本文選題：腦外科危重癥患者 + 營養(yǎng)治療　； 參考：《東南大學》2017年碩士論文

【摘要】：調(diào)查目的:1.了解腦外科危重癥患者營養(yǎng)支持治療的應(yīng)用情況。2.觀察營養(yǎng)支持治療前后的相關(guān)人體測量指標、生化指標以及并發(fā)癥的發(fā)生情況,了解實施營養(yǎng)支持治療前后患者營養(yǎng)狀況。調(diào)查內(nèi)容與方法:調(diào)查對象:以2014年6月-2015年5月在南京某二級醫(yī)院腦外科接受治療的危重癥患者作為調(diào)查對象。根據(jù)納入、排除標準,最終143例患者納入本次調(diào)查,男性95例,女性48例。調(diào)查工具及調(diào)查內(nèi)容:參照相關(guān)文獻制定《腦外科危重癥患者營養(yǎng)治療現(xiàn)況調(diào)查問卷》作為研究工具,收集患者的一般資料、住院期間營養(yǎng)支持治療情況、患者的營養(yǎng)狀況、住院期間并發(fā)癥發(fā)生情況、患者28天疾病轉(zhuǎn)歸情況等。相關(guān)指標的測定:在患者入院24小時內(nèi)完成對患者一般資料的收集及相關(guān)指標的測量。患者入院24小時內(nèi)、住院10天、住院21天完成人體相關(guān)指標測量包括:體重、體質(zhì)指數(shù)(Body mass index,BMI)、肱三頭肌皮褶厚度(Triceps skinfold thickness,TSF)、上臂肌圍(Arm muscle circumference,AMC);臨床生化指標:總淋巴細胞(Total lymphocyte count,TLC)、血清白蛋白(Serum albumin,ALB)。結(jié)果:1.進入調(diào)查序列的腦外科危重癥患者143例,以青壯年居多,平均年齡為48.31 ±15.77歲;其中,男性95例,女性48例;入院時體質(zhì)指數(shù)為22.61±3.63;營養(yǎng)風險篩查2002(Nutritional Risk Screening-2002,NRS 2002)嚴重程度評分均大于3分�；颊咦≡涸�:車禍92例(64.34%)、高處跌落26例(18.18%)、重物擊打16例(11.19%)、不慎跌倒9例(6.29%);入院診斷:硬膜下血腫29例(20.28%)、硬膜外血腫34例(23.78%)、腦挫裂傷42例(29.37%)、顱內(nèi)血腫11例(7.69%)、原發(fā)性腦干損傷13例(9.09%)、復合血腫14例(9.79%)。平均住院天數(shù):22.87±9.89天,28天病死率 16 例(11.19%)。2.患者住院的前48小時內(nèi)均為禁食狀態(tài),根據(jù)患者情況采用全腸外營養(yǎng)支持(Total enteral nutrition,TPN)輔助治療;入院48小時之后的營養(yǎng)支持治療方案有以下兩種:應(yīng)用全腸內(nèi)營養(yǎng)支持(Total enteral nutrition,TEN)的有97例(67.83%),應(yīng)用腸內(nèi)營養(yǎng)支持治療(Enteral nutrition,EN)聯(lián)合腸外營養(yǎng)支持治療(Parenteral nutrition,PN)營養(yǎng)支持的有46例(32.17%)。EN營養(yǎng)制劑選用的是能全力+白普利;PN營養(yǎng)制劑選用脂肪乳、卡文、人血清白蛋白、血漿、全血等,主要是根據(jù)病人情況選用其中的一種或聯(lián)合運用。EN營養(yǎng)支持途徑選用的是經(jīng)鼻胃管或經(jīng)鼻胃腸管,92.31%的患者選用經(jīng)鼻胃管的方式實施EN。對應(yīng)用EN的患者均實施了胃殘余量的監(jiān)測,胃殘余量的臨界值為150mL。因為胃殘余量被迫中斷EN的患者有31例(21.68%)。有胃殘余的31例患者中19例(61.29%)未應(yīng)用胃動力藥;無胃殘余的112例患者中34例(30.36%)應(yīng)用胃動力藥。住院期間,19例患者出現(xiàn)血糖波動需進行血糖監(jiān)測,其中EN組6例、EN+PN組13例。3.應(yīng)用TEN營養(yǎng)支持,平均EN提供能量為目標能量的52.43%;應(yīng)用EN聯(lián)合PN營養(yǎng)支持,住院期間平均EN+PN提供能量為目標能量的35.57%及69.85%。應(yīng)用TEN支持平均EN提供的蛋白質(zhì)是目標蛋白質(zhì)的38.47%。在入院的24小時內(nèi)、10天、21天各時間節(jié)點分別對患者營養(yǎng)相關(guān)指標進行檢測包括人體測量指標(BMI、TSF、AMC)及生化指標(ALB、TLC)。結(jié)果顯示:EN組與EN+PN組入院24小時內(nèi)各項指標間無顯著性差異,且無嚴重營養(yǎng)不良病例。住院第10天時兩組在AMC上具有差異性(t=2.314,p=0.024);住院21天時EN組的各項指標仍繼續(xù)下降,而EN+PN組的TSF、AMC雖然繼續(xù)下降,但ALB、TLC呈現(xiàn)回升趨勢,兩組在TSF(t=2.328,p=0.023),AMC(t=2.368,p=0.021),ALB(t=2.412,p=0.016),TLC(t=2.335,p=0.022)比較差異均有統(tǒng)計學意義。EN組與EN+PN組在臨床并發(fā)癥及臨床最終結(jié)局方面的統(tǒng)計學比較無顯著性差異p0.05,但是EN組并發(fā)癥發(fā)生率為41.23%,28天病死率為13.40%;EN+PN組并發(fā)癥發(fā)生率為30.43%,28天病死率為6.52%,EN組在并發(fā)癥及病死率方面從數(shù)據(jù)上比較要高于EN+PN組。結(jié)論:本研究所調(diào)查醫(yī)院的腦外科危重癥患者以青壯年居多,男性多于女性。外傷為主要住院原因,住院周期較長,病死率較高。該醫(yī)院腦外科危重癥患者住院期間營養(yǎng)支持治療已得到醫(yī)護人員的高度重視,營養(yǎng)支持治療方案的制定及實施逐步趨向標準化;但與2009年成人危重癥患者營養(yǎng)支持治療與評估指南推薦方案(Adult critically ill patients nutritional support treatment and assessment guidelines recommend the program,CPG)相對照,在對患者的營養(yǎng)支持治療規(guī)范性方面仍存在一定的差距:早期腸內(nèi)營養(yǎng)開始時機不規(guī)范,2009年CPG推薦腸內(nèi)營養(yǎng)應(yīng)在患者入院后24-48小時內(nèi)開始(C級推薦)。EN存在供給不足和累積能量攝入的缺乏。EN+PN組在能量供給方面比EN組更充足,在改善患者營養(yǎng)狀況方面EN+PN組優(yōu)于EN組。對危重癥患者而言,及時充足的營養(yǎng)支持對患者的治療及預后至關(guān)重要,在EN提供能量相對不足的情況下,根據(jù)患者實際情況適當給予PN輔助治療可以保證營養(yǎng)及能量的供給,能達到較好的治療效果。
[Abstract]:Objective: 1. to understand the application of nutritional support therapy for critically ill patients in the Department of cerebral surgery.2. observation of the related anthropometric indicators, biochemical indexes and the occurrence of complications before and after nutritional support treatment, and to understand the nutritional status of patients before and after nutritional support treatment. The contents and methods of investigation were: in June 2014, May, May In the Department of cerebral surgery, a two level hospital in Nanjing, the critically ill patients treated in the Department of cerebral surgery were investigated. According to the inclusion and exclusion criteria, the final 143 patients were included in this survey, 95 men and 48 women. The general information of the patients, the nutritional support treatment, the nutritional status of the patients, the incidence of complications during the hospitalization, the patient's 28 day prognosis, and so on. The measurement of the related indexes: the general data collection and the measurement of the related indexes were completed within 24 hours of admission to the hospital, and the patient was admitted to hospital for 24 hours and stayed in hospital for 10 days. 21 days to complete the measurement of human body related indicators, including body weight, body mass index (Body mass index, BMI), brachial triceps skin fold thickness (Triceps skinfold thickness, TSF), upper arm muscle circumference (Arm muscle circumference, AMC); clinical biochemical indicators: total lymphocyte (BMI), serum albumin. In the Department of cerebral surgery, 143 cases of critically ill patients were investigated in the Department of cerebral surgery, with the average age of 48.31 + 15.77 years old, including 95 males and 48 females, and 22.61 + 3.63 at admission; the severity scores of nutritional risk screening 2002 (Nutritional Screening-2002, NRS 2002) were more than 3. Patients were hospitalized: accident accident 92 cases (64.34%), 26 cases (18.18%), 16 cases (11.19%) and 9 cases (6.29%) with heavy weight, 29 cases of subdural hematoma (20.28%), 34 cases of epidural hematoma (23.78%), 42 cases of cerebral contusion and laceration (29.37%), intracranial hematoma 11 cases (7.69%), primary brain stem injury cases and complex hematoma. The death rate of 16 (11.19%).2. patients was fasting in the first 48 hours of hospitalization, with total parenteral nutrition support (Total enteral nutrition, TPN) assisted treatment according to the patient's condition; there were two nutritional support treatments after admission for 48 hours: 97 cases (67.83%) used total enteral support (Total enteral nutrition, TEN). Enteral nutrition, EN (EN) combined with parenteral nutrition support therapy (Parenteral nutrition, PN) nutrition support in 46 cases (32.17%).EN nutrition preparation is the choice of full plus white plali; PN nutrition preparation of fat milk, Kevin, human serum albumin, plasma, whole blood and so on, mainly according to the patient's condition selected among them One or combined use of.EN nutrition support pathway is through nasal gastric tube or transnasal gastrointestinal tube. 92.31% patients perform EN. monitoring of gastric remnants in patients with EN using nasal gastric tube, and the critical value of gastric remnants is 31 (21.68%) patients who have been forced to interrupt EN because of the residual gastric remnants. There are gastric remnants. Of the 31 patients, 19 cases (61.29%) did not use gastric motility medicine; 34 of the 112 patients without gastric remnants (30.36%) applied gastric motility medicine. During the period of hospitalization, 19 patients had blood glucose monitoring, including 6 cases in group EN, 13.3. in group EN+PN, and 52.43% with TEN for 52.43% of the target energy, and EN combined with PN nutrition. The average EN+PN provided energy for 35.57% and 69.85%. for target energy during hospitalization. The protein provided by TEN for the average EN was the 38.47%. of the target protein in the 24 hours of admission, 10 days, and 21 days in each node, respectively, to detect the nutritional indicators of the patients, including the anthropometric indicators (BMI, TSF, AMC) and biochemical indicators (ALB, TLC). The results showed that there was no significant difference between the EN group and the EN+PN group within 24 hours, and there was no serious malnutrition. The two groups in the two groups were different (t=2.314, p=0.024) on the tenth day of hospitalization, and the indexes of the EN Group continued to decline at 21 days of hospitalization, while TSF in the EN+PN group, although AMC continued to decline, showed a rising trend of ALB, TLC, two There was no significant difference between the groups at TSF (t=2.328, p=0.023), AMC (t=2.368, p=0.021), ALB (t=2.412, p=0.016), TLC (t=2.335, p=0.022), and there was no significant difference in clinical complications and clinical outcome, but the incidence of complications was 41.23%, and the mortality rate was 13.40% at 28 days. The incidence of complications was 30.43%, and the mortality rate of 28 days was 6.52%. In group EN, the complications and fatality rates were higher than that in group EN+PN. Conclusion: the critical patients in the Department of cerebral surgery investigated in this study were mostly in young Zhuang years and more males than women. Nutritional support therapy for critically ill patients has been highly valued by medical and nursing staff, and the formulation and implementation of nutritional support treatment schemes are gradually standardized. However, the recommendation for nutritional support treatment and assessment guidelines for adult critical patients in 2009 (Adult critically ill patients nutritional support treatment and assessmen) T guidelines recommend the program, CPG) relative illumination, there is still a certain gap in the standard of nutritional support treatment for patients: early enteral nutrition start time is not standardized. In 2009, CPG recommended enteral nutrition should begin within 24-48 hours after admission (C level recommended).EN there is a lack of supply and accumulation of energy intake.EN+P. Group N is more abundant in energy supply than group EN, and group EN+PN is superior to group EN in improving the nutritional status of patients. For critically ill patients, adequate and adequate nutritional support is essential for the treatment and prognosis of the patients. In the case of relative insufficient energy of EN, appropriate PN adjuvant therapy according to the patient's actual situation can guarantee nutrition. And energy supply can achieve better therapeutic effect.
【學位授予單位】：東南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R651.11;R459.3

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