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1 Bul. Hijiyama Univ. Jun. Col., No.48, 2013 急性期病院の NST 活動と NST 介入により経過良好をみた症例 脳症を伴う肝硬変, 慢性腎不全患者の閉塞性大腸炎合併 S 字状結腸癌に対し, NSTが協力し治療遂行出来た1 例 Nutrition support team NST NST 60 NST Key words NST Nutrition Support NST Nutrition Support Team 1-6 NST NST 2001 NST 2010 * * * * * 105
2 Nutrition Support Team NST NST NST NST NST S NST C 2011 ER cm 57.4kg BMI cm TPLA + HBS-Ag - HCV-AB + T-bill 0.6mg/dl, D.Bil 0.7mg/dl, AST 29IU/L, ALT 29IU/L, LDH 299 IU/L, CK222 IU/L, LAP59 IU/L, ALP259 IU/L, -GPT37 IU/L, ChE107 IU/L, TCHO 151 mg/dl, TP 7.0g/dl, Alb3.0g/dl A/G0.75 BUN37mg/dl, Cr2.50mg/dl, egfr21ml/min, UA4.1 mg/dl, Nac138.6mEq/L, K5.4mEq/L, Cl114.0mEq/L, Ca8.5mg/dl, IP3.6 mg/dl, Mg2.4mg/dl, AMY 170 IU/L, TG76 mg/dl, HDL-C62 mg/dl, CRP0.539mg/dl, PG218mg/dl, NH3-N 189 g/dl, ICG-R 41.1%, ICG-K 0.059, WBC / l,rbc / l, Hg9.9g/ dl, Hct29.6, Plt / l, HbA1c5.1, CEA25.4ng/ml, CA ng/ml, 103.9fl, 34.7pg 33.4g/dl. AST ALT ICG-R 41.1% Child B, BUN37mg/dl Cr2.50mg/dl, egfr21ml/min CEA 25.4ng/ml, CA ng/ml 106
3 急性期病院のNST活動とNST介入により経過良好をみた症例 入院時 腹水穿刺が行われ腹水中の白血球11600/μl 好中球9895/μlの値が認められ39.4 の熱発 腹 痛 の 訴 え が あ っ た 後 日 腸 内 細 菌 Escherichia Coliも 検 出 さ れ 突 発 性 細 菌 性 腹 膜 炎 spontaneous bacterial peritonitis SBP と診断され肝機能障害 感染症に対する治療が開始され たが 症状の改善は遅延していた SBPは腹水患者に発生する感染源不明の細菌性腹膜炎であり 肝硬変患者で合併する頻度が高い 8 肝硬変症にSBPを併発すると消化管出血 肝腎症候群 播種性血管内凝固症候群 disseminated intravascular coagulation DIC を起こしやすくなり 一般に経過は急速で 予後不良である 9 この症例では入院時より抗生剤スルペラゾン SBT/CPZ と利尿剤ラシックス20mgの内服が開始さ れ 感染 浮腫は改善傾向となった 炎症所見 発熱なくスルペラゾン SBT/CPZ とラシックス 20mgの内服は中止された 一方CEA 25.4ng/ml CA ng/mlと腫瘍マーカーは高値であった ため精査が行われた CTにて腹部リンパ節腫脹が認められ 図１ スクリーニングのため内視鏡検査 が行われた 上部内視鏡では静脈瘤 図２ や胃切除後が認められた 図３ さらに大腸内視鏡検査 colonoscopy 以下 CS を施行した 図１ 入院時CT画像 肝硬変 腹水 胸水 静脈瘤 リンパ節腫大 閉塞性腸炎 腸管浮腫がみえる 図２ 上部内視鏡検査では食道静脈瘤が明らかとなった 図３ 胃切除後 107
4 S type2 CS Group5 Aden carcinoma CT S Total parenteral nutrition TPN NST OP Alb 2.1g/dl NST NST NST 1500/ l PNI22.0 SGA C Harris-Benedict basal energy expenditure BEE 1200kcal SF;stress factor 1.2 AF ; active factor 1.3 total daily energy expenditure TEE 1719kcal RF R R 200ml 1742kcal 35.7g C/N ml 1941kcal 35.7g C/N 340 GFO R R PreALB TPN NST TPN EN C/N 300 ALB 2.2g/dl 2.7g/dl PNI
5 急性期病院のNST活動とNST介入により経過良好をみた症例 図５ 図６ 点滴メニュー等経過表 ＣＴでは腹水の著明な減少 腸管浮腫の改善により 腹囲の減少を認めた 善により 腹囲の減少が認められた 図６ そして介入後当初の治療目的であるS状結腸切除術施行され 術後の重篤な合併症はなく 術後５日 目には飲み水が開始され６日目には流動食 漸次固形化食形態の摂取へと移行し 11日目には全粥食の 摂取となった その後術後21日めに独歩 自宅退院となった 109
6 NST NST 10 TPN 11 TPN EN enteral nutrition 12 EN 15 EN TPN EN EN ALB Prognostic Nutritional Index: PNI 1984 PNI ALB TLC 16 PNI PNI 10 g/dl mm PNI 110
7 NST NST TPN NST TPN NST NST NST NST NST 10 NST NST 10 NST 111
8 Higashiguchi T, Yasui, M., Bessho, S. et al Effec of nutrition Support Team based on the New System Potluck Party Method(PPM). Jp.J.Surg.MetabolNutri.34(1) NST. 17 (4) Nutrition Support Team Potluck Party Method(PPM) 14 (2) Hamaoui E. Assessing the nutrition support team, J. parent. Ent. Nutri Regenstein M Nutritional Support Team-alive, well, and still growing. Results of a 1991 A. S. P. E. N. survey. NCPc1992. Wesley.J.R. nutrition support team past present and future.ncp NST VOL Vol.106 No EBN JCN p Braunschweig CL, Levy P, Sheean PM et al: Enteral compared with parenteral nutrition a metaanalysis. Am J Clin Nutr , NST Vol
9 NST NST Abstract Patients saw satisfactory progress by the intervention activities and NST at NST acute care hospitals. Looking at cirrhosis with encephalopathy, with S-shaped colon cancer in obstructive colitis patients with chronic renal failure, one patient was able to cope due to NST treatment. Shitsuyo YOKOYAMA *1, Masao HARANO *2, Kaori NAKAMURA *3, Keiko KANEMARU *4 Chiaki TANAKA *4, Miki TANAKA *4, Tomoko TSUJI *5, Miwa WATANABE *5 Summary Nutritional management is one of the basic medical treatments of diseases and common to all people. A nutrition support team (NST) is a group that carries out treatment beyond the normal circumstances of nutritional management In this study, we report one case in patients with a complex pathology, where a good therapeutic performance has become possible when NST are involved, The patients hospitalized for further examination, was a man in his 60s who had ascites and wes diagnosed with colon cancer. Malnutrition was prolonged because of poor eating after diagnosis of colorectal cancer, the patient was scheduled to undergo surgery, however, he was malnutrition because of prolonged poor eating. After improvement of their general condition, including nutritional status by providing appropriate nutritional therapy before surgery was performed. Via a drain, postoperative ascites were diagnosed and condition of the ascites ximproved, so continued outpatient treatment has become possible. Since the patient was discharged, the condition has been improving. Key words NST, nutritional therapy Received October 31, 2012 Department of Comprehensive Human Life Studies, Hijiyama Junior College, Hijiyama University, Hiroshima, Department of Surgery, Hiroshima City Hospital, Hiroshima, Nursing Unit, Hiroshima City Hospital, Hiroshima, Clinical Laboratory, Hiroshima City Hospital, Hiroshima, Pharmacology Department, Hiroshima City Hospital, Hiroshima 113
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