- 學位論文
比較應用Faisy與Harris-Benedict熱量估算公式於延長使用呼吸器的慢性肺部損傷重症老人的臨床結果表現:以南部某區域教學醫院為例
Comparison between applying Faisy equation and Harris-Benedict equation to ill elderly patients with chronic respiratory failure receiving prolonged mechanical ventilation: A randomized trial in a southern Taiwan regional teaching hospital
摘要
本研究主要目的是對於因呼吸衰竭必須延長使用呼吸器的重症老人，因慢性重症疾病症候群造成的成人-瓜西奧科營養不良症的低白蛋血症與全身性水腫營養不良問題，探討目前使用Harris-Benedict公式評估所需的熱量與蛋白質，是否低估病人的能量需求，及利用Faisy公式，所提供的熱量與蛋白質，是否較能有效降低營養風險，以協助這類呼吸衰竭的病人提早脫離呼吸器。並運用適當且客觀的營養評估法，正確判斷營養狀況,給予合適的營養支持以維持肌肉強度及達到能量需求進而改善營養不良的臨床問題。研究對象為南部某一區域教學醫院住在亞急性呼吸照護中心使用呼吸器大於14天以上的老人共78位，這78位受試者參與這項隨機臨床對照控制試驗，並隨機分派到實驗組與控制組，分別接受Faisy及Harris-Benedict方程式估算的不同熱量(29.65±2.7 kcal/kg/d vs 25.88±1.9 kcal/kg/d)及不同蛋白質飲食(1.53±0.2 g/kg/d vs 1.24±0.1 g/kg/d)的營養治療。營養治療介入時間為入呼吸加護病房開始直到脫離呼吸器轉出呼吸加護病房為止。研究介入為期7個月共收集病人的基本臨床資料，血液生化值，動脈血液氣體分析値，營養狀況評估資料與脫離呼吸器相關資料。運用老人營養風險指標(Geriatric Nutritional risk index; GNRI)評估營養風險並利用SPSS PASW18統計軟體進行實驗結果統計分析。實驗結果顯示Faisy方程式(實驗組)嚴重營養風險(Severe risk)人數比例經營養治療介入後由46.7%降到33.3%；無營養風險(No risk)人數比例由8.9%增加到15.6%，Harris-Benedict方程式(對照組) 經營養治療介入後嚴重營養風險(Severe risk)人數比例由24%增加到27.3%，無營養風險(No risk)人數比例仍維持27.3%，兩組GNRI組間具顯著性差異，p<0.001。對於BMI<20(kg/m2)病人，Faisy方程式(實驗組)的營養治療介入對血中平均白蛋白濃度(2.67±0.4 vs 3.02±0.5 g/l，p<0.001)比Harris-Benedict方程式(對照組)(2.19±0.5 vs 2.46±0.3 g/l，p=0.125)具顯著性差異。兩組成功脫離呼吸器比例並無顯著性差異(25/12(67.6%) vs 19/8(70.4%) ; P = 1.000)，因此次實驗期較短及收案樣本數太少，因此可能影響脫離呼吸器研究結果。本研究以老人營養風險指標(Geriatric Nutritional risk index,GNRI)評估延長使用呼吸器的重症老人營養風險，以主觀性營養評估 (Subjective Global Assessment，SGA) 評估其營養狀況，兩者相輔相成，能確實篩選出營養問題，及時給予合適的營養治療與介入。Faisy方程式評估出的熱量與蛋白質，經實驗結果證實對於這群呼吸衰竭的重症老人可提升GNRI値，且對於BMI< 20 kg / m2者，可提升白蛋白的濃度，因而降低營養風險，給予這類病人最大營養支持的貢獻。
並列摘要
The elderly with lung injury often develop respiratory failure and normally requires tracheostomy and prolonged mechanical ventilation (PMV), which usually demonstrates nutrition problems of hypoalbuminemia and anasarca due to chronic critical illness syndromes caused by adult kwashiorkor-like malnutrition. The study was aimed to investigate whether the Harris-Benedict equation may underestimate the patients’ need of calories and protein, and to exam whether Faisy formula can provide more adequate estimation, and subsequently reduce the risk of malnutrition, and support patients to adopt early weaning of ventilation equipment. A total of 78 subjects participated in this randomized controlled clinical trials. They were from a regional teaching hospital in the southern Taiwan, residing in sub-acute respiratory care center, with average age over 65 years old and had used respirator for more than 14 days. In the experimental group (Faisy), we provided calories of 29.65 ± 2.7kcal/kg/d, and protein of 1.53 ± 0.2g/kg / d, while in control group (Harris-Benedict) provide calories with 25.88 ± 1.9kcal/kg/d, and 1.24 ± 0.1g/kg/d of protein. Diet therapy intervention started when patients entering the RCC(Respiratory care center), and ended when being transferred from RCC. Basic clinical information, blood biochemical parameters, arterial blood gas analysis data, and nutritional assessment with weaning information were collected. GNRI nutritional assessment tools were used to assess the patient's nutritional risk. Results indicated that if calorie and protein was provided based on Faisy equation (experimental group) calculation may alleviate patients’ nutritional crisis and reduce the percentages of patients facing severe nutritional risk (dropped to 33.3% from the 46.7 percent). On the contrary, the proportion of patients in the category of non-nutritional risk (No risk) increased from 8.9% to 15.6 %. Results from the control group, in which patients receiving calorie and protein based on Harris-Benedict equation, showed the proportion of patients with severe nutritional risk slightly increased from 24% to 27.3% (p>0.05), and the proportion of patients with non-nutritional risk remained 27.3%. GNRI showed significant difference between control and experimental groups (p <0.001). For patients with BMI <20 (kg/m2), mean serum albumin concentration (2.67 ± 0.4 vs 3.02 ± 0.5 g / l, p <0.001) in the experimental using Faisy equation significantly higher than those seen in those patients applying Harris -Benedict equation in control group (2.19 ± 0.5 vs 2.46 ± 0.3 g / l, p = 0.125). Successfully weaned ratio between the two groups showed no significant difference (67.6% vs 70.4%; p= 1.000). In this study, we assessed elderly patients with PMV using Geriatric Nutritional risk index (GNRI), and Subjective Global Assessment (SGA). When applied Faisy equation to calculate calories and protein, our results confirmed that the group of elderly people with severe respiratory failure can improve GNRI , and in particular for those patients with BMI less than 20 kg / m2, the approach using Faisy equation could enhance the concentration of albumin, thereby reduced risk, and contribute to provide these patients with maximum nutritional support.