楊鑫

腦卒中早期腸內(nèi)營(yíng)養(yǎng)對(duì)于患者營(yíng)養(yǎng)健康和預(yù)后的影響

楊鑫

目的 探討對(duì)腦卒中患者施以早期腸內(nèi)營(yíng)養(yǎng)方案對(duì)其營(yíng)養(yǎng)健康水平與預(yù)后的影響。方法 134例腦卒中患者依照不同營(yíng)養(yǎng)支持方式分為常規(guī)營(yíng)養(yǎng)組與腸內(nèi)營(yíng)養(yǎng)組,各67例?；诨A(chǔ)護(hù)理,常規(guī)營(yíng)養(yǎng)組采取常規(guī)鼻飼流質(zhì)飲食的方法,腸內(nèi)營(yíng)養(yǎng)組基于常規(guī)營(yíng)養(yǎng)組的治療方案采取早期免疫腸內(nèi)營(yíng)養(yǎng),在入院1、14 d后,比較兩組營(yíng)養(yǎng)指標(biāo)水平［血清白蛋白(ALB)、血紅蛋白(HGB )、血清總蛋白(TP)、轉(zhuǎn)甲狀腺素蛋白(TTR)］、格拉斯哥昏迷評(píng)分法(GCS)評(píng)分。結(jié)果 經(jīng)營(yíng)養(yǎng)指標(biāo)檢測(cè),入院1 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(38.71±4.97)g/L、HGB(134.79±12.48)g/L、TP(68.64±5.13)g/L、TTR(254.16±23.15)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(38.82±4.25)g/L、HGB(134.52±11.85)g/L、TP(68.26±5.21)g/L、TTR(254.42±22.95)mg/L；入院1 d后兩組各項(xiàng)營(yíng)養(yǎng)指標(biāo)比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(36.84±3.15)g/L、HGB(129.12±11.05)g/L、TP(66.74±4.59)g/L、TTR(289.74±23.84)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(32.74±2.41)g/L、HGB(113.74±10.42)g/L、TP(61.41±4.15)g/L、TTR(236.46±22.76)mg/L；腸內(nèi)營(yíng)養(yǎng)組入院14 d后各項(xiàng)營(yíng)養(yǎng)指標(biāo)與入院1 d后比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05),常規(guī)營(yíng)養(yǎng)組各項(xiàng)營(yíng)養(yǎng)指標(biāo)水平則顯著低于入院1 d后和同時(shí)間的腸內(nèi)營(yíng)養(yǎng)組(P＜0.05)。入院1 d后,腸內(nèi)營(yíng)養(yǎng)組GCS中評(píng)分言語(yǔ)反饋(2.31±0.17)分,睜眼功能(2.71±0.18)分,肢體動(dòng)作(3.16±0.14)分,總分(8.18±1.56)分；常規(guī)營(yíng)養(yǎng)組中言語(yǔ)反饋(2.32±0.25)分,睜眼功能(2.59±0.19)分,肢體動(dòng)作(3.12±0.15)分,總分(8.03±1.47)分；入院1 d后兩組GCS各項(xiàng)評(píng)分及總分比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組GCS中評(píng)分言語(yǔ)反饋(3.98±0.15)分,睜眼功能(3.57±0.24)分,肢體動(dòng)作(4.04±0.27)分,總分(11.59±2.13)分；常規(guī)營(yíng)養(yǎng)組中言語(yǔ)反饋(2.24±0.11)分,睜眼功能(2.94±0.21)分,肢體動(dòng)作(3.37±0.23)分,總分(8.55±2.06)分；腸內(nèi)營(yíng)養(yǎng)組入院14 d后GCS各項(xiàng)評(píng)分及總分較入院1 d后顯著上升,且顯著高于同時(shí)間常規(guī)營(yíng)養(yǎng)組的評(píng)分,差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。結(jié)論 早期腸內(nèi)營(yíng)養(yǎng)支持可維持腦卒中所需的營(yíng)養(yǎng)水平,對(duì)患者預(yù)后意識(shí)及感官恢復(fù)有所幫助,是針對(duì)腦卒中患者可行性高的營(yíng)養(yǎng)方案。

腦卒中；早期腸內(nèi)營(yíng)養(yǎng)；鼻飼

由于腦卒中患者應(yīng)激反應(yīng)較為高亢,能量代謝分解亢進(jìn),處于胰島素抵抗的狀態(tài),蛋白的分解量多過(guò)合成量,造成脂肪與糖代謝紊亂,容易合并低蛋白血癥、負(fù)氮平衡等病情。且多數(shù)腦卒中患者具有吞咽困難、難以進(jìn)食的特征,造成免疫能力下降、營(yíng)養(yǎng)狀態(tài)惡化,從而使多器官受到損傷或神經(jīng)系統(tǒng)病情惡化,加劇致死率［1-6］。為此,如何為腦卒中患者實(shí)施營(yíng)養(yǎng)支持成為護(hù)理過(guò)程中不容忽視的環(huán)節(jié)。本院對(duì)于腦卒中患者的營(yíng)養(yǎng)護(hù)理干預(yù)主要有常規(guī)流質(zhì)飲食鼻飼與早期腸內(nèi)營(yíng)養(yǎng)支持兩種方案,通過(guò)分析不同營(yíng)養(yǎng)支持方式對(duì)腦卒中患者營(yíng)養(yǎng)指標(biāo)、免疫指標(biāo)及預(yù)后的影響,旨在研究出早期腸內(nèi)營(yíng)養(yǎng)支持對(duì)腦卒中患者的健康與預(yù)后影響,現(xiàn)總結(jié)如下。

1 資料與方法

1.1 一般資料 選取本院2014年7月～2016年7月接診的腦卒中住院患者134例,依照不同營(yíng)養(yǎng)支持方式分為常規(guī)營(yíng)養(yǎng)組與腸內(nèi)營(yíng)養(yǎng)組,各67例。常規(guī)營(yíng)養(yǎng)組患者平均年齡(63.51±10.18)歲,女男比39：28；腸內(nèi)營(yíng)養(yǎng)組患者平均年齡(64.07±11.24)歲,女男比35:32。納入標(biāo)準(zhǔn)［7］：①患者年齡＜80歲；②經(jīng)頭部影像學(xué)證實(shí)；③達(dá)到第四屆腦血管學(xué)會(huì)確立的標(biāo)準(zhǔn)［8］；④發(fā)病24 h內(nèi)就診；⑤首次發(fā)病,病程＜5 d。排除標(biāo)準(zhǔn)［9］：①對(duì)營(yíng)養(yǎng)液過(guò)敏者；②合并消化道病變者；③患重度心腎疾病者；④有先天性代謝障礙者；⑤干預(yù)周期內(nèi)死亡者；⑥干預(yù)期內(nèi)服用過(guò)血壓、神經(jīng)抑制藥物者。兩組患者性別、年齡等一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05),具有可比性。

1.2 治療及營(yíng)養(yǎng)支持方法

1.2.1 常規(guī)營(yíng)養(yǎng)組 患者按照腦卒中治療方法,滴注抗血小板聚集的藥物或酌情手術(shù)治療,以達(dá)到減輕顱內(nèi)壓、維持腦血管循環(huán)的目的,基于此,加用院方或家屬配置的勻漿流質(zhì)食物,例如雞蛋湯、米湯、奶制品等。每鼻飼200 ml/次,5次/d。14 d為1個(gè)療程。

1.2.2 腸內(nèi)營(yíng)養(yǎng)組 基于常規(guī)營(yíng)養(yǎng)組的治療方案,于入院48 h內(nèi)施行腸內(nèi)營(yíng)養(yǎng)乳劑(TP-HE,華瑞制藥有限公司,國(guó)藥準(zhǔn)字H20056603)腸內(nèi)營(yíng)養(yǎng)支持,結(jié)合患者體重,按照30 ml/(kg·d)標(biāo)準(zhǔn)給予。密切監(jiān)測(cè)患者胃酸,如胃酸超量至200 ml,則拔除鼻飼管2 h。每個(gè)療程14 d。

1.3 觀(guān)察指標(biāo) 營(yíng)養(yǎng)指標(biāo)：以入院1、14 d后為不同觀(guān)察節(jié)點(diǎn),觀(guān)測(cè)患者營(yíng)養(yǎng)指標(biāo)變化：ALB(具維持膠體滲透壓及保護(hù)作用)；HGB (具傳氧作用)；TP(具運(yùn)輸代謝物,維持酸堿度等功能)；TT(具運(yùn)載維生素A的功能)。GCS評(píng)分［10］：依照患者言語(yǔ)反饋(5分),睜眼功能(4分),肢體動(dòng)作(6分),綜合評(píng)定患者意識(shí)水準(zhǔn),分值越高,意識(shí)狀態(tài)越好。

1.4 統(tǒng)計(jì)學(xué)方法 采用SPSS22.0統(tǒng)計(jì)學(xué)軟件進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示,采用t檢驗(yàn)；計(jì)數(shù)資料采用χ2檢驗(yàn)。P＜0.05表示差異具有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 營(yíng)養(yǎng)指標(biāo) 經(jīng)營(yíng)養(yǎng)指標(biāo)檢測(cè),入院1 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(38.71±4.97)g/L、HGB(134.79±12.48)g/L、TP(68.64± 5.13)g/L、TTR(254.16±23.15)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(38.82± 4.25)g/L、HGB(134.52±11.85)g/L、TP(68.26±5.21)g/L、TTR(254.42±22.95)mg/L；入院1 d后兩組各項(xiàng)營(yíng)養(yǎng)指標(biāo)比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(36.84±3.15)g/L、HGB(129.12±11.05)g/L、TP(66.74± 4.59)g/L、TTR(289.74±23.84)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(32.74± 2.41)g/L、HGB(113.74±10.42)g/L、TP(61.41±4.15)g/L、TTR(236.46± 22.76)mg/L；腸內(nèi)營(yíng)養(yǎng)組入院14 d后各項(xiàng)營(yíng)養(yǎng)指標(biāo)與入院1 d后比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05),常規(guī)營(yíng)養(yǎng)組各項(xiàng)營(yíng)養(yǎng)指標(biāo)水平則顯著低于入院1 d后和同時(shí)間的腸內(nèi)營(yíng)養(yǎng)組(P＜0.05)。2.2 GCS評(píng)分 入院1 d后,腸內(nèi)營(yíng)養(yǎng)組GCS評(píng)分中言語(yǔ)反饋(2.31±0.17)分,睜眼功能(2.71±0.18)分,肢體動(dòng)作(3.16± 0.14)分,總分(8.18±1.56)分；常規(guī)營(yíng)養(yǎng)組言語(yǔ)反饋(2.32± 0.25)分,睜眼功能(2.59±0.19)分,肢體動(dòng)作(3.12±0.15)分,總分(8.03±1.47)分；入院1 d后兩組GCS各項(xiàng)評(píng)分及總分比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組GCS評(píng)分中言語(yǔ)反饋(3.98±0.15)分,睜眼功能(3.57±0.24)分,肢體動(dòng)作(4.04±0.27)分,總分(11.59±2.13)分；常規(guī)營(yíng)養(yǎng)組言語(yǔ)反饋(2.24±0.11)分,睜眼功能(2.94±0.21)分,肢體動(dòng)作(3.37±0.23)分,總分(8.55±2.06)分；腸內(nèi)營(yíng)養(yǎng)組入院14 d后GCS各項(xiàng)評(píng)分及總分較入院1 d后顯著上升,且顯著高于同時(shí)間常規(guī)營(yíng)養(yǎng)組的評(píng)分,差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。

3 討論

腦卒中患者常存在吞咽困難,不僅加大了護(hù)理難度,且長(zhǎng)期惡化,會(huì)形成營(yíng)養(yǎng)不良的情況［11,12］。吞咽困難誘發(fā)營(yíng)養(yǎng)不良的作用機(jī)理為患者進(jìn)食受阻,身體容易產(chǎn)生電解質(zhì)紊亂、礦物質(zhì)與維生素的匱乏等,從而機(jī)體缺氧或缺水,影響能量代謝與蛋白質(zhì)的合成,同時(shí),機(jī)體功能被拮抗,還會(huì)增加多重感染,加劇患者致殘或死亡的后果。本院引進(jìn)早期腸內(nèi)營(yíng)養(yǎng)支持項(xiàng)目,獲得了較好成效。腸內(nèi)營(yíng)養(yǎng)支持通過(guò)熱量與蛋白質(zhì)的補(bǔ)充,促進(jìn)細(xì)胞代謝平衡,對(duì)機(jī)體組織有支持作用,降低了負(fù)氮平衡,維護(hù)了免疫系統(tǒng)的穩(wěn)定,對(duì)腸胃蠕動(dòng)有促進(jìn)作用,同時(shí)可改善血液灌注,保護(hù)胃黏膜［13-16］。另外還具有減少細(xì)菌移位的特點(diǎn)。本研究結(jié)果顯示,經(jīng)營(yíng)養(yǎng)指標(biāo)檢測(cè),入院1 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(38.71±4.97)g/L、HGB(134.79±12.48)g/L、TP(68.64± 5.13)g/L、TTR(254.16±23.15)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(38.82± 4.25)g/L、HGB(134.52±11.85)g/L、TP(68.26±5.21)g/L、TTR(254.42±22.95)g/L；入院1 d后兩組各項(xiàng)營(yíng)養(yǎng)指標(biāo)比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組ALB(36.84±3.15)g/L、HGB(129.12±11.05)g/L、TP(66.74± 4.59)g/L、TTR(289.74±23.84)mg/L；常規(guī)營(yíng)養(yǎng)組ALB(32.74± 2.41)g/L、HGB(113.74±10.42)g/L、TP(61.41±4.15)g/L、TTR(236.46±22.76)g/L；腸內(nèi)營(yíng)養(yǎng)組入院14 d后各項(xiàng)營(yíng)養(yǎng)指標(biāo)與入院1 d后比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05),常規(guī)營(yíng)養(yǎng)組各項(xiàng)營(yíng)養(yǎng)指標(biāo)水平則顯著低于入院1 d后和同時(shí)間的腸內(nèi)營(yíng)養(yǎng)組(P＜0.05)。入院1 d后,腸內(nèi)營(yíng)養(yǎng)組GCS評(píng)分中言語(yǔ)反饋(2.31±0.17)分,睜眼功能(2.71±0.18)分,肢體動(dòng)作(3.16±0.14)分,總分(8.18±1.56)分；常規(guī)營(yíng)養(yǎng)組言語(yǔ)反饋(2.32±0.25)分,睜眼功能(2.59±0.19)分,肢體動(dòng)作(3.12±0.15)分,總分(8.03±1.47)分；兩組GCS各項(xiàng)評(píng)分及總分比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。入院14 d后,腸內(nèi)營(yíng)養(yǎng)組GCS評(píng)分中言語(yǔ)反饋(3.98±0.15)分,睜眼功能(3.57± 0.24)分,肢體動(dòng)作(4.04±0.27)分,總分(11.59±2.13)分；常規(guī)營(yíng)養(yǎng)組言語(yǔ)反饋(2.24±0.11)分,睜眼功能(2.94±0.21)分,肢體動(dòng)作(3.37±0.23)分,總分(8.55±2.06)分；腸內(nèi)營(yíng)養(yǎng)組入院14 d后GCS各項(xiàng)評(píng)分及總分較入院1 d后顯著上升,且顯著高于同時(shí)間常規(guī)營(yíng)養(yǎng)組的評(píng)分,差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。說(shuō)明采取腸內(nèi)營(yíng)養(yǎng)支持模式可最大程度減緩營(yíng)養(yǎng)的流失,較為及時(shí)的為患者補(bǔ)充所需物質(zhì),且腸內(nèi)營(yíng)養(yǎng)組患者的意識(shí)狀態(tài)更好。雖然腸內(nèi)營(yíng)養(yǎng)成效鮮明,但營(yíng)養(yǎng)乳劑的成分隨著科技發(fā)展,尚處于不斷研發(fā)、不斷完善的階段。

綜上所述,對(duì)腦卒中患者應(yīng)用早期腸內(nèi)營(yíng)養(yǎng)支持對(duì)其營(yíng)養(yǎng)健康指標(biāo)的穩(wěn)定,保證意識(shí)活動(dòng)能力均有積極意義,有利于患者預(yù)后,是針對(duì)腦卒中患者可行性高的營(yíng)養(yǎng)方案。

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Influence by stroke early enteral nutrition on nutrition health and prognosis in patients

YANG Xin.Department of Nutrition,Benxi City Central Hospital,Benxi 117000,China

Objective To investigate influence by early enteral nutrition on nutrition health level and prognosis in stroke patients.Methods A total of 134 stroke patients were divided by different nutrition support measures into conventional nutrition group and enteral nutrition group,with 67 cases in each group.On the basis of basic nursing,the conventional nutrition group received conventional nasal feeding liquid diet,andthe enteral nutrition group received early immune enteral nutrition in addition to treatment for the conventional nutrition group.Comparison was made on nutrition indexes ［serum albumin (ALB),hemoglobin (HGB),serum total protein (TP) and transthyretin (TTR)]and Glasgow coma scale (GCS) scores between the two groups in 1 and 14 d after admission.Results Detection of nutrition indexes showed that the enteral nutrition group had ALB as (38.71±4.97) g/L,HGB as (134.79±12.48) g/L,TP as (68.64±5.13) g/L and TTR as (254.16±23.15) mg/L in 1 d after admission.The conventional nutrition group had ALB as (38.82±4.25) g/L,HGB as (134.52±11.85) g/L,TP as (68.26±5.21) g/L and TTR as (254.42±22.95) mg/L in 1 d after admission.There was no statistically significant difference of nutrition indexes in 1 d after admission between the two groups (P＞0.05).In 14 d after admission,the enteral nutrition group had ALB as (36.84±3.15) g/L,HGB as (129.12±11.05) g/L,TP as (66.74±4.59) g/L and TTR as (289.74±23.84) mg/L.The conventional nutrition group had ALB as (32.74±2.41) g/L,HGB as (113.74±10.42) g/L,TP as (61.41±4.15) g/L and TTR as (236.46±22.76) mg/L in 1 d after admission.The enteral nutrition group had no statistically significant difference of nutrition indexes between 1 d and 14 d after admission (P＞0.05),while the conventional nutrition group had obviously lower nutrition indexes than those in 1 d after admission and in the enteral nutrition group (P＜0.05).In 1 d after admission,the enteral nutrition group had GCS verbal feedback score as (2.31±0.17) points,eye opening function score as (2.71±0.18) points,body movement score as (3.16±0.14) points,and total score as (8.18±1.56) points.The conventional nutrition group had verbal feedback score as (2.32±0.25) points,eye opening function score as (2.59±0.19) points,body movement score as (3.12±0.15) points,and total score as (8.03±1.47) points.There was no statistically significant difference of GCS scores and total score in 1 d after admission between the two groups (P＞0.05).In 14 d after admission,the enteral nutrition group had GCS verbal feedback score as (3.98±0.15) points,eye opening function score as (3.57±0.24) points,body movement score as (4.04±0.27) points,and total score as (11.59±2.13) points.The conventional nutrition group had verbal feedback score as (2.24±0.11) points,eye opening function score as (2.94±0.21) points,body movement score as (3.37±0.23) points,and total score as (8.55±2.06) points.The enteral nutrition group had obviously higher GCS scores and total score in 14 d after admission than those in 1 d after admission,and its scores were also higher than those in the conventional nutrition group at the same time period.Their difference had statistical significance (P＜0.05).Conclusion Early enteral nutrition support can maintain nutrition level in stroke,and it is helpful for prognosis consciousness and sensory recovery.This method acts as a highly feasible nutrition scheme for stroke patients.

Stroke; Early enteral nutrition; Nasal feeding

10.14164/j.cnki.cn11-5581/r.2017.04.024

2016-12-28］

117000 本溪市中心醫(yī)院營(yíng)養(yǎng)科