肠外与肠内营养的文献1.ppt
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Nutritional Support
Surgical Nutrition Advisory Team
National University Hospital, Singapore
Nutritional Support may supplement normal feeding, or completely replace normal feeding into the gastrointestinal tract
Benefits of Nutritional Support
? Preservation of nutritional status
? Prevention of complications of pritein malnutrition
? ? Post-operative complications
Who requires nutritional support?
? Patients already with malnutrition - surgery/trauma/sepsis
?Patients at risk of malnutrition
Patients at risk of malnutrition
Depleted reserves
Cannot eat for > 5 days
Impaired bowel function
Critical Illness
Need for prolonged bowel rest
How do we detect malnutrition?
Nutritional Assessment
History
Physical examination
Anthropometric measurements
Laboratory investigations
Nutritional Assessment
History
? Dietary history
? Significant weight loss within last 6 months
? > 15% loss of body weight
? compare with ideal weight
? Beware the patient with ascites/ oedema
Types of Nutritional Support
Enteral Nutrition
Parenteral Nutrition
Enteral Feeding is best
More physiologic
Less complications
Gut mucosa preserved
No bacterial translocation
Cheaper
Enteral Feeding is indicated
When nutritional suport is needed
Functioning gut present
No contra-indications
no ileus, no recent anastomosis, no fistula
Types of feeding tubes
Naso-gastric tubes
Oro-gastric tubes
Naso-duodenal tubes
Naso-jejunal tubes
Types of feeding tubes
Gastrostomy tubes
? Percutaneous Endoscopic Gastrostomy (PEG)
? Open Gastrostomy
Jejunostomy tubes
What can we give in tube feeding?
Blenderised feeds
Commercially prepared feeds
? Polymeric
? eg Isocal, Ensure, Jevity
? Monomeric / elemental
? eg Vivonex
Complications of enteral feeding
12% overall complication rate
Gastrointestinal complications
Mechanical complications
Metabolic complications
Infectious complications
Complications of enteral feeding
Gastrointestinal
Distension
Nausea and vomiting
Diarrhoea
Constipation
Intestinal ischaemia
Complications of enteral feeding
Infectious
Aspiration Pneumonia
Bacterial contamination
Complications of enteral feeding
Mechanical
Malposition of feeding tube
Sinusitis
Ulcerations / erosions
Blockage of tubes
Parenteral Nutrition
Parenteral Nutrition
Allows greater caloric intake
BUT
Is more expensive
Has more complications
Needs more technical expertise
Who willbenefit from parenteral nutrition?
Patients with/who
? Abnormal Gut function
? Cannot consume adequate amounts of nutrients by enteral feeding
? Are anticipatedto not be abe to eat orally by 5 days
? Prognosiswarrants aggressive nutritional support
Two main forms of
parenteral nutrition
? Peripheral Parenteral Nutrition
? Central (Total) Parenteral Nutrition
Both differ in
Peripheral Parenteral Nutrition
Given through peripheralvein
? short term use
? mildly stressed patients
? low caloric requirements
? needslarge amounts of fluid
? contraindications to central TPN
What to do before starting TPN
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
Venous Access for TPN
Need venous access to a "large" central line with fast flow to avoid thrombophlebitis
Baseline Lab Investigations
? Full blood count
? Coagulation screen
? Screening Panel # 1
? Ca++, Mg++, PO42-
? Lipid Panel # 1
? Other tests when indicated
Steps to ordering TPN
Steps to ordering TPN
How much volume to give?
? Cater for maintenance & on going losses
? Normal maintenance requirements
? By body weight
? alternatively, 30 to 50 ml/kg/day
? Add on going losses based on I/O chart
? Consider insensible fluid losses also
? eg add 10% for every oC rise in temperature
Steps to ordering TPN
Caloric requirements
Based on Total Energy Expenditure
? Can be estimated using predictive equations
TEE = REE + Stress Factor + Activity Factor
? Can be measured using metabolic cart
Caloric requirements
Stress Factor
Caloric requirements
Activity Factor
Caloric requirements
REE Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W) + (5H) - 6.8A
Females: REE= 655 + (9.6W) + 1.8H - 4.7A
Schofield Equation
25 to 30 kcal/kg/day
How much CHO & Fats?
? "Too much of a good thing causes problems"
? Not more than 4 mg / kg / min Dextrose
(less than 6 g / kg / day)
Rosmarin et al, Nutr Clin Pract 1996,11:151-6
? Not more than 0.7 mg / kg / min Lipid
(less than 1 g / kg / day)
Moore & Cerra, 1991
How much CHO & Fats?
? Fats usually form 25 to 30% of calories
? Not more than 40 to 50%
? Increase usually in severe stress
? Aim for serum TG levels < 350 mg/dl or 3.95 mmol / l
? CHO usually form 70-75 % ofcalories
Steps to ordering TPN
How much protein to give?
? Based on calorie : nitrogen ratio
? Based on degree of stress & body weight
? Based on Nitrogen Balance
Calorie : Nitrogen Ratio
Normal ratio is
150 cal : 1g Nitrogen
Critically ill patients
85 to 100 cal : 1 g Nitrogen in
Based on Stress & BW
? Non-stress patients0.8 g / kg / day
? Mild stress 1.0 to 1.2 g / kg / day
? Moderate stress1.3 to 1.75 g / kg / day
? Severe stress2 to 2.5 g / kg / day
Based on Nitrogen Balance
Aim for positive balance of......（后略) ......
Nutritional Support
Surgical Nutrition Advisory Team
National University Hospital, Singapore
Nutritional Support may supplement normal feeding, or completely replace normal feeding into the gastrointestinal tract
Benefits of Nutritional Support
? Preservation of nutritional status
? Prevention of complications of pritein malnutrition
? ? Post-operative complications
Who requires nutritional support?
? Patients already with malnutrition - surgery/trauma/sepsis
?Patients at risk of malnutrition
Patients at risk of malnutrition
Depleted reserves
Cannot eat for > 5 days
Impaired bowel function
Critical Illness
Need for prolonged bowel rest
How do we detect malnutrition?
Nutritional Assessment
History
Physical examination
Anthropometric measurements
Laboratory investigations
Nutritional Assessment
History
? Dietary history
? Significant weight loss within last 6 months
? > 15% loss of body weight
? compare with ideal weight
? Beware the patient with ascites/ oedema
Types of Nutritional Support
Enteral Nutrition
Parenteral Nutrition
Enteral Feeding is best
More physiologic
Less complications
Gut mucosa preserved
No bacterial translocation
Cheaper
Enteral Feeding is indicated
When nutritional suport is needed
Functioning gut present
No contra-indications
no ileus, no recent anastomosis, no fistula
Types of feeding tubes
Naso-gastric tubes
Oro-gastric tubes
Naso-duodenal tubes
Naso-jejunal tubes
Types of feeding tubes
Gastrostomy tubes
? Percutaneous Endoscopic Gastrostomy (PEG)
? Open Gastrostomy
Jejunostomy tubes
What can we give in tube feeding?
Blenderised feeds
Commercially prepared feeds
? Polymeric
? eg Isocal, Ensure, Jevity
? Monomeric / elemental
? eg Vivonex
Complications of enteral feeding
12% overall complication rate
Gastrointestinal complications
Mechanical complications
Metabolic complications
Infectious complications
Complications of enteral feeding
Gastrointestinal
Distension
Nausea and vomiting
Diarrhoea
Constipation
Intestinal ischaemia
Complications of enteral feeding
Infectious
Aspiration Pneumonia
Bacterial contamination
Complications of enteral feeding
Mechanical
Malposition of feeding tube
Sinusitis
Ulcerations / erosions
Blockage of tubes
Parenteral Nutrition
Parenteral Nutrition
Allows greater caloric intake
BUT
Is more expensive
Has more complications
Needs more technical expertise
Who willbenefit from parenteral nutrition?
Patients with/who
? Abnormal Gut function
? Cannot consume adequate amounts of nutrients by enteral feeding
? Are anticipatedto not be abe to eat orally by 5 days
? Prognosiswarrants aggressive nutritional support
Two main forms of
parenteral nutrition
? Peripheral Parenteral Nutrition
? Central (Total) Parenteral Nutrition
Both differ in
Peripheral Parenteral Nutrition
Given through peripheralvein
? short term use
? mildly stressed patients
? low caloric requirements
? needslarge amounts of fluid
? contraindications to central TPN
What to do before starting TPN
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
Venous Access for TPN
Need venous access to a "large" central line with fast flow to avoid thrombophlebitis
Baseline Lab Investigations
? Full blood count
? Coagulation screen
? Screening Panel # 1
? Ca++, Mg++, PO42-
? Lipid Panel # 1
? Other tests when indicated
Steps to ordering TPN
Steps to ordering TPN
How much volume to give?
? Cater for maintenance & on going losses
? Normal maintenance requirements
? By body weight
? alternatively, 30 to 50 ml/kg/day
? Add on going losses based on I/O chart
? Consider insensible fluid losses also
? eg add 10% for every oC rise in temperature
Steps to ordering TPN
Caloric requirements
Based on Total Energy Expenditure
? Can be estimated using predictive equations
TEE = REE + Stress Factor + Activity Factor
? Can be measured using metabolic cart
Caloric requirements
Stress Factor
Caloric requirements
Activity Factor
Caloric requirements
REE Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W) + (5H) - 6.8A
Females: REE= 655 + (9.6W) + 1.8H - 4.7A
Schofield Equation
25 to 30 kcal/kg/day
How much CHO & Fats?
? "Too much of a good thing causes problems"
? Not more than 4 mg / kg / min Dextrose
(less than 6 g / kg / day)
Rosmarin et al, Nutr Clin Pract 1996,11:151-6
? Not more than 0.7 mg / kg / min Lipid
(less than 1 g / kg / day)
Moore & Cerra, 1991
How much CHO & Fats?
? Fats usually form 25 to 30% of calories
? Not more than 40 to 50%
? Increase usually in severe stress
? Aim for serum TG levels < 350 mg/dl or 3.95 mmol / l
? CHO usually form 70-75 % ofcalories
Steps to ordering TPN
How much protein to give?
? Based on calorie : nitrogen ratio
? Based on degree of stress & body weight
? Based on Nitrogen Balance
Calorie : Nitrogen Ratio
Normal ratio is
150 cal : 1g Nitrogen
Critically ill patients
85 to 100 cal : 1 g Nitrogen in
Based on Stress & BW
? Non-stress patients0.8 g / kg / day
? Mild stress 1.0 to 1.2 g / kg / day
? Moderate stress1.3 to 1.75 g / kg / day
? Severe stress2 to 2.5 g / kg / day
Based on Nitrogen Balance
Aim for positive balance of......（后略) ......
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