肝移植术后早期营养支持的护理

随着肝移植手术的不断开展,与手术相关的并发症逐渐减少,而许多围手术期因素成为影响肝移植成败的关键。近几年,我院成功开展肝移植14例,结合患者不同情况分别进行术后早期营养支持的护理,收到良好疗效,现报告如下。1资料与方法1.1临床资料本组14例,男11例,女3例;30～68岁,平均55.1岁。1例为重症肝炎引起肝功能衰竭,2例为肝门胆管癌并肝功能衰竭,11例为肝癌患者。1.2营养支持的方法包括完全肠外营养(TPN),肠内营养(EN)。术后1～3d每天需摄入总热能100～125.5kJ/kg,其中碳水化合物和脂肪各占50%,主要通过TPN补充。术后4d,每天需摄入总热…     

药物所致低血糖

现将文献药物所致低血糖摘要如下。1左氧氟沙星男,72岁。因慢性支气管炎并感染给予盐酸左氧氟沙星0.3 g静滴,1次/d,用药前血糖检查正常,用药4次后出现出汗、表情淡漠、反应迟钝等,急查末梢指血1.1 mm o l/L,静脉血糖1.0 mm o l/L,给予对症治疗后,血糖恢复至3.9 mm o l/L。笔者提示:老年人合并糖尿病或肾功能不全时,应慎用本品,若病情需要则用药时应注意监测血糖[1]。2加替沙星男,91岁。因慢性支气管炎并感染给予加替沙星0.4 g+生理盐水100 m l静滴,1次/d,用药3 d后查血糖为2.2 mm o l/L,次日降至1.3 mm o l/L,并出现短暂的全身抽搐,停药后…     

以昏迷为首发症状的胰岛素瘤1例

1病历摘要女,61岁。以昏迷2 h为主诉于5:00急诊来院就诊。来院途中抽搐1次。在急诊科行头颅CT检查未见异常,以昏迷待查、脑出血收住我科。查体:BP 18/11 kPa,体形肥胖,呼吸急促,呈深昏迷,双侧瞳孔等大等圆,直径约3.5 mm,对光反应迟钝,膝腱反射引不出,肌张力减退,双侧巴氏征(+)。既往无高血压及糖尿病史,给予营养脑神经细胞治疗,因体型肥胖为进一步排除糖尿病,急查血糖示:0.34 mm o l/L,立即给予静注50%葡萄糖液160 m l,并给予10%葡萄糖液维持静滴,2 h后神志转清,病理反射消失,复查血糖4.9 mm o l/L,遂停止治疗。次日凌晨出现幻视、幻听、失语,急查血糖示1.1 mm o l/L,给予静注高糖及口服糖水后症状很快消失。反复追问病史诉近2 a来不时后半夜有幻觉、躁狂等精神失常表现,晨起进食后症状消失。即行腹部CT检查示:胰岛β细胞瘤。后行手术治疗,术后血糖回升,随访1 a,未再出现精神症状。2讨论胰岛素瘤是临床少见病,多数医师对此缺乏经验,未认真进行鉴别诊断,容易误诊。低血糖昏迷为临床常见症状,胰岛素瘤为器质性低血糖症中较常见的病因,因胰岛素分泌增多,导致低血糖反...     

老年糖尿病患者肺围手术期的处理

目的探讨老年糖尿病患者肺围手术期血糖的控制及其对手术的影响。方法回顾分析 4 5例肺疾病并发糖尿病患者接受肺手术治疗围手术期的血糖调控情况。结果 4 5例患者入院时血糖 (14± 1.5 )mmol/L ,经术前用胰岛素控制 ,血糖稳定至 (7.5± 1.0 )mmol/L后 ,分别接受肺手术治疗 ,术中及术后监测血糖 ,并继续用胰岛素 ,术后血糖为 (7.8± 1.5 )mmol/L。 4 5例中切口感染 3例 (6 .6 % ) ,心率失常 5例 (11.1% ) ,心功能不全 2例 (4.4 % )。结论老年糖尿病患者经正确的围手术期处理 ,将血糖控制在基本正常水平 ,即可耐受复杂的肺脏手术。     

胰十二指肠手术患者早期肠内营养支持耐受性及相关因素分析

目的 探讨胰十二指肠手术(PD)患者早期肠内营养(EN)支持耐受性及相关因素。方法 选取107例PD手术患者为研究对象,根据术后EN耐受情况,将患者分为耐受组和不耐受组。采用单因素和多因素logistic回归分析PD术后患者EN不耐受的影响因素。结果 107例PD术后患者,EN不耐受40例(37.38%),耐受67例(62.62%)。耐受组和不耐受组在年龄、术后随机血糖、术前总胆红素、胰管直径、术后低蛋白血症比较,差异均有统计学意义(χ²分别=5.50、10.43、33.75、27.01、7.97,P均<0.05)。logistic回归分析结果显示,术后随机血糖≥11 mmol/L、术前总胆红素≥300μmol/L、胰管直径<3 mm、术后低蛋白血症是影响PD术后患者EN不耐受的危险因素(OR分别=1.35、3.46、2.15、1.86,P均<0.05)。结论 PD术后患者EN耐受性较差,影响PD术后患者EN不耐受的危险因素有术后随机血糖≥11 mmol/L、术前总胆红素≥300μmol/L、胰管直径<3 mm、术后低蛋白血症。     

CRRT在肝移植术后早期AKI患者治疗中的应用

<正>1肝移植术后死亡原因及AKI概述自1963年第1例肝移植术开展至今,经过50多年不断的发展,肝移植术已成为治疗早期肝癌和急性肝衰竭最有效的方法。尽管随着外科技术的发展以及免疫抑制剂的研究应用,肝移植术后患者的生存率在不断提高,但肝移植术后并发症及围手术期患者的死亡仍是制约肝移植术进一步发展的重要原因。目前来说,肝移植术后早期(通常指存活期1年内)患者的死亡原因主要有感染、器官功能衰竭     

血糖测定前误差的影响因素及解决方法探讨

目的:探讨糖酵解引起的离体血糖下降所造成的血糖分析前误差的主要影响因素及解决方法。方法:随机抽取30例志愿者血标本,观察在4℃、25℃、37℃条件下血糖随时间(0 h、2 h、4 h、6 h、8 h)下降速度;调查40例门诊患者因分析前误差造成的血糖测定偏差;分析普通玻璃管及各种真空采血管(加糖酵解抑制剂、促凝剂、促凝剂+分离胶)及血标本处理方式在减少离体血糖下降的作用。结果:4℃放置8 h未离心标本,血糖平均下降1.01 mm o l/L;而在37℃,血糖平均下降5.07 mm o l/L。40例门诊患者由分析前误差造成的血糖测定平均降低(0.652±0.351)mm o l/L,容易造成糖尿病的误漏诊;氟化钠在前1~2 h抑制效果差;甘油醛抑制剂能保持血糖8 h基本不下降;30例促凝剂管采血后尽早离心(15 m in),离心后放置4 h平均血糖下降(0.113±0.031)mm o l/L。结论:离体血糖的下降速度与血标本采集处理方式、温度、放置时间、管洁度密切相关;采用加促凝剂的真空管采血且及早离心、加甘油醛为血糖抑制剂的方法能较好地解决离体血糖下降引起的分析前误差问题。     

两种检测血糖方法的对比

我院内分泌疗区为了快速和方便的检测血糖,特购买了血糖仪。本资料根据卫生部临床检验中心关于实验室内质量控制、校准和内部比对要求[1],定期对我院内分泌疗区血糖仪与实验室生化分析仪的血糖测定结果进行比对和分析,旨在探讨提高血糖仪检测结果可靠性的质量管理手段。1材料和方法1.1仪器和试剂美国雅培公司生产的Q ID手握式血糖仪及其配套试纸条。美国雅培全自动生化分析仪及其配套的校准液、质控物和试剂。1.2样本来源室内质控标本采用各公司生产的高、中、低血糖模拟液。比对试验标本采用乙二胺四乙酸(EDTA)-K2抗凝全血。1.3方法按文献[2]要求配制5个不同血糖浓度的全血标本。具体操作:收集红细胞压积在40%~50%范围的正常人EDTA-K2抗凝的混合全血标本,用生化分析仪测定血浆葡萄糖糖浓度后分成4份,每份5 m l,在每份标本中加入0.25 m l不同浓度的葡萄糖生理盐水溶液,使其终浓度在2.9~6.1 mm o l/L(水平2)、6.2~8.3 mm o l/L(水平3)、8.4~13.9 mm o l/L(水平4)及14.0~22.2 mm o l/L(水平5)4个范围内。另外,收集1份红细胞压积在40%~50%范...     

疏血通治疗糖尿病周围神经病变疗效观察

糖尿病周围神经病变(DPN)是糖尿病(DM)常见的慢性并发症,发病率可达47%以上[1],严重影响其生活质量,甚至导致患者致残死亡。目前,DPN治疗方法很多,我们采用疏血通治疗DPN,并于治疗前后测定周围神经传导速度,以期用量化指标确定周围神经功能,现报告如下。1对象和方法1.1对象本组诊断符合以下标准:(1)符合1997-07美国糖尿病学会(ADA)年会糖尿病诊断标准:有糖尿病病状,空腹血糖>7.0 mm o l/L,和(或)餐后2 h血糖>11.10 mm o l/L。(2)具有以下神经系统病变:四肢末梢有感觉异常和(或)感觉障碍,均有不同程度的双下肢麻木、疼痛、腱反射减弱…     

开放性胃癌根治术围术期营养支持治疗现状调查

目的:分析开放性胃癌根治术围术期营养支持治疗的现状及可能存在的不足,为进一步改善围术期营养支持治疗提供依据。方法:回顾性分析复旦大学附属中山医院2019年1月至12月择(限)期完成开放性胃癌根治术的1 304例患者的临床资料,比较围术期营养支持比例、途径及成分、相关指标水平等。结果:仅接受术前营养支持者、仅接受术后营养支持者、术前术后均接受营养支持者分别占1.7%、56.9%、8.6%,共占67.2%(876/1 304)。术前采用完全肠外营养支持(total parenteral nutrition, TPN)与肠内营养支持(enteral nutrition, EN)者分别为112、21例(5.3∶1),术后采用TPN、EN、PN+EN者分别为558、102、194例(5.5∶1∶1.9)。术后进行TPN的558例患者中,采用全合一(all in one, AIO)营养液者107例,其总热量、每千克体质量热量、每千克体质量蛋白质补充量、热氮比分别为(1 256.7±169.4)kcal/d、(20.7±4.0)kcal·kg~(-1)·d~(-1)、(1.2±0.5)g·kg~(-1)·d~(-1)、(101.1±53.8)∶1;采用单瓶营养素者451例,总热量、每千克体质量热量、每千克体质量蛋白质补充量、热氮比分别为(325.2±79.2)kcal/d、(5.4±1.7)kcal·kg~(-1)·d~(-1)、(0.4±0.1)g·kg~(-1)·d~(-1)、(58.0±23.7)∶1。术后仅采用AIO进行TPN者术前白蛋白[(39.7±5.0)g/L]、前白蛋白[(211.2±55.6)mg/L]显著低于仅采用单瓶营养素支持者[(41.3±4.0)g/L、(222.4±52.0)mg/L,P0.05],术后血糖[(6.3±2.0)mmol/L]高于采用单瓶营养素支持者[(5.5±1.3)mmol/L,P0.01]。结论:营养支持已得到重视,围术期营养支持较高,但术后TPN中蛋白质/氨基酸供给量未达到指南要求。     

Enteral nutrition in hypermetabolic surgical patients

Enteral nutrition is usually administered with premixed formulas and in a volume determined by the estimated total caloric need of the patient. The present study was undertaken to evaluate the nutritional outcome when isocaloric amounts of three commercial products were given as enteral nutrition in hypermetabolic surgical ICU patients. To qualify for the study, the patients had to be hypermetabolic and must have received and retained the volume of enteral formula estimated to meet energy and nutritional requirements for at least eight consecutive days. Caloric needs were defined as 30 to 35 total cal/kg.day. All data were prospectively collected; all patients had moderate to high-level metabolic stress after surgical intervention. Thirty-five patients participated in the study: 18 received a formula that was 23% amino acids, 20% fat, and had a nonprotein calorie/nitrogen (NPC/N) ratio of 97:1; ten patients received a formula with NPC/N 125:1 that was 17.5% protein and 35% fat; and seven patients received a formula with an NPC/N of 149:1 that was 15.3% amino acids and 2.5% fat. All formulas were given via nasoduodenal tube by continuous pump technique. Patients who received the low NPC/N had significantly greater N retention (p less than .05), increased plasma transferrin levels (p less than .05), and a lower RQ (p less than .05). There was a strong correlation between NPC/N and N retention and the increase in plasma transferrin levels. Thus, dosing enteral nutrition by total estimated caloric need does not presume optimal nutritional outcome. Formula composition is an important determinant of nutritional effect; formulas that have a lower NPC/N with more N and reduced calories as glucose demonstrate better nutritional results.     

Factors determining the appearance of glucose in upper and lower respiratory tract secretions

Objectives (a) To describe the glucose content of normal human airways secretions; (b) to observe the effects of hyperglycemia and airways inflammation on airways glucose.Design Observational studies.Settings (a) St George's Hospital Medical School; (b) diabetes mellitus outpatient clinics; (c) adult general intensive care unit.Patients Nineteen healthy volunteers, 24 volunteers with acute rhinitis, 20 patients with diabetes mellitus, and 60 patients admitted to a general adult intensive care unit.Measurements (a) Non-ventilated patients: simultaneous measurement of blood and nasal glucose concentrations; (b) ICU patients: simultaneous blood, nasal, and endotracheal (ET) glucose concentrations.Results Nasal glucose was undetectable in all healthy volunteers. Glucose was detected in 12/24 volunteers with acute viral rhinitis [1 (1–2) mmol l^–1] and 18/20 people with diabetes [4 (2–7) mmol l^–1]. Glucose was detected in the ET secretions of 31/60 ventilated patients on ICU. Patients with ET glucose had significantly higher blood glucose (9.8±0.4 mmol l^–1) than patients without ET glucose (7.2±0.3 mmol l^–1, P<0.001), and all patients with blood glucose >10.1 mmol l^–1 had glucose in ET secretions. Enteral nutrition did not affect the presence or concentration of glucose in ET secretions.Conclusions Glucose is not normally present in airways secretions, but appears where hyperglycaemia or epithelial inflammation occur. The detection of glucose cannot reliably be used to detect enteral feed aspiration.Abbreviations CSF Cerebrospinal fluid - HbA₁C Glycosylated haemoglobin - ICU Intensive care unit - SEM Standard error of mean     

Evidence for adaptive diet-induced thermogenesis in man during intravenous nutrition with hypertonic glucose

This study was designed to investigate the thermogenic effect of intravenously administered nutrition with glucose (given a fixed nitrogen intake of 12.5 g daily as amino acids) as the principal source of energy. The protocol was designed so that each patient received their energy intake in five consecutive periods of 3 days with intakes ranging from 6650 to 17,100 kJ/day with increments or decrements of 2600 kJ. Thermogenesis from administered glucose was evident between levels of energy supply of 6650 kJ/day and 17,100 kJ/day. The progressive rise in oxygen consumption and carbon dioxide production accounted for a total of 31% of the additional glucose which was administered. The net rate of fat synthesis from glucose reached a maximum 147 g/day at an energy supply of 14,500 kJ/day. This study suggests that both fat synthesis and the associated obligatory thermogenesis is the main component of diet-induced thermogenesis in response to glucose intakes in excess of 150 kJ day-1 kg-1. If the energy cost of fat synthesis (fat associated obligatory thermogenesis) is taken to be 22% of the total energy of the increase in glucose supplied, then only 9% (31-22%) of the glucose can be accounted for by adaptive thermogenesis.     

肝移植术后肠内营养时机选择的探讨

目的 探讨肝移植术后肠内营养的恰当时机.方法 将2005年6月至2006年7月实施原位肝移植术的46例患者随机分为实验组(术后第1天给予肠内营养)和常规组(患者肛门排气、胃肠道功能恢复后给予肠内营养),各23例,比较两组患者的术后感染率、胃肠道功能恢复情况、ICU监护时间、营养费用及并发症发生率.结果 实验组患者肝移植术后肺部感染率、导管源性感染率、营养费用均显著低于常规组(P＜0.05或P＜0.01);胃肠道功能恢复时间、ICU监护时间较常规组短(P＜0.01);并发症发生率和腹腔感染率两组无统计学差异(P＞0.05).结论 肝移植术后第1天给予肠内营养可有效降低肺部和导管源性感染率,促进胃肠道功能恢复,缩短ICU监护时间,降低营养费用.     

危重病患者抢救中胰岛素强化治疗的探讨

目的观察胰岛素强化治疗能否改善重症监护室（ICU）危重患者的预后。方法将116例危重患者随机分为传统治疗组（CT组）和胰岛素强化治疗组（IT组），每4h监测1次床旁血糖。当CT组血糖＞11．9mmol／L时，皮下注射中性可溶性胰岛素控制血糖在10．0～11．1mmol／L；当IT组血糖＞6．1mmol／L时，皮下注射胰岛素控制血糖在4．4～6．1mmol／L。记录患者ICU住院时间、使用呼吸机时间、气管插管或气管套管留置时间、每日早6时平均血糖、每日提供的平均热量、每日胰岛素用量、每日简化治疗干预评分系统-28（TISS-28）评分、人白细胞DR抗原（HLA—DR）、CD4^＋／CD8^＋，死亡、低血糖、肾功能损害（血肌酐＞221／μmol／L）和高胆红素血症（总胆红素＞34．2μmol／L）、输红细胞及发热（口温＞38．5℃）例数。结果CT组病死率（44．83％）远远高于IT组（12．07％），差异有显著性（P＜O．01）；患者ICU住院时间、使用呼吸机时间、气管插管留置时间、每日早6时平均血糖、每日TISS-28评分均明显高于IT组（P＜0．05或P＜0．01）；每日胰岛素用量、HLADR、CD4^＋／CD8^＋均明显低于IT组（P＜0．05或P＜0．01）。两组并发症比较，CT组患者发生肾功能损害、输注红细胞及发热例数均明显高于IT组（P均＜0．01）。结论胰岛素强化治疗控制危重患者血糖在4．4～6．1mmol／L水平确能降低患者的病死率。     

早期肠内营养对肝移植患者术后转归的影响

目的探讨早期肠内营养支持对肝移植患者术后转归的影响。方法将接受肝移植的26例患者随机分为肠内营养组和静脉营养组进行随机对照临床试验,记录患者的感染率、死亡率、住院时间、住院费用、血糖测定值及胰岛素用量。结果肠内营养组感染率、死亡率与静脉营养组差异无显著意义;其住院时间及住院费用比静脉营养组少（P〈0．05）;在控制血糖等效的情况下,术后6d内胰岛素日平均用量比静脉营养组低（P=0．031）。结论肝移植术后早期肠内营养能减轻胰岛素抵抗,降低住院费用并缩短住院时间。     

不同碳水化合物肠内营养液对应激性高血糖患者早期血糖水平与预后的影响

目的观察不同的碳水化合物肠内营养液［肠内营养乳剂（TPF-D）和肠内营养混悬液（TPF）］用于早期肠内营养对应激性高血糖患者血糖水平与预后的影响,探讨其作为应激性高血糖患者早期肠内营养制剂的临床可行性。 方法选入2020年6至10月徐州医科大学附属医院急诊ICU收治的合并应激性高血糖的患者为研究对象。根据入排标准,最终71例患者纳入研究,随机数字表法将其分为观察组（35例,鼻饲TPF-D）和对照组（36例,鼻饲TPF）。收集患者一般资料,包括性别、年龄、急性生理与慢性健康状况（APACHE Ⅱ）评分;记录患者第1、3、7天每4小时一次血糖数据,并计算平均血糖值（GLU_AVE）、平均血糖波动幅度（GLU_MAGE）;计算治疗后3、7 d胰岛素应用总量;监测患者第1、7天相关营养指标变化,如总蛋白（TP）、白蛋白（ALB）、前白蛋白（PA）;记录胃肠道并发症（如反流、呕吐、腹泻、腹胀等）、ICU住院时间及28 d病死率。 结果（1）2组性别比例、年龄、APACHE Ⅱ评分比较,差异均无统计学意义（P＞0.05）。（2）2组第1、3、7天GLU_AVE及第1、3天GLU_MAGE比较,差异均无统计学意义（P＞0.05）;观察组第7天GLU_MAGE显著低于对照组,差异有统计学意义［（0.72±0.08）mmol/L vs（1.56±0.10）mmol/L,t=6.22,P=0.02］。（3）观察组治疗3、7 d胰岛素应用总量显著低于对照组,差异均有统计学意义［（60.40±39.80）U vs（102.70±49.60）U,t=0.17,P=0.02;（110.50±43.30）U vs（202.80±56.40）U,t=2.52,P=0.01］。（4）2组第1、7天TP、PA、ALB比较,差异均无统计学意义（P＞0.05）。（5）2组胃肠道并发症、ICU住院时间、28 d病死率比较,差异均无统计学意义（P＞0.05）。 结论应激性高血糖患者早期营养中,TPF-D较TPF能更好地降低血糖变异性,控制血糖波动幅度,并减少临床中胰岛素用量,但不影响预后。     

Haematological changes during parenteral nutrition of malnourished patients with an enteral disease

The present study assesses the blood haemoglobin concentration, the mean corpuscular haemoglobin concentration and the mean corpuscular volumes, as well as the serum iron levels and the total iron binding capacities in 28 malnourished patients with an enteral disease before and after 10-12 days of pre-operative parenteral nutrition of three different kinds: one with glucose, a second with glucose and fat as energy source, and a third rich in amino acids. About half of the patients in each group also received intramuscular iron supplementation of 1.79 mmol every 2 days. Before the nutritional therapy, 54% of the patients had a subnormal serum iron level; on average, serum iron was 10.5 (SD 7.4) mumol/l. In spite of this, 50% of the patients had a TIBC level less than normal and 43% of the patients within the normal range. Ninety-three percent of the patients had an anaemia which, in most cases, was normochromic and normocytic. On average, blood haemoglobin was 110 (SD 12) g/l. After 10-12 days of parenteral nutrition, the blood haemoglobin concentration decreased independently of the quality of the intravenous alimentation, the serum iron level and the intramuscular iron supplementation. The fall in the blood haemoglobin level was on average 11.2%.(ABSTRACT TRUNCATED AT 250 WORDS)