本文選題：早期腸內(nèi)營(yíng)養(yǎng)　切入點(diǎn)：全胃腸外營(yíng)養(yǎng)　出處：《大連醫(yī)科大學(xué)》2013年碩士論文　論文類(lèi)型：學(xué)位論文

【摘要】：背景：重癥急性胰腺炎（severe acute pancreatitis，SAP）是一種臨床常見(jiàn)的急腹癥，病情兇險(xiǎn)、病死率高。SAP時(shí)患者由于嚴(yán)重的炎癥反應(yīng)，使得機(jī)體處于明顯的高分解代謝和負(fù)氮平衡狀態(tài)，能量消耗顯著增加。同時(shí)，SAP還會(huì)引起營(yíng)養(yǎng)物質(zhì)和電解質(zhì)的代謝紊亂。因此，營(yíng)養(yǎng)支持是SAP患者重要的治療措施。全胃腸外營(yíng)養(yǎng)（total parenteral nutrition，TPN）和早期腸內(nèi)營(yíng)養(yǎng)（early enteral nutrition，EEN）是營(yíng)養(yǎng)支持治療的兩種方式。TPN作為SAP營(yíng)養(yǎng)支持治療的傳統(tǒng)模式，能夠抑制胰腺分泌、減輕胃腸負(fù)擔(dān)，但患者的腸道屏障功能損傷明顯。EEN有助于維護(hù)患者腸粘膜結(jié)構(gòu)和功能的完整，減少腸源性感染等并發(fā)癥的發(fā)生，但容易引起患者的胃腸道不適。因此，目前對(duì)選擇TPN或EEN治療SAP仍存在爭(zhēng)議。 目的：評(píng)價(jià)TPN和EEN治療SAP患者的療效及其安全性，為臨床實(shí)踐提供循證醫(yī)學(xué)依據(jù)。 方法：計(jì)算機(jī)檢索MEDLINE、PubMed、中國(guó)生物醫(yī)學(xué)文獻(xiàn)數(shù)據(jù)庫(kù)（CBM）、中國(guó)知網(wǎng)（CNKI）、維普資訊網(wǎng)（VIP）及Google學(xué)術(shù)搜索引擎(Google Scholar)，檢索時(shí)間為1966年1月至2013年1月。納入所有有關(guān)EEN和TPN治療SAP的隨機(jī)對(duì)照試驗(yàn)（randomized control trial，RCT），同時(shí)查閱所有檢出文獻(xiàn)的參考文獻(xiàn)作為補(bǔ)充。通過(guò)閱讀文獻(xiàn)題目、摘要或全文，排除不符合納入標(biāo)準(zhǔn)的RCT。選擇病死率、胰腺感染發(fā)生率、多器官衰竭發(fā)生率、外科手術(shù)干預(yù)率、腹瀉發(fā)生率、高血糖發(fā)生率作為最后的分析指標(biāo)。在對(duì)納入研究的RCT進(jìn)行質(zhì)量評(píng)價(jià)和數(shù)據(jù)提取后，應(yīng)用RevMan5.2統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。 結(jié)果：有9項(xiàng)RCT納入研究，共包括453例患者，其中EEN組221例、TPN組232例。EEN組中所有SAP患者均經(jīng)空腸遠(yuǎn)端途徑實(shí)施腸內(nèi)營(yíng)養(yǎng)，并且開(kāi)始時(shí)間為入院72h內(nèi)。Meta分析結(jié)果顯示：與TPN相比，，EEN可以顯著降低SAP患者的病死率〔RR=0.35、95%CI（0.20,0.61）、P=0.0002〕、胰腺感染發(fā)生率〔RR=0.41、95%CI（0.24,0.71）、P=0.001〕、外科手術(shù)干預(yù)率〔RR=0.50、95%CI（0.35,0.70）、P＜0.0001〕，同時(shí)減少多器官衰竭〔RR=0.37、95%CI（0.18,0.77）、P=0.008〕和高血糖〔RR=0.47、95%CI（0.24,0.93）、P=0.03〕的發(fā)生。但在腹瀉發(fā)生率方面，EEN組高于TPN組〔RR=5.54、95%CI（2.44,12.57）、P＜0.0001〕。 結(jié)論：目前研究提示：經(jīng)空腸遠(yuǎn)端途徑、入院72h內(nèi)實(shí)施的EEN可以顯著降低SAP患者的病死率、外科手術(shù)干預(yù)率，并明顯減少胰腺感染、多器官衰竭和高血糖的發(fā)生，有助于患者的預(yù)后。因此，SAP患者在無(wú)腸內(nèi)營(yíng)養(yǎng)禁忌癥時(shí)，應(yīng)將EEN作為營(yíng)養(yǎng)支持治療的首選方式。
[Abstract]:Background: severe acute patients with severe acute pancreatitis (SAP) is a common clinical acute abdomen. The patient is in a state of high catabolism and negative nitrogen balance due to severe inflammatory reaction. Energy consumption increased significantly. SAP also caused metabolic disorders of nutrients and electrolytes. Total parenteral nutrition (total parenteral nutrition) and early enteral nutrition (early enteral nutrition) are two methods of nutrition support therapy. TPN is the traditional mode of SAP nutrition support therapy and can inhibit pancreatic secretion. Reduce gastrointestinal burden, but the injury of intestinal barrier function is obvious. EEN is helpful to maintain the integrity of intestinal mucosal structure and function, reduce the occurrence of complications such as enterogenic infection, but it is easy to cause gastrointestinal discomfort in patients. At present, the choice of TPN or EEN for SAP is still controversial. Objective: to evaluate the efficacy and safety of TPN and EEN in the treatment of SAP patients. Methods: a computer-based search of MEDLINE PubMed, China Biomedical Literature Database (CBM), Chinese Biomedical Literature Database (CBM), Chinese Biomedical Database (CNKI), and Google academic search engine (Google) was conducted. The search time was from January 1966 to January 2013. All relevant EEN and TPN therapy SAP were included. The randomized control trialator test was supplemented by a review of all the references in the literature. Abstract or full text, exclude RCT.Select mortality, pancreatic infection, multiple organ failure, surgical intervention rate, diarrhea rate. The incidence of hyperglycemia was used as the final analysis index. After the quality evaluation and data extraction of RCT which was included in the study, the statistical analysis was carried out by RevMan5.2 statistical software. Results: nine subjects of RCT were included in the study, including 453 patients, including 221 patients in EEN group, 232 patients in EEN group. All SAP patients in EEN group were treated with enteral nutrition via distal jejunum pathway. Within 72 hours after admission, the results of Meta-analysis showed that compared with TPN, the mortality rate of patients with SAP was significantly lower than that of TPN. The incidence of pancreatic infection was 0.240.71P0.001, and the rate of surgical intervention was 0.350 / 0.70,0.350.700.000, while reducing the RR0.3795CII 0.180.379CII 0.180.771and the RR775CI0.240.2471P0.001, the surgical intervention rate was 0.350.70mg / 0.000, while reducing the RR0.3795CII 0.180.3795 / 0.180.77 / 0.77 / 0. 008). But the incidence of diarrhea in EEN group was higher than that in TPN group (P < 0.0001). Conclusion: the present study suggests that EEN administered through distal jejunum within 72 hours of admission can significantly reduce the mortality, surgical intervention rate, pancreatic infection, multiple organ failure and hyperglycemia in patients with SAP. Therefore, EEN should be the first choice of nutrition support treatment in patients without enteral nutrition contraindication.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類(lèi)號(hào)】：R576

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