ICU危重症患者肠内营养早期的腹泻调查研究

发布时间：2018-05-13 16:27

本文选题：肠内营养 + 腹泻　；参考：《浙江大学》2017年硕士论文

【摘要】：目的:了解监护室内危重症患者肠内营养早期阶段腹泻的发生情况及相关因素,为提高此类患者的肠内营养治疗水平提供参考。方法:自2016年6月1日至10月31日对浙江省内28家综合性医院的29个ICU进行了前瞻性断面调查。调查对象为新入住ICU且行肠内营养治疗的连续患者。调查时间自患者入住ICU实施肠内营养后开始,连续观察7 d或直至转出ICU。记录患者的一般指标,包括性别、年龄、体重指数、入院诊断;病情严重度指标,包括急性生理与慢性健康评分、营养风险筛查评分2002、是否机械通气、是否使用血管活性药物、血清白蛋白水平;肠内营养指标,包括肠内营养(开始时间、每日给予的液体量、每日给予的热卡量、输注途径、输注方式)、是否使用促胃肠动力药;腹泻相关指标,包括大便次数、大便性状、大便常规中白细胞定性结果、腹泻处理措施(包括暂停肠内营养、使用止泻药物、使用益生菌及其他情况);预后指标,包括机械通气时间、ICU住院时间、ICU期间住院费用、出院预后转归。采用多因素Zogistic回归分析腹泻和死亡的危险因素。结果:1、研究对象的基本信息:纳入研究的533例患者中,男性354例(66.4%),女性179例(33.6%);年龄19～96岁,中位数值为67(51,79)岁;体重指数中位数值为22.0(19.5,23.9)kg/m2;急性生理与慢性健康评分中位数值为18.0(13.0,23.0)分;营养风险筛查评分2002中位数值为4.0(3.0,5.0)分;ICU住院时间中位数值为10.0(6.0,15.0)d;住院病死率为17.3%(92例)。2、肠内营养基本情况:肠内营养开始时间的中位数值为在入ICU后的第1(1,2)d;其中采用幽门前喂养的患者有466例(87.4%),幽门后喂养的患者有67例(12.6%);采用持续输注方式的患者有435例(81.6%),间歇输注方式的患者有98例(18.4%);肠内营养时使用促胃肠动力药的患者有237例(44.5%),未使用促胃肠动力药的患者有296例(55.5%)。肠内营养开始后随着ICU住院时间延长,肠内营养的液体量和热卡值逐渐增加,不同时间的比较差异有统计学意义(P0.001)。3、腹泻的发生情况:研究期间腹泻的发生率为30.8%(164例),其中明确的感染性腹泻发生率为4.1%(22例)。腹泻最常见于肠内营养开始后第1～3d,随着ICU住院时间延长,新发生腹泻的比例逐渐下降,不同时间的发生情况比较差异有统计学意义(P0.001)。腹泻持续时间中位数值为2(1,3)d,每日大便次数中位数值为4(3,5)次。在28家医院中,二甲医院有4家,腹泻发生率为32.8%;三乙医院有10家,腹泻发生率为36.2%;三甲医院有14家,腹泻发生率为26.3%,各级医院腹泻发生情况比较差异无统计学意义(P0.05)。在不同疾病诊断中,呼吸心跳骤停患者的腹泻发生率最高为61.5%(8例),心血管系统疾病患者的腹泻发生率最低为17.8%(8例)。不同疾病的腹泻发生率比较差异有统计学意义(P0.05)。4、腹泻的危险因素:多因素Logistic回归分析表明,使用促胃肠动力药、急性生理与慢性健康评分增高及幽门后喂养途径是腹泻的独立危险因素,相应的OR值(95%CI)为 1.82(1.24-2.65)、1.04(1.02-1.07)、1.90(1.11-3.36)。5、腹泻的处理:164例腹泻患者中,116例(70.7%)进行了相关治疗,处理措施主要有使用止泻药物、使用益生菌、暂停肠内营养及其他措施,分别为97例(59.1%)、55 例(33.5%)、46 例(28.0%)、2 例(1.2%)。97 例使用止泻药物的患者中有82例(84.6%)使用思密达止泻,8例(8.2%)使用易蒙停片止泻,7例(7.2%)使用易蒙停联合思密达止泻;46例有暂停肠内营养的患者,肠内营养中断时间中位数值为10(3,24)h;2例患者口服抗生素治疗。6、预后分析:单因素分析表明,腹泻组较无腹泻组患者机械通气时间延长(6.0 dvs.5.0 d,P=0.003)、ICU 住院时间更长(11.0 dvs.9.0 d,P=0.000)、住院病死率更高(23.2%vs.14.6%,P=0.016)。多因素Zogistic回归分析表明,暂停肠内营养、急性生理与慢性健康评分增高、使用血管活性药物及肠内营养开始时间延后(48h)是死亡的独立危险因素,相应的OR值(95%CI)分别为3.74(1.85-7.54)、1.07(1.04-1.11)、2.31(1.42-3.77)、2.00(1.08-3.70)。结论:本研究范围的ICU危重症患者开始肠内营养1周内的腹泻发生率为30.8%,腹泻最常见于肠内营养开始后第1～3 d,持续时间中位数值为2(1,3)d。病情严重度增高、使用促胃肠动力药、幽门后喂养途径是增加腹泻的高危因素。腹泻患者机械通气和ICU住院时间延长,住院病死率增加,其中暂停肠内营养可能是增加患者死亡风险的原因。
[Abstract]:Objective: to understand the occurrence and related factors of enteral nutrition at the early stage of the critically ill patients in the guardianship, and to provide a reference for improving the level of enteral nutrition in this kind of patients. Methods: from June 1, 2016 to October 31st, a prospective cross-sectional survey was conducted on 29 ICU in 28 comprehensive hospitals in Zhejiang province. Continuous patients who were treated with ICU and enteral nutrition. The time of investigation was from the beginning of ICU after enteral nutrition, a continuous observation of 7 d or until the transfer of ICU. records, including sex, age, body mass index, admission diagnosis, severity index, including acute physiological and chronic health scores, and nutritional risk screening score of 2 002, whether mechanical ventilation, vasoactive drugs, serum albumin levels, enteral nutrition indicators, including enteral nutrition (starting time, daily dose of liquid, daily dose of heat, infusion route, infusion), and whether use of gastrointestinal motility drugs; diarrhoea related indicators, including stool times, stool traits, stool routine Qualitative results of medium white blood cells, measures for treatment of diarrhea (including suspension of enteral nutrition, use of antidiarrheal drugs, use of probiotics and other conditions); prognostic indicators, including mechanical ventilation time, ICU hospitalization time, hospitalization expenses during ICU, prognosis of discharge. Multiple factor Zogistic regression was used to analyze the risk factors of diarrhea and death. Results: 1. Basic information of the image: of the 533 patients enrolled in the study, 354 (66.4%) were male (66.4%) and 179 (33.6%) for women; the median age was 67 (51,79) years old; the median value of body mass index was 22 (19.5,23.9) kg/m2; the median of the acute physiological and chronic health score was 18 (13.0,23.0); the median value of the nutritional risk screening score was 4 (3.) (3.). The median inpatient time of ICU was 10 (6.0,15.0) d; the hospitalized mortality rate was 17.3% (92 cases).2, and the basic nutrition of enteral nutrition: the median value of enteral nutrition was first (1,2) d after ICU; 466 cases (87.4%) were fed before pyloric feeding, 67 patients (12.6%) were fed after pylorus; continuous infusion method was used. There were 435 patients (81.6%) and 98 patients (18.4%) with intermittent infusion; 237 (44.5%) were used for enteral nutrition, 237 (44.5%), and 296 (55.5%) who did not use GI. After the onset of enteral nutrition, the amount of enteral nutrition and the heat card value increased gradually with the length of ICU stay. The difference was statistically significant (P0.001).3, the occurrence of diarrhea: the incidence of diarrhoea in the study period was 30.8% (164 cases), of which the incidence of infectious diarrhea was 4.1% (22 cases). The most common diarrhea was from first to 3D after the beginning of enteral nutrition. With the extension of the time of hospitalization of ICU, the proportion of new diarrhea gradually declined, and the incidence of different times of diarrhea occurred. There were statistical significance (P0.001). The median value of the duration of diarrhea was 2 (1,3) d, and the number of stool times was 4 (3,5). In 28 hospitals, two a hospital had 4, the incidence of diarrhoea was 32.8%; there were 10 in the third hospital and 36.2% in the third Hospital; there were 14 in the Third Hospital, the incidence of diarrhoea was 26.3%, and the diarrhea rate of 26.3% at all levels. There was no significant difference in the incidence of diarrhea (P0.05). In the diagnosis of different diseases, the highest incidence of diarrhea in patients with respiratory and heartbeat arrest was 61.5% (8 cases), and the lowest incidence of diarrhea in patients with cardiovascular system disease was 17.8% (8 cases). The incidence of diarrhea in different diseases was statistically significant (P0.05).4, and the risk factors of diarrhea were: Multifactor Logistic regression analysis showed that the use of GI agents, acute physiological and chronic health scores and pylorus feeding pathway were independent risk factors for diarrhea. The corresponding OR value (95%CI) was 1.82 (1.24-2.65), 1.04 (1.02-1.07), 1.90 (1.11-3.36).5, and diarrhea treatment: 116 (70.7%) of 164 cases of diarrhea were associated with the treatment. Treatment, treatment measures are mainly using antidiarrheal drugs, using probiotics, suspending enteral nutrition and other measures, 97 cases (59.1%), 55 cases (33.5%), 46 cases (28%), 2 cases (1.2%) of.97 cases using antidiarrheal drugs (84.6%) using Smecta antidiarrheal, 8 cases (8.2%) using easy Mongol stop diarrhoea, 7 cases (7.2%) use easy to stop combined thinking. 46 patients with suspended enteral nutrition, 46 patients with enteral nutrition, the median value of enteral nutrition interruption was 10 (3,24) H; 2 patients were treated with oral antibiotics for.6, and the prognosis analysis showed that the duration of mechanical ventilation was longer (6 dvs.5.0 D, P=0.003) in the diarrhea group than in the non diarrhea group (11 dvs.9.0 D, P=0.000), and the hospital stay was longer (11 dvs.9.0 D, P=0.000), and hospitalized. The mortality rate was higher (23.2%vs.14.6%, P=0.016). Multiple factor Zogistic regression analysis showed that the suspension of enteral nutrition, acute physiological and chronic health scores increased, the use of vasoactive drugs and enteral nutrition start time (48h) was an independent risk factor for death, and the corresponding OR value (95%CI) was 3.74 (1.85-7.54), 1.07 (1.04-1.11), 2.31 (1.42-), respectively. 3.77), 2 (1.08-3.70). Conclusion: the incidence of diarrhoea within 1 weeks of enteral nutrition in the ICU critically ill patients in this study was 30.8%, and diarrhea was most common in the first to 3 d after enteral nutrition, the median duration of duration was 2 (1,3) d., the use of gastro intestinal motility, and the post pyloric feeding pathway were the high risk factors for increasing diarrhea. In patients with diarrhea, mechanical ventilation and ICU stay longer and hospitalization fatality rate increase, and suspended enteral nutrition may be the reason for increasing the risk of death.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7

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