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中华重症医学电子杂志 ›› 2025, Vol. 11 ›› Issue (01) : 95 -99. doi: 10.3877/cma.j.issn.2096-1537.2025.01.018

综述

休克状态下早期肠内营养发生非闭塞性肠系膜缺血的风险与预防现状
沈基1,2, 刘威3, 陈红宇1, 詹心萍1, 卢梦诗1, 马加威4, 嵇丹丹4, 罗亮1,3,4,()   
  1. 1. 214002 江苏无锡,南京医科大学附属无锡第二医院重症医学科
    2. 214400 江苏江阴,江阴市人民医院重症医学科
    3. 214122 江苏无锡,江南大学医学院
    4. 214002 江苏无锡,江南大学附属中心医院重症医学科
  • 收稿日期:2024-01-23 出版日期:2025-02-28
  • 通信作者: 罗亮
  • 基金资助:
    江苏省无锡市医学创新团队项目(CⅩTD2021018)无锡市卫生健康委科技成果与适宜技术推广项目(T202449)

Risk and prevention of non-occlusive mesenteric ischemia during enteral nutrition in shock state

Ji Shen1,2, Wei Liu3, Hongyu Chen1, Xinping Zhan1, Mengshi Lu1, Jiawei Ma4, Jiawei Ma4, Liang Luo1,3,4,()   

  1. 1. Department of Critical Care Medicine,Wuxi Second Hospital Affiliated to Nanjing Medical University,Wuxi 214002,China
    2. Department of Critical Care Medicine,Jiangyin People's Hospital,Wuxi 214400,China
    3. Medical School,Jiangnan University,Wuxi 214122,China
    4. Department of Critical Care Medicine,Jiangnan University Medical Center,Wuxi 214002,China
  • Received:2024-01-23 Published:2025-02-28
  • Corresponding author: Liang Luo
引用本文:

沈基, 刘威, 陈红宇, 詹心萍, 卢梦诗, 马加威, 嵇丹丹, 罗亮. 休克状态下早期肠内营养发生非闭塞性肠系膜缺血的风险与预防现状[J/OL]. 中华重症医学电子杂志, 2025, 11(01): 95-99.

Ji Shen, Wei Liu, Hongyu Chen, Xinping Zhan, Mengshi Lu, Jiawei Ma, Jiawei Ma, Liang Luo. Risk and prevention of non-occlusive mesenteric ischemia during enteral nutrition in shock state[J/OL]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2025, 11(01): 95-99.

非闭塞性肠系膜缺血(NOMI)是由非闭塞原因引起的肠道缺血损伤甚至坏死。休克患者循环血量下降为NOMI发生的危险因素之一,休克状态下早期肠内营养(EEN)可能导致肠道氧供需失衡促使NOMI的发生。然而,重症患者发生NOMI时往往诊断困难,且有很高的病死风险。本文通过对休克状态下EEN发生NOMI风险及其预防方面的进展进行综述,旨在为改善NOMI患者预后提供支持。

Non-occlusive mesenteric ischemia is characterized by ischemic injury or necrosis of the intestine stemming from non-obstructive causes. One of the major risk factors for non-occlusive mesenteric ischemia in shock patients is the decrease in blood volume within the circulatory system. Early enteral nutrition during shock may exacerbate the imbalance between the oxygen supply and demand of the intestines,thus facilitating the development of non-occlusive mesenteric ischemia. Nevertheless,diagnosing non-occlusive mesenteric ischemia in critically sick patients is typically challenging,as it is linked to a significant risk of death. This paper will review the advancements on the risks and preventive measures of non-occlusive mesenteric ischemia induced by early enteral nutrition in shock states,which aim to provide support for improving the prognosis of non-occlusive mesenteric ischemia.

图1 不同情况下肠系膜血流、氧流以及能量代谢变化。图a为肠系膜循环血流明显下降时通过氧摄取增多等代偿方式可增加氧/能量供应,当肠道组织摄氧量低于正常水平50%[10]或肠系膜血流下降75%超过12 h[11]后可发生肠道损伤;图b为脓毒症、缺血再灌注时可因炎症等原因促使肠系膜循环血流增加,此时肠上皮氧供大于氧需,氧气顺浓度梯度弥散进入肠腔出现“肠漏氧”,并因肠腔内低氧状态破坏导致肠道菌群失调[19];图c为禁食状态下正常肠系膜循环血流/氧流及能量代谢;图d为进食后正常肠系膜循环血流/氧流及能量代谢,益生菌参与下食物分解产生的短链脂肪酸等进入肠上皮,肠上皮通过氧化代谢将血流增多带来的氧气消耗并提供额外的能量,从而满足消化吸收过程中的大量能量需求[18];图e为进食后血流调节能力下降导致能量供需失衡,血流增长不足和过量都可能导致氧/能量供需失衡,肠上皮内氧稳态失衡,促使肠道损伤发生[19];图f为危重症菌群失调患者进食后能量供需失衡,可使肠道损伤(血流增加,氧供增加)、肠漏氧(促使肠道菌群失调)、菌群失调(导致短链脂肪酸等生成减少,能量供应及氧耗减少)、能量供需失衡(能量供应无法满足消化吸收需要,促使肠道损伤发生)交互导致恶性循环,促使NOMI发生发展 注:NOMI为非闭塞性肠系膜缺血
图2 早期肠内营养相关NOMI的监测与预防 注:NOMI为非闭塞性肠系膜缺血
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