危重患儿喂养不耐受和幽门后喂养
Review Article

危重患儿喂养不耐受和幽门后喂养

María José Solana, Jesús López-Herce, Jorge López

Pediatric Intensive Care Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain

Contributions: (I) Conception and design: MJ Solana; (II) Administrative support: MJ Solana; (III) Provision of study materials or patients: MJ Solana; (IV) Collection and assembly of data: MJ Solana; (V) Data analysis and interpretation: MJ Solana; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Jesús López-Herce, PhD. Pediatric Intensive Care Service, Gregorio Marañón Hospital, Dr. Castelo 47, 28009, Madrid, Spain. Email: pielvi@hotmail.com.

摘要：喂养不耐受(feeding intolerance，FI)是危重患儿临床管理中常见的一个问题，可导致喂养中断从而严重影响预后。目前FI的定义尚未达成共识，因此我们难以了解危重患儿FI的准确患病率、预测因素及预后。胃动力障碍(gastricmotility disorder，GD)是FI最主要的发病机制。GD的病因目前尚不明确，但许多因素(血管活性药物、镇静剂、阿片类药物、肌松药、低灌注)可能与它的发生有关。未来的研究应当集中在阐明危重患儿FI的潜在发病机制以及对FI进行合适且有效的定义。为降低危重患儿FI的患病率，目前有以下几种方法已应用于临床实践：促动力剂使用，食物由聚合配方改为半元素配方，以及将间歇性喂养方式改为连续性喂养。然而，没有足够的证据证明常规使用这些方法的有效性。经幽门后肠内营养(total enteral nutrition，TEN)是治疗危重患儿FI的另一种方式，它已被证明是安全的且耐受性良好，并发症少。TEN能够改善早期营养状况，减少胃潴留和肠内营养中断的次数，从而增加能量的摄入。休克、急性肾损伤(acute kidney injury，AKI)和心脏手术恢复期的患儿可以从这项技术中受益。然而，由于鼻饲管置入有难度，且可造成一些并发症，因此，医护人员必须接受培训，以监测且减少其临床运用相关的并发症。

关键词：幽门后肠内营养；危重患者；胃动力障碍

Received: 04 June 2020; Accepted: 17 September 2020; Published: 30 November 2020.

doi: 10.21037/pm-20-57

喂养不耐受(feeding intolerance，FI)是危重患者的常见问题，它导致喂养中断进而影响预后[1]。由于目前对FI缺乏一致且明确的定义，我们难以了解危重患儿FI的准确患病率、预测因素及预后[2-3]。此外，对FI的错误认识可能会导致不必要的肠内营养延迟，进而导致蛋白质和能量摄入不足，最终引起营养不良的发生[4]。

FI有多种不同定义，但大多数定义包括与胃肠问题(呕吐、腹泻、腹痛或腹胀)相关或不相关的胃潴留量增加。然而，许多其他原因如药物、感染、胃食管反流、腹水或水肿，也可导致危重患者出现这些症状[4]。

1 危重患儿FI的相关因素

危重症儿童通常会出现胃动力障碍(gastricmotility disorder，GD)，这是由胃或十二指肠肌肉组织运动缓慢和/或不协调的运动引起[5]。此外，这些患者常患有胃空肠分离，具体表现为胃张力缺失或运动不足，但小肠蠕动正常[6]，因而使胃残留物增加和腹胀加重，进一步导致误吸、医院获得性肺炎的风险增加[7]以及热量和蛋白质摄入量降低[8]。胃肠动力受损是FI的主要发病机制[7]。GD的病因尚不十分明确，但它的发生可能涉及许多因素[3]。危重患儿常需要镇静药和肌松药，然而这些药物对肠道平滑肌和腹部骨骼肌均有松弛作用，因而导致腹胀[9]。肾上腺素和大剂量多巴胺是危重症患儿常用的药物，它们会减少肠道灌注，从而削弱肠道对营养的耐受性[10]。

患有胃病、腹膜疾病或脑部疾病的患儿发生FI的风险较高[7]。另一方面，由于患儿胃肠道低灌注和肠道炎症，出现循环性休克，从而改变肠组织，导致吸收不良和肠蠕动障碍[11]，这些因素也导致激素水平和迷走神经张力出现变化，胃肠肽水平升高，尤其是胆囊收缩素和多肽YY激素水平，从而影响胃排空[4]。

GD的严重程度取决于疾病的阶段(急性期、稳定期、恢复期)[4]、患者疾病的严重程度以及实现患者病情稳定所需的治疗[12]。患儿对不同营养物质和器官支持的耐受能力会随着疾病的不同阶段而变化，这可以帮助我们建立FI的疾病模型[13]。

最后，与食物配方相关的因素如渗透压、成分或喂养方式也会增加胃潴留[7]。

未来的研究必须集中在阐明危重患儿FI的潜在机制以及对FI进行合适且准确的定义[3,13]。

基于Eveleens等[3]的系统评价和Marino等[13]的社论，开发可用于FI诊断和评估其严重程度的实用工具，使临床医生能够有效地识别和治疗该疾病(表1)。

表1
表1 喂养不耐受的诊断及严重程度
Full table

在临床实践中可以采取以下几种方法以减少危重患儿FI的发生。促动力剂、聚合物食物配方转化为半元素配方以及由间歇喂养改为持续喂养[4]是PICU中用于治疗FI以改善营养吸收状况的常用方法。然而，目前尚没有比较聚合物食物配方与(半)元素食物配方的研究，也没有研究分析促动力药物的作用或喂食方式对FI的影响[4]。因此，没有充分的证据支持这些方法对FI治疗的有效性。

幽门后肠内营养(total enteral nutrition，TEN)是治疗危重症患儿FI的另一种方式。尽管现有证据不能对EN的最佳部位提出建议，但指南[14]建议经胃喂养是EN的首选部位。然而，对于无法耐受经胃喂养、误吸风险高或需要频繁禁食以进行手术或其他操作的危重症儿童，TEN可能是另一种可采用的喂养途径[14-15]。

2 危重患儿幽门后喂养的好处

营养不良与危重患儿的病死率增加有关[16]，而良好的营养状况可以减少并发症并改善预后[17]。肠内营养是儿科重症监护室(pediatric intensive care unit，PICU)的首选营养方式，它可以维持肠道的营养、改善免疫功能，并减少细菌易位和多器官衰竭的发生[17-18]。然而FI却阻碍了PICU中的危重患儿肠内营养，而十二指肠空肠的肠内营养具有安全、耐受性好、并发症少的优点，可成为危重患儿经胃营养或肠道外营养(parenteral nutrition，PN)的替代方案[9,10,19-20]。TEN可以缓解胃潴留、减少肠内营养中断的次数[21-23]，并且可以增加能量摄入，因为它可以促进早期营养，并能快速达到所需的最大营养量[24-27]。早期肠内营养对危重症儿童[25,28-30]和成人[31-33]均有许多益处，因为它改善机体营养状况和免疫功能，并减少脓毒症和肌肉疲劳的发生率[17-18,30,33-34]。此外，早期使用TEN的危重症儿童腹胀的发生率低于较晚使用TEN的儿童[25]。

既往在PICU中对PN和TEN进行比较的研究[35]发现：PN组患儿中相比TEN组患儿发生代谢并发症(高血糖、高三酰甘油血症和胆汁淤积)的人数更多。该研究还强调，TEN相较于PN成本更低，估计每年可节省5 422美元。

3 儿童幽门后置管术

经幽门置管技术复杂，必须由经过培训的医护人员来实施[36]。幽门后置管通常在床旁通过盲插的方式置入[9-10,19,27]。然而，TEN通常因置入饲管的困难而延迟，且导致反复多次尝试[35]。目前有多种技术可推进饲管通过幽门，其中包括使用探针和给管道尖端加重、磁铁，侧卧位，注入空气和促胃肠动力剂[9,17,36-41]。

饲管最好放置在十二指肠的水平部和升部[42]，然而，在无法直视的情况下使饲管通过幽门可能存在一定困难。为成功地插入饲管，有时需要X线透视[43]或内窥镜辅助置管[9,44]。另一种基于电磁引导的方法可用于危重患者[6,37]。该技术使用内置电极探针的管子，将其置于患者的上腹部，可将信号传输到放置于患儿上腹部的接收装置，并可显示出提示饲管位置的图形[6]。电磁引导系统对于危重儿床旁看起来是一种成功、高效且经济的方法，可以用于危重患儿的床旁置入幽门后饲管[37]。

超声技术也适用于胃蠕动严重受损的患者[45]。

置入饲管后，临床医生必须确认饲管放置位置正确，以避免并发症的发生。腹部听诊可以显著提高饲管放置的成功率[46]。影像学也广泛应用于此，但其他无辐射的方法，如测量从管中抽吸的气体体积，以及在饲管插入过程中观察抽吸物pH值和颜色的变化也有一定效果[9-10,19,20,42]。最近，测定胆红素、胃蛋白酶和胰蛋白酶浓度也被研究证明可用于确定饲管位置[42]。

4 危重儿童TEN的指征

危重儿童中的TEN目前的适应证包括FI、肺部误吸风险较高的患儿[14-15]。它也可用于机械通气的患儿、呼吸衰竭未予以机械通气患儿、有神经系统并发症或需要腹部手术的患儿[27]。

一项对PICU的手术后和非手术患儿的前瞻性研究[19]表明：这些患者中的大多数都能耐受TEN，且腹部并发症极少。尽管不同年龄组的喂养耐受性相似，但手术患者的胃肠道并发症发生率明显高于非手术患者。

患有先天性心脏病的患儿由于代谢需求增加、营养摄入减少或由于低心输出量引起的肠黏膜变化继发吸收不良而常常导致营养不良[47]。这些患儿的营养不良会对血液动力学产生不良影响[48]，因此建议在手术前后改善这些患儿的营养状况[49]。在儿科心脏手术后进行TEN被认为是安全的，它使得这些患儿可以尽早开始并迅速推进肠内营养，增加在术后24~48 h内摄入足够能量的机会[9]。此外，这些儿童的腹泻发生率较低[9,36]，这也证实采用TEN的患儿可以通过标准饮食充分吸收营养物质。

TEN对休克的儿童也是有益的[10]，休克发生时，一方面机体氧供和氧耗严重失衡而导致器官灌注不良[50]，尤其内脏灌注不足，可增加肠道并发症发生[51-53]。另一方面，休克治疗时需要使用大剂量的血管活性药物，这些药物进一步减少肠道血流灌注并损害肠道耐受性。尽管休克患儿并发症的发生率高于其他疾病患儿，但将TEN用于休克的危重症患儿仍是可行的[10]。既往的一项研究[10]表明：与因其他疾病而入住PICU的儿童相比，休克的患儿腹胀、胃潴留和腹泻的发生率明显更高；大多数患儿能耐受肠内营养且没有并发症，但有2名患儿发展为坏死性小肠结肠炎，1名患儿因与营养相关的并发症而死亡。因此休克患者必须在密切监测胃肠道并发症的情况下谨慎使用TEN。

大多数住入PICU的最危重患者都会出现急性肾损伤(acute kidney injury，AKI)，这可以是其他综合征(即心力衰竭、肝衰竭和脓毒症)的一部分表现，也可由原发性肾脏疾病引起。AKI患者胃肠道并发症的发生率高于肾功能正常的患者[20,54]。尿毒症可能会延迟胃排空[55]，并引起包括水肿、溃疡在内的胃肠道黏膜病变，进而影响喂养耐受性[56]。由于AKI患儿与其他患儿相比，能量摄入更低，所以TEN对患有AKI的危重患儿是有用的，即使他们正在使用正性肌力药、镇静剂或肌松药[20]。

5 与经幽门饲管相关的并发症

TEN在危重儿童[19,35-36,57]中使用是安全的，且耐受性良好，具有许多优点[23]，但也有机械性损伤和腹部并发症发生的报道[19,36,58]。机械性并发症与经幽门饲管的类型、置管技术、部位和幽门后喂养的持续时间有关。应使用管径小而柔软的管子以减少鼻黏膜损伤、压疮、中耳炎和鼻窦炎的发生率[36]。

经幽门饲管置入必须由受过训练的人员完成，因为该技术复杂，在置入过程中可能出现胸膜或支气管破裂[27,36]。尽管儿童置管较成人患者更容易[7]，但也有婴儿因置入经幽门管而导致十二指肠穿孔的报道[58]。置管困难可使用促动力剂[19]或用内窥镜[9]可视化操作可能会提高插管的成功率。必须通过X线透视确保饲管插入到了合适的位置，尤其是在怀疑有任何并发症发生时[19,58]。

幽门狭窄[59]或肠皮肤瘘[60]的发生很少见，且与长时间的TEN有关。

使用TEN的危重患儿容易出现胃肠道并发症[9-10,19-20]。腹胀、胃潴留和腹泻是最常见的消化道并发症，但很少出现肠内营养中断[19,36,61]。尽管并发症较轻，但这部分患者休克和多巴胺或肾上腺素需求增加的发生率更高[61]。这说明FI可能提示预后不良[19,62]。

休克患者肾上腺素输注速度高于0.3 µg/(kg·min)、低磷血症是危重患儿胃肠道并发症发生的最主要的危险因素[61]。其他危险因素还包括急性肾功能衰竭、低钾血症、多巴胺和维库溴铵输注[61]。

尽管高剂量的正性肌力药可能会降低肠道血液灌注并影响患儿对肠内营养的耐受性，但大多数危重患儿对TEN具有相当好的耐受性[10,61]。接受正性肌力药物的患儿可以在密切监测下接受十二指肠-空肠肠内营养[9-10]。

6 结论

GD是危重儿童的常见问题，导致FI、误吸、肺炎，以及较低的热量和蛋白质摄入。未来的研究必须集中在阐明危重患儿FI的潜在发病机制以及对FI进行合适且有效的定义。

TEN用于危重患儿是可行的，因为它具有安全、耐受性良好、并发症少的优点。此外，幽门后喂养可促进早期营养，减少胃潴留和肠内营养中断次数，增加能量摄入。然而，饲管置入存在一定的困难，并且不能避免并发症的发生。医护人员必须接受培训，以发现和减少与其使用相关的并发症。

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Lyvonne Tume, Frederic Valla and Sascha Verbruggen) for the series “Nutrition in the Critically Ill Child” published in Pediatric Medicine. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-20-57/coif). The series “Nutrition in the Critically Ill Child” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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译者

芦起。医学博士，教授、主任医师，中华医学会儿科学分会新生儿学组青年委员，中国医师协会新生儿科医师分会呼吸专委会委员，重庆市医学会儿科专委会新生儿学组委员，重庆市医学会儿科专委会儿童感染及肝病学组委员，教育部学位论文评审专家。（更新时间：2021/7/14）
审校

罗小丽。电子科技大学医学院附属成都市妇女儿童医院•成都市妇女儿童中心医院。（更新时间：2021/7/14）

(本译文仅供学术交流，实际内容请以英文原文为准。)

doi: 10.21037/pm-20-57
Cite this article as: Solana MJ, López-Herce J, López J. Feed intolerance and postpyloric feeding in the critically ill child . Pediatr Med 2020;3:19.

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