创伤与手术病人营养

1、第21章 创伤和手术病人的营养治疗 1背景知识background 创伤(wound):是指机械损伤。Machine hurt. 创伤、手术WoundOperation负氮平衡negative nitrogen balance 代谢需求Metabolic demand 保证手术、创伤后的营养需求，促进机体恢复。Keep nutrition demand of wound and operation .Promote recovery2 1. 严重创伤病人的营养治疗 The nutritional therapy of serious wound 2. 围手术期病人的营养治疗 The nutri

2、tional therapy of perioperative period 3. 短肠综合征病人的营养治疗 The nutritional therapy of short bowel syndrome 4. 肠瘘病人的营养治疗The nutritional therapy of intestinal fistula 3严重创伤和大手术的病人，高代谢状态，常伴有免疫功能低下。Metabolic demand is increased during wound healing and operation. Depress immune function. 仅提供充足的能量和氮源的营养治疗方法，

3、并不能有效的恢复病人的免疫功能。Enough energy and nitrogen source only can not recover immune function effectively.4一、营养代谢特点Characteristic of nutrient metabolism 二、营养治疗与饮食指导Nutrition therapy and dietary guidance 5能量代谢Energymetabolism 糖代谢Glucose metabolism 蛋白质代谢Proteinmetabolism脂肪代谢Fat metabolism静息能量消耗（rest energy e

4、xpenditure, REE）增加。 儿茶酚胺分泌增加，血糖升高Catecholamine secretion, blood glucose increased 分解增加，负氮平衡Decomposition increased negative nitrogen balance 脂肪动员增加Fat mobilization increase 6早期使用肠外营养，病人肠道功能容许尽早使用肠内营养。parenteral nutrition should be used, patients who bowel function allowed should use enteral nutritio

5、n earlier.膳食由流质饮食、半流质饮食、软质饮食向普通饮食过渡。 Diet transform from liquid diet, semi-liquid diet, soft diet diet to normal diet gradually.能量Energy早期，分解代谢，15001800kcal/d early period, catabolism 恢复，合成代谢，20002500kcal/d recovery, anabolic 能量需求基础能量消耗（BEE）活动系数体温系数应激系数 男性BEE=66.4713.75体重（kg）5.00身高（cm）6.76年龄（岁）女性BEE

6、=655.109.46体重（kg）1.85身高（cm）4.68年龄（岁）7糖和脂肪Carbohydrate and fat 蛋白质Protein蛋白质供给量应达到23g/（kgd）优质蛋白占50%以上。 Protein supply should reach 2 3g / (kg d) High-quality protein, accounting for more than 50%.增加谷氨酰胺的供给量，促进恢复。Increase the supply of glutamine to promote recovery.提供能量和必须脂肪酸。 Provide energy and essen

7、tial fatty acids.脂肪供能应占总能量的30%35%，其余所需能量由碳水化合物和蛋白质提供。Fat account for 30% 35% total energy ,and the rest required providing by the carbohydrate and protein. 8矿物质与维生素Minerals and vitamin 促进组织修复，胶原合成。由含以上营养素丰富的食物提供，必要时也可使用相应制剂。Promote tissue recovery, collagen synthesis. Provide with food contained ric

8、h nutrients, if necessary, can also use corresponding agents. 9一、营养代谢特点Characteristic of nutrient metabolism 二、营养治疗与饮食指导Nutrition therapy and dietary guidance 10 手术创伤初期，机体处于应激状态，表现为交感-肾上腺髓质系统兴奋。 肾上腺素、去甲肾上腺素、糖皮质激素、生长激素和胰高血糖素分泌增加，从而影响营养物质的代谢 。 At the initial surgical wound time, the body is in stress,

9、 manifested as sympathetic - adrenal system excited. Epinephrine, norepinephrine, glucocorticoid, growth hormone and glucagon secrete increasingly , and affecting the metabolism of nutrients.11糖代谢Glucose metabolism 脂肪代谢Fat metabolism蛋白质代谢Proteinmetabolism水、电解质代谢 Water and electrolyte metabolism 分解增加

10、，负氮平衡Decomposition increased negative nitrogen balance分解过度，必需脂肪酸缺乏Over decomposition lack of essential fatty acids 儿茶酚胺分泌增加，血糖升高Catecholamine secretion, blood glucose increased水、电解质代谢紊乱Water, electrolyte metabolism disorder 12手术前的营养治疗与饮食指导Pre-operative nutritional therapy and dietary guidance 术前应尽量改

11、善病人的血红蛋白、血清总蛋白及其他各项营养指标，最大限度地提高其手术耐受力。 preoperative patients hemoglobin, serum total protein and other nutritional indicators should be tried to improve to maximize the tolerance of its operation.尽量采用肠内营养治疗，严重营养不良消化吸收功能障碍者，可联合或单独使用肠外营养治疗。Use of enteral nutrition therapy as far as possible, Digestion

12、 and absorption of severe malnutrition dysfunction may jointly or separately use of parenteral nutrition therapy. 13能 量Energy每日能量供给20002500kcal。Daily energy supply ： 2000 2500kcal 碳水化合物为主要能量来源，占总能量的65。Carbohydrates as the main energy source, accounting for 65% of total energy. 脂肪、蛋白质Fat and Protein脂

13、肪供给量低于正常人，占总能量的1520。Lower than normal supply, Fat supply accounts for 15-20% of total energy.蛋白质充足，优质蛋白占50。Adequate protein supply, high-quality protein, accounting for more than 50%.14矿物质与维生素Minerals and vitamin 每天供给维生素C100mg，胡萝卜素3mg、维生素B1、B2各56mg，维生素PP5060mg，有凝血机制障碍者加用维生素K15mg。术前710天开始补充.Preoperat

14、ive day 7 to 10 added 15手术后的营养治疗与饮食指导Post-operative nutritional therapy and dietary guidance 以肠内营养为主，膳食多从要素营养制剂开始，辅以营养免疫剂，逐步经过流质饮食、半流质饮食、软质饮食向普通饮食过渡。通常采用少食多餐的供餐方式，必要时可采用肠外营养治疗，或肠内、肠外联合营养治疗。 Enteral nutrition first. At the beginning, elements of nutrition diet should be supplied, supplemented with im

15、mune agents. Diet transition from a liquid diet, semi-liquid diet, soft to ordinary diet gradually. If necessary, parenteral nutrition or enteral, parenteral nutrition combined therapy can be treated.16胃肠道手术Gastrointestinal surgery 禁食少渣半流食、半流食 软食 Fasting Semi-flow low residue food, semi-flow foodsof

16、t diet 肝、胆、脾手术 Liver, gallbladder, spleen surgery 低脂、高蛋白的半流饮食；肝硬化流质软食 Low-fat, semi-flow high-protein diet; cirrhosis liquid diet. 17口腔、咽喉部手术 Mouth, throat surgery 禁食冷流质饮食 少渣半流食 软食 Fasting Cold liquid diet Semi-flow low residue foodsoft diet 其他部位手术 Other parts of the operation 颅脑损伤和昏迷 管饲肠内营养 慢性消耗性疾病

17、 高蛋白膳食 18能 量Energy卧床休息男性病人，每日供给能量2000kcal，女性为1800kcal。Male patient with bed rest, daily supply of energy is 2000kcal, and women is 1800kcal. 能经常下床活动后，应增加到25003000kcal。patients who can activity should be increased to 2500 3000kcal. 能量需求基础能量消耗（BEE）活动系数体温系数应激系数 男性BEE=66.4713.75体重（kg）5.00身高（cm）6.76年龄（岁）

18、女性BEE=655.109.46体重（kg）1.85身高（cm）4.68年龄（岁）19糖、脂肪、蛋白质Energy糖每天供给量300400g，脂肪供给总能量的20%30% 。Supply of Carbohydrate 300 400g a day, supply of fat account to 20% 30% of total energy.蛋白质供给充足，每日供给量应达100140g。Adequate supply of protein. 100 140g protein should be supplied per day.矿物质与维生素Minerals and vitamin维生素

19、C，术后每日供给5001000mg。B族维生素每日给予量可增加至正常供给量的23倍。Vitamin C should be supplied with 5001000mg per day.the volume of Vitamin B should be supplied 2 to 3 times more than normal.钾、钠、镁、锌、铁 Potassium, sodium, magnesium, zinc, iron 20一、营养代谢特点Characteristic of nutrient metabolism 二、营养治疗与饮食指导Nutrition therapy and d

20、ietary guidance 21 短肠综合征是指小肠切除后，因小肠吸收面积不足，造成营养素吸收不良，引起以腹泻、水电解质紊乱和进行性营养不良等为主要临床表现的综合征。 Short bowel syndrome is caused by the volvulus, mesentery angei-embolism and serious abdominal injury, malignant tumor and so on, which will lead to be cut and reduce absorption surface of the small intestines to a

21、rouse the malabsorption syndrome.22三大供能营养素多数维生素部分矿物质降低Main energy nutrients majority of vitamin part of mineralswill decrease. 维生素B12胆汁酸吸收障碍Vitamin B12 Bile acid absorption will decrease.小肠排空加快营养吸收不充分Speed up the emptying of small intestine andnutrient absorption is inadequate. 消化液损失胃肠道动力紊乱 Digestiv

22、e juice loss Gastrointestinal motility disorders 23肠外营养 Parenteral nutrition 肠内营养 Enteral nutrition 谷氨酰胺和生长激素 能量供给量为3040kcal/（kgd），采用糖和脂肪双能源形式供给，糖/脂比为1:12:1；氮的供给量为0.150.20g/（kg.d），氮/热比为1:167为宜 用低蛋白、低脂肪流食作为过渡，增加对肠道的刺激。由每次2030ml开始，若病人能耐受，无胃肠道不良反应，可增至每次50100m1，每日36次。食物宜选用稀米汤、稀藕粉、果汁水、维生素糖水等。谷氨酰胺与生长激素联合应

23、用，可以增加短肠综合征病人残存小肠对营养素的吸收，能提高肠粘膜对谷氨酰胺的利用率，维持肠黏膜正常结构和功能，并且显著减少肠外营养需要量。 24一、营养代谢特点Characteristic of nutrient metabolism 二、营养治疗与饮食指导Nutrition therapy and dietary guidance 25 肠瘘是指肠管与腹腔其他空腔脏器，或与体表间存在异常的通道。肠内容物漏出体表称为外瘘，漏入其他空腔脏器称为内瘘。外伤、手术、炎性肠道疾病、肿瘤、放射性损伤等多种因素均可造成肠瘘。 Intestinal fistula is defined that some intestinal contents come out of the intestines and enter into the cavum visc