Application of bedside ultrasound monitoring gastric residual volume and motilite index in critical illness patients with enteral nutrition
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摘要: 目的 探讨床旁超声联合监测胃残余量(gastric residual volume，GRV)、胃窦运动指数(motilite index，MI)在危重症患者肠内营养支持治疗中的应用效果及可能作用机制，旨在为危重症患者肠内营养支持治疗指导提供参考。方法 选择2021年7月至2022年12月南通大学第二附属医院急诊ICU、急诊病区收治的需要肠内营养支持治疗的危重症患者100例为研究对象，采用随机数字表法分为研究组(50例)和对照组(50例)。对照组采用胃管回抽法监测GRV，根据GRV调整肠内营养支持治疗方案；研究组采用超声联合监测GRV和MI，根据GRV和MI调整肠内营养支持治疗方案。比较2组治疗前后血清炎性因子、体液免疫功能、细胞免疫功能、肠黏膜屏障功能、胃肠激素、营养学指标；统计2组预后相关指标、喂养相关并发症、感染相关并发症。结果 研究组患者治疗后血清C-反应蛋白、白细胞介素-6、肿瘤坏死因子-α明显低于同期对照组，白细胞介素-10明显高于同期对照组(P＜0.05)。研究组患者治疗后免疫球蛋白A、免疫球蛋白G、免疫球蛋白M明显高于同期对照组(P＜0.05)。研究组患者治疗后CD3+、CD4+、CD4+/CD8+明显高于同期对照组(P＜0.05)，CD8+明显低于同期对照组(P＜0.05)。研究组患者治疗后血清内毒素、D-乳酸、二胺氧化酶明显低于同期对照组(P＜0.05)。研究组患者治疗后胃动素、5-羟色胺明显高于同期对照组(P＜0.05)，血管活性肽明显低于同期对照组(P＜0.05)。研究组患者治疗后血清白蛋白、前白蛋白、转铁蛋白明显高于同期对照组(P＜0.05)。研究组患者腹内压、达目标喂养时间、机械通气时间、ICU住院时间明显低于对照组(P＜0.05)。研究组患者喂养相关并发症发生率为20.00%，明显低于对照组的68.00%(P＜0.05)。研究组患者感染相关并发症发生率为12.00%，明显低于对照组的34.00%(P < 0.01)。结论 床旁超声联合监测GRV和MI应用于危重症患者肠内营养支持治疗指导中，能够减少喂养及感染相关并发症的发生，促进患者康复。可能与拮抗炎症反应、改善免疫功能与肠黏膜屏障功能、调节胃肠激素与营养状态等因素有关。Abstract: Objective To study the effect and possible mechanism of bedside ultrasound monitoring gastric residual volume(GRV) and motilite index(MI) in enteral nutrition support therapy in critical illness patients, and provide reference for the guidance of enteral nutrition support therapy in critical illness patients.Methods A total of 100 critical illness patients requiring enteral nutrition support therapy from July 2021 to December 2022 were divided into study group(50 cases) and control group(50 cases). Patients in the control group monitored GRV by gastric tube extraction, and adjusted enteral nutrition support therapy scheme according to GRV. Patients in the study group monitored GRV and MI by ultrasound combined, and adjusted enteral nutrition support therapy scheme according to GRV and MI. Then the serum inflammatory factors, humoral immunity, cellular immunity, intestinal mucosal barrier function, gastrointestinal hormones and nutritional indexes were compared before and after treatment between two groups. The feeding-related complications and infection-related complications were analyzed.Results After treatment, the serum C-reactive protein, interleukin-6, and tumor necrosis factor-α in the study group were significantly lower than those in the control group during the same period, and the interleukin-10 was significantly higher than that in the control group(P < 0.05). After treatment, the levels of immunoglobulin A, immunoglobulin G, and immunoglobulin M in the study group were significantly higher than those in the control group during the same period(P < 0.05). After treatment, the CD3+, CD4+, and CD4+/CD8+levels in the study group were significantly higher than those in the control group during the same period(P < 0.05), and the CD8+ level was significantly lower than that in the control group(P < 0.05). After treatment, the levels of serum endotoxin, D-lactate, and diamine oxidase in the study group were significantly lower than those in the control group(P < 0.05). After treatment, the levels of motilin and serotonin in the study group were significantly higher than those in the control group(P < 0.05), and the level of vasoactive peptides was significantly lower than that in the control group(P < 0.05). After treatment, the serum albumin, prealbumin, and transferrin levels in the study group were significantly higher than those in the control group during the same period(P < 0.05). The intra-abdominal pressure, target feeding time, mechanical ventilation time, and ICU hospitalization time in the study group were significantly lower than those in the control group(P < 0.05). The incidence of feeding-related complications in the study group was 20.00%, which was significantly lower than 68.00% in the control group(P < 0.05). The incidence of infection-related complications in the study group was 12.00%, which was significantly lower than 34.00% in the control group(P < 0.01).Conclusion Bedside ultrasound monitoring GRV and MI can reduce the incidence of feeding- and infection-related complications, and promote recovery of patients. It may be related to antagonism of inflammatory reaction, improvement of immune function and intestinal barrier function, regulation of gastrointestinal hormones and nutritional status.
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表 1 2组患者一般资料比较
组别 研究组(50例) 对照组(50例) t/χ2 P 性别/例(%) χ2=0.657 0.418 男 27(54.00) 31(62.00) 女 23(46.00) 19(38.00) 年龄/岁 60.36±8.82 58.60±7.16 t=1.096 0.276 BMI/(kg/m2) 22.97±2.54 22.15±3.10 t=1.447 0.151 入院诊断/例(%) χ2=0.927 0.435 呼吸系统疾病 16(32.00) 19(38.00) 神经系统疾病 13(26.00) 12(24.00) 循环系统疾病 9(18.00) 10(20.00) 泌尿系统疾病 7(14.00) 6(12.00) 其他 5(10.00) 3(6.00) APACHEⅡ评分 17.72±2.67 17.02±3.18 t=1.192 0.236 SOFA评分 5.02±1.36 4.60±1.18 t=1.649 0.102 NRS2002评分 4.32±1.15 4.08±1.10 t=1.066 0.289 合并疾病/例(%) 高血压 21(42.00) 17(34.00) χ2=0.679 0.410 糖尿病 18(36.00) 15(30.00) χ2=0.407 0.524 冠心病 16(32.00) 11(22.00) χ2=1.268 0.260 
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表 2 2组患者营养支持治疗前后血清炎性因子比较
X±S 组别 CRP/(mg/L) IL-6/(ng/L) IL-10/(ng/L) TNF-α/(ng/L) 研究组(50例) 治疗前 142.38±8.92 75.94±4.31 7.40±2.07 44.88±4.33 治疗后 42.82±5.30 43.32±5.51 18.92±3.06 12.16±2.92 t 68.822 33.456 22.076 44.323 P ＜0.001 ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 139.20±11.49 74.98±5.63 7.96±1.74 43.58±4.53 治疗后 68.42±6.28 52.60±6.46 12.18±2.35 20.44±3.78 t 38.235 18.466 10.219 27.733 P ＜0.001 ＜0.001 ＜0.001 ＜0.001 t1 1.546 0.957 1.464 1.422 P1 0.125 0.341 0.146 0.158 t2 22.028 7.728 12.233 12.258 P2 ＜0.001 ＜0.001 ＜0.001 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 3 2组患者营养支持治疗前后体液免疫功能指标比较
X±S 组别 IgA/(g/L) IgG/(g/L) IgM/(g/L) 研究组(50例) 治疗前 1.75±0.17 10.21±1.57 1.18±0.18 治疗后 2.78±0.37 19.04±2.69 2.06±0.24 t 17.764 20.076 20.742 P ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 1.80±0.16 10.69±1.42 1.21±0.15 治疗后 2.44±0.32 14.43±2.03 1.58±0.21 t 12.571 10.664 10.063 P ＜0.001 ＜0.001 ＜0.001 t1 1.515 1.603 0.905 P1 0.133 0.112 0.368 t2 4.915 9.673 10.643 P2 ＜0.001 ＜0.001 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 4 2组患者营养支持治疗前后细胞免疫功能指标比较
X±S 组别 CD3+/% CD4+/% CD8+/% CD4+/CD8+ 研究组(50例) 治疗前 57.30±7.20 31.60±4.69 32.24±3.27 1.01±0.25 治疗后 69.84±8.18 41.98±6.47 26.44±3.32 1.66±0.35 t 8.135 9.186 8.801 10.689 P ＜0.001 ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 58.62±5.79 32.86±4.05 31.22±3.12 1.07±0.22 治疗后 64.80±6.55 38.00±5.29 28.52±2.64 1.36±0.29 t 5.000 5.457 4.668 5.696 P ＜0.001 ＜0.001 ＜0.001 ＜0.001 t1 1.010 1.438 1.596 1.261 P1 0.315 0.154 0.114 0.210 t2 3.401 3.317 3.467 4.667 P2 0.001 0.001 0.001 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 5 2组患者营养支持治疗前后肠黏膜屏障功能比较
X±S 组别 ET/(ng/L) DLA/(mg/L) DAO/(ng/L) 研究组(50例) 治疗前 38.32±5.72 18.42±2.67 5.94±1.58 治疗后 10.22±2.67 6.92±1.76 1.91±0.49 t 31.489 25.412 17.271 P ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 38.02±5.16 18.08±3.32 5.78±1.62 治疗后 16.52±2.89 9.32±1.81 2.65±0.65 t 25.724 16.387 12.647 P ＜0.001 ＜0.001 ＜0.001 t1 0.275 0.564 0.500 P1 0.784 0.574 0.618 t2 11.322 6.722 6.341 P2 ＜0.001 ＜0.001 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 6 2组患者营养支持治疗前后胃肠激素比较
X±S 组别 MTL/(ng/L) VIP/(ng/L) 5-HT/(μg/L) 研究组(50例) 治疗前 138.70±8.74 82.14±9.65 1 535.52±85.48 治疗后 268.98±18.31 55.80±6.23 2 157.80±191.50 t 45.403 16.224 20.983 P ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 140.04±9.97 81.74±8.52 1 537.88±85.56 治疗后 222.82±14.08 64.64±8.03 1 869.50±160.58 t 33.930 10.326 12.888 P ＜0.001 ＜0.001 ＜0.001 t1 0.715 0.220 0.138 P1 0.477 0.827 0.891 t2 14.131 6.150 8.157 P2 ＜0.001 ＜0.001 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 7 2组患者营养支持治疗前后营养学指标比较
X±S 组别 ALB/(g/L) PAB/(mg/L) TRF/(g/L) 研究组(50例) 治疗前 27.62±4.23 156.10±13.38 1.47±0.16 治疗后 37.26±4.72 223.42±21.27 2.24±0.22 t 10.752 18.943 20.166 P ＜0.001 ＜0.001 ＜0.001 对照组(50例) 治疗前 28.20±3.65 160.24±11.56 1.52±0.13 治疗后 32.56±3.95 211.30±16.22 1.92±0.17 t 5.731 18.125 13.469 P ＜0.001 ＜0.001 ＜0.001 t1 0.734 1.656 1.715 P1 0.465 0.101 0.090 t2 5.400 3.204 8.139 P2 ＜0.001 0.002 ＜0.001 t1/P1：2组治疗前比较；t2/P2：2组治疗后比较。
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表 8 2组患者相关预后指标比较
X±S 组别 例数 腹内压/mmHg 达目标喂养时间/d 机械通气时间/d ICU住院时间/d 研究组 50 8.49±1.16 2.30±1.02 8.04±2.59 10.28±2.78 对照组 50 10.08±1.29 3.26±1.21 11.00±2.44 13.46±2.47 t 10.557 4.289 5.882 6.047 P ＜0.001 ＜0.001 ＜0.001 ＜0.001
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表 9 2组患者喂养相关并发症比较
例(%) 组别 例数 腹胀 腹泻 呕吐 胃潴留 ACS 合计 研究组 50 3(6.00) 4(8.00) 2(4.00) 1(2.00) 0 10(20.00) 对照组 50 10(20.00) 12(24.00) 7(14.00) 3(6.00) 2(4.00) 34(68.00) χ2 23.377 P ＜0.001
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表 10 2组患者感染相关并发症比较
例(%) 组别 例数 VAP 血行感染 导管相关感染 合计 研究组 50 5(10.00) 1(2.00) 0 6(12.00) 对照组 50 11(22.00) 4(8.00) 2(4.00) 17(34.00) χ2 6.832 P 0.009
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