外科营养英语

Surgical Nutrition,Basic Concept,Nutrition the progress of body ingest nourishment and digest it to meet physiological need oneselfNutreint,Reasonable Nutrition,Enough heart and all nutrition, proportional Increase digestibility Promote appetiteNo hazardous substanceReasonable meal,Clinical Purpose,Prevent deficiency disease Prevent some normal diseaseRaise curative effectOperation support and promote recoverReduce the complication,Body elementary structure construction,Fundamental unit - cellBackbone of cell - protein(amino acids) Construction of celluar membrane - lipid (lipoprotein, lipopolysaccharide)Cell nuclear nucleinic acid(purine, pyrimidine,glucidamin),Nutrient substance,Saccharidelipideprotein VitaminInorganic saltWater,Heat energy,CarbohydrateFatProteinEffict：Retain body temperature Energy store ATP GTP CoA,Energy consumption,Basal metabolism Physical activitySpecific dynamic action Growth and development,Protein,15% of body weight 、50% of dry cell weight、90% of enzymePhysiology function composition of cellular structure especially physiological function provide energy synthesis nitrogen-containing material,Day conversion rate - 3%(250-300g/d)Requied: 1-1.5g/kg/dHeat production：3.9kcal/gEssential amino acid：8 (branched-chain amino acid - 3),Protein,Metabolism,General metabolism synthesis other protein atabolism carbon chain： CO2, parabiosis nitrogen ： carbamide synthesis other nitrogen-containing substance purine, pyrimidine, theamin, Crea,nitrogen balance discharge 54mg/kg/d positive nitrogen balance negative nitrogen balance total nitrogen balance,Metabolism,Lipide,Fat 20-25% of body weight PHL Cholesterin,Physiological function,Oxydation energize(TG)Main component of biomenbranousEssential fatty acid:linolic acid ,linoleic acid,eicosatetraenoicacidlipoprotein,Carbohydrate,SaccharideSupply energyComposition of cellAbsorb in epimere intestiner parveGlycose,hepatic glycogen 200g, muscle glycogen 300gExhaust hepatic glycogen in 24h at famesBrain, kidney medulla, blood cell can utilization glycose directlly Minimus required: 100150g/d,Carbohydrate,Inorganic salt,Macroelement Ca , P , Mg , Na , K , ClMicroelement Fe , Se , Zn , Cu , I , FOthers microelement,Vitmin,Vit A retinolVit D adjust metabolism of Ca, PVit E anti-oxidationVit K blood clottingVit B1、B2 energy metabolism,oxidoreductionVit C reducerVit B6 synthesis haemoglobin,Outline,Stringent stage by operation, trauma, infectionHigh atabolisim stageNegative nitrogen balance,Characteristic of nutrition,Catabloic phase（post-operation 1-3d） glycogenolysis，negative nitrogen balance（lost 5-15g N/d）Break-over phase（post-operation 4-6d）Anabolic metabolism phase(post-operation 8-14d） positive nitrogen balanceAdipopexis phase,Metabolism in starve,Starve in short term glyconeogenesisStarve in long term acetone body,Alimentary dificiency cause,Preoperation ingest dificient, metabolism change, malabsorption, lossOperation, trauma bleeding 100ml = 3g NPost-operation,Assessment of nutritional status,HistoryPhyical examination height weight skin-fold thickniss upper arm circumference,Constitutional indix BMI = weight（kg）height （m） 18.5 low weight 18.5-22.99 normal 23-24.99 overweight 25-26.99 obesity I grade 30 obesity II grade,2,Assessment of nutritional status,Lab examination reflect protein metabolism： Crea,weight UR 3-MeH plasma protein protein tumover rate nitrogen balance,Assessment of nutritional status,Plasma protein,Assessment of nutritional status,cellular immune function： total lymphocyte count tardive skin supersensitivity test T-cell & NK energy,Assessment of nutritional status,Nutritional support,Preoperation nutritional evaluationPost -operationMethod enteral nutrition、parenteral nutrition,Aim,Improve psychological and physiology functionMinimus adverse effect of catabolicPrevent weight lost Retrieve normal organsim compositionAccelerate reconstitutionShorten hospital dayImprove quality of life,Indication,Weight descent10%Serum albumin30g/LInability normal diet7天MalnutritionPatients with hight risk factors,Malnutrition,Defective nutritionOvernutrition,Type,MarasmusKwashiokorMixed,Marasmus,Decrease weight/heightReduce fatty tissueReduce muscle tissueweaknessNormal plasma protein,kwashiokor,PuffinessHyproteinemiaVisceral protein level decreaseNormal fat store,Difference,Protein-energy malnutrition,Weight loss/analosisWeak Deterioation of organ functionEcto-cell water retentionoedema（hypoproteinemia）,Etiology,Cancer COPDInflammatory bowel diseaseCardiac diseaseChronic nervous systemic diseaseRenal inadequacyCirrhosis,Enteral Nutrition,mode of nutrition support through gastrointestinal by oral use ,nasogastric tube,nasointestinal tube ,jejunum stoma tube，which consistent with physiology status and economic way to prove and retain energy.,Advantage,Prove and retain the structural integrity of intestinal mucosa ,keep the barrier function of intestinal mucosa, prevent bacterial translocdtion from intestineAdvantageous for liver to synthesis visceral proteinSurpass parenteral nutrition in keep and increase body weight with same enery and nitrogen condition,Low request for equipage and technology , more economic than parenteral nutritionPromote excrete of digestive juice and gastrointestinal hormone，and gallbladder contraction,decrease complication Promote recover of enterokinesia,Advantage,Principle,Intestinal tract especial for small bowel have function ,can absorb all kinds of nutrient; tolerance for enteral nutrition ;use EN as far as possible,Indication,Dysphagia and dysmasesiaConscious disturbance and coma Alimentary tract leak：lower output fistula and later periodShort gun syndromeInflammatory bowel disease,Pancreatitis：after intestinal function recover of acute pancreatitis, chronic pancreatic insufficiencymalnutritionHigh atabolism statusChronic wasting diseaseObstruction or operation of upper alimentary tract,Indication,Contraindication,Complete mechanical ileus, bleeding of gastiointestinal, serve abdominal infectionEarly state serve stringent, shock, paralytic ileusEarly period of short gut syndrome,High output fistula of jejunalRefractoriness vomit ,refractoriness diarrhea,serve enteritis,colonitisGastrointestinal function disturbance,gastrointestinal need restEarly stage of acute pancreantitis,Contraindication,When to use,Earlier enteral nutrition：in 24h postoperation littlemore slow fast low densitynormal densityTheory :postoperation alimentary tract parlysis main for gastric colon ,small bowel recover function in 12h,Type of nutrient,Elemental diet: various kinds of nutrient in nature food made artifically，no need to digest,absorb directly nitrogen from amino acid serve digestive function disturbance(elental) nitrogen from aminopeptodrate light,middle digestive function disturbance(Ensure powder) nitrogen from casein normal digestive function,Homogenate diet:suitable for normal gastrointestinal function(Anso、Nutrison Fibre)Mixing,Type of nutrient,Fluid choice,Normal gastrointestianl function complete protein，eg Ensure、Nutrison Fibre、homogenateLow gastrointestinal function elemental diet，eg Ensure Powder、ElentalInfusion to small bowel direct isoosmiaHypermetabolism high energy,Liver function failure less AAA，more BCARenal function failure only provide EAA ，limit non-EAA, reduce accumulation of urea nitrogen,Fluid choice,Respiratory failure redude glucose content,vocate enteral nutrient with high fat content Strengthen immunity abound with peptide,Gln-glutamine,Arg,nucleotide,unsaturated fatty acid,vitamin C,E,A Diabetic (GLucema),Fluid choice,Infusion pathway,Nasogastric tube advantage：suitable all kinds of nutrient disadvantage：back flow aspirationJejunum stoma advantage：less aspiration、long term、diet meanwhile、gastrointestinal decompression meanwhile disadvantage：need operation,Method,Fractionation bolusFractionation infusionContinuous infusionInfusion pump,Notice,Speed 20ml/h 100ml/hDensity 0.5kcal/ml 1 - 1.5kcal/mlTemperature individual difference , season,Complication,Machine infectivity bacteria contaminate aspiration pneumonitisgastrointestinal nausea、vomit、abdominal distention、enterospasm、diarrhea、constipationmetabolic,Diarrhea correlation factors,Area and function of intestinal absorption decreaseServe malnutrition、hypoproteinemiaMucosa excrete increaseIntestinal power decreaseAssociate with medication,High osmotic pressure of nutrientType of enteral nutrientVariety of dietary fiberRate, density, temperature of infusionContaminate,Diarrhea correlation factors,Diarrhea management,Caution medicationIndividual nutritional planElevate plasma protein Element diet（peptide、amino acid）Avoid contaminatePrepare enteral nutrition freshControl infusion speed（infusion pump）antidiarrheal,Parenteral nutrition,Provide enough energy and nutrient by extracadiac alimentary tract(vein)Aim：provide utility metabolic substrate,retain vesceral function and metabolism,no increase vesceral load and metabolism distubance,Principle,Compose of carbohydrate,fat,amino acidDecrease glucose load，40% of non-protein energy support by intralipidNon- protein energy/d 146J/kg（35kcal/kg）None-protein energy:N418J：1g（100cal：1g）,Indication,malnutritionGastrointestinal function disturbanceStress, high analosistrauma、burn、preoperation ,postoperationInability normal diet5 7d,Relative contraindication,Hemorrhagic shockServe hepatic renal inadequacylipodystrophiaServe internal environment disord,Parenteral nutrient,Gigantic nutrient carbohydrate 、protein、fatMinute nutrient vitamin、microelement、electrolyte、insulin water,Energy,Carbohydrate 16.8kJ(4.0kcal)/gFat 38.6kJ(9.2kcal)/gProtein 19.7kJ(4.7kcal)/galcohol 29.4kJ(7.0kcal)/g,Energy requirement,Basal energy expenditure（BEE） Harris-Benedict formula male ：BEE = 66.5+13.7W+5.0H-6.8A femal：BEE = 655+9.6W+1.9H-4.7A W:weight（kg） H：height（cm） A：age（y）,Indirect calorimetry rest energy expence（REE） REE = BEE（1-10%）,Energy requirement,None protein energy,General patient 25-30kcal/kg.d danger 30-40kcal/kg.d glucosefat = 70-50%30-50% fat：1-2g/kg.d glucose：3-6g/kg.d,Amino acid requirement,maintenace：1-1.5g/kg.drepair：1.5-5g/kg.dCompensate extra lost：2-2.5g/kg.d1g N = 6.25g proteinNon-protein energyN = 100-150kcal1g,Intralipid,100% LCT50% LCT + 50% MCT LCT MCT C14 above C6-C12 provide EFA no EFA carnitine oxidation entry chondriosome oxidation slow oxidation fast easy to diposite not easy diposite,“All in one ”nutrient fluid,Suitable heat/nitrogent，save nitrogentDecrease osmotic pressureDecrease metabolism complicationDecrease opportunity of contaminateDecrease nurse work line,“All in one”composition,25% glucose (50%60% of total heat ）20%30% intralipid (30%50% of total heat）Amino acid（7g protein in 100ml ）3% Nacl50150ml10% KCL5060ml25% MgSO410ml,10% Ca gluc5mlInsulin element（I、Fe、Zn、CU、Cr、Mn、Se)Water soluble vitamin（B1、B2、B6、VPP、C、B12、pantothenic acid、folic acid）Lipid soluble vitamin(VA、VD、VE、VK）others（P、Gln-glutamine）,“All in one”composition,Elemental diet,Infusion pathway,Peripheral veinEasy Safe Phlebitis Repeat puncturaLow flow,PCVPSuperficial vein，distal upper limb，look steadily high achievement，low complicationEasy to obstruction，need infusion pumpMore phlebitisEasy to shift,Infusion pathway,Central veinHypsidensity fushing doseNo need to repeat puncturaNeed espert technology，aseps