全胃肠外营养.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,*,全 胃 肠 外 营 养,Total Parenteral Nutrition,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,20,世纪下半叶外科领域的,5,大里程碑,1.,Transplantation,2.,Medical,Imagination,3.,ICU,4.,Key-hole,surgery,5.,TPN,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,全胃肠外营养,1986,年,2,月，上海周绮思女士因患急性肠扭转切除全部小肠，依靠全胃肠外营,养（,TPN,）长期健康生存,.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,全胃肠外营养,1992,年,4,月,8,日，蔡惟成为世界上完全依靠全胃肠外营养（,TPN,）孕育的第一,人，载入吉尼斯世界纪录。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,全胃肠外营养,全胃肠外营养,(Total Parenteral Nutrition,TPN):,又称静脉高营养,(Intravenous Hyperlimentation,IVH),即不经口也不经胃管或胃肠造口,而是经静脉输注营养,液来供应病人所需要的全部营养物质。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,的实现,营养生理学对人体正常和疾病时的,代谢特点和营养需要量的研究成果,各种静脉营养制剂，尤其是结晶氨,基酸和脂肪乳剂的研制成功并投入,工业化生产；,硅橡胶导管的研制成功和深静脉插,管技术的开发。,TPN,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,输入途径,1.,经周围静脉,(PVC),2.,经中心静脉,(CVC),3.,经周围置中心静脉,(PICC),Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,适应证,1,胃肠道梗阻,2,胃肠道吸收功能障碍,：,短肠综合征：广泛小肠切除,70,80,小肠疾病：免疫系统疾病、肠缺血、多发肠瘘,放射性肠炎,严重腹泻、顽固性呕吐,7,天,3,重症胰腺炎,：先输液抢救休克或,MODS,，待生命体征,平稳后，若肠麻痹未消除、无法完全耐受肠内营养，,则属肠外营养适应证。,4,高分解代谢状态,：大面积烧伤、严重复合伤、感染等。,5,严重营养不良,：蛋白质,-,热量缺乏型营养不良常伴胃肠,功能障碍,无法耐受肠内营养。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,应用,TPN,对治疗有益,1,3,2,大手术、创伤,的围手术期,肠外瘘,炎性肠道疾病,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,应用,TPN,对治疗有益,4,5,6,妊娠剧吐,持续,5-7,天以上的呕,吐者,严重营养不良,的肿瘤病人,重要脏器功能,不全,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,禁忌证,胃肠道功能正常，适应肠内营养。,心血管功能或严重代谢紊乱需要控制者。,需急诊手术，不因应用,TPN,而耽误时间。,不可治愈、无存活希望、临终或不可逆昏迷病人,1,2,3,4,“,If,the,gut,works,use,it.”,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,葡萄糖,1.,肠外营养的主要能源物质。,2.,机体所有组织、器官都能利用葡萄糖。,3.,高浓度（,25,，,50,）葡萄糖渗透压高，,对静脉壁刺激性大，不能经周围静脉输注。,4.,来源丰富，价格低廉，监测方便。,5.50,70,的非蛋白热量，,7g/kg/d,。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,脂肪乳剂,1.,高能物质，每克氧化产热,9.3kcal,，为葡萄糖的,2.3,倍，,20,30,的非蛋白热量，应激状态可达,50,，,2g/kg/d,。,2.,颗粒直径,0.6m,，几乎无渗透压并发症；,3.,肝脏对脂肪乳剂中间代谢和转运具有重要作用,单,脂肪乳剂为非蛋白能源时，可发生酮症；,4.,价格昂贵，约为葡萄糖的,15,倍。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,脂肪乳剂,6.,脂肪乳剂最大用量为,2g/kg/d,7.LCT,包含,EFA,，,MCT,不含,EFA,，代谢过程不依赖 肉毒碱。,8.,对肝功能不良病人，选用,LCT/MCT,乳剂（,1,：,1,）,9.,鱼油（,一,3,脂肪酸）：具有调节免疫功能、减轻炎症反应和抑制血小板聚集等功能。,10.,一般主张采用双能源系统。,11.,肿瘤组织缺乏降解脂肪的关键酶，很少利用 脂肪供能。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,氨基酸,1.,是肠外营养的唯一氮源。,2.,蛋白质含氮量,:16%,蛋白质系数,:6.25;,成人在基础需要量的情况下，每日最,低供应量为氮,0.1,0.2g/kg/d,，即复方,氨基酸,0.7g/kg/d,；,3.,实际上，由于希望得到较好的正氮平衡，,每日至少应供应复方氨基酸,1g/kg/d,；,4.,热量与氮之比为,100,150:1,，此时氨基,酸利用最佳。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,氨基酸,5.,分平衡型和特殊型。,6.,芳香氨基酸,(aromaticamino-acids,AAA),包括苯丙氨酸，酪氨酸和色氨酸，主要在肝脏,代谢。支链氨基酸,(branched chain amino-,acids,BCAA),包括缬氨酸、亮氨酸和异亮氨酸，,属,EAA,，主要在肌肉代谢，可通过血脑屏障，在,肝性脑病时应用。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,组成,1.,谷氨酰胺,2.,水、电解质和微量元素,3.,维生素,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,每日推荐剂量,能量,:2030Kcal/(kg.d),水,:30,40ml,kg(,每,1Kcal/kg/d,给水量,11.5ml),葡萄糖,:24g/(kg.d),脂肪,:11.5g/(kg.d),氮量,:0.10.25g/(kg.d),氨基酸,:0.61.5g/(kg.d),电解质,:,钠,80100mmol,钾,60150mmol,氯,80100mmol,钙,510mmol,镁,812mmol,磷,1030mmol,脂溶性维生素,：,A 2500IU D100IU E10mg K110mg,水溶性维生素,：,B1 3mg B2 3.6mgB6 4 mgB12 5 ug,泛酸,15mg,烟酰胺,40mg,叶酸,400ugC 100mg,微量元素,：铜,0.3mg,碘,131ug,锌,3.2mg,硒,3060ug,钼,19ug,锰,0.20.3mg,铬,1020ug,铁,1.2mg,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,全营养混合液（,Total Nutrients Administration,）,全营养混合液（,Total Nutrients Administration,）三升袋：把各种营养液在体外预先混合在三升塑料袋内，再同时输入。,各营养素同时进入体内，各司其职，最接近生理条件 避免了单一营养液输入的一些副作用：,高浓度葡萄糖被稀释使之可以周围静脉输注 避免了脂肪乳剂输入过快的副反应。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,并发症,技术性并发症,原因,空气栓塞,插管时深吸气或导管脱出,导管折断、大血管损伤,操作不熟练或导管材料质 量不高（太硬）,败血症,导管或,TPN,液污染,血、气胸及神经损伤,穿刺不当，误人胸膜腔,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,并发症,代谢性并发症,原因,低血糖,外源性胰岛素用量过大，突然 停输高浓度葡萄糖。,高血糖、高渗性非酮性昏 迷,输入糖总量大、输速快，内源 性胰岛素不足或补充不够。,肝功能损害,葡萄糖超负荷致肝脂肪变性,（未采用双能源）,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C,.,TPN,并发症,代谢性并发症,原因,电解质紊乱，微量元素 缺乏,