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中华重症医学电子杂志

中华重症医学电子杂志 ›› 2022, Vol. 08 ›› Issue (04) : 313 -320. doi: 10.3877/cma.j.issn.2096-1537.2022.04.007

专题笔谈

床旁超声指导肠内营养实施的优势与局限
邹同娟1, 尹万红1,†(), 何伟2, 许媛3, 艾潇琳1, 李雅1   
  1. 1. 610041　成都，四川大学华西医院/华西临床医学院重症医学科
    2. 100730　北京，首都医科大学附属北京同仁医院重症医学科
    3. 102218　北京，清华大学临床医学院　清华大学附属北京清华长庚医院重症医学科
  • 收稿日期:2022-11-08 出版日期:2022-11-28
  • 通信作者: 尹万红

Advantages and pitfalls of bedside ultrasound-guided enteral nutrition implementation

Tongjuan Zou1, Wanhong Yin1,†(), Wei He2, Yuan Xu3, Xiaolin Ai1, Ya Li1   

  1. 1. Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, China
    2. Department of Critical Care Medicine, Beijing Tongren Hospital,Capital Medical University, Beijing 100730, China
    3. Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
  • Received:2022-11-08 Published:2022-11-28
  • Corresponding author: Wanhong Yin
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邹同娟, 尹万红, 何伟, 许媛, 艾潇琳, 李雅. 床旁超声指导肠内营养实施的优势与局限[J]. 中华重症医学电子杂志, 2022, 08(04): 313-320.

Tongjuan Zou, Wanhong Yin, Wei He, Yuan Xu, Xiaolin Ai, Ya Li. Advantages and pitfalls of bedside ultrasound-guided enteral nutrition implementation[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2022, 08(04): 313-320.

早期启动肠内营养（EN）已是重症患者营养治疗的一致推荐及常规应用。但是在EN实施过程中面临着反流、误吸、喂养不耐受（FI）、腹胀、腹泻，甚至肠道缺血、坏死等风险，这会延长患者住院时间，甚至导致不良结局。胃肠功能是影响重症患者EN实施的关键环节。目前评价EN实施效果的常用指标包括胃残余量（GRV）以及胃肠道症状等，但是对于GRV的监测及诊断阈值目前仍存在争议，胃肠道功能评价亦缺乏可靠的指标。近年，随着床旁超声技术的发展，其以床旁、无创、可视化、即时、可重复性强等优点在临床上已被广泛使用，不仅可以用来评价胃肠道结构、功能、血流等情况，在指导EN实施、监测FI、指导鼻肠管安置、营养状态的评价等各方面的价值亦日益凸显，床旁超声是一个可靠的、具有良好应用前景的评价手段。因此，本文针对床旁超声在EN实施过程中的优势以及可能存在的陷阱进行阐述。

关键词: 床旁超声, 肠内营养, 优势, 局限

Early initiation of enteral nutrition (EN) has been the unanimous recommendation and routine use of nutritional therapy in critically ill patients. However, there are risks of reflux, aspiration, feeding intolerance (FI), bloating, diarrhea and even intestinal ischemia and necrosis during the implementation of EN, which can prolong hospital stay and even lead to poor outcomes. Gastrointestinal function is a critical component in implementing EN in critically ill patients. Currently, the most commonly used indicators to evaluate the effectiveness of EN implementation include gastric residual volume (GRV) and gastrointestinal symptoms, etc. However, the threshold for monitoring and diagnosing GRV is still controversial, and there are no reliable indicators of gastrointestinal function. In recent years, with the development of bedside ultrasound technology, it has been widely used in clinical practice for its advantages of being bedside, non-invasive, visualization, immediate and reproducible. Bedside ultrasound is a reliable and promising tool, it can be used not only to evaluate the structure, function, and blood flow of the gastrointestinal tract but also to guide the implementation of EN, monitor FI, guide the placement of nasogastric tubes, and evaluate nutritional status. Therefore, this paper will addresse the advantages and possible pitfalls of bedside ultrasound in the implementation of EN.

Key words: Bedside ultrasound, Enteral nutrition, Advantage, Pitfall
图1 双径线法和描记法计算胃窦横截面积。图a为双径线法；图b为描记法注：L为肝脏；A为胃窦；P为胰腺；SMA为肠系膜上动脉；Ao为腹主动脉
表1 误吸风险半定量评估［15，34］
风险等级 胃内超声图像 意义
0级 空腹 低误吸风险
1级 液体（仅右侧卧位可见） 75%与GRV＜100 ml相关
2级 液体（右侧卧位和仰卧位均可见） 75%与GRV＞100 ml相关
3级 固体 高误吸风险
表2 超声对不同种类胃内容物的定性评估
内容 空胃 清水 牛奶或脓液 固体
胃窦性状 扁平、塌陷或圆形 膨胀的圆形 膨胀的圆形 膨胀的圆形
胃内容回声 无或低回声“牛眼征” 低回声 高回声“星夜征” 高回声“磨玻璃样”
蠕动情况 无 可见（通常快速蠕动） 可见 可见（通常慢速蠕动）
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