B Y T TRNG I HC DC H NI NGUYN TH LAN ANH KHO ST TNH TRNG DINH
DNG CA BNH NHN NM VIN V VIC S DNG DCH TRUYN DINH DNG KHOA THN TIT
NIU BNH VIN BCH MAI KHA LUN TT NGHIP DC S H NI 2013 B Y T TRNG I HC
DC H NI NGUYN TH LAN ANH KHO ST TNH TRNG DINH DNG CA BNH NHN NM VIN
V VIC S DNG DCH TRUYN DINH DNG KHOA THN TIT NIU BNH VIN BCH MAI KHA
LUN TT NGHIP DC SNgi hng dn: 1.TS.DS. Phm Th Thy Vn 2.DS. Nguyn Thu
Minh Ni thc hin: 1.B mn Dc lm sng 2.Bnh vin Bch Mai H NI 2013 Li cm
n Vilng knh trng, ti xin by t li cm n su sc nhtti TS.DS. Phm Th Thy
Vn Ph trng b mn Dc lm sng i hc Dc H Ni v DS. Nguyn Thu Minh Khoa Dc
bnh vin Bch Mai l nhng ngi thy trc tip hng dn, ch bo tn tnh, gip v
truyn t nhng kinh nghim qu bu cho ti hon thnh kha lun ny. Ti cng
xin by t lng bit n chn thnh ti PGS.TS. inh Th Kim Dung Trng khoa
Thn Tit niu bnh vin Bch Mai to mi iu kin thun li gip ti trong qu
trnh nghin cu. T tn y lng, ti lun bit n su sc cng lao to ln ca cc
thy c gio b mn Dc lm sng cng ton th cc thy c trng i hc Dc H Ni dy
d, rn luyn ti trong sut nm nm sng v hc tp ti trng. Cui cng, vi lng
knh yu v hn, con xin t n b m sinh thnh v nui dng con khn ln. Xin cm
n cc anh, ch, em v nhng ngi bn tt lun ng vin, gip ti trong sut thi
gian hc tp v nghin cu. H Ni, thng 05 nm 2013 Nguyn Th Lan Anh MC LC
T VN
........................................................................................................
1 Phn 1: TNG
QUAN...........................................................................................
3 1.1. Suy dinh dng protein nng lng
........................................................... 3
1.1.1.Khi
nim.....................................................................................................
3 1.1.2.Cc hnh thc suy dinh
dng.......................................................................
3 1.1.3.Sinh l
bnh..................................................................................................
3 1.1.4.Biu hin lm
sng........................................................................................
4 1.2. nh gi tnh trng dinh dng
....................................................................
4 1.2.1.Khm tin
s.................................................................................................
4 1.2.2.Khm lm
sng.............................................................................................
5 1.2.2.1. Chiu cao v cn nng
................................................................................
5 1.2.2.2. Cc ch s nhn trc hc
.............................................................................
6 1.2.3.Cc xt nghim cn lm
sng........................................................................
6 1.2.3.1.
Albumin......................................................................................................
7 1.2.3.2. Prealbumin
.................................................................................................
7 1.2.3.3.
Transferrin..................................................................................................
8 1.3. Tnh nhu cu nng lng
...............................................................................
9 1.3.1.Da theo cng
thc.......................................................................................
9 1.3.2.Da theo tnh trng bnh
l.........................................................................
10 1.4. Cc thnh phn dch truyn dinh
dng..................................................... 11
1.4.1.Glucid.........................................................................................................
11 1.4.1.1. Vai tr dinh dng ca
glucid...................................................................
11 1.4.1.2. Nhu cu nng lng theo
glucid................................................................
11
1.4.2.Protid..........................................................................................................
12 1.4.2.1. Vai tr dinh dng ca protid
...................................................................
12 1.4.2.2. Nhu cu nng lng theo
protid................................................................
12
1.4.3.Lipid...........................................................................................................
13 1.4.3.1. Vai tr dinh dng ca lipid
.....................................................................
13 1.4.3.2. Nhu cu nng lng theo
lipid..................................................................
14 1.5. Hng dn s dng DTDD trn bnh nhn suy dinh dng
..................... 14 Phn 2: I TNG V PHNG PHP NGHIN
CU........................... 17 2.1. i tng nghin cu
...................................................................................
17 2.2. Cc ch tiu s dng trong nghin
cu........................................................ 17
2.2.1.Ch s khi c th
BMI...............................................................................
17 2.2.2.Nng lng cung cp
..................................................................................
18 2.2.3.Tnh trng dinh dng
................................................................................
18 2.3. Phng php nghin cu
.............................................................................
18 2.3.1.Kho st thc trng dinh dng ca bnh nhn suy thn ti
khoa................ 19 2.3.2.Kho st tnh hnh cung cp nng lng v thc
trng s dng DTDD....... 19 2.4. X l s
liu...................................................................................................
19 Phn 3: KT QU NGHIN
CU....................................................................
20 3.1. c im bnh nhn ti khoa Thn Tit niu bnh vin Bch Mai ........
20 3.1.1.c im v tui, gii tnh v thi gian nm vin
....................................... 20 3.1.2.Phn loi bnh nhn
theo nhm bnh l v mc suy thn....................... 21 3.1.3.Phn loi
mc ph
.................................................................................
21 3.2. Tnh trng dinh dng ca bnh nhn ti khoa Thn Tit niu ti ngy u
nhp khoa
.....................................................................................................
22 3.2.1.T l bnh nhn theo phn loi BMI
........................................................... 22
3.2.2.T l bnh nhn theo ch s
albumin...........................................................
23 3.3. Kho st tnh hnh cung cp nng lng v s dng DTDD cho bnh nhn ti
khoa.................................................................................................................
24 3.3.1.T l cc loi hnh nui dng ti khoa Thn Tit
niu............................ 24 3.3.2.Cc loi DTDD hay c s dng ti
khoa................................................. 25 3.3.3.T l
cc kiu phi hp DTDD ti
khoa...................................................... 25
3.3.4.Tng lng DTDD c dng trong t iu tr
.................................... 26 3.3.5.Tnh hnh s dng DTDD
trn bnh nhn ph ti khoa ............................... 26 3.3.6.Nng
lng cung cp t ba n v t
DTDD.............................................. 27 3.3.7.Tnh hnh
s dng DTDD theo tnh trng dinh dng ca bnhnhn......... 28 3.3.8.Tnh
hnh cung cp nng lng theo tnh trng dinh dng ca bnh nhn ti khoa.
..............................................................................................
29 Phn 4: BN
LUN............................................................................................
31 4.1. Kho st tnh trng dinh dng ca bnh nhn ti
khoa........................... 31 4.1.1.c im bnh nhn nghin cu
.................................................................
31 4.1.2.Tnh trng dinh dng ca bnh nhn theo BMI v albumin huyt
............. 31 4.2. Kho st tnh hnh cung cp nng lng v s dng DTDD
ti khoa........ 32 KT
LUN..........................................................................................................
36
XUT.............................................................................................................
38 TI LIU THAM KHO PH LC DANH MC CH VIT TT CRPC Reactive Protein
(Protein phn ng C) BEEBasal energy expenditure (Tiu hao nng lng c
bn) BMIBody mass index (Ch s khi c th) DNADetailed Nutritional
Assessment (nh gi dinh dng chi tit) DTDDDch truyn dinh dng
ESPENEuropeanSocietyforParenteralandEnteralNutrition(Hiphi dinh dng
ng tiu ha v ngoi tiu ha Chu u) IBWIdeal body weight (Cn nng l tng)
NHANES IIThesecondNationalHealthandNutritionExaminationSurvey
(Khostnghincusckhevdinhdngqucgialnth hai)
RCTRandomizedcontrolledtrial(Nghinculmsngichng ngu nhin) SDDSuy
dinh dng SGASubjectiveglobalassessment(nhgitngthtnhtrngdinh dng
theo ch quan) SIRSSystemicinflammatoryresponsesyndrome(Hichngvimp
ng ton thn) TEETotal energy expenditure (Tng nng lng tiu hao) DANH
MC BNG Bng 1.1. Cc hnh thc suy dinh dng
(SDD)...................................................... 3 Bng
1.2. BMI v tnh trng dinh dng ca bnh nhn
.........................................6 Bng 1.3. Cc thng s v
albumin v prealbumin, transferrin huyt khi tnh trng dinh dng bnh
thng v khi suy dinh
dng....................................................... 6 Bng
1.4. Nhu cu protein hng ngy tng ng vi tnh trng bnh
nhn............... 13 Bng 1.5. Mt s dch truyn dinh dng hay s dng
bnh vin Bch Mai ...... 16
Bng3.1.Phnbvtui,giitnhvthigiannmvincanhmbnhnhn nghin
cu.............................................................................................................
20 Bng 3.2. Phn loi bnh nhn theo nhm bnh l ti
khoa................................... 21 Bng 3.3. Phn loi mc ph
ca bnh nhn ti khoa....................................... 22 Bng
3.4. Phn loi tnh trng dinh dng ca bnh nhn trong ngy u nhp khoa theo
ch s BMI
.....................................................................................................
23 Bng 3.5. Phn loi tnh trng dinh dng ca bnh nhn trong ngy u nhp
khoa theo ch s albumin huyt
......................................................................................
24 Bng 3.6. Cc loi hnh nui dng ti
khoa......................................................... 24
Bng 3.7. Phn loi cc DTDD hay c s dng ti khoa
................................... 25 Bng 3.8. T l cc kiu phi hp
DTDD ti khoa................................................ 26 Bng
3.9. S lng tng loi DTDD c dng ti khoa
...................................... 26 Bng 3.10. Tnh hnh s dng
DTDD trn bnh nhn ph khoa. ........................ 27 Bng
3.11.Nnglng bnh nhnccungcp hng ngytban vDTDD trong qu trnh iu tr ti
khoa..............................................................................
28 Bng3.12.TnhhnhsdngDTDDcabnhnhnkhoatheotnhtrngdinh dng tnh theo
BMI
.............................................................................................
29 Bng3.13.Tnhhnhcungcpnnglngtheotnhtrngdinhdngcabnh nhn
khoa...........................................................................................................
30 1 T VN Trong nhiu nm qua, c nhiu nghincuchra mitng quan mnh m
gia ch dinh dng v tin trin bnh trn bnh nhn b bnh thn ni chung v trn
bnh nhn suy thn ni ring. Suy dinh dng lm tng thi gian nhp vin, gim
sc khng ca c th v tng cc nguy c bin chng. V vy cn phi xc nh sm nguy
c suy dinh dng trn bnh nhn cung cp y dinh dng gip ci thin hiu qu iu
tr, gim t l bin chng v gim chi ph iu tr. [10] [18] [19] [24] [28]
nhgitnhtrng dinh dng yl mtqutrnh phctp, baogm cc bc nh gi chi tit
ch dinh dng, s thay i cc thnh phn trong c
th,duhiuhoctriuchngcatnhtrngthiuhtdinhdng,vccxt nghim cn lm sng.
[18] [28] Chnh v s phc tp ny m cc xt nghim sng
lcnhanhnh:chskhicth(BMI),ccxtnghimhasinh(albumin,
prealbumin,)cpdngnhgitnhtrngdinhdngchobnhnhn trc khi tri qua cc nh
gi chi tit khc [28] ivinhngbnhnhncngtiuhabthngtnlmchcnng cung cp
dinh dng bng ng tiu ha b hn ch hoc dinh dng qua ng
tiuhakhngsoviyucudinhdngthbnhnhnphiccungcp dinh dng qua dch truyn
dinh dng (DTDD) [25] Vinhngbnhnhncnguycsuydinhdngcaocnphiccung cpy
dinh dng ngaytrnhtnhtrngsaukhitriqua qutrnh iutr bnh nhn b suy dinh
dng nng. c bit trn bnh nhn suy thn t l suy dinh dng lun lun rt cao
(trn 40%) v l mt trong nhng nguyn nhn lm gia tng tltvong nhm bnh
nhn ny.Dovyviccungcp ychtdinh dng l mt trong nhng mc tiu iu tr ca
bnh nhn suy thn. [24] Khoa Thn Tit Niu bnh vin Bch Mai l n v iu tr
bnh thn u ngnh,tuyncuivic im bnh nhn phctp nhngchactngkt nh gi thc
trng dinh dng v hiu qu ca vic s dng DTDD ti khoa. Xut pht t thc t
ny, chng ti thc hin ti: 2 Kho sttnhtrngdinhdng cabnh
nhnnmvinvvicsdng dch truyn dinh dng khoa Thn Tit niu bnh vin Bch
Mai vi cc mc tiu sau: - Kho st tnh trng dinh dng ca bnh nhn ti khoa
Thn Tit niu - Khostthctrngcungcpdinhdngvsdngdchtruyndinh dng ti
khoa Thn Tit niu. Kt qu ca ti hy vng s gp phn a ra gc nhn s b v tnh
trng dinh dng ca bnh nhn v vic s dng DTDD ti khoa Thn Tit niu t
xutraccgiiphp nhmtngcngvics dnghplvchiuqu DTDD trn bnh nhn mc bnh
thn. 3 Phn 1 TNG QUAN 1.1. Suy dinh dng thiu protein nng lng:
1.1.1.Khi nim: Suy dinh dng thiu protein nng lng l kt qu ca s thiu
ht nng lng v protein cn thit cho nhu cu chuyn ha ca c th, do khng c
cung cp ytlngthcn hoc do bnhttlmtng tht thot protein haytng nhu cu
cht dinh dng. [26]1.1.2.Cc hnh thc suy dinh dng Bng 1.1. Cc hnh thc
suy dinh dng (SDD)[1] [26] SDD thiu protein (Kwashiorkor)SDD thiu
nng lng (Marasmus) Gim albumin Thiu mu Ph, tng cn Teo c Chm lnh vt
thng Gim sc khng Gim cn Gim chuyn ha c bn H thn nhit Chm nhp tim Da
km dn hi, teo lp m di da Gptrong:nhimtrngnng,chn
thng/bngnng,suythn,xut huyt Gp trong: khng n ung c do cc
bnhlctnhvngtiuha, nghin ru, tm thnTin lng nng, t l t vong cao
1.1.3.Sinh l bnh: Khi bnh nhn gp chn thng hoc cng thng (v d: chn
thng, nhim trng,phuthutln)tnhtrngsuydinhdngcptnhthngxyradodinh
dngcabnhnhnkhngcpng,dtrnnglngtrongcth nhanh chng cn kit do chn thng
v stress i hi mt nhu cu nng lng rt ln. Khi ngun nng lng d tr
glycogen khng cn th protein t cc c quan ni tng, c bp, c xng s c huy
ng cung cp nng lng t dn n 4 vic tt c cc c quan u b nh hng bi tnh
trng suy dinh dng thiu protein nng lng: [19] - Kt qu r nht l gim
trng lng c th, gim d tr m v gim khi lng c xng. - Protein b mt t
gan, ng tiu ha, thn v tim. Kt qu lm suy gim tun hon protein trong
mu, gim cung lng tim v co bp c tim. Chc nng h hp b nh hng ch yu do
s suy yu v teo cc c h hp, ng tiu ha b nh hng do teo nim mc v mt
nhung mao ca rut non dn n tnh trng hp thu km. - Thay i chc nng min
dch: s lng v chc nng t bo lympho T b gim. [19] [26] 1.1.4.Biu hin
lm sng: Biu hin lm sng ca suy dinh dng thiu protein nng lng thay i
t chm pht trin, gim cn cho n nhiu hi chng lm sng khc. Trong suy
dinh dng thiu protein nng lng th pht do bnh tt, biu hin lm sng ca
tnh trng suy dinh dng b nh hng bi cc yu t nh: mc thiu ht protein -
nng lng, bnh dn n tnh trng thiu ht protein nng lng, v tnh trng dinh
dng ca bnh nhn trc khi mc bnh. Suy dinh dng thiu protein nng lng th
pht nh thng bt u bng biu hin gim cn. Trong trng hp nng, bnh nhn c
th b mt hu ht m d trcacthvbgimkhilngccbitlcthidng,clinsn.
Ngoiracncmtsbiuhinthchtkhcnh:tcthavmng,danht, vim da, vim li, vim
li, bng c trng hoc gan to. [26] 1.2. nh gi tnh trng dinh dng: Cc
phng php lm sng c th nh gi tnh trng dinh dng ca bnh
nhnbaogm:hitins,nhgichn,ccphngphpnhntrchc, khm lm sng v cc xt nghim
cn lm sng. 1.2.1.Khm tin s: 5 Xc nh tt c cc yu t nguy c dn n tnh
trng suy dinh dng v tin sbnhcabnh
nhnbaogm:chnthngnng,bng,nhimtrng,gimcn trongthigiangn
yvccrilonhpthu ddy,rut.Khaithctinsn
ungcabnhnhntnhtonnnglngcungcp,cngnhccthnhphn dinh dng a vo c
th.1.2.2.Khm lm sng: 1.2.2.1. Chiu cao v cn nng: Cn nng c th v thay
i cn nng c th l nhng ch s rt ng tin cy trong nh gi tnh trng dinh
dng. C th s dng nhng ch s sau: Phn trm cn nng l tng (Ideal body
weight - IBW): % cn nng l tng = cn nng hin ti/cn nng l tng 100% Vi
cn nng l tng (IBW) c tnh nh sau: Nam: IBW = 50 kg + 2.3 kg [(chiu
cao (cm) - 152,4)/2,54] N: IBW = 45,5 kg + 2.3 kg [(chiu cao (cm) -
152,4)/2,54] nh gi: 80% - 90%: suy dinh dng nh 70% - 79%: suy dinh
dng trung bnh 0% - 69%: suy dinh dng nng. [25] Ch s khi c th (Body
mass index BMI): BMI = 2) (HWW: cn nng (kg) H: chiu cao (m)i vi bnh
nhn ph, cn nng tnh theo 2 cch: Cch 1: da vo cn nng tiu chun: Cn nng
iu chnh = cn nng thc t + [(cn nng tiu chun cn nng thc t) 0,25] Cn
nng tiu chun c xc nh da vo c s d liu NHANES II [24] Cch 2: da vo mc
ph ca bnh nhn: Ph nh: 3kg Ph trung bnh: 7 8 kg 6 Ph nng; 14 15 kgCn
nng iu chnh = cn nng thc t - cn nng tng ng vi mc ph. [27] Bng 1.2.
BMI v tnh trng dinh dng ca bnh nhn [6] BMI (kg/m2)Tnh trng dinh dng
ca bnh nhn 23-25Tha cn 18,5-23Bnh thng 17-18,5Suy dinh dng nh
16-17Suy dinh dng trung bnh 50%tngdintchbmtcth):3040 kcal/kg/ngy.
[16] Vi trng hp bnh nhn suy thn: 11 Suythntgiaion
14,suythngiaion5clc muhoclcmng bng: 35 kcal/kg/ngy vi bnh nhn <
60 tui, 30 35 kcal/kg/ngy vi bnh nhn 60 tui.
Ghpthn:khiuvi3035kcal/kg/ngy,sauduytrvi2530 kcal/kg/ngy. [23] [24]
Nhvybnh nhn khoaThn Titniu c coilcungcp nng lng khi nng lng cung cp
t mc 30 35 kcal/kg/ngy. [9] 1.4. Cc thnh phn dch truyn dinh dng:
1.4.1.Glucid: 1.4.1.1. Vai tr dinh dng ca glucid: Cungcp
nnglng:lvaitrcayu caglucidcthhot ng.Hn
mtnannglngkhuphnldoglucidcungcp,1gamglucidkhit
chytrongcthcho4Kcal.Glucidnvotrchtchuynthnhnng lng,lngthaschuyn
thnhglycogenvmdtr.Thiuglucid hoc nnglngtoradoglucid hnchth cthshuy
nglipid,thmchc protid cung cp nng lng. Nui dng t bo thn kinh: Trong
vic nui dng cc m thn kinh, c bit l h thn kinh trung ng, glucid ng
vai tr rt quan trng. V t chc thn kinh c kh nng d tr glucid rt km, s
nui dng ch yu nh glucose ca mu mang n, nn trng hp i glucid s gy tr
ngi n hot ng ca t bo thn kinh. Vai tr to hnh: glucid c mt trong t
bo v m nh l mt yu t to hnh. Vai tr kch thch nhu ng rut: S kch thch
nhu ng rut ch yu do vai tr ca cellulose. Cellulose c nhiu trong thc
n ngun gc thc vt, mc du n khng c gi tr dinh dng vi c th ngi, nhng n
c tc dng kch thch co bp d dy, lm tng cng nhu ng rut, kch thch cc
tuyn tiu ha bi tit dch tiu ha. [5] [8] 1.4.1.2. Nhu cu nng lng theo
glucid: 12 TheokhuynnghcaVinDinhDngqucgia,tlglucidtrongkhu
phnnnchimkhong70%tngsnnglng,[5]vlngglucidcungcp khng nn qu 7
g/kg/ngy. [25] 1.4.2.Protid: 1.4.2.1. Vai tr dinh dng ca
protid:Protidlyutto hnhchnh: nlthnh phncutochyuca nhnv
nguynsinhchtcatbo.Mtsprotidchiuthamgiavoccthnh
phncccbp,mu,bchhuyt,hormon,men,khngth.Dovaitrny, protid c lin quan
n mi chc nng sng ca c th (tun hon, h hp, sinh
dchotngthnkinhvtinhthn).cthbnhthng,chcmtv nc tiu khng cha protid.
Protid tham gia vo hu ht cc chc nng sng ca c th: Protid cn thit cho
chuyn ha bnh thng ca cc cht dinh dng khc. c bit l cc vitamin v cht
khong. -Protidgivaitr quytnh duytrshngnhcani mi. Protidto
nnplckeoca muvduytrp lckeo mc nhtnh.nhng ngi bbng,xgan,thiu dinh
dng,thn h nhim mviccungcp protid ca c th khng nhu cu dn n cc ri lon
bnh l nghim trng. -Protid tham gia vo vic duy tr cn bng kim toan
trong c th. Protid kch thch s thm n, v th n gi vai tr chnh tip nhn
cc ch n khc nhau Protid l cht bo v ca c th v n c mt c ba hng ro ca
c th l: da, huyt thanh hoc bch huyt v cc t bo min dch. Cung cp nng
lng: ngoi nhim v cu to c th protid cn l ngun cung cp nng lng. Trong
c th 1 gam protid sau khi t chy hon ton s cung cp cho c th 4 Kcal.
[5] 1.4.2.2. Nhu cu nng lng theo protid: TheokhuynnghcaVinDinhDng
qucgia,tlproteintrongkhu
phnnnchimkhong12%tngsnnglng.[5]Nhucuproteinhngngy 13 camibnhnhn
phthucvomcnng nhcabnhlmcphi,thng thng l t 1,2 2 g/kg/ngy.Bng 1.4.
Nhu cu protein hng ngy tng ng vi tnh trng bnh nhn[17] [25]
1.4.3.Lipid: 1.4.3.1. Vai tr dinh dng ca lipid:
Lipidlngunsinhnnglngquantrng:1gamlipidkhitchytrongc th cho 9 Kcal.
Thc n giu lipid l ngun nng lng m c cn thit cho ngi lao ng nng, cn
thit cho thi k phc hi dinh dng.
Thamgiacutotbo:lipidlthnhphncutocamngtbo,mng
nhn,mngtylpththamgiacuto(cchormoncnhnsterol). Phosphatidlthnh
phncutrc t bothnkinh, no, tim,tuynsinh dc... i vi ngi trng thnh
phosphatid (nh lecithin) l yu t quan trng iu
hachuynhacholesterol.Lecithin hatan cholesterol,phngiivthitr
cholesterol ra khi c th, ngn cho cholesterol khng b ng li trong c
th.Tnh trngNhu cu hng ngy (g/kg/ngy) Bnh thng0,8 Stress nh1,0 1,2
Stress trung bnh1,2 1,5 Stress nng1,5 2,0 Suy dinh dng1,5 Ngi cao
tui1,2 1,5 Suy thn mn trc lc mu0,6 0,8 Suy thn mn c lc mu hoc lc
mng bng 1,2 1,3 Suy thn lc mu lin tc1,0 Bnh thn Suy thn cp vi tnh
trng SDD nng hoc tng d ha 1,5 1,8 14 Cht bo l ngun cung cp cc
vitamin ha tan trong lipid: vitamin A, D, E, K v cc cht sinh hc qu.
Cht bo gy hng v thm ngon cho ba n, gy cm gic no lu v thc n
giumliddyluhn(mchpthucaonhtlkhong3gi30 pht sau n). Cht bo di da v
bao quanh ph tng l t chc bo v, t chc m, gip
cthtrnhkhitcngxucamitrngbnngoinhnng,lnh,va chm. [5] 1.4.3.2. Nhu cu
nng lng theo lipid: TheokhuynnghcaVinDinhDngqucgia,tllipidtrongkhu
phn nn chim khong 18% tng s nng lng [5] v lng lipid khng nn cung cp
qu 2,5 g/kg/ngy. [25] 1.5. Hng dn s dng DTDD trn bnh nhn suy dinh
dng: Nhng bnh nhn sau cn c cung cp thm nng lng thng qua DTDD:
Khngckhnnghpthuquangtiuhadomttrongccnguyn nhn sau: - Nn ko di t 7
14 ngy - Tiu chy nng - Tc rut - Phu thut ct rut non. Ung th Vim ty:
bnh nhn b vim ty nng, ko di v cung cp nng lng qua ng tiu ha khng
trong vng 5 7 ngy Nhng bnh nhn cn chm sc c bit:
-DngDTDDkhicungcpnnglngquangtiuhalchngch
nhivibnhnhnhoccungcpkhngynhucudinhdng trong 5 10 ngy. 15 -
Chcnng1scquansuygim(gan,thn,phi)vnnglngqua ng tiu ha khng ko di dn
n tnh trng suy dinh dng nng bnh nhn. -
Bnhnhnbng:DTDDnncsdngkhinnglngcungcpqua ng tiu ha khng nhu cu dinh
dng trong vng 4 5 ngy. Phu thut: -
Trcphuthut:nhngbnhnhnsuydinhdngvahocnngc
chnhphuthutngtiuhathnncdngDTDDtrcphu thut 7 14 ngy. -
Sauphuthut:nnsdngDTDDchonhngbnhnhnmcungcp nnglng qua ngtiu
halchngch nhhocnnglng khng c cung cp trong vng 7 10 ngy. [13] [15]
Mt s loi dch truyn hay c s dng bnh vin Bch Mai: Trong trng hp bnh
nhn c ch nh dng cc DTDD th bnh vin Bch Mai c hay dng mt s loi DTDD
(bng 1.5). Ngoi nhng DTDD glucid, protid, lipid ring l th bnh vin
cn s dng ti dch truyn 3 ngn vi hn hp 3 thnh phn bsung ycht dinh dng
cho bnh nhntrongtrng hp bnhnhn thiu c 3 thnh phn cht dinh dng. 16
Bng 1.5. Mt s dch truyn dinh dng hay s dng bnh vin Bch Mai Dch
truyn (ml)Nng lng cung cp (kcal) Glucid Glucose 10% (500ml)200
Glucose 20% (500ml)400 ProtidAlvesin 10 E (250ml)100 Aminosteril
10% (500ml)200 Aminoplasmal 5% E (250ml)50 Nephrosteril (250ml)70
Neoamiyu (200ml)48,8 Kidmin 7,2% (200ml)57,6 LipidLipofundin 10%
(500ml)529 Lipovenoes 10% (500ml)540 Intralipid 10% (500ml)500 DTDD
3 thnh phn Kabiven (1440ml)1000 Kabiven (1920ml)1400 Kabiven
(2400ml)1700 Oliclinomel N4 550E (1000ml)610 Oliclinomel N7 1000E
(1000ml)1200 Nutriflex (1250ml)955 Combilipid (1440ml)1000 17 Phn 2
I TNG V PHNG PHP NGHIN CU 2.1. i tng nghin cu: Tt c cc bnh nhn nm
iu tr ti khoa Thn - Tit niu, bnh vin Bch Mai t ngy 11/03/2013
11/04/2013 p ng tiu chun la chn v loi tr sau: Tiu chun la chn: Tui
15 C y cc thng tin v chiu cao, cn nng, tnh trng bnh l. Tiu chun loi
tr: Bnh nhn khng hp tc nghin cu Ph n c thai. Thit k nghin cu: La
chn tt c nhng bnh nhn t tiu chun nghin cu
Theodithngxuynbnhnhn,bnhnvbngtheodicabnhnhn theo mu nghin cu
Ghinhnccthngtincnthitvinvomubnhnphhpvini dung nghin cu (ph lc 1)
2.2. Cc ch tiu s dng trong nghin cu: 2.2.1.Ch s khi c th BMI: BMI =
2) (HWW: cn nng (kg) H: chiu cao (m)i vi bnh nhn ph, cn nng tnh
theo 2 cch: Cch 1: da vo cn nng tiu chun: Cn nng iu chnh = cn nng
thc t + [(cn nng tiu chun cn nng thc t) 0,25] Cn nng tiu chun c xc
nh da vo c s d liu NHANES II Cch 2: da vo mc ph ca bnh nhn: Ph nh:
3kg Ph trung bnh: 7 8 kg 18 Ph nng; 14 15 kgCn nng iu chnh = cn nng
thc t - cn nng tng ng vi mc ph. 2.2.2.Nng lng cung cp: Tin hnh phng
vn bnh nhn xc nh nng lng bnh nhn c cung cp
hngngy:nnglngccungcpthngquaccbanvquadchtruyn
dinhdngglucid,protid,lipid.Sautnhnnglngtrungbnhbnhnhn c cung cp
trong qu trnh iu tr bng cch ly tng nng lng trong c qu trnh chia cho
thi gian nm vin ca bnh nhn. Do dch truyn glucose 5% khng c ch nh
nui dng nhn to nn loi dch truyn ny khng c tnh l DTDD trong phn thng
k nhng nng lng ca dch truyn ny vn c tnh vo tng nng lng dch truyn
cung cp cho bnh nhn. Nng lng thc t bnh nhn c cung cp tnh theo lng
kcal trn 1 kilogram cn nng bnh nhn c cung cp hng ngy (vi bnh nhn ph
s tnh theo cn nng iu chnh).
Bnhnhnbbnhthnnichungccoilcungcpnnglngkhit mc 30 35 kcal/kg/ngy.
2.2.3.Tnh trng dinh dng: Lm sng: phn loi tnh trng dinh dng theo ch
s BMI: Suy dinh dng nh : 17 18,5Suy dinh dng trung bnh: 16 17Suy
dinh dng nng: < 16 Cnlmsng:
phnloitheochsalbuminhuytthanh(g/l)iviccbnh nhn khng b hi chng thn
h, vim cu thn cp v cc bnh l c mt protein qua nc tiu. Suy dinh dng
nh : 28 34Suy dinh dng trung bnh: 21 27Suy dinh dng nng: < 21
2.3. Phng php nghin cu: 19 Phng php m t tin cu trn 110 bnh nhn iu
tr ti khoa. 2.3.1.Kho st thc trng dinh dng ca bnh nhn suy thn ti
khoa: c im bnh nhn nghin cu gm: Tui Gii tnh S ngy nm vin Mc ph Mc
suy thn Ch s BMI Ch s albumin huyt. 2.3.2.Kho st tnh hnh cung cp
nng lng v thc trng s dng DTDD: Kho st cc loi hnh nui dng ti khoa
Kho st cc loi DTDD s dng ti khoa: cc kiu phi hp DTDD v tng lng mi
loi DTDD c dng trong t iu tr. Tnh nnglngtrung bnh bnh nhn c
cungcptrong 1 ngytba nv ba n + DTDD (kcal/kg/ngy) Kho st tnh hnh s
dng DTDD trn bnh nhn ph ti khoa Kho st tnh hnh s dng DTDD theo c im
tnh trng dinh dng ca bnh nhn tnh theo ch s BMI
Khosttnhhnhcungcpnnglngtbanvban+DTDDtheoc im tnh trng dinh dng ca
bnh nhn tnh theo ch s BMI 2.4. X l s liu: S liu c x l theo phng php
thng ky hc vi s tr gip ca phn mm SPSS 16.0 -S dng test 2 so snh hai
t l-Dng test T so snh s khc bit v 2 gi tr trung bnh v test ANOVA so
snh nhiu gi tr trung bnh. Gi tr p < 0,05 c coi l s khc bit c
ngha thng k. 20 Phn 3 KT QU NGHIN CU 3.1.cimbnh nhn ti khoa Thn Tit
niu bnh vin Bch Mai: 3.1.1.c im v tui, gii tnh v thi gian nm vin:
Phn tch s liu trn 110 bnh nhn t thng 3/2013 4/2013 cho chng ta kt
qu c im v tui v gii tnh ti bng sau: Bng 3.1. Phn b v tui, gii tnh v
thi gian nm vin ca nhm bnh nhn nghin cu S bnh nhnT l (%) Nhm tui
(nm) < 404339,1 40 604238,2 > 602522,7 Tng110100 Tui trung
bnh (nm): 46,1 17,7 Gii tnh Nam4238,2 N6861,8 Tng110100 Thi gian nm
vin trung bnh (ngy): 13,9 5,6 Nhn xt: T l bnh nhn n iu tr ni tr ti
khoa Thn Tit niu l 61,8% cao gn gp i so vi bnh nhn nam vi 38,2%.
Bnh nhn iu tr ni tr ti khoa ch yu l bnh nhn di 40 tui, s lng bnh
nhn ny cao nht vi 43 trong tng s 110 bnh nhn. 21 Thi gian nm vin
trung bnh ca bnh nhn ti khoa l 13,9 5,6 (ngy) 3.1.2.Phn loi bnh nhn
theo nhm bnh l v mc suy thn: TikhoaThnTitniuasbnhnhnnhpvinvichnongm
nhiu bnh mc km (v d nh: suy thn hi chng thn h, suy thn giai on cui
do vim cu thn mn) cho nn bng s liu ny th hin s lng ca mi mt bnh l l
s lt bnh nhn mc bnh c ghi trong chn on.Bng 3.2. Phn loi bnh nhn
theo nhm bnh l ti khoa Nhm bnhS bnh nhn (n=110)T l (%) Giai on
343,6 Giai on 465,5 Giai on 56861,8 Suy thn Tng7870,9 Hi chng thn
h2320,9 Vim cu thn5449,1 Bnh khc4540,9 Nhn xt: Ngoi cc nhm bnh l
chnh ti khoa th bnh nhn cn mc km mt s bnh lkhc
mchngtikhngthngkcthtrong bng, lcc bnhl:hp
niuqun,gintoibthn,sithn,ubngquang,nhimkhuntitniu, chy mu nang thn,
thn a nang, i mu, i tho ng, tng huyt p Quanghincuchothysbnhnhn
nmiutrtikhoaThnTitniu
nhiunhtlthucnhmbnhlsuythn,trongbnhnhnsuythngiai on 5 chim t l cao
nht vi 61,8%. Bnh nhn thuc hai nhm vim cu thn v hi chng thn h cng
chim hn 1/2 tng s bnh nhn. 3.1.3.Phn loi mc ph: 22 Bng 3.3. Phn loi
mc ph ca bnh nhn ti khoa Mc phS bnh nhnT l (%) Ph nh1715,5 Ph trung
bnh1715,5 Ph nng98,2 Bnh nhnph Tng4339,2 Bnh nhn khng ph6760,8
Tng110100 Nhn xt: TikhoaThn Tit niuths bnh nhnctriuchng phchimtl
39,2%trong tng s 110 bnh nhn nghin cu. Trong s bnh nhn ph mc
nhvtrungbnhctlbngnhauul15,5%,sbnhnhnphmc nng chim t l t nht vi
8,2%. 3.2.Tnhtrngdinh dng ca bnh nhn ti khoa Thn Tit niu ti ngy u
nhp khoa: 3.2.1.T l bnh nhn theo phn loi BMI: Ti khoa Thn Tit niu
vi c im c nhiu bnh nhn ph vi cc mc ph khc nhau, do cn nng thc t ca
bnh nhn dng tnh ch s BMI s khng chnh xc. V vy trong bng s liu ny
chng ti tnh BMI da vo cn nng hiu chnh. Cch tnh cn nng hiu chnh theo
c s d liu NHANES II v mc ph c nu trong phn tng quan v phn i tng v
phng php nghin cu. 23 Bng 3.4. Phn loi tnh trng dinh dng ca bnh nhn
trong ngy u nhp khoa theo ch s BMI Loi suy dinh dng (SDD)S bnh nhnT
l (%) SDD nng1513,6 SDD va87,3 SDD nh2623,6 Suy dinh dng (SDD)
Tng4944,5 Bnh thng5247,3 Tha cn98,2 Tng110100 Nhn xt: Trong s 110
bnh nhn th c gn 1/2 s bnh nhn b suy dinh dng tnh theo ch s BMI.
Trongsbnhnhnbsuydinhdngthbnhnhnbsuydinhdngnh chim t l cao nht
(23,6%), tip sau l bnh nhn suy dinh dng nng vi t l l 13,6% v cui
cng t l thp nht 7,3% l bnh nhn suy dinh dng va. 3.2.2.T l bnh nhn
theo ch s albumin: Khi s dng ch s albumin nh gi tnh trng dinh dng
th bnh l hi chng thn h v vim cu thn c nh hng ln nng albumin huyt do
m chngtichnhgitnhtrngdinhdngtrnnhngbnhnhnkhngchai chn
ontrn.Trong110 bnh nhn nghin cuc 50 bnh nhnkhng mc hai bnh l trn.
24 Bng 3.5. Phn loi tnh trng dinh dng ca bnh nhn trong ngy u nhp
khoa theo ch s albumin huyt Tnh trng dinh dngCh s albumin (g/l) S
bnh nhnT l (%) Bnh thng> 34714,0 SDD nh28 341224,0 SDD va21
27510,0 Bnh nhn c xt nghim albumin2448,0 Bnh nhn khng c xt nghim
albumin2652,0 Tng50100 Nhn xt: Trong s nhng bnh nhn c lm xt nghim,
bnh nhn suy dinh dng nh chim t l cao nht v bnh nhn suy dinh dng va
chim t l thp nht. 3.3. Kho st tnh hnh cung cp nng lng v s dng DTDD
cho bnh nhn ti khoa: 3.3.1.T l cc loi hnh nui dng ti khoa Thn Tit
niu: Bng 3.6. Cc loi hnh nui dng ti khoa ng nui dngS bnh nhnT l (%)
Qua ng tiu ha n thun7870,9 Phi hp (tiu ha + tnh mch)3229,1
Tng110100 Nhn xt: Qua bng s liu chng ta thy loi hnh nui dng ch yu
ti khoa Thn Titniulhnhthcnuidngquangtiuhanthun.Hnhthcny
cpdngtrn78bnhnhntngngvi70,9%,cnlil32bnhnhn chim 29,1% vi hnh thc
nui dng phi hp ( nui dng qua ng tiu ha 25 kt hp vi nui dng qua ng
tnh mch). Khng c bnh nhn no c nui dng hon ton qua ng tnh mch.
3.3.2.Cc loi DTDD hay c s dng ti khoa: Bng 3.7. Phn loi cc DTDD hay
c s dng ti khoa DTDDNng lng (kcal/chai)S bnh nhn (n=32) Protein
Kidmin 7,2% (200ml)57,64 (12,5) Neoamiyu 200ml48,826 (81,3) Glucid
Glucose 10% (500ml)2003 (9,4) Glucose 20% (500ml)4001 (3,1) Lipid
Lipovenoes 10% (250ml)2701 (3,1) Nhn xt: T kt qu nghin cu trn 32
bnh nhn s dng dch truyn dinh dng ti khoa cho thy: V protid: C 2 loi
dch truyn protein c s dng ti khoa Thn Tit niu bao gm: Kidmin 7,2%
(200ml), Neoamiyu 200ml. Trong Neoamiyu 200ml c s dng nhiu nht ti
khoa. V glucid: C 2 loi dch truyn glucid c s dng ti khoa Thn Tit
niu l: Glucose 10% v Glucose 20%.V lipid: C duy nht 1 loi nh dch
lipid l Lipovenoes 10% (250ml) c s dng ti khoa vi 1 bnh nhn c s
dng. 3.3.3.T l cc kiu phi hp DTDD ti khoa: 26 Bng 3.8. T l cc kiu
phi hp DTDD ti khoa Kiu phi hp DTDDS bnh nhnT l (%) Dng duy nht 1
loi DTDD3196,9 Dng t 2 loi DTDD tr ln13,1 Tng32100 Nhn xt: C hai
loi phi hp DTDD ti khoa, trong chim a s l kiu dng duy nht 1 loi
DTDD trong sut qu trnh iu tr. 3.3.4.Tng lng DTDD c dng trong t iu
tr: Bng 3.9. S lng tng loi DTDD c dng ti khoa Loi DTDDS bnh nhn
(n=32) T l (%) 1 5 chai13,1Kidmin 7,2% (200ml) 6 10 chai39,4 1 5
chai825,0 6 10 chai1650,0Neoamiyu 200ml > 10 chai26,3 Glucose
10% (500ml)1 5 chai39,4 Glucose 20% (500ml)1 5 chai13,1 Lipovenoes
10% (250ml) 1 5 chai13,1 Nhn xt: Tbngsliuchngtathyrngsbnh nhns
dngDTDDtptrung vo s dng dch truyn Neoamiyu 200ml vi mc 6 10 chai
trong 1 t iu tr, cc DTDD khc c s dng rt t. 3.3.5.Tnh hnh s dng DTDD
trn bnh nhn ph ti khoa: 27 Bng 3.10. Tnh hnh s dng DTDD trn bnh nhn
ph khoa. S bnh nhn s dng DTDD (t l %)Tnh trng ph ProtidGlucidLipid
Ph nh (n=17)2 (11,8)1 (5,9)0 Ph trung bnh (n=17) 2 (11,8)00 Ph nng
(n=9)1 (11,1)00 Bnh nhn c ph Tng (n=43)5 (11,6)1 (2,3)0 Bnh nhn
khng ph (n=67)25 (37,3)2 (3,0)1 (1,5) Gi tr thng k*p = 0,003 (Gi tr
thng k*: l gi tr thng k so snh t l s dng DTDD protid ca nhm bnh nhn
ph v khng ph) Nhn xt: Qua bng s liu chng ta thy rng s khc bit v t l
dng DTDD protid 2 nhm bnh nhn ph v khng ph l c ngha thng k (p <
0,05). T l bnh nhn s dng DTDD protid nhiu nht l nhm bnh nhn khng
ph. 3.3.6.Nng lng cung cp t ba n v t DTDD:
NnglngcungcptbanvtDTDDuctnhdavonng lngtrung bnhtcl bngtng nnglngbnh
nhn ccungcptrong t iu tr chia cho s ngy nm vin. 28 Bng 3.11. Nng
lng bnh nhn c cung cp hng ngy t ba n v DTDD trong qu trnh iu tr ti
khoa Nhn xt: Kt qu nghin cu cho thy a s bnh nhn l cha c cung cp nng
lng y t mc 30 n 35 kcal/kg/ngy nh khuyn co, c th l trong 110 bnh
nhn nghin cu ch c 1,8% bnh nhn c cung cp nng lng trong khi 96,4%
bnh nhn cha c cung cp nng lng. V trong 32 bnh nhn s dng DTDD th ch
c 3,1% bnh nhn c cung cp nng lng trong khi 93,8% bnh nhn cha c cung
cp nng lng. Vic bnh nhn c ch nh dng DTDD cng khng thay i t l bnh
nhn ccungcp nnglng,cha ccungcp nnglngvcungcp tha nng lng khoa.
3.3.7.Tnh hnh s dng DTDD theo tnh trng dinh dng ca bnhnhn: Ba nBa n
+ DTDD Nng lng Kcal/kg/ngyS bnh nhn T l (%)S bnh nhn T l (%) <
3010696,410696,4 30 3521,821,8 > 3521,821,8 Ton b nhm bnh nhn
nghin cu (n=110) Nng lng trung bnh 18,1 6,118,3 6,1 <
303093,83093,8 30 3513,113,1 > 3513,113,1 Bnh nhn dng DTDD
(n=32) Nng lng trung bnh 18,0 6,018,7 5,9 29 Bng 3.12. Tnh hnh s
dng DTDD ca bnh nhn khoa theo tnh trng dinh dng tnh theo BMI S bnh
nhn s dng DTDD (t l %)Tnh trng dinh dng ProtidGlucidLipid SDD nng
(n=15) 4 (26,7)1 (6,7)0 SDD va (n=8)1 (12,5)00 Suy dinh dngSDD nh
(n=26) 10 (38,5)3 (11,5)1 (3,8) Bnh thng (n=52)13 (25,0)00 Tha cn
(n=9)2 (22,2)00 Gi tr thng k**p = 0,481 (Gi tr thng k**: l gi tr
thng k so snh t l s dng DTDD protid ca nhm bnh nhn suy dinh dng v
bnh thng + tha cn ) Nhn xt: S khc bit v t l dng DTDD protid 2 nhm
bnh nhn suy dinh dng v bnh thng + tha cn khng c ngha thng k.
3.3.8.Tnhhnhcungcpnnglngtheotnhtrngdinhdngcabnh nhn ti khoa: Nhn xt
bng 3.13: -Tnhhnhcungcpnng lng bnh nhn suy dinh dng nng l nhiu nht
v mc cung cp nng lng cng gim dn t bnh nhn suy dinh dng nng cho n
bnh nhn tha cn. -Skhc bitvcungcp nnglngtrung bnhgiacc nhm:SDD
nngviSDDnh,SDDnngvi bnh thng, SDD nng vi tha cn, SDD va vi tha cn,
SDD nh vi tha cn l c ngha thng k. 30 Bng 3.13.Tnh hnh cung cp nng
lng theo tnh trng dinh dng ca bnh nhn khoa S bnh nhn(t l %)Nng lng
trung bnh Tnh trng dinh dng Nng lng Kcal/kg/ ngy Ba nBa n + DTDD Ba
n +DTDD < 3012 (80)12 (80) 30 351 (6,7)1 (6,7) SDD nng (1)
(n=15)> 352 (13,3)2 (13,3) 22,7 8,1 < 308 (100)8 (100) 30
3500 SDD va (2) (n=8)> 3500 21,3 4,4 < 3025 (96,1)25 (96,1)
30 351 (3,9)1 (3,9) Suy dinh dng SDD nh (3) (n=26)> 3500 18,7
4,9 < 3052 (100)52 (100) 30 3500 Bnh thng (4) (n=52) > 3500
17,2 5,6 < 309 (100)9 (100) 30 3500 Tha cn (5) (n=9) > 3500
14,0 4,6 Gi tr thng kp1-2-3-4-5 = 0,002 (Ghi ch: s khc bit c ngha
thng k gia cc nhm: 1 vi 3, 1 vi 4, 1 vi 5, 2 vi 5 v 3 vi 5.) 31 Phn
4 BN LUN 4.1.Kho st tnh trng dinh dng ca bnh nhn ti khoa: 4.1.1.c
im bnh nhn nghin cu: T l lt bnh nhn mc bnh vim cu thn trong nghin
cu chim gn 50% trong cc bnh thn c iu tr ti khoa Thn- Tit niu. Kt qu
ca nghin cuphhpvithngkcaphgiosTrnVnChtvbcsTrnTh Thnh (1991 - 1995)
ti khoa Thn - Tit niu Bnh vin Bch Mai, t l bnh vim cu thn mn chim
31,5% trong la tui hay gp l 16-44 tui chim 88,32%. [3]
Phnlnbnhnhnnhpvinlbnhnhnsuythngiaioncui,mtnh trng suy dinh dng l ph
bin nhm bnh nhn ny. Trong s ccyu t
nguycdnntinlngxubnhnhnsuythngiaioncuithsuy dinh dng protein nng lng
lyu t ng u, nhiu nghin cu dch t cng ch ra rng vic ci thin tnh trng
dinh dng cng lm ci thin kt qu iu tr ca bnh nhn suy thn giai on cui.
[18] Mt khc y cng l nhmbnhnhn bnhlnngcnchchmscviutrcngnhnhu cu nng
lng kh cao. Nh vy p ng c iu ny th bnh nhn cn c cung cp ngun dinh
dng t bn ngoi mt cch y thng qua cc hnh thc nui dng khc nhau (nh l
qua cc ba n, qua DTDD). [2] 4.1.2.Tnh trng dinh dng ca bnh nhn theo
BMI v albumin huyt: Nng albumin huyt thanh c s dng rng ri nh l ch s
tiu chun cho vic nh gi tnh trng dinh dng. S suy gim nng albumin
huyt thanh cho thy c lin quan n s gia tng t l bnh tt v t vong nhng
bnh nhn suy thn mn. V vy, nng albumin cn c s dng nh l ch s tin lng
bnh.Tuynhin,hinnayangctranhlunvnhycaalbumintrongvic nhgitnhtrng
dinh dng doc nhiutcnhn ngoi dinh dngcthnh 32 hng n s suy gim nng
albumin nh: tnh trng nhim trng, vim, bnh l gan, bnhlhichngthn
hNgoira, albumincthigian bnthikh di (khong 20
ngy)vchimslnglntronghuyt thanh nn biu hin nng
albumingimdigitrbnhthngthngxyrasaukhimtslngln albuminvituntrc
.Do,gitrchn ondinhdngcaalbuminkh mun sau khi tnh trng suy dinh dng
khi pht. Mc d ch s albumin c nhy thp nhng c c hiu cao nn trong rt
nhiu nghin cu nh gi dinh
dng,albuminlunlthngsnhgiquantrngkhngththiu.[10]Nhiu
nghincucngchrarngnhgitnhtrngdinhdngnnctinhnh
nhgitrnnhiuchs,kthpgiachshasinh(albumin,prealbumin, transferrin) v
cc phng php nhn trc hc (ch s khi c th - BMI, dy np gp da vng c tam
u - triceps skin fold, chu vi gia cnh tay), phng php nh gi tng th
tnh trng dinh dng theo ch quan (Subjective Global Assessment SGA).
Nhng do iu kin cha cho php nn nghin cu ny chng ti tin hnh kho st
tnh trng dinh dng trn 2 ch s BMI v albumin huyt (trn cc bnh nhn
khng mc hi chng thn h v/hoc vim cu thn) v tnh c t l
bnhnhnsuydinhdngtngngl44,5%v34%.Trongkhivicc
nghincukhcnhnghincunhgitnhtrngdinhdngtrnbnhnhnsuy thn c lc mu v lc
mng bng ca Kitty J. Jager v cng s th cho kt qu t l suy dinh dng
theo BMI l 16% v theo ch s albumin l 32%. [22] Nghin cu nh gi tnh
trng dinh dng ca bnh nhn chy thn nhn to theo phng php SGA ca
Gurreebun F v cng s cho kt qu t l bnh nhn SDD theo BMI l6,4% v theo
albumin l 20,6%. [21]Hay nghin cu ca Nguyn Th VnAnh ti khoa Thn nhn
to bnh vin Bch Mai m t tnh trng dinh dng ca bnh
nhnsuythnmntnhlcmuchukchoktqutlsuydinhdngtheo BMI l 41% v theo
albumin l 32,3% cng tng i ging vi kt qu ca ti. [4] 4.2.Kho st tnh
hnh cung cp nng lng v s dng DTDD ti khoa: 33 T kt qu ca ti cho thy
ti khoa Thn Tit niu bnh vin Bch Mai s bnh nhn ccungcp
nnglngthmtDTDDl khong 30%cnch
yubnhnhnccungcpnnglngquangtiuha.iunyph hp vi khuyn co ca Hip hi
dinh dng ng tiu ha v ngoi tiu ha
Chuu(EuropeanSocietyforParenteralandEnteralNutrition ESPEN)v
viccungcp nnglngt DTDDcho bnh nhnthn.Bnh nhnchc cung cp nng lng t
DTDD nh mt bin php h tr dinh dng khi ch
nuidngngrutcabnhnhncungcpkhngnnglnghoc bnh nhn c nhng tn thng ng
tiu ha. Cn khi chc nng ng tiu haca bnh nhnvncth p ngc nhucucungcp
dinh dng thbnhnhnnncithinbngcchtngkhuphnnhocnquasonde, nu tnh trng
dinh dng ca bnh nhn vn tip tc xu i th mi dng n DTDD cung cp nng
lng. [14] Trongsuythnmntnhcstrccsnphmcasthoigingprotein nh ur,
creatinin, acid uriclm cho nng cc cht ny trong mu tng cao dn n triu
chng lm sng in hnh ca suy thn l hi chng ur mu cao. Chnh v vy bnh
nhn suy thn cn phi p dng ch n gim m lm chmtintrincabnh.Vch ngim m
nystoranguycthiu cc acid amin thit yu, c bit l bnh nhn suy dinh dng
th nng cc acidaminthityutronghuyttnglrtthp,vdnh:valine,leucine,
isoleucine,lysinevtryptophan.[11]gii quytvnnybnh nhn nn
cbsungccacidaminthityuthngquaDTDDdngringchobnh
nhnsuythnnhlNeoamiyu200ml,Nephrosteril250ml.DovyDTDD c s dng nhiu
nht ti khoa Thn Tit niu l Neoamiyu 200ml l hp
l(81,3%bnhnhndngDTDDdngNeoamiyu200ml).DTDDNeoamiyu
cnhngaminoacidthityuvkhngthityucnthitchobnhnhn
suythn.Liuphpchbsungacidaminthityuchobnhnhnsuythn ngy nay l khng hp
l bi v c mt s acid amin khng thityu nh L Alanin,L acid Aspartic, L
Serin, L Tyrosin l cn thit i vi bnh nhn 34 suy thn. [18] Dch truyn
dinh dng acid amin cng c s dng tp trung
nhmbnhnhnkhngph,iunyphhpvinguyntchnchlng dch vo nhng bnh nhn c ph.
DTDDsdngtikhoacccthnhphn:glucid,protid,lipid.Tuy
nhinkhoamichsdngchyudchtruynacidamincndchtruyn glucid v lipid khng
c s dng nhiu. V cc DTDD c s dng ti khoa
ulDTDD1thnhphnmchacsdngDTDD3thnhphn.Loi
DTDDhnhpnygm3thnhphn:glucid,protid,lipidccc hng sn xut tnh ton k
lng m bo nng v t l tng thnh phn p ngy nhucu nnglngcho bnh nhn,
nngcao hiu quvanton
nhmtrnhthathiuccthnhphntrongqutrnhnuidng.Ngoira, vicsdngDTDD hn
hpcngiptitkimthigiancho ngis dng, trnh c sai st hay tng k trong qu
trnh phi hp cc loi DTDD ring l.ivibnh nhn ph thnnsdngDTDDhn hp
bivloiDTDD nyvagipcungcpnnglngchobnhnhnvagip hnchc lng dch a vo.
[14] Qua kt qu nghin cu c th thy phn ln bnh nhn ti khoa l cha c
cung cp mc nng lng theo khuyn co l t 30 35 kcal/kg/ngy. Ngay
ckhibnhnhncchnhbsungDTDDcngkhngpng mc nng lng yu cu. iu ny c th c l
gii l do bnh nhn khoa khng tun th ch n ung bt buc theo khu phn dinh
dng ca bnh vin m n ung t tc, n sut cm i mua hoc ph, min, chodo ngi
nh mang nnnbnhnhnnungrtthtthng.Mtkhcdobnhttauyu, khng gian bnh vin
ngt ngt nn bnh nhn d mt mi v gim kh nng n ung. Chnh v vy m nng lng
bnh nhn c cung cp t ba n l rt t, trong khi cc bc s thng ch ch trng
n tin trin ca bnh tt m cha quantm y ntnh trng dinh dngca bnh nhn nn
mc d ch nh s dng DTDD cho bnh nhn nhng nng lng cung cp cng khng t c
mc nh khuyn co. 35 NnglngcungcptrungbnhnhmbnhnhnSDDnng,SDDnhv
bnhthngcscithinhnkhisdngthmDTDDcnnhmbnh
nhnSDDtrungbnhvthacnthkhngcscithinkhidngthm DTDD. Nguyn nhn do vic
s dng DTDD khoa ph thuc vo tnh trng ca bnhnhn, bnh
nhncthSDDmctrungbnh nhngvnn ung tt v y th khng cn thit phi dng
DTDD.Vic cung cp nng lng cho bnh nhn ti khoa t ba n cng nh khi bnh
nhncchnhbsungDTDDtngdntbnhnhnthacn,bnh thng,SDD nh, SDDtrung bnhcho
nSDDnng.Kt qu nycng ph hp vi mc tiu iu tr v khc phc tnh trng SDD
bnh nhn thn, bi v tnhtrngsuydinhdngnnglmttrongccyutnguycdnncc bin
chng nguy him m nng n nht l t vong. Ngoi ra trong 1 nghin
culmsngichngngunhin(RandomizedcontrolledtrialRCT)v vic nh gi tc ng
ca cc can thip dinh dng (t vn dinh dng, theo
dikimsotchn)trnbnhnhnsuythngiaion4v5tcgi Campbell KL cng ch ra l
vic tc ng ca cc can thip dinh dng l c ci thin ln v tnh trng dinh
dng cho bnh nhn. [12] 36 KT LUN
Quanghincutrn110bnhnhntikhoaThnTitniubnhvin Bch Mai chng ti c mt s
kt lun nh sau: Tnhtrngdinhdngcabnhnhn ti khoa: -Tnh trng dinh dng
theo ch s BMI (trn 110 bnh nhn): C 44,5% bnh nhn SDD, 47,3% bnh nhn
bnh thng v 8,2% bnh nhn tha cn. Trong 44,5% bnh nhn SDD c 13,6% bnh
nhn SDD nng, 7,3% bnh nhn SDD va v 23,6% bnh nhn SDD nh.
-Tnhtrngdinhdngtheochs albumin huyt (trn 50 bnh nhn khng mc hi chng
thn h v/hoc vim cu thn): C10%bnhnhnSDDva,24%bnhnhnSDDnhv14%bnhnhn
bnh thng. Khng c bnh nhn SDD nng v tha cn. Tnhhnhcungcpnnglngvs dng
DTDD ti khoa: -Phnlnbnh nhnlchaccungcpmcnnglngtheonhkhuyncoca
HiphidinhdngngtiuhavngoitiuhaChuuESPEN
(96,4%),chc1,8%bnhnhnccungcpmcnnglngtheo khuyncol t30
35kcal/kg/ngyv1,8%bnh nhnlccungcp
thannglng.Mcnnglngtrungbnhbnhnhntikhoaccung cp l 18,3 6,1
kcal/kg/ngy. -Vic s dng DTDD ti khoa cha c
phbinvccloiDTDDcngchaadng.asbnhnhnchc
dngdchtruynacidamin(81,3%bnhnhndngDTDDdngNeoamiyu 37
200ml),cndchtruynglucidcdngrttvdchtruynlipidthgn nh khng c dng. 38
XUT -Nn s dng thm cc ch s ha sinh nh prealbumin, transferrin cng vi
ch s albumin v BMI tng tin cy cho vic nh gi tnh trng dinh dng trn
bnh nhn. -Khoa Thn Tit niu nn tch cc khuyn khch bnh nhn n theo sut
n bnh vin tin theo di cng nh nh gi nhu cu dinh dng ca bnh nhn. T s
c nhng gii php b sung nng lng t DTDD mt cch hp l. -Bc s cn ch trng
hn tnh trng dinh dng ca bnh nhn khi iu tr bnh TI LIU THAM KHO Ti
liu ting vit 1.BchVnCng(2007),"Nuidngtrongngoikhoa",Ngoikhoalm sng,
Trung tm o to v bi dng cn b y t, pp. 135-142.
2.Bmndinhdng-antonthcphm(2013),Dinhdnghc,Trng i hc Y khoa Phm Ngc
Thch, Nh xut bn Y hc, pp. 359-363. 3.B mn Ni (2006),Biging bnh hc
ni khoatp 2,Trng i hcY H Ni, Nh xut bn y hc, pp.
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bnhvinBchMai",Tpchdinhdngvthcphm,4 (3+4), pp.
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VDC Media, pp. 12-16. Ti liu ting anh
9.AshleyCaroline,MorlidgeClare(2008),Introductiontorenaltherapeutics,
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10.BanhLe(2006),"SerumProteinsasMarkersofNutrition:WhatAreWe
Treating?", Practical gastroenterology, 43, pp. 46-63.
11.BlumenkrantzMichaelJ.,KoppleJoelD.,GutmanRobertA.(1980),
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1567-1585.
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controlledtrialofnutritionalcounselingonbodycompositionanddietary
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Handbook, A.S.P.E.N, pp. 75-81.
14.CanoN.J.M.,AparicioM.,BrunoriG.(2009),"ESPENGuidelineson
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Clin Chem, 52(12), pp. 2281-5.
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Maxine A., McPhee Stephen J. (2013), Current medical diagnosis
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27.ServicesDepartmentofNutrition,SystemUniversityofVirginiaHealth,
CharlottesvilleVirginia(2011),AdultEnteralandParenteralNutrition
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Status or of Risk of Malnutrition?", Clinical Chemistry, 52, pp.
2177-2179. Ph lc 1: Phiu thu thp thng tin bnh nhn Bnh vin: Bch
MaiKhoa nghin cu: Thn Tit niu PHIU THU THP THNG TIN BNH NHN Thi
gian thu thp thng tin:.. I.Thng tin bnh nhn H tn:M bnh nhn:Tui:Gii:
Ngy vo khoa:Ngy ri khoa: Ngy uNgy th 5Ngy th 10Ngy cui Chiu cao (m)
Cn nng (kg) BMI II.Triu chng lm sng, cn lm sng 1.Tnh trng hin ti:
2.Chn on: 3.Kt qu cn lm sng Xt nghimNgy BUN Creatinin Glucose
A.uric Protein Albumin Prealbumin GOT GPT FeNa K Sinh ha Cl WBC Hb
RBC Cng thc Neu Lymmu MCV WBC RBC Nc tiu Protein III.Dinh dng h tr
NgyPN Nng lng Protein Lipid Glucid Tng lng dch Loi dch truyn
Glucose Amino acid Lipid Dch hn hp Thi gian truyn EN (chi tit) Ba
sng Ba tra Ba ti Tng lng calories IV.Theo di tnh trng bnh nhn theo
ngy V.Tnh trng ra vin . Ph lc 2: Phiu kho st ch n bnh nhn ti khoa
Thn Tit niu, bnh vin Bch Mai Thi gian kho st: H tn bnh nhn: Ging
phng: Ngy nhp khoa:. Anh (ch) hy in thng tin chi tit v ba n ngy hm
qua: -Ba sng (v d: n cho th l cho g? n bao nhiu?...):... -Ba tra:
Cm ( 1 bt, 2 bt, lng bt, vi tha):... Thc n (tht, c, rau g? Xo hay
luc? n bao nhiu?):.. n mn n khc cm (v d nh: ph, bn, min, cho):..
-Ba ti (in chi tit tng t nh cc gi ba tra): -Ngoi ba n chnh c n thm
g khng? (v d nh: hoa qu g? n my qu? Ung sa g? 1 cc, 2 cc hay na cc
hay 1 hp):... Ph lc 3 DANH SCH BNH NHN NGHIN CU TI KHOA THN TIT NIU
BNH VIN BCH MAI (T thng 3/2013 n thng 4/2013) STTH tnTuiGii tnhM
bnh n 1.H Th V28N130204728 2.Thi Ngc L49Nam130009473 3.Nguyn Huy
75Nam130204689 4.Quang Th L54N130007957 5.Dng Th N67N130204772
6.Nguyn Vn L24Nam130009535 7.V Th T21N130007623 8.Nguyn Th
L48N130009040 9.Phm Vn Q69Nam130204650 10.Cao Th H32N130300218
11.Nguyn c N48Nam132000971 12.Bi Th H37N130009176 13.Hong Th
H73N130201318 14.Lng Quyt T50Nam130007632 15.Vi Vn L61Nam130200723
16.Phm Th D32N130200715 17.Trn Th D47N130201021 18.Nguyn Th
H38N130202317 19.Nguyn Th H25N130008847 20.Phng Th 52N130009155
21.V Th L51N130202233 22.Bi Cng D22Nam130005121 23.Trn Th Ngc
A26N130202115 24.Phan Th L48N130009728 25.Bi Th V44Nam130008731
26.Phm Th T27N130200073 27.T Th T53N130004199 28.Trn c
D45Nam130202133 29.V Th Khnh L19N130009103 30.L Th Bo K23N130009161
31.Nguyn Th T23N130000338 32.Phm Hng N71Nam130008254 33.Nguyn Th
S56N130009276 34.Ng Th S55N130202143 35.Nguyn Vn H25Nam130000885
36.Bch Th L52N130202300 37.Hong Vn V49Nam130009213 38.Nguyn Phng
D25N130205980 39.Bi Th H18N130008244 40.Nguyn Xun T34Nam130205057
41.V Huy 22Nam130204609 42.Ng Ngc D28N130204635 43.H Xun
P43Nam130011238 44.Trng Vn M38Nam130039755 45.Don Th Q31N130202260
46.Dng c T39Nam130205943 47. Th Thu G23N130008528 48.Phm Th
B25N130205941 49.Bi Th T64N130009758 50.V Th B74N130009740 51.Mc L
Nh V32Nam130009739 52.u Th H61N130204072 53.Bi Vit T56Nam132000695
54.Trn nh K64Nam130010987 55.m c T24Nam130010974 56.Nguyn Th
N15N130010993 57.Ng Th D36N130204389 58.Nguyn T V44N130007607 59.Ph
Th V33N130010744 60.Nguyn Th B50N130205643 61.Nguyn ng
D55Nam130204920 62.Gip Th H58N130204132 63.Nguyn Th L60N130010266
64.Chu Ngc M20Nam130010865 65.Nguyn Quc T50Nam130011213 66.T Th
T55N130010927 67. Th H49N132000829 68.u Th T23N130204493 69.Nguyn
Th T50N130205344 70.Bi ng L19Nam130011457 71.Nguyn Th S78N130204467
72.L Th Kim T66N132000949 73.L Trung N68Nam130009164 74.Lng c
C26Nam130205243 75.Tng Th M48N130204847 76.Nguyn Th T26N130009732
77.Nguyn Th H83N132000601 78.Hoa Hng N24N131000898 79.o Th
L35N130009722 80.V Th T73N130204272 81.ng Xun H55Nam130205940
82.Trn Th 79N130009752 83.L Thnh C38Nam130009541 84.Trn Th
N40N130009539 85.Bi Th T56N130007868 86.V Vn P63Nam130202129 87.Phm
Ngc T63Nam130202269 88.Trn Minh Q69Nam130202323 89.Hong Minh
K61Nam130202301 90.Phm Th S46N130204666 91.Hong Vn C56Nam130009875
92.Trn Th T37N130009757 93.Nguyn Th M58N130009742 94.Trn Vn
S60Nam130008135 95.Hong K63Nam130204117 96.Nguyn Th L27N130202287
97.L Th C76N130010994 98.Trn Bnh P44Nam130204366 99.Hong Th
T40N130011055 100.H Mnh H49Nam130009697 101.Tng Th T45N130011411
102.Nguyn Vn T83Nam130011177 103.Nguyn Th 76N130011175 104.Hong Th
H51N130009713 105.Trn Th H52N130011174 106.Hong Trung
T29Nam132000372 107.Nguyn Th 31Nam130204471 108.Trn Th
L76N130205181 109. Th B59N130010945 110.ng Th T28N130204221
