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1、全 胃 肠 外 营 养Total Parenteral Nutrition,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,20世纪下半叶外科领域的5大里程碑,1.Transplantation 2.Medical Imagination 3.ICU 4.Key-hole surgery 5.TPN,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,全
2、胃肠外营养,1986年2月，上海周绮思女士因患急性肠扭转切除全部小肠，依靠全胃肠外营养（TPN）长期健康生存.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,全胃肠外营养,1992年4月8日，蔡惟成为世界上完全依靠全胃肠外营养（TPN）孕育的第一人，载入吉尼斯世界纪录。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,全胃肠外营养,全胃肠外营养(T
3、otal Parenteral Nutrition,TPN):又称静脉高营养(Intravenous Hyperlimentation,IVH)即不经口也不经胃管或胃肠造口,而是经静脉输注营养液来供应病人所需要的全部营养物质。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN的实现,营养生理学对人体正常和疾病时的代谢特点和营养需要量的研究成果,各种静脉营养制剂，尤其是结晶氨基酸和脂肪乳剂的研制成功并投入工业化生产；,硅橡胶导管的研制成功和深静脉插管技术的开发。,TP
4、N,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN输入途径,1.经周围静脉(PVC)2.经中心静脉(CVC)3.经周围置中心静脉(PICC),Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital O
5、f K.M.C.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN适应证,1胃肠道梗阻2胃肠道吸收功能障碍：短肠综合征：广泛小肠切除7080 小肠疾病：免疫系统疾病、肠缺血、多发肠瘘 放射性肠炎 严重腹泻、顽固性呕吐7天3重症胰腺炎：先输液抢救休克或MODS，待生命体征 平稳后，若肠麻痹未消除、无
6、法完全耐受肠内营养，则属肠外营养适应证。4高分解代谢状态：大面积烧伤、严重复合伤、感染等。5严重营养不良：蛋白质-热量缺乏型营养不良常伴胃肠 功能障碍,无法耐受肠内营养。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,应用TPN对治疗有益,大手术、创伤的围手术期,肠外瘘,炎性肠道疾病,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,应用TPN对治疗
7、有益,4,5,6,妊娠剧吐,持续5-7天以上的呕吐者,严重营养不良 的肿瘤病人,重要脏器功能不全,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN禁忌证,胃肠道功能正常，适应肠内营养。心血管功能或严重代谢紊乱需要控制者。需急诊手术，不因应用TPN而耽误时间。不可治愈、无存活希望、临终或不可逆昏迷病人,1,2,3,4,“If the gut works,use it.”,Department Of Gastrointestinal and Thyroid Surger
8、y,1st Affilliated Hospital Of K.M.C.,TPN组成,葡萄糖1.肠外营养的主要能源物质。2.机体所有组织、器官都能利用葡萄糖。3.高浓度（25，50）葡萄糖渗透压高，对静脉壁刺激性大，不能经周围静脉输注。4.来源丰富，价格低廉，监测方便。5.5070的非蛋白热量，7g/kg/d。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN组成,脂肪乳剂1.高能物质，每克氧化产热9.3kcal，为葡萄糖的 2.3倍，2030的非蛋白热量，应激状态
9、可达 50，2g/kg/d。2.颗粒直径0.6m，几乎无渗透压并发症；3.肝脏对脂肪乳剂中间代谢和转运具有重要作用,单 脂肪乳剂为非蛋白能源时，可发生酮症；4.价格昂贵，约为葡萄糖的15倍。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN组成,脂肪乳剂6.脂肪乳剂最大用量为2g/kg/d7.LCT包含EFA，MCT不含EFA，代谢过程不依赖 肉毒碱。8.对肝功能不良病人，选用LCT/MCT乳剂（1：1）9.鱼油（一3脂肪酸）：具有调节免疫功能、减轻炎症反应和抑制血
10、小板聚集等功能。10.一般主张采用双能源系统。11.肿瘤组织缺乏降解脂肪的关键酶，很少利用 脂肪供能。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN组成,氨基酸1.是肠外营养的唯一氮源。2.蛋白质含氮量:16%,蛋白质系数:6.25;成人在基础需要量的情况下，每日最 低供应量为氮0.10.2g/kg/d，即复方 氨基酸0.7g/kg/d；3.实际上，由于希望得到较好的正氮平衡，每日至少应供应复方氨基酸1g/kg/d；4.热量与氮之比为100150:1，此时氨基
11、酸利用最佳。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN组成,氨基酸5.分平衡型和特殊型。6.芳香氨基酸(aromaticamino-acids,AAA)包括苯丙氨酸，酪氨酸和色氨酸，主要在肝脏代谢。支链氨基酸(branched chain amino-acids,BCAA)包括缬氨酸、亮氨酸和异亮氨酸，属EAA，主要在肌肉代谢，可通过血脑屏障，在肝性脑病时应用。,Department Of Gastrointestinal and Thyroid Surge
12、ry,1st Affilliated Hospital Of K.M.C.,TPN组成,1.谷氨酰胺 2.水、电解质和微量元素 3.维生素,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN每日推荐剂量,能量:2030Kcal/(kg.d)水:3040mlkg(每1Kcal/kg/d 给水量11.5ml)葡萄糖:24g/(kg.d)脂肪:11.5g/(kg.d)氮量:0.10.25g/(kg.d)氨基酸:0.61.5g/(kg.d)电解质:钠 80100mmol 钾
13、60150mmol 氯 80100mmol 钙 510mmol 镁 812mmol 磷 1030mmol脂溶性维生素：A 2500IU D100IU E10mg K110mg水溶性维生素：B1 3mg B2 3.6mgB6 4 mgB12 5 ug 泛酸15mg 烟酰胺40mg叶酸400ugC 100mg微量元素：铜0.3mg 碘131ug 锌3.2mg 硒3060ug 钼19ug 锰0.20.3mg 铬1020ug 铁1.2mg,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M
14、.C.,全营养混合液（Total Nutrients Administration）,全营养混合液（Total Nutrients Administration）三升袋：把各种营养液在体外预先混合在三升塑料袋内，再同时输入。各营养素同时进入体内，各司其职，最接近生理条件 避免了单一营养液输入的一些副作用：高浓度葡萄糖被稀释使之可以周围静脉输注 避免了脂肪乳剂输入过快的副反应。,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN并发症,Department Of Gas
15、trointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN并发症,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN并发症,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,TPN监测,1.全身情况 2.电解质3.肝功能 4.肾功能 5.营养指标 6.血糖,Dep
16、artment Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Discussion in cases,A 40 year male,recurrent fistula formation in the distal jejunum.He has lost 6 kg in 2 weeks.A central PN catheter is placed and you are asked to write a TPN order.The patient weighs 70 kg.,Departm
17、ent Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Estimated Needs,Calories30 kcal/kg x 70 kg=2100 kcalProtein1.2 g/kg x 70 kg=84 gFluids30 ml/kg x 70 kg=2100 ml,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Step 1:Add Protein,1.84
18、g of protein2.4 kcal/g x 84 g=326 kcal3.2100 kcal 326 kcal=1774 kcal more required,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Step 2:Add lipids,1.1-1.5 g/kg2.70 kg x 1 g/kg=70 g3.70 g=700 kcal4.1774 calories 700 kcal=1074 kcal remaining,Department Of Gastro
19、intestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Step 3:Add Carbohydrate,1.1074 kcal remaining2.1074/3.4 kcal/g carbohydrate=295 gDouble check for maximal carbohydrate infusion295 g carbohydrate/70 kg=4.21 g/kg/d 7g/kg/d,Department Of Gastrointestinal and Thyroid Surgery,1st Affilli
20、ated Hospital Of K.M.C.,Step 4：Determine a Volume,1.70 kg x 30 ml/kg=2100 ml2.Add multivitamins3.Add trace minerals4.Add drugs if necessary,Department Of Gastrointestinal and Thyroid Surgery,1st Affilliated Hospital Of K.M.C.,Step 5：Determine the Components,What if the TPN Form Asks Me to Add Components asSolutions?15%amino acids(15 g/100 ml)We need 84 g=560 ml20%Lipids(20 g/100ml)We need 70 g=350 ml50%Glucose(50 g/100 ml)We need 295 g=590 mlH20 2100 ml volume 1500 ml=600 ml H20Add trace minerals,multivitamins and other drugs,
