俯卧位机械通气患者早期肠内营养支持审查指标的制订及障碍因素分析

doi:10.3761/j.issn.2096-7446.2025.07.006

摘要/Abstract

摘要：

目的了解俯卧位机械通气患者早期肠内营养支持临床应用现状，制订审查指标，分析障碍及促进因素，并制订变革策略。方法通过前期证据总结，纳入16条最佳证据，并制订了20个审查指标。根据临床基线审查结果，分析障碍及促进因素，制订相应变革策略。结果 20个审查指标中，仅1个指标临床执行率为100%，15个指标临床执行率为0，其他指标执行率为8.7%~95.7%。障碍因素主要为缺乏规范化的管理流程及方案、医护人员缺乏相关知识及培训、缺乏多学科合作等，促进因素主要为管理者领导力强、医院具有丰富的循证实践经验和成熟的专科护士队伍、信息化水平高。结论俯卧位机械通气患者早期肠内营养支持的最佳证据与临床实践存在较大差距，应充分利用促进因素、克服障碍因素，实施变革策略，促进证据向临床实践有效转化。

关键词: 俯卧位, 肠内营养, 审查指标, 障碍因素, 循证护理学

Abstract:

Objective To comprehensively evaluate the current status of clinical application of evidence for early enteral nutrition support in ICU prone mechanically ventilated patients and to develop audit indicators，and to analyze the barriers and facilitators，and to formulate strategies for change. Methods Through the evidence summary，16 items of best evidence were included，and 20 audit indicators were developed. Based on the results of the baseline audit of clinical practice，the barriers and facilitators were analyzed，and change strategies were developed. Results Among the 20 indicators reviewed in this study，the clinical implementation rate of only one indicator was 100%，15 indicators were 0，and the range of implementation rates for the other indicators was 8.7%~95.7%. The main barriers were the lack of standardized management procedures，lack of relevant knowledge and training for medical staff，lack of multidisciplinary cooperation. While facilitators were mainly strong leadership of managers，hospitals with rich experience in evidence-based practice and a mature team of specialist nurses，and high level of information technology. Conclusion There is a large gap between the best evidence for early enteral nutrition support for ICU mechanically ventilated patients in the prone position and clinical practice. We should fully utilize the facilitators，overcome the barriers，and implement strategies for change，to promote effective translation of evidence to clinical practice.

Key words: Prone Position, Enteral Nutrition, Audit Indicators, Barriers, Evidence-Based Nursing

王冬雪, 孙丽军, 龚瑛, 吴林静, 郑薇亮. 俯卧位机械通气患者早期肠内营养支持审查指标的制订及障碍因素分析[J]. 中华急危重症护理杂志, 2025, 6(7): 805-811.

WANG Dongxue, SUN Lijun, GONG Ying, WU Linjing, ZHENG Weiliang. Development of audit indicators and analysis of barriers for early enteral nutrition support in prone mechanical ventilation patients[J]. Chinese Journal of Emergency and Critical Care Nursing, 2025, 6(7): 805-811.

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参考文献 28

[1]	李静怡, 张玉侠, 蒋进军, 等. 有创机械通气患者俯卧位实施方案的构建[J]. 中国护理管理, 2022, 22(1):52-57.
	Li JY, Zhang YX, Jiang JJ, et al. Construction of prone position ventilation scheme in patients using invasive mechanical ventilation[J]. Chin Nurs Manag, 2022, 22(1):52-57.
[2]	李豪, 李育红, 王海播, 等. 俯卧位通气患者肠内营养的研究进展[J]. 中华急危重症护理杂志, 2020, 1(3):269-272.
	Li H, Li YH, Wang HB, et al. Research progress of enteral nutrition in prone ventilation patients[J]. Chin J Emerg Crit Care Nurs, 2020, 1(3):269-272.
[3]	Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit[J]. Clin Nutr, 2019, 38(1):48-79. doi: S0261-5614(18)32432-4 pmid: 30348463
[4]	Reintam Blaser A, Starkopf J, Alhazzani W, et al. Early enteral nutrition in critically ill patients:ESICM clinical practice guidelines[J]. Intensive Care Med, 2017, 43(3):380-398. doi: 10.1007/s00134-016-4665-0 pmid: 28168570
[5]	张金. ICU俯卧位通气患者肠内营养喂养不耐受的研究进展[J]. 右江医学, 2021, 49(11):873-877.
	Zhang J. Research progress of enteral nutrition feeding intolerance in patients with prone position ventilation in ICU[J]. Chin Youjiang Med J, 2021, 49(11):873-877.
[6]	倪娜, 王聪聪, 陆丽, 等. 俯卧位通气早期肠内营养的研究进展及护理问题[J]. 中国医药指南, 2021, 19(2):35-36,39.
	Ni N, Wang CC, Lu L, et al. Progress and nursing issues of early enteral nutrition during prone position ventilation[J]. Guide China Med, 2021, 19(2):35-36,39.
[7]	Pearson A, Wiechula R, Court A, et al. The JBI model of evidence-based healthcare[J]. Int J Evid Based Healthc, 2005, 3(8):207-215.
[8]	朱政, 胡雁, 邢唯杰, 等. 不同类型循证问题的构成[J]. 护士进修杂志, 2017, 32(21):1991-1994.
	Zhu Z, Hu Y, Xing WJ, et al. Composition of different types of evidence-based problems[J]. J Nurses Train, 2017, 32(21):1991-1994.
[9]	Alper BS, Haynes RB. EBHC pyramid 5.0 for accessing preappraised evidence and guidance[J]. Evid Based Med, 2016, 21(4):123-125. doi: 10.1136/ebmed-2016-110447 pmid: 27325531
[10]	Brouwers MC, Kho ME, Browman GP, et al. AGREE Ⅱ:advancing guideline development,reporting and evaluation in health care[J]. J De L’association Med Can, 2010, 182(18):E839-E842.
[11]	胡雁, 周英凤. 循证护理——证据临床转化的理论与实践[M]. 上海: 复旦大学出版社, 2021,98.
	Hu Y, Zhou YF. Evidence-based nursing:theory and practice of clinical transformation of evidence[M]. Shanghai: Fudan Uni-versity Press, 2021,98.
[12]	顾莺, 张慧文, 周英凤, 等. JBI循证卫生保健中心关于不同类型研究的质量评价工具:系统评价的方法学质量评价[J]. 护士进修杂志, 2018, 33(8):701-703.
	Gu Y, Zhang HW, Zhou YF, et al. JBI evidence-based health center’s quality assessment tool for different types of research:the quality evaluation of diagnostic and economic evaluation[J]. J Nurses Train, 2018, 33(8):701-703.
[13]	周英凤, 顾莺, 胡雁. JBI循证卫生保健中心关于不同类型研究的质量评价工具——干预性研究的质量评价(一)[J]. 护士进修杂志, 2018, 33(1):24-26.
	Zhou YF, Gu Y, Hu Y, et al. JBI center for evidence-based health care quality evaluation tool for different types of research:quality evaluation of interventional research(I)[J]. J Nurses Train, 2018, 33(1):24-26.
[14]	王春青, 胡雁. JBI证据预分级及证据推荐级别系统(2014版)[J]. 护士进修杂志, 2015, 30(11):964-967.
	Wang CQ, Hu Y. JBI evidence pre-classification and evidence recommendation level system(2014 edition)[J]. J Nurses Train, 2015, 30(11):964-967.
[15]	周英凤, 胡雁, 顾莺, 等. 基于证据的持续质量改进模式图的构建[J]. 中国循证医学杂志, 2017, 17(5):603-606.
	Zhou YF, Hu Y, Gu Y, et al. The framework of evidence-based continued quality improvement[J]. Chin J Evidence-Based Med, 2017, 17(5):603-606.
[16]	中国急诊危重症患者肠内营养治疗专家共识组. 中国急诊危重症患者肠内营养治疗专家共识[J]. 中华急诊医学杂志, 2022, 31(3):281-290.
	Chinese Expert Consensus Group on Enteral Nutrition in Emergency Critically Ill Patients. Expert consensus on enteral nutrition therapy for emergency and critical patients in China[J]. Chin J Emerg Med, 2022, 31(3):281-290.
[17]	胡晓芳, 韩燕, 金瑞华. 肠内营养耐受评估表用于ARDS俯卧位通气病人肠内营养支持的效果分析[J]. 护理研究, 2022, 36(12):2243-2246.
	Hu XF, Han Y, Jin RH. Effect of enteral nutrition tolerance assessment form on enteral nutrition support in patients with ARDS undergoing prone position ventilation[J]. Chin Nurs Res, 2022, 36(12):2243-2246.
[18]	周英凤, 胡雁, 顾莺, 等. 促进基于证据的最佳实践持续改进临床质量[J]. 护理研究, 2016, 30(35):4432-4434.
	Zhou YF, Hu Y, Gu Y, et al. Promoting evidence-based best practices for continuous improvement of clinical quality[J]. J Nurs Res, 2016, 30(35):4432-4434.
[19]	张晓菊, 胡雁, 周英凤, 等. 推动证据向临床转化(九)证据临床转化过程中的障碍因素分析[J]. 护士进修杂志, 2020, 35(15):1382-1386.
	Zhang XJ, Hu Y, Zhou YF, et al. Analysis of obstacle factors in the process of clinical translation of evidence[J]. J Nurs Train, 2020, 35(15):1382-1386.
[20]	蔡凌云, 王雅, 周佳佳, 等. 俯卧位通气重症患者早期肠内营养的证据总结[J]. 中华现代护理杂志, 2022, 28(17):2283-2288.
	Cai LY, Wang Y, Zhou JJ, et al. Summary of evidence of early enteral nutrition in severe patients with prone ventilation[J]. Chin J Mod Nurs, 2022, 28(17):2283-2288.
[21]	安祥, 张志杰, 章明阳, 等. ICU俯卧位通气患者肠内营养管理的最佳证据总结[J]. 现代临床护理, 2023, 22(6):75-82.
	An X, Zhang ZJ, Zhang MY, et al. Management of enteral nutrition in ICU patients under prone ventilation:a summary of best evidences[J]. Mod Clin Nurs, 2023, 22(6):75-82.
[22]	Machado LS, Rizzi P, Silva FM. Administration of enteral nutrition in the prone position,gastric residual volume and other clinical outcomes in critically ill patients:a systematic review[J]. Rev Bras Ter Intensiva, 2020, 32(1):133-142.
[23]	张丽, 杨婷婷, 史丽萍, 等. 俯卧位通气患者肠内营养管理的最佳证据总结[J]. 中华急危重症护理杂志, 2023, 4(2):112-118.
	Zhang L, Yang TT, Shi LP, et al. Summary of the best evidence of enteral nutrition management in prone ventilation patients[J]. Chin J Emerg Crit Care Nurs, 2023, 4(2):112-118.
[24]	孙杨, 曹岚. 超声胃窦运动指数在俯卧位机械通气患者肠内营养中的应用[J]. 中国实用护理杂志, 2020, 36(19):1482-1485.
	Sun Y, Cao L. The monitoring movement index by ultrasound guided the implementation of enteral nutrition in patients with prone mechanical ventilation[J]. Chin J Pract Nurs, 2020, 36(19):1482-1485.
[25]	侯锦. 俯卧位通气患者肠内营养安全性与有效性的系统评价与Meta分析[D]. 北京: 北京协和医学院, 2021.
	Hou J. Systematic review and meta-analysis of the safety and effectiveness of enteral nutrition in patients Meta prone position ventilation[D]. Beijing: Peking Union Medical College, 2021.
[26]	Elke G, Hartl WH, Kreymann KG, et al. Clinical nutrition in critical care medicine-guideline of the German society for nutritional medicine(DGEM)[J]. Clin Nutr ESPEN, 2019,33:220-275.
[27]	刘红, 刘红娟, 刘巧, 等. 重症俯卧位机械通气患者早期肠内营养策略研究[J]. 新疆医科大学学报, 2019, 42(10):1315-1318,1323.
	Liu H, Liu HJ, Liu Q, et al. Early enteral nutrition strategy in severe patients with mechanical ventilation in a prone position[J]. J Xinjiang Med Univ, 2019, 42(10):1315-1318,1323.
[28]	中华护理学会. 成人机械通气患者俯卧位护理团体标准:T/CNAS 23-2023[S]. 2023.
	Chinese Nursing Association. Group standard for prone position nursing of adult patients with mechanical ventilation:T/CNAS 23-2023[S]. 2023.