9 8~24.0kcal/ml 20~ Bourgault, Ipe, Weaver, Swartz, & O Dea, 2007 dumping syndrome Martindale et al., Heyland et al.,

Transcription

1 8 Preventing Common Enteral Feeding Complications 重症病人腸胃道管灌常見合併症之預防 王采芷 * 吳淑芳 梁淑媛 童恒新 林玉萍 2 國立臺北護理健康大學護理系副教授 2 亞東技術學院護理系助理教授 摘要 : 營養支持是提供重症病人在面對疾病壓力與氧合所需能量的一種輔助性治療, 可經由腸胃道管灌 或非腸胃道方式提供給無法主動維持適當營養攝 取的重症病人 腸胃道管灌比靜脈營養更能維持 腸道完整性 有較低的感染併發症風險及營養治 療費用, 而早期的腸道營養支持, 更被認為是一 種可以減輕疾病嚴重度 減少合併症 縮短加護 病房住院天數以及改善病人治療成效的積極治療 策略, 故重症病人之營養支持以腸胃道管灌為優 先考量 然而, 就像其他的治療一樣, 腸胃道管 灌也有其相關的危險性 護理人員應具備相關知 識, 以提供接受腸胃道管灌之重症病人適當的照 護, 因此, 本文就腸胃道管灌臨床適應症 照 護注意事項 常見合併症之評估與預防作深入介 紹 其中照護注意事項包括 : 開始灌食的時機 確認灌食管路插入的位置 胃殘餘量的監測以及 管路阻塞的預防與處置, 而常見合併症主要介紹 肺吸入 腹瀉 嘔吐 低血鈉與高血糖的評估 與預防, 上述實證知識可作為重症照護單位制訂 灌食管路照護標準與規範及人員訓練之參考, 並 藉以提供病人適當的營養支持, 進而促進病人的 預後 關鍵詞 : 腸胃道管灌 肺吸入 腹瀉 嘔吐 代謝併發症 Martindale et al., 2009 Gramlich et al., 2004; Simpson & Doig, 2005 Peter, Moran, & Phillips-Hughes, Martindale et al., 2009; Peter et al., * Heyland, Drover, MacDonald, Novak, & Lam, 200; Lien, Chang, & Chen, 2000 bolus feeding continuous feeding 4~8 200~ ~4 5~20 [email protected] doi:0.6224/jn

2 9 8~24.0kcal/ml 20~ Bourgault, Ipe, Weaver, Swartz, & O Dea, 2007 dumping syndrome Martindale et al., Heyland et al., 2003; Marik & Zaloga, 200 Bourgault et al., 2007; Martindale et al., 2009; Spain, 2002 Bourgault et al., 2007; Martindale et al., 2009 X Bourgault et al., 2007; Martindale et al., 2009; Metheny, % National Patient Safety Agency, 20 PH Metheny, 2009 Bourgault et al., 2007; Metheny, 2006; Metheny, 2009 Metheny, 2009 Metheny, 2009 PH PH 5 PH 6 Metheny, 2009; Phang, Marsh, Barlows, & Schwartz, 2004 ph < 5.5 National Patient Safety Agency, 20 Metheny, 2006; Metheny, 2009 Bourgault et al., 2007; Martindale et al., 2009; Metheny, 2006 Metheny, 2009 X Bourgault et al., 2007; Martindale et al., 2009; Metheny, 2006, 2009 gastric residual volume 200ml ml 500ml Martindale et al., 2009; McClave et al., 2002;

3 20 Preventing Common Enteral Feeding Complications Metheny, 2006 Booker, Niedringhaus, Eden, & Arnold, 2000 Bourgault ml 200ml 200ml 200ml 200cc Bourgault et al., 2007; Martindale et al., 2009; Metheny, 2006 Booker et al., 2000; Bourgault et al., 2007; Williams, 2008 Bourgault et al., ml Bourgault et al., 2007 Williams, 2008 Williams, 2008 pancrelipase viokase ph 7.9 Bourgault et al., 2007 microaspiration pepsin; Metheny, 2006 McClave et al., 2005; Metheny et al., 2006 pepsin Metheny, 2006 Metheny et al., 2006 Metheny, 2006 McClave et al., 2002; Metheny, 200, 2006; Metheny & Titler, metoclopramide, cisapride, low dose erythromycin, domperidone Bourgault et al., 2007; Martindale et al., 2009; Metheny, 2006 FDA food and drug administration Martindale et al., 2009; US Food and Drug Administration, Center for Food Safety and Applied Nutrition, 2003 sorbital

4 2 clostidium difficile pseudomembranous colitis Bourgault et al., 2007; Martindale et al., 2009 Clostridium difficile Martindale et al., Bourgault et al., 2007; Martindale et al., 2009 Bourgault et al., Bourgault et al., 2007 Metheny, 2006 refeeding syndrome Stroud, Duncan, Nightingale, & British Society of Gastroenterology, 2003 Stroud et al., 2003 X Booker, K. J., Niedringhaus, L., Eden, B., & Arnold, J. S. (2000). Comparison of 2 methods of managing gastric residual volumes from feeding tubes. American Journal of Critical Care, 9(5), Bourgault, A. M., Ipe, L., Weaver, J., Swartz, S., & O Dea, P. J. (2007). Development of evidence-based guidelines and critical care nurses knowledge of enteral feeding. Critical Care Nurse, 27(4), Gramlich, L., Kichian, K., Pinilla, J., Rodych, N. J., Dhaliwal, R., & Heyland, D. K. (2004). Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition, 20(0), doi:0.06/j.nut Heyland, D. K., Dhaliwal, R., Drover, J. W., Gramlich, L., Dodek, P., & Canadian Critical Care Clinical Practice Guidelines Committee. (2003). Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. Journal of Parenteral and Enteral Nutrition, 27(5), doi:0.77/ Heyland, D. K., Drover, J. W., MacDonald, S., Novak, F., & Lam, M. (200). Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: Results of a randomized controlled trial. Critical Care Medicine, 29(8), doi:0.097/ Lien, H. C., Chang, C. S., & Chen, G. H. (2000). Can percuta-

5 22 Preventing Common Enteral Feeding Complications neous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis? The American Journal of Gastroenterology, 95(2), doi:0./j x Marik, P. E., & Zaloga, G. P. (200). Early enteral nutrition in acutely ill patients: A systematic review. Critical Care Medicine, 29(2), doi:0.097/ Martindale, R. G., McClave, S. A., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B.,... the A.S.P.E.N. Board of Directors. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Critical Care Medicine, 37(5), doi:0.097/ CCM.0b03e38a406 McClave, S. A., DeMeo, M. T., DeLegge, M. H., DiSario, J. A., Heyland, D. K., Maloney, J. P.,... Zaloga, G. P. (2002). North American summit on aspiration in the critically ill patient: Consensus statement. Journal of Parenteral and Enteral Nutrition, 26(Suppl. 6), S80 S85. doi:0.77/ McClave, S. A., Lukan, J. K., Stefater, J. A., Lowen, C. C., Looney, S. W., Matheson, P. J., Spain, D. A. (2005). Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Critical Care Medicine, 33(2), doi:0.097/0.ccm a Metheny, N. A. (2006). Preventing respiratory complications of tube feedings: Evidence-based practice. American Journal of Critical Care, 5(4), Metheny, N. A. (2009). Verification of feeding tube placement (American Association of Critical-care Nurses [AACN] practice alert). Retrieved from aacn.org/wd/practice/content/feeding-tube-practice-alert. pcms?menu=practice Metheny, N. A., Clouse, R. E., Chang, Y. H., Stewart, B. J., Oliver, D. A., & Kollef, M. H. (2006). Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors. Critical Care Medicine, 34(4), doi:0.097/0. CCM Metheny, N. A., & Titler, M. G. (200). Assessing placement of feeding tubes. The American Journal of Nursing, 0(5), doi:0.097/ National Patient Safety Agency. (20). Patient Safety Alert NPSA/20/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. Retrieved from SiteWeb/getresource.axd?AssetID=29696 Peter, J. V., Moran, J. L., & Phillips-Hughes, J. (2005). A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Critical Care Medicine, 33(), doi:0.097/0. CCM C0 Phang, J. S., Marsh, W. A., Barlows, T. G., & Schwartz, H. I. (2004). Determining feeding tube location by gastric and intestinal ph values. Nutrition in Clinical Practice, 9(6), doi:0.77/ Simpson, F., & Doig, G. S. (2005). Parenteral vs. enteral nutrition in the critically ill patient: A meta-analysis of trials using the intention to treat principle. Intensive Care Medicine, 3(), doi:0.007/s Spain, D. A. (2002). When is the seriously ill patient ready to be fed? Journal of Parenteral and Enteral Nutrition, 26(Suppl. 6), S62 S68. Stroud, M., Duncan, H., Nightingale, J., & British Society of Gastroenterology. (2003). Guidelines for enteral feeding in adult hospital patients. Gut, 52(Suppl. VII), vii-vii2. doi:0.36/gut.52.suppl_7.vii US Food and Drug Administration, Center for Food Safety and Applied Nutrition. (2003). FDA public health advisory: Subject: Reports of blue discoloration and death in patients receiving enteral feedings tinted with the dye, FD&C blue no.. Retrieved from try/coloradditives/coloradditivesinspecificproducts/in- MedicalDevices/ucm42395.htm Williams, N. T. (2008). Medication administration through entral feeding tubes. American Journal of Health-System Pharmacy, 65(24), doi:0.246/ajhp08055

6 23 Preventing Common Enteral Feeding Complications in Critically Ill Adult Patients Tsae-Jyy Wang * Shu-Fang Vivienne Wu Shu Yuan Liang Heng-Hsin Tung Yu-Ping Lin 2 RN, PhD, Associate Professor, Department of Nursing, National Taipei University of Nursing and Health Sciences; 2 RN, PhD, Assistant Professor, Department of Nursing, Oriental Institute of Technology. Abstract: Nutritional support provides critically ill patients with energy and nutrients required to face the demands of their illness and stress. For those unable to ingest orally, enteral feeding rather than parenteral feeding is recommended, as the former better preserves gut integrity, reduces risk of infection, and costs less. Early enteral feeding in critically ill patients is also associated with decreased disease severity, reduced complications, and shortened length of stay. Risks associated with enteral feeding include aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. This article reviews current knowledge on enteral feeding and addresses correct feeding tube placement, proper feeding sites, assessing and managing gastric residual volume, and preventing feeding tube occultation. We also review information related to identifying and controlling risk factors for enteral feeding complications such as aspiration, diarrhea, vomiting, hyponatremia, and hyperglycemia. Nurses can use this information to provide high quality care for enteral feeding patients and develop institutional protocols, guidelines, and standards of care for such patients in intensive care units. Key Words: enteral feeding, aspiration, diarrhea, vomiting, metabolic complications. Accepted for publication: June 5, 202 *Address correspondence to: Tsae-Jyy Wang, No. 365, Ming-Te Rd., Peitou District, Taipei City 29, Taiwan, ROC. Tel: ; [email protected]