胰十二指肠切除术患者围手术期营养支持管理方案的构建与应用

发布时间：2018-01-21 01:11

本文关键词： 胰十二指肠切除术循证实践营养支持 KTA模式　出处：《第二军医大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的本研究旨在构建胰十二指肠切除术患者(pancreaticoduodenectomy,PD)围手术期营养支持管理方案并验证其临床应用效果,以期促进证据转化,提高PD患者围手术期营养支持质量,促进患者康复。具体研究目的包括:(1)评鉴、综合PD患者围手术期营养支持循证证据并选取适用于引入临床实践的证据;(2)描述PD患者围手术期营养支持现状,分析利益相关人群(医生、护士、营养师、管理者)感知的循证实践的阻碍与促进因素以及患者对围手术期营养支持的体验与需求;(3)构建PD患者围手术期营养支持管理方案;(4)评价该方案的临床应用效果。方法以KTA证据行为转化模式为概念框架,通过对国内外围手术期营养支持的指南评价、PD患者围手术期营养支持的相关系统评价再评价以及PD患者术前营养评价工具的研究,获得PD患者围手术期营养支持的最佳证据;通过专家会议法选取适合引入临床实践的证据并建立审查标准;通过参与式观察与质性研究评估试点病房证据应用的促进及阻碍因素,最佳证据与临床实践之间差距;通过专家会议法构建PD患者围手术期营养支持管理方案,有针对性消除障碍因素;通过医护人员自身前后对照试验研究和PD患者非同期前后对照研究获得干预方案的应用效果。结果1.通过系统的证据检索,共纳入5部围手术期营养支持指南;同时通过术前营养评估工具的研究,即应用NRS2002、PG-SGA、NRI、PNI、BMI5种营养评价工具评价100例PD患者术前营养状况,获得NRS2002、PG-SGA与患者术后结局、实验室营养指标相关,且对术后并发症具有中度诊断价值,PD患者术前拟优先选用NRS2002评分,再结合使用PG-SGA评估,最终评鉴、汇总出PD患者围手术期营养支持现有的最佳证据。2.通过专家会议法获得PD患者围手术期营养支持最佳证据五个模块,即术前营养评价、术前营养支持、术后营养支持、营养制剂、营养管理模式,共9条证据,并制定了7条实践审查标准。3.试点病房的围手术期营养支持的临床实践与最佳证据之间存在较大差距,循证实践受诸多因素影响。3.1试点病房循证实践的现况:审查标准执行情况不佳,缺乏规范的营养管理制度及流程。3.2通过15名医务人员半结构式访谈,获得循证实践的阻碍因素,包括证据、应用过程、组织管理、患者、医生因素,促进因素包括营养专项培训、建立多学科协作的营养小组、制定规范的营养管理制度、取得领导层的支持。3.3通过10例pd患者围手术期营养支持体验的质性研究,获得该类患者术后面临饮食压力和管饲营养的痛苦,渴望专业、延续的营养指导,临床医务人员应重视该类患者围手术期营养,采用多学科合作的营养支持小组模式,强化营养教育,促进患者参与自我营养管理。4.通过专家会议法构建pd患者围手术期营养支持管理方案,包括围手术期营养支持管理规范、围手术期营养支持流程、营养支持小组管理模式、营养支持辅助文本以及能量计算软件。并制定方案实施计划,通过营养培训、领导宣讲与支持,分阶段推进方案实施,逐步将证据引入临床。5.方案的实施与效果评价5.1方案的实施:方案于2016年9月启动,通过三个阶段,即人员培训阶段、方案试运行阶段、方案应用阶段,循序渐进地将pd围手术期营养支持相关证据应用到临床营养管理系统中。5.2效果评价5.2.1采用自身前后对照研究,获得试点病房医护人员干预前(2016年5月~8月)、干预后(2016年9月~2017年1月)各审查标准的执行情况,结果显示在5个月的干预期间,干预组医护人员的各审查标准执行率显著高于对照组(p0.05)。5.2.2采用非同期对照研究,获得试点病区干预前53例pd患者、干预后47例pd患者临床结局指标比较情况[两组患者基线一致(p≥0.05)],结果显示干预后患者的术后住院天数、总住院天数较干预前缩短,并发症的发生率较干预前减少,住院期间患者体重下降值、医疗费用较干预前减少(p0.05)。两组患者术后第1、3、7天总蛋白、前白蛋白、白蛋白值差异无统计学意义(p0.05)。术后第1天总胆红素值较干预前降低(p0.05),术后第1、3、7天总胆红素值差异无统计学意义(p0.05)。5.2.3医务人员在方案实施过程中经历了怀疑与期待、磨合与主动、反思与创新的体验历程,来自组织层面的督促、激励、约束与强化,有利于提高医护人员对方案的依从性,激发其创造力。结论1.本研究汇总了pd患者围手术期营养支持最佳证据,内容包括术前适宜的营养评价工具nrs2002和pg-sga、术前营养支持、术后营养支持、营养制剂选择、营养管理模式五个模块,旨在为pd患者围手术期营养支持提供参考依据。2.本研究应用KTA知识转化模式开展PD患者围手术期营养支持循证实践,通过确定问题、证据综合、裁剪形成符合利益相关人群需要的证据并引入临床,分析障碍因素及促进策略,构建管理方案引入证据并实施监测与评价,有效促进了证据转化,缩短了证据与实践的差距。3.本研究构建的PD患者围手术期营养支持管理方案,是建立在循证基础上,考虑了临床情境及患者需求,具有较好的可行性和有效性。
[Abstract]:The purpose of this study was to construct pancreatoduodenectomy patients (pancreaticoduodenectomy, PD) of perioperative nutritional support management scheme and verify its clinical effect, in order to promote the transformation of PD evidence, improve the perioperative nutritional support in patients with quality, promote the rehabilitation of the patients. The main contents include: (1) evaluation, comprehensive perioperative PD nutrition support evidence for selection and introduced into clinical practice evidence; (2) to describe the PD of perioperative nutritional support in patients with the status quo, analysis of stakeholder groups (doctors, nurses, nutritionists, managers) aware of evidence-based practice and promote patients to hinder factors and around the experience and demand of nutritional support the period of operation; (3) to construct the PD of perioperative nutritional support in patients with management scheme; (4) to evaluate the clinical effects of the scheme. Methods KTA behavior transformation model as the conceptual framework of evidence, through to the domestic and external Guide for the evaluation of perioperative nutritional support in patients with PD related research, evaluation system of peri operative nutrition support and re evaluation of PD patients with preoperative nutritional evaluation tools, to obtain the best evidence of peri operative nutrition support in patients with PD; selected by the expert meeting for the introduction of clinical practice of evidence and establish the standard of review; through participation observation and qualitative evaluation factors that hinder and promote the pilot ward evidence application, the gap between the best evidence and clinical practice; to construct the PD of perioperative nutritional support in patients with management scheme through expert meeting method, to eliminate obstacles; the medical staff through self controlled non synchronous control study before and after the intervention in patients with application effect experimental study and PD. Results 1. through systematic evidence retrieval, included 5 perioperative nutrition support guidelines; at the same time through preoperative nutritional assessment The research tools, namely the application of NRS2002, PG-SGA, NRI, PNI, BMI5 nutrition evaluation tool to evaluate 100 cases of PD patients with preoperative nutritional status, NRS2002, PG-SGA and outcome of patients after surgery, laboratory of nutrition indicators related, and has moderate diagnostic value of postoperative complications in PD patients, preoperative NRS2002 score to be preferred then, combined with the use of PG-SGA evaluation, the final evaluation, summarize the PD of perioperative nutritional support in patients with the best available evidence obtained by expert PD.2. of perioperative nutritional support in patients with the best evidence of five modules, namely the preoperative nutrition evaluation, preoperative nutrition support, nutritional support, postoperative nutrition, nutrition model a total of 9 lines of evidence management, and to develop, there is a big gap between the 7 practice examination standard.3. pilot unit of perioperative nutritional support in clinical practice and the best evidence, evidence-based practice is influenced by many factors in.3.1 wards The status of evidence-based practice: review of the implementation of standards is poor, lack of standardized nutrition management system and process of.3.2 by medical personnel from 15 semi-structured interviews, obtained the hindering factors, including evidence of evidence-based practice, application process, organization management, patient, doctor factors, promoting factors including nutrition training, establishing nutrition group multidisciplinary collaboration, develop nutrition standardized management system, to obtain the support of the leadership of.3.3 by PD in 10 cases of perioperative nutritional support in patients with a qualitative study on diet, pressure and feeding the pain, face to obtain this kind of patients for professional, nutritional guidance continues, clinical staff should pay attention to peri operative nutrition of the patients, the nutritional support group model of multi subject cooperation, strengthen nutrition education, promote the patients to participate in self nutrition management of.4. through the expert meeting method. Perioperative PD patients Nutrition management scheme, including the perioperative nutrition management norms, perioperative nutrition support process, nutrition support team management, nutritional support aided text and energy calculation software. And formulate the implementation plan, through nutrition training, leadership and preaching support, in phases to promote the implementation of the program, will gradually implement the implement and evaluation the evidence into clinical.5. program 5.1 program: program started in September 2016, through three stages, namely the stage of personnel training, project commissioning phase, project application stage, step by step to PD perioperative nutrition support evidence evaluation to the.5.2 effect of clinical nutrition management system 5.2.1 by self control study, to obtain pilot ward medical staff before intervention (May 2016 ~8 months), intervention (September 2016 ~2017 January) implementation of the standard of review, the results show in 5 During the months of intervention, the intervention group of medical personnel the examination standard implementation rate was significantly higher than the control group (P0.05).5.2.2 using asynchronous control study, to obtain pilot wards before intervention in 53 PD patients, 47 PD patients after clinical outcomes compared two groups of patients [consistent baseline (P = 0.05). The results showed that after the intervention of patients with postoperative hospitalization days, total hospital stay shorter than that before the intervention, the incidence of complications compared with before intervention, patients with weight loss, reduce the medical expenses than before intervention (P0.05). The two groups of patients with Shu Houdi 1,3,7 days before the total protein, albumin, albumin values were not statistically different (P0.05). After first days of total bilirubin decreased significantly (P0.05), 1,3,7 days after operation there was no significant difference in total bilirubin (P0.05).5.2.3 medical personnel in the program implementation process through doubt and look forward to, and the main running Experience, reflection and innovation, from the organizational level of supervision, incentive, constraint and strengthening, is conducive to improve the compliance of medical staff on the plan, to stimulate their creativity. Conclusions: 1. this study summarizes the PD of perioperative nutritional support in patients with the best evidence, including preoperative appropriate nutritional evaluation tools of nrs2002 and pg-sga nutritional support, preoperative, postoperative nutritional support, nutrition, nutrition management model of five modules, in order to provide reference on the application of KTA.2. knowledge transformation model to support nutrition PD patients in the perioperative period in PD patients perioperative nutritional support of evidence-based practice, the problem of determining evidence synthesis, cutting forming in line with the interests of those in need of evidence and the introduction of clinical analysis of obstacle factors and promotion strategies, the construction management plan and implement the monitoring and evaluation of evidence into the evidence, effectively promote the transformation, shorten the The gap between evidence and practice.3. the perioperative nutrition support management plan of PD patients in this study is based on evidence-based consideration of clinical situations and patient needs, and has good feasibility and effectiveness.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.6

【参考文献】