一项多中心随机对照试验，比较了重症监护机械通气患者中每日三次间歇性肠内体位喂养与连续肠内喂养的效果。

A multicenter randomized controlled trial comparing three-times-a-day intermittent enteral postural feeding to continuous enteral feeding among mechanically ventilated patients in intensive care.

机构信息

Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Australia.

Intensive Care Unit, John Hunter Hospital, Newcastle, Australia.

出版信息

Clin Nutr. 2024 Sep;43(9):2149-2155. doi: 10.1016/j.clnu.2024.07.038. Epub 2024 Jul 31.

DOI:10.1016/j.clnu.2024.07.038

PMID:39137517

Abstract

BACKGROUND AND AIMS

Previous randomized controlled trials (RCTs) comparing intermittent feeding versus continuous feeding used different methods, employed shorter fasting intervals, ignored patients' posture in bed during feeds, and showed mixed results. Prolonged fasting intervals are hypothesized to have several benefits. Additionally, there is evidence for more efficient gastric emptying in the right lateral position. In this multicenter RCT, we aimed to compare the effects of three-times-a-day gastric feeding while in the right lateral tilt position (intermittent postural feeding) versus standard continuous gastric feeding (standard feeding) on gastrointestinal intolerance and mortality among mechanically ventilated patients in ICU.

METHODS

Adult ICU patients with gastric feeding tube in-situ and requiring invasive mechanical ventilation were randomized to either intermittent postural feeding group or to the standard feeding group. The feeding formula, target daily feed volume and posture turns were determined as per standard practice for all patients. Primary outcome was an incidence rate per 100 patient-days of gastrointestinal intolerance, a composite outcome of vomiting, diarrhea or constipation. Secondary outcomes were all-cause hospital mortality, gastrointestinal intolerance-free days, ventilator-free days, episodes of vomiting or diarrhea per patient, and mean diet volume ratio (diet received/diet prescribed).

RESULTS

At five multidisciplinary ICUs, 120 mechanically ventilated, adult ICU patients (median age 65 years, 60% males) were randomly allocated to intermittent postural feeding (n = 61) and standard feeding (n = 59). The primary outcome did not differ between intermittent feeding arm versus standard arm (8.5, 95% confidence interval (CI): 5.9-11.8, versus 6.2, 95% CI: 4.1-9.1 per 100 patient-days; p = 0.23). Gastrointestinal intolerance-free days until day 14 were similar (6 [2-8] versus 5 [2-10]; p = 0.68) in both groups. Number of episodes per patient of vomiting, diarrhea, or constipation also did not differ in between groups. All-cause hospital mortality between intermittent feeding arm versus standard arm was 20% versus 31% (p = 0.17). There were no significant between-group differences in any of the other secondary outcomes.

CONCLUSIONS

Intermittent gastric feeds delivered three-times-a-day while in the right lateral tilt position among mechanically ventilated patients was as well tolerated as the continuous enteral feeding. A definitive RCT to assess other clinically important outcomes is justified.

TRIAL REGISTRATION

ACTRN12616000212459 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365526&isReview=true.

摘要

背景与目的

之前比较间歇性喂养与持续性喂养的随机对照试验（RCT）采用了不同的方法，使用的禁食间隔较短，忽略了患者在喂养期间的卧床姿势，结果也不一致。较长的禁食间隔被假设具有多种益处。此外，右侧卧位时胃排空更有效。在这项多中心 RCT 中，我们旨在比较每日三次胃饲时处于右侧倾斜位（间歇性体位喂养）与标准连续胃饲（标准喂养）对 ICU 机械通气患者的胃肠道不耐受和死亡率的影响。

方法

纳入胃管在位且需要有创机械通气的成年 ICU 患者，随机分配至间歇性体位喂养组或标准连续喂养组。根据所有患者的标准实践确定喂养配方、目标每日喂养量和体位变换。主要结局为每 100 患者日胃肠道不耐受的发生率，即呕吐、腹泻或便秘的复合结局。次要结局为全因住院死亡率、胃肠道不耐受无天数、无呼吸机天数、每位患者的呕吐或腹泻发作次数以及平均饮食量比（实际接受的饮食量/规定的饮食量）。

结果

在五家多学科 ICU 中，纳入 120 名接受机械通气的成年 ICU 患者（中位年龄 65 岁，60%为男性），随机分配至间歇性体位喂养组（n=61）和标准喂养组（n=59）。间歇性喂养组与标准喂养组的主要结局无差异（8.5，95%置信区间（CI）：5.9-11.8，与 6.2，95% CI：4.1-9.1 每 100 患者日；p=0.23）。两组患者第 14 天之前的胃肠道不耐受无天数相似（6[2-8]与 5[2-10]；p=0.68）。两组患者每位患者呕吐、腹泻或便秘的发作次数也无差异。间歇性喂养组与标准喂养组的全因住院死亡率分别为 20%和 31%（p=0.17）。其他次要结局在两组间也无显著差异。