如何合理实施肠外营养支持-吴国豪ppt.ppt

如何合理实施临床营养支持HowtoImplementRationalClinicalNutritionTherapy 吴国豪复旦大学附属中山医院普外科复旦大学普通外科研究所 为什么需要营养支持 那些病人需要营养支持 如何进行合理的营养支持 第一部分 PrevalenceofmalnutritionTheGermanhospitalmalnutritionstudy MatthiasPirlich ClinicalNutrition 2006 25 563 572 癌性恶病质的发生率 NAStephens MEDICINE2007 36 2 78 81 Malnutritioniscommonincancerpatients Malnutritionoccursin30 87 ofcancerpatientsShillsME etal CancerRes1977 37 2366NixonDWetal AmJMed1980 68 683TchekmedyianNSetal Oncology1995 9 79Andreyevetal EurJCancer1998 34 503MonittoCLetal AmJPhysiol2001 281 E289StephensNAetal Medicine2007 36 2 78 81 营养不良的危害 免疫机能下降 脏器功能异常 预后不良 CumulativeMortality Protein EnergyMalnutrition Cederholmetal AmJMed1995 Mortality Monthsafteradmission P 0 01 MalnutritionIsAssociatedwithIncreasedComplications Numerousstudieshavedemonstratedcomplicationsofmalnourishedpatientstobe2 20timesgreaterthanthoseofwellnourishedpatients Buzbyetal AmJSurgical1980 Hickmanetal JPEN1980 Klidjianetal JPEN1982 MalnutritionIsAssociatedwithIncreasedComplications 42 ofpatientswithseveremalnutritionexperiencemajorcomplications9 ofpatientswithmoderatemalnutritionexperiencemajorcomplicationsSeverelymalnourishedpatientsarefourtimesaslikelytohavepost operativecomplicationsaswell nourishedpatients Detskyetal JPEN1987 Detskyetal JAMA1994 ClinicalOutcomesofmalnutrition TewariN etal LungCancer 2007 57 389 394 ClinicalOutcomesofmalnutrition PirlichM ClinicalNutrition 2006 25 563 572 ClinicalOutcomesofmalnutrition p 0 001 SchiesserMetal ClinicalNutrition2008 27 565 570 608patientsadmittedforelectivegastrointestinalsurgery NutritionalriskwasdefinedbyNRS2002andcorrelatedtotheincidenceofpostoperativecomplications ClinicalOutcomesofmalnutrition NRS2002 p 0 001 SchiesserMetal ClinicalNutrition2008 27 565 570 P 0 001 PJRoss BritishJournalofCancer 2004 90 1905 1911 ClinicalOutcomesofmalnutrition BachmannJ JGastrointestSurg 2008 12 1193 1201 作用与目标 调整病人的代谢改变及内稳态失衡 改善营养状态与免疫机能降低医院获得性感染发生率缩短住ICU时间最终改善病死率 营养支持在疾病治疗中的作用 营养支持对营养状态的影响 P 0 04 KleinS JPEN1997 21 133 NutritionalTherapyAffectsOutcomes BraganArchSurg2002 137 174 P 0 02 NutritionalTherapyAffectsOutcomes BraganArchSurg2002 137 174 P 0 001 NutritionalTherapyAffectsOutcomes NeumayerLAJSurgRes2001 95 757 NutritionalTherapyAffectsOutcomes NeumayerLAJSurgRes2001 95 757 P 0 0001 NutritionalTherapyAffectsOutcomes BozzettiFJPEN2000 24 4 14 P 0 03 P 0 02 NutritionalTherapyAffectsOutcomes FanSTetal NEnglJMed1994 331 1547 P 0 02 NutritionalTherapyAffectsOutcomes FanSTetal NEnglJMed1994 331 1547 P 0 01 NutritionalTherapyAffectsOutcomes FanSTetal NEnglJMed1994 331 1547 P 0 004 问题二 那些病人需要营养支持 Whichpatientsshouldwefeed whichpatientscansafelybelefttoresumefeedingthemselves 14days starvation dangerousdepletionofleanbodymassmortalityrisesinICUpatientswithasecondweekofsevereunder feeding5dayswithoutfeedincreasesinfectionsbutnotmortalityoneviewisthereforethat5 7daysisthelimit Whichpatientsshouldwefeed allmalnourishedpatientsallpatientswhoareunlikelytoregainnormaloralintakewithineither2or5 7daysdependingonyourviewonemeta analysissuggestsreducedinfectionsifpatientsarefedwithin48hoursonemeta analysisofearlyTPNversusdelayedENfoundreducedmortalitywithearlyfeeding 外科病人的营养支持 围手术期营养支持短肠综合征炎性肠道疾病肠外瘘重症胰腺炎危重病人器官移植 围手术期营养支持指征 目前认为 营养状况良好病人可耐受一般手术创伤 10天内无营养支持不会产生副作用严重营养不良患者 中等程度营养不良而需接受重大手术患者 手术后一周以上禁食者 手术前营养支持者 严重营养不良而手术前未进行营养支持者 术后出现严重并发症者 临床上普遍存在营养不良营养不良影响患者预后 结论 临床上许多疾病治疗过程中需要进行营养支持 通过合理营养支持改善患者预后 问题三 如何选择营养支持途径 Parenteralnutrition Oneofthemostsignificanttherapeuticaladvancesofthepast50yearsIndications theabilitytoingestnecessarynutrientsforatimeduringincreasedmetabolicdemandsinclinicalsituationsinwhichenteral oral nutritionisnotoronlypartiallyfeasible WhoNeedsParenteralNutrition Anypatientrequiringnutritionsupportwhohasanon functioningorpossibleinadequatelyfunctioninggastrointestinaltractStartassoonaspossibleifthereispre existingmalnutritionormetabolicstressandoral enteralfeedingisunlikelytobeachievedwithin7days 改善肠道功能 完整性防止饥饿或创伤所致的肠道结构异常增加内脏血流刺激肠道免疫功能 维护机体防御水平 EnteralorParenteral 过去10 15的年研究发现EN的作用要优于PN 危重病人胃肠功能的损害 肠黏膜萎缩细胞受损 坏死 EN作用 肠通透性 肠动力 分泌功能 屏障功能 免疫功能 LevyBetal CCM1998 26 1991 94KentigernThorburnetal CM 2004 32 246 49 ENvsPNincriticallyillpatientsmeta analysis 13RCT Infectiouscomplications GramlichLetal Nutrition2004 20 843 848 ENvsPNincriticallyillpatientsmeta analysis 13RCT Mortality GramlichLetal Nutrition2004 20 843 848 第二部分 如何合理提供营养支持 临床上不规范的肠外营养使用仍十分普遍 肠外营养现状 不合理的肠外营养不仅无法达到预期效果 相反会增加并发症 影响病人预后 如何利用目前已有的知识和技术 使肠外营养作用最大化 方法一 提供合适的营养物质 提供合适的能量 计算各营养底物的需要量 选择理想的营养物质 能量代谢 生物体内碳水化合物 蛋白质和脂肪在代谢过程中所伴随的能量释放 转移和利用称为能量代谢 能量代谢与能量需求 能量是维持人体生命活动及内环境稳定最根本需要 也是营养学最基本问题准确了解和测定不同状态下病人的能量消耗是提供合理有效的营养支持及决定营养物质需要量与比例的前提和保证能量在临床营养支持的作用体现在决定营养物质的用量与内容 即确定到底摄入多少热卡 给什么维持机体能量平衡 避免过度喂养或营养不足 这在危重病人尤其重要 能量代谢与能量需求 EnergyBalance EnergyIn EnergyOutWeightMaintenanceEnergyIn EnergyOutWeightGainEnergyIn EnergyOutWeightLoss 机体能量代谢组成 创伤时代谢改变 Stressonenergyexpenditureandproteinlosses 180 160 140 120 100 80 60 REE 40 30 20 10 0 g Nitrogenlosses Majorburn Peritonitis Fracture Starvation days days Long 1977 Am J Clin Nutr 30 1301 1310 能量消耗及需求 能量需求 病人能量消耗和代谢能力决定能量需求过量营养 Overfeeding 导致并发症和副作用危重病人能量供给目标 保存功能 减少消耗 早期营养支持 控制入量 高代谢期应接受低量营养 恢复期或合成期增加营养摄入量过高的能量供给将导致危重病人感染性并发症以及死亡率的增加 强调限制热量的供给量目前尚无可普遍用于危重病人的EE预测公式 LJohnHofferAmJClinNutr 2003Nov 78 5 906 11 能量供给 合并呼吸衰竭病人 过量葡萄糖与能量供给将使RQ增加 增加脱机难度研究显示 接受呼吸支持的重症病人 提供 10 TEE与低喂养 70 ofTEE 或过度喂养 135 ofTEE 组相比 可获得最佳的氮平衡效果 CriticalcareMed2003 7R 108 15 能量消耗的估算方法 Harris Benedict公式是估算正常情况下机体基础能量消耗的经典公式REE kcal d 66 5 13 8W 5H 6 8A 男REE kcal d 665 9 6W 1 8H 4 7A 女W 体重 kg H 身高 cm A 年龄 year Energyguidelinesfornutritionsupport Requirementsarebasedonthefollowingguidelines postoperative25 30kcal kg daypolytrauma30 35kcal kg daysepsis25 40kcal kg dayburns30 45kcal kg day 25 30kcal kg dayissuitableformostcritically illpatients ASPENGuidelines 1993 肠外营养液的基本成分 Roleofcarbohydrates glucoserequirement Glucosemetabolismduringstarvationandcriticalillness Restingenergyexpenditure REE atdifferentglucoseintakesininfants 8 10 12 14 16 18 20 22 24 26 28 35 40 45 50 55 60 65 kcal kgbw d g kgbw d Glucoseintake REE Jonesetal 1993 J Ped Surg28 1121 1125 Disadvantagesofsoleglucosesystem Influenceofinfusionrateonincidenceofhyperglycaemia Retrospectivestudyinpatientsnotnormallypredisposedtohyperglycaemia Rosmarinetal 1996 NutrClinPrac11 151 156 应激性高血糖与营养支持中的血糖控制 严重创伤感染 儿茶酚胺 皮质醇 胰高糖素释放增加 胰岛素分泌量相对或绝对减少 细胞因子作用 中枢 外周作用 胰岛素清除增加 应激性高血糖 应激性高血糖 细胞内氧化作用 自由基与过氧化物产生 诱导单核细胞炎症因子表达 细胞因子释放 损伤中性粒细胞与巨噬细胞的杀伤能力及补体功能 应激性高血糖与营养支持中的血糖控制 Intensiveinsulintherapyinthecriticallyillpatients VanDenBG NJMed 2001 应激性高血糖与营养支持中的血糖控制 VandenBergheGetall NEnglJMed2001 345 1359 1367 应激性高血糖与营养支持中的血糖控制 VandenBergheGetall NEnglJMed2001 345 1359 1367 标准 80 110mg dL Vandenberghe 140mg dL措施 补充外源性胰岛素 减少葡萄糖及非蛋白质热卡的补充量 避免过度喂养 30 应激性高血糖与营养支持中的血糖控制 VandenBergheGetall NEnglJMed2001 345 1359 1367 VandenBergheG etall NEnglJMed2002 346 1586 8 StrategyforusingglucoseinPN Optimizedeliverybutdonotexceedoxidativerate infuseglucoseslowly at2 4mg kg min 5 6 g kg day maximumincriticallyillpatients 3 4g kg dayEnsurenormoglycaemia controlserumglucosemoreaggressivelyrecommendedlevel 120mg dLMinimizeliponeogenesis usemixedfuelsystemofglucose fat 2020 3 19 70 可编辑 PNregimenwithoutlipid A50kgpatientrequires 30kcal kg dtotalenergyTotalenergyrequired 50 30 1500kcal dayIfonlyaminoacidsandglucosearegiven andaminoacidsisgivenat1g kg dayProteincalories 50 4kcal g 200kcalNon proteincalories 1500 200 1300kcalAmountofglucose 1300 4 325g Glucosesolutions theirosmolarity 双能源系统与单用葡萄糖比较 应激状况下双能源系统优于单用葡萄糖提供必需脂肪酸更好的氮积累 更低的CO2产生危重病人脂肪氧化增加 葡萄糖氧化降低更容易控制血糖 Stoneretal 1983 BrJSurg70 32 53 RelationshipbetweenglucoseoxidationandsepsisscoresinpatientsonPN RelationshipbetweenfatoxidationandsepsisscoresinpatientsonPN Stoneretal 1983 BrJSurg70 32 53 Effectofglucosesystemandmixedfuelsystemonventilation Askanazietal 1979 Anesthesiology51 192 SerumglucoseprofileduringPN Carbohydrateonly Carbohydrate fat Hempeletal 1981 Infusionstherapie3 124 132 Increasedlipidfueldependenceinthecriticallyillsepticpatient NanniGetal JTrauma1984Jan 24 1 14 30 Patientgroups Septics n 246 Non septic n 128NutritionRegime1 Glucose TPN2 Occasionalsupplyoflipids Glucose onlyTPNresultsinexcessiveCO2productionwhichmayoverloadCO2eliminationmechanismsofcriticallyillpatientswithventilatoryexchangelimitations Design Prospective controlledtrialPatients CriticallyillNutrition TPNfor5days AA15 Group1 n 8 TPN GGlucose75 Lipid10 Group2 n 8 TPN LGlucose15 Lipid70 Glucose basedTPNincreasesCO2production Effectsofisoenergeticglucose basedorlipid basedPNonglucosemetabolism denovolipogenesis andrespiratorygasexchangesincriticallyillpatients TappyL etal CritCareMed1998 26 860 867 TPN G TPN glucosebased TPN L TPN lipidbased Gastroenterologicalpatients n 16 TPNfor2weeks GroupI Glucosealone 49kcal kgd GroupII Fatemulsion 60 oftheNP energy total51kcal kg d Fatinconjunctionwithglucosemaybemoreeffectiveasanenergysourcethanequicaloricamountsofglucosealone Glucoseorfatasanon proteinenergysource acontrolledclinicaltrialingastroenterologicalpatientsrequiringintravenousnutrition MacFieJ Gastroenterology1981 80 103 107 kg Dual EnergySystem KEYMESSAGES AvoidshyperglycemiaReducesrespiratoryandmetabolicstressSupportsthebestpossiblenitrogenretentionGuaranteesthedeliveryofessentialfattyacidsFacilitatesperipheralinfusionduetolowosmolarity Fatrequirements Lipidemulsions Intralipid Fattyacidpatternofasoybeanoilemulsion Possibleconsequencesofanexcessiveintakeofomega 6fatty linoleic acids unbalancedfattyacidpatternincellmembranesmodificationoftheproductionoflipidmediators prostaglandins leukotrienes promotionofimmunosuppressionandsystemicinflammatoryreactions trauma operation sepsis Carpentieretal 1997 Aresoybeanoilbasedemulsionsimmunosuppressive Battistellaetal 1997 J Trauma43 52 60Polytraumapatients APACHEIIav 22 StandardglucosecontaingTPNwithnolipidvs Intralipid 10days NodifferenceinCD4 CD8 NolipidIntralipidLengthofstay d 2739 ICUstay d 1829 Daysonventilator1527 Pneumonia 1322 Totalinfectiouscomplications3972 ofbaseline P 0 02 NKcellactivity CharacteristicsofMCTvsLCT Typesoflipidemulsions 中 长链脂肪乳剂的优点 大量临床与实验结果证实中 长链脂肪乳剂在临床各个领域均有其代谢优势 JPEN 25 2 Suppl 2002 BenefitsofStructolipid 1 ControlledplasmaTGandMCFAlevels Nordenstr m1995 Flaatten1995 Kruimel1997 ReliablesourceofessentialfattyacidsAswelltoleratedasIntralipid Nordenstr m1995 Sandstr m1995 Bellantone1999 Suitableforlong termPN Rubinetal2000 BenefitsofStructolipid 2 Rapidlyavailableenergy Sandstr metal1995 ImprovedproteineconomycomparedtoLCTandLCT MCTemulsions Kruimeletal1997 Lindgrenetal2001 ExcellentmixingpropertiesAhandynon breakableplasticpackaging 结构脂肪临床对照研究资料有限结构脂肪具有物理混合中 长链脂肪乳剂结构和生化特征并优于后者从药理角度讲 应用酶学技术 开创了脂肪乳剂新领域 可根据各特殊代谢过程需要设计新型制剂 结构脂肪乳剂临床应用评价 含橄榄油脂肪乳剂具有良好的安全性和有效性 含橄榄油脂肪乳剂应用评价 含橄榄油脂肪乳剂在防止脂质过氧化优于其他长链脂肪乳剂 含橄榄油脂肪乳剂对机体免疫系统影响少 适合于小儿和需长期肠外营养病人 Omegaven asasupplement Formulation LipidemulsionLipidsource FishoilConcentration 10 Specialfeature Highcontentof 3fattyacidsPurpose Supplementationofparenteralnutritionwithlong chain 3fattyacidsPackaging 50 100ml glassbottleStorage 0 25 CShelflife 18months 含鱼油的脂肪乳剂在肠外营养时具有良好的安全性 通过调节炎性介质的产生 下调炎性反应 增强机体免疫功能 可改善外科危重病人愈后 总结 OptimalproportionoflipidsinPN Recommendeddailylipidintake adult 1 0 2 0g kg infant 1 0 3 0g kg unstressedpatients 30 40 oftotalcalories stressedpatients 40 55 oftotalcaloriesFactorstoconsider glucoseresistance impairedrespiratorycapacityMonitoring SerumtriglyceridesEnsurepatientisnotintoleranttoanycomponentofthelipidemulsion Proteins Aminoacids TheonlymacronutrientscontainingnitrogenAvarietyofdifferentfunctions Cellandtissuestructure structuralproteinsFunctionalroles transportproteins bloodclottingfactors receptors enzymes hormones immuneglobulines musclecontractility Proteins Aminoacids FreeAApool 70g Cells plasma Proteinsynthesis 300g d Proteolysis 300g d OralintakeofproteinsEnteralnutritionParenteralnutrition Metabolicprocesses neoglucogenesis neuromediators cellenergyWaste CO2 urea Protein Aminoacids 20differentaminoacidsNitrogencontent g L x6 25 AA g L Aminoacidsarelinkedviapeptidebonds Aminoacid 提供机体合成蛋白质所需的底物氨基酸利用率和蛋白质合成受其组成影响目前AA的配比有人乳 全蛋 Rose FAO 及血浆游离氨基酸等模式 各种模式优劣难定临床上常用的氨基酸制剂是平衡型氨基酸溶液 近年各种治疗型氨基酸输液问世复方氨基酸液的研制还在不断发展 最佳组成尚未确定 现有的配方还不是最完善的 Nitrogenrequirements Aminoacid nitrogendosage 0 5 1 5g max 2g kg daynitrogen0 15 0 2g kg dayca 40 essentialaminoacids highqualityMax infusionrate 0 1g kgandhour Roleofelectrolytes ElectrolyterequirementsinPN Roleoftraceelements Dailytraceelementrequirements Vitamins DailyvitaminrequirementsinPN 规范肠外营养输注 用全合一形式 全合一的定义 全合一的优点 全部营养物质经混合后同时均匀地输入体内 有利于更好地代谢和利用避免了传统多瓶输注时出现在某段时间中 某种营养剂输入较多 而另一些营养剂输入较少或甚至未输入的不均匀输入现象 减少甚至避免它们单独输注时可能发生副反应和并发症的机会 全合一的优点 3升塑料输液袋壁薄质软 在大气挤压下随着液体的排空逐渐闭合 不需要用进气针 成为一个全封闭的输液系统 使用方便 减轻了护士的监护工作量 也减少被污染或发生气栓的机会各种营养剂在TNA液中互相稀释 渗透压降低 一般可经外周静脉输注 增加了经外周静脉行肠外营养支持的机会 全合一配制的环境和设备要求 建立肠外营养液配制室 肠外营养液配制室的构成 肠外营养液配制室的规章制度层流空气洁净台 超净工作台 肠外营养支持小组组成 RTUMulti ChamberBags MCB All in One IndividualvsstandardisedUK almost100 AIOby1995Estimated 1996 80 adultsonPNcouldusestandardisedregimensCurrentPerspectivesonPNinAdults BAPENWorkingParty1996 StandardisedRegimens Individualisedprescriptionsrarelyneeded cost outcome 80 neonatal paediatricfeedscouldbestandardisedBeecroftCetal ClinNutr19991883 85 StandardisedRegimens 在发达国家 工业化多腔袋逐渐取代医院自配的PN营养液在瑞士 83 的成人PN采用工业化二腔袋或三腔袋 PichardC etal ClinNutr 20 4 345 50 2001 2004年标准全合一PN在瑞士法国和比利时占全部成人PN患者的比例分别为 86 79 86 ParenteralNutritionpracticesinhospitalpharmaciesinSwitzerland France andBelgium Nutrition2004 20 528 535 Single bottlesystemsrequiredmoreitemsandmanipulations 3CBssatisfiedtheneedsofover80 oftheadultlong termTPNpatientsforthelast5years Three chamberbags PracticalAspects ClinicalNutrition2000 19 245 251 Kabiven CentralandPeripheral3CB Centralhigh 2566ml PeripheralSuppl 1440ml CentralSuppl 1026ml PeripheralLow 1920ml CentralLow 1540ml PeripheralBasic 2400ml CentralBasic 2053ml 1000mlbag 1500mlbag 2500mlbag 2000mlbag IndividualisedvsStandardisedRegimens Time availabilityDelaysinstartingStabilityissues Library ofregimensHighN Highcal PPN LowN Lowcal Lowvol criticallyill post op oncology homePN fluidrestrictedetc ReadyToUse RTU Multi ChamberBags MCB StandardisedRegimens Individualisedprescriptionsrarelyneeded cost outcome 80 neonatal paediatricfeedscouldbestandardisedBeecroftCetal ClinNutr19991883 85 StandardisedRegimens Criticallyillpatients n 25 Septicvsnon septicEnergysupply 25 measuredREEStandardisedTPNsolutionImmediateinfusion remainedunchangedEnergybalance days2 7Substratebalances days2 7ZaunerCetal AmJClinNutr200174265 70 StandardisedRegimens MetabolicresponsesduringadministrationofstandardisedTPNarecomparableinthesepatients Adisease specificmacronutrientcompositionofaTPNformuladoesnotseemtobenecessaryforsepticornon septiccriticallyillpatients ZaunerCetal AmJClinNutr200174265 70 StandardisedRegimens Infantsn 52PRCTStandardisedregimenvscomputer generatedBetterbiochemicalstability decreasewastage promoteweightgainOutcome nodifferences costeffectivenessindoubt theconsiderableflexibilityofcomputerprescribingallowingindividualisation isoflittleornobenefittopatients CadeAetal Doesthecomputerimprovethenutritionalsupportofthenewborn ClinNutr19971619 23 KeystudiesonbenefitsofAIOsand3CBs Patients n 40 aftermajorsurgeryortraumaIntervention TPNwithSBS n 21 orasAIO n 19 for 5daysResults AIOwaswelltolerated SBSrequired a Moreequipment e g Infusionpumps disposableinfusionsets b Moremanpower e g tofixtechnicalalarms All in onebagversussingle bottle systemincriticallyillpatients apro