Medical Sciences Postgraduate Program, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400 CEP 90035-003, Porto Alegre, RS, Brazil; Nutrition and Dietetic Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350 CEP 90035-903, Porto Alegre, RS, Brazil.
Medical Sciences Postgraduate Program, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400 CEP 90035-003, Porto Alegre, RS, Brazil; Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350 CEP 90035-903, Porto Alegre, RS, Brazil.
Clin Nutr. 2020 Dec;39(12):3721-3729. doi: 10.1016/j.clnu.2020.03.033. Epub 2020 Apr 2.
BACKGROUND & AIMS: Enteral nutrition is controversial in hemodynamically unstable patients. This study aimed to evaluate the association between hemodynamic and skin perfusion parameters and enteral nutrition therapy (NT) outcomes in septic shock patients.
Ventilated adults with septic shock were evaluated at bedside upon admission (H0), and at 12 h (H1), 24 h (H2) and 48 h (H3) for mean arterial pressure (MAP), heart rate, urine output, lactate levels, mottling score, capillary refill time (CRT), central-to-toe temperature gradient and norepinephrine dose. Two groups were stratified: NT success (NTS) (≥20 kcal/kg or 11 kcal/kg for obese in the first ICU week) or NT failure (NTF). A generalized linear model and generalized estimating equations were performed.
Over a 19-month period, 2167 admissions were assessed and 141 patients were analyzed (63.5 ± 15.0 years, SAPS-3 75 ± 12, 102 [72%] in the NTS vs. 39 [28%] in NTF). At 12 h, the failure group showed more severe mottling scores, higher lactate levels, norepinephrine dose and central-to-toe temperature gradient. Mottling score at 12 h was a predictor of NT failure (RR 1.28 95%CI [1.09-1.50], p = .003). Over 48 h, higher mottling scores, lactate levels and norepinephrine dosage, % of patients with central-to-toe temperature gradient and CRT ≥3 s were observed in the failure group and higher urine output and MAP values were observed in the success group.
Early improvement in hemodynamic and skin perfusion parameters was associated with success in nutrition therapy, and mottling score at 12 h was a risk factor for nutrition therapy failure. This data could support the recommendation to start NT after hemodynamic and perfusion goals are achieved and to proactively evaluate bedside parameters while implementing NT in critical care setting.
在血流动力学不稳定的患者中，肠内营养存在争议。本研究旨在评估脓毒性休克患者血流动力学和皮肤灌注参数与肠内营养治疗（NT）结局之间的关系。
对入院时（H0）、12 小时（H1）、24 小时（H2）和 48 小时（H3）的通气成人脓毒性休克患者进行床边评估，评估内容包括平均动脉压（MAP）、心率、尿量、乳酸水平、斑点评分、毛细血管再充盈时间（CRT）、中心-脚趾温度梯度和去甲肾上腺素剂量。将两组分层：肠内营养成功（NTS）（≥20 kcal/kg 或 ICU 第一周肥胖患者 11 kcal/kg）或肠内营养失败（NTF）。采用广义线性模型和广义估计方程进行分析。
在 19 个月的时间里，共评估了 2167 例入院患者，其中 141 例患者被纳入分析（63.5±15.0 岁，SAPS-3 75±12，NTS 组 102 例[72%]，NTF 组 39 例[28%]）。在 12 小时时，失败组的斑点评分更严重，乳酸水平更高，去甲肾上腺素剂量和中心-脚趾温度梯度更高。12 小时时的斑点评分是肠内营养失败的预测因素（RR 1.28 95%CI [1.09-1.50]，p=0.003）。在 48 小时内，失败组患者的斑点评分、乳酸水平和去甲肾上腺素剂量更高，中心-脚趾温度梯度和 CRT≥3 s 的患者比例更高，而成功组患者的尿量和 MAP 值更高。
血流动力学和皮肤灌注参数的早期改善与营养治疗的成功相关，12 小时时的斑点评分是营养治疗失败的危险因素。这些数据可以支持在达到血流动力学和灌注目标后开始 NT 治疗的建议，并在重症监护环境中实施 NT 时积极评估床边参数。
