Norton J A, Ott L G, McClain C, Adams L, Dempsey R J, Haack D, Tibbs P A, Young A B
Division of Neurosurgery University of Kentucky Medical Center, Lexington.
J Neurosurg. 1988 Jan;68(1):62-6. doi: 10.3171/jns.1988.68.1.0062.
Calorie and protein supplementation improves nutritional status. This support may improve outcome and decrease morbidity and mortality in acutely brain-injured patients. Investigators have observed a poor tolerance to enteral feedings after brain injury and have noted that this persists for approximately 14 days postinjury. This delay has been attributed to increased gastric residuals, prolonged paralytic ileus, abdominal distention, aspiration pneumonitis, and diarrhea. In the present investigation, 23 brain-injured patients with an admission 24-hour peak Glasgow Coma Scale (GCS) score between 4 and 10 were studied for 18 days from hospital admission. The mean duration from injury to initiation of full-strength, full-rate enteral feeding was 11.5 days. Seven of the 23 patients tolerated enteral feedings within the first 7 days following hospital admission (mean 4.3 days), four patients tolerated feedings between 7 and 10 days postadmission (mean 9 days), and 12 patients did not tolerate feedings until after 10 days postinjury (mean 15.9 days). There was a marginally significant relationship between low GCS scores on admission and length of days to enteral feeding tolerance (p = 0.07). A significant inverse relationship was observed between daily peak intracranial pressure (ICP) and time to tolerance of feedings (p = 0.02). There was no significant relationship between feeding tolerance and days to return of bowel sounds (p = 0.12). Serum albumin levels decreased during the investigation (mean +/- standard error to the mean: 3.2 +/- 0.12 gm/dl on Day 1; 2.7 +/- 0.23 gm/dl on Day 16; normal = 3.5 to 5.0 gm/dl), whereas the percentage of patients tolerating feedings increased over the course of the study. The authors conclude that patients with acute severe brain injury do not adequately tolerate feedings via the enteral route in the early postinjury period. Tolerance of enteral feeding is inversely related to increased ICP and severity of brain injury. It is suggested that parenteral nutritional support is required following brain injury until enteral nutrition can be tolerated.
补充热量和蛋白质可改善营养状况。这种支持可能会改善急性脑损伤患者的预后并降低发病率和死亡率。研究人员观察到脑损伤后患者对肠内喂养的耐受性较差，并指出这种情况在受伤后约14天持续存在。这种延迟归因于胃残余量增加、麻痹性肠梗阻延长、腹胀、吸入性肺炎和腹泻。在本研究中，对23名入院时格拉斯哥昏迷量表（GCS）24小时峰值评分在4至10分之间的脑损伤患者从入院起进行了18天的研究。从受伤到开始全强度、全速率肠内喂养的平均持续时间为11.5天。23名患者中有7名在入院后的前7天内耐受肠内喂养（平均4.3天），4名患者在入院后7至10天内耐受喂养（平均9天），12名患者直到受伤后10天（平均15.9天）才耐受喂养。入院时低GCS评分与肠内喂养耐受天数之间存在微弱的显著关系（p = 0.07）。观察到每日颅内压（ICP）峰值与喂养耐受时间之间存在显著的负相关关系（p = 0.02）。喂养耐受性与肠鸣音恢复天数之间无显著关系（p = 0.12）。在研究期间血清白蛋白水平下降（均值±均值标准误：第1天为3.2±0.12 g/dl；第16天为2.7±0.23 g/dl；正常范围为3.5至5.0 g/dl），而耐受喂养的患者百分比在研究过程中增加。作者得出结论，急性重型脑损伤患者在受伤后的早期不能充分耐受经肠内途径喂养。肠内喂养的耐受性与ICP升高和脑损伤严重程度呈负相关。建议脑损伤后需要肠外营养支持，直到能够耐受肠内营养。
