Intensive Care Unit, Alfred Hospital, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
Crit Care Med. 2012 Aug;40(8):2342-8. doi: 10.1097/CCM.0b013e318255d87e.
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.
Prospective, randomized, controlled trial.
Seventeen multidisciplinary, closed, medical/surgical, intensive care units in Australia.
One hundred and eighty-one mechanically ventilated adults who had elevated gastric residual volumes within 72 hrs of intensive care unit admission.
Patients were randomly assigned to receive early nasojejunal nutrition delivered via a spontaneously migrating frictional nasojejunal tube, or to continued nasogastric nutrition.
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).
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.
目前的指南建议对危重症成人进行肠内营养；然而，胃动力差常导致营养目标无法实现。我们假设早期鼻空肠营养会改善肠内营养的输送。
前瞻性、随机、对照试验。
澳大利亚 17 个多学科、封闭式、内科/外科、重症监护病房。
181 名接受机械通气且在重症监护病房入院后 72 小时内胃残留量升高的成年人。
患者被随机分配接受早期经鼻空肠营养，通过自行迁移的摩擦性鼻空肠管输送，或继续接受鼻胃营养。
主要结局是标准化估计能量需求的肠内营养输送比例。次要结局包括呼吸机相关性肺炎、胃肠道出血和住院死亡率的发生率。92 名患者被分配到早期鼻空肠营养组，89 名患者被分配到继续鼻胃营养组。两组的基线特征相似。在中位时间 15（四分位距 7-32）小时后，79 名（87%）早期鼻空肠营养患者的鼻空肠管被确认进入小肠。来自肠内营养的目标能量输送比例为早期鼻空肠营养组 72%，鼻胃营养组 71%（平均差异 1%，95%置信区间-3%至 5%，p=.66）。呼吸机相关性肺炎（20%与 21%，p=.94）、呕吐、 witnessed aspiration、腹泻和死亡率的发生率相似。轻微但非严重的胃肠道出血在早期鼻空肠营养组更为常见（12[13%]与 3[3%]，p=.02）。
在胃残留量轻度升高且已接受鼻胃营养的机械通气患者中，早期鼻空肠营养并未增加能量输送，也似乎并未降低肺炎的发生率。轻微胃肠道出血的发生率增加。不建议对这类患者常规放置鼻空肠管。
