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  • 學位論文

不同鼻胃管灌食方法對重症加護病房病人 胃殘餘量、腹脹、嘔吐之分析:回溯性研究

The Effects of Nasogastric Tube Feeding Methods on Gastric Residual Volumes, Distension, and Vomiting in ICU Patients: A Retrospective Study

指導教授 : 許雅娟

摘要


重症加護病房病人因疾病嚴重度較高,意識狀態多為昏迷程度或吞嚥障礙,且呼吸器使用比例高,過去報告74%病人會使用鼻胃管灌食提供營養,選擇灌食方式有連續性管灌食及間歇性管灌食,國內外研究有關不同鼻胃管灌食方法對病人胃殘餘量、腹脹及嘔吐結果不一。故本研究目的旨在分析重症加護病房病人使用連續性鼻胃管灌食法與間歇性鼻胃管灌食法發生胃殘餘量、腹脹和嘔吐之情形及差異性。 本研究為電子病歷回溯性研究設計,對象為南部某一醫學中心成人內科加護病房使用鼻胃管灌食病人。收案條件包括(一)大於20歲者、(二)已置有鼻胃管進行鼻胃管灌食至少5天者。排除條件:(一)中斷鼻胃管灌食超過24小時者、(二)此次住院行腸道手術患者、(三)已收案為安寧照護者、(四)診斷為腸缺血、腸阻塞病人。共有712位個案符合資格,使用連續性灌食方式為537人(75.4%),及間歇性灌食方式為175人(24.6%)。平均年齡為70.12歲,連續性灌食方式平均年齡為69.91歲,間歇性灌食方式平均年齡為70.76歲;二組男性比例高於女性;連續性灌食組疾病嚴重度(ApachII)平均分數高於間歇性灌食組;二組疾病診斷以敗血性感染症佔較高比例。 卡方檢定結果,第三、四、五天連續性灌食組和間歇性灌食組與有無胃殘餘量,均呈現顯著差異(p=<001)。調整意識狀態、呼吸器、鎮定劑及升壓劑使用情形後,ANCOVA結果顯示第三及第四天第一餐到第六餐,連續性灌食組的平均胃殘餘容量顯著高於間歇性灌食組(第三天p=.003;.001;<.001;<.001;<.001;<.001);(第四天p=<.001;<.001;<.001;<.001;<.001;<.001),第五天結果顯示第三、五、六餐平均胃殘餘容量顯著高於間歇性灌食組(p=.024;.023;.014)。卡方檢定結果呈現,第五天連續性灌食組腹脹盛行率顯著高於間歇性灌食組(p=.031);邏輯式分析結果顯示,間歇性灌食組第五天腹脹盛行率僅是連續性灌食組的0.587倍,且有統計上顯著差異(p=.034)。百分比分析結果連續性灌食組第三、四、五天的嘔吐發生率0.6-1.9%,間歇性灌食組嘔吐發生率0-0.6%。 此研究結果發現,連續性管灌食組的胃殘餘容量高於間歇性管灌食組,腹脹及嘔吐盛行率也是連續性管灌食組高於間歇性管灌食組,亦發現嘔吐盛行率遠低於國外研究,以及八到九成的腹脹盛行率,都是臨床護理人員照護以及選擇管灌食方式值得參考之實證結果。

並列摘要


Among critically ill patients, as their higher severity of the disease, comatous consciousness level and possible dysphagia, the proportion of ventilator use is higher. According to the literatures, 74% of these patients use nasogastric (NG) feeding for nutrition support. There are different methods for NG feeding, as continuous feeding or bolus feeding. The impacts of different feeding methods on the patient's residual gastric volume, abdominal distension, and vomiting vary. The aims of this study was to analyze effects of different NG tube feeding methods on the patient's residual gastric volume, abdominal distension, and vomiting in Intensive Care Units (ICU). A retrospective study was conducted in a medical center in Southern Taiwan. Data were collected in adult medical ICUs. Seven hundred twelve eligible patients were enrolled in the study, divided into either group of continuous feeding (C group, N = 537) or group of bolus feeding (B group, N = 175) by type of NG feeding method. Inclusion criteria were (1) age above 20 years old; and (2) NG feeding at least 5 days. Exclusion criteria included that patients (1) interrupted NG feeding longer than 24 hours ; (2) received intestinal surgery; (3) received for hospices care; (4) and diagnosed with intestinal ischemia or intestina obstruction. The overall average age was 70.12 years old, with the group C of 69.91 years old and the group B of 70.76 years old. The proportion of male patients was higher than female patients among both groups. The group C had higher scores on Acute Physiology and Chronic Health Evaluation (APACHE II). The percentage of sepsis as initial admission diagnosis was the top one ranking on both groups.Chi square tests showed that there was a significant difference on gastric residual volumes on the third, fourth, and fifth days between group C and group B (p<0.001). After adjusting for consciousness level, ventilator support, the use of sedation, and the use of vasopressor, ANCOVA showed that patients on the group C had more gastric residual volumes than group B on both the third and fourth days and the first to sixth of meals (all p-value <0.05). Chi square tests showed that the group C had a higher incidence of abdominal distention on the fifth day than group B (p=0.034). The incidences of vomiting in the group C on the third, fourth, and fifth days were among 0.6-1.9%, and 0-0.6% for group B. The results showed higher gastric residual volumes in the continuous feeding group than those in the bolus feeding group. Comparing to patients in the bolus feeding group, higher incidences of abdominaldistension, and vomiting in the continuous feeding group was found in this study. The present findings indicated the incidences of vomiting was lower than past data reported in previous studies. The incidence of vomiting was lower than those international studies. However, given the additional finding of extremely high incidences of abdominal distention among 80-90% of patients with NG tube feeding provide health care professionals a strong scientific evidence to make an appropriate decision appropriate decision on the choice of adquent tube feeding method.

參考文獻


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