臺灣博碩士論文加值系統

燒燙傷不是一個單純的傷害，而是一個複雜的創傷。其治療過程極為棘手，且出院後還有一段漫長的身體、心理復健以及龐大的醫療支出。而動物和臨床研究發現，含麩胺酸或精胺酸的營養配方對創傷或灼傷患者具有減緩代謝速率、降低蛋白質分解、增進正氮平衡、促進傷口癒合、減少感染及敗血症的發生率、增加病患的存活率並減少住院日。因此本研究目的在於探討嚴重燒燙傷患者給予腸道免疫加強配方的營養支持後的結果。篩選自民國87年8月自91年10月期間住在成大燒傷中心，年齡介於20 ~55歲，傷口深度大於2°以上，且灼傷面積介於30% ~ 70% 之燒燙傷患者為研究對象，共21位。並隨機分為兩組：一、控制組(10位)：提供一般高蛋白腸道配方，二、實驗組（11位）：提供腸道免疫加強配方，至少滿12天。記錄每日營養攝取量及腸道耐受性（包括噁心、嘔吐、腹脹、腹瀉），並於住院第一天、第四天、第七天、第十四天，檢測營養攝取量、營養指標（白蛋白、前白蛋白、運鐵蛋白）免疫能力、氮排出量與氮平衡。結案後統計病患營養指標改變及併發症發生率。
結果：（1）熱量攝取方面，兩組都在受傷後第七天及第十四天時，其累計平均熱量攝取量都有逐漸增加分別為（D7：2386 ± 948 vs. 2616 ± 480 kcal/day），（D14：3170 ± 579 vs.3235 ± 353 kcal/day）並達到建議攝取量的70% 與90%以上，但兩組無顯著差異。（2）蛋白質攝取方面，也逐一呈現倍數增加，但其間亦無顯著差異；受傷後第一天（63.2 ± 30 vs. 63.2 ± 25 g/day），受傷後第七天（117 ± 47.5 vs. 139 ± 37.1 g/day），受傷後第十四天（150.3 ± 50.4 vs. 185.1 ± 35.6 g/day）。而各組內的蛋白質攝取量是隨天數而顯著增加（p<0.05）。（3）在營養指標方面，兩組間血清白蛋白並無顯著差異。至於血清前白蛋白變化值回升方面，兩組比較後，實驗組在受傷後的第十四天與第二天的變化值和第七天與第二天的變化值，都有顯著回升( p < 0.05 )。（4）尿液分析方面，兩組在受傷後的第七天，仍無法達到正氮平衡（-12.3 ± 10.1 g/day vs. -7.1 ± 4.3 g/day）或（-9.1 ±10.2 g/day vs. –6.3 ± 4.9 g/day），只有在受傷後第十四天時對照組與實驗組比較，實驗組可達正氮平衡（-6.29 ± 11.7 g/day vs. 0.9 ± 8.4 g/day）or （-5.1 ± 10.4 g/day vs. 0.8 ± 8.7 g/day），但並無顯著差異。（五）在腸道適應症上，實驗組患者有顯著較好的適應症（p<0.05）。
結論：腸道免疫加強配方對嚴重燒燙傷患者，可有效促進血清前白蛋白變化值的回升，與有益於腸道的適應性。

The purpose of this study was to assess the outcomes of enteral immune –enhancing formula in severe burned patients. From August 1998 until October 2002 , 21 burned patients from Burn Center of National Cheng Kung University hospital were randomized to receive early enteral nutrition with a enteral enhaning - immune formula（experimental n=11）or a high protein enteral formula.（control：10）Various nutritional, clinical, urinary, immunologic parameters were observed on postburned day 2, 4, 7, 14. Data analysis were performed by student t- test. , paired t- test and chi-square.
Result：After 12 days of feeding the two groups had increased in energy ,protein, arginine and glutamine intake. Patients receiving “enteral enhaning-immune formula” experienced significantly better gastrointestinal tolerance than control group (p<0.05)，increase of serum prealbumin different between postburned day 7and day 14. (p<0.05) , and serum transferrin on postburned day 7. (p<0.05)
In conclusion, this trial suggested this “enteral enhaning-immune formula” offer clinical benefits in severe burned patients.
Key words：severe burned patients、enteral enhaning-immune formula 、gastrointestinal tolerance、mortality

目錄
中文摘要----------------------------------------------------------------- -------I
英文摘要-------------------------------------------------------------------------iii
誌謝-------------------------------------------------------------------------------iv
目錄--------------------------------------------------------------------------------v
圖目錄----------------------------------------------------------------------------vi
表目錄----------------------------------------------------------------------------vii
附錄目錄-------------------------------------------------------------------------viii
第一章 緒論
第一節 研究動機-------------------------------- ---- 1
第二節 研究目的------------------------------------- 2
第二章 文獻回顧
第一節 燒傷後的生理、代謝變化-----------------4
第二節 燒燙傷患者營養支持的建議--------------6
第三節 免疫營養素在燒傷-------------------------10
第三章 材料和方法
第一節 實驗設計及流程----------------------------18
第二節 研究對象與方法----------------------------20
一、研究對象-------------------------------20
二、研究時間-------------------------------20
三、營養配方內容-------------------------20
四、營養支持方法-------------------------21
五、營養需求評估-------------------------21
六、傷口深度和面積評估----------------23
第三節 血液及尿液的收集及檢驗方法----------24
第四節 體位測量-------------------------------------33
第五節 併發症的診斷-------------------------------33
第六節 燒傷嚴重度的評估-------------------------35
第七節 統計分析-------------------------------------35
第四章 研究限制--------------------------------------------------37
第五章 結果
第一節 病患基本資料-------------------------------38
第二節 營養素攝取分析----------------------------39
第三節 血清生化值分析----------------------------40
第四節 尿液分析-------------------------------------42
第五節 免疫能力分析-------------------------------43
第六節 併發症分析----------------------------------44
第七節 死亡率與住院天數比較-------------------44
第六章 討論
第一節 腸道免疫加強配方對營養素攝取的探
討----------------------------------------------45
第二節 腸道免疫加強配方對血清生化值影
響的探討-------------------------------------45
第三節 腸道免疫加強配方對尿素氮排出與
氮平衡影響的探討-------------------------47
第四節 腸道免疫加強配方對併發症影響的
探討-------------------------------------------48
第七章 結論---------------------------------------------------------51
第八章 參考文獻---------------------------------------------------52

表目錄

表 2.1-1 燒燙傷後的生理病理變化----------------------------68
表 2.1-2 燒燙傷後的代謝變化----------------------------------69
表 5.1-1 病患基本資料-------------------------------------------70
表 5.2-1 兩組患者熱量、蛋白質之每日平均攝取量-------71
表 5.2-2 兩組患者精胺酸、麩胺酸之每日平均攝取量----72
表 5.3-1 血清生化數值的比較----------------------------------73
表 5.3-2 血清生化數值的比較----------------------------------74
表 5.3-3 血清白蛋白、前白蛋白、運鐵蛋白變化值比較-75
表 5.4-1尿素氮排出量、一日總尿素氮排出量、氮平衡
的比較----------------------------------------------------76
表 5.5-1 總淋巴球數的比較-------------------------------------77
表 5.5-1 總淋巴球數便化值的比較----------------------------78
表 5.6-1 併發症比較----------------------------------------------79
表 5.7-1 死亡率、存活者住院天數----------------------------80

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