急性期脳梗塞の嚥下障害、栄養、脱水

急性期脳梗塞患者の入院時と退院時の嚥下障害、栄養、脱水に関する論文を紹介します。

Michael A. Crary, Jamie L. Humphrey, Giselle Carnaby-Mann, Raam Sambandam, Leslie Miller and Scott Silliman. Dysphagia, Nutrition, and Hydration in Ischemic Stroke Patients at Admission and Discharge from Acute Care. Dysphagia 2012, DOI: 10.1007/s00455-012-9414-0

急性期脳梗塞患者76人の入院時と退院時もしくは入院後7日目の栄養（プレアルブミン）、脱水（BUNとCrの比）、嚥下障害の有無、脳卒中の重症度を調査しました。

結果ですが、嚥下障害は37％に認めました。入院時、32％にプレアルブミン低値、53％にBUNとCrの比の高値を認めました。プレアルブミンは嚥下障害に寄与していませんでした。嚥下障害患者は有意にBUNとCrの比が高値でした。

入院時および退院時の脱水の有無は、嚥下障害、栄養状態、脳卒中の重症度と関連していました。以上より、脳梗塞発症後1週間では、嚥下障害は栄養状態と関連しないが脱水と関連するという結論です。

嚥下障害と脱水の関連を示した点は意義があると思います。ただ今回の研究では栄養状態をプレアルブミン値だけで評価していることが気になります。少なくともBMIや1週間の体重変化も栄養状態として評価すべきですし、できればSGAやMNAなどが望ましいと思います。

プレアルブミンはCRP高値、脱水、肝硬変などの影響をうけます。これらを考慮（調整）しないで嚥下障害と栄養の関連はないというのは言いすぎだと感じました。あくまで嚥下障害とプレアルブミンの関連は今回認めなかったにとどめておくべきでしょう。

Abstract

Dysphagia may predispose stroke patients toward undernutrition and hydration. These comorbidities increase patient risks for reduced functional outcome and short-term mortality. Despite this impact, available information on relationships among dysphagia, nutrition, and hydration status in acute stroke is limited and conflicted. This study evaluated nutrition and hydration status in ischemic stroke patients with versus without clinically significant dysphagia at admission and at discharge from acute care. Sixty-seven patients admitted to the stroke unit in a tertiary-care hospital provided data for this study. On the day of hospital admission and upon discharge or at 7 days post admission, serum biochemical measures were obtained for nutrition (prealbumin) and hydration status (BUN/Cr). Clinical evaluation for dysphagia, nutrition status, and stroke severity were completed an average of 1.4 days following hospital admission. Dysphagia was identified in 37 % of the cohort. At admission 32 % of patients demonstrated malnutrition based on prealbumin levels and 53 % demonstrated evidence of dehydration based on BUN/Cr levels. No differences in nutrition status were attributed to dysphagia. Patients with dysphagia demonstrated significantly higher BUN/Cr levels (greater dehydration) than patients without dysphagia at admission and at discharge. Dehydration at both admission and discharge was associated with dysphagia, clinical nutrition status, and stroke severity. Results of this study support prior results indicating that dysphagia is not associated with poor nutrition status during the first week post stroke. Dehydration status is associated with dysphagia during this period. The results have implications for future confirmatory research and for clinical management of dysphagia in the acute stroke period.