發(fā)布時間：2018-05-02 11:38

  本文選題：先天性心臟病 + 營養(yǎng)風(fēng)險評估�。� 參考：《南京醫(yī)科大學(xué)》2015年博士論文

【摘要】：營養(yǎng)不良在先天性心臟病(Congenital heart disease, CHD)住院患兒中非常普遍,尤其在合并心功能衰竭、肺動脈高壓等高危風(fēng)險因素情況下對臨床預(yù)后及患兒生長發(fā)育的影響尤其明顯。如何對此類患兒進(jìn)行營養(yǎng)風(fēng)險篩查及營養(yǎng)支持己成為國內(nèi)外研究的熱點。隨著手術(shù)技術(shù)及術(shù)后重癥監(jiān)護(hù)水平的提高,先天性心臟病手術(shù)低齡化趨勢越來越明顯,大多數(shù)患兒能夠在嬰幼兒階段得以救治。手術(shù)時機(jī)越早,就越有利于患兒在生長發(fā)育上更早的趕上同齡兒童,但越小年齡手術(shù),患兒所面臨的各種風(fēng)險包括營養(yǎng)風(fēng)險就越高,營養(yǎng)支持的挑戰(zhàn)就越大。由于國內(nèi)兒科臨床營養(yǎng)發(fā)展的滯后,CHD圍手術(shù)期營養(yǎng)風(fēng)險評估及支持尚處在起步階段,特別是嬰幼兒CHD圍手術(shù)期臨床營養(yǎng)支持的規(guī)范遠(yuǎn)遠(yuǎn)落后于發(fā)達(dá)國家。臨床醫(yī)務(wù)人員對CHD圍手術(shù)期營養(yǎng)風(fēng)險及營養(yǎng)支持重視度認(rèn)識不足,尚未常規(guī)展開營養(yǎng)風(fēng)險篩查、營養(yǎng)狀況評估以及規(guī)范化營養(yǎng)支持。CHD住院患兒中營養(yǎng)風(fēng)險比例究竟是多少尚無依據(jù),營養(yǎng)支持方法不規(guī)范,很多治療手段僅僅靠臨床經(jīng)驗而缺乏以循診醫(yī)學(xué)方法為基礎(chǔ)的臨床驗證資料。CHD患兒圍手術(shù)期經(jīng)常面臨喂養(yǎng)不足或喂養(yǎng)過渡而導(dǎo)致感染,營養(yǎng)不良相關(guān)并發(fā)癥及死亡率增加等不良結(jié)局。本研究擬通過基于兒童營養(yǎng)風(fēng)險及發(fā)育不良篩查工具(Screening Tool for Risk on Nutritional status and Growth. Kids, STRONGKIDS)制定的營養(yǎng)風(fēng)險評估表,研究先天性心臟病住院患兒中營養(yǎng)風(fēng)險發(fā)生率及常見影響因素,并結(jié)合專業(yè)的營養(yǎng)支持團(tuán)隊開展早期腸內(nèi)營養(yǎng)支持(Enteral Nutrition, EN),縮短術(shù)后禁食時間,規(guī)范喂養(yǎng)方式及營養(yǎng)配方,并與既往營養(yǎng)支持模式資料進(jìn)行對照研究,分析C-反應(yīng)蛋白、白蛋白、視黃醛蛋白、前白蛋白以及出入院體重、首次大便時間、呼吸機(jī)輔助時間、重癥監(jiān)護(hù)時間(intensive care unit, ICU)等臨床預(yù)后指標(biāo)及腸內(nèi)營養(yǎng)支持時喂養(yǎng)中斷次數(shù)的差異和可能對策,開展先天性心臟病圍手術(shù)期靜息能量代謝規(guī)律研究,通過對不同類型CHD及不同手術(shù)方式患兒術(shù)后靜息能量的檢測,明確CHD靜息能量規(guī)律并探討現(xiàn)有Harris-Benedict(H-B)公式術(shù)后能量預(yù)測的準(zhǔn)確率進(jìn)行研究,為先天性心臟病術(shù)后個性化能量供給提供理論依據(jù)。通過上述研究促進(jìn)CHD圍手術(shù)期營養(yǎng)支持和臨床管理,改善患兒預(yù)后。第一部分先天性心臟病住院患兒營養(yǎng)風(fēng)險評估目的通過營養(yǎng)風(fēng)險評估,分析CHD圍手術(shù)期營養(yǎng)風(fēng)險特征及與臨床結(jié)局的關(guān)系方法在兒童營養(yǎng)風(fēng)險及發(fā)育不良篩查工具STRONGKIDS基礎(chǔ)上設(shè)計我院營養(yǎng)風(fēng)險評估表,對2010年8月—2013年4月780例CHD住院患兒進(jìn)行營養(yǎng)風(fēng)險評估,分析CHD住院患兒營養(yǎng)風(fēng)險發(fā)生率及與年齡、肺動脈高壓和營養(yǎng)不良的關(guān)系,研究營養(yǎng)風(fēng)險程度對CHD臨床結(jié)局的影響。結(jié)果780例CHD住院患兒(室間隔缺損[ventricular septal defect, VSD]522例、房間隔缺損[atrial septal defect, ASD]133例、法洛四聯(lián)癥[tetralogy of Fallot, TOF] 70例、動脈導(dǎo)管未閉[Patent ductus arteriosus, PDA]55例),中、重度營養(yǎng)風(fēng)險發(fā)生率共33.3%.其中0-1歲年齡段中、重度營養(yǎng)風(fēng)險發(fā)生率49.2%,1-3歲的26.2%和3歲以上的7.6%。所有中、重度營養(yǎng)風(fēng)險患兒中合并肺動脈高壓比例達(dá)95%(247/260)、營養(yǎng)不良發(fā)生率為91%(237/260)。重度營養(yǎng)風(fēng)險術(shù)后感染發(fā)生率高達(dá)46%,而中度營養(yǎng)風(fēng)險術(shù)后感染發(fā)生率為32%,重度營養(yǎng)風(fēng)險患兒住院時間(12.65±6.66d vs 10.44±5.22d)和重癥監(jiān)護(hù)時間(3.29±2.21d vs 2.17+1.79d)均長于中度營養(yǎng)風(fēng)險患兒。結(jié)論CHD患兒存在中、重度營養(yǎng)風(fēng)險,并預(yù)示不良的臨床結(jié)局。肺動脈高壓、營養(yǎng)不良加重患兒營養(yǎng)風(fēng)險。開展?fàn)I養(yǎng)風(fēng)險篩查,應(yīng)成為圍術(shù)期營養(yǎng)管理的首要步驟。第二部分：早期腸內(nèi)營養(yǎng)支持對先天性心臟病患兒臨床預(yù)后的影響第一章早期腸內(nèi)營養(yǎng)支持對先天性心臟病圍手術(shù)期臨床預(yù)后的影響目的探討早期腸內(nèi)營養(yǎng)支持對CHD術(shù)后血、生化指標(biāo)、胃腸道功能及臨床結(jié)局的影響方法選取2013.10-2014.10年齡6月-1歲的50例體外循環(huán)VSD修補(bǔ)術(shù)后患兒,開展早期腸內(nèi)營養(yǎng)支持,根據(jù)早期腸內(nèi)營養(yǎng)支持方案,術(shù)后當(dāng)天撤離呼吸機(jī),拔管后6h開始EN、長期呼吸機(jī)輔助者,術(shù)后常規(guī)留置鼻-胃管并于12-24h開始EN、記錄出入院體重、首次大便時間、入院和術(shù)后3天C-反應(yīng)蛋白(C-reactive protein, CRP)水平、術(shù)前和出院前視黃醛蛋白(Retinoic aldehyde protein, RBP)和前白蛋白(prealbumin, Pre-ALB)水平、喂養(yǎng)中斷次數(shù)以及ICU時間、呼吸機(jī)輔助時間等。回顧性查閱50例2010.10-2011.10年尚未常規(guī)開展早期腸內(nèi)營養(yǎng)支持時體外循環(huán)VSD修補(bǔ)術(shù)后患兒資料。結(jié)果術(shù)前兩組CRP均8mg/L、RBP、Pre-ALB濃度無統(tǒng)計學(xué)差異(P=0.68)；術(shù)后3天早期EN組CRP顯著低于對照組(45.16±16.22 vs 67.32±35.45 mg/L),出院前早期EN組RBP(0.28±0.14 vs 0.18±0.11)及Pre-ALB(35.15+12.22 vs25.21±14.18)均顯著高于對照組(P0.05)。與對照組相比,早期EN組出入院體重呈正向增長(0.13±0.17kg vs -0.06±0.16kg,P0.05)、首次大便時間提前(33.0±1.64h vs 56.50±1.37h,P0.05)；兩組在呼吸機(jī)輔助時間、ICU時間上差異均無統(tǒng)計學(xué)意義(P=0.53)；腸內(nèi)營養(yǎng)時早期EN組喂養(yǎng)中斷次數(shù)(68次)和對照組(65次)無明顯差異(P0.05)。結(jié)論早期EN促進(jìn)胃腸道適應(yīng)、保護(hù)胃腸粘膜、盡早恢復(fù)胃腸動力,降低術(shù)后感染幾率并不增加喂養(yǎng)中斷發(fā)生。早期腸內(nèi)營養(yǎng)支持與ICU時間及呼吸機(jī)輔助時間無關(guān)。第二章先天性心臟病圍手術(shù)期腸內(nèi)營養(yǎng)支持中斷原因的分析及對策目的調(diào)查CHD圍手術(shù)期間腸內(nèi)營養(yǎng)中斷次數(shù)及并探討臨床可能的對策。方法選取2013.12-2014.12住院的360例CHD患兒,設(shè)計專業(yè)量表,統(tǒng)計圍手術(shù)期腸內(nèi)營養(yǎng)支持(經(jīng)口或經(jīng)鼻胃管飼)不同中斷原因及次數(shù),分析導(dǎo)致喂養(yǎng)中斷非胃腸道因素和胃腸道因素比例及可能臨床對策。結(jié)果360例CHD患兒(VSD218例、ASD89例、TOF53例),年齡1個月-6歲,有198人(55%)在腸內(nèi)營養(yǎng)支持過程中至少有一次喂養(yǎng)中斷,中斷總次數(shù)高達(dá)498次,平均2.52次/人.其中,非胃腸道因素共355次(68%),胃腸道因素150次(28.7%),其他因素18次(3.4%)。1月-1歲患兒平均中斷數(shù)1.50次/人,高于1歲以上患兒的平均中斷數(shù)1.24次/人,其中又以胃腸道因素更加明顯。結(jié)論CHD腸內(nèi)營養(yǎng)支持時喂養(yǎng)中斷以非胃腸道因素為主。低年齡患兒腸內(nèi)營養(yǎng)時更易發(fā)生喂養(yǎng)中斷,并以胃腸道因素為主。部分喂養(yǎng)中斷可通過改變喂養(yǎng)方式、胃腸動力藥物使用等減少中斷次數(shù)和提高喂養(yǎng)量。第三部分先天性心臟病術(shù)后能量代謝規(guī)律研究目的應(yīng)用靜息能量代謝儀對CHD術(shù)后患兒能量代謝進(jìn)行監(jiān)測,探討Harris-Benedict公式預(yù)測準(zhǔn)確率,并明確術(shù)后能量代謝規(guī)律及影響因素。方法選擇2013年8月—2014年8月50例CHD手術(shù)患兒,術(shù)后8小時血流動力學(xué)穩(wěn)定狀態(tài)下,應(yīng)用靜息能量代謝儀監(jiān)測患兒靜息能量值(Resting Energy Expenditure,REE),并與Harris-Benedict公式預(yù)測值(Predictive value, Pred)結(jié)果比較。REE/Pred(%)110為高代謝狀態(tài),90-110_為正常代謝狀態(tài),90為低代謝狀態(tài),記錄體外循環(huán)時間、主動脈阻斷時間、肌肉松弛藥物使用、呼吸機(jī)輔助時間、重癥監(jiān)護(hù)(intensive care unit, ICU)時間等,分析影響患兒術(shù)后代謝狀態(tài)的因素及不同代謝狀態(tài)與臨床結(jié)局的關(guān)系。結(jié)果50例CHD住院患兒(男22例,女28例)年齡6月-1歲。,非體外循環(huán)組(微創(chuàng)封堵VSD)10例,術(shù)后均未使用肌肉松弛藥物,12小時內(nèi)均停呼吸機(jī)改鼻導(dǎo)管吸氧；體外循環(huán)VSD修補(bǔ)20例、TOF矯治20例,術(shù)后均予多巴胺3-10ug/kg循環(huán)支持,部分給予肌肉松弛藥物,呼吸機(jī)輔助時間24-96小時,ICU時間64-120小時。50例患兒中僅13例(26%)術(shù)后REE/Pred(%)為正常代謝,非體外循環(huán)10例術(shù)后均為高代謝；20例非紫紺型體外循環(huán)術(shù)后12例為高代謝、8例為正常代謝狀態(tài)(2例使用肌肉松弛藥)。體外循環(huán)法洛四聯(lián)癥矯治術(shù)后有8例高代謝,5例正常代謝、7例低代謝,低代謝患兒體外循環(huán)時間、主動脈阻斷時間、呼吸機(jī)輔助時間及ICU時間均顯著長于正常代謝和高代謝患兒,并使用過肌肉松弛藥物。結(jié)論CHD術(shù)后能量代謝存在明顯個體差異,Harris-Benedict公式值預(yù)測準(zhǔn)確率較差。體外循環(huán)時間、主動脈阻斷時間及術(shù)后肌肉松弛藥物的使用是影響術(shù)后代謝狀態(tài)的重要因素。不同代謝狀態(tài),其臨床結(jié)局不同。
[Abstract]:Malnutrition is very common in children with congenital heart disease (Congenital heart disease, CHD), especially in patients with high risk factors such as heart failure, pulmonary hypertension and other risk factors. The effects of nutritional risk screening and nutritional support on these children are becoming more and more important. With the improvement of surgical techniques and postoperative intensive care, the trend of congenital heart disease operation is becoming more and more obvious, and most of the children can be treated in the infant stage. The earlier the operation time is, the more it will help the children to catch up with the same age children earlier in the growth and development, but the younger the operation, the children are operated on, the children are operated on, children are operated on children, the children are operated on, the children are operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on at a smaller age. The higher the risks are, the higher the nutritional risk is, the greater the challenge for nutritional support. Due to the lag of the domestic pediatric clinical nutrition development, the nutritional risk assessment and support in the perioperative period of CHD is still in its infancy, especially the standard of clinical nutritional support in the perioperative period of CHD in infants is far behind the developed countries. The importance of nutritional risk and nutritional support in the perioperative period of CHD was insufficient. The nutritional risk screening, nutritional status assessment and the proportion of nutritional risk in the hospitalized children with standardized nutritional support.CHD were not yet based, the nutritional support method was not standardized, and many treatment methods were only based on clinical experience and lack of evidence-based diagnosis. Medical methods based clinical validation data of.CHD children are often faced with adverse outcomes such as inadequate feeding or feeding transition, resulting in malnutrition related complications and increased mortality. This study is intended to be based on a child nutritional risk and dysplasia screening tool (Screening Tool for Risk on Nutritional status and). Growth. Kids, STRONGKIDS) developed a nutritional risk assessment table to study the incidence of nutritional risk and common influencing factors in inpatient children with congenital heart disease, and to develop early enteral nutrition support (Enteral Nutrition, EN) with professional nutrition support team, shorten the time of postoperative fasting, standardize feeding methods and nutritional formula, and not only A comparative study of nutritional support model data was carried out to analyze the clinical prognostic indicators such as C- reactive protein, albumin, retinol, prealbumin and entry and exit body weight, first stool time, ventilator assisted time, intensive care unit (ICU), and the difference in the number of interruptions in enteral nutrition support and the possible countermeasures To carry out the study of resting energy metabolism in the perioperative period of congenital heart disease. Through the detection of resting energy after the operation of different types of CHD and different surgical methods, the law of resting energy of CHD was clearly defined and the accuracy of the energy prediction after the operation of the existing Harris-Benedict (H-B) formula was investigated in order to individualize after operation of congenital heart disease. To provide theoretical basis for quantity supply. Through these studies, the nutritional support and clinical management of CHD perioperative period were promoted to improve the prognosis of children. The first part of the nutritional risk assessment of inpatients with congenital heart disease was assessed by nutritional risk assessment, and the nutritional risk characteristics of CHD perioperative period and the relationship with clinical outcome were analyzed in the nutritional risk of children. The nutritional risk assessment table was designed on the basis of the dysplasia screening tool STRONGKIDS, and 780 cases of CHD hospitalized children from August 2010 to April 2013 were evaluated. The incidence of nutritional risk in CHD hospitalized children and the relationship with age, pulmonary hypertension and malnutrition were analyzed. The effect of nutritional risk on the clinical outcome of CHD was studied. Results 780 cases of CHD hospitalized children (ventricular septal defect [ventricular septal defect, VSD]522 case, atrial septal defect [atrial septal defect, ASD]133 cases, [tetralogy of Fallot of tetralogy of Fallot, 70 cases, patent ductus arteriosus), the incidence of severe nutritional risk was 0-1 years old In the segment, the incidence of severe nutritional risk was 49.2%. In all 7.6%., 1-3 years of age 26.2% and over 3 years old, the proportion of pulmonary hypertension in children with severe nutritional risk was 95% (247/260), the incidence of malnutrition was 91% (237/260). The incidence of postoperative infection was 46%, and the incidence of postoperative infection was 32% and severe battalion. The hospitalization time (12.65 + 6.66d vs 10.44 + 5.22d) and intensive care time (3.29 + 2.21d vs 2.17+1.79d) were longer than those of moderate nutrition risk children. Conclusion the severe nutritional risk in children with CHD is in the presence of severe nutritional risk, and indicates poor clinical outcome. Pulmonary hypertension and nutritional risk are not aggravated. Nutritional risk screening should be carried out. The primary step for perioperative nutrition management. The second part: the effect of early enteral nutrition support on the clinical prognosis of children with congenital heart disease: Chapter 1 the effect of early enteral nutrition support on the clinical prognosis of congenital heart disease in order to explore the blood, biochemical index, gastrointestinal function and function of early enteral nutrition support after CHD The method of influence of clinical outcome was selected in 50 cases of 2013.10-2014.10 age -1 years old in June after VSD repair. Early enteral nutrition support was carried out. According to early enteral nutrition support scheme, breathing machine was evacuated on the same day after operation, 6h began EN after extubation, long ventilator assisted, postoperative routine retention of nose stomach tube and 12-24h start EN. The body weight, the first stool time, the admission and the level of C- reactive protein (C-reactive protein, CRP) 3 days after the operation, the level of Retinoic aldehyde protein, RBP and prealbumin (prealbumin, Pre-ALB) before and before the operation, the frequency of feeding interruption, ICU time, and the time of ventilator assisted were reviewed before and before the operation. 50 cases of 2010.10-2 were reviewed retrospectively. 11.10 years after 11.10 years of early enteral nutrition support, the results showed that there was no statistical difference between CRP and 8mg/L, RBP and Pre-ALB in the two groups before operation (P=0.68), and the CRP in EN group was significantly lower than that of the control group (45.16 + 16.22 vs 67.32 + 35.45 mg/L) in the early 3 days after the operation, and RBP (0.28 + 0.14 0.18 + 0.18 +) before discharge. And Pre-ALB (35.15+12.22 vs25.21 + 14.18) were significantly higher than that of the control group (P0.05). Compared with the control group, the initial body weight of the early EN group was positively increased (0.13 + 0.17kg vs -0.06 + 0.16kg, P0.05), and the first stool time was ahead of time (33 + 1.64h vs 56.50 +). The two groups had no statistical difference in the time of ventilator assistance. P=0.53; there was no significant difference between the interruption times in the early EN group (68 times) and the control group (P0.05). Conclusion early EN promoted gastrointestinal adaptation, protected gastrointestinal mucosa, resumed gastrointestinal motility as soon as possible, and decreased postoperative infection rate did not increase the occurrence of interruption in feeding. Early enteral nutrition support and ICU time and ventilator assistance The second chapter analysis and Countermeasures of the interruption of enteral nutrition support in the perioperative period of congenital heart disease. Objective to investigate the number of interruptions of enteral nutrition during CHD perioperative period and to explore the possible clinical countermeasures. Methods 360 cases of CHD children hospitalized in hospital were selected and the professional scale was designed and the perioperative enteral nutrition support (through oral administration) was statistically analyzed. The causes and times of different interruptions were analyzed, and the proportion of non gastrointestinal factors and gastrointestinal factors and possible clinical countermeasures were analyzed. Results 360 children with CHD (VSD218, ASD89, TOF53), 1 months of age -6, 198 (55%) had at least one feeding interruption in the process of enteral nutrition support, and the total number of interruptions was as high as 4 98 times, an average of 2.52 times per person. Among them, non gastrointestinal factors were 355 times (68%), gastrointestinal factors were 150 times (28.7%), other factors 18 times (3.4%).1 month -1 years old, the average interruption number was 1.50 times / people, higher than the average interruption of children over 1 years of age 1.24 / human, and the gastrointestinal factors were more obvious. Conclusion CHD enteral nutrition support when feeding interruption is not Gastroenteric factors are the main factors. The feeding interruption is more prone to enteral nutrition in children with low age, and gastrointestinal factors are the main factors. Partial feeding interruption can reduce the number of interruptions and raise the feeding amount by changing feeding mode, gastrointestinal motility drug use and so on. The third part of the energy metabolism after congenital heart disease is used to apply resting energy The metabolic apparatus was used to monitor the energy metabolism of children after CHD, to explore the accuracy of Harris-Benedict formula prediction, and to determine the energy metabolism and influence factors after operation. Methods 50 children with CHD operation from August 2013 to August 2014 were selected and the resting energy metabolic instrument was used to monitor the resting energy of the children under the 8 hour postoperative hemodynamic stability. Value (Resting Energy Expenditure, REE), and compared with the Harris-Benedict formula prediction value (Predictive value, Pred) results,.REE/Pred (%) 110 is high metabolic state, 90-110_ for normal metabolic state, 90 is low metabolic state, record cardiopulmonary bypass time, aortic obstruction time, muscle relaxation drug use, ventilator assisted time, intensive care ( Intensive care unit, ICU) time and other factors affecting the postoperative metabolic state of children and the relationship between different metabolic states and clinical outcomes. Results 50 children with CHD (22 males and 28 females) were aged -1 years old in June. 10 cases of non extracorporeal circulation group (minimally invasive VSD) were not used for muscle relaxation after operation, and the nasal breathing machine was stopped within 12 hours. Catheter oxygen inhalation; 20 cases of VSD repair in extracorporeal circulation and 20 cases of TOF correction. All of them were supported by dopamine 3-10ug/kg circulation, partially given muscle relaxation drugs, ventilator assisted time 24-96 hours, ICU time 64-120 hours in 13 cases (26%) of only 13 cases (26%) as normal metabolism, non extracorporeal circulation 10 cases were high metabolism; 20 cases were not. 12 cases were high metabolism after cyanotic cardiopulmonary bypass and 8 cases were normal metabolic state (2 cases of muscle relaxant). 8 cases of high metabolism, 5 normal metabolism, 7 low metabolism, low metabolism children's cardiopulmonary bypass time, aorta interruption time, ventilator assisted time and ICU time were significantly longer than normal generations after cardiopulmonary bypass for tetralogy of Fallot. Xie Hegao metabolized children and used muscle relaxation drugs. Conclusion there are obvious individual differences in energy metabolism after CHD, and the prediction accuracy of Harris-Benedict formula is poor. The time of cardiopulmonary bypass, aortic blocking time and the use of muscle relaxation drugs after operation are important factors affecting the postoperative metabolic state. The outcome is different.

【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R726.5

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