通过胃镜避免气管切开患者中断管饲的初步研究

　　为了预防肺部并发症，目前的麻醉指南要求气管切开患者术前至少4小时停止管饲。然而对于重症患者，气管切开术所致的营养支持中断不利于患者营养供应及康复。

　　为此，美国纽约奥尔巴尼医学中心、休斯顿卫理公会医院观察56例行气管切开术的患者，其中11例管饲不中断（TF组），其余45例按照麻醉指南术前中断管饲（NPO组）。

　　结果发现，两组之间术后急性呼吸窘迫综合征及肺炎发生率均无统计学差异，两组均未出现误吸现象，且两组死亡率也无差异。

　　因此，气管切开术前维持管饲并不增加术后并发症发生率及患者死亡率。

JPEN J Parenter Enteral Nutr. 2017;41(2):292-293.

NPO by the gastroscope: a pilot study avoiding tube feed interruptions in patients requiring tracheostomy.

Lisa M. Angotti; Marcel Tafen; Ashar Ata; Stefanie Sueda; Colleen Casey; Yashar Ettekal; Christina Lee; Daniel Bonville; Steven C. Stain.

Albany Medical Center, Albany, New York, USA; Houston Methodist Hospital, Houston, Texas, USA.

Purpose: Adequate nutrition for the critically ill is paramount for improved outcomes. To reduce the rate of malnutrition in intubated intensive care unit (ICU) patients, clinicians have eliminated tube feed interruption prior to select procedures not involving the airway or gastrointestinal (GI) tract; however, tracheostomy procedures were previously excluded given a lack of data regarding safety. This study examined the hypothesis that preprocedural tube feed interruption is not required prior to tracheostomy.

Methods: Current anesthesia guidelines require that tube feeds be held a minimum of 4 hours prior to tracheostomy. Working with anesthesia staff, we developed a protocol that would allow continued feeding for some patients, based on the willingness of individual anesthesiologists to participate. All patients undergoing tracheostomy with or without percutaneous endoscopic gastrostomy (PEG) placement by the Acute Care Surgery service at a single institution between December 1, 2015, and June 30, 2016, were included in the analysis. Data, including demographics, operating room (OR) and consultation times, operative data, nil per os (NPO) status, and complications, were collected by retrospective chart review.

Results: During the study period, 56 patients underwent tracheostomy with or without PEG placement. Of those, 11 patients were taken to the OR without tube feed interruption and were assigned to the tube feed (TF) group. The remaining 45 patients (NPO group) had tube feeds held per the existing anesthesia protocol. The 2 groups were statistically similar with regard to age, sex, race, and risk of mortality (ROM). Preoperative serum albumin in the TF group was similar (3.2 vs 2.9). There was no statistically significant increase in postoperative pulmonary complications in the TF group vs the NPO group: acute respiratory distress syndrome (0% vs 2.2%) and pneumonia (9.1% vs 8.9%). There were no documented cases of intraoperative aspiration in either group. There was no increase in mortality in the TF group (9.1% vs 22.2%, P = .43). The NPO patients had tube feeds held for an average of 25.4 ± 19.0 hours (range 5–89 hours) with an average missed caloric intake of 1983.5 ± 1590.8 calories. Patients in the TF group had a shorter average time to the OR (40.4 vs 50.6 hours from time of consultation to OR [P = .54] and 7.9 vs 12.8 hours from booking case to OR [P = .40]). Average length of stay for the TF group was 26.3 days vs 31.1 days for the NPO group (P = .45).

Conclusions: There was no increase in postoperative pulmonary complications or mortality in the patients maintained on tube feeds prior to undergoing tracheostomy, and they experienced less delay in reaching the operating room. Meanwhile, patients kept NPO per protocol sustained a substantial caloric deficit while awaiting surgery. Tracheostomy and PEG placement without tube feed interruption is feasible, is safe, and reduces malnutrition. Protocols should be developed where tube feed interruptions are avoided in patients with a secure airway undergoing surgery, including tracheostomy.

DOI: 10.1177/0148607116686023