外科营养-surgical-nutrition-上交大瑞金.ppt

上海交通大学医学院附属瑞金医院普外科Basic ConceptNutrition the progress of body ingest nourishment and digest it to meet physiological need oneselfNutreint 2Reasonable NutritionEnough heart and all nutrition,proportional Increase digestibility Promote appetiteNo hazardous substanceReasonable meal3Clinical PurposePrevent deficiency disease Prevent some normal diseaseRaise curative effectOperation support and promote recoverReduce the complication4Body elementary structure constructionFundamental unit-cellBackbone of cell-protein(amino acids)Construction of celluar membrane-lipid(lipoprotein,lipopolysaccharide)Cell nuclear nucleinic acid(purine,pyrimidine,glucidamin)5Nutrient substanceSaccharidelipideprotein VitaminInorganic saltWater6Heat energyCarbohydrateFatProteinEffict：Retain body temperature Energy store ATP GTP CoA7Energy consumptionBasal metabolism Physical activitySpecific dynamic action Growth and development8 Protein15%of body weight、50%of dry cell weight、90%of enzymePhysiology function composition of cellular structure especially physiological function provide energy synthesis nitrogen-containing material9Day conversion rate-3%(250-300g/d)Requied:1-1.5g/kg/dHeat production：3.9kcal/gEssential amino acid：8(branched-chain amino acid-3)Protein10MetabolismGeneral metabolism synthesis other protein atabolism carbon chain：CO2,parabiosis nitrogen：carbamide synthesis other nitrogen-containing substance purine,pyrimidine,theamin,Crea 11nitrogen balance discharge 54mg/kg/d positive nitrogen balance negative nitrogen balance total nitrogen balanceMetabolism12LipideFat 20-25%of body weight PHL Cholesterin13Physiological functionOxydation energize(TG)Main component of biomenbranousEssential fatty acid:linolic acid,linoleic acid,eicosatetraenoicacidlipoprotein14CarbohydrateSaccharideSupply energyComposition of cellAbsorb in epimere intestiner parveGlycose15hepatic glycogen 200g,muscle glycogen 300gExhaust hepatic glycogen in 24h at famesBrain,kidney medulla,blood cell can utilization glycose directlly Minimus required:100150g/d Carbohydrate16Inorganic saltMacroelement Ca,P,Mg,Na,K,ClMicroelement Fe,Se,Zn,Cu,I,FOthers microelement17VitminVit A retinolVit D adjust metabolism of Ca,PVit E anti-oxidationVit K blood clottingVit B1、B2 energy metabolism,oxidoreductionVit C reducerVit B6 synthesis haemoglobin18OutlineStringent stage by operation,trauma,infectionHigh atabolisim stageNegative nitrogen balance19Characteristic of nutritionCatabloic 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 phase20Metabolism in starveStarve in short term glyconeogenesisStarve in long term acetone body21Alimentary dificiency causePreoperation ingest dificient,metabolism change,malabsorption,lossOperation,trauma bleeding 100ml=3g NPost-operation 22Assessment of nutritional statusHistoryPhyical examination height weight skin-fold thickniss upper arm circumference2324Constitutional 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 grade2Assessment of nutritional status25Lab examination reflect protein metabolism：Crea,weight UR 3-MeH plasma protein protein tumover rate nitrogen balanceAssessment of nutritional status26proteinumHalf-life（d）Normal rangeALBTFNPALB205235g/L2.5-2.0g/L180mg/LPlasma proteinAssessment of nutritional status27 cellular immune function：total lymphocyte count tardive skin supersensitivity test T-cell&NK energy Assessment of nutritional status28Nutritional supportPreoperation nutritional evaluationPost-operationMethod enteral nutrition、parenteral nutrition 29AimImprove psychological and physiology functionMinimus adverse effect of catabolicPrevent weight lost Retrieve normal organsim compositionAccelerate reconstitutionShorten hospital dayImprove quality of life30IndicationWeight descent10%Serum albumin30g/LInability normal diet7天MalnutritionPatients with hight risk factors31MalnutritionDefective nutritionOvernutrition32TypeMarasmusKwashiokorMixed33MarasmusDecrease weight/heightReduce fatty tissueReduce muscle tissueweaknessNormal plasma protein34kwashiokorPuffinessHyproteinemiaVisceral protein level decreaseNormal fat store35DifferencecharacteristicmarasmuskwashiokordefectNormal weightoedemaSerum-albuminenergy60%nonormalprotein60-80%yesLow36Protein-energy malnutritionWeight loss/analosisWeak Deterioation of organ functionEcto-cell water retentionoedema（hypoproteinemia）37EtiologyCancer COPDInflammatory bowel diseaseCardiac diseaseChronic nervous systemic diseaseRenal inadequacyCirrhosis 38Enteral 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.39Advantage 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 condition40Low 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 enterokinesiaAdvantage 41Principle Intestinal tract especial for small bowel have function,can absorb all kinds of nutrient;tolerance for enteral nutrition;use EN as far as possible 42Indication Dysphagia and dysmasesiaConscious disturbance and coma Alimentary tract leak：lower output fistula and later periodShort gun syndromeInflammatory bowel disease 43Pancreatitis：after intestinal function recover of acute pancreatitis,chronic pancreatic insufficiencymalnutritionHigh atabolism statusChronic wasting diseaseObstruction or operation of upper alimentary tractIndication 44Contraindication Complete mechanical ileus,bleeding of gastiointestinal,serve abdominal infectionEarly state serve stringent,shock,paralytic ileusEarly period of short gut syndrome45High output fistula of jejunalRefractoriness vomit,refractoriness diarrhea,serve enteritis,colonitisGastrointestinal function disturbance,gastrointestinal need restEarly stage of acute pancreantitisContraindication 46When 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 12h47Type of nutrientElemental 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 function48Homogenate diet:suitable for normal gastrointestinal function(Anso、Nutrison Fibre)Mixing Type of nutrient49Fluid choiceNormal gastrointestianl function complete protein，eg Ensure、Nutrison Fibre、homogenateLow gastrointestinal function elemental diet，eg Ensure Powder、ElentalInfusion to small bowel direct isoosmiaHypermetabolism high energy50Liver function failure less AAA，more BCARenal function failure only provide EAA，limit non-EAA,reduce accumulation of urea nitrogenFluid choice51Respiratory 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 choice52Infusion pathwayNasogastric tube advantage：suitable all kinds of nutrient disadvantage：back flow aspirationJejunum stoma advantage：less aspiration、long term、diet meanwhile、gastrointestinal decompression meanwhile disadvantage：need operation53Method Fractionation bolusFractionation infusionContinuous infusionInfusion pump54Notice Speed 20ml/h 100ml/hDensity 0.5kcal/ml 1-1.5kcal/mlTemperature individual difference,season55Complication Machine infectivity bacteria contaminate aspiration pneumonitisgastrointestinal nausea、vomit、abdominal distention、enterospasm、diarrhea、constipationmetabolic56Diarrhea correlation factorsArea and function of intestinal absorption decreaseServe malnutrition、hypoproteinemiaMucosa excrete increaseIntestinal power decreaseAssociate with medication57High osmotic pressure of nutrientType of enteral nutrientVariety of dietary fiberRate,density,temperature of infusionContaminateDiarrhea correlation factors58Diarrhea managementCaution medicationIndividual nutritional planElevate plasma protein Element diet（peptide、amino acid）Avoid contaminatePrepare enteral nutrition freshControl infusion speed（infusion pump）antidiarrheal59Parenteral nutritionProvide 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 distubance60Principle 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）61Indication malnutritionGastrointestinal function disturbanceStress,high analosistrauma、burn、preoperation,postoperationInability normal diet5 7d62Relative contraindicationHemorrhagic shockServe hepatic renal inadequacylipodystrophiaServe internal environment disord63Parenteral nutrientGigantic nutrient carbohydrate、protein、fatMinute nutrient vitamin、microelement、electrolyte、insulin water64EnergyCarbohydrate 16.8kJ(4.0kcal)/gFat 38.6kJ(9.2kcal)/gProtein 19.7kJ(4.7kcal)/galcohol 29.4kJ(7.0kcal)/g65Energy requirementBasal 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）66Indirect calorimetry rest energy expence（REE）REE=BEE（1-10%）Energy requirement67None protein energyGeneral 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 68Amino acid requirementmaintenace：1-1.5g/kg.drepair：1.5-5g/kg.dCompensate extra lost：2-2.5g/kg.d1g N=6.25g proteinNon-protein energyN=100-150kcal1g69Intralipid100%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 diposite70“All in one”nutrient fluidSuitable heat/nitrogent，save nitrogentDecrease osmotic pressureDecrease metabolism complicationDecrease opportunity of contaminateDecrease nurse work line 71“All in one”composition25%glucose(50%60%of total heat）20%30%intralipid(30%50%of total heat）Amino acid（7g protein in 100ml）3%Nacl50150ml10%KCL5060ml25%MgSO410ml7210%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”composition73Elemental diet7475Infusion pathwayPeripheral veinEasy Safe Phlebitis Repeat puncturaLow flow76PCVPSuperficial vein，distal upper limb，look steadily high achievement，low complicationEasy to obstruction，need infusion pumpMore phlebitisEasy to shiftInfusion pathway77Central veinHypsidensity fushing doseNo need to repeat puncturaNeed espert technology，asepsisPneumothoras septicemiaInfusion pathway78Fundation Nuttition requestTime of therapySave and risk factorsNursing condition79Complication Vessel correlated:septicaemia、pneumothorax、air embolismMetabolism:hyperglycemia、hypoglycemia、hyperosmalar nonketotic diabetic moma、lack of EFA、electrolyte metabolism and acid-base balance disorder,lack of microelementLiver and biliary cholestatic hepatitis、jaudice,high aminopherase80Cholestatic hepatitis Excess glucose transform to fatty acid,accumulation in liverExcess inralipid,extrinsic source fatty acide accumulation Excess amino acid Decrease gut hormone secretion because of lack of food stimulus，CCK secretion decreasedysbacteria、toxic effect of metabolic81Prevention Decrease heat of non proteinantibioticPromote gall bladder emptying and gastrointestinal nomal activitiy Prophylactic cholecystectomy82Effect to gastric mucosaLong term fast lead to enteric epithelium artophy，intestine wall thinnigz，damange to intestinal barriea,function decreasebacterial translocation,enterogenic infection,Cholestatic hepatitis、septicaemia83PrincipleHarmless to patientsEnough protein is more improntant than heatAs far as possible by gastiointestinal84ENPNPPN CPNEN+PNLimit time：PNLong term：ENPrinciple8586