关于高血压脑出血患者建立肠内营养最佳时机的临床研究

Clinical Study on the Optimal Time to Establish Enteral Nutrition in Hypertensive Intracerebral Hemorrhage Patients

目的研究高血压脑出血患者开始建立肠内营养的时间,以揭示其建立肠内营养的最佳时机。方法选取2010年7月-2011年9月收治的高血压脑出血患者69例,随机将其分为A、B、C组,A组23例在血流动力学稳定后24 h内采取鼻胃管方式开始建立肠内营养;B组23例在24～48 h内开始肠内营养支持;C组23例在48～72 h开始肠内营养支持,并分别于营养支持前1 d及营养支持后的14 d检测三组患者三头肌皮皱厚度、上臂肌围、血清白蛋白、血红蛋白水平等相关营养指标的波动情况;监测第3、14天各组患者腹泻、便秘、应激性溃疡、肺部感染等临床并发症的发生情况。结果相关营养指标监测结果研究发现:建立肠内营养支持14 d后,三组患者其三头肌皮皱厚度及上臂肌围在营养支持前后差异无统计学意义(P>0.05);A、B组患者其血清白蛋白及血红蛋白水平在营养支持后较前有增高表现,差异有统计学意义(P<0.05),且B组患者其血清白蛋白及血红蛋白水平增高程度较A组更为显著;C组患者其血清白蛋白水平在营养支持后有增高表现,且差异有统计学意义(P<0.05),但血红蛋白水平较前比较差异无统计学意义(P>0.05)。相关临床并发症发生率的研究结果如下:给予肠内营养支持3 d后,A、C组患者分别与其余两组比较发现,其腹泻、胃潴留、应激性溃疡、肺部感染发生率较其余两组比较差异无统计学意义(P>0.05);B组患者与其余两组比较,其应激性溃疡发生率较其余两组减低,且差异有统计学意义(P<0.05);腹泻、胃潴留、肺部感染较其余两组比较无显著差异;但随着观察时间的不断延长,在肠内营养支持后的14 d,A组患者较其余两组比较,其腹泻、胃潴留、应激性溃疡发生率仍无显著差异,但其肺部感染的发生率较B组增高,而较C组减低,且差异有统计学意义(P<0.05);B组患者较其余两组比较,其腹泻、应激性溃疡、肺部感染的发生率较其余两组均减低,且差异有统计学意义(P<0.05),并且其肺部感染发生率减低程度较A组明显,其胃潴留发生率与其余两组比较时差异无统计学意义(P>0.05);C组患者与其余两组比较,其应激性溃疡、肺部感染个例发生率较其余两组增高,但差异无统计学意义(P>0.05)。结论高血压脑出血患者于血流动力学稳定后的24～48 h内给予建立肠内营养支持,可利于患者相关营养指标的恢复,减少相关临床并发症的发生,可能会在一定程度益于患者的预后。

Objective To investigate the time to establish enteral nutrition （EN） in intracerebral hemorrhage （ICH） patients, in order to reveal the best time to establish EN. Methods Sixty-nine intracerebral hemorrhage patients treated in the Affiliated Hospital of Chengdu University between July 2010 and September 2011 were selected in our study. We divided the patients into three groups randomly with 23 patients in each group. Patients in group A began to receive EN establishment through a nasogastric tube 24 hours after hemodynamic stability; patients in group B began EN 24 to 48 hours after hemodynamic stability; and patients in group C started EN support within 48 to 72 hours of hemodynamic stability. We detected the level fluctuations of nutrition indicators such as the triceps skin fold thickness, ann muscle circumference, serum albumin, and hemoglobin one day before EN and 14 days after EN in all three groups. Moreover, we monitored the incidenceof complications like diarrhea, constipation, stress ulcers, and lung infections in each group on the 3rd andl4th day. Results Fourteen days after EN establishment, there were no significant differences in triceps skin fold thickness and upper arm muscle circumference among the three group of patients before and after nutritional support （P 〉 0.05）. The levels of seruna albumin and hemoglobin in group A and B were increased after the nutritional support, and the differences were statistically significant （P 〈 0.05）, and the elevated extent levels of serum albumin and hemoglobin of group B was higher than those of group A. The serum albumin level increased in group C after nutritional support, and the difference was statistically significant （P 〈 0.05）, but we found no significant difference in hemoglobin level after the support （P 〉 0.05）. Three days after the EN support, group A and group C patients, compared with the other two groups respectively, diarrhea, gastric retention, stress ulcer, pulmonary infection rates showed no significant differences （P 〉 0.05）. Compared with the other two groups, stress ulcer incidence in group B patients was lower and the difference was statistically significant （P 〈 0.05）, but diarrhea, gastric retention, and pulmonary infection showed no significant difference. Fourteen days after EN support, compared with the other two groups, diarrhea, gastric retention, stress ulcer incidences in group A still had no significant differences, but the incidence of lung infection was higher than group B, lower than group C, and the differences were statistically significant （P 〈 0.05）. Compared with the other two groups, diarrhea, ulcer, and lung infection rates were lower in group B, and the differences were statistically significant, and the lung infection rate decrease was more obvious than group A, but we found no significant differences in the incidence of gastric retention when compared with the other two groups （P 〉 0.05）. Compared with the other two groups, stress ulcer, and pulmonary infection incidence was higher in group C patients, but did not reach significant differences （P 〉 0.05）. Conclusions Establishment of enteral nutrition support 24 to 48 hours after hemodynamic stability for intracerebral hemorrhage patients can be beneficial to the recovery of patient-related nutrition indicators, reduce the incidence of clinical comlolieations, and the prognosis of patients may benefit to a certain extent.