【作者】 陈勇鹏；

【导师】 陈善成；

【作者基本信息】 暨南大学 ， 神经外科， 2007， 硕士

【摘要】 目的：急性脑卒中由于应激往往引起一系列以大量瘦体组织丢失，机体抵抗力下降为特征的局部和全身的代谢反应，病情越重反应越严重。主要表现为能量消耗增加、高分解代谢、高血糖、胃肠道功能改变等。其代谢介质往往导致继发性神经功能损害和多个器官功能障碍。脑卒中的患者由于意识障碍，吞咽困难，不能进食，营养支持一直受到重视。传统观念认为急性脑卒中早期，因患者出现意识障碍，进食困难以及胃轻瘫等问题使胃肠营养难以实施，故多主张早期完全胃肠外营养(TPN)。近来，由于肠源性感染的提出，以及静脉营养带来的导管，代谢，感染等并发症，外科肠道营养尤其是早期肠道营养已逐渐受到重视。目前，急性脑卒中，特别是临床上常见的高血压脑出血(HICH)患者。早期胃肠营养的研究还缺乏比较客观和系统的资料。本研究前瞻性地研究了高血压脑出血(HICH)术后早期胃肠道营养对于改善预后，营养状况，降低高代谢反应和维护胃肠道功能等方面的作用，进一步探讨了高血压脑出血术后早期胃肠道营养的作用机理和临床应用。方法：高血压脑出血(HICH)住院病人36例。男29例，女7例。年龄57~78岁，GCS 6~11评分。入院后均在6小时内手术，随机分为早期胃肠道营养组(EEN组)和早期完全胃肠外营养组(TPN组)。两组平均年龄、GCS评分、身高、体重、损伤类型及治疗措施无明显差异。EEN组和TPN组病人营养支持均为术后48小时，EEN组给予经鼻胃管24小时持续滴注安素(ENSURE，美国雅培公司)；TPN组静滴肠外营养液。研究期限至术后28天。结果：两组均在术后2周内均为负氮平衡，EEN组术后6天24小时排出氮明显高于TPN组(P＜0.05)，故EEN组术后6天的氮平衡优于TPN组(P＜0.05)。血清白蛋白术后表现为持续低蛋白血症，研究期间两组无显著差别。肌酐身高指数(ICr)也显下降趋势，但EEN组在术后14、28天仍明显优于TPN组(P＜0.05)。两组术后血糖、血浆胰岛素和皮质醇在术后显著上升(P＜0.05-0.01)，两组高血糖水平在术后第6天达高峰，此时，EEN组血糖和血浆胰岛素水平显著低于TPN组(P＜0.05~P＜0.01)。EEN组的皮质醇水平在术后低于TPN组(P＜0.05-0.01)，术后28天回复正常范围，而TPN组仍高于正常。与TPN组比较，术后6天内EEN组的返流，误吸无明显增加，而EEN组的上消化道出血，腹胀，腹泻，便秘和拒食的发生率显著减少(p＜0.05~P0.01)。在术后28天，EEN组体重平均丢失4.73kg，而TPN组则丢失6.24kg，EEN组的大多数营养指标显著优于TPN组(P＜0.05~P＜0.01)，GCS评分也明显高于TPN组(P＜0.05)。结论：高血压脑出血(HICH)术后对通过鼻胃管持续滴注喂养方法的提供早期胃肠道营养方法有良好的耐受性。研究表明，高血压脑出血(HICH)术后早期胃肠道营养支持不仅避免了TPN高血糖等代谢并发症，还能减少机体瘦体组织分解，保存体重，降低术后高分解代谢的作用机理与减少循环中的应激激素的释放，更重要的是减轻了肠道的缺血再灌注损伤，维护了胃肠道结构和功能，这对改善高血压脑出血后全身营养状态和神经功能的恢复大有裨益。更多还原

【Abstract】 Background : Patients with acute cerebral apoplexy require nutritional support becease of an accelerated metabolism and prolonged inability to eat. Because of unconsciousness , hypoalimentation , the high incedence of gastropareis, enteral nutritional support of patient with acute head injury has traditionally been difficult and let to frequentuse of total parenteral nutrition (TPN). In recent years, recognizing the advantage of enteral feeding and complications of metalolism indcued by TPN, the enteral nutrition, in especial early enteral feeding, has been paid much attention to the treatment of severe head injury. To date, it shows lack of objective and serial data about clinical study of early enteral feeding post acute apoplexy stroke, especially, hypertension cerebral hemorrhage (HICH) . This pospect study evaduats that tolerance of modified nasogastric feeding as early nutritional support, attempts to appraise the mechanism and clinical effect of early enteral feeding, versus TPN with equivalent caloric and nitrogen intake, on improving outcome, nutritional state, modulating hypermetabolism and maintaining gut functions in HICH patients.Methods: 36 cases were collected, male 29, female 7, age 57~78yrs, GCS score 6~11. All the patients were admitted operation within 6hrs, and divided randomly into early enteral feeding group (EEFg), and total parenteral nutrition group (TPNg). There were no significant difference in age, GCS score, bodyweight, type of neurological in jury, and associated treatment. Nutritional support of two groups of patients were started within 48 hrs post injury, ENSURE (ABBOTT LABORATORIES, America) was supplemented by nose-gastide tube feeding within 48 hrs postin jury in EENg. Patients were studied from hospital admission to 28 days postin jury.Results: Positive nitrogen balance is not achieved in two groups during 2 wks postinjury, the 24 hrs total nitrogen loss in EENg decreased more than that of TPNg on 6 days postinjury (P＜0. 05), EENg had greater cumulative nitrogen balances compared with the TPNg on 6 days postinjury (P＜0. 05) . Serum albumin was well maitained at mild levels of "depletion", and there were notsignificantly between two groups. The trend of the ICr is about the same, TPNg on 14, 28 days postinjury is signifcantly lower than those of EENg (P＜0.05) .Serum glucose, Insulin and cortisol are increased postinjury(P＜0. 05-0.01). Hyperglycemia of two groups were to peak on 6 day postinjury. At this time, Serum glucose, Insulin in EENg is significantly lower than that of TPNg (P＜0. 05) . Cortisol on EENg is much lower than TPNg at most timepoints (P＜0. 05-0.01), relapse to normal range, but that of TPNg is anomaly.As compare with TPNg, *** of EENg were not increased during 6 days postinjury (p＜0. 05~P0. 01). However, controlled study demonstrated a reduction in gastric bleeding, *, diarrhea, constipation and* with early enteral feeding(P＜0. 05). On 4 wks postinjury, EENg lost a mean weight 4.73 kg, TPNg lost 6.24 kg (P＜0. 05), most of the nutritional appraisal of EENg are significantly better than those of TPNg (P＜0. 05), GCS score in EENg was noted to be higher inTPNg (P＜0. 05).Conclusion: Evidence indicates that aggressive early enteral feeding regnimens using small nasogastric tude are tolerared better than previously believed. It is indicated that the early enteral feeding not only could effectively avoid hyerglycemia of TPN, but also lessen massive loss of lean body mass and preserve bodyweight. It is suggested that the early nutrition reduced hypermetabolism were by means of decreasing the level of mediator such as catablic hormone in blood stream, and was noticely associated with a lower incidence of the gut reperfusion injury, assertting, gastric-intestinal structure and function. The optimal enteral nutritional support can improve the whole nutrition state and be beneficial to neurologic recovery following head injury.更多还原