2022年医学专题—广州营养支持讲座(1).ppt

2006/09/09,1,肠外营养(yngyng)支持,第一页，共一百零四页。,2006/09/09,2,患者Z，男，42岁，体重70 kg，急性重症胰腺炎第3天。昨天体温39 oC，胃液500 ml，尿1500 ml，血尿淀粉酶升高(shn o)，血常规示WBC总数及中性WBC升高。如何进行营养支持？,病例(bngl)报告,When?,第二页，共一百零四页。,2006/09/09,3,问题1 谁需要(xyo)营养支持？,第三页，共一百零四页。,2006/09/09,4,营养不良包括营养素摄入不足(bz)、营养素代谢障碍造成的如何营养状态紊乱，包括营养过度。流动门诊患者 1-15%门诊留观患者25-60%住院患者35-65%,营养不良,第四页，共一百零四页。,2006/09/09,5,增加发病率与死亡率延缓伤口愈合(yh)增加并发症延长住院时间增加医疗费用增加再次住院率,营养不良,第五页，共一百零四页。,2006/09/09,6,营养(yngyng)筛查,病史首测参数体重下降体重食欲、恶心(xn)身高摄食量BMI,第六页，共一百零四页。,2006/09/09,7,体质指数(BODY MASS INDEX,BMI)=体重(kg)/身高(shn o)2(m2)等级BMI指数正常值18.5=BMI23.5蛋白质:热量营养不良I级17.0-18.4蛋白质:热量营养不良II级16.0-16.9蛋白质:热量营养不良III级 16,营养(yngyng)筛查,第七页，共一百零四页。,2006/09/09,8,营养(yngyng)筛查,BMI与死亡率 25 kg/m2overweight 30 kg/m2Obese;significant mortality,第八页，共一百零四页。,2006/09/09,9,体重过度降低(jingd)或增加均可视为营养不良，其评判标准为在6个月内因非主观原因比平时体重降低或增加10%左右，或比过去1个月的体重降低或增加5%，或体重为理想体重的20%。理想体重计算公式：男：（身高cm-80）0.710%女：（身高cm-70）0.610%,营养(yngyng)筛查,第九页，共一百零四页。,2006/09/09,10,等级理想体重的正常值90轻度(qn d)营养不良80-90中度营养不良60-79重度营养不良60,营养(yngyng)筛查,第十页，共一百零四页。,2006/09/09,11,Nutritional Riks IndexSubjective global assessmentMalnutrition Universal Screening Tool(MUST)Nutritional Risk Screening(NRS 2002)MNA(elderly),营养(yngyng)筛查,第十一页，共一百零四页。,2006/09/09,12,MUST,0(LOW)1(MEDIUM)2 or more(HIGH)ROUTINE CLINICAL CARE OBSERVE TREAT,Acute disease effectAdd a score of 2 if there hasbeen or is likely to be no ornutritional intake for 5 days,Hospital-refer to dietitian orimplement local policies.Generally food first followed byfood fortification and supplementsCare Homes(as for hospital)Community(as for hospital),BMI(kg/m2)0:20.01:=18.5-20.02 18.5,Weight loss in 3-6 months0:10%,Hospital-document dietary andfluid intake for 3 daysCare Homes(as for hospital)Community-Repeat screening,e.g.from 6 mo(withdietary advice if necessary),Repeat screeningHospital-every weekCare Homes-every monthCommunity-every year forspecial groups,e.g.those 75 y,第十二页，共一百零四页。,2006/09/09,13,NRS 2002,Is BMI 20.5?YesNoHas the patient lost weight within the last 3 months?YesNoHas the patient had a reduced dietary intake in the last week?YesNo4.Is the patient severely ill?(e.g.ICU)YesNo If“No“to all questions,re-screened at weekly intervals.If“Yes“to any question,the final screening is performed.,Answer,Initial screening,第十三页，共一百零四页。,2006/09/09,14,NRS 2002,Final screening(Impaired nutritional status)AbsentScore 0=Normal nutritional statusMildScore 1Wt loss 5%in 3 months or Food intake below 50-75%normal requirement in preceeding weekModerateScore 2Wt loss 5%in 2 months or BMI 18.5 20.5+impaired general condition or Food intake 25-50%normal requirement in preceeding weekSevereScore 3Wt loss 5%in 1 mo(15%in 3 mo)or BMI 18.5+impaired general condition or Food intake 0-25%normal requirement in preceeding week,第十四页，共一百零四页。,2006/09/09,15,NRS 2002,Head injury,bone marrow transplantation,Intensive care patients(APACHE10).,Score 3,Severe,Major abdominal surgery,stroke.Severe pneumonia,hematologic malignancy,Score 2,Moderate,Hip fracture,chronic patients,in particular with acute complications:cirrhosis,COPD,chronic hemodialysis,diabetes,oncology,Score 1,Mild,Normal nutritional requirements,Score 0,Absent,Final screening(Severity of disease),第十五页，共一百零四页。,2006/09/09,16,NRS 2002,Impaired nutritonal statusweight loss%over time,food intake,BMI(Score 0-3)Severity of disease mild to severe(Score 0-3)Age over 70 years ad 1 pointIf the total score is 3 ore more nutritional support is indicated,第十六页，共一百零四页。,2006/09/09,17,问题(wnt)2 给什么？,第十七页，共一百零四页。,2006/09/09,18,水(Water)碳水化合物(Carbohydrate)氨基酸(Amino acids)脂肪(zhfng)(Lipid)维生素(Vitamines)电解质(Electrolytes)微量元素(Trace elements),七大(q d)营养素,第十八页，共一百零四页。,2006/09/09,19,第十九页，共一百零四页。,2006/09/09,20,生理状态下的液体平衡(pnghng)入量（ml）出量（ml）饮水500-1200尿 650-1600固体食物700-1000出汗500（内含水60%97%）粪便50-100物质代谢内生水300呼吸300总计 1500-25001500-2500,水,每克糖、蛋白质和脂肪氧化(ynghu)所产生的水量分别为1.07,0.34,0.56ml,第二十页，共一百零四页。,2006/09/09,21,水,2/3原则(yunz)人体2/3的体重为水重量，人体2/3的水在细胞内液，1/3的水在细胞外液，2/3的细胞外液为组织间液，1/3的水血管内。,第二十一页，共一百零四页。,2006/09/09,22,碳水化合物,葡萄糖 Glucose最常用的碳水化合物制剂，能被所有器官直接利用,大脑优先使用葡萄糖供能，红细胞及白细胞则只能以其为能源物质。每1g葡萄糖产热量4kcal。缺点是它的代谢必须依赖胰岛素，对糖尿病和手术(shush)创伤所致胰岛素不足状态下的病人必须补充外源性胰岛素。,第二十二页，共一百零四页。,2006/09/09,23,碳水化合物,Name Tissue Km glucoseFunctionGLUT 1 most tissues 1 mMBasal uptake of glucose(brain,red cells)GLUT 2 Liver 15 mMuptake and release of glucose Pancreaseby the liver beta-cell glucose beta cellsreceptorGLUT 3 most tissues 1 mMBasal uptakeGLUT 4 skeletal muscle 5 mMInsulin-stimulated Adipose tissueGlucose uptake,Normal blood glucose concentration is 4-8 mM,第二十三页，共一百零四页。,2006/09/09,24,碳水化合物,果糖 Fructose最甜的糖。在无胰岛素条件下转化为肝糖原，对糖尿病、慢性肝炎、肝硬化病人供给能量(nngling)比葡萄糖为佳，对血管壁刺激小，引起血栓性静脉炎的危险性少。大量注入果糖可使血尿酸迅速升高，ATP缺乏，引起恶心、上腹部疼痛以及血管扩张等不良反应。酸中毒病人不宜使用，也不宜单独代替葡萄糖使用,有部分病人不能耐受果糖。,第二十四页，共一百零四页。,2006/09/09,25,碳水化合物,乙醇 Alcohol乙醇代谢产热可达7kcal/g，而不致引起渗透压负荷和不从尿中损失，有的病人用后有舒适感，成人每日可给100g，但大量或长期输入可抑制骨髓造血机能，对肝脏有毒性作用(zuyng)，个人耐受性差异大。作为能量来源，评价不一。,第二十五页，共一百零四页。,2006/09/09,26,脂肪(zhfng),短链脂肪酸（C1-4）甲酸、醋酸、丙酸、丁酸中链脂肪酸（C6-12）己酸、辛酸、癸酸、月桂酸长链脂肪酸（C14以上(yshng)）肉豆蔻酸、棕榈酸、硬脂酸、油酸、亚油酸、亚麻酸,第二十六页，共一百零四页。,2006/0