接受造血干细胞移植患者的肠外营养应用
2010-03-12 18:14:58   来源：   作者：  评论：0 点击：

目的：接受造血肝细胞移植患者（HSCT）住院期间由于经口摄入不足和胃肠道并发症经常使用肠外营养（PN）。接受PN的HSCT患者高血糖、感染发生率上升，住院时间（LOS）延长，红细胞/血小板输血需求增加，移植经常延迟。美国肠外肠内营养学会指南目前推荐营养不良的HSCT患者及预计不能吸收足够营养7～14天以上患者需使用PN。本研究的目的是观察拟行HSCT患者使用PN相关风险。

　　方法：回顾性分析了2003～2008年期间市级综合性医院中337例接受HSCT患者。患者根据住院期间是否接受PN分组。患者按营养师处方PN实施前（1/1/03～12/31/05）和按营养师处方PN实施后（1/1/06～12/31/08）进一步分类。统计分析采用卡方检验和独立样本t检验。

　　结果：337例接受HSCT患者中104例患者（31%）使用PN。两组性别（PN组：55/104【53%】男性，非PN组：130/233【56%】男性）、年龄（PN组：47.2±12.9岁，非PN组：49.9±13.5岁）及BMI（PN组：27.7±6.0，非PN组：28.1±6.1）无显著差异。异体移植患者使用PN比例较自体移植患者高（46/85【54%】，58/252【23%】，p<0.0001）。急性髓样白血病或急性淋巴细胞白血病患者使用PN比例与其他诊断患者相比明显升高（18/38【47%】，86/299【29%】；p=0.019）。使用PN患者与未使用PN患者相比死亡率明显升高（9/104【8.6%】，3/233【1.3%】；p=0.002），LOS明显延长（28.8±16.2，19.5±5.9；p<0.0001），入院ICU较多（23/104【22%】，15/233【6%】；p<0.0001）。两组ICU的LOS及感染并发症无显著差异。此外，营养师处方PN实施前后比较，实施后使用PN明显较少（63/133【47%】，41/204【20%】，p<0.0001）。性别（营养师处方PN实施前：男性51%，营养师处方PN实施后：男性56%）与年龄（营养师处方PN实施前：47.6±11.9岁，营养师处方PN实施后：46.6±14.4岁）无显著差异。两组之间BMI存在统计学差异，但是无临床意义（营养师处方PN实施前：28.9±6.3，营养师处方PN实施后：25.7±5.1；p=0.009）。

　　结论：由于使用PN会影响预后，所以为了进一步减少这些脆弱患者使用PN尚需进一步努力。本研究结果显示营养师处方PN实施后PN使用明显减少。尚需进一步研究探讨何种HSCT患者（如疾病严重程度或胃肠道并发症严重程度和持续时间）可能从PN中获益。

Clinical Nutrition Week 2010 Nutrition Practice Abstracts

Abstracts of Distinction

Nutr Clin Pract. 2010 Feb;25(1):95.

P5 - Parenteral Nutrition Utilization in Patients Receiving Hematopoietic Stem Cell Transplant

Cheryl Sullivan, MS,RD,CNSD; Sarah Peterson, MS,RD,CNSC; Yimin Chen, MS,RD,CNSD; Kelly Kinnare, MS,RD,CNSD; Diane Sowa, MBA,RD

Rush University Medical Center, Chicago, IL.

Introduction: Patients undergoing hematopoietic stem cell transplant (HSCT) often receive parenteral nutrition (PN) during their hospitalization due to inadequate oral intake and gastrointestinal complications. Increased incidence of hyperglycemia, infection, increased hospital length of stay (LOS), greater requirements for red blood cell/platelet transfusion and delayed engraftment has been observed in HSCT patients who received PN. Current guidelines from the American Society for Parenteral and Enteral Nutrition recommend that PN be used in HSCT patients who are malnourished and expected to be unable to absorb adequate nutrients for 7-14 days. The objective of the current study was to determine the risks associated with PN utilization among patients admitted for a HSCT. Methods: A retrospective chart review was completed for 337 patients who underwent a HSCT from 2003-2008 in a tertiary care urban academic medical center. Patients were categorized as having received PN or not during their hospitalization. Patients were further categorized to compare before dietitian PN order-writing privileges (1/1/03 to 12/31/05), to after dietitian PN order-writing privileges (1/1/06 to 12/31/08). Statistical analysis was completed with Chi-square tests and Independent t-tests. Results: Of the 337 patients who received a HSCT, 104 patients (31%) were started on PN. There were no significant differences in sex (PN group: 55/104 [53%] male vs. non-PN group: 130/233 [56%] male), age (PN group: 47.2±12.9 years vs. non-PN group: 49.9±13.5 years) or BMI (PN group: 27.7±6.0 vs. non-PN group: 28.1±6.1). A higher percentage of allogeneic HSCT patients received PN compared to autologous HSCT patients (46/85 [54%] vs. 58/252 [23%], respectively; p<0.0001). A significantly higher percent of patients with a diagnosis of acute myeloid leukemia or acute lymphocytic leukemia received PN (18/38 [47%] vs. 86/299 [29%]; p=0.019) compared to patients requiring PN with all other diagnoses. Patients who received PN had a significantly higher mortality (9/104 [8.6%] vs. 3/233 [1.3%]; p=0.002), longer hospital LOS (28.8 days±16.2 vs. 19.5 days±5.9; p<0.0001) and more admits to the ICU (23/104 [22%] vs. 15/233 [6%]; p<0.0001) compared to patients who did not receive PN. There were no significant differences in ICU LOS or infectious complications between groups. Additionally, when comparing before to after dietitian PN order-writing privileges, significantly fewer patients were started on PN (63/133 [47%] vs. 41/204 [20%], respectively; p<0.0001). There were no significant differences in sex (before PN order-writing privileges: 51% male vs. after PN order-writing privileges: 56% male) and age (before PN order-writing privileges: 47.6±11.9 years vs. after PN order-writing privileges: 46.6±14.4 years). There was a statistically significant, but clinically irrelevant difference in BMI between the two groups (before PN order-writing privileges 28.9±6.3 vs. after PN order-writing privileges: 25.7±5.1; p=0.009). Conclusions: Additional efforts are needed to further reduce total PN utilization in this highly vulnerable patient population as PN use has been associated with negative outcomes. In the current project, there was a significant decrease in PN utilization after dietitians obtained PN order-writing privileges. Additional research is needed to identify objective criteria (such as a severity of illness score or severity and duration of GI complications) for patients undergoing HSCT to determine which patients may benefit from PN.