【摘要】：目的:探討消化系統(tǒng)惡性腫瘤患者圍手術(shù)期能量代謝及營養(yǎng)狀況的變化,為理想的疼痛管理提供參考。方法:選取上海瑞金醫(yī)院普外科住院接受消化系統(tǒng)惡性腫瘤手術(shù)治療患者,術(shù)前運(yùn)用Harris-Benedict公式(H-B公式)估算靜息能量消耗(resting energy expenditure,REE);圍手術(shù)期監(jiān)測(cè)血清白蛋白(albumin,Alb)、血清前白蛋白(prealbumin,PAlb)等指標(biāo);運(yùn)用Quark RMR能量代謝監(jiān)測(cè)系統(tǒng)進(jìn)行圍手術(shù)期靜息能量消耗和呼吸熵(respiratory quotient,RQ)。另設(shè)健康對(duì)照組,評(píng)價(jià)Quark RMR能量代謝監(jiān)測(cè)系統(tǒng)的準(zhǔn)確性及可靠性,比較健康人群REE、RQ與消化系統(tǒng)惡性腫瘤患者術(shù)前REE、RQ的差異;分析消化系統(tǒng)惡性腫瘤患者圍手術(shù)期REE、RQ、Alb、PAlb的變化情況;比較不同手術(shù)方式對(duì)患者術(shù)后REE、RQ及營養(yǎng)狀態(tài)的影響;分析圍手術(shù)期疼痛管理、術(shù)后疼痛程度與圍手術(shù)期REE的關(guān)系。結(jié)果:實(shí)際納入健康受試者10例,消化系統(tǒng)惡性腫瘤患者33例。在REE監(jiān)測(cè)方面,Quark RMR的實(shí)測(cè)值接近H-B公式的估測(cè)值(p0.05)。消化系統(tǒng)惡性腫瘤患者術(shù)前REE較健康人群升高(p0.05),術(shù)前RQ則低于健康人群(p0.05)。術(shù)后第2天REE較術(shù)前明顯升高(p0.05),術(shù)后第5天REE較術(shù)后初期有所下降,接近術(shù)前水平,但仍略高于術(shù)前(p0.05);術(shù)后第2天RQ較術(shù)前明顯降低(p0.05),術(shù)后第5天RQ則稍低于術(shù)前水平(p0.05);開放性手術(shù)組的變化幅度略大于腹腔鏡手術(shù)組。術(shù)后第1天Alb水平較術(shù)前降低(p0.05),但術(shù)后第4天Alb已完全恢復(fù)(p0.05);術(shù)后PAlb水平較術(shù)前進(jìn)行性下降,且下降幅度明顯(p0.05);手術(shù)方式對(duì)Alb及PAlb的變化無明顯影響。術(shù)中鎮(zhèn)痛藥物的用量與術(shù)前REE無特定關(guān)系;術(shù)后REE水平與疼痛程度呈正相關(guān),良好的術(shù)后鎮(zhèn)痛有助于患者術(shù)后恢復(fù)。結(jié)論:Quark RMR能量代謝監(jiān)測(cè)系統(tǒng)操作簡(jiǎn)便、結(jié)果可靠�；颊叩幕A(chǔ)狀況、手術(shù)方式、營養(yǎng)狀況、疼痛程度等均對(duì)消化系統(tǒng)惡性腫瘤患者圍手術(shù)期能量代謝存在影響。監(jiān)測(cè)圍手術(shù)期能量代謝情況和營養(yǎng)狀況,對(duì)評(píng)估患者基礎(chǔ)狀況、制定合理的治療方案及疼痛管理方案均有重要意義,有利于患者術(shù)后恢復(fù)。
[Abstract]:Objective: to investigate the changes of energy metabolism and nutritional status in patients with malignant tumors of digestive system during perioperative period. Methods: the patients in general surgery department of Shanghai Ruijin Hospital were selected for surgical treatment of malignant tumors of digestive system. Harris-Benedict formula (H-B formula) was used to estimate the resting energy consumption (resting energy expenditure,REE) before operation. Serum albumin (albumin,Alb) and serum prealbumin (prealbumin,PAlb) were monitored during perioperative period and resting energy consumption and respiratory entropy (respiratory quotient,RQ) were measured by Quark RMR energy metabolism monitoring system. The accuracy and reliability of Quark RMR energy metabolism monitoring system were evaluated in a healthy control group, and the difference of REE,RQ before operation between healthy people and patients with digestive system malignant tumor was compared. To analyze the changes of REE,RQ,Alb,PAlb in patients with malignant tumors of digestive system during perioperative period, to compare the effect of different operation methods on REE,RQ and nutritional status of patients after operation. To analyze the relationship between perioperative pain management, postoperative pain degree and perioperative REE. Results: 10 healthy subjects and 33 patients with malignant tumors of digestive system were included. In terms of REE monitoring, the measured value of, Quark RMR was close to the estimated value of H-B formula (p0.05). The preoperative REE of patients with digestive system malignant tumor was higher than that of healthy people (p0.05), but the preoperative RQ was lower than that of healthy people (p0.05). On the second day after operation, REE was significantly higher than that before operation (p0. 05). On the 5th day after operation, the level of REE was lower than that before operation, which was close to the preoperative level, but still slightly higher than that before operation (p0. 05). On the second day after operation, RQ was significantly lower than that before operation (p0.05), and on the 5th day after operation, the level of RQ was slightly lower than that before operation (p0.05), and the range of changes in open operation group was slightly larger than that in laparoscopic operation group. On the first day after operation, the level of Alb was lower than that before operation (p0.05), but on the 4th day after operation, the level of Alb recovered completely (p0.05), and the level of PAlb decreased progressively after operation (p0.05). The changes of Alb and PAlb were not affected by the operation method. There was no specific relationship between the dosage of intraoperative analgesic drugs and preoperative REE, but there was a positive correlation between postoperative REE level and the degree of pain. Good postoperative analgesia was helpful to the recovery of postoperative patients. Conclusion: Quark RMR energy metabolism monitoring system is simple and reliable. The basic condition, operation mode, nutritional status and pain degree of patients with malignant tumors of digestive system have influence on energy metabolism in perioperative period. Monitoring the energy metabolism and nutritional status in perioperative period is of great significance to evaluate the patients' basic condition and to formulate reasonable treatment and pain management plan, which is beneficial to the postoperative recovery of patients.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R614;R735

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