Stan odżywienia pacjenta jest szczególnie ważnym czynnikiem w procesie leczenia ran. Dlatego tak ważna jest prawidłowa jego ocena. Pomóc w tym mogą proste narzędzia, które pozwolą na rozpoznanie niedożywienia.
Gotowe narzędzia oceny stanu odżywienia stosuje się w celu przeprowadzenia wstępnego badania skriningowego i rozpoznania niedożywienia i/lub określenia, czy niedożywienie może się rozwinąć lub nasilić. Zalicza się do nich takie badania jak NRS 2002, MUST (malnutrition universal screening tool), MNA (mini nutritional assessment) oraz SGA (subjective globar assessment).
Na czym polega badanie NRS?
NRS 2002 to ocena odżywienia pacjenta pod kątem rozpoznania niedożywienia, a także ryzyka jego wystąpienia w warunkach szpitalnych. Polega ona na tzw. skriningu wstępnym, czyli odpowiedzi na takie pytania, jak:
- Czy wartość BMI < 20,5?
- Czy w ciągu ostatnich trzech miesięcy doszło do utraty masy ciała?
- Czy w ostatnim tygodniu zmniejszyła się ilość przyjmowanego pożywienia?
- Czy chory jest w ciężkim stanie?
Jeżeli odpowiedź na minimum jedno powyższe pytanie jest twierdząca, należy kontynuować badanie. Jeżeli natomiast odpowiedź na wszystkie pytania była przecząca, badanie należy przeprowadzić ponownie po 7 dniach.
Jak ocenić parametry stanu odżywienia pacjenta?
Kontrolując parametry stanu odżywienia pacjenta należy wziąć pod uwagę:
- masę ciała,
- wskaźnik masy ciała,
- grubość fałdu skórnego nad mięśniem trójgłowym ramienia,
- pomiar siły mięśniowej,
- stężenie albumin w surowicy krwi,
- całkowitą liczbę limfocytów,
- bilans azotowy,
- subiektywną globalną ocenę stanu odżywienia (SGA),
- inne nowoczesne techniki.
Najłatwiejszym sposobem oceny stanu odżywienia jest pomiar masy ciała. Głównym czynnikiem, który wpływa na szybki spadek masy ciała jest zmniejszenie całkowitej wody ustrojowej, tzw. TBW – total body water. Wpływ na spadek masy ciała w dłuższym okresie będzie miała natomiast ilość spożywanych pokarmów.
Kolejnym czynnikiem w procesie oceny stanu odżywienia jest określenie wskaźnika masy ciała, tzw. BMI – body mass index. Aby go wyliczyć, należy podzielić masę ciała przez wzrost² (BMI = masa ciała (kg)/wzrost²(m). Wartości BMI przedstawiają się następująco:
< 18 – niedożywienie,
18 – 20 – zagrożenie niedożywieniem,
21 – 25 – norma,
26 – 30 – nadwaga,
> 31 – otyłość.
Aby ocenić stan odżywienie pacjenta mierzy się również grubość fałdu skórnego nad mięśniem trójgłowym ramienia. Grubość fałdu skórnego u pacjentów niedożywionych jest mniejsza niż 11 mm u mężczyzn, natomiast 14 mm u kobiet.
W celu rozpoznania niedożywienia wykonuje się również pomiar siły mięśniowej, która powinna być proporcjonalna do masy mięśni szkieletowych i stanu odżywienia. Specjalnym narzędziem, zwanym dynamometrem ocenia się objętość powietrza wydmuchniętego z płuc w czasie pierwszej sekundy maksymalnie natężonego wydechu (FEV1). Dzięki temu jesteśmy w stanie oznaczyć siłę mięśni oddechowych, która u pacjentów niedożywionych charakteryzuje się wyraźnym osłabieniem.
Następną wartością, którą należy określić jest stężenie albumin w surowicy krwi. Ich wartość u pacjentów niedożywionych spada poniżej 2,8 g/dl. Z uwagi na to, że prawidłowe stężenie albumin może się utrzymywać jeszcze przez wiele tygodni po ograniczeniu spożycia pokarmów, ocenę tą możemy stosować jedynie w przypadku przewlekłego niedożywienia. Należy wówczas wziąć pod uwagę zawartość wody w ustroju, potencjalne upośledzenie czynności wątroby, a także drogi utraty białka z organizmu, takie jak rany czy przetoki.
Ze względu na to, że niedożywienie w konsekwencji prowadzi do spadku całkowitej liczby limfocytów, równie ważne jest jej dokładne określenie. Zbyt niski ich poziom prowadzi do upośledzenia funkcji układu odpornościowego, jak również wzrostu liczby powikłań septycznych. Całkowita liczba limfocytów u osób niedożywionych w średnim stopniu waha się w granicach 900-1500/mm³, natomiast niedożywionych w stopniu ciężkim ta wartość wynosi poniżej 900/mm³.
Określenie stanu odżywienia pacjenta musi opierać się również o wartość bilansu azotowego. U pacjentów niedożywionych tzw. ujemny bilans azotowy następuje na skutek stanu wzmożonej utraty białek ustrojowych, która ma związek z wydalaniem azotu. Jest to nic innego jak utrata większej ilości białka niż przyjmowana w pokarmach.
Z uwagi na to, że większość azotu usuwana jest z organizmu w moczu, wartość bilansu azotowego można określić dzięki dobowej zbiórce moczu. Ponadto istotne są również inne drogi utraty białka. Wartość utraty dobowej azotu u osoby zdrowej waha się w granicy 11 g na dobę, natomiast u pacjentów w stanach septycznych ten poziom może wynosić 3-4 razy więcej, tj. do 30-40 g na dobę. Należy pamiętać, iż utrata 1 g azotu jest równa utracie 6,25 g białka, a to z kolei równa się 25 g masy mięśniowej.
Istotną kwestią w ocenie stanu odżywienia jest również subiektywna globalna ocena stanu odżywienia (SGA), której podstawą jest wywiad żywieniowy i elementy oceny fizykalnej. Należy wówczas sprawdzić takie czynniki jak:
- Zmiana masy ciała w ciągu ostatnich 6 miesięcy i 2 tygodni,
- Objawy ze strony przewodu pokarmowego trwające dłużej niż 2 tygodnie (m.in. biegunki, nudności, wymioty),
- Zmiany w sposobie odżywiania się,
- Wydolność fizyczną,
- Zaniki mięśniowe,
- Zaniki tkanki podskórnej,
- Występowanie obrzęków i wodobrzusza.
Wówczas możliwe będzie określenie stopnia niedożywienia. Stopień A wskazuje na prawidłowy stan odżywienia, B świadczy o podejrzeniu niedożywienia lub niedożywieniu średniego stopnia, natomiast C o wyniszczeniu.
W ocenie stanu odżywienia pacjenta stosuje się również inne nowoczesne techniki, takie jak pomiar masy mięśniowej i tkanki tłuszczowej przy użyciu absorpcjometrii rentgenowskiej (DXA), indeks masy mięśniowej oceniany w tomografii komputerowej oraz określenie składu ciała metodą impedancji bioelektrycznej (BIA).
Źródło: Głuszek S., Chirurgia podstawy, Wydanie II uaktualnione i rozszerzone, Warszawa 2019, s. 392-394
Przeczytaj także: Najczęstsze powikłania chirurgii małoinwazyjnej
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