Y Hpc TP. Ho Chi M m h * Tap 21 * So 6 * 2017 Nghien cmi Y hpc
TAM SOAT DINH D I / O N G 6 BENH NHAN DI CHlfNG TAI BIEN MACH MAU NAO DL/QtC NUOI AN QUA SONDE MUI DA DAY
Nguyen Thj Thanh Van*, Lam Vinh Nien**, Nguyen Thf Thu Thdo***, Trdn QuangHim', Luu Ngdn Tam", Tq Thi Tuyei Mai***
TOM
TATDqt vdn de: Binh nh&n tai biih mqdi mdu ndo phdi nudi an qua ong thdng mUi dq day Id doi tugng cd nguy ca suy dinh duang cao, nhieng hiin cd raJ it nghien cieu ddnh gid tinh trqng dinh dmng ciia nhimg benh rdi&n ndy.
Muc tiiu: Xdc dinh ti le suy dinh duong tren cdc berih nhdn di chung tai bieh mqch mau ndo duac nuoi dn qua sonde mdi dq day, dong th&i ciing xem xet moi tuang quan giifa cdc phucmg phdp ddnh gid Ddi tugng vd phuang phdp nghien cihi: Nghien cieu md ta cdt ngang tren 91 binh nhdn bi tai bim mqch mdu ndo dugc dqt ong thdng mdi dq ddy nudi dn. Phuong phdp t&m sodt dinh duang dugc sie dung Id SGA, BMI vd albumin.
Kei qud: Ti li suy dinh duang a binh nh&n di chung tai bim mqch mdu ndo dugc nudi dn qua sonde theo cdc phucmg phdp SGA, BMI vd albumin mdu Ian lugt Id 75,8%, 8,6% vd 65,9%. Co moi tucmg quan thu&n giim phuang phdp ddnh gid tinh trqng dinh duang theo SGA vd albumin (r = 0,427, p < 0,001), giiea SGA vd BMI (r = 0,579, p< 0,001).
KM luam Ti le suy dinh duang khi ddnh gid theo phuang phdp SGA cao hem so v&i albumin mdu vd Blvn.
Do nhieng hqn che ciia zhec do he&ng nhdn trac, SGA Id phuong phdp dugc de nghi dei&m sodt dinh duang & ddi tugng benh nhan ndy.
Tit khoa: tinh trqng dinh duang, di chieng tai bim mqch mdu ndo, nuoi an qua ong ABSTRACT
NUTRTTION SCREENING ON NASOGASTRIC TUBE FEEDING PATIENTS WITH SEQUELAE OF CEREBROVASCULAR DISEASES
Nguyen Thi Thanh Van, Lam Vinh Nien, Nguyen Thi Thu Thao, Tran Quang Hien, Luu Ngan Tam, Ta Thi Tuyet Mai * Y Hoc TP. Ho Chi Minh * Vol. 21 - No 6 - 2017: 139 - 145 Background: Cerebrovascular patimts with tube feeding are at high risk of malanutrition; hcrwever, there is Utile study on nutrition status of these patimts.
Objective: To investigate the malnutrition rate of tube feeding patimts with sequelae of cerebrovascular diseases, and the relationship of nutrition screming methods.
Materials and method: Cross-sectional study was performed on 91 tube feeding patients zvith sequelae of cerebrovascular diseases. Nutrition screening methods used zvere SGA, BMI and serum albumin.
Results: Malnutrition rate of iubefieding patimts with sequelae of cerebrovascular disease by SGA, BMI and serum albumin was 75.8%, 8.6% and 65.9%, respectively. Positive correlation existed betwem SGA and serum albumin(r = 0.427, p < 0.001), SGA and BMI (r = 0.579, p < 0.001).
* B^nh vi?n Nguyin Trai, ** Dai hoc Y Duoc TPHCM,
* * * B ^ vien Nhan din Gia Dinh, "B^nh vien Chan thuong chinh hinh, "'Benh vi&n Chg Ray Tdc gid hin lac: PGS. Ta Thi Tuyet Mai, DT: 0909726721; Email: [email protected]
N g h i e n c m i Y hpc Y H p c TP. Hb Chi M m h * T a p 21 * So 6 * 2017 Conclusions: Malnutiition rate by SGA is higher than that of serum alhumhi and BMI. Due to limitation of anthropometric measurements, SGA is suggested as the method of choice in these subjects
Keywords: nutrition status, sequelae of cerebrovascular diseases, tube feeding
de danh gia tinh trang dinh d u o n g cua benh n h a n gom BMI (nhan trac), albumin (sinh hoa) va SGA. Chiing toi xac dinh ti le suy dinh d u o n g tren d a n so nghien cthi la cac benh nhan di chiing tai bi&i mach m a u nao difoc nu6i an qua sonde mui da day, dong ti\6i ciing xem xet moi tuong quan giua cac phuofng p h a p danh gia nay voi nhau.
DQ[Tl/gNG-PHl/aNGFHAPNGfnENCL)tj DAT VAN DE
Benh nhan tai bien mach mau nao phai nuoi an qua ong thong mih da day la doi tuong co nguy CO suy dinh duong cao. Tuy nhien, lieu benh nhan tai bien mach m a u nao co d u g c nuoi d u o n g p h u h g p voi tinh trang benh va n h u cau chuyen hoa khong hay tinh trang dinh d u o n g a i a cac benh nhan nay n h u the nao van chua dugc quan tam. Cho den nay, CO rat it nghien ciiu danh gja tinh trang dinh duong ciia benh nhan tai bien mach mau nao phai nuoi an qua coig thong miu da day, dac biet la nghien ciiu trong nuoc.
Co nhieu phirong p h a p de danh gia dinh duong, moi p h u o n g p h a p co mot y nghia rieng. Tmh trang dinh d u o n g ngucd benh co the d u g c danh gia m o t each toan dien n h u tii bieu hien tong the qua chi so BMI (Body Mass Index), SGA (Subjective Global Assessment - Danh gia tong the theo d u i quan), d m bieu hien tung thanh p h a n co ihe n h u lop m a d u o i da (do nep gap da v u n g co tam dau - TSF), co vimg canh tay (do dien tich CO v u n g canh tay- AMA) hay khoi nac, mo, khoi te bao, khoi ngoai te bao.. (do t r o khang dien), nong d o chat trong m a u (cac loai protein, lipid mau...). Tinh trang dinh d u o n g con d u g c danh gia ve mat chiic nang n h u siic co, chiic nang mien dich va dieu tra khau p h a n an. Cho den nay van chua co bat ky m p t p h u o n g p h i p fi^o d u g c coi la "tieu chuan vang" trong d i n h gia tmh t r ^ g dinh duong. Tuy nhien, SGA d u g c khuyen nghi la cong cy danh gia nhanh tinh trgng dinh d u o n g benh nhan n h a p vien'^), vi khong xam lah, khong ton kem, lai co do nhay cao (98%) va dp dac hieu cao (82%)P'2.^. Trong nghien ciiu nay chiing toi s u d u n g 3 p h u o n g p h a p
D o i t u g n g n g h i e n c u u
Benh nhan nhap vien dieu tri tai benh vien Nguyen Trai bi tai bi&i mach mau nao dang dugc nuoi an qua ong thong miii da day thoi gian hi thang 12/2014 d&i thang 12/2015.
Tiiu chi chon henh
Nhiing henh nhan duoc diEm doan tai bim mach mau nao, bi kho nuot va dong y tham gia nghien Clhi.
Tieuchiloaitrk
Benh nhan dang bi phu, bang bimg do benh Iy gan than.
Benh nhan bi gu veo cot song.
Benh nhan bi doan chi.
Benh nhan tien can co benh ly gay kho nuot Benh nhan Va gia ifeih khong dong y tham giangbienoiu.
C o m a u _ ^ 0 - a / 2 ) P ( l - p )
" d^
n: Co mau
Z = 1,96 do tin cgiy 95%, a = 0,05 p: ti le suy dinh duOTig 6 benh nhan tai bien mach mau nao; chpn p = 0, 34 theo nghien ciiu cua Dennis M.
d do chinh xac (Chon d= 0,1)
=> n = 84 benh nhan
Y Hpc TP. Ho Chi Minh * Tap 21 * S£t 6 * 2017 Nghien cmi Y hpc
Phuang phap nghien ciiu Thiet ke nghiin cdu
N g ^ e n cuu mo ik cat ngang Phucmg phdp tien hdtdi
Danh sach tat ca cac benh nhan tai bioi mach mau nao co chi dinh nuoi an bang ong thong mih d? day duoc nhap vien dieu tri tai khoa hoi siic cap ciiu - chong doc va khoa noi than kinh benh vien Nguyen Trai dupe dua vao nghien ciiu.
Khai thac benh sir: hoi can nang truoc day cua benh nhan la bao nhieu, thai diem can liic nao, benh nhan bi sut bao nhien kg trong vong bao lau, co Ihay doi che do an khong; hoi cac trieu chiing bat thuang 6 duang tieu hoa nhu bimg an, buon non, non, tieu chay; hoi kha nang sinh hoat hang ngay co bi suy giam hay khong...
Kham Iam sang: danh gia tinh trang phii, bang bung, teo co, mat mo duoi da va ghi nhan la binh thuong, miic dp nhe-vua, hay miic dp nang.
Do luong nhan trac do can nang, chieu cao (diing hoac nam hoac tinh tii chieu dai sai tay), tinh BMI
Xet nghiem: Do nong dp albumin/mau dupe ihuc hien tai khoa xet nghiem benh vien Nguyen Trai.
Phuong phap thu th|,p s6 lieu
Dan so nghien ciiu duoc thu thap tir benh an nghien ciiu, dupe tim hanh danh gia tinh trang dinh duong Ian lupt biing cac phuong phap nhu SGA, BMI, albumin trong mau.
Xu ly thong ke
Bang phan mem SPSS 16.0.
KETQUA
Chiing toi tieh hanh nghien ciiu dupe tren 91 benh nhan bi tai bien mach mau nao dupe dat ong thong miii da day nuoi an thoa day du cac tieu chi nghi&i ciiu.
Dac diem chung
Bdng 1. Dac diim chung (n=91 bmh nh&n)
Tuoi Can n§ng (kg) Chiiu cao (m) BMI (kg/nfl Albumin/mau (g/dl)
Nho nhit 49 31 1,45 14,53 2,1
L<5<nnhlt 94 85 1.75 31,22 4.67
Tmng binh ± Dp l^h chuIn
75,57 ±10,63 53,78±11,18 1,60 ±0,08 21,01 ±3,77 3.2 ±0.6 Nhom tuoi
Bdng 2. Phan bd^tudi trong d&n sd'nghOn cieu Dptudi
<60 60-69 70-79
>80
Tilef/.) 11,0 8,9 42,3 37,8 Nghien ciiu chiing toi cho thay, benh tai bim mach mau nao xay ra phan 1cm 6 dp tuoi tren 70 (g^80%).
Gidi Unh
Bdng 3. Ph&n bo gi&i tinh Giai tinh
Nam Ni}
Til#(%) 49,0%
51,0%
Nam va nii chiem gan bang nhau (Nam 51%
va nii 49%).
Berth lytmi Bdng 4. Benh ly rien
B|nt) 1]^ nSn Tang huyet dp (THA) Dai thio difong (DTD) Benti th|n man ^TM) Tang huyet ap + Dai &iao dircmg Tang huyit Ap * Benh than mgn 0ai thao diJ^ng + B^nh thgn mgn Tang huyet ap + BTD + B^nh th|n mgn
Tyt$(%) 84,6 33,0 12,1 30^8 11,0 6.6 5,5 Benh ly gap nhieu nhat trong mau nghim ciiu la tang huyet ap voi ty le la 84,6 % (77/91 benh nhan), ke do la tang huyet ap kem benh dai thao duong hay DTD don thuan.
Tinh t r ^ g dinh dimng cua b^nh nhan Tinh trqng dinh dudng theo SGA
Qua khai thac benh sii va tham kham lam sang theo phuang phap danh gia tinh trang dinh dirang tong the theo chii quan (SGA) a 91 benh
N g h i e n c m i Y hoc Y Hpc TP. H o Chi M i n h » T%p 21 * So 6 * 2017 nhan, chiing toi phat hien 75,8% (69/91 b m h
nhan) benh nhan bj suy dinh dudng (SGA-B va Q , trong do SDD nang (SGA<:) chion 24,2%
(22/91 benh nhan) dan so nghien ciiu.
Bdng 5. Tmh trqng dJnh du&ng theo SGA Tinh t[?ng dinh dirang
SGA-A SGA-B SGfrC
Til#(%) 24,2 61,6 24,2 Tinh trqng dinh duang Iheo BMI
g 6. Tinh trqng dinh duang theo BMI Tmh ti^ng dinh dirang Binh thu^g (Biril 18,&-22.9) Suy dinh dudng nhevdtmngbinh (BMi
16,0-18,5) Suy dinh duang n^ng (BMi < 16.0)
Tile(%) 24.2 51.6 24.2 Xet theo BMI chung toi chi giii nhan duoc
^ 30% (22/ 91 benh nhan) benh nhan bj suy dinh duong (khi BMI < 18,Skgfnf), trong do SDD
n | n g chi chian 4i4% (4/ 91 benh nhan) (khi BMI
<16,0kgta').
Titih trgng dinh duang theo albumin mdu Bang 7. Tinh trang suy dinh dudng theo aSnanin
Tinh trgng dinh dudng Binh thu-ong (albumin mSu > 3.5 g/dl)
Suy dinh du^g nh? vd taing binh (albumm m ^ 3.03,49 s^O Suy dinh dirorig n ^ {albumin mdu <
3,09/dl)
Til?(%) 24,2 51,6 24,2 Hon 2f3 so tnrang hgp (65,9%, 60/91 benh nhan) co giam albumin/mau, trong do giam ngng la 26,4% (24/91 b m h nhan).
T u o n g q u a n giua SGA voi cac chi so BMI va a b u m i n m a u
Tucmg quan giiai SGA vd BMI
SGA CO moi tuong quan thuan voi chi so BMI (r = 0,579, p < 0,001) (Bieii do 1).
Tong diem SGA
Biai do 1. Bim dd tuang quan giua tlwng so SGA vd dii soBMl (r = 0,579, p < 0,001) Bdng 8. Tuang quan giiia SGA vd BMI
CScchis6 Bltli SGA
SGA 0,679
Gid trip
<0,001 BMI 0,579
Gii Hip 0,001
albumin/mau (r = 0,427, p < 0,001) (Bang 6).
Bdng 6. Tuang quan gjiea SGA vd albumin mdu
Tucmg quan giOa SGA vd albumin mdu SGA CO moi tuong quan thugn voi
Cic chi
si
Albumin SGA
SGA 0,427
Giibip
<0.001 Albumin
0,427 GiibtP
<.0O1
Y Hpc TP. H o Chi Minh * Tap 21 * So 6 * 2017 Nghien cihi Y hgc
Tong diem SGA
Bim do 2. Bim do tuang quan giiea thdng sffSGA va BANLUAN
Benh nhan trong nghien cihi ciia chung toi tuong doi Ion tuoi, trung binh 75 tuoi, trong do gan 80% co dp tuoi S 70. Co the do tuoi tho trung binh dan so eiia nuoc ta tang nen so benh nhan Ion tuoi ding nhieu hon. Ve gioi, chung toi khong tim thay sy khac biet giua tan suat nam va n u trong nghien cuu nay. Dieu nay eiing phii hop v6i mpt so nghien cihi khac ve dp tuoi va gioi tinh ciia benh nhan tai bien mgch mau nao<*''*^>.
Nuoc ta la mot trong cac quoc gja co toe dp gia tang cac benh ly m?n tinh khong lay (tim mach, dai thao duong) nhanh chong dang bao d5ng. Him tan suat mac cao huyet ap trong epng dong 6 nuoc ta la 48% d nguoi trudng thanh, 5,7% dan so mac benh DTD. Cac benh ly' nay la ket qua ciia si^ thay doi loi song (dinh duong thiia, thiia can, beo phi, it van dpng, but thuoc la), cupc song nhieu cang th3ngO^. Neu benh khong dupe ki&n soat tot, de dan den cac bim co tim mach (tai bi&i mach mau nao, nhoi mau co tim...), suy th$n, hi vong. Tang huyet ap va dai thao ducmg thuang ket hop voi nhau va ty le benh tang (heo liia tuoi. Phoi hop THA va DTD
chi sd'albumin (r = 0,427, p < 0,001)
lam gia tang nguy co bien chiing va tii vong 6 quan the benh nhan DTD. Trong nghim cuu ctia chiing toi, tang huyet ap ro rang chimi tan suat cao nhat, 84,6%, ke do la benh DTD don thuan (33%) hay THA kem voi benh DTD (30,8%).
Tien hanh danh gia chi so BMI, chung toi ghi nhan benh nhan co kho khan khi diing thang hay nam thang, do yeu co khop. Chi so BMI trung brnh trong nghien ciiu cua chiing t6i la 21,01 ± 3,77, gan giong voi ket qua trong mpt so nghien a i u khaci*'-^, co le la do ciing the tang CO dia cua nguoi Viet Nam.
Albumin huyet thanh la xet nghiem djnh lupng pho bim nhat danh gia tinh trang dinh duong dam 6 benh nhan nhap vien, phan anh linh trang dinh dudng cua benh nhan. Nong dp albumin mau bi anh buong bed tinh trang dich trong ca the. Tuy nhien, albumin huyet thanh khong phai la mpt thSng so tot de phan anh tinh trang suy dinh duong ^d no la chi to it nhay cam hon so voi viec kham lam sang va hoi benh sti.
Albumin mau trung binh ciia chiing toi la 3,2 ± 0,5 tuong tu voi ket qua nghi&i eiiu ciia Luu Ngan Tam la tii 3,8 - 4,2P>.
N g h i e n ciru Y hoc Y Hpc TP. Hb Chi Minh * T | p 21 * So 6 * 2017
Trong nhieu phuong phap danh gia dinh duong, SGA dupe khuym nghi boi Hpi dinh duong lam sang Chau Au, Chau A va sii dung pho b i m o nhieu nu6c. Trong nghien ciiu ciia chiing toi, ti 10 suy dinh duong theo SGA chiem 75,8% dan so nghien ciiu (69/91 benh nhan), trong do tan suat suy dinh duong nang la 24,2%. Ket qua ciia ehiing t6i co cao hon so voi cac tac gia khac cung bang phuong phap SGA (56,3% benh nhan bi dot quy co suy dinh du6ng<^, 19,2% benh nhan tai b i m mach mau nao suy dinh duongi^"! hay 49,3% suy dinh duong trung binh va 24,7% suy dinh duong nangfs)). Dieu nay co the la do tuoi trung binh trong nghien ciiu chiing toi cao hon*^' va ti le suy dinh duong ghi nhan xuat hien cang cao 6 benh nhan cang Ion tuoi'"*.
Neu nhu suy dinh duong theo SGA chiem rat cao (75,8% benh nhan) thi suy dinh duong theo chi so khoi eo the (BMI) chi phat h i ^ dupe 2S^%. Dieu nay cung khong co gi ngac nhien, vi BMI chi dua don thuan tren can nang va chieu cao, trong khi SGA c6 nhieu thong so danh gia hon. Mpt benh nhan co BMI binh thirong diua ban da khong suy dinh duong, boi ^n neii truoc do benh nhan co sut can khong chu y, an uong giam Slit, siic v | n dpng giam, teo mo hay eo nhe... du BMI se khong giiip leh dupe trong danh gja cac miic dp suy dinh duong. Khong nhiing vay, benh nhan neu co phii do thieu duong thi BMI van co the trong gioi han binh thuong. Su khac biet nay ciing da dupe chting minh tti hai nghien ciiu trong nuoc 6 b m h nhan nhap vim.
Suy dinh duong a benh nhan nhap vien nhu tai benh vim Bach Mai la 58% theo SGA va 21,4%
theo BMIt^^)^ tai benh vim Chp Riy (n = 710 b m h nhan) la 43% theo SGA va 25% theo BMJPt.
Mpt phuong phap khac de danh gja dinh duong la do nong dp albumin trong mau.
albimiin mau thap bieu hien tinh trang suy dinh duong (trii khi co suy chiic nang gan hay benh ly than gay mat dam) do thieii hut dam keo dai trong che dp an hang ngay ciia benh nhan. Tuy chua CO nghien cuu nao ve khau phian dinh
duong d benh nhan Ion tuoi 6 nuoc ta, nhung thur te CO the thay rang benh nhan Ion tuoi mac nhieu loai benh ly man tinh (tim mgch, dai thao duong, benh than mgn) thuong an uong rat it, t h i ^ nang lupng, dam va nhieu chat truong di&i, dan d m suy dinh duong. Dieu nay ciing dupe minh chiing la 85,8% benh nhan trong nghidn cihi nay bt suy dinh dirang (bang SGA), trong do albumin mau tiiap xuat hien 65,9%. Dgc biet '&n suat suy dinh duong nang theo SGA va theo albumin mau gan nhu tuong duong (24,2%
SGA-C va 26,4% albumin mau).
Khi nghim ciiu moi tuong quan gjiia 3 phuong phap nay, chung toi tfiay co moi tuong quan thuan giiia SGA voi BMI (r = 0,579, p <
0,001), va voi albumin mau (r = 0,427, p < 0,001).
Bmh nhan co miic dp SGA cang nang tlu gia tri BMI va albumin mau cang thap. Dieu nay co mot y ngMa thiet thuc trong thuc hanh lam sang, dimg SGA de sang loc nhanh suy dinh duong tiiay vi dung BMI, vi BMI co nhieu hgn che trong danh gia tinh trang dinh duong (nhu da de cgp 6 tren), ciing nhu thay cho albumin mau, mpt phuong phap xam lan hon ciing nhu ton ]/:sm hon so voi SGA. Thiet nglu voi & i suat suy dinh duong cao, dong thoi no co tac dpng bat loi cua suy dinh duong len ket cupc lam sang (tang nguy CO nhiem trimg, kha nang hoi phuc kem, keo dai thoi gian nam vi^n hay keo dai thoi gian thd may o b^nh nhan nang)'^), nen dimg phuong phap SGA thuong qui trong th\rc hanh Iam sang.
Tir do cac nha lam sang co the dua ra ke hoach dieu tri dinh duong kip thoi, hpp ly cho benh nhan hi suy dinh duong, nham cai thien k ^ qua dieu tri, gop phan dang ke trong tang cuong h i ^ qua dieu trj phuc hoi chiic nang sau tai bi&i mach mau nao.
KETLUAN
Ti le suy dinh duong d benh nhan di chiing tai bim mach mau nao dupe nuoi an qua sonde theo SGA cao hon so vdi danh gia theo BMI va albumin mau (ti le Ian lupt la 75,8%, 8,6% va 65,9%). Co mSi tuong quan thu?n giiia
144
Y Hpc TP. H o Chi Minh * T?p 21 * So 6 * 2017 Nghien curu Y hpc
phiKmg phap danh gia tinh brang dinh duong iheo SGA va albumin (r = 0,427, p <
0,001), giua SGA va BMI (r=0,579, p < 0,001). 6 nhiing benh nhan co tuoi, benh nhan bj tai bim mach mau nao van de do can ngng va chieu cao CO nhiing ban che, so do khong dupe chinh xac nen chi so BMI chac chan cd sai so. Doi vdi cac phuang phap sinh boa de danh gia dinh duong CO dp nhay va dp dac hieu cao bon, benh nhan d g ^ cac trung tam y te cd dieu kien Hep can duoc thugn Ipi hon, nhung khong phai cho nao benh nhan cung cd the danh gja dinh duong bang phuong phap nay dupe. SGA la phuong phap thuc hien khong khd, khong xam lah, khong ton kem khi duoc tap huah ky bdi chuyen gia cd nhieu kinh nghiem trong linh virc dinh dudng lam sang. Do do n m dimg phuong phap SGA thay cho BMI va xet nghiem albumin mau trong
•danh gia nhanh suy dinh duong cho benh nhan cao tuoi bi tai bim mach mau nao trong thuc hanh Iam sang.
TAI LIEU THAM KHAO
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Ngdy nh&n bdi bdo: 24/05/2014 Ngdy phdn biin nhdn xet bai bdo: 11/06/2014 Ngdy bdi bdo dtegc ddng: 30/10/2017
