如何合理实施肠外营养支持吴国豪PPT课件

.,1,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,.,2,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,.,3,PrevalenceofmalnutritionTheGermanhospitalmalnutritionstudy,MatthiasPirlich，ClinicalNutrition(2006)25,563572,.,4,.,5,癌性恶病质的发生率,NAStephens;MEDICINE2007;36:(2):78-81,.,6,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,.,7,营养不良的危害,免疫机能下降,脏器功能异常,预后不良,.,8,CumulativeMortality:Protein-EnergyMalnutrition,Cederholmetal,AmJMed1995.,Mortality%,Monthsafteradmission,P0.01,.,9,MalnutritionIsAssociatedwithIncreasedComplications,Numerousstudieshavedemonstratedcomplicationsofmalnourishedpatientstobe2-20timesgreaterthanthoseofwellnourishedpatients.,Buzbyetal,AmJSurgical1980.Hickmanetal,JPEN1980.Klidjianetal,JPEN1982.,.,10,MalnutritionIsAssociatedwithIncreasedComplications,42%ofpatientswithseveremalnutritionexperiencemajorcomplications9%ofpatientswithmoderatemalnutritionexperiencemajorcomplicationsSeverelymalnourishedpatientsarefourtimesaslikelytohavepost-operativecomplicationsaswell-nourishedpatients,Detskyetal,JPEN1987.Detskyetal,JAMA1994.,.,11,ClinicalOutcomesofmalnutrition,TewariN，etal:LungCancer(2007)57,389394,.,12,ClinicalOutcomesofmalnutrition,PirlichM，ClinicalNutrition(2006)25,563572,.,13,ClinicalOutcomesofmalnutrition,p0.001;,SchiesserMetal:ClinicalNutrition2008;27:565-570,608patientsadmittedforelectivegastrointestinalsurgery.NutritionalriskwasdefinedbyNRS2002andcorrelatedtotheincidenceofpostoperativecomplications,.,14,ClinicalOutcomesofmalnutrition,NRS2002,pTPNfor2weeks:GroupI:Glucosealone(49kcal/kgd)GroupII:Fatemulsion(60%oftheNP-energy,total51kcal/kg/d),“Fatinconjunctionwithglucosemaybemoreeffectiveasanenergysourcethanequicaloricamountsofglucosealone.”,Glucoseorfatasanon-proteinenergysource:acontrolledclinicaltrialingastroenterologicalpatientsrequiringintravenousnutrition.MacFieJ,Gastroenterology1981;80:103-107,kg,.,81,Dual-EnergySystem:KEYMESSAGES,AvoidshyperglycemiaReducesrespiratoryandmetabolicstressSupportsthebestpossiblenitrogenretentionGuaranteesthedeliveryofessentialfattyacidsFacilitatesperipheralinfusionduetolowosmolarity,.,82,Fatrequirements,.,83,Lipidemulsions,Intralipid,.,84,Fattyacidpatternofasoybeanoilemulsion,.,85,Possibleconsequencesofanexcessiveintakeofomega-6fatty(linoleic)acids,unbalancedfattyacidpatternincellmembranesmodificationoftheproductionoflipidmediators(prostaglandins,leukotrienes)promotionofimmunosuppressionandsystemicinflammatoryreactions(trauma,operation,sepsis),Carpentieretal.,1997,.,86,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,.,87,CharacteristicsofMCTvsLCT,.,88,Typesoflipidemulsions,.,89,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,.,90,BenefitsofStructolipid(1),ControlledplasmaTGandMCFAlevels(Nordenstrm1995,Flaatten1995,Kruimel1997)ReliablesourceofessentialfattyacidsAswelltoleratedasIntralipid(Nordenstrm1995,Sandstrm1995,Bellantone1999)Suitableforlong-termPN(Rubinetal2000),.,91,BenefitsofStructolipid(2),Rapidlyavailableenergy(Sandstrmetal1995)ImprovedproteineconomycomparedtoLCTandLCT/MCTemulsions(Kruimeletal1997,Lindgrenetal2001)ExcellentmixingpropertiesAhandynon-breakableplasticpackaging,.,92,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,.,93,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,.,94,Omegavenasasupplement,Formulation:LipidemulsionLipidsource:FishoilConcentration:10%Specialfeature:Highcontentof-3fattyacidsPurpose:Supplementationofparenteralnutritionwithlong-chain-3fattyacidsPackaging:50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,.,96,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,.,97,Proteins/Aminoacids,TheonlymacronutrientscontainingnitrogenAvarietyofdifferentfunctions:Cellandtissuestructure:structuralproteinsFunctionalroles:transportproteinsbloodclottingfactorsreceptorsenzymeshormonesimmuneglobulinesmusclecontractility.,.,98,Proteins/Aminoacids,FreeAApool(70g),Cells,plasma,Proteinsynthesis(300g/d),Proteolysis(300g/d),OralintakeofproteinsEnteralnutritionParenteralnutrition,Metabolicprocesses:-neoglucogenesis-neuromediators-cellenergyWaste(CO2,urea),.,99,Protein/Aminoacids,20differentaminoacidsNitrogencontent(g/L)x6.25=AA(g/L)Aminoacidsarelinkedviapeptidebonds,.,100,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,.,101,Nitrogenrequirements,.,102,Aminoacid/nitrogendosage?,0.51.5g(max.2g)/kg/daynitrogen0.150.2g/kg/dayca.40%essentialaminoacidshighqualityMax.infusionrate:0.1g/kgandhour,.,103,Roleofelectrolytes,.,104,ElectrolyterequirementsinPN,.,105,Roleoftraceelements,.,106,Dailytraceelementrequirements,.,107,Vitamins,.,108,DailyvitaminrequirementsinPN,.,109,规范肠外营养输注用全合一形式,.,110,全合一的定义,.,111,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,.,112,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,.,113,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,.,114,RTUMulti-ChamberBags(MCB),.,115,All-in-One,IndividualvsstandardisedUK-almost100%AIOby1995Estimated(1996)80%adultsonPNcouldusestandardisedregimensCurrentPerspectivesonPNinAdults.BAPENWorkingParty1996,.,116,StandardisedRegimens,Individualisedprescriptionsrarelyneeded(cost20:528535.,.,119,Single-bottlesystemsrequiredmoreitemsandmanipulations.3CBssatisfiedtheneedsofover80%oftheadultlong-termTPNpatientsforthelast5years.,Three-chamberbags:PracticalAspects,ClinicalNutrition2000,19:245-251,.,120,KabivenCentralandPeripheral3CB,Centralhigh(2566ml),PeripheralSuppl.(1440ml)CentralSuppl.(1026ml),PeripheralLow(1920ml)CentralLow(1540ml),PeripheralBasic(2400ml)CentralBasic(2053ml),1000mlbag,1500mlbag,2500mlbag,2000mlbag,.,121,IndividualisedvsStandardisedRegimens,Time/availabilityDelaysinstartingStabilityissuesLibraryofregimensHighN/Highcal/PPN/LowN/Lowcal/Lowvol(criticallyill,post-op,oncology,homePN,fluidrestrictedetc)ReadyToUse(RTU)Multi-ChamberBags(MCB),.,122,StandardisedRegimens,Individualisedprescriptionsrarelyneeded(costdecreasewastage;promoteweightgainOutcome-nodifferencescosteffectivenessindoubt.theconsiderableflexibilityofcomputerprescribingallowingindividualisation.isoflittleornobenefittopatientsCadeAetal.Doesthecomputerimprovethenutritionalsupportofthenewborn?ClinNutr19971619-23,.,126,KeystudiesonbenefitsofAIOsand3CBs,Patients:n=40,aftermajorsurgeryortraumaIntervention:TPNwithSBS(n=21)orasAIO(n=19)for5daysResults:-AIOwaswelltolerated-SBSrequired:a)Moreequipment(e.g.Infusionpumps,disposableinfusionsets)b)Moremanpower(e.g.tofixtechnicalalarms),All-in-onebagversussingle-bottle-systemincriticallyillpatients:aprospectiverandomizedtrialEbenerC,ClinNutr2002(Abstract),.,127,Objective:IntroductionofanewPNorderformproposingAIOwascomparedtotheoldorderformaskingforanindividualisedregimen.,Results:-StandardisedTPNregimedecreasetheriskoferrorfrom93to11%,KeystudiesonbenefitsofAIOsand3CBs,StandardizedTPNorderformreducesstafftimeandpotentialforerror.MitchellKAetal.Nutrition1990;6(6):457-60,.,128,危重病人的低热卡营养支持,1994年Zaloga首先提出“PermissiveUnderfeeding”概念,认为危重病人过早、过度营养支持可刺激病理状态的(细菌感染、炎性反应、免疫抑制)等发生短时间摄入不足将大大抑制病理状态的进程,最大程度减少对器官功能的损害创伤后机体全身性炎性反应、高代谢状况、胰岛素抵抗，此时高热卡摄入可造成高蛋白分解代谢因此提出“允许性摄入不足”概念,.,129,PermissiveUnderfeeding,正常饮食组（301kcal/kg/d）和高热量/蛋白组(528kcal/kg/d),喂养6天后行盲肠结扎,高热量/蛋白组氮平衡及体重增加,但死亡率增高(96小时,53%vs.14%),同时蛋白合成降低YamazakiKJSurgRes1986;40:152腹膜炎模型豚鼠按照不同能量水平提供营养,结果虽然摄入不足组体重下降,但存活率上升(57.2),而20及40过度营养组存活率为0AlexanderJWAnnSurg1989,209:334,.,130,Permi