炎性肠梗阻病人的营养支持FreseniusKabi

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,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,*,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,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,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,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,“卡文,”,杯,第一届外科中青年医师综合技能展示大赛,炎性肠梗阻病人的营养支持,炎性肠梗阻病人的营养支持,作者,:,付玉东,医院,:,北京市怀柔区第一医院,科室,:,普外科,时间,:2010 3 20,2,病例模式版本,【,一般资料,】,：,性别 男,年龄,85,岁,体重,58,公斤,身高,172CM,病例模式版本,【,主诉,】,：,突发右下腹痛,2,天。,病例模式版本,【,病史,】,：患者于,2,天前无明显诱因突发右下腹痛，阵发性、无放射痛，伴恶心呕吐，突出为胃内容物，无血性液。无寒颤发热病史，有腹泻病史，为粘液样便，无里急后重及黑便血便史。无尿频、尿急、尿痛及肉眼血尿病史。腹痛逐渐加重，于本院内科急诊就诊，给予对症、补液及抗生素治疗。无明显好转，请外科会诊考虑：腹痛待查，,1.,急性阑尾炎；,2.,消化道穿孔。给予收入外科治疗。起病以来，患者精神状态差，二便如上述。,既往有高血压病史,20,年。,2003,年行前列腺增生手术。否认糖尿病史。,病例模式版本,【,体检,】,：,T:36.0P:106,次,/,分,BP:180/100,mmHg,意识清醒，皮肤粘膜无苍白。双肺呼吸音粗。心脏听诊正常。腹部膨隆。全腹有压痛、反跳痛，肌紧张，以右下腹为著。肝浊音界正常。移动性浊音阴性。肠鸣音减弱。腹股沟区及阴囊未见明显肿块。双下肢无肿胀，神经系统无阳性体征。,病例模式版本,【,辅助检查,】,：血尿常规、肾功、电解质及凝血系列均正常范围。心电图大致正常。,胸片示双肺纹理增粗。,腹部,CT,示：肠管扩张积气。腹腔积液。,病,例,例,模,模,式,式,版,版,本,本,【,诊,断,断,】,：,弥,弥,漫,漫,性,性,腹,腹,膜,膜,炎,炎,急,性,性,阑,阑,尾,尾,炎,炎,？,？,消,化,化,道,道,穿,穿,孔,孔,？,？,病,例,例,模,模,式,式,版,版,本,本,【,治,疗,疗,经,经,过,过,】,：,入,院,院,后,后,积,积,极,极,术,术,前,前,准,准,备,备,，,，,在,在,全,全,麻,麻,下,下,行,行,剖,剖,腹,腹,探,探,查,查,，,，,术,术,中,中,见,见,回,回,肠,肠,、,、,升,升,结,结,肠,肠,、,、,横,横,结,结,肠,肠,扩,扩,张,张,，,，,乙,乙,状,状,结,结,肠,肠,冗,冗,长,长,，,，,系,系,膜,膜,顺,顺,时,时,针,针,扭,扭,转,转,180,度,，,，,肠,肠,壁,壁,扩,扩,张,张,、,、,淤,淤,血,血,、,、,颜,颜,色,色,暗,暗,红,红,，,，,无,无,明,明,显,显,坏,坏,死,死,。,。,腹,腹,腔,腔,有,有,淡,淡,红,红,色,色,渗,渗,液,液,约,约,500,毫,升,升,。,。,术,术,中,中,诊,诊,断,断,为,为,：,：,乙,乙,状,状,结,结,肠,肠,扭,扭,转,转,。,。,行,行,乙,乙,状,状,结,结,肠,肠,部,部,分,分,切,切,除,除,，,，,降,降,结,结,肠,肠,-,乙,状,状,结,结,肠,肠,端,端,侧,侧,吻,吻,合,合,术,术,。,。,术,术,后,后,营,营,养,养,状,状,态,态,评,评,分,分,(NRS2002),为,6,分,。,。,APACHEII,评,分,分,为,为,18,分,。,。,早,早,期,期,经,经,深,深,静,静,脉,脉,给,给,予,予,全,全,胃,胃,肠,肠,外,外,营,营,养,养,。,。,按,按,照,照,病,病,情,情,轻,轻,重,重,进,进,行,行,能,能,量,量,和,和,基,基,本,本,底,底,物,物,调,调,整,整,，,，,重,重,症,症,急,急,性,性,应,应,激,激,期,期,按,按,20kcal/kg/d,给,予,予,卡,卡,文,文,1440ML,及,力,力,太,太,100ML,治,疗,疗,，,，,四,四,天,天,后,后,消,消,化,化,道,道,功,功,能,能,初,初,步,步,恢,恢,复,复,，,，,按,按,25kcal/kg/d,同,时,时,加,加,用,用,肠,肠,内,内,营,营,养,养,。,。,初,初,期,期,应,应,用,用,短,短,肽,肽,型,型,肠,肠,内,内,营,营,养,养,剂,剂,，,，,待,待,消,消,化,化,道,道,功,功,能,能,完,完,全,全,恢,恢,复,复,后,后,给,给,予,予,全,全,肠,肠,内,内,营,营,养,养,支,支,持,持,，,，,采,采,用,用,高,高,能,能,高,高,蛋,蛋,白,白,营,营,养,养,（,（,瑞,瑞,高,高,）,）,。,。,病,病,人,人,营,营,养,养,状,状,态,态,改,改,善,善,，,，,血,血,清,清,白,白,蛋,蛋,白,白,由,由,术,术,后,后,早,早,期,期,的,的,27.9g/l,提,高,高,到,到,34.2g/l,。,并,并,逐,逐,渐,渐,可,可,进,进,半,半,流,流,食,食,。,。,术,后,后,第,第,9,天,，,，,病,病,人,人,出,出,现,现,腹,腹,胀,胀,、,、,恶,恶,心,心,、,、,呕,呕,吐,吐,、,、,停,停,止,止,排,排,气,气,排,排,便,便,，,，,腹,腹,痛,痛,轻,轻,微,微,。,。,查,查,体,体,：,：,腹,腹,胀,胀,明,明,显,显,，,，,未,未,见,见,肠,肠,型,型,及,及,蠕,蠕,动,动,波,波,，,，,腹,腹,部,部,未,未,及,及,包,包,块,块,，,，,全,全,腹,腹,轻,轻,压,压,痛,痛,、,、,无,无,反,反,跳,跳,痛,痛,及,及,肌,肌,紧,紧,张,张,。,。,叩,叩,诊,诊,为,为,浊,浊,音,音,，,，,听,听,诊,诊,肠,肠,鸣,鸣,音,音,弱,弱,。,。,腹,腹,部,部,CT,检查，,肠,肠壁广,泛,泛水肿,、,、增厚,，,，肠腔,积,积液少,量,量。诊,断,断为术,后,后炎性,肠,肠梗阻,，,，给予,：,：（,1,）禁食,，,，胃肠,减,减压；,（,（,2,）使用,生,生长抑,素,素持续,静,静脉泵,入,入减少,消,消化液,分,分泌，,减,减少肠,内,内炎性,渗,渗出；,（,（,3,）使用,质,质子泵,抑,抑制剂,剂,剂；（,4,）应用,抗,抗生素,控,控制感,染,染；（,5,）再次,进,进行全,胃,胃肠外,营,营养支,持,持，注,意,意水、,电,电解质,平,平衡，,纠,纠正低,蛋,蛋白血,症,症；（,6,）中医,针,针灸，,及,及新斯,的,的明足,三,三里封,闭,闭。能,量,量按,25kcal/kg/d,给予卡,文,文,1920ML.,加力太,100ML,治疗，,以,以保护,修,修复肠,粘,粘膜屏,障,障，减,少,少细菌,移,移位。,经,经,26,天积极,治,治疗，,病,病人排,气,气排便,，,，腹胀,缓,缓解，,恢,恢复肠,内,内营养,后,后无腹,胀,胀腹痛,，,，无恶,性,性呕吐,。,。术后,5,周可进,半,半流食,，,，无不,适,适症状,。,。,病例模,式,式版本,【,病理,】,：,(,乙状结,肠,肠）部,分,分浆膜,粗,粗糙，,粘,粘膜皱,襞,襞部分,消,消失，,呈,呈暗红,色,色。,镜,镜下,：,：粘膜,灶,灶状坏,死,死，粘,膜,膜下层,水,水肿，,血,血管扩,张,张充血,及,及新鲜,出,出血，,浆,浆膜纤,维,维组织,增,增生。,病例模,式,式版本,【,讨论,】,炎性肠,梗,梗阻的,概,概念最,早,早由黎,介,介寿于,1995,年首次,提,提出，,系,系在腹,部,部手术,后,后早期,，,，由于,手,手术创,伤,伤或腹,腔,腔内炎,症,症等原,因,因导致,肠,肠壁水,肿,肿和渗,出,出而形,成,成的一,种,种机械,性,性与动,力,力性同,时,时存在,的,的粘连,性,性肠梗,阻,阻,其发病,率,率为,0.69%,14%,。常见,于,于手术,范,范围大,，,，肠管,暴,暴露时,间,间长，,腹,腹腔污,染,染重的,病,病例。,本,本病例,均,均有上,述,述特征,。,。腹部,手,手术对,肠,肠管损,伤,伤、腹,腔,腔内积,血,血积液,等,等致炎,物,物质残,留,留，导,致,致肠壁,水,水肿和,渗,渗出并,形,形成粘,