| Background and objectiveIn recent years,some critical patients in intensive care unit(ICU)were found multiple peripheral nerve injury manifested as limb numbness,paralysis and respiratory muscle paralysis.The physical signs of decreased muscle strength,muscle tension and muscle volume,terminal sensory disturbance,unable to cough and breathe even respiratory failure.Characteristics of electromyography showed chiefly that sensory and motor fibers axonal injury combined with demyelination.Biopsy of the affected nerves showed decreased density of myelinated fibers,axonal degeneration and demyelination,and axonal regeneration.These lesions were known as critical illness polyneuropathy(CIP).CIP generally lead to paralysis or paralysis aggravation.It also cause inability to cough and expectorate,which lead to difficulty to control lung infection.Mechanical ventilation was necessory when respiratory failure occurred.CIP lead to difficult weaning and lengh of hospitalization in patients who used mechanical ventilation.More attention has been paid on CIP in recent years because of the bad consequences.Cases of stroke complicated CIP had been reported occasionally,but it was lack of systematic study of the incidence,severity,risk factors and prognosis of CIP in severe stroke patients.In clinical practice,it was found that gastroparesis,gastroesophageal reflux,gastrointestinal hemorrhage were generally complicated in patients with critical cerebral stroke and which lead to difficult to imply enteral nutrition.Enteral nutrition was viewed as a long-term nutritional support strategy because it could regulate the intestinal flora to prevent enterogenic infection and regulate immunity and intestinal function more close to physiological conditions.Enteral nutrition should be used as in patients with critical cerebral stroke.One of the causes and pathogenesis of CIP was undemutrition and immune disorder.The objectives of this study included:(1)To explore the incidence of CIP and the risk factors in patients with critical cerebral stroke,(2)To explore the effects of enteral nutrition by percutaneous endoscopic gastrostomy(PEG)immune and nutritional status and CIP complication.The aim of the study was to provide theoretical and practical basis for prevention and treatment of CIP of critical cerebral stroke.MethodsIn this study,critical cerebral stroke included the following diseases:large area cerebral infarction,brainstem infarction with conscious disorder,cerebral hemisphere hemorrhage more than 30ml within 1 hours of the onset,primary intraventricular hemorrhage resulting in the whole ventriculars casting,brainstem hemorrhage more than 5ml,cerebellar hemorrhage more than 15ml,spontaneous subarachnoid hemorrhage(SAH)of Hunt-Hess grade II-IV within 1 hours after the onset.235 cases of critical cerebral stroke were divided into 2 groups,the observation group(n=119)was given enteral nutrition by indwelling PEG while the controlled group(n=116)was given enteral nutrition by indwelling nasogastric tube.T lymphocyte subtypes,albumin,prealbumin,tumor necrosis factor a(TNF-a)and transforming growth factor ?1(TGF-?1)examination of fasting venous blood as well as EMG of the four limbs were inspected in 24 hours after hospitalization.Albumin,prealbumin and nutrition risk in critically ill(NUTRIC)score were examined per 1-2 days to inspect whether nutritional support was appropriate and to adjust the nutritional programme.T lymphocyte subtypes,TNF-a and TGF-?1 were examined per 1-2 days to inspect the immunity situation.EMG of the four limbs were inspected again after 3 weeks after hospitalization.The following indexes were observed:(1)The incidence of CIP and the risk factors in patients with critical cerebral stroke,(2)T lymphocyte subtypes,TNF-a,TGF-?1,albumin,prealbumin,NUTRIC score,the incidence of CIP,electrophysiological parameters of peripheral nerves in the two groups in the time of admition and 3 weeks after hospitalization.Outcomes1.There were 33 cases met the diagnostic criterias of CIP in the patients with critical cerebral stroke in the time of 3 weeks after hospitalization.14.04%patients would complicate with CIP.11 cases(9.24%)in the observation group while 11 cases(18.97%)in the matched group were found among them.The incidence of CIP in the observation group was lower than in the matched group.2.The risk factors for CIP in patients with critical cerebral stroke included male,over 60 years,sepsis,MOF,invasive mechanical ventilation,parenteral nutrition,malnutrition and immunologic derangement.Sepsis,MOF,invasive mechanical ventilation,malnutrition and immunologic derangement were independent risk factors.3.The immunity situation were found abnormal significantly manifested with decreased ratio of CD4+T cell and level of TGF-?1,increased ratio of CD8+T cell and level of TNF-a,decreased ratio of CD4+/CD8+ in the two groups in the time of admition.The items mentioned above were ameliorated after 3 weeks after hospitalization in the two groups,and the items in the observation group were ameliorated than the controlled group.4.There was no significant difference in serum albumin and prealbumin levels and NUTRIC score between the 2 groups on admission.After 3 weeks of treatment,serum albumin and prealbumin levels were decreased and NUTRIC score was elevated in the controlled group while there was no statistical difference in the observation group.The items mentioned above in the observation group were better than the controlled group in the time of 3 weeks after hospitalization.5.There was no significant difference in distal latency,nerve conduction velocity and wave amplitude of complex muscle action potential(CMAP)in median nerve,ulnar nerve,radial nerve,peroneal nerve and tibial nerve between the 2 groups on admission.After 3 weeks of treatment,There was no significant difference in the items mentioned above in ulnar nerve and radial nerve while median nerve,peroneal nerve and tibial nerve were worse statistically in the observation group.There were significant differences in the items of all nerves in the controlled group ffter 3 weeks of treatment.There were significant differences in the items mentioned above in median nerve,peroneal nerve and tibial nerve while There was no significant difference in ulnar nerve and radial nerve between the two groups.There was no significant difference in nerve conduction velocity and wave amplitude of sensory nerve action potential(SNAP)in peripheral nerve between the 2 groups on admission.After 3 weeks of treatment,some items mentioned above were worse but did not exceed the reference value range while there were significant difference in other items in the observation group.All items were worse statistically but did not exceed the reference value range.There were significant differences in all items between the two groups after 3 weeks of treatment.Conclusions1.14.04%patients with critical cerebral stroke would complicate with CIP.The risk factors for CIP included male,over 60 years,sepsis,MOF,invasive mechanical ventilation,parenteral nutrition,malnutrition and immunologic derangement.Sepsis,MOF,invasive mechanical ventilation,malnutrition and immunologic derangement were independent risk factors.2.Nutritional and immunity situation could be ameliorated by enteral nutrition with PEG in patients with critical cerebral stroke.3.The risk of CIP could be deduced by enteral nutrition with PEG due to ameliorate nutritional and immunity situation in patients with critical cerebral stroke. |
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