【看護師解説】高カロリー輸液と介護
高カロリー輸液や中心静脈栄養と言った言葉を聞いたことがありますか？介護や医療の仕事をされている方はもちろんのこと、ご家族に利用されている方もいらしゃるかもしれませんね。今日は中心静脈栄養についてまとめてみました。
目次
中心静脈栄養？高カロリー輸液って?どんなものが点滴に入っているの？
中心静脈栄養はTPN（Total Parenteral Nutrition)とも呼ばれ、口から食事が食べれない方や消化器を休ませる必要がある方に対して利用するものです。場合によっては口から食べ物を摂取しながら、併用する場合もあります。一般に使う点滴との違いは、どのくらいの期間使用できるかという点と、高濃度の点滴を使用すると言うことです。
通常であれば口から食べ物を取り消化されることによってあらゆる栄養分が体内に吸収できるされます。それを点滴で血液から直接摂取し、取り入れようと考えているものが中心静脈栄養です。
人間が生きていくうえで必要なカロリーや栄養を点滴で補おうとするものであるため、糖質、アミノ酸、脂質、電解質やビタミンと言った内容の濃いものが中心静脈栄養の点滴には入っています。
中心静脈栄養のメリット・デメリット【注意点】
では中心静脈栄養の主なメリットとデメリットを考えていきます。またこの中心静脈栄養への考え方は人によって異なる場合もあります。
メリット
①水分、栄養など必要な分を点滴より補給できる
⇒直接口から食事を摂ることができない方は、これが一番の目的です。
生命維持のために栄養や水分を取ることは必須です。しかし老化や病気のため自力での栄養や水分摂取が困難な方は多くいらっしゃいます。医師の指示等によっては経管栄養などの方法もありますが、経管栄養にもメリットとデメリットが存在することと、経管栄養が適応にならない場合もあります。それらの点を考慮した上で中心静脈栄養を選択される場合があります。
②長期間利用することができる
⇒栄養の摂取方法の一つとして、胃管（鼻から管を通して胃までとどかせる管）を利用して経管栄養を注入し、栄養の摂取をする場合があります。これは胃ろう（胃に直接穴を開け、管を遠す）造設の選択をされない場合に利用される手段ですが、この場合基本的には4週間未満が望ましいと日本静脈経腸栄養学会はガイドラインにまとめています。
③毎日病院へ行く必要がない
必要物品や機器が揃い、管理ができれば自宅にて毎日使用できます。
その代わり、異常な状態等の知識が中心静脈栄養の機器を使用する本人や家族に求められます。
④針は自身で管理できる
⇒中心静脈栄養の点滴と繋がるチューブの先を中心静脈栄養専用の針に繋げます。
その後、針を自身に、（または家族等に）刺してもらうのですが、簡単に刺せるよう前もって中心静脈栄養を利用される方に、その土台（カテーテル）を埋め込んでもらいます。
⑤外出や入浴に制限がないタイプのものもあり、生活に支障が少ない
⇒外出や入浴に制限が出ないよう、機械や中心静脈栄養の物品にも工夫がなされています。
デメリット
①合併症が生じる
⇒血管から様々な栄養分の入った濃い点滴を投与することになります。そのため身体にかかる負担が全くないとは言えません。また長期間食事を摂取しないことによる合併症や点滴に必要な物品からも合併症を生じることがあります。
②感染症を引き起こすおそれがある
⇒身体に注射を刺しやすい土台（カテーテル）を埋め込み、心臓に近い太い血管に挿入します。しかし、もともと体内にないものを埋め込むわけですから、身体からすると異物でしかありません。針を刺した先から感染を起こすことがあります。そのためにもしっかりと感染をしないような対策を取る必要があります
③医療的な管理が必要
⇒針を刺す土台が詰まったり、感染を起こしたりと万が一の場合は病院を受診しなくてはなりません。またその前に土台（カテーテル）を埋め込むことが必要ですから、医療的な処置から始まることは間違いありません。
④人によっては不自然な生命維持と感じる
⇒口から摂る栄養や水分ではないため、「点滴（薬）に生かされている」と感じてしまう方もいらっしゃいます。食事の経口摂取、経管栄養、中心静脈栄養とそれぞれの栄養摂取方法を比較し、自身、または家族の予後を考えながら希望に沿ってアプローチしていく必要があるテーマです。
⑤手術が必要となってくる
ここまでに何度か出てきている針を刺す土台（カテーテル）を体内に埋め込むには外科的手術が必要になります。1-2時間程度で行われるもので難易度の高い手術ではないと言われています。
中心静脈栄養のについてのケアや観察の注意
ここでは中心静脈栄養を使用している場合に起きるケアや観察点を一例を紹介します。
◆中心静脈栄養を利用するAさん。妻と2人暮らし。2か月まえから中心静脈栄養を開始してました。手技はほとんどAさん自身で行える状態です。
①昨日からAさんは発熱が続いています。針を刺している部位も赤くなっていることにAさんの妻が気づいました。Aさんは針周囲を痛がっています。
⇒カテーテルが汚染、感染している可能性があります。かかりつけ医をすぐに受診するか、問い合わせをしましょう。
②朝から中心静脈栄養を交換し、投与を開始。Aさんが「ハリを刺した部位が腫れているのではないか？」と妻に聞き見てもらったところ、確かに腫れている様子でした。
⇒カテーテルの破損が考えられます。かかりつけ医をすぐに受診するか、問い合わせをしましょう。
③妻がAさんの胸元を見ると、Aさんの服に血液がついています。中心静脈栄養のチューブが抜けているのを発見しました。Aさんはパニックです。
⇒まずはおちつき、針を刺した部分を清潔なガーゼで抑え止血し、かかりつけ医に問い合わせをしましょう。
④針を交換しようと準備しているAさん。準備前に手を洗わず、手が汚れたままです。
⇒針は自身でも交換することができます。しかし、汚れた手は感染のもと。
清潔な手・室内環境で針の刺の交換を行うことは徹底しましょう。
まとめ
中心静脈栄養と関わりのある方は多くはないかもしれません。それでもこれから数十年の間、高齢者が増える日本で中心静脈栄養を利用される方に接することが有ったり、お会いすることや増えることもあるはずです。
また身近な方が中心静脈栄養を必要とする場面に会うも考えられます。今回ご紹介したAさんの事例は、中心静脈栄養に関する一部の内容です。
これを機にさらに中心静脈栄養に対し興味をもっていただければ幸いです。さらに詳しく理解を深めるには、介護の専門の窓口や病院で聞いてみることが一番です。
「今後の生活環境が変わる事への不安」や「介護を使って生活をどうデザインをしていったら良いか」など介護は協力体制で成り立っております。 ちょっとでも解決できる、ストレス軽減できる記事を目指し、一つの相談場所のメディアを目指しております。
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