Department of Surgery, Queen'sUniversity, Kingston, Ontario, Canada.
JPEN J Parenter Enteral Nutr. 2010 Nov-Dec;34(6):644-52. doi: 10.1177/0148607110372391.
To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described.
International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared.
A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy.
Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.
为了确定质量改进的机会，本文描述了与内科患者相比，重症外科患者的营养充足情况。
本分析将 2007 年和 2008 年在 269 个重症监护病房（ICU）进行的国际、前瞻性和观察性研究合并。各研究点提供了从 ICU 入院到 ICU 出院的机构和患者特征以及营养数据，最长时间为 12 天。对比入住 ICU 至少 3 天的内科和外科患者。
共纳入 5497 例机械通气的成年患者；37.7%的患者有外科 ICU 入院诊断。外科患者接受肠内营养（EN）的可能性较低（54.6%比 77.8%），接受肠外营养（PN）的可能性较高（13.9%比 4.4%）（P<0.0001）。在 ICU 开始接受 EN 的患者中，外科患者平均晚开始 EN 21.0 小时（57.8 比 36.8 小时，P<0.0001）。因此，外科患者从 EN 获得的规定热量较少（33.4%比 49.6%，P<0.0001）或从所有营养来源获得的热量较少（45.8%比 56.1%，P<0.0001）。这些差异在调整患者和研究点特征后仍然存在。接受心血管和胃肠道手术的患者更有可能使用 PN，使用 EN 的可能性较低，开始使用 EN 的时间较晚，总的营养和 EN 充足率也较低。使用喂养和/或血糖控制方案与更高的营养充足率相关。
外科患者接受的营养比内科患者少。心血管和胃肠道手术患者发生医源性营养不良的风险最高。需要采取策略来提高营养管理水平，包括使用方案。
