臺灣博碩士論文加值系統

論文摘要內容：
營養支持對重症患者是一項重要議題，患者因多發性器官衰竭引發胃排空不佳、消化吸收不良。一般患者因使用呼吸器須使用腸道灌食，腸道灌食須經鼻胃管或鼻腸管灌食。本研究比較兩種管灌方式對內科重症患者營養支持及併發症之差異性。結果：在食物殘餘方面，使用鼻腸管灌食在第一週內每天都比鼻胃管灌食有較低之每日灌食殘餘量且呈顯著性差異。在每天卡路里及蛋白質攝取量，鼻腸管灌食組皆高於鼻胃管灌食組，且從第一天就呈現統計上差異。兩組灌食皆呈現隨住院天數，灌食殘餘量逐漸下降，卡路里及蛋白質攝取量逐日上升，在Albumin、Pre-albumin、UUN及nitrogen balance方面兩組第1、4、7天，Albumin、pre-albumin逐漸上升，負氮平衡逐漸減少，但兩組未達統計上差異（p＞0.05）。在併發症方面，鼻胃管灌食發生嘔吐及呼吸器相關性肺炎比率較高，嘔吐有達統計上差異（p＜0.05）；而呼吸器相關性肺炎未呈統計上之差異，其他發燒、腹瀉、菌血症、腸胃道出血並無明顯差異。總住院天數、ICU住院天數及呼吸器使用天數、死亡率都沒有明顯的差異。
　　鼻腸管灌食對內科重症患者較快速達到營養支持的目標，較不會有
食物殘餘量，在血清白蛋白（albumin）、前白蛋白（pre-albumin）或正氮
平衡上與鼻胃管灌食則沒有統計上顯著差異，併發症除了嘔吐此項目有
差異外其他項目則無統計上之差異，住院天數、呼吸器使用天數及死亡
率亦沒有統計上差異。故鼻腸管灌食在內科加護病房當病患有潛在性吸
入性肺炎時可提供患者營養支持的另一種方法。

Nutritional support is an important issue for critical patients. Gastric delay empty and impaired intestinal nutritional absorption are related from multiple organ failure. Critical cases usually depend on Nasal gastric tube or nasal duodenal tube feeding as a result of ventilator dependent. The difference between nasal gastric tube(NG) and nasal duodenal tube feeding(ND) are compared in this article. As for the amount of residual food, the nasal duodenal feeding group has less residual food, better calorie and protein absorption at the first week, which are significantly meaningful at the first day. The increasing of daily calorie and protein absorption and decrease in residual food amount are noted as the prolongation of hospital stay. Albumin and pre-albumin elevation, nitrogen balance and UUN attenuation are also observed at the first, 4th and 7th days over the both groups, but they are not significantly different in statistics（p＞0.05）. The complications such as vomiting and ventilator related pneumonia are higher at NG group, vomiting is significantly higer（p<0.05）; there is no difference between the two groups comparing the fever, diarrhea, bacteremia and UGI bleeding. There is also no difference between the two groups comparing the total hospital stay, ICU stay, ventilation days and mortality. Nasal duodenal feeding can reach the nutritional support faster and less residual food. But the albumin, pre-albumin, nitrogen balance or complications showed no differences except vomitting. It does not decrease hospital staying days, ventilator depending days and mortality rate. As a result of nutritional support view point, nasal duodenal feeding still is helpful and can be used at the medical ICU patients.

摘要 I
Abstract Ⅱ
誌謝………………………………………………………………………... Ⅳ
目錄 ………………Ⅴ
圖表目錄 Ⅸ
第一章、緒論 1
第二章、文獻回顧 4
2.1 加護病房之重症病人 4
2.2 重症病人的生理代謝情形 4
2.2.1 衰退期及漲潮期 4
2.2.2 感染引發的代謝及生理變化 5
2.3病情評估－APACHEⅡ評分系統 6
2.4 重症病患的熱量及營養需求 8
2.4.1 能量 8
2.4.1.1 熱量估算 9
2.4.1.1.1 直接測量法 9
2.4. 1.1.2間接熱量測量法 9
2.4. 1.1.3 公式估算法 10
2.4.2 蛋白質 11
2.4.3 碳水化合物 11
2.4.4 脂質 11
2.5 營養評估 12
2.5.1 主觀性營養評估 12
2.5.2 營養評估的客觀方法 14
2.5.2.1體位測量 14
2.5.2.1.1 身高 14
2.5.2.1.2 體重 15
2.5.2.1.3 身體質量指數 15
2.5.2.1.4 皮下脂肪厚度 16
2.5.2.2 生化檢驗 17
2.5.2.2.1白蛋白 17
2.5.2.2.2 前白蛋白 17
2.5.2.2.3總淋巴總數 18
2.5.2.2.4 氮平衡 18
2.5.2.2.5 運鐵蛋白 19
2.5.2.2.6 鐵蛋白 19
2.5.2.2.7 肌酸酐/身高指數 19
2.5.2.3 飲食攝取 20
2.5.2.4 營養監控的指標及公式 20
2.6重症病患營養支持的方法及路徑的選擇 21
2.6.1 靜脈營養 22
2.6.2 腸道營養 22
2.6.2.1 鼻至胃灌食 24
2.6.2.2 鼻至十二指腸及鼻至空腸灌食 24
2.6.2.3 胃造口灌食 24
2.6.3 靜脈營養VS 腸道營養 24
2.7 重症患者腸道營養持的時機 26
2.8 影響腸道營養進行因素 27
2.8.1 腸胃道蠕動情形 27
2.8.2 胃排空 27
2.8.3 腹瀉 28
2.8.3.1 血清白蛋白與腹瀉之關係 28
2.8.3.2 禁食對腹瀉的影響 29
2.9 呼吸器相關肺炎 29
2.9.1 造成VAP的危險因子 30
2.9.1.1 病人相關因子 30
2.9.1.2 感控相關因子 30
2.9.1.3 氣管內管相關因子 31
2.9.1.4 腸胃道相關因子 31
2.9.1.5 體位 31
2.9.2 預防措施 31
第三章、材料與方法 31
3.1 實驗架構 33
3.2實驗設計及實驗流程 33
3.2.1研究對象 33
3.2.2研究時間………………………………………………………….34
3.3研究材料……………………………………………………………...37
3.4 研究方法……………………………………………………………..37
3.4.1病患基本資料……………………………………………………37
3.4.2 體位測量………………………………………………………...37
3.4.3 病患熱量需求評估……………………………………………...38
3.4.4 營養支持的方式………………………………………………..39
3.4.5生化檢驗值檢測…………………………………………………40
3.4.5.1 白蛋白（Albumin）……………………………………..40
3.4.5.2 前白蛋白（Prealbumin）……………………………….41
3.4.5.3 尿素氮（Urine Urea Nitrogen； UUN）………………42
3.4.6 合併症評估……………………………………………………...43
3.4.6.1 嘔吐………………………………………………………..43
3.4.6.2 腹瀉………………………………………………………..43
3.4.6.3 發燒……………………………………………………….43
3.4.6.4上腸胃道出血……………………………………………..43
3.4.6.5 呼吸器相關肺炎………………………………………….43
3.4.6.6 其他感染………………………………………………….43
3.4.6.7 預後……………………………………………………….44
3.5 統計分析…………………………………………………………….44
第四章 結果
4.1 基本資料分析………………………………………………………….45
4.2 病患疾病之診斷……………………………………………………….47
4.3營養攝取情形…………………………………………………………..50
4.3.1卡路里攝取量………………………………………………………50 4.3.2蛋白質攝取量……………………………………………………..53
4.3.3熱量與實際需求量百分比………………………………………..56
4.4 灌食殘餘量情形………………………………………………………59
4.5前白蛋白（Pre-albumin）、白蛋白（Albumin）、尿素氮（UUN）
及氮平衡（Nitrogen balance）差異………………………………..62
4.5.1前白蛋白（Pre-albumin）……………………………………….62 4.5.2 白蛋白（Albumin）……………………………………………64
4.5.3 尿素氮（UUN）………………………………………………….66 4.5.4 氮平衡（Nitrogen balance）……………………………………68
4.6 氮平衡（Nitrogen balance）與 APACHE II score的關係……….70
4.7 併發症及死亡率方面…………………………………………………71
第五章 討論…………………………………………………………………74
第六章 結論…………………………………………………………………78
參考文獻………………………………………………………………………79
附錄 ……………………………………………………………………85
作者簡介…………………………………………………………………….89

參考文獻

李珮琳、呂欣如。 2005。 加護病房之病人安全—以呼吸器相關肺炎（VAP）感染與Acinetobactor baumannii相關因素分析及護理措施為例。 慈濟醫學。 17（suppl 4）：47-49。
金惠民、賴昭鴻、蔡秀悅、金美雲、王秀媛。 1991。 疾病營養與膳食療養。
邱艷芬。 1995。 應用APACHE SCORE 於加護病房護理行政業務之探討。 慈濟醫學。 7:187-193。
邱艷芬。 1995。重症期間之代謝變化與護理。 護理雜誌。 42（2）：7-13。
邱艷芬。 1998。 重症病人接受腸道營養初期發生腸道不適應症之影響因素及因應策略之探討。 護理研究。 6(6)：461-473。
班仁知、林俊修、林任先、郭文福、張高耀、馮南雄。 2004。 呼吸器相關肺炎不同診斷方法之比較。 感染控制雜誌。 14：2001-2009。

唐高駿。 1998。 加護病房之使用及成本效益。 臨床醫學。 41：414-437。
陳淑娟。 2002。 臨床營養學。 合記圖書出版社。
陳瑛瑛、王復德。 1998。 呼吸治療裝置引起院內呼吸道感染之預防。 呼吸照護簡訊。 4:39-45。
陳映容、林麗真。 2001。 營養評估。藥學雜誌。 17(1)：7-15。
楊雪松 。1997。 實用急症處理手冊。 合計圖書出版社。
賴鴻緒等人合編。 2006。 臨床營養學靜脈暨腸道營養。 時新出版有限公司。
蔡秀玲、蔡佩芬、郭靜香。 1993。 營養評估手冊。 國興出版社。
蔡淑芳、周聰成、陳冠如、陳雪美、陳麗真、彭巧珍、蔡秀玲。 1999。 第一版。 藝軒圖書出版社。
嚴小燕、彭銘業、楊美紅、陳依雯、張靜美、張峰義。 2001。 某醫學中心Acinetobactor baumannii院內感染調查。 感染控制雜誌。 11：216-226。
Bistrian BR, Blackburn GL, Schrimshaw NS. 1975. Cellular immunity in semistarved status in hospital ized adults. Am J Clin Nutr. 28:1148-1156.
Braga M, Vignali A, Gianotti L. 1996. Immune and nutritional effect of early rnteral nutrition after major abdominal operations, Eur J Surg. 162: 105-115.
Bristrian BR, Kolts BE. 1987. Hypoalbuminemia as an indicator of diarrhea incidence in critically ill patients. Crit Care Med. 15: 506-509.
Bosscha K, Nieuwenhuijs VB, Vos A. 1998. Gastrointestinal motility and gastric tube feeding in mechnically ventilation patients. Critical Care Medicine. 26(9): 1510-1517.
Bufo A, Feldman S,. Daniels G. 1994. Early postoperative feeding. Dis. Colon Rectum. 37: 1260-1265.
Buzby GP, Williford WO, Peterson OL, Crosby LD, Page CP, Reinhardt GF, Mullen JL. 1998a. Arandomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr. 47: 357-365.
Calson DE. 1995. Nutrition for the critically ill. Wolf Rinke Associates, Inc. 9-32.
Carr C, Ling K, Boulos P. 1996. Randomized trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ. 312:869-871.
Christman JW, McCain RW. 1993. A sensible approach to the nutrition
support of mechanically ventilated critically ill patients. Intensive Care Med. 19: 129-136.
Chan S, McCowen KC, Blackburn GL. 1999. Nutrition management in the ICU. Chest 115: 145S-148S.
Chen CC, Schilling LS, Lyder CH. 2001. A concept analysis of
malnutrition in elderly. Journal of Advanced Nursing. 36(1):131-142.
Comasia A, Raguso YM, Dupertuis, Claude Pichard. 2003. The role of visceral proteins in the nutritional assessment of intensive care unit patients. Current Opinion in Clinical Nutrition and Metabolic Care. 6:211-216.
Correia MI, Waitzberg DL. 2003. The impact of malnutrition on morbidity,
mortality,length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 22:219-220.
Cook JD, Skikne BS. 1982. Serum ferrin: a possible model for the assessment of nutrition store. Am J Clin Nur. 35: 1180-1185.
Covelli HD, Black JW, Olsen MS, Beekman JF. Respiratory failure predicted by high carbohydrate loads. 1981. Ann Inter Med 95: 579-581.
Davies SW, Energy requirements and energy expenditure in infancy. 1992.
Eur J Clin Nutr. 46（suppl）:s29-35.
David LS, Shannon L, Mackenzie B, Morad H. 2004. Enteral nutrition and mucosal immunity:implications for feeding strategies in surgery and trauma. Canadian Journal of Surgery. 47(2):109-116.
Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittakers, Mendelson RA, Jeejeebhoy KN. 1987. What is subject global assessment of nutritional status？ JPEN. 11:8-13.
Day Lisa, Scotts NA, Frankfurt A. 2001 . Gastric versus duodenal feeding in patients with neurological disease: A pilot study. J Neuro Nursing 33: 148-159.
Dark DS,Pingleton SK, Kerby GR. 1985. Hypercapnia during wearing:a comparison of nutritional support. Chest . 88: 141-143.
Esparza J, Bojvin MA, Hart Shorne MF. 2001. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med 27: 660-664.
Frankenfield DC, Muth ER, Rowe WA. 1998. The Harris-Benedict studies of human basal metabolism:History and limitations.J,Am.Diet Assoc. 4: 439-445.
Harris JA, Benedict FG. 1919. A Biometric Study of Basal Metabolism in Man. Washington DC: Carnegie Institute.Publication No.279.
Hasler,WL. 1999. Disorders of gastric emptying. IN Yamada T (ed) .Textbook of Gastroenterology, 3rd ed. Lippincott Williams and Wilkins, Philadelphia,PA. 1341-1369.
Harvey KB, Moldawer LL, Bistrian BR, Blackburn GL. 1981. Biological measures for the formulation of hospital prognostric index. Am J Clin Nutr. 34:2013-2022.
Heyland DK, Drover JW, MacDonald S, Novak F. 2001. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary
microaspiration;results of a randomized controlled trial.Crit Care Med 29: 1495-1501.
Haskel Y, Udassin R, Freund HR, Zhang JM, Hanani M. 1993. Liquid enteral diets induce bacterial translocation by increasing cecal flora without changing intestinal motility. Journal of Parenteral & Enteral Nutrition. 25(2):60-4.
Hoffer LJ. 2003. Protein and energy provision in critical illness. Am J Clin Nutr. 78:906-11.
Ireton-Jones CS, Turner WW, Liepa GU, Baxter CR. 1992. Equation for estimating energy expenditure in burn patients with special reference to ventilatory status. J Burn Care Rehabil. 13:330-333.
Jeffrey JL, Michael JM. 1998. Nutritional Support in Critical illness. Yale journal of biology and medicine. 71:449-456.
Jolliet P, Pichard C, Biolo G. 1998. Enternal nutrition in intensive care patients:a practical approach. Intensive Care Med 24: 848-859.
Kearns PJ,Chin D,Mueller L. 1999. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized controlled trial. J Trauma 46: 992-996.
Knaus WA, Draper EA, Wanger DP, Draper EA, Zimmerman JE. 1985. APACHEΠ:A severity of disease classification system critical care medicine.13: 818-829.
Kortbeek JB, Haigh PI, Doig C. 1999. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma 46: 992-996.
Kudsk KA, Minard G, Wojtysiak SL. 1994. Visceral protein response to
enteral versus parenteral nutrition and sepsis in patients with trauma. Ann Surgery 116：516-523.
Khuri-Bulos NA, Shennak M, Agabi S. 1999. Nosocomial infections in the intensive care units at university hospital in a developing country：Comparison with National Noscomial infections Surveillance intensive care unit rates. Am J Infect Control. 27:547-552.
Marshall JC. Girotti MJ. 1995. From premise to principle: the impact of the gut hypothesis on the practice of critical care surgery. Canadian Journal of Surgery. 38(2):132-41.
Manning ECM, Shenkin A. 1995. Nutritional assessment in critical ill. Cri Care. 11:603-634.
Marik PE, Zaloga GP. 2001. Early enteral nutrition in acutely ill patients: a systematic review. Critical Care Medicine. 29(12):2264-70.
Meyer NA, Kudsk KA.2003. Enteral versus parenteral nutrition: alterations in mechanisms of function in mucosal host defenses. Nestle Nutrition Workshop Series Clinical & Performance Program. (8):133-42.
Moore EE, Jones TN. 1986. Benefits of immediate jejunostomy feeding after major abdominal trauma-Aprospective, randomized study. J Trauma. 26: 874-879.
Seltzer MH, Slocum BA, Cataldi-Belcher EL. 1982. Instant nutritional assessment: Absolute weight loss and surgical mortality. JPEN. 6: 218-221.
Senkal M, Mumme A, Eickhoff U. 1997. Early postoperative enteral immunonutrition:Clinical outcome and cost comparison analysis in surgical patients. Crit Care Med. 1489-1496.
Simmons RL, Steeed DL. 1992. Basic Science Review for Surgeons. Philadelphia:WB Sauders. p.120.
Souba W, Wilmore D. 1994. Diet and nutrition in the case of the patient with surgery,trauma and sepsis.vol. 2. 8th ed.
Spain DA, Deweese RG, Reynolds MA. 1995. Transpyloric passage of feeding tubes in patients with head injury dose not decrease complications. J Trauma 39: 1100-1102.

Starker PM, Gump FE, AskNzi J, Elwyn DH, Kinney JM. 1982. Serum albumin levels as an index of nutrition support. Surgery. 91: 194-199.
Swinamer DL, Phang PT, Jones RL, Grace M, King EG. 1987. Twenty-four hour energy expenditure in critically ill patients. Crit Care Med. 15: 637-643.
Stechmiller JK. 2003. Early nutritional screening of older adult. Journal of infusion nursing. 26(3):170-177.
Stroud M, Duncan H, Nightingale J. 2003. Guidelines for enteral feeding in adult hostital patients. Gut 52(Suppl Ⅶ)vii1-12.
Roberts SR, Kennerly DA, Keane D, Keane D, Geroge C. 2003. Nutrition support in the intensive care unit Adequacy,Timeliness,and Outcomes.Critical Care Nurse 23(6):49-57.
Trujillo EB, Robinson MK, Jacob DO.1999.Nutrition assessment in the critically ill. Critical Care Nurse. 19(1): 67-78.
Velez J, Lince L, Restrepo J. 1997. Early enternal nutrition in gastrointestinal surgry. Nutrition. 13: 442-445.
Zaloga GP. Nutrition in Critical Care. 1994. Mosby:St. Louis. 169-191.
Zaloga GP, Bortenschlager L, Black KW. 1992. Immediated postoperative enteral feeding decrease weight loss and improve healing alter abdominal surgery in rats. Crit Care Med. 20: 115-118.