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1、会计学1surgicalnutrition正式正式(zhngsh)外科营外科营养养第一页，共79页。2Questions n nWhat is surgical nutrition？n nBenefits of Nutritional Support?n nWho requires nutritional support?n nHow can we get nutritional support?第1页/共79页第二页，共79页。3What is surgical nutrition？n nThe nutritional problems in surgical diseasesn nIncl
2、uding enteral and parenteral nutrition第2页/共79页第三页，共79页。Enteral nutritionn nUse of an intact gastrointestinal tract for nutritional supportn nBenefits:physiologic;immunologic;saffety;cost;第3页/共79页第四页，共79页。Indications for enteral feedingn nMalnourished patients who have an intact gastrointratinal trac
3、t should initially be given enteral feeding.第4页/共79页第五页，共79页。Possible contraindications to enteral feedingPossible contraindications to enteral feedingn nShort bowel,gastrointestinal obstruction,gastrointestinal bleeding,ileus,fistulas,diarrhea,protracted vomiting ect.第5页/共79页第六页，共79页。Parenteral nut
4、ritionn nThe gastrointestinal tract can not be used.n nTwo methods:peripheral Parenteral nutrition and total Parenteral nutritionl第6页/共79页第七页，共79页。8Benefits of Nutritional Supportn nPreservation of nutritional statusn nPrevention of complications of protein malnutrition n nPost-operative complicatio
5、ns 第7页/共79页第八页，共79页。9n nNutritional support,along with antibiotics,Nutritional support,along with antibiotics,blood transfusion,critical care monitoring,blood transfusion,critical care monitoring,advances in anesthesia,organ advances in anesthesia,organ transplantation,and cardiopulmonary transplant
6、ation,and cardiopulmonary bypass,ranks high among advances in bypass,ranks high among advances in surgery achieved in the 20th centurysurgery achieved in the 20th century。第8页/共79页第九页，共79页。10n nAlthough modern practice is to make aggressive use of the gut for nutritional supportn n intravenous nutrit
7、ion remains a critical therapy in instances in which enteral support cannot be achievedn neither because the gut cannot be used or because caloric requirements cannot be met by the gut alone and must be supplemented parenterally.第9页/共79页第十页，共79页。11NUTRIENT REQUIREMENTS AND SUBSTRATES n nThe body req
8、uires an energy source to remain in a steady state.n nCalories n nCalories can come from glucose or fat.The metabolism of lg glucose yields 3.4kcal.The metabolism of lg fat yields 9.2kcal.Fat can be used to provide as much as 60%of daily caloric requirements.第10页/共79页第十一页，共79页。12Proteinn nProtein ba
9、lance reflects the sum of protein synthesis and protein breakdown.The quality of a protein is related to its amino acid composition.The 20 amino acids are divided into essential amino acids(EAAs)and nonessential amino acids(NEAAs)depending on whether they can be synthesized in the body.第11页/共79页第十二页
10、，共79页。13Fatty Acids n nFatty acids are classified as short-chain,medium-chain,or long-chain.n nThe body is able to synthesize fats from other dietary substrates,but two of the long-chain fatty acids(linoleic and-linolenic)are essential.n n Efficient functioning of the immune system depends upon a ba
11、lance of eicosanoid production between the-6 and-3 PUFA.第12页/共79页第十三页，共79页。14Vitaminsn n Vitamins are involved in metabolism,wound healing,and immune function.第13页/共79页第十四页，共79页。15Trace Elements n nTrace elements have important functions in metabolism,immunology,and wound healing.n nSubclinical trac
12、e element deficiencies occur in many common diseases.第14页/共79页第十五页，共79页。16Malnutrition Introductionn nMalnutrition occurs in approx.40%of hospitalised patientsMalnutrition occurs in approx.40%of hospitalised patientsn nMalnutrition can lead to increased post-operative morbidity Malnutrition can lead
13、 to increased post-operative morbidity and mortalityand mortalityn nImpairment of skeletal,cardiac,respiratory muscle Impairment of skeletal,cardiac,respiratory muscle functionfunctionn nImpairment of immune functionImpairment of immune functionn nAtrophy of GITAtrophy of GITn nImpaired healingImpai
14、red healing第15页/共79页第十六页，共79页。17Nutritional Pathophysiology第16页/共79页第十七页，共79页。18Pathophysiologyn nProteins and amino acidsn nRequire daily intake 0.8 g kg-1 ie.56 g for a 70 kg personn nEssential:a.a only obtained by dietary sourcen nNon-essential:can be endogenously synthesisedn nconditionally esse
15、ntial:a.a unable to be synthesised under certain conditions eg.Stress,surgeryn nL-alanine,L-glutamate,L-asparateL-alanine,L-glutamate,L-asparate第17页/共79页第十八页，共79页。19PathophysiologyNutritional Balance=N Nutritional Balance=N inputinput-N -N outputoutput1 g N=6.25 g proteinN input=(protein in g/6.25)N
16、 output=24h urinary urea nitrogen+non-urinary N losses(estimated normal non-urinary Nitrogen losses about 3-4g/d)(estimated normal non-urinary Nitrogen losses about 3-4g/d)第18页/共79页第十九页，共79页。20n nFatty acidsn nShort,medium chain FA directly enter portal systemn nLong chain FA transported as triglyce
17、ridesn nEssential FA unable to be synthesised ie.Linoleic and linolenic acid.n nDeficiency causes skin,kidney disordersPathophysiology第19页/共79页第二十页，共79页。21Pathophysiologyn nEnergy requirements:Energy requirements:n nTotal daily expenditure 25-30 kcal kgTotal daily expenditure 25-30 kcal kg-1-1n nRes
18、ting metabolic rateResting metabolic raten nActivity energy expenditureActivity energy expendituren nDiet induced energy expenditureDiet induced energy expendituren nSources:Sources:n nFatsFats9 kcal g9 kcal g-1-1n nProteinProtein4 kcal g4 kcal g-1-1n nCarbohydratesCarbohydrates4 kcal g4 kcal g-1-1n
19、 nAlcohol Alcohol 7 kcal g7 kcal g-1-1第20页/共79页第二十一页，共79页。22Patho-physiologyn nEnergy requirements:n nBMR calculated by Harris-Benedict equationn n66.47+13.75 x W+5 x H 66.47+13.75 x W+5 x H 6.76xA6.76xAn nAdditional caloric needs calculated by an injury factor,eg.n nMinor operation Minor operation
20、1.2 x BMR1.2 x BMRn nTraumaTrauma1.3 x BMR1.3 x BMRn nSepsis Sepsis 1.6 x BMR1.6 x BMRn nBurnsBurns2.1 x BMR2.1 x BMR第21页/共79页第二十二页，共79页。23Pathophysiologyn nVitaminsn nKey metabolic rolesn nFat soluable(A,D,E,K)or water soluable第22页/共79页第二十三页，共79页。24Pathophysiologyn nTrace elementsn nZinc wound heal
21、ing,protein and nucleic acid synthesisn nFe energy transfern nCopper collagen synthesisn nSelenium anti-oxidant enzyme system第23页/共79页第二十四页，共79页。25Pathophysiologyn nChanges in Starvation:n ndecrease energy expenditure,liver glycogen depletion in 24hn nhepatic and muscle gluconeogenesis depleted afte
22、r 24hn nlater consume fat第24页/共79页第二十五页，共79页。26Pathophysiologyn nChanges in trauma and sepsisn nCatabolic phasen nIncrease resting energy expenditureIncrease resting energy expendituren nLoss of body nitrogen,muscle breakdownLoss of body nitrogen,muscle breakdownn nIncrease glucose production(glycog
23、enolysis),deplete liver Increase glucose production(glycogenolysis),deplete liver storesstoresn nIncrease lipolysisIncrease lipolysisn nEarly anabolic phasen nLate anabolic phase第25页/共79页第二十六页，共79页。27Who requires nutritional support?n nPatients already with malnutrition-surgery/trauma/sepsisn nPatie
24、nts at risk of malnutritionn nSurgical patients who have lost more than 10%of their customary body weight will have delayed wound healing and an incridence of postoperative complications.第26页/共79页第二十七页，共79页。28Patients at risk of malnutritionn nDepleted reservesn nCannot eat for 5 daysn nImpaired bow
25、el functionn nCritical Illness n nNeed for prolonged bowel rest第27页/共79页第二十八页，共79页。29How do we detect malnutrition?第28页/共79页第二十九页，共79页。30Nutritional Assessmentn nHistory n nPhysical examinationn nAnthropometric measurementsn nLaboratory investigations第29页/共79页第三十页，共79页。31Historyn nDietary historyDie
26、tary historyn nSignificant weight loss within last 6 monthsSignificant weight loss within last 6 monthsn n 15%loss of body weight 15%loss of body weightn ncompare with ideal weightcompare with ideal weightn nBeware the patient with ascites/oedemaBeware the patient with ascites/oedema第30页/共79页第三十一页，共
27、79页。32History and physical examinationHistory and physical examinationn nThe nutritional assessment is based on information from the history and physical examination.n nA complete medical history is essential to identify factors that predispose the patient to an altered nutritional status.第31页/共79页第
28、三十二页，共79页。33Physical Examinationn nA A careful careful physical physical examination examination begins begins with with an an overall assessment of the patients appearance.overall assessment of the patients appearance.n nEvidence of muscle wastingEvidence of muscle wastingn nDepletion of subcutaneo
29、us fatDepletion of subcutaneous fatn nPeripheral oedema,ascitesPeripheral oedema,ascitesn nFeatures of Vitamin deficiencyFeatures of Vitamin deficiencyn neg nail and mucosal changeseg nail and mucosal changesn nEchymosis and easy bruisingEchymosis and easy bruisingn nEasy to detect 15%lossEasy to de
30、tect 15%loss第32页/共79页第三十三页，共79页。34Anthropometric Measurements n n Anthropometry is the science of assessing body size,weight,and proportions.n n Ideal body weight(IBW)=Height(cm)-l00 x0.9n n Body mass index(BMI)=Weight(kg)/Height(m2)第33页/共79页第三十四页，共79页。35Anthropometric Measurementsn nWeight for Heig
31、ht comparisonn nBody Mass Index(10%decrease)n nTriceps-skinfold n nMid arm muscle circumferencen nBioelectric impedancen nHand grip dynamometryn nUrinary creatinine/height index第34页/共79页第三十五页，共79页。36Laboratory Data n nThe visceral protein reserve is estimated from the serum total protein,albumin,and
32、 transferrin levels;total lymphocyte count;and antigen skin testing.第35页/共79页第三十六页，共79页。37Determining Energy Requirementsn nThe adult daily caloric requirement is calculated by using the total energy expenditure(TEE)equation,which includes three variables-height,weight,and age 第36页/共79页第三十七页，共79页。38
33、Lab investigationsn nalbumin 30 mg/dln npre-albumin 12 mg/dln ntransferrin 150 mmol/ln ntotal lymphocyte count 1800/mm3n ntests reflecting specific nutritional deficitsn neg Prothrombin timeeg Prothrombin timen nSkin anergy testing第37页/共79页第三十八页，共79页。39How can we administrate nutritional support?第38
34、页/共79页第三十九页，共79页。40Nutritional Supportn nTypes Types n nEnteral NutritionEnteral Nutritionn nParenteral NutritionParenteral Nutrition 第39页/共79页第四十页，共79页。41Enteral Feeding is bestn nEnteral nutrition(EN):use of intact gastrointestinal tract for nutritional supportn nBenefits:n nPhysiologic&Metabolicn
35、 nImmunologicn nSafetyn nCost第40页/共79页第四十一页，共79页。42Indications of Enteral Feedingn nWhen nutritional suport is neededn nFunctioning gut presentn nNo contra-indicationsn nno ileusn nno recent anastomosis of gutn nno fistula第41页/共79页第四十二页，共79页。43What can we give in tube feeding?n nBlenderised feedsn n
36、Commercially prepared feeds n nPolymeric n neg Isocal,Ensure,Jevityeg Isocal,Ensure,Jevityn nMonomeric/elemental n neg Vivonexeg Vivonex第42页/共79页第四十三页，共79页。44Complications of enteral feedingComplications of enteral feedingn n12%overall complication raten nGastrointestinal complicationsn nMechanical
37、complicationsn nMetabolic complicationsn nInfectious complications第43页/共79页第四十四页，共79页。45Complications of enteral feedingn nGastrointestinaln nDistensionn nNausea and vomiting n nDiarrhoean nConstipationn nIntestinal ischaemia第44页/共79页第四十五页，共79页。46Complications of enteral feedingComplications of ente
38、ral feedingn nMechanicaln nMalposition of feeding tuben nSinusitisn nUlcerations/erosionsn nBlockage of tubes第45页/共79页第四十六页，共79页。47Complications of enteral feedingn nInfectiousn nAspiration Pneumonian nBacterial contamination第46页/共79页第四十七页，共79页。48Parenteral Nutrition第47页/共79页第四十八页，共79页。49Parenteral
39、NutritionAllows greater caloric intakeBUTIs more expensiveHas more complicationsNeeds more technical expertise第48页/共79页第四十九页，共79页。50Who will benefit from parenteral nutrition?第49页/共79页第五十页，共79页。51IndicationsPatients with/who Patients with/who n nAbnormal Gut functionn nCannot consume adequate amount
40、s of nutrients by enteral feedingn nAre anticipated to not be abe to eat orally by 5 daysn nPrognosis warrants aggressive nutritional support第50页/共79页第五十一页，共79页。52Two main forms of Two main forms of parenteral nutritionparenteral nutritionn nPeripheral Parenteral Nutritionn nCentral(Total)Parenteral
41、 NutritionBoth differ in position of feed2.primary caloric source3.potential complications4.methods of administration第51页/共79页第五十二页，共79页。53Peripheral Parenteral NutritionGiven through peripheral vein1.1.short term use short term use 2.2.mildly stressed patientsmildly stressed patients3.3.low caloric
42、 requirements low caloric requirements 4.4.needs large amounts of fluid needs large amounts of fluid 5.5.contraindications to central TPN(total contraindications to central TPN(total parenteral nutrition)parenteral nutrition)第52页/共79页第五十三页，共79页。54Total Parenteral Nutritionn nWhat to do before starti
43、ng TPN?1.1.Nutritional AssessmentNutritional Assessment2.2.Venous access evaluationVenous access evaluation3.3.Baseline weightBaseline weight4.4.Baseline lab investigationsBaseline lab investigations第53页/共79页第五十四页，共79页。55Venous Access for TPNNeed venous access to a“large”central line with fast flow
44、to avoid thrombophlebitisLong peripheral lineLong peripheral linesubclavian approachsubclavian approachinternal jugular approachinternal jugular approachexternal jugular approachexternal jugular approachSuperior Vena CavaSuperior Vena Cava第54页/共79页第五十五页，共79页。56Steps to administrate TPN1.Determine To
45、tal Fluid Volume2.Determine Non-N Caloric needs3.Determine Protein requirements4.Determine Electrolyte and Trace element requirements5.Determine need for additives第55页/共79页第五十六页，共79页。57How much volume to give?n nCater for maintenance&on going losses n nNormal maintenance requirements n nBy body weig
46、htn nalternatively,30 to 50 ml/kg/dayn nAdd on going losses based on I/O chartn nConsider insensible fluid losses alson neg add 10%for every eg add 10%for every o oC rise in temperatureC rise in temperature第56页/共79页第五十七页，共79页。58Caloric requirementsBased on Total Energy Expendituren nCan be estimated
47、 using predictive equationsTEE=REE+Stress Factor+Activity FactorTEE=REE+Stress Factor+Activity Factorn nCan be measured using metabolic cart第57页/共79页第五十八页，共79页。59Caloric requirementsStress Factor Malnutrition-30%peritonitis+15%soft tissue trauma+15%fracture+20%fever(per oC rise)+13%Moderate infectio
48、n+20%Severe infection+40%40%BSA Burns+100%第58页/共79页第五十九页，共79页。60Caloric requirementsActivity FactorBed-bound+20%Ambulant+30%Active+50%第59页/共79页第六十页，共79页。61Caloric requirementsREE Predictive equationsHarris-Benedict EquationHarris-Benedict EquationMales:REE=66+(13.7W)+(5H)-6.8AMales:REE=66+(13.7W)+(5
49、H)-6.8AFemales:REE=655+(9.6W)+1.8H-4.7AFemales:REE=655+(9.6W)+1.8H-4.7ASchofield EquationSchofield Equation25 to 30 kcal/kg/day25 to 30 kcal/kg/day第60页/共79页第六十一页，共79页。62How much CHO&Fats?“Too much of a good thing causes problems”n nNot more than 4 mg/kg/min Dextrose(less than 6 g/kg/day)(less than 6
50、 g/kg/day)n nNot more than 0.7 mg/kg/min Lipid(less than 1 g/kg/day)(less than 1 g/kg/day)第61页/共79页第六十二页，共79页。63How much CHO&Fats?n nFats usually form 25 to 30%of caloriesn nNot more than 40 to 50%n nIncrease usually in severe stressn nAim for serum TG levels 350 mg/dl or 3.95 mmol/ln nCHO(carbohydr