【醫(yī)學(xué)精品課件】胃腸外營(yíng)養(yǎng) (Parenteral nutrition, PN )

1、 胃腸外營(yíng)養(yǎng) (Parenteral nutrition, PN )浙江大學(xué)醫(yī)學(xué)院附屬邵逸夫醫(yī)ICU 潘孔寒1986年2月，上海周綺思女士因患急性腸扭轉(zhuǎn)切除全部小腸，華瑞決定長(zhǎng)期無(wú)償向提供生存所需的全套全靜脈營(yíng)養(yǎng)產(chǎn)品. 1992年4月8日，歷史將記住這一天。蔡惟成為世界上完全依靠人工全靜脈營(yíng)養(yǎng)孕育的第一人。周綺思母女的事例也因此被載入吉尼斯世界紀(jì)錄。 References History of parenteral nutrition. JPEN， 27:225-232, 2003 A.S.P.E.N. Board of Directors and the Clinical Guideline

2、s Taskforce: Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN， 26(Suppl):1138,2002Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. JPEN， 27:355373, 2003危重患者營(yíng)養(yǎng)支持指導(dǎo)意見(jiàn)草案(中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì)).中國(guó)

3、危重病急救醫(yī)學(xué),10(18)：582590,2006 住院患者腸外營(yíng)養(yǎng)支持的適應(yīng)證草案)(中華醫(yī)學(xué)會(huì)腸外腸內(nèi)營(yíng)養(yǎng)學(xué)分會(huì)).中國(guó)危重病急救醫(yī)學(xué),10(18)：591594,2006 循證醫(yī)學(xué)：證據(jù)分級(jí)A級(jí) 以良好研究為根底的證據(jù)來(lái)支持指南 (前瞻、隨機(jī)試驗(yàn))B級(jí) 以較好研究為根底的證據(jù)來(lái)支持指南 (設(shè)計(jì)較好但無(wú)隨機(jī)化)C級(jí) 依據(jù)專(zhuān)家觀點(diǎn)和共識(shí)來(lái)制訂指南ContributorsJonathan Evans Rhoads, MD, Surgical Nutritionist the Harrison Department of Surgery at the University of Pennsyl

4、vania Stanley Dudrick, MD, Henry Vars, PhD, Douglas Wilmore, MD, and others at the University of Pennsylvania The full development of parenteral nutrition, as we know it today, was dependent on endless hours of effort by dedicated nurses, pharmacists, and dietitians.HistoryComplete parenteral or IV

5、nutrition is a therapeutic method that has been available for approximately 50 years The successful development of this mode of therapy, in a modern sense, was initiated in the late 1930s, but its practical clinical use did not emerge until the 1960s. History1The discovery of the circulation of the

6、blood by William Harvey in 1628 formed the basis for the rationale for IV injections and infusions. A decade later, an important contribution to the development of IV infusions was made during the severe cholera epidemic of 1831 to 1832 by the Scottish physician Latta.He was the first to infuse wate

7、r and salts (saline) into a patient, who quickly recovered and survived. History2Edward Hodder, in Canada in 1873, infused fat in the form of milk into 3 cholera patients. Two of the patients recovered completely, but the third cholera patient did not survive despite the milk infusion. History 3 STU

8、DIES WITH GLUCOSEIt seems obvious in retrospect that the field of parenteral nutrition could not progress successfully before much more was known in the basic sciences. Arthur Beidl and Rudely Krauts, in 1896, were the first to infuse glucose IV in humans. The terms glucose fever and salt fever Hist

9、ory4 STUDIES WITH GLUCOSEIn 1915, Woodyatt and co-workers reported studies on IV administration of glucose in humans. They reported that about 0.85 g of glucose/kg per hour could be supplied by IV without ensuing glucosuria. This classic early study predated glucose clamp investigations by more that

10、 50 years. They stated: IV nutrition with glucose is thus proved to be a feasible clinical proposition, and the way is opened for experiments with amino acids, polypeptides, etc.History5 STUDIES WITH GLUCOSEMatas, in 1924, was the first to use a continuous drip infusion of glucose, and some years la

11、ter, Zimmerman, in 1945, described the infusion of IV solutions through an IV catheter placed in the superior vena cava.This approach was used by Dennis and Dennis and Karlson, who reported the support of surgical patients with the continuous infusion of a solution of 20% glucose along with some vit

12、amins, electrolytes, and 300 to 400 mL of plasma. History6 STUDIES WITH GLUCOSEThe next major contribution was the infusion of hypertonic glucose and all necessary nutrients by Dudrick et al.History 7 The Use of Plasma as a Protein SourceIn 1946, Albright and his research team at the Massachusetts G

13、eneral Hospital in Boston investigated the metabolic fate of infused plasma protein in humans and demonstrated that such infusions contributed to positive nitrogen balance. History8 PROTEIN HYDROLYSATES AND CRYSTALLINE AMINO ACIDSRobert Elman, a surgeon who worked in St Louis In 1937, he published t

14、he first successful studies evaluating the IV infusion of amino acids in the form of a fibrinogen hydrolysate in man.This was an indisputable landmark in the development of IV nutrition . Undoubtedly, Elman deserves the complement given to him by Arvid Wretlind, who referred to him as the father of

15、IV nutrition.History9 FatIt was realized early on that optimal use of the amino acids in solutions could only be achieved by simultaneously providing adequate amounts of necessary energy. In those days, glucose was the only available nonprotein source that could be given IV.History10 Fat & parentera

16、l nutritionThe first to develop a nontoxic readily available fat emulsion was the Swedish scientist Arvid Wretlind, who in 1961, introduced Intralipid together with O. Schuberth. For his many developmental contributions, it seems appropriate to call Arvid Wretlind the father of complete parenteral n

17、utrition History11 Parenteral nutrition In 1962, one of the first symposiums on parenteral nutrition was held in Kungalv, Sweden. This was the first time details of a TPN program were presented. History12 Parenteral nutrition In 1968, a new landmark in the history of parenteral nutrition was passed

18、by Dudrick et al, who demonstrated that a catheter placed in the superior vena cava could be used over extended periods of time to administer a solution of concentrated glucose, along with all other essential nutrients.History13 Parenteral nutritionDudrick et als regimen : Glucose system The Swedish

19、 regimen : Fat systemRhoads : HyperalimentationHistory14 Parenteral nutrition & HPNA contemporary parenteral feeding program consists of water, energy (carbohydrates and fat), amino acids, vitamins, and trace elements. It is extremely important that these nutrients are administered together. An impr

20、ovement, aimed to simplify the infusions, was the introduction of the All-in-One system, where all nutrients are mixed in 1 bag at the local pharmacy or at a pharmaceutical company. The method was introduced by Solassol et al in 1972. 專(zhuān)用營(yíng)養(yǎng)支持(SNS)應(yīng)用流程圖營(yíng)養(yǎng)評(píng)估胃腸功能有EN胃腸功能特殊配方標(biāo)準(zhǔn)營(yíng)養(yǎng)素受限正常局部PN補(bǔ)充過(guò)渡至EN營(yíng)養(yǎng)素耐受適時(shí)過(guò)渡至

21、經(jīng)口喂養(yǎng)適時(shí)過(guò)渡至全面的配方及經(jīng)口喂養(yǎng)無(wú)PN短期外周PN胃腸功能恢復(fù)中心PN長(zhǎng)期或液體限制無(wú)彌漫性腹膜炎腸梗阻頑固性嘔吐腸麻痹頑固性腹瀉胃腸缺血營(yíng)養(yǎng)篩查營(yíng)養(yǎng)不良定義 營(yíng)養(yǎng)狀態(tài)紊亂，包括營(yíng)養(yǎng)攝入缺乏、營(yíng)養(yǎng)代謝障礙、 營(yíng)養(yǎng)過(guò)度。營(yíng)養(yǎng)不良發(fā)生相關(guān)因素 病人病前狀態(tài)，營(yíng)養(yǎng)攝入缺乏的程度和時(shí)間，并發(fā) 其它疾病。營(yíng)養(yǎng)不良發(fā)生率 3055%住院病人 重癥病人，不管用什么方法評(píng)估，都將被定 為營(yíng)養(yǎng)不良。營(yíng)養(yǎng)篩查營(yíng)養(yǎng)不良后果死亡率和患病率升高創(chuàng)口愈合延遲并發(fā)癥發(fā)生率升高再住院率升高住院時(shí)間延長(zhǎng)、費(fèi)用升高 營(yíng)養(yǎng)篩查參數(shù) 正常范圍 輕度 中度 重度體重 (%) 90 8090 6079 60體質(zhì)指數(shù) 18.523

22、1718.4 1616.9 90 8090 6080 90 8090 6079 95 8594 7084 30 3025 24.920 20轉(zhuǎn)鐵蛋白(g/l) 2.04.0 1.52.0 1.01.5 2 1.62.0 1.21.5 1500 12001500 8001200 800氮平衡(g/l) +1 5 10 10 15 15營(yíng)養(yǎng)篩查主觀全面評(píng)定 subjective globe assessment,SGA微型營(yíng)養(yǎng)評(píng)估 mini nutritional assessment, MNA營(yíng)養(yǎng)不良風(fēng)險(xiǎn)篩查2002 nutrition risk screening NRS2002SNS的應(yīng)用S

23、NS 以治療為目的，經(jīng)口、經(jīng)胃腸或經(jīng)胃腸外提供營(yíng)養(yǎng)EN 通過(guò)置入胃腸的管道 非意愿地提供營(yíng)養(yǎng)PN 通過(guò)靜脈提供營(yíng)養(yǎng)條件 非急診措施，需在患者血流動(dòng)力學(xué)穩(wěn)定后起用。 SNS的應(yīng)用最大的爭(zhēng)議：PN和EN的相對(duì)適應(yīng)癥認(rèn)為：不接受EN的危重病人可能會(huì)經(jīng)歷腸內(nèi)菌群移位(translocation of intestinal flora)及相關(guān)的內(nèi)毒素釋放，從而激活炎癥通路inflammatory pathways。認(rèn)為： 多系統(tǒng)器官衰竭的病因、進(jìn)展及死亡與上述產(chǎn)生的全身炎癥激活有關(guān)。但至今，很少有關(guān)人類(lèi)的資料來(lái)證實(shí)這點(diǎn)。EN 似乎能幫助維持腸道的粘膜結(jié)構(gòu)和功能。SNS的應(yīng)用沒(méi)有充足的隨機(jī)、前瞻、對(duì)照試驗(yàn)

24、作薈萃分析來(lái)比較EN和PN在各種疾病中的應(yīng)用情況，所以不能明確在許多疾病中EN較PN的優(yōu)越性許多研究說(shuō)明：PN較EN容易到達(dá)營(yíng)養(yǎng)治療目的，且即使在胃腸功能良好的情況下，只有PN才能取得適宜SNS。SNS的應(yīng)用另一爭(zhēng)議起用SNS的理想時(shí)機(jī)已有建議：疾病早期使用EN可減輕應(yīng)急反響，提高耐受性。報(bào)道：術(shù)后6-12h對(duì)EN的耐受性很好，但這只提供了可行性，并沒(méi)說(shuō)明有必然的益處。SNS的應(yīng)用何時(shí)起用PN復(fù)雜，常被問(wèn)及的問(wèn)題無(wú)相關(guān)的前瞻，隨機(jī)臨床試驗(yàn)2個(gè)試驗(yàn)入院后或手術(shù)后1014天不進(jìn)食或無(wú)SNS患者較差的臨床結(jié)果，較長(zhǎng)的住院時(shí)間，較高的醫(yī)療費(fèi)用故可起用SNS已有714天經(jīng)口攝食缺乏或估計(jì)714天經(jīng)口攝食

25、缺乏的患者SNS應(yīng)用實(shí)踐指南SNS用于不能通過(guò)經(jīng)口來(lái)滿足營(yíng)養(yǎng)需求的患者。B需用SNS時(shí)，EN優(yōu)于PN 。B需用SNS時(shí)，PN用于胃腸功能不佳或不能使用或經(jīng)口或EN不能提供適宜營(yíng)養(yǎng)的患者。 B患者已有714天經(jīng)口攝食缺乏或估計(jì)714天經(jīng)口攝食缺乏的患者可起用SNS 。 B成人正常需要SNS營(yíng)養(yǎng)需求量應(yīng)根據(jù)正規(guī)的個(gè)體化營(yíng)養(yǎng)評(píng)估結(jié)果而定。每種營(yíng)養(yǎng)成分的需求應(yīng)隨營(yíng)養(yǎng)狀態(tài)，疾病，器官功能，代謝狀況，使用的藥物，營(yíng)養(yǎng)支持的時(shí)間而變化。沒(méi)有標(biāo)準(zhǔn)EN和PN配方。調(diào)查說(shuō)明患者常常接受提供多余能量的配方。成人正常需要補(bǔ)充的熱卡應(yīng)恰當(dāng)?shù)貪M足根底的能量消耗，并提供滿足一定水平的體力活動(dòng)，從而維持健康體重指數(shù)。正常成人

26、能量需求2035kcal/kg/d ( 85145kj/kg/d)糖7g/kg/d, 脂肪2.5g/kg/d(165cm=身高-100165cmMale: 身高-105Female: 身高-100 成人正常需要正常人體能量的需求Harris-Benedict公式 男：BEE(kcal/d 女：BEE(kcal/d碳水化合物：3570的非蛋白熱量，7g/kg。脂肪：2030的非蛋白熱量，應(yīng)激狀態(tài)可達(dá)50，=體外表積40% 2.0 肌肉做功活動(dòng) 發(fā)熱 度 成人正常需要確定蛋白質(zhì)需要量1g氮=6.25g蛋白質(zhì)正常蛋白質(zhì)需要量: 約1g/kg/d在有前述多種應(yīng)激時(shí)，乘上系數(shù)熱氮比: 所需能量(kcal

27、)/150=所需氮量, 即1:150配方(每150kcal非蛋白熱量需氮1g) 成人正常需要碳水化合物：占60%。TPN最正確輸注速度：4-5mg/kg/min標(biāo)準(zhǔn)TPN含21%的葡萄糖危重病人最大可達(dá)400-500g/dDM、COPD病人適當(dāng)減少透析病人可從透析液中吸收大量葡萄糖，可據(jù)情況減少用量 成人正常需要脂肪：3%-30% 在膿毒癥病人可達(dá)40%-50%。碳水化合物:脂肪 熱量最正確比例 70:30胃腸外營(yíng)養(yǎng)途徑實(shí)踐指南PN應(yīng)通過(guò)一遠(yuǎn)端位于上腔靜脈或右心房的導(dǎo)管提供 A置管后應(yīng)攝胸片，除非用放射介入技術(shù)經(jīng)由頸內(nèi)或上肢靜脈置入 B置放中心靜脈導(dǎo)管時(shí)應(yīng)采取全面無(wú)菌措施 B操作前應(yīng)用Chlo

28、rhexidine 消毒皮膚 B使用前和抽血前hub應(yīng)消毒 C不必常規(guī)經(jīng)導(dǎo)絲更換導(dǎo)管 A高危病人和高危醫(yī)療場(chǎng)所感染率高推薦使用抗菌導(dǎo)管B長(zhǎng)期置管患者應(yīng)使用低劑量抗凝藥 B由經(jīng)特殊培訓(xùn)的護(hù)理小組管理接受PN治療的患者的靜脈管路 B 療效監(jiān)測(cè)實(shí)踐指南在SNS治療期間應(yīng)定期監(jiān)測(cè)營(yíng)養(yǎng)參數(shù)(氮平衡、血清蛋白和能量平衡)和臨床結(jié)果(生活質(zhì)量、患病率和死亡率、住院時(shí)間和住院費(fèi)用)。(B) 定期比較營(yíng)養(yǎng)參數(shù)/臨床結(jié)果和SNS冶療目標(biāo)，及時(shí)修改營(yíng)養(yǎng)處方。 (C) 腸內(nèi)及腸外營(yíng)養(yǎng)并發(fā)癥再喂養(yǎng)綜合征： 低磷、低鉀、低鎂、水鈉潴留高糖血癥和低糖血癥代謝性酸中毒高甘油三酯血癥二氧化碳產(chǎn)生過(guò)多 腸內(nèi)及腸外營(yíng)養(yǎng)并發(fā)癥肝膽并

29、發(fā)癥PN代謝性骨病導(dǎo)管性膿毒癥(PN)食管反流和誤吸(EN)嘔吐、腹脹、腹瀉(EN)過(guò)度喂養(yǎng)并發(fā)癥并發(fā)癥監(jiān)測(cè)實(shí)踐指南起用SNS時(shí)，有再飼綜合征(refeeding syndrome)危險(xiǎn)的營(yíng)養(yǎng)不良患者應(yīng)仔細(xì)監(jiān)測(cè)血清磷、鎂、鉀、糖水平。 (B)糖尿病患者或有不耐受糖危險(xiǎn)的患者起用SNS時(shí)，應(yīng)減慢輸注糖的速度，同時(shí)嚴(yán)密監(jiān)測(cè)血糖、尿糖。 (C)一經(jīng)起用SNS，胰島素量調(diào)整后應(yīng)經(jīng)常監(jiān)測(cè)血糖直至穩(wěn)定。 (B)起用SNS時(shí)，應(yīng)經(jīng)常監(jiān)測(cè)血清電解質(zhì)(鈉、鉀、氯、碳酸氫鹽)直至穩(wěn)定。 (B)并發(fā)癥監(jiān)測(cè)實(shí)踐指南靜脈使用脂肪乳劑或調(diào)整劑量的患者應(yīng)監(jiān)測(cè)血清甘油三酯直至穩(wěn)定。 (C)接受PN患者應(yīng)定期監(jiān)測(cè)肝功能。 (A

30、)起用SNS時(shí)，應(yīng)測(cè)量骨密度并作定期檢查 (C) 接受EN患者有明顯誤吸危險(xiǎn)時(shí)，應(yīng)考慮置幽門(mén)后營(yíng)養(yǎng)管。 (C)老年患者應(yīng)用實(shí)踐指南老年患者(65歲)均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。 (B)年齡和生活方式類(lèi)參數(shù)可用來(lái)評(píng)估老年患者營(yíng)養(yǎng)狀態(tài)。 (C)在接受藥物治療的老年患者應(yīng)評(píng)估其潛在的藥物-營(yíng)養(yǎng)物間作用。 (B)在給老年患者開(kāi)飲食或SNS醫(yī)囑時(shí)，應(yīng)考慮此年齡組特殊營(yíng)養(yǎng)物需求。 (B) 碳水化合物：55-60%；維生素B-12、B-6、C和葉酸相對(duì)缺乏；水：30ml/kg或至少1500ml/d。肥胖患者應(yīng)用實(shí)踐指南肥胖患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。(B)條件允許時(shí)，應(yīng)用間接能耗測(cè)定法來(lái)

31、評(píng)估肥胖患者的能量需求，因?yàn)?，在評(píng)估肥胖患者的能量需求時(shí)，能量預(yù)計(jì)公式(如Harris-Benedict公式)均有較大的限制。 (B)在治療輕度和中度應(yīng)激的肥胖患者時(shí)，推薦低熱卡配方(其中蛋白質(zhì)：1g/kg IBW) 。 (A)糖尿病患者應(yīng)用實(shí)踐指南糖尿病患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。 (A) 住院糖尿病患者之血糖應(yīng)控制在100-200mg/dl范圍。 (A)提供給糖尿病患者的EN和PN中大分子營(yíng)養(yǎng)組分應(yīng)個(gè)體化，并且防止使用過(guò)多熱卡。 (B) PN：0.1u RI/1g糖心臟病患者應(yīng)用實(shí)踐指南心臟惡液質(zhì)(cardiac cachexia) ：是一種發(fā)生在少數(shù)NYHA級(jí)或級(jí)充血性心衰(

32、CHF)患者的重度營(yíng)養(yǎng)不良綜合征。包括瘦肉組織缺失(含重要器官如心臟)并導(dǎo)致行為狀態(tài)和免疫功能下降。與生存率下降有關(guān)。伴心臟惡液質(zhì)患者或CPB術(shù)后伴并發(fā)癥患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。(B)PN限于有術(shù)后并發(fā)癥且胃腸道不宜使用的心臟病患者。 (C)心臟手術(shù)患者使用EN應(yīng)延至血流動(dòng)力學(xué)穩(wěn)定之時(shí)。 (C)肺病患者應(yīng)用實(shí)踐指南COPD或ARDS患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。(B)肺病患者的能量攝入應(yīng)控制在或低于估計(jì)需求量以減少CO2的產(chǎn)生。(B)不推薦肺病患者常規(guī)使用改進(jìn)的低碳水化合物-高脂肪營(yíng)養(yǎng)配方。(B)使用含n-3脂肪酸的改進(jìn)腸內(nèi)營(yíng)養(yǎng)配方可能對(duì)早期ARDS患者有效。(B)容

33、量限制型營(yíng)養(yǎng)配方適用于血流動(dòng)力學(xué)狀態(tài)要求容量限制的ARDS病人。(B)應(yīng)嚴(yán)密監(jiān)測(cè)肺病患者的血清磷水平。(A)肝病患者應(yīng)用實(shí)踐指南肝病患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。(B)肝病患者的營(yíng)養(yǎng)評(píng)估應(yīng)包括維生素A、D、E、K和Zinc。(B)肝硬化患者應(yīng)分4-6次攝入每日所需能量。(B)顯性肝性腦病的急性管理應(yīng)包括限制蛋白的攝入(1.0g/kg/d)。(A)富含支鏈氨基酸的飲食和SNS配方只適于慢性腦病對(duì)藥物治療無(wú)效患者。(B)與肝硬化有關(guān)的肝癌患者于肝切除術(shù)圍手術(shù)期時(shí)應(yīng)予營(yíng)養(yǎng)支持。(A)短腸綜合征患者應(yīng)用實(shí)踐指南作廣泛腸切除或SBS患者均處營(yíng)養(yǎng)不良危險(xiǎn)狀態(tài)，應(yīng)作營(yíng)養(yǎng)篩查。(B)SBS患者假設(shè)結(jié)腸完整應(yīng)使用富含復(fù)合碳水化合物-少含脂肪的飲食。(A)回腸末端切除100cm的患者每月應(yīng)注射VitB-12。(A)假設(shè)經(jīng)口或EN不能滿足SBS患者營(yíng)養(yǎng)需求，那么應(yīng)用PN。(A)腎病患者應(yīng)用實(shí)踐指南進(jìn)展期慢性腎衰患者未行透析且監(jiān)測(cè)條件良好，g/kg/d) 。(A)CRF行血透或腹透患者應(yīng)采取蛋白質(zhì)/kg/d。(B)ARF患者接受SNS時(shí)，應(yīng)給予含必需氨基酸和非必需氨基酸(脫氨毒)的平衡混合物。 (A)持續(xù)血濾患者應(yīng)給予至少1.0g