發(fā)布時間：2018-03-22 07:43

  本文選題：重癥急性胰腺炎　切入點：腸內(nèi)營養(yǎng)　出處：《天津醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的:觀察鼻胃管與三腔鼻空腸管腸內(nèi)營養(yǎng)(enteral nutrition,EN)支持對重癥急性胰腺炎(severe acute pancreatitis,SAP)患者炎癥指標、耐受性和預后的影響,探討三腔鼻空腸管早期EN對SAP的營養(yǎng)支持意義。方法:選取2014年1月至2016年12月急診ICU收治的68例SAP患者,隨機分成三腔鼻空腸管EN組(觀察組)36例和鼻胃管EN組(對照組)32例。入院后觀察組患者立即置入三腔鼻空腸管,對照組患者立即置入鼻胃管,兩組患者均給予相同的基礎(chǔ)治療。在此基礎(chǔ)上,血流動力學相對穩(wěn)定,胃腸功能恢復時立即開始EN。觀察指標:記錄所有患者一般臨床資料,并于入院時取血測定血液生化、常規(guī)等實驗室指標,計算入院時APACHE II評分、MCTSI評分。在治療后第1、3、5、7、14天再次計算APACHEⅡ評分。記錄EN開始時間和到達全量時間。測定入院時和治療第7天的前白蛋白水平。于入院時和第3、7天測定血清C-反應蛋白水平以及入院時和治療第7天的血清TNF-α、IL-6水平。記錄患者腹脹/腹痛緩解時間,觀察并記錄EN期間胃潴留、返流、腹瀉,和腹痛加重的情況。最后總結(jié)總有效率、病死率,以及ICU住院時間。所有數(shù)據(jù)建立數(shù)據(jù)庫,應用SPSS20.0軟件進行統(tǒng)計分析。結(jié)果1)一般資料比較兩組患者的性別構(gòu)成、年齡、入院時的發(fā)病時間、主要病因構(gòu)成等一般資料的差異無統(tǒng)計學意義(P0.05)。入院時病情程度:觀察組和對照組入院時的APACHEⅡ評分分別是9.22±3.48、9.25±3.11,MCTSI評分為4.56±1.48、4.69±1.49,差異無統(tǒng)計學意義(P0.05)。2)EN開始和全量時間觀察組EN開始時間為2.56±1.23天,對照組為3.59±1.27天,經(jīng)t檢驗,差異顯著(P=0.001),觀察組EN到達全量的時間為7.36±2.70天,對照組為8.78±2.86天,差異有統(tǒng)計學意義(P0.05)。3)兩組患者APACHEⅡ評分變化比較觀察組和對照組在治療第1天的APACHEⅡ分別為6.17±3.26、7.53±4.47,第3天分別為3.53±1.7、5.9±4.09,第5天分別為2.25±1.7、4.31±3.29,第7天分別為2.14±2.51、2.47±2.92,第14天分別為1.53±3.46、1.53±2.9。組內(nèi)比較在治療的前7天差異有統(tǒng)計學意義(P0.05),兩組間比較在第3天、第5天差異有統(tǒng)計學意義(P0.05)。4)炎癥指標變化入院時觀察組與對照組的CRP水平為127.6±74.3mg/L、131.2±82.2mg/L,治療后第1天116.7±74.49mg/L、127.9±82.1mg/L,第3天68.8±55.1mg/L、75.2±60.4mg/L,第7天的31.5±29.7mg/L、35.3±31.4mg/L,兩組CRP水平均呈下降趨勢,組內(nèi)比較差異有統(tǒng)計學意義(P0.05),但兩組間比較差異無統(tǒng)計學意義(P0.05);入院時觀察組和對照組的TNF-α水平分別為37.16±8.07pg/ml、37.28±7.78pg/ml,IL-6水平分別為1.81±12.32pg/ml、81.64±12.23pg/ml,治療后第7天TNF-α分別為25.32±7.27pg/ml、27.36±7.27pg/ml,IL-6為56.02±12.49pg/ml、57.72±12.79pg/ml。治療前后兩組的TNF-α和IL-6水平均有顯著改善(P0.05),組間比較無統(tǒng)計學意義(P0.05)。5)營養(yǎng)評估入院時觀察組和對照組的PA值分別為128.5±31.1g/L、134.4±38.3g/L,治療第7天觀察組PA值為189.1±23.9g/L,對照組PA值為174.58±27.7g/L,均較入院升高,組內(nèi)比較差異顯著(P0.01),組間比較入院時PA值差異無統(tǒng)計學意義(P0.05),治療第7天觀察組PA值更高,差異有統(tǒng)計學意義(P0.05)。6)急性胰腺炎癥狀和實驗室指標變化腹脹/腹痛緩解時間觀察組較對照組分別為55.22±18.93小時,73.88±23.43小時,差異有統(tǒng)計學意義(P0.05)。EN的并發(fā)癥發(fā)生率兩組分別為:6例和12例(P0.05),胃潴留/返流的發(fā)生率觀察組為1例,對照組7例(P0.01),腹瀉的發(fā)生率觀察組2例,對照組3例(p0.05),腹痛/腹脹加重的發(fā)生率觀察組3例,對照組2例(P0.05)。7)臨床效果比較觀察組和對照組的總有效率分別是80.55%和78.12%,差異無統(tǒng)計學意義(P0.05);兩組死亡人數(shù)分別是觀察組1例、對照組2例,差異無統(tǒng)計學意義(P0.05)。ICU住院時間兩組分別為8.56±3.47天、10.5±3.93天,差異有統(tǒng)計學意義(P0.05)。結(jié)論:1.三腔鼻空腸管EN支持能更快緩解SAP的臨床癥狀、改善病情,縮短ICU住院時間。2.三腔鼻空腸管較鼻胃管更加安全,發(fā)生返流/胃潴留的風險更低,有臨床推廣價值。3.三腔鼻空腸管和鼻胃管途徑EN對于SAP療效和預后影響相當。
[Abstract]:Objective: To observe the three cavity nasogastric tube and nasojejunal tube enteral nutrition (enteral, nutrition, EN) on severe acute pancreatitis (severe acute, pancreatitis, SAP) inflammation index, effects of tolerance and prognosis, to investigate the three cavity nasointestinal tube nutrition support for SAP EN. Methods: 68 cases of SAP from January 2014 to December 2016 with emergency ICU were randomly divided into three cavities, nasojejunal tube EN group (observation group) 36 cases and nasogastric tube group EN (control group) 32 cases. The observation immediately placed three cavity nj-en groups of patients after admission, patients in the control group, nasogastric tube, two groups of patients were given the same basic treatment. On this basis, relatively stable hemodynamics, recovery of gastrointestinal function immediately began EN. outcome measures: the records of all patients with clinical data and blood samples were collected from the hospital routine determination of blood biochemical, and other laboratory parameters, calculation of admission AP ACHE II score, MCTSI score. APACHE score calculated again in the first 1,3,5,7,14 days after treatment. EN recording start time and reaches full amount of time. Measured at admission and seventh days of treatment. The level of prealbumin on admission and day 3,7 measured the levels of serum C- reactive protein and admission and seventh days of treatment serum TNF- alpha, the level of IL-6. Record the patients in remission time of abdominal pain / abdominal distension, observe and record EN during gastric retention, reflux, diarrhea, abdominal pain and worsening. Finally, the total efficiency, mortality, and hospitalization in ICU. All data should establish a database, using SPSS20.0 software for statistical analysis. Results of the 1 general sex) the data were compared between the two groups of age, the onset time of admission, no significant difference was found in the etiology of general data (P0.05). At the time of admission severity: observation group and control group at the time of admission APACHE score Were 9.22 + 3.48,9.25 + 3.11, MCTSI score was 4.56 + 1.48,4.69 + 1.49, there was no statistically significant difference (P0.05).2) EN start and total time of the observation group EN start time was 2.56 + 1.23 days, the control group was 3.59 + 1.27 days, by t test, significant differences were observed in group EN (P=0.001). To the full amount of time was 7.36 + 2.70 days, the control group was 8.78 + 2.86 days, the difference was statistically significant (P0.05).3) group and control group in APACHE first days of treatment II were 6.17 + 3.26,7.53 + 4.47 comparison of two groups were observed in patients with APACHE score changes, third days were 3.53 + 1.7,5.9. 4.09, fifth days were 2.25 + 1.7,4.31 + 3.29, seventh days were 2.14 + 2.51,2.47 + 2.92, fourteenth days were 1.53 + 3.46,1.53 + 2.9. group compared with 7 days before treatment difference was statistically significant (P0.05), between the two groups in third days, fifth days was statistically significant difference (P0.05.4)) and inflammatory indexes Admission to the observation group and the control group CRP was 127.6 + 74.3mg/L, 131.2 + 82.2mg/L, first days after treatment was 116.7 + 74.49mg/L, 127.9 + 82.1mg/L, third days and 68.8 + 55.1mg/L, 75.2 + 60.4mg/L, seventh days, 31.5 + 29.7mg/L, 35.3 + 31.4mg/L, CRP levels of the two groups were decreased, compared within the group the difference was statistically significant (P0.05), but there was no significant difference between the two groups (P0.05); admission TNF- level in the observation group and the control group were 37.16 + 8.07pg/ml, 37.28 + 7.78pg/ml, IL-6 levels were 1.81 + 12.32pg/ml, 81.64 + 12.23pg/ml, seventh days after treatment were 25.32 + alpha TNF- 7.27pg/ml, 27.36 + 7.27pg/ml, IL-6 = 56.02 + 12.49pg/ml, 57.72 + 12.79pg/ml. before and after treatment of the two groups of TNF- alpha and IL-6 water average was significantly improved (P0.05), no statistical significance between the two groups (P0.05).5) nutritional assessment on admission control group and the observation group PA values were 128 .5鹵31.1g/L,134.4鹵38.3g/L,娌葷枟絎，

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