Gottschlich M M, Warden G D, Michel M, Havens P, Kopcha R, Jenkins M, Alexander J W
Shriners Burns Institute, Cincinnati Unit, Ohio 45219.
JPEN J Parenter Enteral Nutr. 1988 Jul-Aug;12(4):338-45. doi: 10.1177/0148607188012004338.
The hypermetabolic state observed in thermally injured patients warrants aggressive nutritional management. Enteral support is the preferred route of nutrient delivery, however diarrhea is reported to be a persistent complication of continuous nasogastric or nasoduodenal hyperalimentation. Diarrhea adds to problems in patient care, disturbs fluid and electrolyte balance, and worsens nutritional status. There has been the impression that tube feeding hyperosmolality, antibiotics, and low serum albumin induce diarrhea. However, in view of the sparsity of published work, a prospective study was undertaken to determine the incidence of diarrhea and to define factors associated with its cause. Of the 50 patients studied, 16 (32%) developed diarrhea. Stool cultures were negative for pathogenic organisms. Although the risk of diarrhea was associated with antibiotics (p less than 0.005), several nutrients also had an impact. Results demonstrated a significant relationship between dietary lipid content (p less than 0.05) or vitamin A intake (p less than 0.001) and diarrhea. Implementation of tube feeding within 48 hrs postburn was also associated with a decreased incidence of diarrhea (p less than 0.001). This paper describes a modular tube feeding program in which diarrheal frequency is lessened (p less than 0.0001). Surprisingly, tube feeding osmolality, drugs used to prevent stress ulcers, or hypoalbuminemia did not have an adverse effect on intestinal absorption. The cause of diarrhea in burn patients is obviously multifactorial. It is concluded that a low fat (less than 20% of caloric intake), vitamin A enriched (greater than 10,000 IU/day), early enteral support program maximizes conditions which promote tube feeding tolerance while minimizing nutrient malabsorption during the nutritional rehabilitation of thermal injury.
热损伤患者出现的高代谢状态需要积极的营养管理。肠内营养支持是营养供给的首选途径，然而据报道，持续性鼻胃管或鼻十二指肠高营养支持会导致腹泻这一并发症持续存在。腹泻增加了患者护理的难度，扰乱了体液和电解质平衡，并使营养状况恶化。人们一直认为管饲高渗性、抗生素和低血清白蛋白会引发腹泻。然而，鉴于已发表的相关研究较少，因此开展了一项前瞻性研究，以确定腹泻的发生率，并明确与其病因相关的因素。在研究的50例患者中，有16例（32%）出现腹泻。粪便培养未检出致病微生物。虽然腹泻风险与抗生素有关（p<0.005），但几种营养素也有影响。结果表明，膳食脂肪含量（p<0.05）或维生素A摄入量（p<0.001）与腹泻之间存在显著关系。烧伤后48小时内实施管饲也与腹泻发生率降低有关（p<0.001）。本文描述了一种模块化管饲方案，腹泻频率降低（p<0.0001）。令人惊讶的是，管饲渗透压、用于预防应激性溃疡的药物或低白蛋白血症对肠道吸收没有不良影响。烧伤患者腹泻的原因显然是多因素的。研究得出结论，低脂肪（热量摄入的20%以下）、富含维生素A（大于10,000 IU/天）的早期肠内营养支持方案，在热损伤营养康复过程中，能最大限度地创造促进管饲耐受性的条件，同时将营养物质吸收不良降至最低。
