臺灣博碩士論文加值系統

目的：
藉由中、西醫協同治療，改善內科重症加護病房病人胃排空延遲情形，減少胃殘餘量，進而促進腸道營養吸收，改善重症病患預後。
方法：
以前瞻性、平行對照研究設計，於中部某醫學中心成人內科加護病房，收治對象為20歲以上成年人、有呼吸器使用、腸胃功能不良合併胃輕癱的內科重症加護單位病患。排除對象為：病人年齡小於20歲、或大於90歲者，近期重大開腹手術，全胃切除，腹內腫瘤、癌症，腸阻塞，腸缺血，急性胰臟炎，嚴重休克(使用2種以上升壓劑)，對常見腸胃蠕動劑(如：Metoclopramide、Mosapride或Erythromycin)過敏，或正在使用與腸胃蠕動劑有拮抗作用藥物者，具有心律不整等心臟病或裝有心臟節律器、腦深層電刺激器或其他電子植入物者，孕婦、癲癇患者，服用抗凝血劑者。將納入病患隨機分配為實驗組(使用臨床腸胃蠕動劑+電針)與對照組(使用臨床腸胃蠕動劑)。實驗組除臨床使用腸胃蠕動劑外，另接受電針治療(取穴: 內關、三陽絡、合谷、足三里、上巨虛、下巨虛、太衝及太白﹚；接電針之穴位為「內關-三陽絡」及「足三里-太白」，電針頻率為2 Hz，強度<9.8 mA，治療每次15分鐘，1週6次。(1)主要療效指標：比較兩組在治療期間平均胃殘餘容積，以及全日腸道營養熱量攝取與全日目標熱量百分比；(2)次要療效指標：比較兩組發生吸入性肺炎比率、呼吸器使用天數、加護病房住院天數、出加護病房結果。
結果：
於2018年03月到2019年03月研究倫理審查委員會核准期間，總共於內科加護病房總共完成完整收案10位實驗組、3位對照組病患；實驗組其中7位男性、3位女性；對照組為3位男性；接受電針治療的10位實驗組病人，在電針介入治療前後的胃殘餘容積的平均減少361.5毫升，達顯著差異(p<0.001)，腸道營養灌食量平均增加643毫升，有顯著差異(p<0.05)，此外，腸道營養的攝取熱量療程後平均增加912.8大卡，也達顯著水準(p<0.001)。但若以符合80%的全日腸道營養目標熱量攝取而言，只有50%的病人能達標。對照組的病患，在接受常規促腸蠕動藥物治療前後的胃殘餘容積平均減少313.3毫升（p＜0.05），但在腸道營養灌食量與熱量上未產生治療前後的差異。實驗組、對照組兩組在治療前後的胃殘餘容積減少、腸道營養灌食量二者未產生統計學上的差異，但在腸道營養的攝取熱量差異上，實驗組較對照組日平均多了1011.1大卡（p＜0.05）。
結論：
此研究案將中西整合醫學以電針治療導入疾病複雜及嚴重度較高的內科重症加護領域，在初步的結果顯示電針合併促腸胃蠕動藥物的中西整合醫學治療，可明顯增進內科重症病患的腸胃道活動，減少病患的胃殘餘容積，緩解胃排空延遲，也因此增加了重症病患腸道營養攝食的容量，提升腸道營養攝取的熱量，對突破臨床內科重症病患只能依賴藥物促進腸胃功能的瓶頸提供了契機；治療過程中，病患雖有多種的維生儀器依賴，也能維持病患的生命徵象穩定與儀器運作如常，證明電針治療在重症加護領域仍屬安全低風險的療法，雖因人力與時間限制，無法達到較高實證醫學等級的臨床研究目標，對於是否能以此模式達到改善重症病患預後，仍待更大規模與嚴謹的研究。

Background:
Gastrointestinal dysfunction is a common clinical problem in intensive care units (ICU). Past studies have shown more than half patients in intensive care unit had the symptoms of vomiting, delayed gastric emptying, or poor digestion. These citations could increase infection risk, prolong mechanical ventilation and hospital stay time, even increase hospital mortality. Prokinetic agents are prescribed for gastrointestinal dysmotility in critical ill patients. Previous studies showed that there are kinds of side effect (ex: cardiovascular event, arrhythmia, extrapyramidal syndrome) of the commonly used Prokinetic drugs in clinic. Thus, these drugs have the restrictions on the use of elderly patients. In addition, these pharmaceutical therapy have limited help in stimulating gastrointestinal motility. To break through the limitation in clinic, we try to use traditional Chinese medicine acupuncture treatment to improve gastrointestinal activity in medical critical ill patients.
Methods:
This study is a prospective, parallel controlled study design in an adult medical intensive care unit in middle Taiwan. The study cases were collected from adults over 20 years old patients in medical intensive care units with mechanical ventilation assessment and gastrointestinal dysfunction or gastroparesis. Excluded objects: (1) Patients younger than 20 years old or older than 90 years old (2) History of major abdominal surgery, total gastrectomy.(3) intra-abdominal tumors, cancer (4) Intestinal blockage. (5) Ischemia bowel disease. (6)Acute pancreatitis. (7) The patient who are allergic to common gastrointestinal motility agents (such as: Metoclopramide, Mosapride, or Erythromycin) (8) The patient who have the contraindication to gastrointestinal motility agents. (9) Those patients with electrical stimulators implantation. (10) Pregnant women. (11) Patients with epilepsy. (12) Patents who are taking anticoagulants therapy.
The included patients were randomly to two groups. The study group patients received gastrointestinal motility agent plus electro-acupuncture therapy. The control group patients received the conventional gastrointestinal motility pharmaceutical therapy. The acupoint selection of Electroacupuncture treatment are: PC-6 (Neiguan), TE-8 (Sanyangluo), LI-4 (Hegu), ST-36 (Zusanli), ST-37 (Shangjuxu), ST-39 (Xiajuxu), LR-3 (Taichong) and SP-3 (Taibai). The pair acupoints for electroacupuncture are “Neiguan–Sanyangluo” and “Zusanli–Taibai”. The electro-acupuncture protocol is frequency 2 Hz, intensity <9.8 mA, for 15 minutes. The primary outcomes were the gastric residual volume, daily enteral nutrition (EN) feeding amount, and percentage of daily target Calorie intake of EN. The secondary outcome were the incidence of aspiration pneumonia, the ventilator depending days, the length of ICU stay, and the result of ICU discharge.
Results:
From March, 2018 to March, 2019 in Institutional Review Board approval period, we totally enrolled 10 patients in the study group and 3 patients in the control group. There were 7 males and 3 females in the study group. The gastric residual volume in study group reduced 361.5ml on average (p<0.001) after electroacupuncture intervention. The increasing of daily EN feeding amount and calorie were also significantly increasing in the study group. But there was only 50% (5/10) study group patients achieved the 80% daily calorie target.
Conclusions:
The World Health Organization has confirmed the efficacy of acupuncture in gastrointestinal system diseases many years ago. The electroacupuncture has been used in clinic for decades. Our study try to use electroacupuncture therapy in medical critically ill field. Although this study could not achieve the higher quality evidence research due to case number and time constraints. But the preliminary results showed that the integration of the Transitional Chinese and Western medical treatment with acupuncture intervention and pharmaceutical therapy could improve the gastric emptying and EN intake in medical critical ill patients. We look forward to further research with similar model.

第一章 前言 1
第一節 研究背景 1
第二節 研究動機與目的 1
第二章 文獻探討 2
第一節 重症加護病患的腸道活動與營養支持 2
第二節 中醫在重症加護病患腸道問題的角色 5
第三章 材料與方法 6
第一節 研究設計 6
第二節 研究流程 7
第三節 統計與分析 11
第四章 結果 12
第一節 收案結果與受試者基本資料 12
第二節 電針介入後對內科重症病患胃殘餘容積的改變 14
第三節 電針介入後對腸道營養攝食的改變 16
第五章 討論 19
第六章 結論 22
參考文獻 23
附錄 26

1.張博庾、董建華、周仲瑛，中醫內科學，知音出版社，台北，1998
2.吳宏乾，最新腧穴圖鑑，知音出版社，台北，2012
3.Mentec, Hervé MD; Dupont, Hervé MD; Bocchetti, Maria RN; Cani, Pascale RN; Ponche, Frédérique RN; Bleichner, Gérard MD. Critical Care Medicine. 2001;29:1955-1961
4.Ritz MA, Fraser R, Tam W, Dent J. Impacts and patterns of disturbed gastrointestinal function in critically ill patients. Am J Gastroenterol. 2000;95:3044-3052
5.Btaiche IF, Chan LN, Pleva M, Kraft MD. Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract. 2010;25:32-49
6.Elke G, Wang M, Weiler N, Day AG, Heyland DK. Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Crit Care. 2014;18:R29
7.Pfab F, Winhard M, Nowak-Machen M, Napadow V, Irnich D, Pawlik M, Bein T, Hansen E. Acupuncture in critically ill patients improves delayed gastric emptying: a randomized controlled trial. Anesth Analg. 2011;112:150-155
8.Wang L. Clinical observation on acupuncture treatment in 35 cases of diabetic gastroparesis. J Tradit Chin Med. 2004;24:163-165
9.Man-Ling Kao, Yao-Li Chen, Shu-Ching Lee, Sung-Yen Huang, Ping-Yi Lin. Electroacupuncture Improves Gastric Emptying in Critically Ill Neurosurgical Patients: A Pilot Study. Evid Based Complement Alternat Med. 2017;2017:1892161
10.Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007;13:3909-3917
11.Bauer AJ, Boeckxstaens GE. Mechanisms of postoperative ileus. Neurogastroenterol Motil. 2004;16 Suppl 2:54-60
12.Nind G, Chen WH, Protheroe R, Iwakiri K, Fraser R, Young R, Chapman M, Nguyen N, Sifrim D, Rigda R, Holloway RH. Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients. Gastroenterology. 2005;128:600-606
13.McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40:159-211
14.Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, Hiesmayr M, Mayer K, Montejo JC, Pichard C, Preiser JC, van Zanten ARH, Oczkowski S, Szczeklik W, Bischoff SC. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38:48-79
15.Camilleri M. Clinical practice. Diabetic gastroparesis. N Engl J Med. 2007;356:820-829
16.MacLaren R, Kiser TH, Fish DN, Wischmeyer PE. Erythromycin vs metoclopramide for facilitating gastric emptying and tolerance to intragastric nutrition in critically ill patients. JPEN J Parenter Enteral Nutr. 2008;32:412-419.
17.Nguyen, Nam Q. MBBS (Hons), FRACP; Chapman, Marianne BMBS, FANZCA, FJFICM; Fraser, Robert J. MBBS, FRACP, PhD; Bryant, Laura K. BHSc; Burgstad, Carly BHSc (Hons); Holloway, Richard H. MBBS, FRACP, MD. Prokinetic therapy for feed intolerance in critical illness: One drug or two? Crit Care Med. 2007;35:2561-2567
18.Hui Li, Tian He, Qian Xu, Zhe Li, Yan Liu, Fang Li, Bo-Feng Yang, Cun-Zhi Liu. Acupuncture and regulation of gastrointestinal function. World J Gastroenterol 2015;21:8304-8313
19.Wang L. Clinical observation on acupuncture treatment in 35 cases of diabetic gastroparesis. J Tradit Chin Med. 2004;24:163-165
20.Li G, Huang C, Zhang X, Xie H, Cheng H, Tang Y, Li Z. The short-term effects of acupuncture on patients with diabetic gastroparesis: a randomised crossover study. Acupunct Med. 2015;33:204-209
21.Pang B, Zhou Q, Li JL, Zhao LH, Tong XL. Treatment of refractory diabetic gastroparesis: Western medicine and traditional Chinese medicine therapies. World J. Gastroenterol. 2014;20:6504-6514
22.Ming-Hua Du, Hong-Min Luo, Sen Hu, Yi Lv, Zhi-Long Lin, Li Ma, Electroacupuncture improves gut barrier dysfunction in prolonged hemorrhagic shock rats through vagus anti-inflammatory mechanism. World J Gastroenterol. 2013;19:5988-5999
23.Meng JB, Jiao YN, Zhang G, Xu XJ, Ji CL, Hu MH, Lai ZZ, Zhang M. Electroacupuncture Improves Intestinal Dysfunction in Septic Patients: A Randomised Controlled Trial. Biomed Res Int. 2018;2018:8293594