苏皖地区部分重症医师对重症病人营养支持指南临床实施情况调查与分析
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摘要
目的:调查苏皖地区部分重症医师对重症病人最新营养指南临床执行情况,为进一步改善重症病人营养支持策略提供临床依据。方法:以2016年美国危重病医学会(SCCM)和肠外与肠内营养协会(ASPEN)共同修改制定的"成年危重病病人营养支持治疗与评估指南推荐方案"为指导,制定调查问卷,对江苏地区、安徽地区部分重症医师进行现场不记名问卷调查。结果:(1)调查对象营养支持指南临床实施得分为(10.92±2.11)分,占总分(21分)的52.02%,及格人数为69人,占总人数的22.9%。(2)营养评估维度执行正确率最高,达69.20%,胃肠道术后病人营养支持维度执行正确率最低,只有16.18%。得分最低的5个项目为-脂肪酸的应用范围、谷氨酰胺的应用范围、胃潴留时停用肠内营养的指针、评估营养风险的最佳指标以及早期营养支持蛋白质目标。(3)综合ICU重症医师临床营养实施得分(11.04±2.07)明显高于专科ICU(10.23±2.22,P <0.05),但不同单位级别、工作年限和职称的重症医师得分无统计学差异(P> 0.05)。结论:苏皖地区对最新营养指南临床实施情况处于中下水平,主要应在营养风险评估、早期营养支持蛋白质目标、胃潴留时停用肠内营养的指针以及免疫营养制剂的营养方面加强培训。
Objective: To investigate the clinical practice of Nutritional Support Guidelines for critically ill patients by some doctors of intensive care units(ICU) in Jiangsu and Anhui area. Methods: Referring to the recommendation which was entitled "adult critically ill patients nutritional support treatment and assessment guidelines recommend the program" jointly made by American Society of Critical Care Medicine(SCCM) and Association of Parenteral and Association of Parenteral and Enteral Nutrition(ASPEN) in 2016, questionnaire was designed and used for on-the-spot blind survey to some critical care physicians in Jiangsu and Anhui area. Results:(1) The respondent scores of the nutrition guideline for the clinical survey were(10.92±2.11), accounting for 52.02% of the total score(21 points), and the passing respondents were 69, which accounted for 22.9% of the total.(2) The highest correct rate of implementation was 69.20% on the nutritional assessment dimension, while the lowest rate was 16.18% in the postoperative patients with gastrointestinal tract. The five items with the lowest scores were the application range of-fatty acids, the application scope of glutamine, the shutoff indicator of enteral nutrition due to gastric retention, the best assessing index for nutritional risks, and the protein goals of early nutrition support.(3) The respondent score(11.04±2.07) of comprehensive ICUs was significantly higher than that in special ICU [(10.23+2.22), P < 0.05], but the hospital levels, working time and professional titles had no significant difference( P > 0.05). Conclusion: The clinical practice of the latest nutritional guidelines in the Jiangsu and Anhui area is in the middle and lower levels, and the strengthened training need be implemented mainly in the assessment of nutrition risk, protein targets of early nutrition support, the shutoff indicator due to gastric retention, and the application of immunonutrition.
Objective: To investigate the clinical practice of Nutritional Support Guidelines for critically ill patients by some doctors of intensive care units(ICU) in Jiangsu and Anhui area. Methods: Referring to the recommendation which was entitled "adult critically ill patients nutritional support treatment and assessment guidelines recommend the program" jointly made by American Society of Critical Care Medicine(SCCM) and Association of Parenteral and Association of Parenteral and Enteral Nutrition(ASPEN) in 2016, questionnaire was designed and used for on-the-spot blind survey to some critical care physicians in Jiangsu and Anhui area. Results:(1) The respondent scores of the nutrition guideline for the clinical survey were(10.92±2.11), accounting for 52.02% of the total score(21 points), and the passing respondents were 69, which accounted for 22.9% of the total.(2) The highest correct rate of implementation was 69.20% on the nutritional assessment dimension, while the lowest rate was 16.18% in the postoperative patients with gastrointestinal tract. The five items with the lowest scores were the application range of-fatty acids, the application scope of glutamine, the shutoff indicator of enteral nutrition due to gastric retention, the best assessing index for nutritional risks, and the protein goals of early nutrition support.(3) The respondent score(11.04±2.07) of comprehensive ICUs was significantly higher than that in special ICU [(10.23+2.22), P < 0.05], but the hospital levels, working time and professional titles had no significant difference( P > 0.05). Conclusion: The clinical practice of the latest nutritional guidelines in the Jiangsu and Anhui area is in the middle and lower levels, and the strengthened training need be implemented mainly in the assessment of nutrition risk, protein targets of early nutrition support, the shutoff indicator due to gastric retention, and the application of immunonutrition.
引文
[1]Wischmeyer PE.The evolution of nutrition in critical care:how much,how soon?.Crit Care,2013,17 Suppl 1:S7.
[2]Lew CCH,Yandell R,Fraser RJL,et al.Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit:A Systematic Review.JPEN J Parenter Enteral Nutr,2017,41(5):744-758.
[3]McClave SA,Martindale RG,Vanek VW,et al.Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:Society of Critical Care Medicine(SCCM)and American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.).JPEN J Parenter Enteral Nutr,2009,33(3):277-316.
[4]Mendes R,Policarpo S,Fortuna P,et al.Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study.JCrit Care,2017,37:249.
[5]Rahman A,Hasan RM,Agarwala R,et al.Identifying criticallyill patients who will benefit most from nutritional therapy:Further validation of the"modified NUTRIC"nutritional risk assessment tool.Clin Nutr,2016,35(1):158-162.
[6]Allingstrup MJ,Esmailzadeh N,Wilkens Knudsen A,et al.Provision of protein and energy in relation to measured requirements in intensive care patients.Clin Nutr,2012,31(4):462-468.
[7]National Heart L,Blood Institute Acute Respiratory Distress Syndrome Clinical Trials N,Rice TW,et al.Initial trophic vs full enteral feeding in patients with acute lung injury:the EDENrandomized trial.JAMA,2012,307(8):795-803.
[8]Rice TW,Wheeler AP,Thompson BT,et al.Enteral omega-3 fatty acid,gamma-linolenic acid,and antioxidant supplementation in acute lung injury.JAMA,2011,306(14):1574-1581.
[9]Pasin L,Landoni G,Zangrillo A.Glutamine and antioxidants in critically ill patients.N Engl J Med,2013,369(5):482-484.
[10]Wernerman J,Kirketeig T,Andersson B,et al.Scandinavian glutamine trial:a pragmatic multi-centre randomised clinical trial of intensive care unit patients.Acta Anaesthesiol Scand,2011,55(7):812-818.
[11]Mulherin DW,Sacks GS.Uncertainty about the safety of supplemental glutamine:an editorial on"A randomized trial of glutamine and antioxidants in critically ill patients".Hepatobiliary Surg Nutr,2015,4(1):76-79.
[12]Montejo JC,Minambres E,Bordeje L,et al.Gastric residual volume during enteral nutrition in ICU patients:the REGANEstudy.Intensive Care Med,2010,36(8):1386-1393.
[13]Reignier J,Mercier E,Le Gouge A,et al.Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding:a randomized controlled trial.JAMA,2013,309(3):249-256.
[14]黎介寿.我国临床营养支持的现状与展望.肠内肠外营养,2000,7(1):1-3.
[2]Lew CCH,Yandell R,Fraser RJL,et al.Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit:A Systematic Review.JPEN J Parenter Enteral Nutr,2017,41(5):744-758.
[3]McClave SA,Martindale RG,Vanek VW,et al.Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:Society of Critical Care Medicine(SCCM)and American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.).JPEN J Parenter Enteral Nutr,2009,33(3):277-316.
[4]Mendes R,Policarpo S,Fortuna P,et al.Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study.JCrit Care,2017,37:249.
[5]Rahman A,Hasan RM,Agarwala R,et al.Identifying criticallyill patients who will benefit most from nutritional therapy:Further validation of the"modified NUTRIC"nutritional risk assessment tool.Clin Nutr,2016,35(1):158-162.
[6]Allingstrup MJ,Esmailzadeh N,Wilkens Knudsen A,et al.Provision of protein and energy in relation to measured requirements in intensive care patients.Clin Nutr,2012,31(4):462-468.
[7]National Heart L,Blood Institute Acute Respiratory Distress Syndrome Clinical Trials N,Rice TW,et al.Initial trophic vs full enteral feeding in patients with acute lung injury:the EDENrandomized trial.JAMA,2012,307(8):795-803.
[8]Rice TW,Wheeler AP,Thompson BT,et al.Enteral omega-3 fatty acid,gamma-linolenic acid,and antioxidant supplementation in acute lung injury.JAMA,2011,306(14):1574-1581.
[9]Pasin L,Landoni G,Zangrillo A.Glutamine and antioxidants in critically ill patients.N Engl J Med,2013,369(5):482-484.
[10]Wernerman J,Kirketeig T,Andersson B,et al.Scandinavian glutamine trial:a pragmatic multi-centre randomised clinical trial of intensive care unit patients.Acta Anaesthesiol Scand,2011,55(7):812-818.
[11]Mulherin DW,Sacks GS.Uncertainty about the safety of supplemental glutamine:an editorial on"A randomized trial of glutamine and antioxidants in critically ill patients".Hepatobiliary Surg Nutr,2015,4(1):76-79.
[12]Montejo JC,Minambres E,Bordeje L,et al.Gastric residual volume during enteral nutrition in ICU patients:the REGANEstudy.Intensive Care Med,2010,36(8):1386-1393.
[13]Reignier J,Mercier E,Le Gouge A,et al.Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding:a randomized controlled trial.JAMA,2013,309(3):249-256.
[14]黎介寿.我国临床营养支持的现状与展望.肠内肠外营养,2000,7(1):1-3.
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