婴幼儿先天性心脏病围手术期营养风险评估及营养支持的研究

发布时间：2018-05-02 11:38

本文选题：先天性心脏病 + 营养风险评估　；参考：《南京医科大学》2015年博士论文

【摘要】：营养不良在先天性心脏病(Congenital heart disease, CHD)住院患儿中非常普遍,尤其在合并心功能衰竭、肺动脉高压等高危风险因素情况下对临床预后及患儿生长发育的影响尤其明显。如何对此类患儿进行营养风险筛查及营养支持己成为国内外研究的热点。随着手术技术及术后重症监护水平的提高,先天性心脏病手术低龄化趋势越来越明显,大多数患儿能够在婴幼儿阶段得以救治。手术时机越早,就越有利于患儿在生长发育上更早的赶上同龄儿童,但越小年龄手术,患儿所面临的各种风险包括营养风险就越高,营养支持的挑战就越大。由于国内儿科临床营养发展的滞后,CHD围手术期营养风险评估及支持尚处在起步阶段,特别是婴幼儿CHD围手术期临床营养支持的规范远远落后于发达国家。临床医务人员对CHD围手术期营养风险及营养支持重视度认识不足,尚未常规展开营养风险筛查、营养状况评估以及规范化营养支持。CHD住院患儿中营养风险比例究竟是多少尚无依据,营养支持方法不规范,很多治疗手段仅仅靠临床经验而缺乏以循诊医学方法为基础的临床验证资料。CHD患儿围手术期经常面临喂养不足或喂养过渡而导致感染,营养不良相关并发症及死亡率增加等不良结局。本研究拟通过基于儿童营养风险及发育不良筛查工具(Screening Tool for Risk on Nutritional status and Growth. Kids, STRONGKIDS)制定的营养风险评估表,研究先天性心脏病住院患儿中营养风险发生率及常见影响因素,并结合专业的营养支持团队开展早期肠内营养支持(Enteral Nutrition, EN),缩短术后禁食时间,规范喂养方式及营养配方,并与既往营养支持模式资料进行对照研究,分析C-反应蛋白、白蛋白、视黄醛蛋白、前白蛋白以及出入院体重、首次大便时间、呼吸机辅助时间、重症监护时间(intensive care unit, ICU)等临床预后指标及肠内营养支持时喂养中断次数的差异和可能对策,开展先天性心脏病围手术期静息能量代谢规律研究,通过对不同类型CHD及不同手术方式患儿术后静息能量的检测,明确CHD静息能量规律并探讨现有Harris-Benedict(H-B)公式术后能量预测的准确率进行研究,为先天性心脏病术后个性化能量供给提供理论依据。通过上述研究促进CHD围手术期营养支持和临床管理,改善患儿预后。第一部分先天性心脏病住院患儿营养风险评估目的通过营养风险评估,分析CHD围手术期营养风险特征及与临床结局的关系方法在儿童营养风险及发育不良筛查工具STRONGKIDS基础上设计我院营养风险评估表,对2010年8月—2013年4月780例CHD住院患儿进行营养风险评估,分析CHD住院患儿营养风险发生率及与年龄、肺动脉高压和营养不良的关系,研究营养风险程度对CHD临床结局的影响。结果780例CHD住院患儿(室间隔缺损[ventricular septal defect, VSD]522例、房间隔缺损[atrial septal defect, ASD]133例、法洛四联症[tetralogy of Fallot, TOF] 70例、动脉导管未闭[Patent ductus arteriosus, PDA]55例),中、重度营养风险发生率共33.3%.其中0-1岁年龄段中、重度营养风险发生率49.2%,1-3岁的26.2%和3岁以上的7.6%。所有中、重度营养风险患儿中合并肺动脉高压比例达95%(247/260)、营养不良发生率为91%(237/260)。重度营养风险术后感染发生率高达46%,而中度营养风险术后感染发生率为32%,重度营养风险患儿住院时间(12.65±6.66d vs 10.44±5.22d)和重症监护时间(3.29±2.21d vs 2.17+1.79d)均长于中度营养风险患儿。结论CHD患儿存在中、重度营养风险,并预示不良的临床结局。肺动脉高压、营养不良加重患儿营养风险。开展营养风险筛查,应成为围术期营养管理的首要步骤。第二部分：早期肠内营养支持对先天性心脏病患儿临床预后的影响第一章早期肠内营养支持对先天性心脏病围手术期临床预后的影响目的探讨早期肠内营养支持对CHD术后血、生化指标、胃肠道功能及临床结局的影响方法选取2013.10-2014.10年龄6月-1岁的50例体外循环VSD修补术后患儿,开展早期肠内营养支持,根据早期肠内营养支持方案,术后当天撤离呼吸机,拔管后6h开始EN、长期呼吸机辅助者,术后常规留置鼻-胃管并于12-24h开始EN、记录出入院体重、首次大便时间、入院和术后3天C-反应蛋白(C-reactive protein, CRP)水平、术前和出院前视黄醛蛋白(Retinoic aldehyde protein, RBP)和前白蛋白(prealbumin, Pre-ALB)水平、喂养中断次数以及ICU时间、呼吸机辅助时间等。回顾性查阅50例2010.10-2011.10年尚未常规开展早期肠内营养支持时体外循环VSD修补术后患儿资料。结果术前两组CRP均8mg/L、RBP、Pre-ALB浓度无统计学差异(P=0.68)；术后3天早期EN组CRP显著低于对照组(45.16±16.22 vs 67.32±35.45 mg/L),出院前早期EN组RBP(0.28±0.14 vs 0.18±0.11)及Pre-ALB(35.15+12.22 vs25.21±14.18)均显著高于对照组(P0.05)。与对照组相比,早期EN组出入院体重呈正向增长(0.13±0.17kg vs -0.06±0.16kg,P0.05)、首次大便时间提前(33.0±1.64h vs 56.50±1.37h,P0.05)；两组在呼吸机辅助时间、ICU时间上差异均无统计学意义(P=0.53)；肠内营养时早期EN组喂养中断次数(68次)和对照组(65次)无明显差异(P0.05)。结论早期EN促进胃肠道适应、保护胃肠粘膜、尽早恢复胃肠动力,降低术后感染几率并不增加喂养中断发生。早期肠内营养支持与ICU时间及呼吸机辅助时间无关。第二章先天性心脏病围手术期肠内营养支持中断原因的分析及对策目的调查CHD围手术期间肠内营养中断次数及并探讨临床可能的对策。方法选取2013.12-2014.12住院的360例CHD患儿,设计专业量表,统计围手术期肠内营养支持(经口或经鼻胃管饲)不同中断原因及次数,分析导致喂养中断非胃肠道因素和胃肠道因素比例及可能临床对策。结果360例CHD患儿(VSD218例、ASD89例、TOF53例),年龄1个月-6岁,有198人(55%)在肠内营养支持过程中至少有一次喂养中断,中断总次数高达498次,平均2.52次/人.其中,非胃肠道因素共355次(68%),胃肠道因素150次(28.7%),其他因素18次(3.4%)。1月-1岁患儿平均中断数1.50次/人,高于1岁以上患儿的平均中断数1.24次/人,其中又以胃肠道因素更加明显。结论CHD肠内营养支持时喂养中断以非胃肠道因素为主。低年龄患儿肠内营养时更易发生喂养中断,并以胃肠道因素为主。部分喂养中断可通过改变喂养方式、胃肠动力药物使用等减少中断次数和提高喂养量。第三部分先天性心脏病术后能量代谢规律研究目的应用静息能量代谢仪对CHD术后患儿能量代谢进行监测,探讨Harris-Benedict公式预测准确率,并明确术后能量代谢规律及影响因素。方法选择2013年8月—2014年8月50例CHD手术患儿,术后8小时血流动力学稳定状态下,应用静息能量代谢仪监测患儿静息能量值(Resting Energy Expenditure,REE),并与Harris-Benedict公式预测值(Predictive value, Pred)结果比较。REE/Pred(%)110为高代谢状态,90-110_为正常代谢状态,90为低代谢状态,记录体外循环时间、主动脉阻断时间、肌肉松弛药物使用、呼吸机辅助时间、重症监护(intensive care unit, ICU)时间等,分析影响患儿术后代谢状态的因素及不同代谢状态与临床结局的关系。结果50例CHD住院患儿(男22例,女28例)年龄6月-1岁。,非体外循环组(微创封堵VSD)10例,术后均未使用肌肉松弛药物,12小时内均停呼吸机改鼻导管吸氧；体外循环VSD修补20例、TOF矫治20例,术后均予多巴胺3-10ug/kg循环支持,部分给予肌肉松弛药物,呼吸机辅助时间24-96小时,ICU时间64-120小时。50例患儿中仅13例(26%)术后REE/Pred(%)为正常代谢,非体外循环10例术后均为高代谢；20例非紫绀型体外循环术后12例为高代谢、8例为正常代谢状态(2例使用肌肉松弛药)。体外循环法洛四联症矫治术后有8例高代谢,5例正常代谢、7例低代谢,低代谢患儿体外循环时间、主动脉阻断时间、呼吸机辅助时间及ICU时间均显著长于正常代谢和高代谢患儿,并使用过肌肉松弛药物。结论CHD术后能量代谢存在明显个体差异,Harris-Benedict公式值预测准确率较差。体外循环时间、主动脉阻断时间及术后肌肉松弛药物的使用是影响术后代谢状态的重要因素。不同代谢状态,其临床结局不同。
[Abstract]:Malnutrition is very common in children with congenital heart disease (Congenital heart disease, CHD), especially in patients with high risk factors such as heart failure, pulmonary hypertension and other risk factors. The effects of nutritional risk screening and nutritional support on these children are becoming more and more important. With the improvement of surgical techniques and postoperative intensive care, the trend of congenital heart disease operation is becoming more and more obvious, and most of the children can be treated in the infant stage. The earlier the operation time is, the more it will help the children to catch up with the same age children earlier in the growth and development, but the younger the operation, the children are operated on, the children are operated on, children are operated on children, the children are operated on, the children are operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on, the child is operated on at a smaller age. The higher the risks are, the higher the nutritional risk is, the greater the challenge for nutritional support. Due to the lag of the domestic pediatric clinical nutrition development, the nutritional risk assessment and support in the perioperative period of CHD is still in its infancy, especially the standard of clinical nutritional support in the perioperative period of CHD in infants is far behind the developed countries. The importance of nutritional risk and nutritional support in the perioperative period of CHD was insufficient. The nutritional risk screening, nutritional status assessment and the proportion of nutritional risk in the hospitalized children with standardized nutritional support.CHD were not yet based, the nutritional support method was not standardized, and many treatment methods were only based on clinical experience and lack of evidence-based diagnosis. Medical methods based clinical validation data of.CHD children are often faced with adverse outcomes such as inadequate feeding or feeding transition, resulting in malnutrition related complications and increased mortality. This study is intended to be based on a child nutritional risk and dysplasia screening tool (Screening Tool for Risk on Nutritional status and). Growth. Kids, STRONGKIDS) developed a nutritional risk assessment table to study the incidence of nutritional risk and common influencing factors in inpatient children with congenital heart disease, and to develop early enteral nutrition support (Enteral Nutrition, EN) with professional nutrition support team, shorten the time of postoperative fasting, standardize feeding methods and nutritional formula, and not only A comparative study of nutritional support model data was carried out to analyze the clinical prognostic indicators such as C- reactive protein, albumin, retinol, prealbumin and entry and exit body weight, first stool time, ventilator assisted time, intensive care unit (ICU), and the difference in the number of interruptions in enteral nutrition support and the possible countermeasures To carry out the study of resting energy metabolism in the perioperative period of congenital heart disease. Through the detection of resting energy after the operation of different types of CHD and different surgical methods, the law of resting energy of CHD was clearly defined and the accuracy of the energy prediction after the operation of the existing Harris-Benedict (H-B) formula was investigated in order to individualize after operation of congenital heart disease. To provide theoretical basis for quantity supply. Through these studies, the nutritional support and clinical management of CHD perioperative period were promoted to improve the prognosis of children. The first part of the nutritional risk assessment of inpatients with congenital heart disease was assessed by nutritional risk assessment, and the nutritional risk characteristics of CHD perioperative period and the relationship with clinical outcome were analyzed in the nutritional risk of children. The nutritional risk assessment table was designed on the basis of the dysplasia screening tool STRONGKIDS, and 780 cases of CHD hospitalized children from August 2010 to April 2013 were evaluated. The incidence of nutritional risk in CHD hospitalized children and the relationship with age, pulmonary hypertension and malnutrition were analyzed. The effect of nutritional risk on the clinical outcome of CHD was studied. Results 780 cases of CHD hospitalized children (ventricular septal defect [ventricular septal defect, VSD]522 case, atrial septal defect [atrial septal defect, ASD]133 cases, [tetralogy of Fallot of tetralogy of Fallot, 70 cases, patent ductus arteriosus), the incidence of severe nutritional risk was 0-1 years old In the segment, the incidence of severe nutritional risk was 49.2%. In all 7.6%., 1-3 years of age 26.2% and over 3 years old, the proportion of pulmonary hypertension in children with severe nutritional risk was 95% (247/260), the incidence of malnutrition was 91% (237/260). The incidence of postoperative infection was 46%, and the incidence of postoperative infection was 32% and severe battalion. The hospitalization time (12.65 + 6.66d vs 10.44 + 5.22d) and intensive care time (3.29 + 2.21d vs 2.17+1.79d) were longer than those of moderate nutrition risk children. Conclusion the severe nutritional risk in children with CHD is in the presence of severe nutritional risk, and indicates poor clinical outcome. Pulmonary hypertension and nutritional risk are not aggravated. Nutritional risk screening should be carried out. The primary step for perioperative nutrition management. The second part: the effect of early enteral nutrition support on the clinical prognosis of children with congenital heart disease: Chapter 1 the effect of early enteral nutrition support on the clinical prognosis of congenital heart disease in order to explore the blood, biochemical index, gastrointestinal function and function of early enteral nutrition support after CHD The method of influence of clinical outcome was selected in 50 cases of 2013.10-2014.10 age -1 years old in June after VSD repair. Early enteral nutrition support was carried out. According to early enteral nutrition support scheme, breathing machine was evacuated on the same day after operation, 6h began EN after extubation, long ventilator assisted, postoperative routine retention of nose stomach tube and 12-24h start EN. The body weight, the first stool time, the admission and the level of C- reactive protein (C-reactive protein, CRP) 3 days after the operation, the level of Retinoic aldehyde protein, RBP and prealbumin (prealbumin, Pre-ALB) before and before the operation, the frequency of feeding interruption, ICU time, and the time of ventilator assisted were reviewed before and before the operation. 50 cases of 2010.10-2 were reviewed retrospectively. 11.10 years after 11.10 years of early enteral nutrition support, the results showed that there was no statistical difference between CRP and 8mg/L, RBP and Pre-ALB in the two groups before operation (P=0.68), and the CRP in EN group was significantly lower than that of the control group (45.16 + 16.22 vs 67.32 + 35.45 mg/L) in the early 3 days after the operation, and RBP (0.28 + 0.14 0.18 + 0.18 +) before discharge. And Pre-ALB (35.15+12.22 vs25.21 + 14.18) were significantly higher than that of the control group (P0.05). Compared with the control group, the initial body weight of the early EN group was positively increased (0.13 + 0.17kg vs -0.06 + 0.16kg, P0.05), and the first stool time was ahead of time (33 + 1.64h vs 56.50 +). The two groups had no statistical difference in the time of ventilator assistance. P=0.53; there was no significant difference between the interruption times in the early EN group (68 times) and the control group (P0.05). Conclusion early EN promoted gastrointestinal adaptation, protected gastrointestinal mucosa, resumed gastrointestinal motility as soon as possible, and decreased postoperative infection rate did not increase the occurrence of interruption in feeding. Early enteral nutrition support and ICU time and ventilator assistance The second chapter analysis and Countermeasures of the interruption of enteral nutrition support in the perioperative period of congenital heart disease. Objective to investigate the number of interruptions of enteral nutrition during CHD perioperative period and to explore the possible clinical countermeasures. Methods 360 cases of CHD children hospitalized in hospital were selected and the professional scale was designed and the perioperative enteral nutrition support (through oral administration) was statistically analyzed. The causes and times of different interruptions were analyzed, and the proportion of non gastrointestinal factors and gastrointestinal factors and possible clinical countermeasures were analyzed. Results 360 children with CHD (VSD218, ASD89, TOF53), 1 months of age -6, 198 (55%) had at least one feeding interruption in the process of enteral nutrition support, and the total number of interruptions was as high as 4 98 times, an average of 2.52 times per person. Among them, non gastrointestinal factors were 355 times (68%), gastrointestinal factors were 150 times (28.7%), other factors 18 times (3.4%).1 month -1 years old, the average interruption number was 1.50 times / people, higher than the average interruption of children over 1 years of age 1.24 / human, and the gastrointestinal factors were more obvious. Conclusion CHD enteral nutrition support when feeding interruption is not Gastroenteric factors are the main factors. The feeding interruption is more prone to enteral nutrition in children with low age, and gastrointestinal factors are the main factors. Partial feeding interruption can reduce the number of interruptions and raise the feeding amount by changing feeding mode, gastrointestinal motility drug use and so on. The third part of the energy metabolism after congenital heart disease is used to apply resting energy The metabolic apparatus was used to monitor the energy metabolism of children after CHD, to explore the accuracy of Harris-Benedict formula prediction, and to determine the energy metabolism and influence factors after operation. Methods 50 children with CHD operation from August 2013 to August 2014 were selected and the resting energy metabolic instrument was used to monitor the resting energy of the children under the 8 hour postoperative hemodynamic stability. Value (Resting Energy Expenditure, REE), and compared with the Harris-Benedict formula prediction value (Predictive value, Pred) results,.REE/Pred (%) 110 is high metabolic state, 90-110_ for normal metabolic state, 90 is low metabolic state, record cardiopulmonary bypass time, aortic obstruction time, muscle relaxation drug use, ventilator assisted time, intensive care ( Intensive care unit, ICU) time and other factors affecting the postoperative metabolic state of children and the relationship between different metabolic states and clinical outcomes. Results 50 children with CHD (22 males and 28 females) were aged -1 years old in June. 10 cases of non extracorporeal circulation group (minimally invasive VSD) were not used for muscle relaxation after operation, and the nasal breathing machine was stopped within 12 hours. Catheter oxygen inhalation; 20 cases of VSD repair in extracorporeal circulation and 20 cases of TOF correction. All of them were supported by dopamine 3-10ug/kg circulation, partially given muscle relaxation drugs, ventilator assisted time 24-96 hours, ICU time 64-120 hours in 13 cases (26%) of only 13 cases (26%) as normal metabolism, non extracorporeal circulation 10 cases were high metabolism; 20 cases were not. 12 cases were high metabolism after cyanotic cardiopulmonary bypass and 8 cases were normal metabolic state (2 cases of muscle relaxant). 8 cases of high metabolism, 5 normal metabolism, 7 low metabolism, low metabolism children's cardiopulmonary bypass time, aorta interruption time, ventilator assisted time and ICU time were significantly longer than normal generations after cardiopulmonary bypass for tetralogy of Fallot. Xie Hegao metabolized children and used muscle relaxation drugs. Conclusion there are obvious individual differences in energy metabolism after CHD, and the prediction accuracy of Harris-Benedict formula is poor. The time of cardiopulmonary bypass, aortic blocking time and the use of muscle relaxation drugs after operation are important factors affecting the postoperative metabolic state. The outcome is different.

【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R726.5

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