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1 硕士学位论文论文题目 NRS-2002 营养风险筛查的临床应用及评价研究生姓名指导教师姓名专业名称研究方向论文提交日期翟茂东秦环龙普外科胃肠外科 2012 年 5 月

3 NRS-2002 营养风险筛查的临床应用及评价中文摘要 NRS-2002 营养风险筛查的临床应用及评价中文摘要第一部分住院患者营养风险的初步筛查目的通过对住院患者营养风险筛查, 结合大样本数据分析, 提出住院患者中不同学科营养风险的发生发展规律方法采用连续取样的方法选取 2009 年 8 月年 12 月上海市第六人民医院七个科室收治的住院患者为研究对象符合入选标准者入院后详细询问病史, 应用 NRS-2002 评分系统对每例患者分别进行术前评估, 并调查患者住院期间营养支持应用情况结果 1. 住院患者总体营养风险发生率为 24.6%;2. 外科总体营养风险的发生率为 19.4%, 其中胃肿瘤以及肝胆胰肿瘤最高, 分别为 48.9%,41.3%; 内科总营养风险发生率高于外科, 尤其以神经内科, 消化内科, 呼吸内科最高, 分别为 44.3% 38.8% 35.1%;3. 相比内科各科室营养支持, 有营养风险的外科住院患者营养支持率略高, 为 44.1%; 外科疾病中对胃肠肿瘤营养支持率较高, 分别为 84.8%,64.1%, 而对其他外科疾病营养支持率相对偏低结论外科住院患者营养风险的发生率明显低于内科各科室, 但外科营养支持率高于内科提示营养不良和营养风险不但是外科需要重视的问题, 更是内科需要关注的问题关键词 NRS-2002 营养支持营养风险外科内科 I

4 中文摘要 NRS-2002 营养风险筛查的临床应用及评价第二部分胃肠肿瘤患者营养风险与营养支持调查目的调查外科胃肠肿瘤住院患者营养风险及住院期间的营养支持状况, 分析营养风险与肿瘤分期营养支持及并发症的关系方法选取 2009 年 9 月 1 日年 6 月 31 日我院普外科收治胃肠肿瘤住院患者, 入院时使用营养风险筛查工具 NRS-2002 进行营养风险筛查, 调查住院期间的营养支持状况及统计患者的肿瘤分期及并发症发生率结果胃肠肿瘤总营养风险发生率为 38.9%, 胃肿瘤和结直肠肿瘤分别为 49.2%,32.8% IV 期的胃肿瘤和结直肠肿瘤营养风险最高 87.3%,58.8% IIA 期的胃肿瘤和 I 期的结直肠肿瘤营养风险最低 16.15%,9.8% 有营养风险和无营养风险胃肿瘤患者的营养支持率分别为 62.3% 和 48.6% 有营养风险和无营养风险结直肠肿瘤患者的营养支持率分别为 37.7%,51.4% 肠外营养和肠内营养比值为 1.25:1 有营养风险的胃肠肿瘤患者并发症发生率为 32.4%, 明显高于无营养风险患者的 20.4% 有营养风险的胃肠肿瘤患者应用营养支持者并发症发生率为 27.5% 明显低于未用营养支持患者的 40.8%. 在无营养风险的胃肿瘤患者中应用营养支持者并发症发生率明显低于未用营养支持者 (P=0.0306), 而在无营养风险的结直肠肿瘤患者中应用营养支持与否与并发症发生率无关 (P=0.4647) 结论胃肠肿瘤住院患者营养风险较高, 并且营养风险发生率与肿瘤分期有关, 有营养风险的胃肠肿瘤患者并发症发生率高于无营养风险者, 给予有营养风险的胃肠肿瘤患者营养支持可以减少并发症的发生关键词 :NRS-2002 营养支持营养风险胃肠肿瘤并发症肿瘤分期 II

5 NRS-2002 营养风险筛查的临床应用及评价中文摘要第三部分肝胆胰患者营养风险筛查与临床结局分析目的调查肝胆胰外科住院患者营养风险及住院期间的营养支持状况, 分析营养风险与临床结局的关系方法选择我院 2011 年 7 月至 2012 年 1 月期间肝胆胰外科住院患者, 入院时使用 NRS-2002 进行营养风险筛查, 调查住院期间的营养支持状况, 统计患者并发症发生率及住院时间结果共有 411 例住院患者入选, 总营养风险发生率为 20.6%, 肝癌的营养风险发生率最高 (59.3%), 其次为胆管癌 (32%), 胆囊息肉营养风险发生率最低 (4.4%); 有营养风险的患者术后并发症的发生率明显高于无营养风险的患者 (44.7% VS 19.6%,P<0.001); 而在严重并发症发生率方面两者无显著差异 (34.2% VS 32.8 %, P=0.885) 有营养风险的患者中应用营养支持者并发症发生率平均住院时间均明显下降 (38.1%VS 63.6%,P=0.038;15.41±2.47d VS 17.00±3.38d,P=0.021) 无营养风险的患者中应用营养支持者并发症发生率未见明显下降, 相反却升高 (21.9% VS 17.5%, P=0.319 ), 住院时间也较未用营养支持的患者延长 (12.75±2.63d VS 11.75±2.97d,P=0.002) 结论肝胆胰外科住院患者中恶性疾病患者营养风险较高, 有营养风险的患者不良并发症发生率高于无营养风险患者, 给予有营养风险患者营养支持可以改善临床结局关键词 NRS-2002 营养风险营养支持肝胆胰外科并发症住院时间第四部分老年胃癌患者术前营养支持的应用目的 III

6 中文摘要 NRS-2002 营养风险筛查的临床应用及评价对 70 岁以上有营养风险的胃癌手术患者, 给予术前营养支持治疗, 探讨对有营养风险的老年患者实施营养支持治疗的意义方法将 52 例 70 岁以上确诊的胃癌患者随机分组为研究组及对照组, 对新确诊胃癌患者进行营养风险筛查, 研究组术前给予肠内营养支持, 观察两组患者手术前后体重血清白蛋白及血清 IgA 变化记录患者胃肠功能恢复时间及住院天数, 住院期间吻合口瘘切口感染肺部感染等并发症的发生情况结果研究组体质量下降幅度小于对照组 (5.1±1.5 VS 3.3±1.7kg;P<0.01=, 术后研究组白蛋白回升速度较快, 术后第 3 天时, 研究组白蛋白水平较对照组高 (P<0.05), IgA 水平术后第 1 第 3 天时均较对照组同期水平增高研究组较对照组并发症发生率明显下降 (52.7% VS 88.5%,P=0.012), 术后住院时间也较对照组患者延长 (16.8±2.0d VS 19.6±3.6d,P=0.001) 结论根据 NRS-2002 评分标准,70 岁以上老年胃癌手术患者存在营养风险, 给予术前预防性营养支持, 可改善此类患者术后营养状况, 降低并发症发生率, 改善患者临床结局关键词 NRS-2002 术前营养支持并发症住院时间胃癌老年作者 : 翟茂东指导老师 : 秦环龙 IV

7 Clinical application and evaluation of the nutritional risk screening 2002 Abstract Clinical application and evaluation of the nutritional risk screening 2002 Abstract Part I Preliminary screening of inpatient nutritional risk Objective We aimed to screen nutrition risk of hospitalized patients,and then analysis the large sample datas, and proposed the different disciplines of nutritional risk between hospitalized patients. Methods Totally 33 thousand adult patients in 7 departments of Shanghai Sixth People's Hospital were enrolled from August 2009 to December 2011 by fix-point consecutive sampling. Nutritional Risk Screening 2002(NRS-2002) was performed and nutritional support was evaluated in all patients. Results 1.Overall prevalence of nutritional risk was 24.6%. 2.The over all prevalence of nutritional risks in General Surgery was 15.7 %.Patients with gastrointestinal and hepatobiliary and pancreatic diseases had higher risks than others, which were 36.0% and 64.0%. The total nutritional risk in Medicine is higher than Surgery,especially Respiratory Medicine,Neurology Medicine,Digestive Medicine had the higher prevalence of nutritional risk, which were 44.3% 38.8% and 35.1%. 3. Compared to the medicine departments, surgical patients at nutritional risk have higher nutritional support rates,which was 44.1%; especially gastrointestinal tumors diseases,which were 84.8% and 64.1%, while nutritional support rate of the other surgical diseases was relatively low. V

8 Abstract Clinical application and evaluation of the nutritional risk screening 2002 Conclusions The prevalence of surgical patients nutritional risk was significantly lower than medicine departments, but nutrition support in surgery is higher than medicine. Malnutrition and nutritional risk were not only the issues surgical departments need to focus on, but also medicine department should. Key words NRS-2002 ;Nutritional support ; Nutritional risk ;General Surgery; Medicine Part II Investigate nutritional risk and nutritional support in hospitalized patients with gastrointestinal tumors Objective To investigate the status of nutritional risk as well as nutritional support in patients with gastrointestinal tumor. Methods In this prospective cohort study, patients with gastrointestinal tumor were recruited from September 2009 to June Patients were screened by using Nutritional Risk Screening 2002 (NRS-2002) at admission. Data of the nutritional risk, application of nutritional support, complications, and tumor staging were collected. Results Nine hundred and sixty-one patients with gastrointestinal tumor were enrolled,the overall prevalence of nutritional risk was 38.9% (374/961) at admission,49.2% in gastric tumor and 32.8% in colorectal tumor,respectively. The highest prevalence was found in stage Ⅳ gastric tumor 87.3%,and colorectal tumor 58.8% while the lowest prevalence was found in stage ⅡA gastric tumor 16.1% and stageⅠcolorectal tumor 9.8%. 62.3% (152/244) of gastric tumor patients with nutritional risk while 48.6% (144/296) without nutritional risk received nutritional support. 37.7% (92/244) of colorectal tumor patients with nutritional risk while 51.4% (152/296) without nutritional risk received nutritional support. The ratio of parental nutrition and enteral VI

9 Clinical application and evaluation of the nutritional risk screening 2002 Abstract nutrition was 1.25:1. The rate of complications in the gastrointestinal tumor patients with nutritional risk was higher than that in the patients without nutritional risk (32.4% VS 20.4%, P=0.000). For the gastrointestinal tumor patients with nutritional risk, the complication rate of the patients with nutritional support was significantly lower than that of the patients without nutritional support (27.5% VS 40.8%,P=0.0086). For the gastrointestinal tumor patients without nutritional risk, the complication rate of gastric tumor patients with nutritional support was significantly lower than that of the patients without nutritional support (P=0.0396), while the complication rate was not significantly different in the colorectal tumor patients with nutritional support or not (P=0.4647). Conclusions Patient with gastrointestinal tumor has a high nutritional risk which is related to tumor staging. Patients with nutritional risk have more complications, and nutritional support is beneficial to the patients with nutritional risk by a lower complication rate. Key words NRS-2002 ;Nutritional support; Nutritional risk; Gastrointestinal tumor; Complications; Tumor staging Part III Investigate nutritional risk and clinical outcomes in hospitalized patients with hepatobiliary and pancreatic diseases by using NRS2002 Objective To investigate nutritional risk and nutritional support in hospitalized patients with hepatobiliary and pancreatic diseases, and to analysis the relationship between nutritional risk and clinical outcomes. Methods In this prospective cohort study, patients with hepatobiliary and pancreatic diseases were recruited from July 2011 to January Patients were screened by using Nutritional Risk Screening 2002 (NRS-2002) at admission. Data of the nutritional risk, application of nutritional support, complications and length of stay were collected. VII

10 Abstract Clinical application and evaluation of the nutritional risk screening 2002 Results Four hundred and eleven patients with hepatobiliary and pancreatic diseases were recruited, the overall prevalence of nutritional risk was 20.6% at admission,59.3% in liver cancer, 32% in the bile duct cancer,while the lowest nutritional risk was found in liver cysts (4.4%). The rate of complications in the patients with nutritional risk was higher than in the patients without nutritional risk(44.7% VS 19.6%,P<0.001).Serious complications in patients with nutritional risk were not significant different with patients without nutritional risk(34.2% VS 32.8 %,P=0.885). For the patients with nutritional risk,the complications rates and the average length of stay of patients with nutritional support were significant lower than those without nutritional support (38.1%VS 63.6%, P=0.038;15.41±2.47d VS 17.00±3.38d,P=0.021);For the patients without nutritional risk, the complications of patients with nutritional support was significant higher than those without nutritional support (21.9% VS 17.5%,P=0.319),while the average length of stay of patients with nutritional support was significant longer than those without nutritional support (12.75±2.63d VS 11.75±2.97d,P=0.002). Conclusions Patients with hepatobiliary and pancreatic diseases have a higher nutritional risk in malignant disease,and patients with nutritional risk have more complications nutritional support is beneficial to the patients with nutritional risk by improving clinical outcomes. Keywords Hepatobiliary and pancreatic diseases;nutritional risk ;NRS-2002 ;Nutritional support;complications; Hospital stay Part IV Clinical studies on preventive enteral nutritional support in elderly patients with gastric cancer Objective VIII

11 Clinical application and evaluation of the nutritional risk screening 2002 Abstract To study the significance of nutritional support before operation in gastric cancer patients who were more than 70 years old with nutritional risk by NRS-2002 scoring system. Methods Every gastric cancer patients who were more than 70 years old had nutritional risk by NRS-2002 scoring system.the 52 patients enrolled with nutritional risk were given enteral nutritional support before operation,and enteral and parenteral nutritional support after operation.the changes in body weight,serum albumin,iga,the time of passage of gas by anus,the incidence of complications,and the time of hospital stay after operation were recorded. Results One week after operation, the preventive EN group showed less decrease in body weight as compared to control group, which was statistically significant(5.1±1.5 VS 3.3±1.7kg;P<0.01). The levels of serum albumin and IgA on day 1 and day 3 after operation in preventive EN group were significantly higher than those in control group. Compared to control group, the preventive EN group significantly showed decreased the incidence of complications(5.1±1.5 VS 3.3±1.7kg;P<0.01), postoperative hospital stay (16.8±2.0d VS 19.6±3.6d,P=0.001). Conclusions Gastric cancer patients who were more than 70 years old may benefit from preventive enteral nutrition, which improves the patients' nutritional condition and clinical outcomes, enhances their immunologic function. Keywords Gastric cancer;nutritional support; Bodyweight ; Hospital stay;serum albumin; IgA Written by Zhai MD Supervised by Qin HL IX

13 目录前言...1 第一部分初筛结果...8 第二部分胃肠肿瘤患者营养风险与营养支持调查...11 第三部分肝胆胰患者营养风险筛查与临床结局分析...15 第四部分老年胃癌患者术前营养支持的应用...20 第五部分讨论...25 第六部分结论与建议...32 附图...33 参考文献...35 中英文对照缩略语词表...38 致谢...39

15 NRS-2002 营养风险筛查的临床应用及评价前言前言 1. 营养风险概念 2002 年欧洲肠内肠外营养学会 (ESPEN) 专家组在 128 个随机对照临床研究 (randomized controlled clinical trials,rct) 的基础上, 提出了一个有循证医学依据的营养风险筛查工具 (NRS-2002,nutritional risk screening 2002 ) [1], 并在 2003 年给出了营养风险较为明确的定义营养风险的概念可概括为现存的或潜在的营养和代谢状况影响疾病或手术后临床结局的风险, 也可理解为营养风险是指现存的或潜在的营养因素导致患者出现不良临床结局的风险营养风险与营养不良 ( 不足 ) 营养不良风险在内涵上有很大差别营养风险是指营养因素导致不良临床结局的风险, 而营养不良风险只是指发生营养不良的风险, 不涉及临床结局营养不良用来描述现存的营养受损状态营养风险概念的发展所基于的假设是营养支持不仅适用于已有营养不良的患者, 而且也适用于由于疾病手术或创伤导致的应激代谢状态, 营养需要量增加的患者营养风险概念的范围要比营养不良 ( 不足 ) 广泛 2. 为什么要进行营养风险筛查 1976 年 Bistrin 等报告, 住院患者营养不良发生率高达 70% 但 30 多年来, 大量调查显示, 住院患者的营养不良发生率已有了较大的不同 1994 年,Mc Whirter [2] 等报告, 以体质指数 BMI<20kg/m 2 为判定标准, 营养不良的发生率在普通内科患者中为 46%, 在呼吸内科患者中为 45%, 在普外科患者中为 27%, 在老年住院患者中为 43% 这表明营养不良在住院患者中是广泛存在的, 而且不只限于以往人们所关注的外科患者和重症患者实际上, 内科系统的胃肠道疾病患者肾病患者神经系统疾病患者和呼吸系统疾病患者, 其营养不良的发生率高过外科择期手术患者 2002 年, Fettes [3] 等的调查显示, 腹部择期手术患者营养不良的发生率仅为 9% 2008 年由中华医学会肠外肠内营养学分会组织蒋朱明教授进行的全国范围的多中心研究 [4], 对来自呼吸科肾内科消化内科神经内科普外科胸外科等 6 专科的共计多例住院患者进行营养筛查, 结果显示, 总的营养不良发生率约为 10%, 营养风险发 1

16 前言 NRS-2002 营养风险筛查的临床应用及评价生率为 35.6% Schiesser [5] 对 608 例胃肠手术患者的前瞻性研究显示, 有营养风险患者并发症发生率显著增高, 住院时间显著延长 Amaral [6] 研究发现, 有营养风险患者的平均住院费用比无风险患者高 20% 因此营养风险是预测临床结局的重要因素之一, 临床医师应重视住院患者的营养不良, 及时给予相应的营养支持, 避免不良的临床结局的发生 3. 常用营养状况评价方法目前, 在临床工作中应用的营养评定工具有 10 余种之多, 包括使用单一指标和复合指标两类传统的单一指标包括以下 5 个方面的内容 : 膳食调查 ; 人体组成 ; 人体测量 ( 主要指标包括 BMI 三头肌皮褶厚度上臂围上臂肌围握力和腰臀围比值等 ); 生化和实验室测定 ( 包括血清白蛋白转铁蛋白 (TFN) 前白蛋白(PA) 视黄醇结合蛋白 (RBP) 氮平衡肌酐身高指数(CHI) 血浆氨基酸谱测定免疫功能测定等 ); 临床检查 : 通过病史采集及体格检查来发现营养缺乏的体征早期研究已明确, 采用单一指标评定住院患者营养状况局限性多, 误差较大近年来研究主要集中在探讨复合指标的筛查工具, 以提高筛查的敏感性和特异性目前有多个筛选工具, 如主观全面评估 (SGA,subjective global assessment) 营养不良通用筛选工具 (MUST,malnutrition universal screening tool) 简易营养评估(MNA, mini-nutritional assessment) 营养风险指数(NRI,nutrition risk index) 以及营养风险筛查 2002(NRS-2002) 等 3.1 主观全面评定法 (SGA) 是美国肠外肠内营养学会 (ASPEN) 推荐的临床营养状况评估工具其特点是以详细的病史与临床检查为基础, 省略人体测量和生化检查有研究显示, 通过 SGA 评估发现的营养不足患者, 并发症的发生率是营养良好患者的 3~4 倍但 SGA 作为营养风险筛查工具有一定局限性, 如 SGA 更多反映的是疾病状况, 而非营养状况 ;SGA 不适用于区分轻度营养不足, 侧重反映慢性或已存在的营养不足, 不能及时反映患者营养状况的变化目前, 该筛查工具缺乏筛查结果与临床结局的证据支持, 同时因其未把观察指标和如何将患者进行分类直接联系起来, 使该工具不能满足临床快速筛查的目的因该工具是一个主观评估工具, 使用者要接受专门培训, 作为常规营养筛查工具并不实用 3.2 营养不良通用筛查工具 (MUST) 是由英国肠外肠内营养协会多学科营养 2

864 现代药物与临床 Drugs & Clinic 第 31 卷第 6 期 2016 年 6 月 of apoptosis related factors, decrease the incidence of adverse reactions, which is of great

864 现代药物与临床 Drugs & Clinic 第 31 卷第 6 期 2016 年 6 月 of apoptosis related factors, decrease the incidence of adverse reactions, which is of great 现代药物与临床 Drugs & Clinic 第 31 卷第 6 期 2016 年 6 月 863 曲妥珠单抗联合多西紫杉醇治疗 Her-2 阳性乳腺癌的临床研究 * 周永安, 刘训碧黄石市中心医院 ( 普爱院区 ) 乳腺肿瘤外科, 湖北黄石 435000 摘要 : 目的探析注射用曲