重症病人的TPN治疗_精品文档优质PPT.ppt

1、Total Poisonous Nutrition？TPNTotal parenteral nutrition:potion or poison?Khursheed N JeejeebhoyAm J Clin Nutr 2001;74:1603.PN标准治疗n肠衰竭nTPN出现前，大量小肠切除后的严重营养不良，导致较高的病死率（即使EN和生长激素的肠康复治疗，TPN仍是短肠综合征早期必须的）。国内外均有HPN维持病人正常生活的病例。n n危重病人危重病人nHeyland 荟萃分析了26个随机对照的临床实验。其中2211例危重病人接受了TPN，TPN（相对于口服+葡萄糖）并不影响总体病死率。TP

2、N可减少并发症率（特别是营养不良病人）。Heyland DK,MacDonald S,Keefe L,et al.Total parenteral nutrition in the critically ill patient.A meta-analysis.JAMA 1998;280:20139.n13个随机对照的临床实验（1100病人）显示，术前TPN可降低10%的并发症的风险，术后TPN可增加并发症的风险。Klein S,Kinney J,Jeejeebhoy KN,et al.Nutrition support in clinical practice:review of publis

3、hed data and recommendations for future research directions.Summary of a conference sponsored by the National Institutes of Health,American Society for Parenteral and Enteral Nutrition,and American Society for Clinical Nutrition.Am J Clin Nutr 1997;66:683706.n395例营养不良病人接受开腹/胸手术，TPN组（TPN for 7 to 15

4、days before surgery and 3 days afterward）感染并发症增加。亚组分析，重度营养不良者围手术期TPN相对对照组非感染并发症降低，感染并发症无差异。VA TPN Cooperative Study.Perioperative total parenteral nutrition in surgical patients.N Engl J Med 1991;325:52532.n90例营养不良（weight loss of 10%or more）胃结直肠癌病人，TPN组（10 days of preoperative and 9 days of postoper

5、ative）可减少1/3的并发症的发生率。Bozzetti F,Gavazzi C,Miceli R,et al.Perioperative total parenteralnutrition in malnourished,gastrointestinal cancer patients:a randomized,clinical trial.JPEN J Parenter Enteral Nutr 2000;24:714.EN的益处n防止黏膜萎缩n动物实验显示，TPN可导致肠黏膜萎缩Miura S,Tanaka S,Yoshioka M,et al.Changes in intestina

6、l absorption of nutrients and brush border glycoproteins after total parenteral nutrition in rats.Gut 1992;33:4849.n但是，对照组？（Rats allowed free access to food were used as controls.）n8位正常志愿者接受TPN 14 天，内镜空肠活检肠黏膜萎缩。Buchman AL,Moukarzel AA,Bhuta S,et al.Parenteral nutrition is associated with intestinal

7、morphologic and functional changes in humans.JPEN J Parenter Enteral Nutr.1995 Nov-Dec;19（6）:453-60.n但是，对照组？（None）。不允许人类长期禁饮食而不输液。TPN肠黏膜萎缩?禁食，饥饿肠萎缩!not only mucosa,but also muscle莫须有n n防止细菌易位防止细菌易位n n血、肠浆膜、系膜淋巴结和肝培养可发现与肠道内相血、肠浆膜、系膜淋巴结和肝培养可发现与肠道内相同的细菌。同的细菌。n细菌易位是人类（动物）spontaneous event n肠道废用导致的肠黏膜萎缩，

8、可增加细菌易位。n实际上，临床上，PN并不比EN更常见细菌易位导致的有实际意义的感染。n即使肠梗阻病人，细菌易位更常见，临床上也鲜见因此所致的腹腔脓肿、肝脓肿或脓毒症。n细菌易位能否引起实际意义的感染，可能与细菌的质、量和机体的免疫力有关。营养素与脓毒症n能量摄入过多带来的并发症的风险与高血糖有关，而高糖血症似乎与脓毒症有关。Zaloga GP,Roberts P.Permissive underfeeding.New Horiz 1994;2:25763.n无论PN还是EN，过多的能量摄入都可造成脓毒症的风险。nMoore的随机对照的实验显示，在腹部手术病人，接受TPN者脓毒症的发生率高于给

9、予EN者。但是，TPN组摄入的能量（包括葡萄糖）明显高于EN组。（注：86%的病人耐受EN）Moore FA,Moore EE,Jones TN,et al.TEN versus TPN following major abdominal trauma-reduced septic morbidity.J Trauma 1989;29:91623.nCerra的随机对照的实验显示，在脓毒症病人，EN并未预期地降低MOSF的发生率（相对于TPN）。Cerra FB,McPherson JP,Konstantinides FN,et al.Enteral nutrition does not pr

10、event multiple organ failure syndrome（MOSF）after sepsis.Surgery 1988;104:72733.并发症n总体并发症，Lipmann总结了9个随机对照实验，7个实验显示EN高于PN。Lipman TO.Grains or veins:is enteral nutrition really better than parenteral nutrition?A look at the evidence.JPEN J Parenter Enteral Nutr 1998;22:16782.n制剂的进步减少了TPN代谢并发症nLCT/MCTn

11、alpha-tocopherol-enriched LCT/MCT nstructured lipids（SL）nglutamine supplementation总结nTPN最适合于肠衰竭的病人，对于合并营养不良的危重病人是有益的。nOverfeeding易发生于TPN（EN少见），可能增加并发症。n有经验的专业人员（experienced team）控制下的TPN并不比EN产生更多的并发症。n在EN不能满足预定摄入的情况下，PN为补充途径。Khursheed N Jeejeebhoy.Total parenteral nutrition:Am J Clin Nutr 2001;1603.T

12、PN能量与氨基酸供给n n通常认为，危重病人的每日能量消耗（通常认为，危重病人的每日能量消耗（EEEE）比正常静息能比正常静息能量消耗（量消耗（REEREE）高出高出50%50%，约，约3636kcal/kgkcal/kg。Elwyn DH,Kinney JM,Askanazi J.Energy expenditure in surgical patients.Surg Clin North Am 1981;61:54556.n n许多文献报告危重病人的许多文献报告危重病人的REEREE为为36403640kcal/kgkcal/kg。Hwang TL,Huang SL,Chen MF.The

13、 use of indirect calorimetry in critically ill patients:the relationship of measured energy expenditure to Injury Severity Score,Septic Severity Score,and APACHE II Score.J Trauma 1993;34:24751.Frankenfield DC,Omert LA,Badellino MM,et al.Correlation between measured energy expenditure and clinically

14、 obtained variables in trauma and sepsis patients.JPEN J Parenter Enteral Nutr 1994;18:398403.n n实际上，许多危重病人的实际上，许多危重病人的REEREE是正常的。是正常的。ZaunerZauner的研究结的研究结果是果是2323kcal/kgkcal/kg。其他一些文献报告为其他一些文献报告为22-2522-25kcal/kg kcal/kg（before/during TPN）（before/during TPN）。Zauner C,Schuster BI,Schneeweiss B.Simil

15、ar metabolic responses to standardized total parenteral nutrition of septic and nonseptic critically ill patients.Am J Clin Nutr 2001;26570.Hoffer Hoffer LJ.LJ.Protein and energy provision in critical illness.Am J Clin Nutr 2003;748:90611.EE预测nHB公式计算值比实际测量值高出10%左右。n从HB公式可以看出：nREE随年龄增长而下降n在一特定时期，病人的身高、和年龄是不变的，因疾病或饥饿而变化只有体重。肥胖和消瘦均影响计算值。Harris-Benedict EquationMales:REE=66.5+13.75W+5.003H-6.775AFemales:REE=655.1+9.563W+1.850H-4.676A where W is