高血压脑出血术后早期鼻饲肠内营养的合理应用
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摘要
目的：急性脑卒中由于应激往往引起一系列以大量瘦体组织丢失，机体抵抗力下降为特征的局部和全身的代谢反应，病情越重反应越严重。主要表现为能量消耗增加、高分解代谢、高血糖、胃肠道功能改变等。其代谢介质往往导致继发性神经功能损害和多个器官功能障碍。脑卒中的患者由于意识障碍，吞咽困难，不能进食，营养支持一直受到重视。传统观念认为急性脑卒中早期，因患者出现意识障碍，进食困难以及胃轻瘫等问题使胃肠营养难以实施，故多主张早期完全胃肠外营养(TPN)。近来，由于肠源性感染的提出，以及静脉营养带来的导管，代谢，感染等并发症，外科肠道营养尤其是早期肠道营养已逐渐受到重视。目前，急性脑卒中，特别是临床上常见的高血压脑出血(HICH)患者。早期胃肠营养的研究还缺乏比较客观和系统的资料。本研究前瞻性地研究了高血压脑出血(HICH)术后早期胃肠道营养对于改善预后，营养状况，降低高代谢反应和维护胃肠道功能等方面的作用，进一步探讨了高血压脑出血术后早期胃肠道营养的作用机理和临床应用。
方法：高血压脑出血(HICH)住院病人36例。男29例，女7例。年龄57~78岁，GCS 6~11评分。入院后均在6小时内手术，随机分为早期胃肠道营养组(EEN组)和早期完全胃肠外营养组(TPN组)。两组平均年龄、GCS评分、身高、体重、损伤类型及治疗措施无明显差异。EEN组和TPN组病人营养支持均为术后48小时，EEN组给予经鼻胃管24小时持续滴注安素(ENSURE，美国雅培公司)；TPN组静滴肠外营养液。研究期限至术后28天。
结果：两组均在术后2周内均为负氮平衡，EEN组术后6天24小时排出氮明显高于TPN组(P＜0.05)，故EEN组术后6天的氮平衡优于TPN组(P＜0.05)。血清白蛋白术后表现为持续低蛋白血症，研究期间两组无显著差别。肌酐身高指数(ICr)也显下降趋势，但EEN组在术后14、28天仍明显优于TPN组(P＜0.05)。
两组术后血糖、血浆胰岛素和皮质醇在术后显著上升(P＜0.05-0.01)，两组高血糖水平在术后第6天达高峰，此时，EEN组血糖和血浆胰岛素水平显著低于TPN组(P＜0.05~P＜0.01)。EEN组的皮质醇水平在术后低于TPN组(P＜0.05-0.01)，术后28天回复正常范围，而TPN组仍高于正常。
与TPN组比较，术后6天内EEN组的返流，误吸无明显增加，而EEN组的上消化道出血，腹胀，腹泻，便秘和拒食的发生率显著减少(p＜0.05~P0.01)。在术后28天，EEN组体重平均丢失4.73kg，而TPN组则丢失6.24kg，EEN组的大多数营养指标显著优于TPN组(P＜0.05~P＜0.01)，GCS评分也明显高于TPN组(P＜0.05)。
结论：高血压脑出血(HICH)术后对通过鼻胃管持续滴注喂养方法的提供早期胃肠道营养方法有良好的耐受性。研究表明，高血压脑出血(HICH)术后早期胃肠道营养支持不仅避免了TPN高血糖等代谢并发症，还能减少机体瘦体组织分解，保存体重，降低术后高分解代谢的作用机理与减少循环中的应激激素的释放，更重要的是减轻了肠道的缺血再灌注损伤，维护了胃肠道结构和功能，这对改善高血压脑出血后全身营养状态和神经功能的恢复大有裨益。
Background : Patients with acute cerebral apoplexy require nutritional support becease of an accelerated metabolism and prolonged inability to eat. Because of unconsciousness , hypoalimentation , the high incedence of gastropareis, enteral nutritional support of patient with acute head injury has traditionally been difficult and let to frequentuse of total parenteral nutrition (TPN). In recent years, recognizing the advantage of enteral feeding and complications of metalolism indcued by TPN, the enteral nutrition, in especial early enteral feeding, has been paid much attention to the treatment of severe head injury. To date, it shows lack of objective and serial data about clinical study of early enteral feeding post acute apoplexy stroke, especially, hypertension cerebral hemorrhage (HICH) . This pospect study evaduats that tolerance of modified nasogastric feeding as early nutritional support, attempts to appraise the mechanism and clinical effect of early enteral feeding, versus TPN with equivalent caloric and nitrogen intake, on improving outcome, nutritional state, modulating hypermetabolism and maintaining gut functions in HICH patients.
Methods: 36 cases were collected, male 29, female 7, age 57~78yrs, GCS score 6~11. All the patients were admitted operation within 6hrs, and divided randomly into early enteral feeding group (EEFg), and total parenteral nutrition group (TPNg). There were no significant difference in age, GCS score, bodyweight, type of neurological in jury, and associated treatment. Nutritional support of two groups of patients were started within 48 hrs post injury, ENSURE (ABBOTT LABORATORIES, America) was supplemented by nose-gastide tube feeding within 48 hrs postin jury in EENg. Patients were studied from hospital admission to 28 days postin jury.
Results: Positive nitrogen balance is not achieved in two groups during 2 wks postinjury, the 24 hrs total nitrogen loss in EENg decreased more than that of TPNg on 6 days postinjury (P＜0. 05), EENg had greater cumulative nitrogen balances compared with the TPNg on 6 days postinjury (P＜0. 05) . Serum albumin was well maitained at mild levels of "depletion", and there were notsignificantly between two groups. The trend of the ICr is about the same, TPNg on 14, 28 days postinjury is signifcantly lower than those of EENg (P＜0.05) .
Serum glucose, Insulin and cortisol are increased postinjury(P＜0. 05-0.01). Hyperglycemia of two groups were to peak on 6 day postinjury. At this time, Serum glucose, Insulin in EENg is significantly lower than that of TPNg (P＜0. 05) . Cortisol on EENg is much lower than TPNg at most timepoints (P＜0. 05-0.01), relapse to normal range, but that of TPNg is anomaly.
As compare with TPNg, *** of EENg were not increased during 6 days postinjury (p＜0. 05~P0. 01). However, controlled study demonstrated a reduction in gastric bleeding, *, diarrhea, constipation and* with early enteral feeding(P＜0. 05). On 4 wks postinjury, EENg lost a mean weight 4.73 kg, TPNg lost 6.24 kg (P＜0. 05), most of the nutritional appraisal of EENg are significantly better than those of TPNg (P＜0. 05), GCS score in EENg was noted to be higher inTPNg (P＜0. 05).
Conclusion: Evidence indicates that aggressive early enteral feeding regnimens using small nasogastric tude are tolerared better than previously believed. It is indicated that the early enteral feeding not only could effectively avoid hyerglycemia of TPN, but also lessen massive loss of lean body mass and preserve bodyweight. It is suggested that the early nutrition reduced hypermetabolism were by means of decreasing the level of mediator such as catablic hormone in blood stream, and was noticely associated with a lower incidence of the gut reperfusion injury, assertting, gastric-intestinal structure and function. The optimal enteral nutritional support can improve the whole nutrition state and be beneficial to neurologic recovery following head injury.
方法：高血压脑出血(HICH)住院病人36例。男29例，女7例。年龄57~78岁，GCS 6~11评分。入院后均在6小时内手术，随机分为早期胃肠道营养组(EEN组)和早期完全胃肠外营养组(TPN组)。两组平均年龄、GCS评分、身高、体重、损伤类型及治疗措施无明显差异。EEN组和TPN组病人营养支持均为术后48小时，EEN组给予经鼻胃管24小时持续滴注安素(ENSURE，美国雅培公司)；TPN组静滴肠外营养液。研究期限至术后28天。
结果：两组均在术后2周内均为负氮平衡，EEN组术后6天24小时排出氮明显高于TPN组(P＜0.05)，故EEN组术后6天的氮平衡优于TPN组(P＜0.05)。血清白蛋白术后表现为持续低蛋白血症，研究期间两组无显著差别。肌酐身高指数(ICr)也显下降趋势，但EEN组在术后14、28天仍明显优于TPN组(P＜0.05)。
两组术后血糖、血浆胰岛素和皮质醇在术后显著上升(P＜0.05-0.01)，两组高血糖水平在术后第6天达高峰，此时，EEN组血糖和血浆胰岛素水平显著低于TPN组(P＜0.05~P＜0.01)。EEN组的皮质醇水平在术后低于TPN组(P＜0.05-0.01)，术后28天回复正常范围，而TPN组仍高于正常。
与TPN组比较，术后6天内EEN组的返流，误吸无明显增加，而EEN组的上消化道出血，腹胀，腹泻，便秘和拒食的发生率显著减少(p＜0.05~P0.01)。在术后28天，EEN组体重平均丢失4.73kg，而TPN组则丢失6.24kg，EEN组的大多数营养指标显著优于TPN组(P＜0.05~P＜0.01)，GCS评分也明显高于TPN组(P＜0.05)。
结论：高血压脑出血(HICH)术后对通过鼻胃管持续滴注喂养方法的提供早期胃肠道营养方法有良好的耐受性。研究表明，高血压脑出血(HICH)术后早期胃肠道营养支持不仅避免了TPN高血糖等代谢并发症，还能减少机体瘦体组织分解，保存体重，降低术后高分解代谢的作用机理与减少循环中的应激激素的释放，更重要的是减轻了肠道的缺血再灌注损伤，维护了胃肠道结构和功能，这对改善高血压脑出血后全身营养状态和神经功能的恢复大有裨益。
Background : Patients with acute cerebral apoplexy require nutritional support becease of an accelerated metabolism and prolonged inability to eat. Because of unconsciousness , hypoalimentation , the high incedence of gastropareis, enteral nutritional support of patient with acute head injury has traditionally been difficult and let to frequentuse of total parenteral nutrition (TPN). In recent years, recognizing the advantage of enteral feeding and complications of metalolism indcued by TPN, the enteral nutrition, in especial early enteral feeding, has been paid much attention to the treatment of severe head injury. To date, it shows lack of objective and serial data about clinical study of early enteral feeding post acute apoplexy stroke, especially, hypertension cerebral hemorrhage (HICH) . This pospect study evaduats that tolerance of modified nasogastric feeding as early nutritional support, attempts to appraise the mechanism and clinical effect of early enteral feeding, versus TPN with equivalent caloric and nitrogen intake, on improving outcome, nutritional state, modulating hypermetabolism and maintaining gut functions in HICH patients.
Methods: 36 cases were collected, male 29, female 7, age 57~78yrs, GCS score 6~11. All the patients were admitted operation within 6hrs, and divided randomly into early enteral feeding group (EEFg), and total parenteral nutrition group (TPNg). There were no significant difference in age, GCS score, bodyweight, type of neurological in jury, and associated treatment. Nutritional support of two groups of patients were started within 48 hrs post injury, ENSURE (ABBOTT LABORATORIES, America) was supplemented by nose-gastide tube feeding within 48 hrs postin jury in EENg. Patients were studied from hospital admission to 28 days postin jury.
Results: Positive nitrogen balance is not achieved in two groups during 2 wks postinjury, the 24 hrs total nitrogen loss in EENg decreased more than that of TPNg on 6 days postinjury (P＜0. 05), EENg had greater cumulative nitrogen balances compared with the TPNg on 6 days postinjury (P＜0. 05) . Serum albumin was well maitained at mild levels of "depletion", and there were notsignificantly between two groups. The trend of the ICr is about the same, TPNg on 14, 28 days postinjury is signifcantly lower than those of EENg (P＜0.05) .
Serum glucose, Insulin and cortisol are increased postinjury(P＜0. 05-0.01). Hyperglycemia of two groups were to peak on 6 day postinjury. At this time, Serum glucose, Insulin in EENg is significantly lower than that of TPNg (P＜0. 05) . Cortisol on EENg is much lower than TPNg at most timepoints (P＜0. 05-0.01), relapse to normal range, but that of TPNg is anomaly.
As compare with TPNg, *** of EENg were not increased during 6 days postinjury (p＜0. 05~P0. 01). However, controlled study demonstrated a reduction in gastric bleeding, *, diarrhea, constipation and* with early enteral feeding(P＜0. 05). On 4 wks postinjury, EENg lost a mean weight 4.73 kg, TPNg lost 6.24 kg (P＜0. 05), most of the nutritional appraisal of EENg are significantly better than those of TPNg (P＜0. 05), GCS score in EENg was noted to be higher inTPNg (P＜0. 05).
Conclusion: Evidence indicates that aggressive early enteral feeding regnimens using small nasogastric tude are tolerared better than previously believed. It is indicated that the early enteral feeding not only could effectively avoid hyerglycemia of TPN, but also lessen massive loss of lean body mass and preserve bodyweight. It is suggested that the early nutrition reduced hypermetabolism were by means of decreasing the level of mediator such as catablic hormone in blood stream, and was noticely associated with a lower incidence of the gut reperfusion injury, assertting, gastric-intestinal structure and function. The optimal enteral nutritional support can improve the whole nutrition state and be beneficial to neurologic recovery following head injury.
引文
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2. Dennis M, Lewis S, Cranswick G, Forbes J. A multicentre randomised trial evaluating feeding policies in patientsadmitted to hospital with a recent stroke. Health Technol Assess. 2006 Jan;10(2): ⅲ-ⅳ,ⅸ-ⅹ, 1-120.
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8. Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev. 2000;(2): CD000323. Review.
9. Krakau K, Hansson A, Karlsson T, et al. Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition. 2007 Apr;23(4): 308-17. Epub 2007 Mar 21.
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1. Poels BJ, Brinkman-Zijlker HG, Dijkstra PU, et al. Malnutrition, eating difficulties and feeding dependence in a stroke rehabilitation centre. Disabil Rehabil. 2006 May 30;28(10): 637-43.
2. Finestone HM. Safe feeding methods in stroke patients. Lancet. 2000 May 13;355(9216): 1662-3.
3. Dennis M, Lewis S, Cranswick G, Forbes J. A multicentre randomised trial evaluating feeding policies in patientsadmitted to hospital with a recent stroke. Health Technol Assess. 2006 Jan;10(2): ⅲ-ⅳ, ⅸ-ⅹ, 1-120.
4. Kubo H, Nakayama K, Ebihara S, et al. Medical treatments and cares for geriatric syndrome: new strategies learned from frail elderly. Tohoku J Exp Med. 2005 Mar;205(3): 205-14.
5. Finestone HM, Greene-Finestone LS. Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. CMAJ. 2003 Nov 11;169(10): 1041-4.
6. Kraus JJ, Metzler MD, Coplin WM. Critical care issues in stroke and subarachnoid hemorrhage. Neurol Res. 2002;24 Suppl 1: S47-57.
7. Blackmer J. Tube feeding in stroke patients: a medical and ethical perspective. Can J Neurol Sci. 2001 May;28(2): 101-6.
8. Dennis M. Nutrition after stroke. Br Med Bull. 2000;56(2): 466-75.
9. Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev. 2000;(2): CD000323. Review.
10. Krakau K, Hans,son A, Karlsson T, et al. Nutritional treatmentof patients with severe traumatic brain injury during the first six months after injury. Nutrition. 2007 Apr;23(4): 308-17. Epub 2007 Mar 21
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15. McArdle A.H. PH.D, Palmason C, A.R.T., et al. A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery, 1981, 90 (4): 616-623.
16．陈敏章，蒋朱明．静脉内高营养的临床应用，水与电解质平衡．北京：人民卫生出版社，1974：447．
17．江志伟．肠外营养支持的基础理论及临床应用．中国实用外科杂志，2001，21 (12)：761-765．
18. Chalela JA, Haymore J, Schellinger PD, Kang DW, Warach S. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3):331-4.
19．季云秋，姜建东．急性脑卒中患者的营养状况及其与预后的关系．江苏临床医学杂志， 1999，3(2)：120-121．
20．石向群，汪泳，杨金升等．急性脑卒中后营养状况恶化的影响因素分析．中国老年杂志， 2003，23(7)：464-465．
21. Antoni Davaios MD, Wifred Ricart MD, Ferran Gonzalcz-Huix MD, et al. Stroke. aha journals, 1996, 27:1028-1032.
22．汪泳，刘昕，朱任之等．急性脑卒中后营养状况恶化机制的探讨．中国急救医学， 2002，22(11)：650-651．
23. Ockenga J, Pirlich M Lochs H. Food for stroke: why don't the studies give clear answers?Lancet. 2005 Jun 11-17;365(9476):2005; author reply 2005-6.
24．王之敏，惠国桢，周建烈等．严重脑外伤病人早期蛋白质、氨基酸代谢的改变及其以免疫功能的影响．肠外与肠内营养，1994，1(1)：34-37．
25．黄东健，刘运生。重症脑损伤早期鼻饲肠内营养应用研究．中华神经外科杂志，2001， 17(2)：162-164
26. Donnan GA, Dewey HM. Stroke-and nutrition: food for thought. Lancet. 2005 Feb 26-Mar 4;365(9461): 729-30.
27. Diminioni L,Tricki O, Michizuki H, et al. Prevention of severe posrburn hypermetaolism and catabodism by immediate inrtagastric feeding. J Burn Care Rehab 1984;5: 106-112.
28. Ickenstein GW, Stein J, Ambrosi D, et al. Predictors of survival after severe dysphagic stroke. J Neurol. 2005 Dec;252(12): 1510-6. Epub 2005 Sep 5.
29. Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005 Dec;86(12 Suppl 2): S101-S114.
30．杨慕龙，周良辅．颅脑外伤后的代谢变化和营养支持．中华创伤杂志，1994，10 (2)： 97-98．
31. Young AB MD, Linda G MD. The acute-phase response of the brain-injured patient. [J] Neurosurg, 1988, 69: 375-380.
32. Clifton GL, Robertson CS, Grossman RG, et al. The metabolic response to severe head injury. [J] Neurosurg, 1984, 60:687-696.
33. Weeks E, Elia M, Observation on the patterns of 24-hour energy expenditure changes in boby composeition and gastric emptying in head injured patients receiving nasogastric tube feeding. Journal of parenteral and enteral nutrions, 1999, 20 (1): 31-37.
34. Minard G, Kudsk KA. Is early feeding beneficial? How early is early?. New Horizons, 1994, 2:156-163.
35. Bruder N, Dumon JC, Francois G. Evolution of energy expenditure and nitrogen excretion in severe head-injured patients. Crit Care Med, 1991, 19:42-48.
36. Gianotti L, Netson JL, Alexander JW, et al. Post injury hypermetabolic response and magitude of translocation: Prevention by early enteral nutrition. Nutrition 1994;10(3): 225-231
37．王少龙、汪仕良、尤忠义、黎鳖．早期肠道营养降低严重烧伤后多代谢的临床研究， 中华外科杂志，1996：35(1)：44-46．
38. Wolfe RR, Goodenough RD, Burke JF, et al. Reaponse of protein and urea kineties in burn patients to different to levels of protein intake. Am Surg, 1983, 197:163-171.
39. Zaloga GP. Timing and route of nutritional support, In:Nutrition in Critical Care. Zaloga GP (Ed). St. Louis, Mosby Year. Book, 1994:297-330.
40．杨道贵， 梅文杰， 舒志军．外科感染与营养支持．肠外与肠内营养杂志，1995， 2(4)：252-258．
41. Davalos A, Ricart W, Gonzalez-Huix F, et al. Effect of malnutrition after acute stroke on clinical outcome. [J] Stroke, 1996, 27 (6) : 1028-1032.
42. Chalela JA, Haymore J, Schellinger PD, et al. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3): 331-4.
43. Minard G, Kudsk KA. Is early feeding beneficial? How early is early?. New Horizons, 1994, 2:156-163.
44. Fried T, Dempsey D, Guenter P, et al. Barbiturates improve nutrition balance. in patients with severe head trauma. Alistr JPEN, 1984, 8:86.
45. Gosling-P. The cellular, immune, and metabolic response to trauma. Crit-Rev-Clin-Lab-Sci, 1998, 35 (1):59-112.
46. Philippe G, MD, John D, MD, et al. Nutrition and the neurosurgical patient. [J] Neurosurg, 1984, 60:219-232.
47. Grimble-RF. Nutritional mlculation of cytokine biolohy. Nutrition, 1998, 14 (7-8): 630-640.
48．邵洪， 黎鳌， 注仕良．严重烧伤后早期肠道营养对代谢的影响．中华创伤杂志， 1994，10(3)：300-308．
49. Harper JP. Nasogastric tube feedings and hyperglycemin. J Nurs Scholarsh. 2005;37(4): 300.
50. Lam AM, Winn HR, Cullen BF, et al. Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg, 1991, 75:545-551.
51．李宝民，张纪，许百男等．神经外科监护病房治疗急性上消化道出血81例报告．中华创伤杂志，1993，9(1)：27-28．
52．张赛，杨树源，王明璐等．严重脑外伤急性期血糖变化的临床意义．中华创伤杂志， 1994，10(1)：2-4．
53. Smithard DG, O'Neill PA, Park C et al. Complications and outcome after acute stroke. Does dysphagia matter' Stroke 1996: 27:1200-4
54. Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications following acute stroke. Stroke, 1996; 27:415-20
55. Boeknam CR, Krill CE. Bacterial and fungal infections complicating parenteral alimentation in infants and children. [J]Pediatr Surg, 1970, 5:117.
56. Alverdy, MD, Hoon Sang Chi, MD, George F Sheldon, MD. The effect of parenteral nutrition on gastrointestinal immunity--the importance of enteral stimulation. Gastroenterology, 1985, 202 (6): 681-683.
57. Li-YS, Li-JS, Jiang-TW, et al. Glycyl-glutamine-enriched long-term total parenteral nutrition attenuates bacterial translocation following small bowel transplantation in the pig. [J] Surg Res, 1999, 82 (1): 106-111.
58．黎介寿．肠功能障碍．肠外与肠内营养，1998，5(2)：63-65．
59. James R, Gines D, Menlove A, et al. Nutrition support (tube feeding) as a rehabilitation intervention. Arch Phys Med Rehabil. 2005 Dec;86(12 Suppl 2): S82-S92.
60．黄东健，刘运生，王智坚．严重脑损伤后早期肠内营养支持的合理应用，肠内与肠外营养，1999年12月第6卷第4期，187~191．
61. Dennis MS, Lewis SC, Warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005 Feb 26-Mar 4;365(9461): 764-72.
62. Preshaw RM. Management of dysphagia. CMAJ. 2004 Mar 30;170(7):1079; author reply 1079, 1082. No abstract available.
63. Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acutestroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004 Jun;75(6): 852-6.
64. Williams LS. Feeding patients after stroke: who, when, and how. Ann Intern Med. 2006 Jan 3;144(1):59-60.
65．黎介寿．重视营养支持的合理应用．中华外科杂志，1995，33(5)：259-260．
66. Iizuka M, Reding M. Use of percutaneous endoscopic gastrostomy feeding tubes and functional recovery in stroke rehabilitation: a case-matched controlled study. Arch Phys Med Rehabil. 2005 May;86(5):1049-52.
2. Dennis M, Lewis S, Cranswick G, Forbes J. A multicentre randomised trial evaluating feeding policies in patientsadmitted to hospital with a recent stroke. Health Technol Assess. 2006 Jan;10(2): ⅲ-ⅳ,ⅸ-ⅹ, 1-120.
3. Kubo H, Nakayama K, Ebihara S, et al. Medical treatments and cares for geriatric syndrome: new strategies learned from frail elderly. Tohoku J Exp Med. 2005 Mar;205(3): 205-14.
4. Finestone HM, Greene-Finestone LS. Rehabilitation medicine: 2. Diagnosis of dysphagia and itsnutritional management for stroke patients. CMAJ. 2003 Nov 11;169(10): 1041-4.
5. Kraus JJ, Metzler MD, Coplin WM. Critical care issues in stroke and subarachnoid hemorrhage. Neurol Res. 2002;24 Suppl 1: S47-57.
6. Blackmer J. Tube feeding in stroke patients: a medical and ethical perspective. Can J Neurol Sci. 2001 May;28(2): 101-6.
7. Dennis M. Nutrition after stroke. Br Med Bull. 2000;56(2): 466-75.
8. Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev. 2000;(2): CD000323. Review.
9. Krakau K, Hansson A, Karlsson T, et al. Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition. 2007 Apr;23(4): 308-17. Epub 2007 Mar 21.
10．黄东健，刘运生．早期胃肠道营养支持对严重脑损伤后营养状况和神经功能的影响，肠内与肠外营养杂志，2000年1月第7卷第1期，28~30．
11．黄东健，刘运生，王智坚．重症脑损伤后早期肠内与肠外营养支持的临床对照研究， 中华创伤杂志，2000年6月第16卷第，6期，323~324．
12．刘放南，李元新．微量凯氏定氮法在外科营养支持中的应用， 肠外与肠内营养， 1995；2(3)：199-200．
13．陈仁享．现代临床营养学，北京：人民军医出版社，1996年7月，117-126．
14．查良锭．实用营养治疗手册，中国标准出版社，1994年6月，第2版，295-327．
15. Williams LS. Feeding patients after stroke: who, when, and how. Ann Intern Med. 2006 Jan 3;144(1): 59-60. No abstract available.
16. Donnan GA, Dewey HM. Stroke and nutrition: Food for thought. Lancet. 2005 Feb 26-Mar 4;365(9461): 729-30.
17. Oliver A, Allen KR, Taylor J. Trace element concentrations in patients on home enteral feeding: two cases of severe copper deficiency. Ann Clin Biochem. 2005 Mar;42(Pt 2): 136-40.
18. Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004 Jun;75(6): 852-6.
19. Wejda BU, Soennichsen B, Huchzermeyer H, Mayr B, Cirkel U, Dormann AJ. Successful jejunal nutrition therapy in a pregnant patient with apallic syndrome. Clin Nutr. 2003 Apr;22(2): 209-11.
20. Ha L, Hauge T. Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in Patients with stroke. Scand J Gastroenterol. 2003 Sep;38(9): 962-6.
21. Roberts-PR. Nutrition in the head-injured patient, New- Hoviz. 1995 Aug;3(3): 506-517.
22．黄东健，刘运生．重症脑损伤早期鼻饲肠内营养应用研究．中华神经外科杂志， 2001，17(2)：162-164．
23. Rodrigue N, Cote R, Kitsch C, et al. Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach. Axone. 2002 Mar;23(3): 31-7.
24. Healy S, McNamara E. Tube feeding controversial patients: what do dietitians think? J Hum Nutr Diet. 2002 Dec;15(6): 445-53.
25. John alverdy, MD., Hoon Sang Chi, MD., George F Sheldon, MD. The effect of Parenteral nutrition on Gastrointestinal Immjnity The importance of Enteral Stimulation, Gastroenterology, 1985;202(6): 681-683.
26. Harper JP. Nasogastric tube feedings and hyperglycemia. J Nurs Scholarsh. 2005;37(4): 300.
27. Chalela JA, Haymore J, Schellinger PD, et al. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3): 331-4.
28. Ickenstein GW, Stein J, Ambrosi D, et al. Predictors of survival after severe dysphagic stroke. J Neurol. 2005 Dec;252(12): 1510-6. Epub 2005 Sep 5.
29. Diminioni L, Tricki O, Michizuki H, et al. Prevention of severe posrburn hypermetaolism and catabodism by immediate inrtagastric feeding. J Burn Care Rehab 1984;5: 106-112.
30．王少龙，汪仕良，尤忠义，黎鳖．早期肠道营养降低严重烧伤后多代谢的临床研究，中华外科杂志，1996；35(1)：44-46．
31. Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005 Dec;86(12 Suppl 2): S101-S114.
32. James R, Gines D, Menlove A, et al. Nutrition support (tube feeding) as a rehabilitation intervention. Arch Phys Med Rehabil. 2005 Dec;86(12 Suppl 2): S82-S92.
33．黄东健，刘运生，王智坚．严重脑损伤后早期肠内营养支持的合理应用，肠内与肠外营养，1999年12月第6卷第4期，187~191．
34. Dennis MS, Lewis SC, Warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005 Feb 26-Mar 4;365(9461): 764-72.
35. Gianotti L , Netson JL, Alexander JW, et al. Post injury hypermetabotic response and magitude of translocation: Prevention by early enteral nutrition. Nutrition 1994;10(3): 225-231.
36. Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004 Jun;75(6): 852-6.
37. Ockenga J, Pirlich M, Lochs H. Food for stroke: why don't the studies give clear answers? Lancet. 2005 Jun 11-17;365(9476): 2005; author reply 2005-6.
38. Sanders H, Newall S, Norton B, Holmes GT. Gastrostomy feeding in the elderly after acute dysphasgic stroke. J Nutr Health Aging. 2000;4(1): 58-60.
39. ChalelaJA, Haymore J, Schellinger PD, et al. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3): 331-4.
40. Finestone HM. Safe feeding methods in stroke patients. Lancet. 2000 May 13:355(9216): 1662-3.
41. Oh H, Suh Y, Hwang S, Seo W. Effects of nasogastric tube feeding on serum sodium, potassium, and glucose levels. J Nurs Scholarsh. 2005;37(2): 141-7.
42. Dziewas R, Ludemann P, Konrad C, Stogbauer F. Simple method for placing nasogastric tubes in patients with dysphagia. Lancet. 2001 Sep 1; 358 (9283): 725-6.
43. Ott L, Young B, Phillips R, et al. Altered gastric emptying in the head-injured patient: Relationship to feeding intolerance. J Neurosurg 1991; 74: 783-742.
44. Moore GA, Moore EE, Jones TN, et al. TEN versus TPN following major abdominal trauma-Reduced septic morbidity. J Trauma 19,89; 29: 916-923.
1. Poels BJ, Brinkman-Zijlker HG, Dijkstra PU, et al. Malnutrition, eating difficulties and feeding dependence in a stroke rehabilitation centre. Disabil Rehabil. 2006 May 30;28(10): 637-43.
2. Finestone HM. Safe feeding methods in stroke patients. Lancet. 2000 May 13;355(9216): 1662-3.
3. Dennis M, Lewis S, Cranswick G, Forbes J. A multicentre randomised trial evaluating feeding policies in patientsadmitted to hospital with a recent stroke. Health Technol Assess. 2006 Jan;10(2): ⅲ-ⅳ, ⅸ-ⅹ, 1-120.
4. Kubo H, Nakayama K, Ebihara S, et al. Medical treatments and cares for geriatric syndrome: new strategies learned from frail elderly. Tohoku J Exp Med. 2005 Mar;205(3): 205-14.
5. Finestone HM, Greene-Finestone LS. Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. CMAJ. 2003 Nov 11;169(10): 1041-4.
6. Kraus JJ, Metzler MD, Coplin WM. Critical care issues in stroke and subarachnoid hemorrhage. Neurol Res. 2002;24 Suppl 1: S47-57.
7. Blackmer J. Tube feeding in stroke patients: a medical and ethical perspective. Can J Neurol Sci. 2001 May;28(2): 101-6.
8. Dennis M. Nutrition after stroke. Br Med Bull. 2000;56(2): 466-75.
9. Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev. 2000;(2): CD000323. Review.
10. Krakau K, Hans,son A, Karlsson T, et al. Nutritional treatmentof patients with severe traumatic brain injury during the first six months after injury. Nutrition. 2007 Apr;23(4): 308-17. Epub 2007 Mar 21
11．蒋朱明．临床营养(外科营养)的发展概况．中国实用外科杂志，1995，15 (6)：323-324．
12．蒋朱明， 朱预．人工胃肠支持．第一版， 北京：人民卫生出版社， 1993：1-40．
13．黎介寿．认真总结营养支持的临床经验．肠外与肠内营养， 1996，3(4)：185-186．
14．吴孟超， 仲剑平．外科新理论与新技术．第一版，上海：上海科技教育出版社， 1996，93-119．
15. McArdle A.H. PH.D, Palmason C, A.R.T., et al. A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery, 1981, 90 (4): 616-623.
16．陈敏章，蒋朱明．静脉内高营养的临床应用，水与电解质平衡．北京：人民卫生出版社，1974：447．
17．江志伟．肠外营养支持的基础理论及临床应用．中国实用外科杂志，2001，21 (12)：761-765．
18. Chalela JA, Haymore J, Schellinger PD, Kang DW, Warach S. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3):331-4.
19．季云秋，姜建东．急性脑卒中患者的营养状况及其与预后的关系．江苏临床医学杂志， 1999，3(2)：120-121．
20．石向群，汪泳，杨金升等．急性脑卒中后营养状况恶化的影响因素分析．中国老年杂志， 2003，23(7)：464-465．
21. Antoni Davaios MD, Wifred Ricart MD, Ferran Gonzalcz-Huix MD, et al. Stroke. aha journals, 1996, 27:1028-1032.
22．汪泳，刘昕，朱任之等．急性脑卒中后营养状况恶化机制的探讨．中国急救医学， 2002，22(11)：650-651．
23. Ockenga J, Pirlich M Lochs H. Food for stroke: why don't the studies give clear answers?Lancet. 2005 Jun 11-17;365(9476):2005; author reply 2005-6.
24．王之敏，惠国桢，周建烈等．严重脑外伤病人早期蛋白质、氨基酸代谢的改变及其以免疫功能的影响．肠外与肠内营养，1994，1(1)：34-37．
25．黄东健，刘运生。重症脑损伤早期鼻饲肠内营养应用研究．中华神经外科杂志，2001， 17(2)：162-164
26. Donnan GA, Dewey HM. Stroke-and nutrition: food for thought. Lancet. 2005 Feb 26-Mar 4;365(9461): 729-30.
27. Diminioni L,Tricki O, Michizuki H, et al. Prevention of severe posrburn hypermetaolism and catabodism by immediate inrtagastric feeding. J Burn Care Rehab 1984;5: 106-112.
28. Ickenstein GW, Stein J, Ambrosi D, et al. Predictors of survival after severe dysphagic stroke. J Neurol. 2005 Dec;252(12): 1510-6. Epub 2005 Sep 5.
29. Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005 Dec;86(12 Suppl 2): S101-S114.
30．杨慕龙，周良辅．颅脑外伤后的代谢变化和营养支持．中华创伤杂志，1994，10 (2)： 97-98．
31. Young AB MD, Linda G MD. The acute-phase response of the brain-injured patient. [J] Neurosurg, 1988, 69: 375-380.
32. Clifton GL, Robertson CS, Grossman RG, et al. The metabolic response to severe head injury. [J] Neurosurg, 1984, 60:687-696.
33. Weeks E, Elia M, Observation on the patterns of 24-hour energy expenditure changes in boby composeition and gastric emptying in head injured patients receiving nasogastric tube feeding. Journal of parenteral and enteral nutrions, 1999, 20 (1): 31-37.
34. Minard G, Kudsk KA. Is early feeding beneficial? How early is early?. New Horizons, 1994, 2:156-163.
35. Bruder N, Dumon JC, Francois G. Evolution of energy expenditure and nitrogen excretion in severe head-injured patients. Crit Care Med, 1991, 19:42-48.
36. Gianotti L, Netson JL, Alexander JW, et al. Post injury hypermetabolic response and magitude of translocation: Prevention by early enteral nutrition. Nutrition 1994;10(3): 225-231
37．王少龙、汪仕良、尤忠义、黎鳖．早期肠道营养降低严重烧伤后多代谢的临床研究， 中华外科杂志，1996：35(1)：44-46．
38. Wolfe RR, Goodenough RD, Burke JF, et al. Reaponse of protein and urea kineties in burn patients to different to levels of protein intake. Am Surg, 1983, 197:163-171.
39. Zaloga GP. Timing and route of nutritional support, In:Nutrition in Critical Care. Zaloga GP (Ed). St. Louis, Mosby Year. Book, 1994:297-330.
40．杨道贵， 梅文杰， 舒志军．外科感染与营养支持．肠外与肠内营养杂志，1995， 2(4)：252-258．
41. Davalos A, Ricart W, Gonzalez-Huix F, et al. Effect of malnutrition after acute stroke on clinical outcome. [J] Stroke, 1996, 27 (6) : 1028-1032.
42. Chalela JA, Haymore J, Schellinger PD, et al. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit Care. 2004;1(3): 331-4.
43. Minard G, Kudsk KA. Is early feeding beneficial? How early is early?. New Horizons, 1994, 2:156-163.
44. Fried T, Dempsey D, Guenter P, et al. Barbiturates improve nutrition balance. in patients with severe head trauma. Alistr JPEN, 1984, 8:86.
45. Gosling-P. The cellular, immune, and metabolic response to trauma. Crit-Rev-Clin-Lab-Sci, 1998, 35 (1):59-112.
46. Philippe G, MD, John D, MD, et al. Nutrition and the neurosurgical patient. [J] Neurosurg, 1984, 60:219-232.
47. Grimble-RF. Nutritional mlculation of cytokine biolohy. Nutrition, 1998, 14 (7-8): 630-640.
48．邵洪， 黎鳌， 注仕良．严重烧伤后早期肠道营养对代谢的影响．中华创伤杂志， 1994，10(3)：300-308．
49. Harper JP. Nasogastric tube feedings and hyperglycemin. J Nurs Scholarsh. 2005;37(4): 300.
50. Lam AM, Winn HR, Cullen BF, et al. Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg, 1991, 75:545-551.
51．李宝民，张纪，许百男等．神经外科监护病房治疗急性上消化道出血81例报告．中华创伤杂志，1993，9(1)：27-28．
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