however, poor gastric motility often prevents nutritional targets being met. We hypothesized that early nasojejunal nutrition would improve the delivery of enteral nutrition.Design: Prospective, randomized, controlled trial.Setting: Seventeen multidisciplinary, closed, medical/surgical, intensive care units in Australia.Patients: One hundred and eighty-one mechanically ventilated adults who had elevated gastric residual volumes within 72 hrs of intensive care unit admission.Interventions: Patients were randomly assigned to receive early nasojejunal nutrition delivered via a spontaneously migrating frictional nasojejunal tube, or to continued nasogastric nutrition.Measurements and Main Results: The primary outcome was the proportion of the standardized estimated energy requirement that was delivered as enteral nutrition. Secondary outcomes included incidence of ventilator-associated pneumonia, gastrointestinal hemorrhage, and in-hospital mortality rate. There were 92 patients assigned to early nasojejunal nutrition and 89 to continued nasogastric nutrition. Baseline characteristics were similar. Nasojejunal tube placement into the small bowel was confirmed in 79 (87%) early nasojejunal nutrition patients after a median of 15 (interquartile range 7-32) hrs. The proportion of targeted energy delivered from enteral nutrition was 72% for the early nasojejunal nutrition and 71% for the nasogastric nutrition group (mean difference 1%, 95% confidence interval -3% to 5%, p = .66). Rates of ventilator-associated pneumonia (20% vs. 21%, p = .94), vomiting, witnessed aspiration, diarrhea, and mortality were similar. Minor, but not major, gastrointestinal hemorrhage was more common in the early nasojejunal nutrition group (12 [13%] vs. 3 [3%], p = .02).Conclusions: In mechanically ventilated patients with mildly elevated gastric residual volumes and already receiving nasogastric nutrition, early nasojejunal nutrition did not increase energy delivery and did not appear to reduce the frequency of pneumonia. The rate of minor gastrointestinal hemorrhage was increased. Routine placement of a nasojejunal tube in such patients is not recommended. (Crit Care Med 2012; 40: 2342-2348)