- 期刊
心衰竭使用左心輔助器後接受心臟移植病人營養照護個案報告
Nutrition Care of a Heart Failure Case- Using Left Ventricular Assist Device to Receive Heart Transplantion Patient
摘要
左心衰竭病人臨床常需使用左心室輔助器（left ventricular assist devices, LVAD）維持生命等待心臟移植重生，個案是一位37歲男性罹患高血壓且無常規藥物控制，平日飲食為高油、高糖、少運動的科技業人，此次因工作時忽感呼吸喘被送入醫院加護病房治療。因呼吸衰竭併心臟功能不全，使用呼吸器、葉克膜及左心室輔助器維持生命，左心室射出率僅17%，腎功能也一度變惡化需以連續性透析方式維持腎功能，葉克膜移除後裝上左心室輔助器維持心臟功能，待病人狀況穩定後給予呼吸訓練，等待心臟移植手術。照護期間因肌力與意識改變，電腦斷層檢查確定為中風。病人入住加護病房後，生命徵象穩定48小時內即給予鼻胃管灌食進行腸道營養支持，並同時給予心肺復健與吞嚥功能訓練，狀況穩定後帶著左心輔助器轉病房等待心移植。病房給予鼻胃管餵食並嘗試經口進食之吞嚥轉換飲食，經數日努力由口進食量漸多且無嗆食問題後，鼻胃管移除，於4個月後等到心臟移植。心臟移植術後3個月內給予高熱量、高蛋白飲食以維持手術傷口修復。病人移植後因終生需服用抗排斥藥物，因病人未婚加上中風造成單側肢體無力無法生活自理，移植術後飲食與營養照護相關注意事項衛教對象為案姊。衛教內容包含：食物製備衛生教育（避免生食、飲用水需煮沸）、避免感染、定時服用抗排斥藥物維持血中濃度、避免排藥物與食物（柚子）交互作用影響藥物濃度、避免補充或食用增強免疫能力的中藥材如人參等。衛教亦包含移植手術穩定後，須注意抗排斥藥物造成的併發症及高血糖、高血脂、肥胖及高尿酸血症等，良好的術後控制，才能維持心臟正常功能與存活率。病人出院後入住護理之家，也常規於門診追蹤。藉由這位急性心衰竭個案照顧過程，探討心臟移植前後在不同時期營養照護重點及注意事項，提供未來臨床營養照護參考。
並列摘要
Patients with left heart failure often require use of left ventricular assist device (Left Ventricular assist devices, LVAD) to rebirth life and wait for heart transplants. The case is a 37 year-old man with hypertension and irregular drugs control, who had daily diet with high fat and high simple sugar, and worked as engineer with less exercise in technology industry. At this time, he was suffered from sudden of shortness of breath at work and then was admitted to the intensive care unit for treatment in our hospital. Respiratory failure and cardiac insufficiency with only 17% of left ventricular ejection rate were noted. Thus, he was received ventilator and left ventricular assist devices for maintaining his life. The worsening renal function was noted and he was received continuous dialysis for maintaining kidney function. Ventilator was removed and left ventricular assist devices were used for maintaining heart function alone after the patient with stable condition and breathing training. This case was then on the waiting list for receiving heart transplant. During hospitalization, nasogastric tube was inserted for feeding, and then was prescribed to shift to oral feeding the conversion diet. After several days of efforts by increasing food intake, no choking problem was attacked and nasogastric tube was removed. After 4 months, the heart transplant was performed. High calorie and high protein diet was prescribed for promoting surgical wound healing within 3 months after heart transplantation. Transplant patients need to take anti-rejection drugs for life-long time. This patient was single and has very limited ability to care for himself due to having incidence of stroke with unilateral lower limb weakness. Thus, diet and nutrition education was delivered to him and his sister. Food safety issues were taught and focusing on avoidance on consuming raw foods and regularly use of boiled tap water. Averting infection and ensuring antirejection medicine taken regularly for stabilizing the blood concentration were also emphasized. To avoid having antirejection drug and food interaction, pomelo and ginseng which are likely to boost immunity and affect concentration of anti-rejection in blood should be avoided. Additionally, post-transplant metabolic alterations including hyperglycemia, hyperlipidemia, obesity and hyperuricemia are also likely to occur due to long term use of antirejection drugs, caution must be taken in maintaining metabolic and heart functions in order to improve survival. This case was then regularly followed up in the nursing home and the out-patient department. In this report, we shared our experiences of nutrition management for a patient with acute heart failure episode as well as before-after heart transplant.