肠内营养在小儿外科中应用的临床研究

发布时间：2018-04-09 06:18

本文选题：小儿外科　切入点：禁食　出处：《安徽医科大学》2015年硕士论文

【摘要】：目的营养是保障人体正常生长、发育、内环境稳定、正常代谢的不可缺少的物质。小儿因其身体正处于生长发育期,对营养的需求有其特殊性；而外科患儿经常处于重度感染、创伤、手术打击等导致的应激状态中,热能消耗较快,再加上部分患儿因为自身或疾病原因不能经口摄入食物,可迅速发展为蛋白质---热能营养不良,造成机体免疫功能和重要脏器功能下降,很容易出现感染、营养相关的并发症,从而导致住院时间的延长,甚至造成死亡率的增加。因此,采取正确的方法改善营养不良,对于保证细胞代谢功能的稳定,组织、器官正常结构、功能的维持以及正常免疫功能的维持,组织、器官的愈合,疾病的康复具有极其重要的意义。目前,研究表明,肠内营养治疗(Enteral nutrition EN)可以纠正营养不良,促进胃、肠道的发育,而且其符合生理要求,并发症发生几率较少,也更经济。本研究的目的是探讨肠内营养在小儿外科中应用的可行性、价值、可靠性、适用证、优点、并发症及注意事项。方法1.回顾性分析、研究我院2007年6月至2014年2月78例采用鼻空肠营养管进行EN治疗的外科患儿的临床资料。2.营养液选择及给予方式：1岁以内的患儿,我们选择雀巢公司的蔼儿舒(主要为氨基酸、短肽)；1岁以上的患儿,我们选择雀巢公司的小百肽或Nutricia公司的能全素(主要为短肽)。给予方式,我们选择经鼻空肠管24小时持续、匀速泵入。3.评估EN治疗的耐受性指标：根据回抽的胃残余营养素的量、呕吐的次数及呕吐量、腹胀、腹痛情况、排便次数及粪便的性状、量来评估患儿在治疗过程中对EN的耐受性。4.评价营养状态的指标：收集EN治疗前及治疗后患儿的体重、血红细胞计数(redblood cell count, RBC)、血红蛋白(hemoglobin, HGB)、血清淋巴细胞计数(serum lymphocyte count, SLC)、血清白蛋白(serum albumin, SA)、前白蛋白(prealbumin, PA)、血肌酐(blood serum creatinine, BSC)、尿素氮(blood urea nitrogen, BUN)等指标,并进行对比,通过统计学分析来判断机体营养状况的改变。5.计量资料以χ±s表示,禁食前后、EN治疗前后,均采用t检验。P0.05表示差异有统计学意义,P0.01表示差异有显著统计学意义。结果1.一般资料1.1我们选取2007年6月至2014年2月78例不能经口进食而采用鼻空肠营养管进行EN治疗的患儿,年龄1天-9岁,(2.9±2.4)岁；EN治疗前体重(12.70±6.92)kg；男孩53例,女孩25例。胰腺炎22例,小肠闭锁14例,肝脏挫裂伤10例,十二指肠隔膜状狭窄9例,肝母细胞瘤5例,环状胰腺6例,十二指肠穿孔6例,食道闭锁6例。1.2 EN治疗时间78例患儿均采用鼻空肠营养管进行EN治疗,顺利完成EN治疗。EN治疗时间：7-37d(17.5±9.4)d,时间在10d内21例,10-15d的19例,15d以上的38例。1.3不良反应治疗期间6例(7.7%)出现腹泻,排便6～8次/d,每次量约50 ml/kg,大便为黄色或绿色稀水样便；4例(5.1%)出现恶心、呕吐,呕吐物为透明或黄色、绿色液体,回抽胃内残余的营养液量,为单位时间内营养液入量的1倍；5例(6.4%)出现轻微腹胀,连续两次测量腹围大于标准腹围2.5cm;6例(7.7%)轻微腹痛； 4例(5.1%)低钠、低钾；无吸入性肺炎,消化道出血等症状。2.EN前后营养指标改变我们选取78例患儿中禁食3d且未经营养治疗的39例患儿,收集其体重,血红细胞计数、血红蛋白、血淋巴细胞计数、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指标,并与禁食前比较。体重、血红细胞计数、血红蛋白、血清白蛋白、前白蛋白指标下降明显,差异具有统计学意义(P0.05)；其中,前白蛋白差异具有显著统计学意义(P0.01)；淋巴细胞计数、血肌酐、血尿素氮差异不明显,结果无统计学意义(P0.05)。选取78例经过EN治疗的患儿,对比EN治疗前及EN治疗3d后的体重、红细胞计数,血红蛋白、淋巴细胞计数、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指标。体重、红细胞计数,淋巴细胞计数、血红蛋白、血清白蛋白、血肌酐、血尿素氮指标有所变化,但差异不明显,无统计学意义(P0.05)；前白蛋白数值增加明显,差异具有显著统计学意义(P0.01)。说明短期内(3d内),EN治疗未能明显改变患儿营养状态。选取78例患儿中EN治疗时间在10d以上的57例患儿,对比禁食前及EN治疗10d后的体重、红细胞计数,血红蛋白、淋巴细胞计数、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指标。体重、红细胞计数,血红蛋白、血清白蛋白、前白蛋白指标明显增加,差异具有统计学意义(P0.05),其中红细胞计数、血红蛋白、血清白蛋白、前白蛋白指标改变具有显著统计学意义(P0.01)；淋巴细胞计数、血肌酐、血尿素氮差异不明显,结果无统计学意义(P0.05)(表8)。说明经过10d EN治疗后,患儿营养状态较EN治疗前明显改善。选取78例患儿中EN治疗时间在15d以上的38例患儿,收集其体重,血红细胞计数、血红蛋白、血淋巴细胞计数、血清白蛋白、前白蛋白、血肌酐、血尿素氮等指标,并与禁食前进行比较。体重、血清白蛋白、前白蛋白指标上升明显,差异具有统计学意义(P0.05);红细胞计数、血红蛋白、淋巴细胞计数、血肌酐、血尿素氮差异不明显,结果无统计学意义(P0.05)。说明经过EN治疗15d后,患儿营养状况有所改善,EN治疗可以为外科患儿提供足够的营养支持,保障其疾病的康复及正常的生长发育。3.治疗结果经EN支持治疗10d后,患儿营养状态改善,精神状态良好,无精神萎靡、营养不良、贫血症状,体重较治疗前有所增加,年长患儿可正常下地活动,无四肢软弱无力等症状。结论1.肠内营养在小儿外科中的应用是安全、有效的,可以为患儿提供正常生长、发育及组织修复、愈合所需的营养；促进患儿胃肠道功能恢复；促进疾病的恢复。2.严格检测各项指标,密切注意患儿呕吐、腹胀、排便情况以及有无腹痛,及时抽取胃残余量,随时调整肠内营养的配方、给予方式、速度,有助于肠内营养治疗的正常进行。3.对比、分析肠内营养治疗前后患儿体重、血红细胞计数、血红蛋白、血清淋巴细胞计数、血清白蛋白、转铁蛋白、血肌酐、血尿素氮等指标的变化,可以得出结论：肠内营养支持治疗符合患儿生理消化、吸收过程；对于维持肠粘膜屏障功能的完整性有着一定的作用；可以减少肠道内毒素的释放、菌群异位；更好地促进机体免疫机能的恢复；并发症小、安全、方便、经济。对于不能正常饮食或正常饮食不能满足营养需要的外科患儿,只要其血流动力学稳定,胃、肠功能未完全丧失,机体血流动力学平稳,就应及时进行EN支持治疗。
[Abstract]:The purpose is to protect the nutrition of the body's normal growth, development, homeostasis, indispensable for the normal metabolism of the material. In children due to their body is in the growth period, has its special nutritional requirements; and often in surgery in children with severe infection, trauma, surgical strikes as a result of stress, thermal energy consumption faster, then with some children because they can not own or the cause of the disease by oral ingestion of food, but for the rapid development of - protein energy malnutrition, resulting in immune function and organ function decline, it is prone to infection, nutrition related complications, resulting in prolonged hospitalization, even lead to increased mortality. Therefore, take the right method for improving nutrition, to ensure the stability of the metabolic function of cells, tissues, organs to maintain the normal structure and function, and maintain normal immune function of the tissue, organ Healing is of great importance for the rehabilitation of the disease. At present, the research shows that enteral nutrition therapy (Enteral nutrition EN) can correct malnutrition, promote gastric, intestinal development, and meet the physiological requirements, the incidence of complications is less, and more economical. The purpose of this study is to investigate the feasibility of enteral nutrition in pediatric surgery application value, reliability, applicability, advantages, complications and precautions. Methods Retrospective analysis of 1. studies, 78 patients with nasal jejunum nutrition tube EN treatment of children outside the clinical data of.2. nutrition selection and give way in our hospital from June 2007 to February 2014: less than 1 year old children, we choose Nestle's ailing son Shu (such as amino acids, peptides); children over the age of 1, we choose Nestle company 100 small peptide or Nutricia company nengquansu (mainly short peptide). Given the way we choose After 24 hours of continuous nj-en, tolerance index uniform pump.3. evaluation EN treatment: according to the gastric residual nutrition retraction of the voxel volume, the number and amount of vomiting, vomiting, abdominal distension, abdominal pain, defecation and fecal traits, quantity evaluation index of tolerance to.4. of EN in the evaluation of nutritional status in the course of treatment in children: children with weight EN collected before and after treatment, the red blood cell count (redblood cell, count, RBC), hemoglobin (hemoglobin, HGB), serum lymphocyte count (serum lymphocyte count, SLC), serum albumin (serum, albumin, SA), prealbumin (prealbumin, PA serum creatinine (blood), serum creatinine, BSC), blood urea nitrogen (blood urea, nitrogen, BUN) and other indicators, and compared by statistical analysis to determine the change of.5. measurement data of nutritional status for x + s said, before and after fasting, EN before and after treatment, were treated by T .P0.05 said the difference was statistically significant, P0.01 said the difference was statistically significant. Results 1. of 1.1 general data from June 2007 to February 2014 78 cases we cannot eat by mouth and children with nasal jejunal tube were treated with EN for 1 days, age -9 years old, (2.9 + 2.4); EN weight before treatment (12.70. Kg; 6.92) were 53 boys, 25 girls. 22 cases of acute pancreatitis, 14 cases of intestinal atresia, liver contusion in 10 cases, duodenal membranous stenosis in 9 cases, 5 cases of hepatoblastoma, 6 cases of annular pancreas, 6 cases of duodenal perforation, 6 cases of esophageal atresia.1.2 EN in treatment of 78 cases of patients were treated with time naso jejunal tube treated by EN completed EN treatment.EN treatment time: 7-37d (17.5 + 9.4) d, at the time of 10d in 21 cases, 19 cases of 10-15d, 6 cases of 38 cases of adverse reactions during.1.3 treatment than 15d (7.7%) diarrhea, defecation 6~8 times /d, each about 50 ml/kg shit. Yellow or green watery stool; 4 cases (5.1%) of nausea, vomiting, vomiting of transparent yellow or green liquid, to draw nutrition liquid remaining in the stomach, 1 times the amount of nutrient solution per unit time; 5 cases (6.4%) had mild abdominal distension, two consecutive times to measure more than the standard 2.5cm abdominal circumference (7.7%); 6 cases of mild abdominal pain; 4 cases (5.1%) of low sodium, low potassium; no aspiration pneumonia, gastrointestinal bleeding and other symptoms before and after.2.EN nutrition index change we selected 78 cases of fasting 3D and 39 patients without nutritional therapy, collect the weight of red blood cells count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators, and compared with fasting. Body weight, red blood cell count, hemoglobin, serum albumin, prealbumin index decreased significantly, the difference was statistically significant (P0.05); among them, prealbumin There was a statistically significant difference (P0.01); lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05). Selected 78 cases of children with EN after treatment, compared with EN before and after the treatment of 3D EN weight, red blood cell count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators. Weight, blood cell count, lymphocyte count, hemoglobin, serum albumin, serum creatinine, blood urea nitrogen index change, but the difference was not significant, no statistical significance (P0.05); prealbumin value increased significantly, the difference was statistically significant (P0.01). In the short term (3D), EN treatment did not change significantly with nutritional status. 57 cases from 78 cases of EN in children with treatment time in more than 10d, compared before and after the treatment of 10d EN fasting weight, red blood cell count, hemoglobin , lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators. Weight, blood cell count, hemoglobin, serum albumin, prealbumin index increased significantly, the difference was statistically significant (P0.05), the red blood cell count, hemoglobin, serum albumin, prealbumin index change was statistically significant (P0.01); lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05) (Table 8). After 10d EN treatment, the nutritional status of children with EN significantly improved after treatment. 38 cases from 78 cases of EN in children with treatment time in more than 15d, the collection body weight, red blood cell count, hemoglobin, lymphocyte count, serum albumin, prealbumin, serum creatinine, blood urea nitrogen and other indicators, and compared with fasting. Body weight, serum albumin, prealbumin index rose Ming Obviously, the difference was statistically significant (P0.05); red blood cell count, hemoglobin, lymphocyte count, serum creatinine, blood urea nitrogen was not significantly different, the results were not statistically significant (P0.05). After EN after 15d treatment, the nutritional status of children improved, EN treatment can provide adequate nutritional support for surgical patients, guarantee the the rehabilitation of the disease and the normal growth of.3. treatment results by EN support after 10d treatment, children with nutritional status improved, good mental state, listlessness, malnutrition, anemia, weight had increased than before treatment, older children can be normal activities without limbs and other symptoms. 1. weak and feeble conclusion the application of enteral nutrition in pediatric surgery is safe and effective, can provide children with normal growth, development and tissue repair, wound healing for children with gastrointestinal nutrition; promote functional recovery; promote disease recovery.2. Strict detection indicators, pay close attention to children with vomiting, abdominal distension, defecation and abdominal pain, timely extraction gastric residual, adjust the formula of enteral nutrition given way, speed, contribute to the normal.3. comparison of enteral nutrition therapy, analysis of body weight before and after enteral nutrition in the treatment of children, red blood cell count hemoglobin, serum, lymphocyte count, serum albumin, transferrin, serum creatinine, blood urea nitrogen and other indicators of change, we can draw the conclusion: enteral nutrition support therapy with children with physiological digestion and absorption process; has a certain role for maintaining the integrity of the intestinal mucosal barrier function; can reduce the intestinal endotoxin release of bacteria ectopic; promote immune function recovery; complication of small, safe, convenient and economic. For not the normal diet or normal diet can not meet the nutritional needs of surgical patients EN support should be carried out in time as long as the hemodynamics are stable, the function of the stomach, the intestines is not completely lost, and the hemodynamics of the body is stable.

【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R726.5;R459.3

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