戊巴比妥催眠状态下颅脑损伤患者成功肠内喂养的评价
2010-03-12 20:17:18   来源：丁香园   作者：  评论：0 点击：

目的：营养在外伤性颅脑损伤的恢复中起着关键作用。热量需求的增加，胃耐受不良以及通路问题经常使为这些患者提供充足的营养受限。此外，戊巴比妥催眠状态下颅内压增高患者给与营养更加困难。尽管戊巴比妥催眠状态下颅脑损伤患者耐受肠内营养（EN）的能力尚存在争议，但是仍然推荐颅脑损伤患者使用EN。我们医院采用床边造影下放置经幽门小肠管饲实施EN。本研究的目的是评价戊巴比妥催眠状态下颅脑损伤患者通过小肠管饲接受肠内喂养的成功率。

　　方法：本研究是一项回顾性病例分析。入选戊巴比妥催眠状态下且接受EN的成人患者。记录了患者一般信息，EN耐受性和喂养并发症。喂养并发症包括腹泻、腹胀、重度痉挛以及小肠坏死。同时记录胃残留量以辨别导管错位或偏移。连续两次测量胃残留量超过200ml被认为是喂养并发症，需重新评价放置情况。同时收集患者转归包括重症监护病房（ICU）治疗和住院时间（LOS）及患者存活率。采用描述性统计说明研究人群特征。P<0.05代表差异具有显著统计学意义。所有统计分析采用SPSS16.0版计算。

　　结果：本研究入选了53例患者，大多数（60.4%）为男性。数据采用均值±标准差表示。患者年龄为40±14.7岁，体重为82.8±22.2kg，格拉斯哥昏迷评分为6.4±3.7。蛛网膜下腔出血和硬膜下出血是主要和次要受伤原因，分别占50.9%和20.8%。戊巴比妥使用开始于87.6±72.7小时之内，输注时间为154.8±113.1小时。戊巴比妥推注总剂量为457.9±775.4mg，每日戊巴比妥剂量（不包括推注剂量）为1941±2655mg。EN开始于53.4±59.5小时之内，治疗持续555.8±481.3小时。46例患者（86.8%）能够耐受EN治疗。喂养并发症包括胃残留15.1%（n=8），和腹泻22.6%（n=12）。共有7.5%的患者（n=4）出现腹胀影响了喂养量。2例患者出现小肠坏死。仅有1例患者中断了EN，改用肠外营养。14例患者（26.4%）恢复至经口饮食，19例患者（35.8%）由医院回到家中或康复中心继续EN。ICU的LOS为22.7±18.9天，医院LOS为27.2±22.8天。35.8%的患者死亡。

　　结论：戊巴比妥催眠状态下外伤性颅脑损伤患者能够接受并耐受直接注入小肠的EN。

Clinical Nutrition Week 2010 Nutrition Practice Abstracts

Abstracts of Distinction

Nutr Clin Pract. 2010 Feb;25(1):97-8.

P9 - Evaluation of Enteral Feeding Success in Head Injured Patients Placed in Pentobarbital Induced Comas

Jane Gervasio, Pharm.D., BCNSP1; Jonathan Egel, Pharm.D.1; Joshua McGehee, Pharm.D.1; Gabriel Drew Stillabower, Pharm.D.1; Nicole Ponton, Pharm.D.1; Lawrence Bortenschlager, M.D.2; Timothy Pohlman, M.D.2

1Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN; 2Clarian Health Partners at Methodist Hospital, Indianapolis, IN.

Introduction: Nutrition plays a critical role in the recovery of a traumatic brain injury. Increased caloric needs, gastric intolerance and access problems often undermine efforts to provide adequate nutrition in this population. Additionally, patients with increased intracranial pressure placed in a pentobarbital comas further challenge the administration of nutrition. Enteral nutrition (EN) is recommended for head trauma patients however controversy exists regarding the patients in pentobarbital induced comas ability to tolerate EN. At our institution, standard of practice is verified placement using bedside imaging of a transpyloric small bowel feeding tube for the administration of EN. The objective of this study was to evaluate the success of small bowel enteral feeding in head injured patients placed into pentobarbital induced comas receiving EN. Methods: This study was a retrospective charts review. Adult patients placed in a pentobarbital induced coma and initiated on EN were included. Demographic information, EN tolerance and feeding complications were recorded. Feeding complications included watery diarrhea, a distended abdomen, severe cramping, and small bowel necrosis. Gastric residual volumes were also recorded to identify tube misplacement or migration. Residual volumes greater than 200 mls for 2 consecutive measurements were considered a feeding complication and placement was reassessed. Patient outcomes were also collected and included intensive care unit (ICU) and hospital length of stay (LOS) and patient survival. Descriptive statistics were utilized to define the characteristics of the study population. A p-value less than 0.05 was considered statistically significant. All the statistical analyses were conducted using Statistical Package for Social Sciences version 16.0. Results: Fifty-three patients were included in the study, with the majority (60.4%) being males. Data are reported as mean±standard deviation. Patient age was 40±14.7 years, weight was 82.8±22.2 kg and admission Glasgow Coma Score was 6.4±3.7. Subarachnoid and subdural hemorrhage was the primary and secondary cause of injury, occurring in 50.9% and 20.8% of the patients, respectively. Pentobarbital initiation was started within 87.6±72.7 hours with a length of infusion time of 154.8±113.1 hours. Total pentobarbital bolus doses were 457.9±775.4 mg and daily pentobarbital doses (excluding boluses) were 1941±2655 mg. EN was initiated within 53.4±59.5 hours and administered for 555.8±481.3 hours. EN therapy was tolerated in 46 (86.8%) of the patients. Feeding complications reported included gastric residuals, 15.1% (n=8) and watery diarrhea, 22.6% (n=12). A total of 7.5% of patients (n=4) had a distended abdomen that influenced feeding volumes. Small bowel necrosis was reported in 2 patients. In only one patient was EN discontinued and parenteral nutrition initiated. Fourteen patients (26.4%) were able to advance to an oral diet and 19 (35.8%) patients were discharged from the hospital to home or a rehabilitation center on EN. ICU LOS was 22.7±18.9 days and hospital LOS was 27.2±22.8 days. Death occurred in 35.8% of patients. Conclusions: Patients placed in a pentobarbital coma for a traumatic brain injury are able to receive and tolerate EN infused into the small bowel.