Can we stomach gastric feeding in critically ill patients with gastrointestinal intolerance?
Can we stomach gastric feeding in critically ill patients with gastrointestinal intolerance?
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胃肠道不耐受的重症患者可以胃饲吗？
DOI：
10.1097/ccm.0b013e318258f057
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发表时间：
2012
影响因子：
8.8
通讯作者：
Rice,ToddW
中科院分区：
文献类型：
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作者：
Rice,ToddW
观察数据表明，肠内营养与危重患者的更好结局相关（1-3）。这些研究还表明，增加营养输送与改善结局相关，尽管这些数据受到疾病严重程度的混淆，并且病情较重的患者不太可能耐受肠内营养，并且更可能有更差的结局。胃肠道不耐受常常限制危重患者的肠内营养输送。两种最常见的不耐受是胃残留量增加和呕吐。幽门后放置肠内营养管是临床实践中试图克服这些不耐受的一种方法，但幽门后营养管的益处仍存在争议。早期的研究发现，幽门远端进食的患者比胃内进食的患者获得的目标卡路里百分比更高（4，5）。然而，这些研究中的数据收集是在开始肠内喂养时开始的，而不考虑将喂养管置于幽门后位置时可能发生的任何延迟。一项针对异质性危重患者组的9项研究的荟萃分析表明，忽略这种延迟可能会混淆结果（6）。Marik和Zaloga发现，与幽门后途径相比，随机接受胃内营养的患者开始肠内喂养的时间平均短16小时。随机分配至两组的患者之间的总体热量输送相似。Ho及其同事（7）在对11项随机研究的单独荟萃分析中也发现热量输送没有差异。其他观察数据表明，提供肠内营养会增加机械通气患者呕吐、误吸和呼吸机相关性肺炎（VAP）的风险（8）。许多人认为这些风险来自胃肠道不耐受，特别是胃残留量增加和肠内食物反流到食管及以上。将肠内营养管放置在幽门远端应该可以降低这种风险。然而，以前的随机试验发现了与这一理论相矛盾的结果。Hsu及其同事（9）发现，与胃肠道喂养相比，幽门后管增加了重症医学患者的肠内营养输送量，并减少了呕吐和VAP。白色及其同事（10）使用几乎完全相同的纳入和排除标准，将102例患者随机分为初始幽门后或胃肠道喂养组，发现两组之间在热量输送、胃肠道不耐受或VAP方面没有差异。同样，两项荟萃分析发现，幽门后放置肠内营养管并不能降低死亡率、肺炎发生率、误吸率或重症监护病房住院时间（5，6）。
Observational data suggest that enteral nutrition is associated with better outcomes in critically ill patients (1–3). These studies also suggest that increased nutrient delivery is associated with improved outcomes, although these data are confounded by severity of illness and the fact that sicker patients are both less likely to tolerate enteral nutrition and more likely to have worse outcomes. Gastrointestinal intolerances often limit delivery of enteral nutrition in critically ill patients. Two of the most common intolerances are elevated gastric residual volumes and vomiting. Postpyloric placement of the enteral feeding tube represents one method utilized in clinical practice in an attempt to overcome these intolerances, yet the benefit of postpyloric feeding tubes remains controversial. Early studies found that patients fed distal to the pyloris received a higher percentage of their goal calories than those fed into the stomach (4, 5). However, data collection in these studies began at the time of initiation of enteral feeds, regardless of any delay that may have occurred while placing a feeding tube into the postpyloric position. A meta-analysis of nine studies in a heterogeneous group of critically ill patients suggested that ignoring this delay may have confounded the results (6). Marik and Zaloga found that time to initiation of enteral feeding was, on average, 16 hrs shorter in patients randomized to receive enteral nutrition via the gastric compared to the postpyloric route. Overall caloric delivery was similar between the patients randomized to the two groups. Ho and colleagues (7) also found no difference in caloric delivery in a separate meta-analysis of 11 randomized studies.Other observational data suggest that the provision of enteral nutrition increases the risk of vomiting, aspiration, and ventilator-associated pneumonia (VAP) in mechanically ventilated patients (8). Many believe these risks arise from gastrointestinal intolerances, especially elevated gastric residual volumes and regurgitation of enteral food into the esophagus and above. Placement of the enteral feeding tube distal to the pyloris should logically reduce this risk. However, previous randomized trials have found conflicting results to this theory. Hsu and colleagues (9) found that postpyloric tubes increased the amount of enteral nutrition delivered and also reduced vomiting and VAP compared to gastrically delivered enteral feedings in critically ill medical patients. Using almost the exact same inclusion and exclusion criteria, White and colleagues (10) randomized 102 patients to either initial postpyloric or gastric enteral feedings and found no difference between the groups with regard to caloric delivery, gastrointestinal intolerances, or VAP. Likewise, two meta-analyses found that postpyloric placement of the enteral feeding tube did not reduce mortality, development of pneumonia, aspiration, or intensive care unit length of stay (5, 6).