1、,第21章 创伤和手术病人的营养治疗,背景知识 background,创伤(wound):是指机械损伤。Machine hurt.,创伤、手术 Wound Operation,负氮平衡 negative nitrogen balance,代谢需求 Metabolic demand,保证手术、创伤后的营养需求，促进机体恢复。 Keep nutrition demand of wound and operation . Promote recovery,1. 严重创伤病人的营养治疗The nutritional therapy of serious wound,2. 围手术期病人的营养治疗 The
2、 nutritional therapy of perioperative period,3. 短肠综合征病人的营养治疗 The nutritional therapy of short bowel syndrome,4. 肠瘘病人的营养治疗 The nutritional therapy of intestinal fistula,严重创伤和大手术的病人，高代谢状态，常伴有免疫功能低下。 Metabolic demand is increased during wound healing and operation. Depress immune function.,仅提供充足的能量和氮源的
3、营养治疗方法，并不能有效的恢复病人的免疫功能。 Enough energy and nitrogen source only can not recover immune function effectively.,一、营养代谢特点 Characteristic of nutrient metabolism,二、营养治疗与饮食指导 Nutrition therapy and dietary guidance,能量代谢 Energy metabolism,糖代谢 Glucose metabolism,蛋白质代谢 Protein metabolism,脂肪代谢 Fat metabolism,静息能
4、量消耗 （rest energy expenditure, REE）增加。,儿茶酚胺分泌增加，血糖升高 Catecholamine secretion,blood glucose increased,分解增加，负氮平衡 Decomposition increased negative nitrogen balance,脂肪动员增加 Fat mobilization increase,早期使用肠外营养，病人肠道功能容许尽早使用肠内营养。 parenteral nutrition should be used, patients who bowel function allowed should
5、use enteral nutrition earlier.,膳食由流质饮食、半流质饮食、软质饮食向普通饮食过渡。 Diet transform from liquid diet, semi-liquid diet, soft diet diet to normal diet gradually.,能 量 Energy,早期，分解代谢，15001800kcal/d early period, catabolism,恢复，合成代谢，20002500kcal/d recovery, anabolic,能量需求基础能量消耗（BEE）活动系数体温系数应激系数男性BEE=66.4713.75体重（kg）
6、5.00身高（cm）6.76年龄（岁）女性BEE=655.109.46体重（kg）1.85身高（cm）4.68年龄（岁）,糖和脂肪 Carbohydrate and fat,蛋白质 Protein,蛋白质供给量应达到23g/（kgd） 优质蛋白占50%以上。Protein supply should reach 2 3g / (kg d) High-quality protein, accounting for more than 50%.,增加谷氨酰胺的供给量，促进恢复。 Increase the supply of glutamine to promote recovery.,提供能量和必
7、须脂肪酸。Provide energy and essential fatty acids.,脂肪供能应占总能量的30%35%，其余所需能量由碳水化合物和蛋白质提供。 Fat account for 30% 35% total energy ,and the rest required providing by the carbohydrate and protein.,矿物质与维生素 Minerals and vitamin,促进组织修复，胶原合成。由含以上营养素丰富的食物提供，必要时也可使用相应制剂。,Promote tissue recovery, collagen synthesis.
8、 Provide with food contained rich nutrients, if necessary, can also use corresponding agents.,一、营养代谢特点 Characteristic of nutrient metabolism,二、营养治疗与饮食指导 Nutrition therapy and dietary guidance,手术创伤初期，机体处于应激状态，表现为交感-肾上腺髓质系统兴奋。 肾上腺素、去甲肾上腺素、糖皮质激素、生长激素和胰高血糖素分泌增加，从而影响营养物质的代谢 。,At the initial surgical woun
9、d time, the body is in stress, manifested as sympathetic - adrenal system excited. Epinephrine, norepinephrine, glucocorticoid, growth hormone and glucagon secrete increasingly , and affecting the metabolism of nutrients.,糖代谢 Glucose metabolism,脂肪代谢 Fat metabolism,蛋白质代谢 Protein metabolism,水、电解质代谢 Wa
10、ter and electrolyte metabolism,分解增加，负氮平衡 Decomposition increased negative nitrogen balance,分解过度，必需脂肪酸缺乏 Over decomposition lack of essential fatty acids,儿茶酚胺分泌增加，血糖升高 Catecholamine secretion,blood glucose increased,水、电解质代谢紊乱 Water, electrolyte metabolism disorder,手术前的营养治疗与饮食指导 Pre-operative nutritio
11、nal therapy and dietary guidance,术前应尽量改善病人的血红蛋白、血清总蛋白及其他各项营养指标， 最大限度地提高其手术耐受力。preoperative patients hemoglobin, serum total protein and other nutritional indicators should be tried to improve to maximize the tolerance of its operation.,尽量采用肠内营养治疗， 严重营养不良消化吸收功能障碍者，可联合或单独使用肠外营养治疗。Use of enteral nutrit
12、ion therapy as far as possible, Digestion and absorption of severe malnutrition dysfunction may jointly or separately use of parenteral nutrition therapy.,能 量 Energy,每日能量供给20002500kcal。 Daily energy supply ： 2000 2500kcal,碳水化合物为主要能量来源，占总能量的65。 Carbohydrates as the main energy source, accounting for
13、65% of total energy.,脂肪、蛋白质 Fat and Protein,脂肪供给量低于正常人，占总能量的1520。 Lower than normal supply, Fat supply accounts for 15-20% of total energy.,蛋白质充足，优质蛋白占50。 Adequate protein supply, high-quality protein, accounting for more than 50%.,矿物质与维生素 Minerals and vitamin,每天供给维生素C100mg， 胡萝卜素3mg、 维生素B1、B2各56mg，
14、维生素PP5060mg， 有凝血机制障碍者加用维生素K15mg。,术前710天开始补充. Preoperative day 7 to 10 added,手术后的营养治疗与饮食指导 Post-operative nutritional therapy and dietary guidance,以肠内营养为主，膳食多从要素营养制剂开始，辅以营养免疫剂，逐步经过流质饮食、半流质饮食、软质饮食向普通饮食过渡。通常采用少食多餐的供餐方式，必要时可采用肠外营养治疗，或肠内、肠外联合营养治疗。,Enteral nutrition first. At the beginning, elements of nu
15、trition diet should be supplied, supplemented with immune 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.,胃肠道手术 Gastrointestinal surgery,禁食,少渣半流食、半流食,软食
16、,Fasting,Semi-flow low residue food, semi-flow food,soft diet,肝、胆、脾手术Liver, gallbladder, spleen surgery,低脂、高蛋白的半流饮食；肝硬化流质软食Low-fat, semi-flow high-protein diet; cirrhosis liquid diet.,口腔、咽喉部手术Mouth, throat surgery,禁食,冷流质饮食,少渣半流食,软食,Fasting,Cold liquid diet,Semi-flow low residue food,soft diet,其他部位手术
17、Other parts of the operation,颅脑损伤和昏迷,管饲肠内营养,慢性消耗性疾病,高蛋白膳食,能 量 Energy,卧床休息男性病人， 每日供给能量2000kcal，女性为1800kcal。 Male patient with bed rest, daily supply of energy is 2000kcal, and women is 1800kcal.,能经常下床活动后，应增加到25003000kcal。 patients who can activity should be increased to 2500 3000kcal.,能量需求基础能量消耗（BEE）
18、活动系数体温系数应激系数男性BEE=66.4713.75体重（kg）5.00身高（cm）6.76年龄（岁）女性BEE=655.109.46体重（kg）1.85身高（cm）4.68年龄（岁）,糖、脂肪、 蛋白质 Energy,糖每天供给量300400g，脂肪供给总能量的20%30% 。 Supply of Carbohydrate 300 400g a day, supply of fat account to 20% 30% of total energy.,蛋白质供给充足，每日供给量应达100140g。 Adequate supply of protein. 100 140g protein
19、 should be supplied per day.,矿物质与维生素 Minerals and vitamin,维生素C，术后每日供给5001000mg。B族维生素 每日给予量可增加至正常供给量的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.,钾、钠、镁、锌、铁 Potassium, sodium, magnesium, zinc, iron,一、营养代谢特点 Characte
20、ristic of nutrient metabolism,二、营养治疗与饮食指导 Nutrition therapy and dietary guidance,短肠综合征是指小肠切除后，因小肠吸收面积不足，造成营养素吸收不良，引起以腹泻、水电解质紊乱和进行性营养不良等为主要临床表现的综合征。,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
21、cut and reduce absorption surface of the small intestines to arouse the malabsorption syndrome.,三大供能营养素 多数维生素 部分矿物质降低 Main energy nutrients majority of vitamin part of minerals will decrease.,维生素B12 胆汁酸吸收障碍 Vitamin B12 Bile acid absorption will decrease.,小肠排空加快 营养吸收不充分 Speed up the emptying of small
22、 intestine and nutrient absorption is inadequate.,消化液损失 胃肠道动力紊乱 Digestive juice loss Gastrointestinal motility disorders,能量供给量为3040kcal/（kgd），采用糖和脂肪双能源形式供给，糖/脂比为1:12:1；氮的供给量为0.150.20g/（kg.d），氮/热比为1:167为宜,用低蛋白、低脂肪流食作为过渡，增加对肠道的刺激。由每次2030ml开始，若病人能耐受，无胃肠道不良反应，可增至每次50100m1，每日36次。食物宜选用稀米汤、稀藕粉、果汁水、维生素糖水等。,
23、谷氨酰胺与生长激素联合应用，可以增加短肠综合征病人残存小肠对营养素的吸收，能提高肠粘膜对谷氨酰胺的利用率，维持肠黏膜正常结构和功能，并且显著减少肠外营养需要量。,一、营养代谢特点 Characteristic of nutrient metabolism,二、营养治疗与饮食指导 Nutrition therapy and dietary guidance,肠瘘是指肠管与腹腔其他空腔脏器，或与体表间存在异常的通道。肠内容物漏出体表称为外瘘，漏入其他空腔脏器称为内瘘。外伤、手术、炎性肠道疾病、肿瘤、放射性损伤等多种因素均可造成肠瘘。,Intestinal fistula is defined th
24、at some intestinal contents come out of the intestines and enter into the cavum viscera of the abdomen caused by the abnormal perforation in the intestinal wall. The common intestinal fistula in the clinic is caused by the incomplete suture of the intestinal wall, the artificial anus, the trauma of
25、the abdomen, the infection of the abdomen or the tumour.,水、电解质紊乱和酸碱平衡失调 Water, electrolyte and acid-base balance disorders.,消化酶大量丢失 Digestive enzymes missing,营养物质摄入不足 Inadequate intake of nutrients,热能供给为2025kcal/（kgd），以糖和脂肪乳双能源的形式供能，糖供给为150200g/d，糖和脂肪热卡比1:1，脂肪乳以中长链为主供给，以氨基酸为氮源，热/氮比100:1150:1。,食物的选择开始时为流食，逐步过渡到半流食或软食，也可以选用肠内营养制剂，给予的原则由少到多、由稀到稠，同时减少并最终停用肠外营养治疗。能量按每日能量消耗量供给，蛋白质占总能量的15，碳水化合物占6065，脂类占2530。,谷氨酰胺是肠黏膜的重要能源物质，可作为氮源参与蛋白质的合成；生长抑素能减少肠液量，与肠外营养治疗合用可以进一步减少肠瘘流量，促进瘘口自愈；生长激素可以改善营养状态与组织愈合能力。,谢谢,
