本文選題：小兒外科　切入點(diǎn)：禁食　出處：《安徽醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的營養(yǎng)是保障人體正常生長、發(fā)育、內(nèi)環(huán)境穩(wěn)定、正常代謝的不可缺少的物質(zhì)。小兒因其身體正處于生長發(fā)育期,對營養(yǎng)的需求有其特殊性；而外科患兒經(jīng)常處于重度感染、創(chuàng)傷、手術(shù)打擊等導(dǎo)致的應(yīng)激狀態(tài)中,熱能消耗較快,再加上部分患兒因?yàn)樽陨砘蚣膊≡虿荒芙?jīng)口攝入食物,可迅速發(fā)展為蛋白質(zhì)---熱能營養(yǎng)不良,造成機(jī)體免疫功能和重要臟器功能下降,很容易出現(xiàn)感染、營養(yǎng)相關(guān)的并發(fā)癥,從而導(dǎo)致住院時(shí)間的延長,甚至造成死亡率的增加。因此,采取正確的方法改善營養(yǎng)不良,對于保證細(xì)胞代謝功能的穩(wěn)定,組織、器官正常結(jié)構(gòu)、功能的維持以及正常免疫功能的維持,組織、器官的愈合,疾病的康復(fù)具有極其重要的意義。目前,研究表明,腸內(nèi)營養(yǎng)治療(Enteral nutrition EN)可以糾正營養(yǎng)不良,促進(jìn)胃、腸道的發(fā)育,而且其符合生理要求,并發(fā)癥發(fā)生幾率較少,也更經(jīng)濟(jì)。本研究的目的是探討腸內(nèi)營養(yǎng)在小兒外科中應(yīng)用的可行性、價(jià)值、可靠性、適用證、優(yōu)點(diǎn)、并發(fā)癥及注意事項(xiàng)。方法1.回顧性分析、研究我院2007年6月至2014年2月78例采用鼻空腸營養(yǎng)管進(jìn)行EN治療的外科患兒的臨床資料。2.營養(yǎng)液選擇及給予方式：1歲以內(nèi)的患兒,我們選擇雀巢公司的藹兒舒(主要為氨基酸、短肽)；1歲以上的患兒,我們選擇雀巢公司的小百肽或Nutricia公司的能全素(主要為短肽)。給予方式,我們選擇經(jīng)鼻空腸管24小時(shí)持續(xù)、勻速泵入。3.評估EN治療的耐受性指標(biāo)：根據(jù)回抽的胃殘余營養(yǎng)素的量、嘔吐的次數(shù)及嘔吐量、腹脹、腹痛情況、排便次數(shù)及糞便的性狀、量來評估患兒在治療過程中對EN的耐受性。4.評價(jià)營養(yǎng)狀態(tài)的指標(biāo)：收集EN治療前及治療后患兒的體重、血紅細(xì)胞計(jì)數(shù)(redblood cell count, RBC)、血紅蛋白(hemoglobin, HGB)、血清淋巴細(xì)胞計(jì)數(shù)(serum lymphocyte count, SLC)、血清白蛋白(serum albumin, SA)、前白蛋白(prealbumin, PA)、血肌酐(blood serum creatinine, BSC)、尿素氮(blood urea nitrogen, BUN)等指標(biāo),并進(jìn)行對比,通過統(tǒng)計(jì)學(xué)分析來判斷機(jī)體營養(yǎng)狀況的改變。5.計(jì)量資料以χ±s表示,禁食前后、EN治療前后,均采用t檢驗(yàn)。P0.05表示差異有統(tǒng)計(jì)學(xué)意義,P0.01表示差異有顯著統(tǒng)計(jì)學(xué)意義。結(jié)果1.一般資料1.1我們選取2007年6月至2014年2月78例不能經(jīng)口進(jìn)食而采用鼻空腸營養(yǎng)管進(jìn)行EN治療的患兒,年齡1天-9歲,(2.9±2.4)歲；EN治療前體重(12.70±6.92)kg；男孩53例,女孩25例。胰腺炎22例,小腸閉鎖14例,肝臟挫裂傷10例,十二指腸隔膜狀狹窄9例,肝母細(xì)胞瘤5例,環(huán)狀胰腺6例,十二指腸穿孔6例,食道閉鎖6例。1.2 EN治療時(shí)間78例患兒均采用鼻空腸營養(yǎng)管進(jìn)行EN治療,順利完成EN治療。EN治療時(shí)間：7-37d(17.5±9.4)d,時(shí)間在10d內(nèi)21例,10-15d的19例,15d以上的38例。1.3不良反應(yīng)治療期間6例(7.7%)出現(xiàn)腹瀉,排便6～8次/d,每次量約50 ml/kg,大便為黃色或綠色稀水樣便；4例(5.1%)出現(xiàn)惡心、嘔吐,嘔吐物為透明或黃色、綠色液體,回抽胃內(nèi)殘余的營養(yǎng)液量,為單位時(shí)間內(nèi)營養(yǎng)液入量的1倍；5例(6.4%)出現(xiàn)輕微腹脹,連續(xù)兩次測量腹圍大于標(biāo)準(zhǔn)腹圍2.5cm;6例(7.7%)輕微腹痛； 4例(5.1%)低鈉、低鉀；無吸入性肺炎,消化道出血等癥狀。2.EN前后營養(yǎng)指標(biāo)改變我們選取78例患兒中禁食3d且未經(jīng)營養(yǎng)治療的39例患兒,收集其體重,血紅細(xì)胞計(jì)數(shù)、血紅蛋白、血淋巴細(xì)胞計(jì)數(shù)、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指標(biāo),并與禁食前比較。體重、血紅細(xì)胞計(jì)數(shù)、血紅蛋白、血清白蛋白、前白蛋白指標(biāo)下降明顯,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)；其中,前白蛋白差異具有顯著統(tǒng)計(jì)學(xué)意義(P0.01)；淋巴細(xì)胞計(jì)數(shù)、血肌酐、血尿素氮差異不明顯,結(jié)果無統(tǒng)計(jì)學(xué)意義(P0.05)。選取78例經(jīng)過EN治療的患兒,對比EN治療前及EN治療3d后的體重、紅細(xì)胞計(jì)數(shù),血紅蛋白、淋巴細(xì)胞計(jì)數(shù)、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指標(biāo)。體重、紅細(xì)胞計(jì)數(shù),淋巴細(xì)胞計(jì)數(shù)、血紅蛋白、血清白蛋白、血肌酐、血尿素氮指標(biāo)有所變化,但差異不明顯,無統(tǒng)計(jì)學(xué)意義(P0.05)；前白蛋白數(shù)值增加明顯,差異具有顯著統(tǒng)計(jì)學(xué)意義(P0.01)。說明短期內(nèi)(3d內(nèi)),EN治療未能明顯改變患兒營養(yǎng)狀態(tài)。選取78例患兒中EN治療時(shí)間在10d以上的57例患兒,對比禁食前及EN治療10d后的體重、紅細(xì)胞計(jì)數(shù),血紅蛋白、淋巴細(xì)胞計(jì)數(shù)、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指標(biāo)。體重、紅細(xì)胞計(jì)數(shù),血紅蛋白、血清白蛋白、前白蛋白指標(biāo)明顯增加,差異具有統(tǒng)計(jì)學(xué)意義(P0.05),其中紅細(xì)胞計(jì)數(shù)、血紅蛋白、血清白蛋白、前白蛋白指標(biāo)改變具有顯著統(tǒng)計(jì)學(xué)意義(P0.01)；淋巴細(xì)胞計(jì)數(shù)、血肌酐、血尿素氮差異不明顯,結(jié)果無統(tǒng)計(jì)學(xué)意義(P0.05)(表8)。說明經(jīng)過10d EN治療后,患兒營養(yǎng)狀態(tài)較EN治療前明顯改善。選取78例患兒中EN治療時(shí)間在15d以上的38例患兒,收集其體重,血紅細(xì)胞計(jì)數(shù)、血紅蛋白、血淋巴細(xì)胞計(jì)數(shù)、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指標(biāo),并與禁食前進(jìn)行比較。體重、血清白蛋白、前白蛋白指標(biāo)上升明顯,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);紅細(xì)胞計(jì)數(shù)、血紅蛋白、淋巴細(xì)胞計(jì)數(shù)、血肌酐、血尿素氮差異不明顯,結(jié)果無統(tǒng)計(jì)學(xué)意義(P0.05)。說明經(jīng)過EN治療15d后,患兒營養(yǎng)狀況有所改善,EN治療可以為外科患兒提供足夠的營養(yǎng)支持,保障其疾病的康復(fù)及正常的生長發(fā)育。3.治療結(jié)果經(jīng)EN支持治療10d后,患兒營養(yǎng)狀態(tài)改善,精神狀態(tài)良好,無精神萎靡、營養(yǎng)不良、貧血癥狀,體重較治療前有所增加,年長患兒可正常下地活動(dòng),無四肢軟弱無力等癥狀。結(jié)論1.腸內(nèi)營養(yǎng)在小兒外科中的應(yīng)用是安全、有效的,可以為患兒提供正常生長、發(fā)育及組織修復(fù)、愈合所需的營養(yǎng)；促進(jìn)患兒胃腸道功能恢復(fù)；促進(jìn)疾病的恢復(fù)。2.嚴(yán)格檢測各項(xiàng)指標(biāo),密切注意患兒嘔吐、腹脹、排便情況以及有無腹痛,及時(shí)抽取胃殘余量,隨時(shí)調(diào)整腸內(nèi)營養(yǎng)的配方、給予方式、速度,有助于腸內(nèi)營養(yǎng)治療的正常進(jìn)行。3.對比、分析腸內(nèi)營養(yǎng)治療前后患兒體重、血紅細(xì)胞計(jì)數(shù)、血紅蛋白、血清淋巴細(xì)胞計(jì)數(shù)、血清白蛋白、轉(zhuǎn)鐵蛋白、血肌酐、血尿素氮等指標(biāo)的變化,可以得出結(jié)論：腸內(nèi)營養(yǎng)支持治療符合患兒生理消化、吸收過程；對于維持腸粘膜屏障功能的完整性有著一定的作用；可以減少腸道內(nèi)毒素的釋放、菌群異位；更好地促進(jìn)機(jī)體免疫機(jī)能的恢復(fù)；并發(fā)癥小、安全、方便、經(jīng)濟(jì)。對于不能正常飲食或正常飲食不能滿足營養(yǎng)需要的外科患兒,只要其血流動(dòng)力學(xué)穩(wěn)定,胃、腸功能未完全喪失,機(jī)體血流動(dòng)力學(xué)平穩(wěn),就應(yīng)及時(shí)進(jìn)行EN支持治療。
[Abstract]:The purpose is to protect the nutrition of the body's normal growth, development, homeostasis, indispensable for the normal metabolism of the material. In children due to their body is in the growth period, has its special nutritional requirements; and often in surgery in children with severe infection, trauma, surgical strikes as a result of stress, thermal energy consumption faster, then with some children because they can not own or the cause of the disease by oral ingestion of food, but for the rapid development of - protein energy malnutrition, resulting in immune function and organ function decline, it is prone to infection, nutrition related complications, resulting in prolonged hospitalization, even lead to increased mortality. Therefore, take the right method for improving nutrition, to ensure the stability of the metabolic function of cells, tissues, organs to maintain the normal structure and function, and maintain normal immune function of the tissue, organ Healing is of great importance for the rehabilitation of the disease. At present, the research shows that enteral nutrition therapy (Enteral nutrition EN) can correct malnutrition, promote gastric, intestinal development, and meet the physiological requirements, the incidence of complications is less, and more economical. The purpose of this study is to investigate the feasibility of enteral nutrition in pediatric surgery application value, reliability, applicability, advantages, complications and precautions. Methods Retrospective analysis of 1. studies, 78 patients with nasal jejunum nutrition tube EN treatment of children outside the clinical data of.2. nutrition selection and give way in our hospital from June 2007 to February 2014: less than 1 year old children, we choose Nestle's ailing son Shu (such as amino acids, peptides); children over the age of 1, we choose Nestle company 100 small peptide or Nutricia company nengquansu (mainly short peptide). Given the way we choose After 24 hours of continuous nj-en, tolerance index uniform pump.3. evaluation EN treatment: according to the gastric residual nutrition retraction of the voxel volume, the number and amount of vomiting, vomiting, abdominal distension, abdominal pain, defecation and fecal traits, quantity evaluation index of tolerance to.4. of EN in the evaluation of nutritional status in the course of treatment in children: children with weight EN collected before and after treatment, the red blood cell count (redblood cell, count, RBC), hemoglobin (hemoglobin, HGB), serum lymphocyte count (serum lymphocyte count, SLC), serum albumin (serum, albumin, SA), prealbumin (prealbumin, PA serum creatinine (blood), serum creatinine, BSC), blood urea nitrogen (blood urea, nitrogen, BUN) and other indicators, and compared by statistical analysis to determine the change of.5. measurement data of nutritional status for x + s said, before and after fasting, EN before and after treatment, were treated by T .P0.05 said the difference was statistically significant, P0.01 said the difference was statistically significant. Results 1. of 1.1 general data from June 2007 to February 2014 78 cases we cannot eat by mouth and children with nasal jejunal tube were treated with EN for 1 days, age -9 years old, (2.9 + 2.4); EN weight before treatment (12.70. Kg; 6.92) were 53 boys, 25 girls. 22 cases of acute pancreatitis, 14 cases of intestinal atresia, liver contusion in 10 cases, duodenal membranous stenosis in 9 cases, 5 cases of hepatoblastoma, 6 cases of annular pancreas, 6 cases of duodenal perforation, 6 cases of esophageal atresia.1.2 EN in treatment of 78 cases of patients were treated with time naso jejunal tube treated by EN completed EN treatment.EN treatment time: 7-37d (17.5 + 9.4) d, at the time of 10d in 21 cases, 19 cases of 10-15d, 6 cases of 38 cases of adverse reactions during.1.3 treatment than 15d (7.7%) diarrhea, defecation 6~8 times /d, each about 50 ml/kg shit. Yellow or green watery stool; 4 cases (5.1%) of nausea, vomiting, vomiting of transparent yellow or green liquid, to draw nutrition liquid remaining in the stomach, 1 times the amount of nutrient solution per unit time; 5 cases (6.4%) had mild abdominal distension, two consecutive times to measure more than the standard 2.5cm abdominal circumference (7.7%); 6 cases of mild abdominal pain; 4 cases (5.1%) of low sodium, low potassium; no aspiration pneumonia, gastrointestinal bleeding and other symptoms before and after.2.EN nutrition index change we selected 78 cases of fasting 3D and 39 patients without nutritional therapy, collect the weight of red blood cells count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators, and compared with fasting. Body weight, red blood cell count, hemoglobin, serum albumin, prealbumin index decreased significantly, the difference was statistically significant (P0.05); among them, prealbumin There was a statistically significant difference (P0.01); lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05). Selected 78 cases of children with EN after treatment, compared with EN before and after the treatment of 3D EN weight, red blood cell count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators. Weight, blood cell count, lymphocyte count, hemoglobin, serum albumin, serum creatinine, blood urea nitrogen index change, but the difference was not significant, no statistical significance (P0.05); prealbumin value increased significantly, the difference was statistically significant (P0.01). In the short term (3D), EN treatment did not change significantly with nutritional status. 57 cases from 78 cases of EN in children with treatment time in more than 10d, compared before and after the treatment of 10d EN fasting weight, red blood cell count, hemoglobin , lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators. Weight, blood cell count, hemoglobin, serum albumin, prealbumin index increased significantly, the difference was statistically significant (P0.05), the red blood cell count, hemoglobin, serum albumin, prealbumin index change was statistically significant (P0.01); lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05) (Table 8). After 10d EN treatment, the nutritional status of children with EN significantly improved after treatment. 38 cases from 78 cases of EN in children with treatment time in more than 15d, the collection body weight, red blood cell count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators, and compared with fasting. Body weight, serum albumin, prealbumin index rose Ming Obviously, the difference was statistically significant (P0.05); red blood cell count, hemoglobin, lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05). After EN after 15d treatment, the nutritional status of children improved, EN treatment can provide adequate nutritional support for surgical patients, guarantee the the rehabilitation of the disease and the normal growth of.3. treatment results by EN support after 10d treatment, children with nutritional status improved, good mental state, listlessness, malnutrition, anemia, weight had increased than before treatment, older children can be normal activities without limbs and other symptoms. 1. weak and feeble conclusion the application of enteral nutrition in pediatric surgery is safe and effective, can provide children with normal growth, development and tissue repair, wound healing for children with gastrointestinal nutrition; promote functional recovery; promote disease recovery.2. Strict detection indicators, pay close attention to children with vomiting, abdominal distension, defecation and abdominal pain, timely extraction gastric residual, adjust the formula of enteral nutrition given way, speed, contribute to the normal.3. comparison of enteral nutrition therapy, analysis of body weight before and after enteral nutrition in the treatment of children, red blood cell count hemoglobin, serum, lymphocyte count, serum albumin, transferrin, serum creatinine, blood urea nitrogen and other indicators of change, we can draw the conclusion: enteral nutrition support therapy with children with physiological digestion and absorption process; has a certain role for maintaining the integrity of the intestinal mucosal barrier function; can reduce the intestinal endotoxin release of bacteria ectopic; promote immune function recovery; complication of small, safe, convenient and economic. For not the normal diet or normal diet can not meet the nutritional needs of surgical patients EN support should be carried out in time as long as the hemodynamics are stable, the function of the stomach, the intestines is not completely lost, and the hemodynamics of the body is stable.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R726.5;R459.3

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本文編號(hào)：1725222