南京某二级医院脑外科危重症患者营养治疗现状调查

发布时间：2018-06-15 07:06

本文选题：脑外科危重症患者 + 营养治疗　；参考：《东南大学》2017年硕士论文

【摘要】：调查目的:1.了解脑外科危重症患者营养支持治疗的应用情况。2.观察营养支持治疗前后的相关人体测量指标、生化指标以及并发症的发生情况,了解实施营养支持治疗前后患者营养状况。调查内容与方法:调查对象:以2014年6月-2015年5月在南京某二级医院脑外科接受治疗的危重症患者作为调查对象。根据纳入、排除标准,最终143例患者纳入本次调查,男性95例,女性48例。调查工具及调查内容:参照相关文献制定《脑外科危重症患者营养治疗现况调查问卷》作为研究工具,收集患者的一般资料、住院期间营养支持治疗情况、患者的营养状况、住院期间并发症发生情况、患者28天疾病转归情况等。相关指标的测定:在患者入院24小时内完成对患者一般资料的收集及相关指标的测量。患者入院24小时内、住院10天、住院21天完成人体相关指标测量包括:体重、体质指数(Body mass index,BMI)、肱三头肌皮褶厚度(Triceps skinfold thickness,TSF)、上臂肌围(Arm muscle circumference,AMC);临床生化指标:总淋巴细胞(Total lymphocyte count,TLC)、血清白蛋白(Serum albumin,ALB)。结果:1.进入调查序列的脑外科危重症患者143例,以青壮年居多,平均年龄为48.31 ±15.77岁;其中,男性95例,女性48例;入院时体质指数为22.61±3.63;营养风险筛查2002(Nutritional Risk Screening-2002,NRS 2002)严重程度评分均大于3分。患者住院原因:车祸92例(64.34%)、高处跌落26例(18.18%)、重物击打16例(11.19%)、不慎跌倒9例(6.29%);入院诊断:硬膜下血肿29例(20.28%)、硬膜外血肿34例(23.78%)、脑挫裂伤42例(29.37%)、颅内血肿11例(7.69%)、原发性脑干损伤13例(9.09%)、复合血肿14例(9.79%)。平均住院天数:22.87±9.89天,28天病死率 16 例(11.19%)。2.患者住院的前48小时内均为禁食状态,根据患者情况采用全肠外营养支持(Total enteral nutrition,TPN)辅助治疗;入院48小时之后的营养支持治疗方案有以下两种:应用全肠内营养支持(Total enteral nutrition,TEN)的有97例(67.83%),应用肠内营养支持治疗(Enteral nutrition,EN)联合肠外营养支持治疗(Parenteral nutrition,PN)营养支持的有46例(32.17%)。EN营养制剂选用的是能全力+白普利;PN营养制剂选用脂肪乳、卡文、人血清白蛋白、血浆、全血等,主要是根据病人情况选用其中的一种或联合运用。EN营养支持途径选用的是经鼻胃管或经鼻胃肠管,92.31%的患者选用经鼻胃管的方式实施EN。对应用EN的患者均实施了胃残余量的监测,胃残余量的临界值为150mL。因为胃残余量被迫中断EN的患者有31例(21.68%)。有胃残余的31例患者中19例(61.29%)未应用胃动力药;无胃残余的112例患者中34例(30.36%)应用胃动力药。住院期间,19例患者出现血糖波动需进行血糖监测,其中EN组6例、EN+PN组13例。3.应用TEN营养支持,平均EN提供能量为目标能量的52.43%;应用EN联合PN营养支持,住院期间平均EN+PN提供能量为目标能量的35.57%及69.85%。应用TEN支持平均EN提供的蛋白质是目标蛋白质的38.47%。在入院的24小时内、10天、21天各时间节点分别对患者营养相关指标进行检测包括人体测量指标(BMI、TSF、AMC)及生化指标(ALB、TLC)。结果显示:EN组与EN+PN组入院24小时内各项指标间无显著性差异,且无严重营养不良病例。住院第10天时两组在AMC上具有差异性(t=2.314,p=0.024);住院21天时EN组的各项指标仍继续下降,而EN+PN组的TSF、AMC虽然继续下降,但ALB、TLC呈现回升趋势,两组在TSF(t=2.328,p=0.023),AMC(t=2.368,p=0.021),ALB(t=2.412,p=0.016),TLC(t=2.335,p=0.022)比较差异均有统计学意义。EN组与EN+PN组在临床并发症及临床最终结局方面的统计学比较无显著性差异p0.05,但是EN组并发症发生率为41.23%,28天病死率为13.40%;EN+PN组并发症发生率为30.43%,28天病死率为6.52%,EN组在并发症及病死率方面从数据上比较要高于EN+PN组。结论:本研究所调查医院的脑外科危重症患者以青壮年居多,男性多于女性。外伤为主要住院原因,住院周期较长,病死率较高。该医院脑外科危重症患者住院期间营养支持治疗已得到医护人员的高度重视,营养支持治疗方案的制定及实施逐步趋向标准化;但与2009年成人危重症患者营养支持治疗与评估指南推荐方案(Adult critically ill patients nutritional support treatment and assessment guidelines recommend the program,CPG)相对照,在对患者的营养支持治疗规范性方面仍存在一定的差距:早期肠内营养开始时机不规范,2009年CPG推荐肠内营养应在患者入院后24-48小时内开始(C级推荐)。EN存在供给不足和累积能量摄入的缺乏。EN+PN组在能量供给方面比EN组更充足,在改善患者营养状况方面EN+PN组优于EN组。对危重症患者而言,及时充足的营养支持对患者的治疗及预后至关重要,在EN提供能量相对不足的情况下,根据患者实际情况适当给予PN辅助治疗可以保证营养及能量的供给,能达到较好的治疗效果。
[Abstract]:Objective: 1. to understand the application of nutritional support therapy for critically ill patients in the Department of cerebral surgery.2. observation of the related anthropometric indicators, biochemical indexes and the occurrence of complications before and after nutritional support treatment, and to understand the nutritional status of patients before and after nutritional support treatment. The contents and methods of investigation were: in June 2014, May, May In the Department of cerebral surgery, a two level hospital in Nanjing, the critically ill patients treated in the Department of cerebral surgery were investigated. According to the inclusion and exclusion criteria, the final 143 patients were included in this survey, 95 men and 48 women. The general information of the patients, the nutritional support treatment, the nutritional status of the patients, the incidence of complications during the hospitalization, the patient's 28 day prognosis, and so on. The measurement of the related indexes: the general data collection and the measurement of the related indexes were completed within 24 hours of admission to the hospital, and the patient was admitted to hospital for 24 hours and stayed in hospital for 10 days. 21 days to complete the measurement of human body related indicators, including body weight, body mass index (Body mass index, BMI), brachial triceps skin fold thickness (Triceps skinfold thickness, TSF), upper arm muscle circumference (Arm muscle circumference, AMC); clinical biochemical indicators: total lymphocyte (BMI), serum albumin. In the Department of cerebral surgery, 143 cases of critically ill patients were investigated in the Department of cerebral surgery, with the average age of 48.31 + 15.77 years old, including 95 males and 48 females, and 22.61 + 3.63 at admission; the severity scores of nutritional risk screening 2002 (Nutritional Screening-2002, NRS 2002) were more than 3. Patients were hospitalized: accident accident 92 cases (64.34%), 26 cases (18.18%), 16 cases (11.19%) and 9 cases (6.29%) with heavy weight, 29 cases of subdural hematoma (20.28%), 34 cases of epidural hematoma (23.78%), 42 cases of cerebral contusion and laceration (29.37%), intracranial hematoma 11 cases (7.69%), primary brain stem injury cases and complex hematoma. The death rate of 16 (11.19%).2. patients was fasting in the first 48 hours of hospitalization, with total parenteral nutrition support (Total enteral nutrition, TPN) assisted treatment according to the patient's condition; there were two nutritional support treatments after admission for 48 hours: 97 cases (67.83%) used total enteral support (Total enteral nutrition, TEN). Enteral nutrition, EN (EN) combined with parenteral nutrition support therapy (Parenteral nutrition, PN) nutrition support in 46 cases (32.17%).EN nutrition preparation is the choice of full plus white plali; PN nutrition preparation of fat milk, Kevin, human serum albumin, plasma, whole blood and so on, mainly according to the patient's condition selected among them One or combined use of.EN nutrition support pathway is through nasal gastric tube or transnasal gastrointestinal tube. 92.31% patients perform EN. monitoring of gastric remnants in patients with EN using nasal gastric tube, and the critical value of gastric remnants is 31 (21.68%) patients who have been forced to interrupt EN because of the residual gastric remnants. There are gastric remnants. Of the 31 patients, 19 cases (61.29%) did not use gastric motility medicine; 34 of the 112 patients without gastric remnants (30.36%) applied gastric motility medicine. During the period of hospitalization, 19 patients had blood glucose monitoring, including 6 cases in group EN, 13.3. in group EN+PN, and 52.43% with TEN for 52.43% of the target energy, and EN combined with PN nutrition. The average EN+PN provided energy for 35.57% and 69.85%. for target energy during hospitalization. The protein provided by TEN for the average EN was the 38.47%. of the target protein in the 24 hours of admission, 10 days, and 21 days in each node, respectively, to detect the nutritional indicators of the patients, including the anthropometric indicators (BMI, TSF, AMC) and biochemical indicators (ALB, TLC). The results showed that there was no significant difference between the EN group and the EN+PN group within 24 hours, and there was no serious malnutrition. The two groups in the two groups were different (t=2.314, p=0.024) on the tenth day of hospitalization, and the indexes of the EN Group continued to decline at 21 days of hospitalization, while TSF in the EN+PN group, although AMC continued to decline, showed a rising trend of ALB, TLC, two There was no significant difference between the groups at TSF (t=2.328, p=0.023), AMC (t=2.368, p=0.021), ALB (t=2.412, p=0.016), TLC (t=2.335, p=0.022), and there was no significant difference in clinical complications and clinical outcome, but the incidence of complications was 41.23%, and the mortality rate was 13.40% at 28 days. The incidence of complications was 30.43%, and the mortality rate of 28 days was 6.52%. In group EN, the complications and fatality rates were higher than that in group EN+PN. Conclusion: the critical patients in the Department of cerebral surgery investigated in this study were mostly in young Zhuang years and more males than women. Nutritional support therapy for critically ill patients has been highly valued by medical and nursing staff, and the formulation and implementation of nutritional support treatment schemes are gradually standardized. However, the recommendation for nutritional support treatment and assessment guidelines for adult critical patients in 2009 (Adult critically ill patients nutritional support treatment and assessmen) T guidelines recommend the program, CPG) relative illumination, there is still a certain gap in the standard of nutritional support treatment for patients: early enteral nutrition start time is not standardized. In 2009, CPG recommended enteral nutrition should begin within 24-48 hours after admission (C level recommended).EN there is a lack of supply and accumulation of energy intake.EN+P. Group N is more abundant in energy supply than group EN, and group EN+PN is superior to group EN in improving the nutritional status of patients. For critically ill patients, adequate and adequate nutritional support is essential for the treatment and prognosis of the patients. In the case of relative insufficient energy of EN, appropriate PN adjuvant therapy according to the patient's actual situation can guarantee nutrition. And energy supply can achieve better therapeutic effect.
【学位授予单位】：东南大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R651.11;R459.3

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