重症患者喂养不耐受的研究进展

对于有高营养风险以及口服饮食无法满足正常需求的住院患者,应尽早开始实施肠内营养治疗,但喂养不耐受被认为是不能达到目标营养量的主要原因.目前喂养不耐受在国际上尚缺乏统一的定义、明确的原因及有效的治疗方法.本文对喂养不耐受相关的定义、可能原因及治疗方法等进行总结,为临床进一步研究如何减少喂养不耐受的发病率提供理论指导.     

重型颅脑损伤患者肠内营养的早期应用及护理研究

目的:探讨重型颅脑损伤患者进行早期肠内营养的效果及护理措施.方法:对45例重型颅脑损伤患者进行早期肠内营养并对并发症进行预防性护理,在治疗前后检测血红蛋白、淋巴细胞、白蛋白、血清前白蛋白、转铁蛋白,及测量肱三头肌皮褶厚度.结果:发生腹泻7例,反流3例,胃潴留3例,2例死于原发病;营养指标除血清前白蛋白外治疗后降低与治疗前比较无统计学意义(p＞0.05).结论:对重型颅脑损伤患者早期开始肠内营养可以尽快补充所需能量及蛋白质有利于减轻并扭转负氮平衡.细致专业的护理是达到治疗目的的必保证.     

早期分阶段营养支持对重型颅脑损伤患者的影响

目的 观察不同营养支持方法对重型颅脑损伤患者的影响.为该类患者提供合理的营养支持方案。方法 将80例重型颅脑损伤患者随机分为观察组和对照组，各40例。观察组于伤后采取早期（24h内）分阶段肠内营养（EN）加肠外营养（PN），直至逐渐过渡到完全EN；对照组于伤后进行PN，禁食3d后行EN。观察两组并发症发生率及血生化指标。结果营养支持期间并发症发生率观察组显著低于对照组（P〈0.01.P〈0.05）；血红蛋白、血清蛋白显著高于对照组（均P〈0.05）；血糖值显著低于对照组（P〈0.05）。结论 重型颅脑损伤患者早期分阶段EN联合PN营养支持能减少并发症的发生，有利于患者康复。     

重型颅脑损伤并发症的预见性护理

目的:探讨护理干预对减少重型颅脑损伤患者并发症的影响.方法:选择经确诊的重型颅脑损伤患者63例,对照组采取常规护理,观察组在常规护理基础上,实施预见性护理干预措施,并比较2组住院32天并发症的发生情况.结果:观察组并发症的发生率明显低于对照组,2组差别有统计学意义(P＜0.05).结论:对重型颅脑损伤患者实施预见性护理干预可减少并发症发生,提高教治成功率.     

早期分阶段营养支持对重型颅脑损伤患者的影响

目的观察不同营养支持方法对重型颅脑损伤患者的影响,为该类患者提供合理的营养支持方案。方法将80例重型颅脑损伤患者随机分为观察组和对照组,各40例。观察组于伤后采取早期(24h内)分阶段肠内营养(EN)加肠外营养(PN),直至逐渐过渡到完全EN;对照组于伤后进行PN,禁食3d后行EN。观察两组并发症发生率及血生化指标。结果营养支持期间并发症发生率观察组显著低于对照组(P<0.01,P<0.05);血红蛋白、血清蛋白显著高于对照组(均P<0.05);血糖值显著低于对照组(P<0.05)。结论重型颅脑损伤患者早期分阶段EN联合PN营养支持能减少并发症的发生,有利于患者康复。     

重型颅脑损伤病人胃肠内营养并发症的护理

重型颅脑损伤病人由于伤后呈高代谢、高分解状态,能量消耗急剧,易引起不同程度的营养不良,影响疾病的治疗和痊愈。常用的营养供给方式有肠外营养(TPN)和肠内营养(EN)两种。胃肠外营养往往不能满足颅脑损伤后的     

重型颅脑损伤昏迷患者的护理

目的总结98例重型颅脑损伤患者的护理体会。方法对98例患者的观察和护理。针对患者的意识、瞳孔、生命体征的观察,进行心理护理、皮肤护理,保持呼吸道的通畅、吸氧、呼吸机的合理应用、测量血氧饱和度,减少患者的并发症。结果98例重型颅脑损伤的患者,经过精心护理,采取有效的护理措施,59例患者度过难关得到良好的恢复,有14例轻、中度残疾,仅有4例损伤过重,多处骨折致使重残;有3例由于伤势过重(农村患者占60%),得不到紧急救护,脑部缺氧时间过长,致使植物生存状;有18例患者合并多脏器功能衰竭,抢救无效死亡。结论有效的护理降低了重型颅脑损伤的死亡率。     

重型颅脑损伤患者营养支持的临床研究

目的 探讨重型颅脑损伤营养支持的临床疗效及最佳途径。方法 64例重型颅脑损伤患者随机分为肠内营养组（EN组）和肠外营养组（PN组）,急诊手术后36－48h开始经不同途径进行额定热卡和氮量的营养支持,监测各项营养指标、代谢指标及营养支持并发症,计算营养费用。结果 EN与PN均有效地维持了各项营养指标,但PN组代谢指标、营养支持并发症及营养费用均是高于EN组。结论 早期积极的营养支持能改善机体的营养状况。PN与EN均能获得满意疗效,而N更具有营养全面、简易安全、方便价廉等优点,应作为营养支持的首选途径。     

外科术后经空肠肠内营养不耐受干预的研究进展

外科患者发生营养不良风险高,经空肠肠内营养是在临床广泛应用的营养支持疗法,但在临床应用过程可发生各种不耐受情况致使肠内营养被迫中断,影响康复进程。作者就营养不耐受的相关概念、发生率、影响因素以及临床实践有效的干预措施展开文献综述,以期指导临床规范化治疗肠内营养不耐受,保证能量供给。     

重型鼎脑损伤病人肠内营养的护理

重型颅脑损伤病人因意识障碍不能自行进食,易引起不同程度的营养障碍,并由此引发一系列病理生理功能紊乱,影响疾病的治疗和预后.为了解肠内营养(鼻饲)对重型颅脑损伤治疗的影响,1996年1月至1999年1月我们对69例重型颅脑损伤病人(肠内营养组)制定并实施了阶段化肠内营养护理方案,并与同期肠外(静脉)营养组进行了效果比较.报告如下.     

Factors affecting oral feeding with severe traumatic brain injury

Safe and adequate nutrition, vital to the recovery from a traumatic brain injury, can be severely compromised by the presence of dysphagia. This study identified injury severity and swallowing factors that were associated with impaired oral intake in patients with severe brain injury. An admitting Glasgow Coma Scale (GSC) 3-5; a Rancho Los Amigos Scale of Cognitive Functioning (RLA) Level II; a computed tomography (CT) scan exhibiting midline shift, brainstem involvement, or brain pathology requiring emergent operative procedures; or ventilation time >/=15 days identified patients at highest risk for abnormal swallowing, aspiration, and delay in initiation of oral feeding and achievement of total oral feeding. When combined in multivariate models, RLA Level, CT scan, ventilation time and aspiration emerged as significant independent predictors of impaired oral intake.     

Enteral nutrition in patients with severe traumatic brain injury: reasons for intolerance and medical management

Approximately, 50% of patients with severe traumatic brain injury (TBI) exhibit intolerance to enteral nutrition (EN). This intolerance hampers the survival and rehabilitation of this subpopulation to a great extent, and poses various difficulties for clinicians due to its complex underlying mechanisms. This review discusses the possible reasons for intolerance to EN following severe TBI, current trends in medical management, as well as other related issues that are experienced by many clinicians.     

Metabolism and nutrition in patients with moderate and severe traumatic brain injury: A systematic review

Primary objective: To examine the evidence on the metabolic state and nutritional treatment of patients with moderate-to-severe traumatic brain injury (TBI). Research design: A systematic review of the literature. Methods and procedures: From 1547 citations, 232 articles were identified and retrieved for text screening. Thirty-six studies fulfilled the criteria and 30 were accepted for data extraction. Main outcomes and results: Variations in measurement methods and definitions of metabolic abnormalities hampered comparison of studies. However, consistent data demonstrated increased metabolic rate (96-160% of the predicted values), of hypercatabolism (-3 to -16 g N per day) and of upper gastrointestinal intolerance in the majority of the patients during the first 2 weeks after injury. Data also indicated a tendency towards less morbidity and mortality in early fed patients. Conclusions: The impact of timing, content and ways of administration of nutritional support on neurological outcome after TBI remains to be demonstrated.     

Platelet dysfunction in patients with severe traumatic brain injury

Coagulopathy is a common phenomenon in traumatic brain injury (TBI) and a major contributor to a poor outcome. Thrombocytopenia is a strong negative prognostic factor in TBI, but bleeding tendency can be present even with a normal platelet count. We investigated platelet function in patients with TBI by means of modified thromboelastography (i.e., platelet mapping [TEG-PM]). Four groups were studied: (1) patients with severe isolated TBI (n = 20), (2) patients with general trauma without TBI (the ICU group, n = 10), (3) patients with chronic alcohol abuse (n = 7; as alcohol abuse is common in patients with TBI), and (4) healthy volunteers (n = 10). We measured platelet counts in venous blood (Plt), Ivy bleeding time, standard TEG parameters, and platelet responses to arachidonic acid (AA) and adenosindiphosphate (ADP), using TEG-PM. TBI patients had a lower Plt (180 +/- 68 x 10(9) ; mean +/- SD) and a longer bleeding time (674 +/- 230 sec) than healthy controls, (256 +/- 43 x 10(9), p < 0.01) and (320 +/- 95 sec, p < 0.005), respectively. TBI patients had dramatically lower platelet responses to AA (0-86%, mean 22%) compared to healthy controls (57-89%, mean 73%), the ICU group (4-75%, mean 49%), and the alcohol abusers (17-88%, mean 64%; p < 0.001). Responses to ADP did not differ significantly between the groups. Patients with low responsiveness to AA at admittance to the hospital were likely to develop bleeding complications later. Patients with TBI develop platelet dysfunction, which most likely contributes to bleeding complications. The observed platelet dysfunction appears to involve the cyclooxygenase pathway. TEG-PM analysis can be used to identify patients with a high risk of bleeding complications.     

Extracellular glycerol in patients with severe traumatic brain injury

Objective： To study the factors affecting extracellular glycerol （Gly） in patients with severe traumatic brain injury （STBI）.
Methods： Perilesional extracellular Gly and cerebral blood flow （CBF） in 53 patients with STBI were consecutively monitored. Simultaneously, the intracranial pressure （ICP） and cerebral perfusion pressure （CCP） were monitored. The hourly minimum of CCP and CBF and the hourly maximum of ICP levels were matched with the hourly Gly. Gly values were divided into several groups according to regional ICP （〈 15 nun Hg or 〉 15 nun Hg）, CCP （〈70 nun Hg or 〉70 nun Hg）, CBF （〈50 AU or 50-150 AU） and the outcomes （death or persistent vegetative state group, severe or moderate disability group, and good recovery group）.
Results： In comparison with the severe or moderate disability group, the Gly concentration of the death or persistent vegetative state group increased significantly, but CBF and CCP decreased significantly. In comparison with the good recovery group, the Gly concentration of the severe or moderate disability group increased significantly, but CBF and CCP decreased significantly. The Gly concen- trations in patients with ICP〉15 mm Hg, CCP〈70 mm Hg and CBF〈50 AU were respectively higher than those of patients with ICP 〈15 mm Hg, CCP〉70 mm Hg and 50AU 〈CBF〈150AU. In patients with diffuse axial injury, the mean Gly concentration was （201.17±55.00） μmol/L, which was significantly higher than that of the patients with epidural hematoma （n=7, 73.26±8.37, P〈O.05） or subdural hematoma （n=9, 114.67 ±62.88, P〈O.05）, but it did not increase signifi- cantly when compared with those in patients with contusion （n=24, 167.48±52.63）.
Conclusion： Gly can be taken as a marker for degrada- tion of membrane phospholipids and ischemia, which reflects the severity of primary or secondary insult.     

Management of severe traumatic brain injury

Severe brain injuries, most often occurring in young subjects, are a major source of lost work years. These injuries are medical and surgical emergencies. Prehospital management of severe brain injuries requires intubation and mechanical ventilation aimed at normal arterial carbon dioxide pressure. Signs of transtentorial herniation: Uni- or bilateral mydriasis requires immediate perfusion of 20% mannitol or hypertonic sodium chloride. Neurological disorders after head injury justify emergency cerebral computed tomography. The presence of a mass syndrome or signs of transtentorial herniation are in principle indications for surgery. Specialized hospital management is essential. In the case of refractory intracranial hypertension, the cerebral perfusion pressure and osmotherapy should be adapted to the volume of the cerebral contusion. The use of deep hypothermia and barbiturates should be minimized as much as possible. Magnetic resonance imaging makes it possible to identify the cerebral lesions.     

Vocational outcome of aphasic patients following severe traumatic brain injury

The incidence and course of aphasia, and its impact on vocational outcome, were determined in a group of 351 patients with severe traumatic brain injury TBI . Aphasia was found in 111 , the common forms being amnestic 56 , 22 39 , expressive 10 3 , 4 39 and receptive 10 5 , 8 39 , as found on the first language assessment. No age difference was found between the aphasic and nonaphasic patients. Coma was more common in the aphasics than the non-aphasics 95 and 82 , respectively , although its mean duration was shorter. Aphasics had more severe locomotor deficits p 0 01, Fisher test and tended towards more severe cognitive disorders p 0 07, Fisher test . There was no difference between the groups in incidence of behavioural disturbances or occupational outcome. Most of the aphasic patients improved after therapy, and two recovered completely. The presence of aphasia did not have negative prognostic implications for occupational outcome.     

Early enteral nutrition and clinical outcomes of severe traumatic brain injury patients in acute stage: a multi-center cohort study

Guidelines for patients with severe traumatic brain injury (sTBI) published in 2007 recommend providing early nutrition after trauma. Early enteral nutrition (EN) started within 48 h post-injury reduces clinical malnutrition, prevents bacterial translocation from the gastrointestinal tract, and improves outcome in sTBI patients sustaining hypermetabolism and hypercatabolism. The aim of this study was to examine the effect of early EN support on survival rate, Glasgow Coma Scale (GCS) score, and clinical outcome of sTBI patients. Medical records of sTBI patients with GCS scores 4-8 were recruited from 18 hospitals in Taiwan, excluding patients with GCS scores ≤3. During 2002-2010, data from 145 EN patients receiving appropriate calories and nutrients within 48 h post-trauma were collected and compared with 152 non-EN controls matched for gender, age, body weight, initial GCS score, and operative status. The EN patients had a greater survival rate and GCS score on the 7th day in the intensive care unit (ICU), and a better outcome at 1 month post-injury. After adjusting for age, gender, initial GCS score, and recruitment period, the non-EN patients had a hazard ratio of 14.63 (95% CI 8.58-24.91) compared with EN patients. The GCS score during the first 7 ICU days was significantly improved among EN patients with GCS scores of 6-8 compared with EN patients with GCS scores of 4-5 and non-EN patients with GCS scores of 6-8. This finding demonstrates that EN within 48 h post-injury is associated with better survival, GCS recovery, and outcome among sTBI patients, particularly in those with a GCS score of 6-8.