Fan-Mei Kong,Yu-Ling Wang

1Cardiac Surgery ICU of Qingdao Municipal Hospital,Qingdao,China; 2Tianjin Hospital of ITCWM Nankai Hospital,Tianjin,China.

ABSTRACT

Key words:Moxibustion,Acupoint application,Severe acute pancreatitis,Enteral nutrition,Tolerance

1.INTRODUCTION

Severe acute pancreatitis (SAP) is a common acute and critical illness,with acute onset,complicated and variable disease,and the mortality rate can reach 30% [1 - 2],more studies have pointed out that the mortality rate can reach 36%-50%,and the later combined infections have a higher mortality rate [3].SAP patients are in a state of high decomposition and high metabolism,fat mobilization,protein decomposition,gluconeogenesis,insulin resistance and decreased immunity,often accompanied by severe metabolic disorders,and the body is in a negative nitrogen balance [4].In recent years,studies have shown that enteral nutrition can promote the maintenance of mucosal repair[5].Preventing intestinal endotoxemia caused by intestinal mucosal dysfunction from causing a "second blow" to the whole body and intestinal bacterial translocation can maintain intestinal function,protect the intestinal mucosal barrier,reduce secondary infection caused by intestinal bacteria and endotoxin translocation,and significantly improve the clinical prognosis of patients.However,studies have shown that the incidence of feeding intolerance in critically ill patients is as high as 30.5% to 65.7% [6- 7].Chen T,et al.have shown that the incidence of enteral nutrition intolerance in patients with SAP for enteral nutrition is as high as 58.7%,seriously affecting the treatment and prognosis of patients[8].In this study,moxibustion combined with acupoint application was applied to patients with SAP enteral nutrition,and the implementation effect was good.

2.OBJECTS AND METHODS

2.1 Objects

Ninety-six patients with severe acute pancreatitis who underwent enteral nutrition in a third-grade class-A general hospital in Tianjin from January 2017 to December 2017 were selected as objects.Diagnostic criteria:Refer to the 2013 Guidelines for the Diagnosis and Treatment of Acute Pancreatitis in China [9].Inclusion criteria:(1) Age between 18 - 80 years old; (2) meets AP diagnostic criteria while meeting one of the following conditions,APACHE II score ＞ 8 points,Balthazar CT grades up to D or E; temporarily not undergoing surgery; (3) proposed enteral nutrition support ＞ 7 days; (4) select acupoint skin intact,no damage and voluntary treatment.Exclusion criteria:(1) Including serious heart,brain,kidney and other organ diseases or shock and other high-risk symptoms; (2) patients with mental illness,senile dementia or cognitive impairment,mental retardation; (3) pregnant women and lactating patients; those who are allergic to acupoint application or drug components; (4) those who undergo surgery on admission,who are treated with mechanical ventilation; (5) patients with complications such as gastrointestinal bleeding,intestinal fistula,intestinal obstruction,severe intestinal paralysis.

2.2 Research methods

2.2.1 Group A.The control group implemented usual care methods.The pipeline marking is clear,pay attention to the position of the marking,and record the exposed length every day[10 - 11].Before the daily infusion,first confirm that the nasal jejunal tube is in the gastrointestinal tract,then rinse the tube with warm water 30 - 50 mL.When infusion of nutrient solution continuously,it should be flushed once with warm water every 4 hours [12]; bedside elevation of 30 - 45° can reduce the incidence of aspiration pneumonia; strictly control the concentration,temperature,speed and quantity of nutrient solution infusion,following the principle of low to high concentration,speed from slow to fast,and volume from small to large [13].Pay attention to monitoring changes in blood glucose,water and electrolytes during treatment,and accurately record patient intake and output.The energy supply is based on the guidelines for enteral nutrition in the United States and the guidelines for parenteral nutrition in the 2008 clinical guidelines [14 - 15].

2.2.2 Group B.Acupoint application method is supplemented by acupoint application method based on routine nursing method.Select Shenque (CV8) Zhongwan (CV12),Bilateral Zusanli(ST36),and Bilateral Yongquan (KI1) for acupoint application.The selection of the time point follows the law of theZiwuliuzhu,combined with clinical practice,choose a daily acupoint application treatment from 7:00 am to 9:00 am,30 minutes each time.The spleen and stomach are most active during this time period,which can enhance the effect.Select the points refers to GB/T12346-2006,Acupuncture Point Name and Position,make a warm water-prepared drug (Wuzhuyu (Fructus Evodiae),Banxia (Rhizoma Pinelliae),and Shengjiang (Rhizoma Zingiberis Recens) are prepared into a paste at a ratio of 3:1:3) into a disposable acupoint stick of 7 × 7 cm size,the area of the applicator is a circle of 3 cm in diameter,the size and thickness are like 1 yuan coin,which is 0.2 - 0.3 cm,expose the application site,clean the local skin with 0.9% saline,and apply it to the corresponding acupuncture points.Patients usually apply for 4 hours before they can be removed.During the application,if it falls off,the nurse should be notified in time to re-apply to ensure that the patient's local and general conditions are observed.If there are allergies such as rash,blisters,itching,etc.,it should be treated in time.

2.2.3 Group C.On the basis of acupoint application method,supplemented with moxibustion.Select the points refers to GB/T12346-2006,Acupuncture Point Name and Position,select acupoint application method,use multi-purpose moxibustion apparatus (DAJ-10) for moxibustion treatment of patients.The time of moxibustion treatment is the same as acupoint application,that is,7:00 am to 9:00 am,30 minutes each time.On the basis of acupoint application,the moxibustion head is fixed on the corresponding acupoint on the acupoint.Set the treatment time to 30 minutes,treatment temperature to 45℃,strengthen the inspection during the treatment.

2.2.4 Evaluation index.(1) Enteral nutrition tolerance:The study evaluated the patient's tolerance using the Enteral Nutrition Inlerance Assessment Form,enteral nutrition tolerance scores are divided into 3 levels:Good tolerated,no symptoms of intolerance; moderate tolerant,a symptom of intolerance,and adherence to enteral nutrition by controlling speed or changing formula; intolerance,a symptom of intolerance,and no significant improvement in the symptoms after treatment,must stop the enteral nutrition [16].Symptoms of intolerance in the indications of enteral nutrition intolerance include vomiting,bloating / intra-abdominal pressure,diarrhea,bowel sounds,stomach residuals and aspiration.(2) Nutritional indicators:Pre-intervention,intervention day 3,intervention day 7 serum albumin and serum pre-protein levels.(3) Comfort:This study used Kolcaba's sim-plified comfort scale,which was developed by the American nursing specialist Kolcaba on the development of a comfortable care framework.She tested the reliability and validity of the scale to prove the amount.The table has good reliability and validity,and Cronbach's alpha is 0.96.The scale was introduced into China by the translation of Zhu LX and others [17].She measured the reliability and validity of the scale in patients after thoracic surgery.As a result,the scale is suitable for use in China.The simplified General Comfort Questionnaire content validity is Content validity index = 0.86,Cronbach's alpha is 0.92,and Cronbach's alpha varies from 0.53 to 0.85 in each dimension.The scale is divided into four dimensions:physical,mental,social,and environmental.2,3,7-17,19,21,22,25,26,27,and 30 are reverse questions,and the rest are positive questions.The scale uses a 1 to 4 likert level 4 rating.Positive question 1 indicates very disagreement with 1 point,4 indicates very agree with 4 points,reverse question 1 indicates very disagree with 4 points,and 2 indicates disagreement 3 points,3 means agreeing to score 2 points,and 4 means very agreeing to score 1 point.The lowest score for the total score is 30 points and the highest score is 120 points.The higher the score,the more comfortable it is.The total score≤60 is divided into low comfort,the total score is 60-90 divided into moderate comfort,and the total score ≧ 90 divided into high comfort.

2.2.5 Quality control.(1) Formation of a clinical research team:The clinical research management team consists of three parts:1)Experts group:It consists of 1 chief nurse and 2 chief physicians of hepatobiliary surgery and 2 head nurses.It mainly conducts quality management control and professional technical support for clinical intervention implementation.2) Steering group:It consists of chief nurses and chief nurses,3 people in total,who are mainly responsible for monitoring the implementation of the study.3) Implementation group:It consists of 4 responsible nurses and 2 postgraduate students,the responsible nurses and graduate students are responsible for the specific implementation of the project,and the graduate students are responsible for data collection and analysis.(2) Staff training:The implementation personnel of this research are all senior nurses or above,have more than 5 years of work experience,and are the backbone of Chinese medicine nursing staff.They complete the 100 hours training of Chinese medicine.They are evaluated by the nursing director and the chief nurse for their theoretical and operational assessment.Implement this study to ensure the effectiveness of the intervention.

该天然气的低位发热量为Qdr=36.59MJ/Nm3，高位发热量为Qgr=40.52 MJ/Nm3，两者相差为3.93 MJ/Nm3，该差值即为烟气中水蒸气的汽化潜热。在一般燃气锅炉排烟温度下，水蒸气仍处于过热状态，因而由锅炉排烟所带走的汽化潜热占低位发热量的比例可用式1求得。

2.2.6 Statistical analysis.Data analysis was performed using SPSS 20.0 statistical software.Two-sided test was used,and α =0.05 was used as the test level.Measuring data for normality testing,after the homogeneity of variance test using variance analysis (F),described by x̅± S; If it does not conform to the normal distribution,using rank sum test (H),described by M (Q).Counting data using Chi-square test,described by constituent ratio.Chi-square test for marital status,occupation,medical expenses,etc.Rank sum test for education level,family income,etc.

Table1.General demographic data of the study subjects

Table2.Comparison of the incidence of enteral nutrition intolerance in three groups (n,%)

3.RESULTS

3.1 Comparison of general data of three groups of patients

A total of 91 subjects were enrolled in the intervention and completed data collection,including 31 in the usual care group,30 in the acupoint application group,and 30 in the moxibustion combined with acupoint application group.One patient in the usual care group fell off,and the patient was transferred to hospital for treatment due to changes in the condition.Two patients in the acupoint application treatment group fell off,and the patients were unwilling to continue to receive treatment for personal reasons.Two patients with moxibustion combined with acupoint sticking group fell off,one patient was transferred to hospital for treatment,and the data was incomplete.One patient was voluntarily withdrawing due to personal reasons.There was no significant difference in the general data between the three groups (P＞0.05),which was comparable,as shown in Table1.

3.2 Comparison of the incidence of enteral nutrition intolerance in three groups

Group A,11 people are good tolerated (35.5%),6 people are moderate tolerated (19.4%),and 14 people are intolerant(45.2%); Group B,15 people are good tolerated (50.0%),7 people are moderate tolerated (23.3%),and 8 people are intolerant(26.7%); Group C,21 people are good tolerated (70.0%),3 people are moderate tolerated (10.0%),and 6 people are intolerant(20.0%).The result is displayed (see Table3 for details) that there was a significantly statistical difference in the incidence of enteral tolerance in the three groups (P＜ 0.05).Further two-two comparisons,there was significant difference between group A and group B (χ2= -2.002,P= 0.045),group A and group C (χ2=-2.609,P= 0.009),group B.There was no significant difference between the two groups (χ2= -0.587,P= 0.557),as shown in Table2.

Table3.Changes in albumin and pre-protein levels at each time point in the three groups ()

Table3.Changes in albumin and pre-protein levels at each time point in the three groups ()

Group Albumin Pre-protein Before intervention Intervention day 3 Intervention day 7 Before intervention Intervention day 3 Intervention day 7 A (n = 31) 30.79 ± 0.59 32.60 ± 0.68 34.25 ± 0.91 125.97 ± 1.91 137.78 ± 3.80 145.06 ± 2.57 B (n = 30) 30.94 ± 0.47 33.15 ± 0.86 35.13 ± 0.81 125.60 ± 1.92 139.67 ± 3.78 149.77 ± 2.74 C (n = 30) 30.83 ± 0.47 33.45 ± 0.94 35.58 ± 0.84 126.40 ± 2.18 142.63 ± 3.55 151.23 ± 2.47 F 0.628 8.277 19.035 1.198 13.259 47.233 P 0.536 0.001 0.000 0.307 0.000 0.000

3.3 Changes in the levels of nutritional indicators in the three groups of patients

The albumin and pre-protein data of the analyzed subjects were collected before intervention,on the third day of intervention,and on the seventh day of intervention.Before the intervention,the difference was not statistically significant (P＞ 0.05),and the difference between the third day of intervention and the seventh day of intervention was statistically significant (P＜ 0.05).Further two-two comparisons,albumin levels in three groups of patients,on the third day of intervention,the difference between group A and group B (P= 0.011),group A and group C (P=0.000) were statistically significant.There was no difference between group B and group C (P＞ 0.05); On the 7 th day of intervention,the difference between group A and group B (P=0.000),group A and group C (P= 0.000) were statistically significant.There was a difference between group B and group C(P= 0.04).Pre-protein levels in the three groups of patients,before the intervention,the difference was not statistically significant (P＞ 0.05),the difference between the 3rd day and the 7th day of intervention was statistically significant (P＜ 0.05).Further two-two comparison,on the third day of intervention,there were significant differences between group A and group B(P= 0.049),group A and group C (P= 0.000),and group B and group C (P= 0.003).On the 7th day of intervention,there was significant difference between group A and group B (P= 0.000),group A and group C (P= 0.000),group B and group C (P=0.031),seen in Table3.

3.4 Comparison of comfort level in three groups of patients

Before intervention,there was no significant difference between group A and group B,group A and group C,and group B and group C (P＞ 0.05),after 7 days of intervention,the level of comfort in the three groups was statistically significant (P＜0.05).Further comparison between the two groups,on the 7 th day of intervention,the difference between group A and group B(P= 0.029),group A (P= 0.000),group B and group C (P=0.000) were statistically significant),as shown in Table4.

Table4.Changes in comfort level of the three groups of patients ()

Table4.Changes in comfort level of the three groups of patients ()

Group Before intervention Intervention day 7 A 67.61 ± 3.76 80.03 ± 2.73 B 68.23 ± 3.76 81.70 ± 3.05 C 67.87 ± 4.38 88.97 ± 3.01 F 0.163 79.504 P 0.850 0.000

4.DISCUSSION

4.1 Intervention effect of moxibustion combined with acupoint application on enteral nutrition tolerance in three groups of patients

The acupoint application method not only has the acupoint stimulation effect,but also absorbs the active ingredients of the drug through the skin tissue,exerts obvious pharmacological effects,and thus has dual therapeutic effects.The acupoints have external sensitivity and amplification effect on the drug,which can make the physical and chemical effects of the drug stay in the acupoint for a long time or release to the whole body to produce an overall regulation,this is not only a simple superposition of the effects of acupoint stimulation and drug absorption,but an interaction,which can achieve the therapeutic effect that cannot be achieved by simple medication or acupuncture,resulting in an effect of one plus one greater than two and simple operation without side effects [17].The acupoint application medications in this study include Wuzhuyu (Fructus Evodiae),Banxia (Rhizoma Pinelliae),and Shengjiang (Rhizoma Zingiberis Recens),Wuzhuyu (Fructus Evodiae) was first published inShennongBencao Jing,its function is warming spleen and stomach and relieving diarrhea,regulating stomach and lowering adverse qi,dispersing stagnated liver qi for promoting bile flow,stop vomiting.Wei N,et al.showed that Wuzhuyu (Fructus Evodiae) has an anti-ulcer effect and has an effect on the gastrointestinal tract(such as promoting gastric emptying,antiemetic,antidiarrheal,reducing gastric secretion,reducing the acidity of gastric acid,etc.) and Wuzhuyu (Fructus Evodiae) has the effect of protecting liver Qi and promoting bile flow[18].Xiao Q,et al.indicate that modern pharmacology shows the total alkaloids in Banxia (Rhizoma Pinelliae) have anti-tumor,antitussive,anti-inflammatory,antiemetic and other pharmacological effects [19].Xiang JM,et al.showed that Shengjiang (Rhizoma Zingiberis Recens) mainly contains volatile oil,gingerol and diphenylheptane,its pharmacological effects include anti-vomiting,anti-gastric ulcer,anti-bacterial,anti-inflammatory,analgesic and anti-tumor effects[20].In this study,Shenque (CV8),Zhongwan (CV12),Bilateral Zusanli (ST36),and Bilateral Yongquan (KI1) were selected for the corresponding acupoints,Shenque (CV8) belongs to conception channel,starting from the abdomen,its anatomical position is located in the center of the abdomen,and adjacent organs such as stomach,hepatobiliary,pancreas,and intestine belong to the digestive system,therefore,Shenque (CV8) plays an important therapeutic role in digestive diseases [21 - 22].Zhongwan(CV12) has the effects of regulating Qi-flowing for harmonizing stomach,eliminating dampness,regulating middle energizer,and regulating ascend and descend [23].Zusanli (ST36) belongs to he-sea point of Yangming stomach meridian,which is a classic point for clinical regulation of gastrointestinal function.Yongquan (KI1) in the sole,stimulate the point to play a role in stopping diarrhea [24].Moxibustion mainly plays the role of medicinal and warming of moxa,achieve the goal of supporting healthy qi and removing pathogenic factors and coordinating yin and yang.Moxibustion is applied to the corresponding acupuncture points to produce a synergistic effect,which is beneficial to promote better absorption and function of the drug effect,thereby effectively improving the tolerance of enteral nutrition in patients.

4.2 Intervention effect of moxibustion combined with acupoint application on nutritional indicators of three groups of patients

Albumin,pre-protein and total protein are commonly used indicators to reflect the nutritional status of patients,among them,pre-protein and albumin belong to visceral protein,which is the main indicator of nutrition monitoring,pre-protein can respond to changes in patient nutrition in a short period of time,while albumin can respond to stable nutritional changes in patients.Studies have shown that SAP patients are in a state of high decomposition and high metabolism,fat mobilization,protein breakdown,gluconeogenesis,insulin resistance and decreased immunity,often accompanied by severe metabolic disorders,the body is in a negative nitrogen balance [4].Malnutrition can reduce the patient's immunity,muscle weakness,poor wound healing,delay in hospital stay,and affect patient prognosis.In this study,moxibustion combined with acupoint application treatment can effectively alleviate the symptoms of enteral nutrition intolerance,thereby effectively ensuring the effect of enteral nutrition,thereby improving the nutritional status of patients and enhancing the immunity of patients.At the same time,it can stimulate the intestinal mucosa,reduce the displacement of the intestinal flora,reduce the occurrence of complications,and promote the early recovery of patients.Chen XP,et al.observed that effect of Chinese medicine acupoint application treatment can improve nutritional status of patients with advanced cancer[26].Eighty patients were divided into control group and experimental group,the control group was treated with enteral nutrition,and the experimental group was treated with acupoint application on the basis of the control group,the results showed that the traditional Chinese medicine acupoint application treatment can effectively improve the nutritional status of patients.Sun H,et al.showed that Chinese medicine moxibustion improves malnutrition in peritoneal dialysis patients [27].

4.3 Intervention effect of moxibustion combined with acupoint application on comfort of three groups of patients

In this study,moxibustion combined with acupoint application can alleviate the symptoms such as diarrhea,bloating,nausea and vomiting,and reduce the incidence of enteral nutrition intolerance in patients with enteral nutrition,thereby increasing patient comfort.Moxibustion can promote blood circulation and coordinate yin and yang through the conduction warming effect of meridians.Moxibustion combined with acupoint application can promote the drug to play a synergistic effect,and can effectively improve patient comfort.Zhou JW,et al.showed that Wuzhuyu (Fructus Evodiae) applied umbilical to treat pain after hemorrhoid surgery has achieved good results [28].Studies by Lai GH,et al.showed that moxibustion can significantly increase the comfort of patients with catheterization after urological surgery [30].

5.CONCLUSION

Moxibustion combined with acupoint application can improve the tolerance of enteral nutrition in patients,improve the nutritional status of patients to a certain extent,and the operation is simple and easy.This study selected a single hospital,the sample is insufficiently representative,and the research time is relatively short.It is suggested that future research can conduct multi-regional multi-center randomized controlled study,increase the sample size,and explore the long-term efficacy of moxibustion combined with acupoint application.

Authors’ contributionsFMK contributed to the composition of the article and the design of the research; YLW and FMK helped to collect cases,data statistics and analysis; YLW contributed to the article's conceiving and checking.

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