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標題: | 先天性心臟病嬰幼兒術後於加護病房內之能量需求及相關因子 The energy requirement and its related factors of infants with congenital heart disease after cardiac surgery in the intensive care unit |
作者: | Hsin-Yi Li 李昕苡 |
指導教授: | 楊曉玲(Hsiao-Ling Yang) 楊曉玲(Hsiao-Ling Yang | slyang@ntu.edu.tw | ), |
關鍵字: | 先天性心臟病,間接能量測定法,能量需求,靜態能量消耗,預測方程式, Congenital heart surgery,Indirect calorimetry,energy requirement,resting energy expenditure,predicted equation, |
出版年 : | 2022 |
學位: | 碩士 |
摘要: | 研究背景:許多先天性心臟病病患於嬰幼兒時期須接受心臟手術以使生命得以延續,但嬰幼兒的身體能量儲備量低,加上心臟手術產生的壓力反應及傷口需要癒合等因素,因此需要更多的能量來幫助身體修復及復原,然而目前尚無臨床指引或實證指出此時期合宜的能量供給量,使得臨床上提供此類病童適當之熱量以平衡代謝需求仍是常見的障礙,因此透過本研究之探討,希冀可以了解先天性心臟病嬰幼兒術後於加護病房內的能量需求及影響能量需求之相關因素,以做為未來能量供給之參考。 研究目的:(1)了解先天性心臟病嬰幼兒術後於加護病房內之能量需求、(2)了解先天性心臟病嬰幼兒術後於加護病房內之能量攝取是否充足、(3)了解先天性心臟病嬰幼兒術後於加護病房內之能量需求與預測方程式之間的差異程度、(4)探討影響加護病房內先天性心臟病嬰幼兒術後能量需求之相關因子。 研究方法:使用前瞻性研究設計,自2020年9月至2021年5月期間依本研究之收案條件,納入50位0至3歲接受心臟手術而入住兒童外科加護病房的嬰幼兒,於手術後第一天至第七天以間接能量測定法測量病童每日之靜態能量消耗量,再比較病童每日記錄之實際供給能量,得知其能量平衡情形;同時以Schofield equation、FAO/WHO/UNU、Harris-Benedict和Mifflin St. Jeor equation等四種常用的方程式計算病童之能量需求,並與間接能量測定法測量之靜態能量消耗數值相比較,了解其能量需求與消耗差異,再運用布蘭德-奧特曼差異圖(Bland- Altman plot)及計算均方根誤差(root-mean-square error, RMSE)驗證每項預測方程式之準確度。最後,為進一步了解靜態能量消耗在人口學屬性及疾病治療特性中的相關因子,以病歷閱覽方式收集人口學屬性及疾病治療特性之資料及利用統計軟體R version 4.1.2版進行逐步回歸分析。 研究結果:參與本研究的50位先天性心臟病術後之嬰幼兒中,有效測得靜態能量消耗為47名,年齡平均為12.6 ± 10.3月,體重平均為7.8 ± 2.5 Kg,其中男性占61.7 %(n = 29),疾病嚴重度以中度者占最多(n = 27,57.4 %),其次為重度(n = 11,23.4 %);此次入院接受首次心臟手術者約占68.1 %,接受第三次心臟手術及以上占19.2 %。在能量供給與消耗的平衡方面,先天性心臟病嬰幼兒術後入住加護病房期間之平均能量攝入為32.1 ± 17.4 kcal/kg/day,平均靜態能量消耗為54.2 ± 22.0 kcal/kg/day,整體而言,術後第1天的靜態能量消耗為最高,第2天開始下降至第7天呈現平穩狀態,其中0-12月之先天性心臟病嬰幼兒於手術後第五天開始,其能量攝入已多於靜態能量消耗,12-36月之嬰幼兒則是手術後七天內仍未達到其所需能量需求。間接能量測定法與預測方程式估算出來的靜態能量消耗比較方面,四種常見方程式中,與間接能量測定法測得的靜態能量消耗差距最小的是Schofield equation(1.75 %),其次是FAO/WHO/UNU(3.46 %),再者是Mifflin St. Jeor equation(4.38 %),差距最大則是Harris-Benedict(34.81 %),其中Schofield equation與FAO/WHO/UNU皆低估了能量需求,而Mifflin St. Jeor equation及 Harris - Benedict則為高估。最後,在能量需求模型的預測方面,影響先天性心臟病嬰幼兒術後第1天之靜態能量消耗相關因子為體重(p < .001)及心肺體外循環時間(p < .01),調整後的解釋變異量為70.4 %(p < .05);第2-7天之相關因子同為體重(p < .001)及心肺體外循環時間(p < .05),其調整後的解釋變異量為87.6 %(p < .001)。 討論與結論:本研究透過間接能量測定法,瞭解先天性心臟病之嬰幼兒術後在加護病房內之能量需求情形,整體而言,其平均熱量供給皆少於其所需之熱量;從預測方程式估算之靜態能量消耗中得知,Schofield equation、FAO/WHO/UNU及Mifflin St. Jeor equation等方程式與間接能量測定法所測得之靜態能量消耗的差異均在10 % 以內,其中Schofield equation之預測力為最佳(1.75 %)。在影響先天性心臟病嬰幼兒術後能量需求之相關因子方面,體重與心肺體外循環時間為預測因素,因此在評估能量需求方面,除了人口學屬性外,與疾病手術相關之因素仍需納入考量。 Research background: Many patients with congenital heart disease (CHD) need cardiovascular surgery during infancy to prolong their lives. Infants and young children have low physical energy reserves, which may make it challenging to meet the extra energy consumption of the stress from heart surgery and wound healing. However, there is no clinical guideline or research evidence could be followed to offer appropriate calories to children who receive cardiac surgery and during surgery intensive care unit (SICU) stay. Therefore, how to provide adequate nutrition to children with CHD in the SICU is still a common issue. Research purpose: (1) To investigate the energy requirement of infants and toddlers with CHD in the SICU after cardiovascular surgery, (2) To examine whether their energy intake is sufficient, (3) To check the accuracy of energy estimate equations by comparing them with the indirect calorimetry, (4) to explore the predictors of the energy requirement of infants and toddlers with CHD in the SICU after cardiovascular surgery. Research methods: We performed this study using a prospective and quantitative research design. Fifty infants and toddlers from 0 to 3 years old admitted to the Children's SICU after receiving cardiovascular surgery were enrolled according to the inclusion criteria from September 2020 to May 2021. The participants' resting energy expenditures (REE) were measured using indirect calorimetry (IC) from the first day to the seventh day after the operation and compared with their calorie intake to know their energy balance. Four commonly used energy-predicted equations, including the Schofield equation, FAO/WHO/UNU, Harris-Benedict, and Mifflin St. Jeor equation, were used to calculate the REEs of participants. Furthermore, we examine the accuracy of the equations by comparing the REEs, which were measured by equations and IC using the Bland-Altman plot and root-mean-square error (RMSE). To further understand the predictors of REE, the demographic attributes and disease and treatment characteristics data were collected by medical records and then analyzed using stepwise regression analysis of the statistical Software R version 4.1.2 Research results: The REEs of 47 (94%) participants were successfully measured with an average age of 12.6 ± 10.3 months, an average weight of 7.8 ± 2.5 Kg, and 29 (61.7 %) were boys. Most participants were diagnosed with complex CHD (57.4 %), followed by moderate severity (23.4 %); about 2/3 of the patients had their first-time cardiac operation, while 19.2 % had their third time or more open-heart surgery. For energy balance in the first seven days of SICU, the average energy intake of infants with CHD was 32.1 ± 17.4 kcal/kg/day, and the REE was 54.2 ± 22.0 kcal/kg/day, which showed negative balance. The REE on the 1st day after the operation was the highest, declining on the 2nd day and keeping nearly steady-state to the 7th day. The energy intake exceeded the REE on the fifth day after operation among the participants aged 0-12 months, but the energy intake did not meet their energy requirements within all seven days after surgery among participants aged 12-36 months. Among the four commonly used energy predicted equations, compared with REE measured by IC, the energy requirement calculated by the Schofield equation had the slightest difference (1.75%), followed by FAO/ WHO/UNU (3.46%), the Mifflin St. Jeor equation (4.38%), and Harris-Benedict (34.81%). Harris- Benedict and Mifflin St. Jeor's equation overestimated energy requirements, and the Schofield equation and FAO/WHO/UNU underestimated. Finally, in the multiple regression model, the predictors of REE on the first postoperative day were body weight and cardiopulmonary bypass (CPB) time (p < .01) with the Adjusted R- square = 0.72 (p-value < .05); the predictors on days 2-7 included body weight and CPB time with the Adjusted R- square = 0.87(p-value < .001). Discussion and Conclusions: We used IC to measure the REE of infants and toddlers with CHD during the first seven days after heart surgery in SICU. We found the average energy intake was less than the energy expenditure during this period. The differences in energy requirements between those estimated by energy-predicted equations and those measured by the IC method were within 10%, and the Schofield equation showed the best accuracy. In the related factors affecting the postoperative energy demand of infants with CHD, body weight had a significant positive correlation, while CPB time had a significantly negatively correlated. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/84476 |
DOI: | 10.6342/NTU202203947 |
全文授權: | 同意授權(限校園內公開) |
電子全文公開日期: | 2027-06-27 |
顯示於系所單位: | 護理學系所 |
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