摘要目的 探讨采取肠内营养(EN)耐受评估标准化流程管理对重症加强治疗病房(ICU)内气管切开长期住院患者院内感染及预后的影响.方法 采用前瞻性队列研究,选择2015年1月至2017年12月常州市第一人民医院ICU收治的46例因气管切开需要长期机械通气的患者,以2016年6月30日开始EN耐受评估标准化流程管理为时间节点,将2015年1月1日至2016年6月30日收治的患者作为对照组(25例),2016年7月1日至2017年12月31日收治的患者作为观察组(21例).两组患者均给予常规EN治疗方案及常规对症支持治疗;观察组患者进行EN耐受评估标准化流程管理,主要通过EN耐受评估对患者进行EN指导;对照组给予常规EN管理方案(常规护士汇报医生,并做进一步处理).比较两组患者治疗30 d内的营养支持相关指标(血清白蛋白、血清前白蛋白、血清胆碱酯酶) 、 EN喂养耐受性指标 (30 d内胃肠道动力药物平均使用量、平均每例患者EN中断时间、消化道出血发生率) 、 预后相关指标 〔呼吸机相关性肺炎(VAP)发生率、月平均住院费用、药品比例、抗菌药物占药比〕.结果 与常规EN管理方案的对照组比较,采用标准化流程管理的观察组患者血清白蛋白、前白蛋白、胆碱酯酶均明显升高〔白蛋白(g/L):32.86±4.83比28.16±3.62,前白蛋白(mg/L):186.42±62.84比163.26±73.49,胆碱酯酶(U/L):3 482.34±369.92比2 986.86±491.49,均P＜0.05〕 , 胃肠道动力药物平均使用量明显减少(mg :11.20±3.86比15.23±5.68,P＜0.05),平均每例患者EN中断时间明显延长(h :6.38±3.59比4.96±2.28,P＜0.05), 消化道出血发生率明显下降(19.04%比24.00%,P＜0.05), VAP发生率明显降低(18.64%比21.36%,P＜0.05), 抗菌药物占药比明显减少(62.43%比76.59%,P＜0.05),但药品比例、月平均住院费用与对照组比较差异无统计学意义〔药品比例:36.88%比38.42%,月平均住院费用(万元):4.36±0.57比4.39±0.49,均P＞0.05〕.结论 对ICU气管切开长期机械通气患者进行EN耐受评估标准化流程管理可改善患者营养状况,降低院内感染发生率,进而有利于改善患者预后.

abstractsObjective To investigate the effect of enteral nutrition (EN) tolerance assessment standardized process management on nosocomial infection and prognosis in patients with tracheotomy and long-term mechanical ventilation (MV) in intensive care unit (ICU). Methods A prospective cohort study was conducted. Forty-six patients who required long-term MV due to tracheotomy admitted to ICU of Changzhou First People's Hospital from January 2015 to December 2017 were enrolled. Taking the standardized process management of EN tolerance assessment from June 30th, 2016 as the time spot, patients admitted from January 1st, 2015 to June 30th, 2016 were taken as the control group (25 cases) and patients admitted from July 1st, 2016 to December 31st, 2017 as the observation group (21 cases). The two groups were all given conventional EN treatment and conventional symptomatic supportive treatment. Patients in the observation group was given the EN tolerance standardized process management, and received the nutritional risk screening score. While the control group was given a conventional EN management protocol (nurses routinely reported to the doctor and then gave further action). The nutritional support related indicators within 30 days of treatment (including serum albumin, serum pre-albumin, serum cholinesterase), the EN feeding tolerance index (the average amount of gastrointestinal motility drugs used within 30 days, the average EN interruption time per patient, and the incidence of gastrointestinal bleeding) and the prognosis-related indicators [including the incidence of ventilator-associated pneumonia (VAP), the monthly average hospitalization cost, the proportion of drugs, and the ratio of antibiotics to drugs] were compared. Results Compared with the control group, serum albumin, pre-albumin and cholinesterase were significantly increased in the observation group [albumin (g/L): 32.86±4.83 vs. 28.16±3.62, pre-albumin (mg/L):186.42±62.84 vs. 163.26±73.49, cholinesterase (U/L): 3 482.34±369.92 vs. 2 986.86±491.49, all P < 0.05], the average use of gastrointestinal motility drugs was significantly reduced (mg: 11.20±3.86 vs. 15.23±5.68, P < 0.05), the average EN interruption time was significantly longer in each patient (hours: 6.38±3.59 vs. 4.96±2.28, P < 0.05), and the incidence of gastrointestinal bleeding was significantly decreased (19.04% vs. 24.00%, P < 0.05), the incidence of VAP was significantly decreased (18.64% vs. 21.36%, P < 0.05), and the antibiotics accounted for a significant decrease (62.43% vs. 76.59%, P < 0.05), but there was no significant difference in the proportion of drugs and monthly average hospitalization expenses [drug ratio: 36.88% vs. 38.42%, monthly average hospitalization cost (ten thousand yuan):4.36±0.57 vs. 4.39±0.49, both P > 0.05]. Conclusion For the patients with tracheotomy and long-term MV of ICU, the enteral nutrition tolerance assessment standardized process management can improve the nutritional status, reduce the incidence of nosocomial infections, and improve the prognosis of the patients.