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1、肠外营养肠外营养非手术肿瘤与肝硬化患者的临床应用肠外营养（肠外营养（perenteral nutrition perenteral nutrition，PNPN）是经静脉为无法经胃肠道摄取或摄取营养物不能满足自身代谢需要的患者提供包括氨基酸、脂肪、碳水化合物、维生素及矿物质在内的营养素，以抑制分解代谢，促进合成代谢并维持结构蛋白的功能。所有营养素完全经肠外获得的营养支持方式称为全肠外营养全肠外营养(total parenteral nutrition,TPN)。定义定义2 Liver Cirrhosis Liver Cirrhosis Liver Cirrhosis Liver Cirrhos
2、isUnless necessary，EN is better thanPN.及及时评估，早期介入估，早期介入Give i.v.glucose(23 g/kg d-1)when patients have to abstain from food for more than 12 h.（C）Give PN when the fasting period lasts longer than 72 h.（C）Consider PN in patients with unprotected airways and encephalopathy when cough and swallow refle
3、xes are compromised.（C）Use early postoperative PN if patients cannot be nourished sufficiently by either oral or enteral route.（A）After liver transplantation,use early postoperative nutrition;PN is second choice to EN.（C）PN is recommended inadequate food and enteral intake(60%of estimated energy exp
4、enditure)is anticipated for more than 10 days or facing a period longer than one week of starvation and enteral nutritional support is not feasible-及及时评估，早期介入估，早期介入Therapeutic goals for PN in cancer patients are the improvement of function and outcome by:（C）：预防和治疗恶病质/减少抗肿瘤治疗的并发症/抑制抗肿瘤治疗的副作用/提高生活质量PN
5、 is ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failure（A）The routine use of PN during chemotherapy,radiotherapy or combined therapy is not recommended(A).PN is recommended in patients with severe mucositis or severe
6、 radiation enteritis（C）Non-surgical Oncology Non-surgical Oncology Non-surgical Oncology Non-surgical Oncology3BMI 2002年ESPEN大会上，推出了用于成年住院患者的营养风险筛查（Nutritional Risk Screening）SGA评估营养状况评估营养状况128个临床RCT，共8944例接受营养支持的患者进行评估，评价营养支持对某些疾病临床结局。4NRS 20025每天肠外营养热卡供给量及构成比热卡卡 25kcal/kg25kcal/kg 葡萄糖 50-60%脂肪 25-
7、50%蛋白质 15%6简单换算公式简单换算公式1g葡萄糖4kcal1g蛋白质氨基酸4kcal1g脂肪9kcal1g氮6.25g蛋白质7每日需补充热卡 60kg*25kcal/kg=1500kcal蛋白质供能（0.8-1g/kg）1g/kg*60kg*4kcal/g=240kcal脂肪乳供能应占非蛋白热量的25-50%（D）：1260kcal*2550%=310-630kcal（35-70g）剩余由葡萄糖供应：630-940kcal（160-235g）以体重为以体重为60kg60kg的患者为例的患者为例8PN配方中应包括谷氨酰胺谷氨酰胺剂量达到0.35g/kg/d对临床结局的影响方显现出统计学意
8、义。(A)0.35*60=21g （100ml，20g）严重肾功能不全（肌酐清除率25ml/分）及严重肝功能不全（失代偿）禁用肠外肠内营养临床指南肠外肠内营养临床指南(2006)中华医学会肠外肠内营养学分会中华医学会肠外肠内营养学分会9存在肝硬化失代偿或肝性脑病的患者，应给以含有BCAA的肠内营养。（A）存在肝性脑病，且需要接受肠外营养的患者可考虑经静脉补充BCAA。(C)不推荐在没有肝性脑病或肝功能不全的患者常规使用静脉BCAA。（D）肠外肠内营养临床指南肠外肠内营养临床指南(2006)10更高效的提供热卡，减少液体量氧化分解时产生较葡萄糖少，减少蓄积补充亚油酸、亚麻酸等必需脂肪酸与氨基酸合
9、用利于改善负氮状态脂肪乳脂肪乳11 Liver Cirrhosis Liver Cirrhosis Liver Cirrhosis Liver CirrhosisProvide energy to cover 1.3 x REE(Resting Energy Expenditure）（C）（35-40kcal/kg）Give glucose to cover 50%-60%of non-protein energy requirements.（C）Reduce glucose infusion rate to 23 g/kg/d in case of hyperglycemia and con
10、sider the use of i.v.insulin.（C）Provide amino acids at 1.21.5 g/kg/d.（C）15 In encephalopathy III or IV,consider the use of solutions rich in BCAA and low in AAA,methionine and tryptophane.（A）Total daily energy expenditure in cancer patients may be assumed to be similar to healthy subjects,or 2025 kc
11、al/kg/day for bedridden and 2530 kcal/kg/day for ambulatory patients.（C）The majority of cancer patients requiring PN for only a short period of time do not need a special formulation.Using a higher than usual percentage of lipid(e.g.50%of non-protein energy),may be beneficial for those with frank ca
12、chexia needing prolonged PN(C)Non-surgical Oncology Non-surgical Oncology Non-surgical Oncology Non-surgical Oncology12成人（以体重60公斤为例）糖电解质输液治疗的推荐方案：水必需量为20002500ml，电解质Na+为50mmol，Cl-为50mmol，K+为2050mmol（A）。肠外肠内营养临床指南肠外肠内营养临床指南(2006)中华医学会肠外肠内营养学分会中华医学会肠外肠内营养学分会水电解质平衡水电解质平衡13简单换算公式简单换算公式1g氯化钠17mmol Na+1.5
13、g氯化钾20mmol K+50mmol3g氯化钠2050mmol1.5g3.75g氯化钾14In alcoholic liver disease,administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernickes encephalopathy.（C）PN制剂中应补充维生素及微量元素维生素及微量元素维生素及微量元素15电解质钠 32mmol1.9g 氯化钠钾 24mmol1.8g 氯化钾微量元素卡文（卡文（14401440mlml）中能量中能量构成构成比比 共共计1000kcal1000
14、kcal葡萄糖 97g：400kcal脂肪 51g：460kcal氨基酸 34g：140kcal16Liver cirrhosisLiver cirrhosisLiver cirrhosisLiver cirrhosis60kg*25kcal/kg*1.3=1950kcal60kg*25kcal/kg=1500kcal卡文1440ml1000kcal谷氨酰胺 or BCAA or 复合氨基酸（1.2-1.5g/kg：72-90g，扣除卡文中尚需 38-56g，150-224kcal）葡萄糖125g 500kcal 20%脂肪乳250ml450kcal补充电解质复合维生素监测血糖，静脉使用胰岛素
15、卡文1440ml1000kcal谷氨酰胺 20g80kcal葡萄糖 100g400kcal(20%脂肪乳 250ml)（lipid 50%）补充电解质复合维生素监测血糖，静脉使用胰岛素Non-surgical oncologyNon-surgical oncologyNon-surgical oncologyNon-surgical oncology17ESPEN Guidelines on Parenteral Nutrition:Hepatology;Clinical Nutrition 28(2009):436-444ESPEN Guidelines on Parenteral Nutrition:Non-surgical oncology;Clinical Nutrition 28(2009):445-454肠外肠内营养临床指南;中华医学会肠外肠内营养学分会（2006）参考文献参考文献18