本文關(guān)鍵詞： 胰十二指腸切除術(shù) 循證實(shí)踐 營(yíng)養(yǎng)支持 KTA模式　出處：《第二軍醫(yī)大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的本研究旨在構(gòu)建胰十二指腸切除術(shù)患者(pancreaticoduodenectomy,PD)圍手術(shù)期營(yíng)養(yǎng)支持管理方案并驗(yàn)證其臨床應(yīng)用效果,以期促進(jìn)證據(jù)轉(zhuǎn)化,提高PD患者圍手術(shù)期營(yíng)養(yǎng)支持質(zhì)量,促進(jìn)患者康復(fù)。具體研究目的包括:(1)評(píng)鑒、綜合PD患者圍手術(shù)期營(yíng)養(yǎng)支持循證證據(jù)并選取適用于引入臨床實(shí)踐的證據(jù);(2)描述PD患者圍手術(shù)期營(yíng)養(yǎng)支持現(xiàn)狀,分析利益相關(guān)人群(醫(yī)生、護(hù)士、營(yíng)養(yǎng)師、管理者)感知的循證實(shí)踐的阻礙與促進(jìn)因素以及患者對(duì)圍手術(shù)期營(yíng)養(yǎng)支持的體驗(yàn)與需求;(3)構(gòu)建PD患者圍手術(shù)期營(yíng)養(yǎng)支持管理方案;(4)評(píng)價(jià)該方案的臨床應(yīng)用效果。方法以KTA證據(jù)行為轉(zhuǎn)化模式為概念框架,通過(guò)對(duì)國(guó)內(nèi)外圍手術(shù)期營(yíng)養(yǎng)支持的指南評(píng)價(jià)、PD患者圍手術(shù)期營(yíng)養(yǎng)支持的相關(guān)系統(tǒng)評(píng)價(jià)再評(píng)價(jià)以及PD患者術(shù)前營(yíng)養(yǎng)評(píng)價(jià)工具的研究,獲得PD患者圍手術(shù)期營(yíng)養(yǎng)支持的最佳證據(jù);通過(guò)專家會(huì)議法選取適合引入臨床實(shí)踐的證據(jù)并建立審查標(biāo)準(zhǔn);通過(guò)參與式觀察與質(zhì)性研究評(píng)估試點(diǎn)病房證據(jù)應(yīng)用的促進(jìn)及阻礙因素,最佳證據(jù)與臨床實(shí)踐之間差距;通過(guò)專家會(huì)議法構(gòu)建PD患者圍手術(shù)期營(yíng)養(yǎng)支持管理方案,有針對(duì)性消除障礙因素;通過(guò)醫(yī)護(hù)人員自身前后對(duì)照試驗(yàn)研究和PD患者非同期前后對(duì)照研究獲得干預(yù)方案的應(yīng)用效果。結(jié)果1.通過(guò)系統(tǒng)的證據(jù)檢索,共納入5部圍手術(shù)期營(yíng)養(yǎng)支持指南;同時(shí)通過(guò)術(shù)前營(yíng)養(yǎng)評(píng)估工具的研究,即應(yīng)用NRS2002、PG-SGA、NRI、PNI、BMI5種營(yíng)養(yǎng)評(píng)價(jià)工具評(píng)價(jià)100例PD患者術(shù)前營(yíng)養(yǎng)狀況,獲得NRS2002、PG-SGA與患者術(shù)后結(jié)局、實(shí)驗(yàn)室營(yíng)養(yǎng)指標(biāo)相關(guān),且對(duì)術(shù)后并發(fā)癥具有中度診斷價(jià)值,PD患者術(shù)前擬優(yōu)先選用NRS2002評(píng)分,再結(jié)合使用PG-SGA評(píng)估,最終評(píng)鑒、匯總出PD患者圍手術(shù)期營(yíng)養(yǎng)支持現(xiàn)有的最佳證據(jù)。2.通過(guò)專家會(huì)議法獲得PD患者圍手術(shù)期營(yíng)養(yǎng)支持最佳證據(jù)五個(gè)模塊,即術(shù)前營(yíng)養(yǎng)評(píng)價(jià)、術(shù)前營(yíng)養(yǎng)支持、術(shù)后營(yíng)養(yǎng)支持、營(yíng)養(yǎng)制劑、營(yíng)養(yǎng)管理模式,共9條證據(jù),并制定了7條實(shí)踐審查標(biāo)準(zhǔn)。3.試點(diǎn)病房的圍手術(shù)期營(yíng)養(yǎng)支持的臨床實(shí)踐與最佳證據(jù)之間存在較大差距,循證實(shí)踐受諸多因素影響。3.1試點(diǎn)病房循證實(shí)踐的現(xiàn)況:審查標(biāo)準(zhǔn)執(zhí)行情況不佳,缺乏規(guī)范的營(yíng)養(yǎng)管理制度及流程。3.2通過(guò)15名醫(yī)務(wù)人員半結(jié)構(gòu)式訪談,獲得循證實(shí)踐的阻礙因素,包括證據(jù)、應(yīng)用過(guò)程、組織管理、患者、醫(yī)生因素,促進(jìn)因素包括營(yíng)養(yǎng)專項(xiàng)培訓(xùn)、建立多學(xué)科協(xié)作的營(yíng)養(yǎng)小組、制定規(guī)范的營(yíng)養(yǎng)管理制度、取得領(lǐng)導(dǎo)層的支持。3.3通過(guò)10例pd患者圍手術(shù)期營(yíng)養(yǎng)支持體驗(yàn)的質(zhì)性研究,獲得該類患者術(shù)后面臨飲食壓力和管飼營(yíng)養(yǎng)的痛苦,渴望專業(yè)、延續(xù)的營(yíng)養(yǎng)指導(dǎo),臨床醫(yī)務(wù)人員應(yīng)重視該類患者圍手術(shù)期營(yíng)養(yǎng),采用多學(xué)科合作的營(yíng)養(yǎng)支持小組模式,強(qiáng)化營(yíng)養(yǎng)教育,促進(jìn)患者參與自我營(yíng)養(yǎng)管理。4.通過(guò)專家會(huì)議法構(gòu)建pd患者圍手術(shù)期營(yíng)養(yǎng)支持管理方案,包括圍手術(shù)期營(yíng)養(yǎng)支持管理規(guī)范、圍手術(shù)期營(yíng)養(yǎng)支持流程、營(yíng)養(yǎng)支持小組管理模式、營(yíng)養(yǎng)支持輔助文本以及能量計(jì)算軟件。并制定方案實(shí)施計(jì)劃,通過(guò)營(yíng)養(yǎng)培訓(xùn)、領(lǐng)導(dǎo)宣講與支持,分階段推進(jìn)方案實(shí)施,逐步將證據(jù)引入臨床。5.方案的實(shí)施與效果評(píng)價(jià)5.1方案的實(shí)施:方案于2016年9月啟動(dòng),通過(guò)三個(gè)階段,即人員培訓(xùn)階段、方案試運(yùn)行階段、方案應(yīng)用階段,循序漸進(jìn)地將pd圍手術(shù)期營(yíng)養(yǎng)支持相關(guān)證據(jù)應(yīng)用到臨床營(yíng)養(yǎng)管理系統(tǒng)中。5.2效果評(píng)價(jià)5.2.1采用自身前后對(duì)照研究,獲得試點(diǎn)病房醫(yī)護(hù)人員干預(yù)前(2016年5月~8月)、干預(yù)后(2016年9月~2017年1月)各審查標(biāo)準(zhǔn)的執(zhí)行情況,結(jié)果顯示在5個(gè)月的干預(yù)期間,干預(yù)組醫(yī)護(hù)人員的各審查標(biāo)準(zhǔn)執(zhí)行率顯著高于對(duì)照組(p0.05)。5.2.2采用非同期對(duì)照研究,獲得試點(diǎn)病區(qū)干預(yù)前53例pd患者、干預(yù)后47例pd患者臨床結(jié)局指標(biāo)比較情況[兩組患者基線一致(p≥0.05)],結(jié)果顯示干預(yù)后患者的術(shù)后住院天數(shù)、總住院天數(shù)較干預(yù)前縮短,并發(fā)癥的發(fā)生率較干預(yù)前減少,住院期間患者體重下降值、醫(yī)療費(fèi)用較干預(yù)前減少(p0.05)。兩組患者術(shù)后第1、3、7天總蛋白、前白蛋白、白蛋白值差異無(wú)統(tǒng)計(jì)學(xué)意義(p0.05)。術(shù)后第1天總膽紅素值較干預(yù)前降低(p0.05),術(shù)后第1、3、7天總膽紅素值差異無(wú)統(tǒng)計(jì)學(xué)意義(p0.05)。5.2.3醫(yī)務(wù)人員在方案實(shí)施過(guò)程中經(jīng)歷了懷疑與期待、磨合與主動(dòng)、反思與創(chuàng)新的體驗(yàn)歷程,來(lái)自組織層面的督促、激勵(lì)、約束與強(qiáng)化,有利于提高醫(yī)護(hù)人員對(duì)方案的依從性,激發(fā)其創(chuàng)造力。結(jié)論1.本研究匯總了pd患者圍手術(shù)期營(yíng)養(yǎng)支持最佳證據(jù),內(nèi)容包括術(shù)前適宜的營(yíng)養(yǎng)評(píng)價(jià)工具nrs2002和pg-sga、術(shù)前營(yíng)養(yǎng)支持、術(shù)后營(yíng)養(yǎng)支持、營(yíng)養(yǎng)制劑選擇、營(yíng)養(yǎng)管理模式五個(gè)模塊,旨在為pd患者圍手術(shù)期營(yíng)養(yǎng)支持提供參考依據(jù)。2.本研究應(yīng)用KTA知識(shí)轉(zhuǎn)化模式開(kāi)展PD患者圍手術(shù)期營(yíng)養(yǎng)支持循證實(shí)踐,通過(guò)確定問(wèn)題、證據(jù)綜合、裁剪形成符合利益相關(guān)人群需要的證據(jù)并引入臨床,分析障礙因素及促進(jìn)策略,構(gòu)建管理方案引入證據(jù)并實(shí)施監(jiān)測(cè)與評(píng)價(jià),有效促進(jìn)了證據(jù)轉(zhuǎn)化,縮短了證據(jù)與實(shí)踐的差距。3.本研究構(gòu)建的PD患者圍手術(shù)期營(yíng)養(yǎng)支持管理方案,是建立在循證基礎(chǔ)上,考慮了臨床情境及患者需求,具有較好的可行性和有效性。
[Abstract]:The purpose of this study was to construct pancreatoduodenectomy patients (pancreaticoduodenectomy, PD) of perioperative nutritional support management scheme and verify its clinical effect, in order to promote the transformation of PD evidence, improve the perioperative nutritional support in patients with quality, promote the rehabilitation of the patients. The main contents include: (1) evaluation, comprehensive perioperative PD nutrition support evidence for selection and introduced into clinical practice evidence; (2) to describe the PD of perioperative nutritional support in patients with the status quo, analysis of stakeholder groups (doctors, nurses, nutritionists, managers) aware of evidence-based practice and promote patients to hinder factors and around the experience and demand of nutritional support the period of operation; (3) to construct the PD of perioperative nutritional support in patients with management scheme; (4) to evaluate the clinical effects of the scheme. Methods KTA behavior transformation model as the conceptual framework of evidence, through to the domestic and external Guide for the evaluation of perioperative nutritional support in patients with PD related research, evaluation system of peri operative nutrition support and re evaluation of PD patients with preoperative nutritional evaluation tools, to obtain the best evidence of peri operative nutrition support in patients with PD; selected by the expert meeting for the introduction of clinical practice of evidence and establish the standard of review; through participation observation and qualitative evaluation factors that hinder and promote the pilot ward evidence application, the gap between the best evidence and clinical practice; to construct the PD of perioperative nutritional support in patients with management scheme through expert meeting method, to eliminate obstacles; the medical staff through self controlled non synchronous control study before and after the intervention in patients with application effect experimental study and PD. Results 1. through systematic evidence retrieval, included 5 perioperative nutrition support guidelines; at the same time through preoperative nutritional assessment The research tools, namely the application of NRS2002, PG-SGA, NRI, PNI, BMI5 nutrition evaluation tool to evaluate 100 cases of PD patients with preoperative nutritional status, NRS2002, PG-SGA and outcome of patients after surgery, laboratory of nutrition indicators related, and has moderate diagnostic value of postoperative complications in PD patients, preoperative NRS2002 score to be preferred then, combined with the use of PG-SGA evaluation, the final evaluation, summarize the PD of perioperative nutritional support in patients with the best available evidence obtained by expert PD.2. of perioperative nutritional support in patients with the best evidence of five modules, namely the preoperative nutrition evaluation, preoperative nutrition support, nutritional support, postoperative nutrition, nutrition model a total of 9 lines of evidence management, and to develop, there is a big gap between the 7 practice examination standard.3. pilot unit of perioperative nutritional support in clinical practice and the best evidence, evidence-based practice is influenced by many factors in.3.1 wards The status of evidence-based practice: review of the implementation of standards is poor, lack of standardized nutrition management system and process of.3.2 by medical personnel from 15 semi-structured interviews, obtained the hindering factors, including evidence of evidence-based practice, application process, organization management, patient, doctor factors, promoting factors including nutrition training, establishing nutrition group multidisciplinary collaboration, develop nutrition standardized management system, to obtain the support of the leadership of.3.3 by PD in 10 cases of perioperative nutritional support in patients with a qualitative study on diet, pressure and feeding the pain, face to obtain this kind of patients for professional, nutritional guidance continues, clinical staff should pay attention to peri operative nutrition of the patients, the nutritional support group model of multi subject cooperation, strengthen nutrition education, promote the patients to participate in self nutrition management of.4. through the expert meeting method. Perioperative PD patients Nutrition management scheme, including the perioperative nutrition management norms, perioperative nutrition support process, nutrition support team management, nutritional support aided text and energy calculation software. And formulate the implementation plan, through nutrition training, leadership and preaching support, in phases to promote the implementation of the program, will gradually implement the implement and evaluation the evidence into clinical.5. program 5.1 program: program started in September 2016, through three stages, namely the stage of personnel training, project commissioning phase, project application stage, step by step to PD perioperative nutrition support evidence evaluation to the.5.2 effect of clinical nutrition management system 5.2.1 by self control study, to obtain pilot ward medical staff before intervention (May 2016 ~8 months), intervention (September 2016 ~2017 January) implementation of the standard of review, the results show in 5 During the months of intervention, the intervention group of medical personnel the examination standard implementation rate was significantly higher than the control group (P0.05).5.2.2 using asynchronous control study, to obtain pilot wards before intervention in 53 PD patients, 47 PD patients after clinical outcomes compared two groups of patients [consistent baseline (P = 0.05). The results showed that after the intervention of patients with postoperative hospitalization days, total hospital stay shorter than that before the intervention, the incidence of complications compared with before intervention, patients with weight loss, reduce the medical expenses than before intervention (P0.05). The two groups of patients with Shu Houdi 1,3,7 days before the total protein, albumin, albumin values were not statistically different (P0.05). After first days of total bilirubin decreased significantly (P0.05), 1,3,7 days after operation there was no significant difference in total bilirubin (P0.05).5.2.3 medical personnel in the program implementation process through doubt and look forward to, and the main running Experience, reflection and innovation, from the organizational level of supervision, incentive, constraint and strengthening, is conducive to improve the compliance of medical staff on the plan, to stimulate their creativity. Conclusions: 1. this study summarizes the PD of perioperative nutritional support in patients with the best evidence, including preoperative appropriate nutritional evaluation tools of nrs2002 and pg-sga nutritional support, preoperative, postoperative nutritional support, nutrition, nutrition management model of five modules, in order to provide reference on the application of KTA.2. knowledge transformation model to support nutrition PD patients in the perioperative period in PD patients perioperative nutritional support of evidence-based practice, the problem of determining evidence synthesis, cutting forming in line with the interests of those in need of evidence and the introduction of clinical analysis of obstacle factors and promotion strategies, the construction management plan and implement the monitoring and evaluation of evidence into the evidence, effectively promote the transformation, shorten the The gap between evidence and practice.3. the perioperative nutrition support management plan of PD patients in this study is based on evidence-based consideration of clinical situations and patient needs, and has good feasibility and effectiveness.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R473.6

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