论文部分内容阅读
目的:探讨合并血流动力学不稳定的重症患者早期开始肠内营养耐受性及其对临床预后的影响。方法:2014年5月至2016年5月在浙江省人民医院连续招募预期在重症医学科（ICU）住院时间超过48 h，且血流动力学不稳定的重症患者。前瞻性采集患者临床、实验室和生存数据，并评估急性胃肠损伤（acute gastrointestinal injury，AGI）分级。患者接受血管活性药物支持，维持血流动力学稳定（平均动脉压≥65 mmHg）6 h后开始尝试肠内营养（enteral nutrition,EN），并按照EN开始时机分为3组：早期EN组（EN开始0.05）,而7 d未喂养组患者胃储留发生率较少(16.7% n vs.33.3%，n P=0.05)，但消化道出血风险增加（47.2% n vs.26.1%，n P=0.02）。与晚期EN组和7 d未喂养组相比，早期EN组患者28 d（30.4% n vs. 47.9% n vs..55.6%，n P=0.01）和60 d病死率（38.0% n vs. 53.4% n vs 63.9%，n P=0.017）显著降低。进一步多因素Cox回归分析显示：EN喂养时机（早期n vs晚期：n χn 2≥5.83，n P≤0.03；早期n vs 7 d未喂养：n χn 2≥7.90，n P<0.01）、血肌酐（n χn 2≥5.06，n P≤0.02）、白蛋白水平（n χn 2≥6.41，n P<0.05）、AGI分级（n χn 2≥8.15，n P0.05). Whereas, patients in the no initiation of EN within 7 days of ICU admission had a lower prevalence of gastric residual volume (16.7% n vs. 33.3%, n P=0.05), but higher prevalence of GI bleeding (47.2% n vs. 26.1%, n P=0.02). Compared with those in the late EN group and in no initiation of EN within 7 days of ICU admission, patients in the early EN group had lower 28- (30.4% n vs. 47.9% n vs. 55.6%, n P=0.01) and 60-day mortality rates (38.0% n vs. 53.4% n vs. 63.9%, n P=0.017). Multivariate Cox regression analysis showed that the timing of EN initiation on the admission to ICU (early EN n vs. late EN, n χn 2≥5.83, n P<0.05; early EN n vs. no initiation of EN, n χn 2≥7.90, n P<0.01), serum creatinine ( n χn 2=5.06, n P<0.05), plasma albumin (n χn 2≥6.41, n P<0.01), AGI grade (n χn 2≥8.15, n P<0.01), and APACHE II score ( n χn 2≥9.62, n P<0.01) were independent predictors for 28- and 60-day mortality.n Conclusions:Early EN on admission to ICU could be tolerated, and is significantly associated with lower risk of 28- and 60-day mortality in critically ill patients with vasoactive medication to maintain hemodynamic stability.