如何合理实施肠外营养支持吴国豪ppt课件

如何合理实施临床营养支持如何合理实施临床营养支持 How to Implement Rational Clinical Nutrition Therapy 吴国豪吴国豪 复旦大学附属中山医院普外科复旦大学附属中山医院普外科 复旦大学普通外科研究所复旦大学普通外科研究所 为什么需要营养支持为什么需要营养支持? ? 那些病人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？ 第一部分第一部分 Prevalence of malnutritionPrevalence of malnutrition The German hospital malnutrition study Matthias Matthias PirlichPirlich，Clinical Nutrition (2006) 25, 563572Clinical Nutrition (2006) 25, 563572 癌性恶病质的发生率癌性恶病质的发生率 N A Stephens; N A Stephens; MEDICINE MEDICINE 2007;2007;36:36:( (2 2):78-81):78-81 Malnutrition is common in cancer patientsMalnutrition is common in cancer patients Malnutrition occurs in 30-87% of cancer patientsMalnutrition occurs in 30-87% of cancer patients Shills Shills ME;etME;et al: Cancer al: Cancer ResRes 1977; 37: 2366 1977; 37: 2366 Nixon DW et al: Am J Med1980; 68: 683Nixon DW et al: Am J Med1980; 68: 683 TchekmedyianTchekmedyian NS et al: Oncology 1995; 9: 79 NS et al: Oncology 1995; 9: 79 AndreyevAndreyev et et al:Eural:Eur J Cancer 1998;34:503 J Cancer 1998;34:503 MonittoMonitto CL et al: Am J CL et al: Am J PhysiolPhysiol 2001; 281: E289 2001; 281: E289 Stephens NA et al: Stephens NA et al: MMedicineedicine 2007;2007;36:36:( (2 2):78-81):78-81 LOGO 营养不良的危害营养不良的危害 免疫机能下降 脏器功能异常 预后不良 Cumulative Mortality: Protein- Energy Malnutrition CederholmCederholm et al, Am J Med 1995. et al, Am J Med 1995. Mortality %Mortality % Months after admission P Energy Out Weight Gain Energy In 5dICU 5d） 医院死亡（全部病人）医院死亡（全部病人） 医院死亡（住医院死亡（住ICU 5dICU 5d） 死于死于MOFMOF与与SepsisSepsis， 并发症发生：并发症发生： 住住ICUICU天（中位数，住天（中位数，住ICU 5d ICU 5d ） 呼吸支持时间（中位数，呼吸支持时间（中位数，5d of 5d of 住住ICUICU） 需要肾替代治疗需要肾替代治疗 合并高胆红素血症合并高胆红素血症 在在ICUICU发生发生SepsisSepsis 783 0.8% 0.8% 0.0%0.0% 8.0%8.0% 20.2%20.2% 10.9%10.9% 26.3%26.3% 4.2%4.2% 15 day15 day 12 day12 day 8.2%8.2% 26.7%26.7% 7.8%7.8% 765 5.0%5.0% 0.3%0.3% 4.6%4.6% 10.6%10.6% 7.2%7.2% 16.8%16.8% 1.0%1.0% 12 day12 day 10.0 day10.0 day 4.8%4.8% 22.4%22.4% 4.2%4.2% Gastroenterological patients (n=16) =TPN for 2 weeks : Group I: Glucose alone (49 kcal/kg d) Group II: Fat emulsion (60 % of the NP-energy, total 51 kcal/kg/d) “ “Fat in conjunction with glucose may be more effective as an energy Fat in conjunction with glucose may be more effective as an energy source than source than equicaloricequicaloric amounts of glucose alone.” amounts of glucose alone.” Glucose or fat as a non-protein energy source: a controlled clinical trial in gastroenterological patients requiring intravenous nutrition. MacFie J, Gastroenterology 1981; 80:103-107 kg Dual-Energy System: KEY MESSAGES Glucose and lipids as energy source Avoids hyperglycemia Reduces respiratory and metabolic stress Supports the best possible nitrogen retention Guarantees the delivery of essential fatty acids Facilitates peripheral infusion due to low osmolarity Fat requirementsFat requirements Lipid emulsionsLipid emulsions Intralipid Fatty acid pattern of a soybean oil emulsionFatty acid pattern of a soybean oil emulsion Possible consequences of an excessivePossible consequences of an excessive intake intake of omega-6 fatty (linoleic) acidsof omega-6 fatty (linoleic) acids unbalanced fatty acid pattern in cell membranes unbalanced fatty acid pattern in cell membranes modification of the production of lipid mediators modification of the production of lipid mediators ( ( prostaglandins, leukotrienes)prostaglandins, leukotrienes) promotion of immunosuppression and systemic promotion of immunosuppression and systemic inflammatory reactions (trauma, operation, sepsis) inflammatory reactions (trauma, operation, sepsis) Carpentier et al., 1997Carpentier et al., 1997 Are Are soybean oil based emulsions soybean oil based emulsions immunosuppressive ?immunosuppressive ? BattistellaBattistella et al. (1997) J. Trauma 43, 52-60 et al. (1997) J. Trauma 43, 52-60 PolytraumaPolytrauma patients (APACHE II av. 22) patients (APACHE II av. 22) Standard glucose Standard glucose containgcontaing TPN TPN withwith no no lipid vslipid vs. . Intralipid Intralipid (10 (10 daysdays) ) No No differencedifference in CD4/CD8 in CD4/CD8 No No lipidlipid IntralipidIntralipid LengthLength of of staystay (d) (d)27 27 39* 39* ICU ICU staystay (d) (d)1818 29* 29* DaysDays on on ventilatorventilator1515 27* 27* PneumoniaPneumonia (#) (#)1313 22* 22* Total Total infectious infectious complications complications 3939 72 72 No No lipidlipid Lipid Lipid 0 0 5050 100100 150150 200200 250250 300300 % of % of baselinebaseline P = 0.02P = 0.02 NK NK cell activitycell activity Characteristics of MCT vs LCTCharacteristics of MCT vs LCT Types of lipid emulsions L L L L M L L M M/L M/L M/L M/L SLr SLr SLr SLr SLd SLd SLd SLd LPL/HL LCFA + GlycerolMCFA + LCFA + Glycerol 中/长链脂肪乳剂的优点 大量临床与实验结果证实大量临床与实验结果证实 中中 / / 长链脂肪乳剂在临床各长链脂肪乳剂在临床各 个领域均有其代谢优势！个领域均有其代谢优势！ JPEN, 25 (2) Suppl., 2002 Benefits of Structolipid (1) Controlled plasma TG and MCFA levels (Nordenstrm 1995, Flaatten 1995, Kruimel 1997) Reliable source of essential fatty acids As well tolerated as Intralipid (Nordenstrm 1995, Sandstrm 1995, Bellantone 1999) Suitable for long-term PN (Rubin et al 2000) Benefits of Structolipid (2) Rapidly available energy (Sandstrm et al 1995) Improved protein economy compared to LCT and LCT/MCT emulsions (Kruimel et al 1997, Lindgren et al 2001) Excellent mixing properties A handy non-breakable plastic packaging 结构脂肪临床对照研究资料有限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结构脂肪具有物理混合中/ /长链脂长链脂 肪乳剂结构和生化特征并优于后者肪乳剂结构和生化特征并优于后者 从药理角度讲从药理角度讲, ,应用酶学技术应用酶学技术, ,开开 创了脂肪乳剂新领域创了脂肪乳剂新领域, ,可根据各特可根据各特 殊代谢过程需要设计新型制剂殊代谢过程需要设计新型制剂 结构脂肪乳剂结构脂肪乳剂 临床应用评价临床应用评价 含橄榄油脂肪乳剂具有良好的含橄榄油脂肪乳剂具有良好的 安全性和有效性安全性和有效性 含橄榄油脂肪含橄榄油脂肪 乳剂应用评价乳剂应用评价 含橄榄油脂肪乳剂在防止脂质过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含橄榄油脂肪乳剂对机体免疫系统影响 少少, ,适合于小儿和需长期肠外营养病人适合于小儿和需长期肠外营养病人 OmegavenOmegaven as a supplement as a supplement Formulation:Formulation:Lipid emulsionLipid emulsion Lipid source:Lipid source:Fish oilFish oil Concentration: Concentration: 10 % 10 % Special feature:Special feature: High content of High content of -3 fatty acids-3 fatty acids Purpose:Purpose: Supplementation of parenteral Supplementation of parenteral nutrition with long-chain nutrition with long-chain -3 fatty acids-3 fatty acids Packaging:Packaging:50 ;通过调通过调 节炎性介质的产生节炎性介质的产生, ,下调炎性下调炎性 反应反应, ,增强机体免疫功能增强机体免疫功能, ,可改可改 善外科危重病人愈后善外科危重病人愈后 总总 结结 Optimal proportion of lipids in PNOptimal proportion of lipids in PN Recommended daily lipid intake: - - adult: 1.0 - 2.0 g/kgadult: 1.0 - 2.0 g/kg； - - infant: 1.0 - 3.0 g/kg infant: 1.0 - 3.0 g/kg - unstressed patients: 30 - 40% of total calories- unstressed patients: 30 - 40% of total calories - stressed patients: 40 - 55% of total calories- stressed patients: 40 - 55% of total calories Factors to consider: glucose resistance， impaired respiratory capacity Monitoring: Serum triglycerides Ensure patient is not intolerant to any component of the lipid emulsion Proteins/AminoProteins/Amino acids acids The only macronutrients containing nitrogen A variety of different functions: Cell and tissue structure: structural proteins Functional roles: transport proteins blood clotting factors receptors enzymes hormones immune globulines muscle contractility Proteins/Amino acids Healthy adult: 11 kg proteins (male) (muscle) Free AA pool (70 g) Cells plasma ProteinProtein synthesissynthesis (300g/d)(300g/d) ProteolysisProteolysis (300g/d)(300g/d) Oral intake of proteins Enteral nutrition Parenteral nutrition Metabolic processes: - neoglucogenesis - neuromediators - cell energy Waste (CO2, urea) Protein/Amino acids 20 different amino acids Nitrogen content (g/L) x 6.25= AA (g/L) Amino acids are linked via peptide bonds Amino acidAmino acid 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 Nitrogen requirementsNitrogen requirements Amino acid/nitrogen dosage ? 0.5 1.5 g (max. 2 g) /kg/day nitrogen 0.15 0.2 g/kg/day ca. 40% essential amino acids high quality Max. infusion rate: 0.1 g / kg and hour Role of electrolytesRole of electrolytes Electrolyte requirements in PNElectrolyte requirements in PN Role of trace elementsRole of trace elements Daily trace element requirementsDaily trace element requirements VitaminsVitamins Daily vitamin requirements in PNDaily vitamin requirements in PN 规范肠外营养输注规范肠外营养输注用全合一形式用全合一形式 全合一的定义全合一的定义 全合一的优点全合一的优点 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 全合一的优点全合一的优点 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 全合一配制的环境和设备要求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 RTU Multi-Chamber Bags (MCB)RTU Multi-Chamber Bags (MCB) All-in-OneAll-in-One Individual vs Individual vs standardisedstandardised UK - almost 100% AIO by 1995UK - almost 100% AIO by 1995 Estimated (1996) 80% adults on PN could use Estimated (1996) 80% adults on PN could use standardisedstandardised regimens regimens Current Perspectives on PN in Adults. BAPEN Working Party 1996 Current Perspectives on PN in Adults. BAPEN Working Party 1996 StandardisedStandardised Regimens Regimens IndividualisedIndividualised prescriptions rarely needed prescriptions rarely needed (cost 20:528 535.pharmacies in Switzerland, France, and Belgium. Nutrition 2004;20:528 535. Single-bottle systems required more items and manipulations. 3 CBs satisfied the needs of over 80% of the adult long-term TPN patients for the last 5 years. Three-chamber bags: Practical Aspects Clinical Nutrition 2000, 19: 245-251 Kabiven Central and Peripheral 3CB Central high (2566 ml) Peripheral Suppl. (1440 ml) Central Suppl. (1026 ml) Peripheral Low (1920 ml) Central Low (1540 ml) Peripheral Basic (2400 ml) Central Basic (2053 ml) 1000 ml bag 1500 ml bag2500 ml bag 2000 ml bag 600 800 1000 1200 1400 1600 1800 2000 2200 481216 gN Individualised Individualised vsvs Standardised Regimens Standardised Regimens Time/availability Time/availability Delays in startingDelays in starting Stability issuesStability issues Library of regimensLibrary of regimens High N/High cal/PPN/Low N/Low cal/Low High N/High cal/PPN/Low N/Low cal/Low volvol (critically ill, post-op, oncology, home PN, (critically ill, post-op, oncology, home PN, fluid restricted etc)fluid restricted etc) Ready To Use (RTU)Ready To Use (RTU) Multi-Chamber Bags (MCB)Multi-Chamber Bags (MCB) StandardisedStandardised Regimens Regimens IndividualisedIndividualised prescriptions rarely needed prescriptions rarely needed (cost decrease wastage; promote Better biochemical stability; decrease wastage; promote weight gainweight gain Outcome - no differencesOutcome - no differences cost effectiveness in doubt .the considerable flexibility cost effectiveness in doubt .the considerable flexibility of computer prescribing allowing of computer prescribing allowing individualisationindividualisation.is .is of little or no benefit to patientsof little or no benefit to patients CadeCade A et al. Does the computer improve the nutritional support of the A et al. Does the computer improve the nutritional support of the newborn? newborn? ClinClin NutrNutr 1997 16 19-23 1997 16 19-23 Key studies on benefits of AIOs and 3 CBs Patients: n= 40, after major surgery or trauma Intervention: TPN with SBS (n= 21) or as AIO (n=19) for 5 days Results:-AIO was well tolerated -SBS required: a) More equipment (e.g. Infusion pumps, disposable infusion sets) b) More manpower (e.g. to fix technical alarms) All-in-one bag versus single-bottle-system in critically ill patients: a prospective randomized trial Ebener C, Clin Nutr 2002 (Abstract) Objective: Introduction of a new PN order form proposing AIO was compared to the old order form asking for an individualised regimen. Results: - Standardised TPN regime decrease the risk of error from 93 to 11 % Key studies on benefits of AIOs and 3 CBs Standardized TPN order form reduces staff time and potential for error. Mitchell KA et al. Nutrition1990;6(6):457-60 危重病人的低热卡营养支持危重病人的低热卡营养支持 1994年Zaloga首先提出“ “Permissive Underfeeding”Permissive Underfeeding” 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“ “允许性摄入不足允许性摄入不足” ” 概念 Permissive UnderfeedingPermissive Underfeeding 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 Yamazaki K J Yamazaki K J SurgSurg ResRes 1986;40:152 1986;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0 Alexander JW Ann Alexander JW Ann SurgSurg 1989,209:334 1989,209:334 Permissive UnderfeedingPermissive Underfeeding NolenNolen等等比较限制食物的大鼠(2040)和自由饮 食大鼠, 虽然前者生长慢、体积小, 但存活时间显著 延长(856/924 vs. 706 天) Nolen GA J Nolen GA J NutrNutr 1972;102:1477 1972;102:1477 BergBerg