第六節(jié)綜合評價(jià)

1、第六節(jié)綜合評價(jià)Thegoalsofnutritionalassessmentaretodefineaccuratelythenutritionalstatusofanindividualpatient,toidentifyclinicallyrelevantmalnutrition,andtouseassessmenttoolstomonitorchangesinnutritionalstatusduringnutritionalsupport.Nutritionalassessmentcanbedeterminedbasedonsingleanthropometric,biochemical

2、,orimmunologicalmeasures.However,theidealtestofnutritionalstatusmustbesensitiveandspecificenoughtobeunaffectedbyfactorsthatarenotrelatedtonutritionandmustrespondtonutritionalrepletion.Giventhedynamicnatureofdisease,findingonetestthatmeetsthiscriterionisunlikely.Inviewofthislimitation,anutritionalind

3、exthatisandaggregateofseveralindividualnutritionalindicesneedstobedevisedinordertoprovideanoverallpictureofapatientsnutritionalstatus.Thefollowingthreeassessmentindicesareexamplesofthisapproachofusingmultipleparameters:A.prognosticnutritionalindex(PNI);B.thehospitalprognosticindicator(HPI);C.subject

4、iveglobalassessment(SGA).目前，多數(shù)學(xué)者主張采用綜合性營養(yǎng)評定方法，以提高營養(yǎng)評價(jià)的靈敏性和特異性。預(yù)后營養(yǎng)指數(shù)(prognosticnutritionalindex,PND該指數(shù)是對4種營養(yǎng)狀態(tài)評定參數(shù)與外科病人預(yù)后的相關(guān)性分析(由Mullen等于1980年提出)?！九R床意義】可以預(yù)期手術(shù)后并發(fā)癥的發(fā)生率與死亡率?！居?jì)算公式】PNI(%)=158-16.6xALB(g%)-0.78xTSF(mm)-0.20 xTFN(mg%)-5.80 xDCH其中：ALB為血清白蛋白，TSF為三頭肌皮褶厚度，TFN為血清轉(zhuǎn)鐵蛋白，DCH表示遲發(fā)性超敏皮膚反應(yīng)試驗(yàn)(硬結(jié)直徑5mm者，

5、DCH=2；5mm者，DCH=1；無反應(yīng)者，DCH=0)?！驹u定標(biāo)準(zhǔn)】PNIV30%，表示發(fā)生術(shù)后并發(fā)癥及死亡的可能性均很??；30%40%，表示存在輕度手術(shù)危險(xiǎn)性；40%50%，表示存在中度手術(shù)危險(xiǎn)性；50%，表示發(fā)生術(shù)后并發(fā)癥及死亡的可能性均較大。營養(yǎng)危險(xiǎn)指數(shù)(nutritionalriskindex,NRI)【臨床意義】是對外科病人術(shù)前3種營養(yǎng)評定參數(shù)的結(jié)果計(jì)算術(shù)后營養(yǎng)危險(xiǎn)指數(shù)(由Sato于1982年提出)?！居?jì)算公式】NRI=10.7xALB+0.0039xTLC+0.11xZn-0.044xAge其中，ALB表示血清白蛋白，TLC表示淋巴細(xì)胞計(jì)數(shù)，Zn表示血清鋅水平，Age表示年齡?！?/p>

6、評定標(biāo)準(zhǔn)】NRI60,表示危險(xiǎn)性低；NRl55,表示存在高危險(xiǎn)性。營養(yǎng)評定指數(shù)(nutritionalassessmentindex,NAI)【臨床意義】該指數(shù)是對食管癌病人進(jìn)行營養(yǎng)狀況評定的綜合指數(shù)(由Masatolwasa等于1983年提出)。【計(jì)算公式】NAI=2.64xAMC+0.60 xPA+3.76xRBP+0.017xPPD-53.80其中，AMC表示上臂肌圍(cm),PA表示血清前白蛋白(mg%),PPD表示用純化蛋白質(zhì)衍生物進(jìn)行延遲超敏皮膚實(shí)驗(yàn)(硬結(jié)直徑5mm者，PPD=2；25,則表示術(shù)后并發(fā)癥的發(fā)生率較高。住院病人預(yù)后指數(shù)(hospitalprognosticindex,

7、HPI)【臨床意義】HPI對死亡率的預(yù)測可達(dá)71%,靈敏度達(dá)74%，特異性為66%,但目前還未在臨床普遍應(yīng)用?！居?jì)算公式】HPI=0.92xALB(g/L)-1.00 xDCH-1.44xSEP+0.98xDX-1.09其中：DCH值在有1種或多種陽性反應(yīng)取1,所有均呈陽性時(shí)取2；SEP為敗血癥，有取1,無取2；DX為癌癥診斷，有取1,無取2。【評定標(biāo)準(zhǔn)】HPI=1,表示有75%的生存率；HPI=0,表示有50%的生存幾率；HPI=-2,表示僅有10%的生存幾率。主觀全面評定(subjectiveglobalassessment,SGA)【臨床意義】SGA亦稱全面臨床評定(globalclin

8、icalassessment,GCA)，其特點(diǎn)是以詳細(xì)的病史與臨床檢查為基礎(chǔ),省略人體測量和生化檢查。其理論基礎(chǔ)是,身體組成改變與進(jìn)食改變,消化吸收功能的改變，肌肉的消耗，身體功能及活動(dòng)能力的改變等相關(guān)聯(lián)。在重度營養(yǎng)不良時(shí)，SGA與人體組成評定方法(bodycompositionassessment)有較好的相關(guān)性。TheclinicianrateseachmedicalhistoryandphysicalexaminationparameterasanA,B,orContheSGAscoringsheet.Accordingtoalloftheseparametersratings,thel

9、cinicalobserverassignsanoverallSGAclassificationthatcorrespondstothesubjectiveopinionofthepatientsnutritionstatus.Itresultsina-l3evelclassification:normalnourished,moderatemalnourished(oratriskofmalnutrition),andseveremalnourished(orpoornutritionstatus).SeeTable7-6-2.Table7-6-2SubjectiveGlobalAssess

10、mentratingformHistoryWeightchangeandheight:Currentheightcm,Weightkg.Overalllossinpast6months:kg,%.Changeinpasttwoweeks(use+or-):kg,%.(Thepercentageofbodyweightlostinpast6monthsischaracterizedas:mild(10%)Dietaryintakechange(relativetousualintake)NochangeChangeduration=days.Type:SuboptimalsoliddietHyp

11、ocaloricliquidsStarvationSupplement:(circle)nilvitaminminerals(Dietaryintakeisclassifiedasnormalorabnormalasjudgedbyachangeinintakeandwhetherthecurrentdietisnutritionallyadequate.)Gastrointestinalsymptomsthatpersistedfor2weeksNoneNauseaVomitingDiarrheaPainAtrestOneatingFunctionalcapacityNodysfunctio

12、nDysfunction:durationdaysType:WorkingsuboptimallyAmbulatorybutnotworkingBedriddenDiseaseanditsrelationtonutritionalrequirementsPrimarydiagnosisMetabolicdemand(stress):NostressModeratestressHighstress(burns,sepsis,severetrauma)Physicalstatus(foreachtraitspecify:0=normal,1=milddeficit,2=establisheddef

13、icit)Lossofsubcutaneousfat(measuredinthetricepsregionandthemid-axillaryline)Musclewasting(inthetemporalareasandinthedeltoidsandquadriceps)Edema(intheankleandsacralregions)AsciteMucosallesionsCutaneousandhairchanges(hairscolorandappearance)SGAGrade(A:well-nourished;B:havingmoderateorsuspectedmalnutri

14、tion;C:havingseveremalnutrition)SGA的主要內(nèi)容及評定標(biāo)準(zhǔn)見表7-6-3。表7-6-3SGA的主要內(nèi)容及評定標(biāo)準(zhǔn)指標(biāo)A級B級C級1近期(2周)體重改變2飲食改變3胃腸道癥狀(持續(xù)2周)4活動(dòng)能力改變5.應(yīng)激反應(yīng)6肌肉消耗7三頭肌皮脂厚度8.踝部水腫無/升高無無/食欲不減無/減退無/低度無正常無減少5%減少輕微惡心、嘔吐能下床走動(dòng)中度輕度輕度減少輕度減少5%不進(jìn)食/低熱量流食嚴(yán)重惡心、嘔吐臥床咼度重度重度減少重度上述8項(xiàng)中，至少5項(xiàng)屬于C級或B級者，可分別被定為重或中度營養(yǎng)不良7.微型營養(yǎng)評定(mininutritionalassessment,MNA)微型營養(yǎng)評

15、定的評價(jià)內(nèi)容包括：人體測量(anthropometry):包括身高、體重及體重喪失；整體評定(globalassessment):包括生活類型、醫(yī)療及疾病狀況(如消化功能狀況等)；膳食問卷(dietaryquestionnaire)：食欲、食物數(shù)量、餐次、營養(yǎng)素?cái)z入量、有否攝食障礙等；主觀評定(subjectiveassessment)：對健康及營養(yǎng)狀況的自我監(jiān)測等。根據(jù)上述各項(xiàng)評分標(biāo)準(zhǔn)計(jì)分并相加。見表7-6-4。Table7-6-4MiniNutritionAssessmentQuestioniare(MNAQ)ItemAnthropometricassessmentDietaryasses

16、sment1.Bodymassindex,kg/m211.No.ofmealsperday0=BMI190=11=BMI19,211=22=BMI21,232=33=BMI2312.EatsD,L/E,M/F/Peveryday2.Mid-armcircumference,cm0.0=Yesto0or10.0=MAC2213.Eatsfruitsorvegetablestwiceaday3.Calfcircumference,cm0=No0=CC311=Yes1=CC3114.Lossofappetite4.Weightlossduringlast3months0=Severe0=3kg1=M

17、oderate1=Doesnotknow2=None2=1-3kg15.Dailyfluidconsumption,cups3=None0.0=50=No16.Modeoffeeding1=Yes0=Needsassistance6.Takes3drugsaday1=Self-fedwithdifficulty0=No2=Self-fedwithoutdifficulty1=YesSelf-assessment7.Stressoracutedisease17.Self-assessedmalnutrition0=No0=Major1=Yes1=Moderate/doesnotknow8.Mobility2=None0=bedorchair-bound18.Healthstatuscomparedwithpeers1=Doesno