創(chuàng)傷與手術病人營養(yǎng)

1、第21章 創(chuàng)傷和手術病人的營養(yǎng)治療 1背景知識background 創(chuàng)傷(wound):是指機械損傷。Machine hurt. 創(chuàng)傷、手術WoundOperation負氮平衡negative nitrogen balance 代謝需求Metabolic demand 保證手術、創(chuàng)傷后的營養(yǎng)需求，促進機體恢復。Keep nutrition demand of wound and operation .Promote recovery2 1. 嚴重創(chuàng)傷病人的營養(yǎng)治療 The nutritional therapy of serious wound 2. 圍手術期病人的營養(yǎng)治療 The nutri

2、tional therapy of perioperative period 3. 短腸綜合征病人的營養(yǎng)治療 The nutritional therapy of short bowel syndrome 4. 腸瘺病人的營養(yǎng)治療The nutritional therapy of intestinal fistula 3嚴重創(chuàng)傷和大手術的病人，高代謝狀態(tài)，常伴有免疫功能低下。Metabolic demand is increased during wound healing and operation. Depress immune function. 僅提供充足的能量和氮源的營養(yǎng)治療方法，

3、并不能有效的恢復病人的免疫功能。Enough energy and nitrogen source only can not recover immune function effectively.4一、營養(yǎng)代謝特點Characteristic of nutrient metabolism 二、營養(yǎng)治療與飲食指導Nutrition therapy and dietary guidance 5能量代謝Energymetabolism 糖代謝Glucose metabolism 蛋白質代謝Proteinmetabolism脂肪代謝Fat metabolism靜息能量消耗（rest energy e

4、xpenditure, REE）增加。 兒茶酚胺分泌增加，血糖升高Catecholamine secretion, blood glucose increased 分解增加，負氮平衡Decomposition increased negative nitrogen balance 脂肪動員增加Fat mobilization increase 6早期使用腸外營養(yǎng)，病人腸道功能容許盡早使用腸內營養(yǎng)。parenteral nutrition should be used, patients who bowel function allowed should use enteral nutritio

5、n earlier.膳食由流質飲食、半流質飲食、軟質飲食向普通飲食過渡。 Diet transform from liquid diet, semi-liquid diet, soft diet diet to normal diet gradually.能量Energy早期，分解代謝，15001800kcal/d early period, catabolism 恢復，合成代謝，20002500kcal/d recovery, anabolic 能量需求基礎能量消耗（BEE）活動系數(shù)體溫系數(shù)應激系數(shù) 男性BEE=66.4713.75體重（kg）5.00身高（cm）6.76年齡（歲）女性BEE

6、=655.109.46體重（kg）1.85身高（cm）4.68年齡（歲）7糖和脂肪Carbohydrate and fat 蛋白質Protein蛋白質供給量應達到23g/（kgd）優(yōu)質蛋白占50%以上。 Protein supply should reach 2 3g / (kg d) High-quality protein, accounting for more than 50%.增加谷氨酰胺的供給量，促進恢復。Increase the supply of glutamine to promote recovery.提供能量和必須脂肪酸。 Provide energy and essen

7、tial fatty acids.脂肪供能應占總能量的30%35%，其余所需能量由碳水化合物和蛋白質提供。Fat account for 30% 35% total energy ,and the rest required providing by the carbohydrate and protein. 8礦物質與維生素Minerals and vitamin 促進組織修復，膠原合成。由含以上營養(yǎng)素豐富的食物提供，必要時也可使用相應制劑。Promote tissue recovery, collagen synthesis. Provide with food contained ric

8、h nutrients, if necessary, can also use corresponding agents. 9一、營養(yǎng)代謝特點Characteristic of nutrient metabolism 二、營養(yǎng)治療與飲食指導Nutrition therapy and dietary guidance 10 手術創(chuàng)傷初期，機體處于應激狀態(tài)，表現(xiàn)為交感-腎上腺髓質系統(tǒng)興奮。 腎上腺素、去甲腎上腺素、糖皮質激素、生長激素和胰高血糖素分泌增加，從而影響營養(yǎng)物質的代謝 。 At the initial surgical wound time, the body is in stress,

9、 manifested as sympathetic - adrenal system excited. Epinephrine, norepinephrine, glucocorticoid, growth hormone and glucagon secrete increasingly , and affecting the metabolism of nutrients.11糖代謝Glucose metabolism 脂肪代謝Fat metabolism蛋白質代謝Proteinmetabolism水、電解質代謝 Water and electrolyte metabolism 分解增加

10、，負氮平衡Decomposition increased negative nitrogen balance分解過度，必需脂肪酸缺乏Over decomposition lack of essential fatty acids 兒茶酚胺分泌增加，血糖升高Catecholamine secretion, blood glucose increased水、電解質代謝紊亂Water, electrolyte metabolism disorder 12手術前的營養(yǎng)治療與飲食指導Pre-operative nutritional therapy and dietary guidance 術前應盡量改

11、善病人的血紅蛋白、血清總蛋白及其他各項營養(yǎng)指標，最大限度地提高其手術耐受力。 preoperative patients hemoglobin, serum total protein and other nutritional indicators should be tried to improve to maximize the tolerance of its operation.盡量采用腸內營養(yǎng)治療，嚴重營養(yǎng)不良消化吸收功能障礙者，可聯(lián)合或單獨使用腸外營養(yǎng)治療。Use of enteral nutrition therapy as far as possible, Digestion

12、 and absorption of severe malnutrition dysfunction may jointly or separately use of parenteral nutrition therapy. 13能 量Energy每日能量供給20002500kcal。Daily energy supply ： 2000 2500kcal 碳水化合物為主要能量來源，占總能量的65。Carbohydrates as the main energy source, accounting for 65% of total energy. 脂肪、蛋白質Fat and Protein脂

13、肪供給量低于正常人，占總能量的1520。Lower than normal supply, Fat supply accounts for 15-20% of total energy.蛋白質充足，優(yōu)質蛋白占50。Adequate protein supply, high-quality protein, accounting for more than 50%.14礦物質與維生素Minerals and vitamin 每天供給維生素C100mg，胡蘿卜素3mg、維生素B1、B2各56mg，維生素PP5060mg，有凝血機制障礙者加用維生素K15mg。術前710天開始補充.Preoperat

14、ive day 7 to 10 added 15手術后的營養(yǎng)治療與飲食指導Post-operative nutritional therapy and dietary guidance 以腸內營養(yǎng)為主，膳食多從要素營養(yǎng)制劑開始，輔以營養(yǎng)免疫劑，逐步經(jīng)過流質飲食、半流質飲食、軟質飲食向普通飲食過渡。通常采用少食多餐的供餐方式，必要時可采用腸外營養(yǎng)治療，或腸內、腸外聯(lián)合營養(yǎng)治療。 Enteral nutrition first. At the beginning, elements of nutrition diet should be supplied, supplemented with im

15、mune agents. Diet transition from a liquid diet, semi-liquid diet, soft to ordinary diet gradually. If necessary, parenteral nutrition or enteral, parenteral nutrition combined therapy can be treated.16胃腸道手術Gastrointestinal surgery 禁食少渣半流食、半流食 軟食 Fasting Semi-flow low residue food, semi-flow foodsof

16、t diet 肝、膽、脾手術 Liver, gallbladder, spleen surgery 低脂、高蛋白的半流飲食；肝硬化流質軟食 Low-fat, semi-flow high-protein diet; cirrhosis liquid diet. 17口腔、咽喉部手術 Mouth, throat surgery 禁食冷流質飲食 少渣半流食 軟食 Fasting Cold liquid diet Semi-flow low residue foodsoft diet 其他部位手術 Other parts of the operation 顱腦損傷和昏迷 管飼腸內營養(yǎng) 慢性消耗性疾病

17、 高蛋白膳食 18能 量Energy臥床休息男性病人，每日供給能量2000kcal，女性為1800kcal。Male patient with bed rest, daily supply of energy is 2000kcal, and women is 1800kcal. 能經(jīng)常下床活動后，應增加到25003000kcal。patients who can activity should be increased to 2500 3000kcal. 能量需求基礎能量消耗（BEE）活動系數(shù)體溫系數(shù)應激系數(shù) 男性BEE=66.4713.75體重（kg）5.00身高（cm）6.76年齡（歲）

18、女性BEE=655.109.46體重（kg）1.85身高（cm）4.68年齡（歲）19糖、脂肪、蛋白質Energy糖每天供給量300400g，脂肪供給總能量的20%30% 。Supply of Carbohydrate 300 400g a day, supply of fat account to 20% 30% of total energy.蛋白質供給充足，每日供給量應達100140g。Adequate supply of protein. 100 140g protein should be supplied per day.礦物質與維生素Minerals and vitamin維生素

19、C，術后每日供給5001000mg。B族維生素每日給予量可增加至正常供給量的23倍。Vitamin C should be supplied with 5001000mg per day.the volume of Vitamin B should be supplied 2 to 3 times more than normal.鉀、鈉、鎂、鋅、鐵 Potassium, sodium, magnesium, zinc, iron 20一、營養(yǎng)代謝特點Characteristic of nutrient metabolism 二、營養(yǎng)治療與飲食指導Nutrition therapy and d

20、ietary guidance 21 短腸綜合征是指小腸切除后，因小腸吸收面積不足，造成營養(yǎng)素吸收不良，引起以腹瀉、水電解質紊亂和進行性營養(yǎng)不良等為主要臨床表現(xiàn)的綜合征。 Short bowel syndrome is caused by the volvulus, mesentery angei-embolism and serious abdominal injury, malignant tumor and so on, which will lead to be cut and reduce absorption surface of the small intestines to a

21、rouse the malabsorption syndrome.22三大供能營養(yǎng)素多數(shù)維生素部分礦物質降低Main energy nutrients majority of vitamin part of mineralswill decrease. 維生素B12膽汁酸吸收障礙Vitamin B12 Bile acid absorption will decrease.小腸排空加快營養(yǎng)吸收不充分Speed up the emptying of small intestine andnutrient absorption is inadequate. 消化液損失胃腸道動力紊亂 Digestiv

22、e juice loss Gastrointestinal motility disorders 23腸外營養(yǎng) Parenteral nutrition 腸內營養(yǎng) Enteral nutrition 谷氨酰胺和生長激素 能量供給量為3040kcal/（kgd），采用糖和脂肪雙能源形式供給，糖/脂比為1:12:1；氮的供給量為0.150.20g/（kg.d），氮/熱比為1:167為宜 用低蛋白、低脂肪流食作為過渡，增加對腸道的刺激。由每次2030ml開始，若病人能耐受，無胃腸道不良反應，可增至每次50100m1，每日36次。食物宜選用稀米湯、稀藕粉、果汁水、維生素糖水等。谷氨酰胺與生長激素聯(lián)合應

23、用，可以增加短腸綜合征病人殘存小腸對營養(yǎng)素的吸收，能提高腸粘膜對谷氨酰胺的利用率，維持腸黏膜正常結構和功能，并且顯著減少腸外營養(yǎng)需要量。 24一、營養(yǎng)代謝特點Characteristic of nutrient metabolism 二、營養(yǎng)治療與飲食指導Nutrition therapy and dietary guidance 25 腸瘺是指腸管與腹腔其他空腔臟器，或與體表間存在異常的通道。腸內容物漏出體表稱為外瘺，漏入其他空腔臟器稱為內瘺。外傷、手術、炎性腸道疾病、腫瘤、放射性損傷等多種因素均可造成腸瘺。 Intestinal fistula is defined that some intestinal contents come out of the intestines and enter into the cavum visc