Basic concept
Parenteral Nutrition (PN) ndiko kupihwa kwekudya kunovaka muviri kubva mutsinga serutsigiro rwekudya kusati kwaitwa uye mushure mekuvhiyiwa uye kune vanorwara zvakanyanya. Zvokudya zvose zvinopiwa parenterally, inonzi total parenteral nutrition (TPN). Nzira dzekudya kwevabereki dzinosanganisira peripheral intravenous nutrition uye central intravenous nutrition. Parenteral nutrition (PN) ndiyo inopinda mutsinga yezvokudya zvinodiwa nevarwere, kusanganisira macalories (carbohydrates, mafuta emulsions), anokosha uye asingakoshi amino acids, mavitamini, electrolytes, uye trace elements. Kudya kwevabereki kwakakamurwa kuita chikafu chakakwana chevabereki uye chikamu chekuwedzera chikafu chevabereki. Chinangwa ndechekugonesa varwere kuchengetedza chimiro chekudya, kuwedzera uremu uye kuporeswa kwemaronda kunyangwe vasingakwanisi kudya zvakajairwa, uye vana vadiki vanogona kuramba vachikura nekukura. Intravenous infusion nzira uye infusion matekiniki anodiwa vimbiso kune yevabereki chikafu.
Zviratidzo
Chiratidzo chikuru chekudya kwevabereki ndeavo vane kusashanda kwegastrointestinal kana kutadza, kusanganisira avo vanoda rubatsiro rwekudya kwevabereki kumba.
Mugumisiro unokosha
1. Kuvharwa kwematumbo
2. Kusashanda zvakanaka kwemudumbu: ① Short bowel syndrome: yakakura diki resection > 70% ~ 80%; ② Zvirwere zviduku: zvirwere zvekudzivirira zvirwere, intestinal ischemia, multiple intestinal fistulas; ③ Radiation enteritis, ④ Manyoka akanyanya, kurutsa pabonde kusingagoneke> mazuva manomwe.
3. Chirwere chakanyanya pancreatitis: Kutanga kuvharwa kununura kuvhunduka kana MODS, mushure mokunge zviratidzo zvakakosha zvakagadzikana, kana mutezo wemukati usina kubviswa uye kudya kwemukati hakugoni kushivirira zvakakwana, chiratidzo chekudya kwevabereki.
4. High catabolic state: kupisa kwakanyanya, kukuvara kwakanyanya kwemusanganiswa, zvirwere, nezvimwewo.
5. Kusadya kwakakwana kwezvokudya zvinovaka muviri: Kushaikwa kweprotein-calorie kushayikwa kwezvokudya zvinovaka muviri kunowanzoperekedzwa nokusashanda zvakanaka kwomudumbu uye haigoni kushivirira kudya kunovaka muviri.
Tsigiro inoshanda
1. Perioperative nguva yekuvhiyiwa kukuru uye kushungurudzika: Kutsigira kwezvokudya hakuna chinhu chakakosha kune varwere vane hutano hwakanaka. Pane zvinopesana, zvinogona kuwedzera matambudziko ehutachiona, asi zvinogona kuderedza matambudziko epashure kune varwere vane kushaya zvokudya zvinovaka muviri. Varwere vanoshaya zvokudya zvakanyanya vanoda rubatsiro rwekudya kwemazuva 7-10 vasati vavhiyiwa; kune avo vanotarisirwa kuti vatadze kudzorera kushanda kwepamuviri mukati memazuva 5-7 mushure mekuvhiyiwa kukuru, rubatsiro rwehutano hwevabereki hunofanira kutanga mukati meawa 48 mushure mekuvhiyiwa kusvikira murwere ave nekudya kwakakwana. Zvokudya zvemukati kana kudya kwekudya.
2. Enterocutaneous fistulas: Pasi pemamiriro ekudzivirira hutachiona uye mvura yakakwana uye yakakodzera, rubatsiro rwekudya runovaka muviri runogona kuita kuti inopfuura hafu yefistula ye enterocutaneous iporese ivo pachavo, uye kuvhiyiwa kwechokwadi kwakava kurapwa kwekupedzisira. Kutsigira kwekudya kwevabereki kunogona kuderedza kubuda kwemvura mudumbu uye fistula kuyerera, iyo inobatsira kudzora hutachiona, kuvandudza hutano hwekudya, kunatsiridza kurapa, uye kuderedza kuvhiyiwa uye kufa.
3. Zvirwere zvinoputika: Chirwere cheCrohn, ulcerative colitis, intestinal tuberculosis uye vamwe varwere vari muchikamu chechirwere chekushanda, kana kuti yakaoma nekuputika kwepamuviri, intestinal fistula, kuvharwa kwematumbo uye kubuda ropa, nezvimwewo, chikafu chevabereki inzira inokosha yekurapa. Inogona kubvisa zviratidzo, kuvandudza kudya, kuzorora mudumbu, uye kufambisa kugadziriswa kwemukati mucosa.
4. Varwere vechirwere chekushaya zvokudya zvinovaka muviri: Kune varwere vane uremu hwemuviri ≥ 10% (yakajairika uremu hwemuviri), rubatsiro rwevabereki kana enteral chikafu chinofanira kupiwa 7 kusvika 10 mazuva asati avhiyiwa, kusvikira kudya kwemukati kana kudzokera kukudya mushure mekuvhiyiwa. kusvikira.
5. Kusakwana kwenhengo dzakakosha:
① Kusakwana kwechiropa: varwere vane chiropa cirrhosis vari muhutano husina kunaka hwekudya nekuda kwekusakwana kwekudya. Munguva yeperioperative nguva yechiropa cirrhosis kana bundu rechiropa, hepatic encephalopathy, uye 1 kusvika 2 vhiki mushure mekuisirwa chiropa, avo vasingakwanisi kudya kana kugamuchira chikafu chemukati vanofanirwa kupihwa parenteral nutrition Nutritional rutsigiro.
② Renal insufficiency: acute catabolic chirwere (utachiona, kukuvadzwa kana kukundikana kwenhengo dzakawanda) pamwe chete nekutadza kwerenal, kusingaperi renal kukundikana dialysis varwere vane kushaya zvokudya zvinovaka muviri, uye vanoda rubatsiro rwekudya kwevabereki nokuti havagoni kudya kana kugamuchira kudya kunovaka muviri. Munguva yedialysis yekusingaperi renal kukundikana, parenteral nutrition musanganiswa inogona kuiswa panguva yekuwedzerwa ropa.
③ Kusakwana kwemoyo nemapapu: kazhinji kunosanganiswa neprotein-energy yakasanganiswa kushaya chikafu. Kudya kwemukati kunovandudza mamiriro ehutano uye gastrointestinal basa mune chisingaperi obstructive pulmonary chirwere (COPD) uye inogona kubatsira varwere vane mwoyo kusakundikana (uchapupu hunoshaikwa). Chiyero chakanaka cheglucose kumafuta muvarwere veCOPD hachisati chagadziriswa, asi huwandu hwemafuta hunofanira kuwedzerwa, huwandu hweglucose uye infusion rate inofanira kudzorwa, mapuroteni kana amino acids anofanira kupiwa (inenge lg / kg.d), uye glutamine yakakwana inofanira kushandiswa kune varwere vane chirwere chemapapu chakakomba. Inobatsira kuchengetedza alveolar endothelium uye intestinal-associated lymphoid tissue uye kuderedza pulmonary complications. ④Inflammatory adhesive intestinal obstruction: perioperative parenteral nutrition support ye4 kusvika kumavhiki e6 inobatsira pakudzorerwa kwematumbo uye kusunungurwa kwekudzivirira.
Contraindications
1. Avo vane maitiro anowanzoitwa gastrointestinal, kugadzirisa kune kudya kunovaka muviri kana kupora basa remudumbu mukati memazuva mashanu.
2. Kusingarapike, hapana tariro yekupona, kufa kana kusagadziriswa pakoma.
3. Avo vanoda kuvhiyiwa kwekukurumidzira uye havagoni kushandisa rubatsiro rwekudya vasati vavhiyiwa.
4. Kushanda kwemwoyo kana kukanganisa kwakanyanya kwemagetsi kunoda kudzorwa.
Nutritional nzira
Kusarudzwa kwenzira yakakodzera yekudya kwevabereki kunoenderana nezvinhu zvakadai semurwere vascular puncture history, venous anatomy, coagulation status, inotarisirwa nguva yevabereki kudya, kuiswa kwekutarisira (kuchipatara kana kwete), uye chimiro chechirwere chinokonzera. Kune vanorwara, yenguva pfupi yeperipheral venous kana yepakati venous intubation ndiyo inonyanya kusarudzwa; kune varwere vekugara kwenguva refu mune zvisiri zvechipatara, peripheral venous kana central venous intubation, kana subcutaneous infusion mabhokisi anonyanya kushandiswa.
1. Peripheral intravenous parenteral nutrition route
Zviratidzo: ① Nguva pfupi yevabereki kudya (<2 mavhiki), zvinovaka muviri mhinduro osmotic pressure isingasviki 1200mOsm/LH2O; ② Central venous catheter contraindication kana isingagoneki; ③ Catheter utachiona kana sepsis.
Zvakanakira nekuipira: Iyi nzira iri nyore uye iri nyore kuita, inogona kudzivirira matambudziko (mechanical, infection) ine chekuita nechepakati venous catheterization, uye zviri nyore kuona kuitika kwephlebitis nekukurumidza. Izvo zvisingabatsiri ndezvokuti iyo osmotic pressure ye infusion haifaniri kunge yakanyanyisa, uye kudzokorora puncture kunodiwa, iyo inowanzoita phlebitis. Nokudaro, haina kukodzera kushandiswa kwenguva refu.
2. Kudya kwevabereki kuburikidza nepakati tsinga
(1) Zvinoratidza: parenteral nutrition kweanopfuura mavhiki e2 uye nutrient solution osmotic pressure yakakwirira kudarika 1200mOsm/LH2O.
(2) Catheterization nzira: kuburikidza nemukati wejugular vein, subclavian vein kana peripheral vein yekumusoro kwepamusoro kune vena cava yepamusoro.
Zvakanakira uye kuipa: Iyo subclavian vein catheter iri nyore kufamba uye kutarisira, uye dambudziko guru pneumothorax. Catheterization kuburikidza nemukati wejugular vein inoderedza kufamba kwejugular uye kupfeka, uye zvakakonzera matambudziko mashoma emunharaunda hematoma, arterial kukuvara uye catheter utachiona. Peripheral vein-to-central catheterization (PICC): Mutsinga wakakosha wakafara uye uri nyore kuisa pane cephalic vein, iyo inogona kudzivisa matambudziko makuru akadai sepneumothorax, asi inowedzera kuitika kwethrombophlebitis uye intubation dislocation uye kuoma kwekushanda. Izvo zvisina kukodzera parenteral zvinovaka muviri nzira ndeyekunze jugular vein uye femoral vein. Iyo yekutanga ine mwero wepamusoro wekukanganisa, nepo iyo yekupedzisira ine mwero wepamusoro wehutachiona hwehutachiona.
3. Kupinza ne subcutaneously embedded catheter kuburikidza nechepakati venous catheter.
Nutrition system
1. Kudya kwevabereki kweakasiyana masisitimu (akawanda-bhodhoro serial, ese-mune-imwe uye diaphragm mabhegi):
①Multi-bhodhoro serial kutapurirana: Mabhodhoro akawanda emushonga unovaka muviri unogona kusanganiswa uye kuparadzirwa serially kuburikidza ne "nzira nhatu" kana Y-yakaita infusion chubhu. Kunyange zvazvo iri nyore uye iri nyore kushandisa, ine zvakawanda zvayakaipira uye haifanire kutsigirwa.
②Total nutrient solution (TNA) kana yese-mune-imwe (AIl-in-One): Iyo aseptic yekusanganisa tekinoroji yezvese zvinovaka muviri mhinduro ndeyekubatanidza zvese zvinovaka muviri zvevabereki zuva nezuva (glucose, mafuta emulsion, amino acids, electrolytes, mavhitamini uye trace elements) ) yakasanganiswa mubhegi uye wozoiswa. Iyi nzira inoita kuti kuiswa kwekudya kwevabereki kuve nyore, uye kuiswa panguva imwe chete yezvakasiyana-siyana zvinovaka muviri zvinonzwisisika kune anabolism. Kupedza Nekuda kwekuti mabhegi anonyungudika ane mafuta epolyvinyl chloride (PVC) anogona kukonzera kumwe kuita muchetura, polyvinyl acetate (EVA) yakashandiswa seyakanyanya mbishi yemabhegi ekudya kwevabereki parizvino. Kuti uve nechokwadi chekugadzikana kwechikamu chega chega mumhinduro yeTNA, kugadzirira kunofanirwa kuitwa nenzira yakatarwa (ona Chitsauko 5 kuti uwane ruzivo).
③Diaphragm bhegi: Mumakore achangopfuura, matekinoroji matsva uye mapurasitiki matsva (polyethylene/polypropylene polymer) akashandiswa mukugadzira mabhegi ekugadzirisa chikafu chevabereki. Chigadzirwa chitsva chekudya chinovaka muviri (chibhegi chemakamuri maviri, bhegi remakamuri matatu) chinogona kuchengetwa pamhepo tembiricha kwemwedzi makumi maviri nemana, kudzivirira dambudziko rekusvibiswa kwemushonga unogadzirwa muchipatara. Inogona kuve yakachengeteka uye zviri nyore kushandiswa kune parenteral nutrition infusion kuburikidza nepakati tsinga kana peripheral vein muvarwere vane zvakasiyana zvinovaka muviri zvinodiwa. Izvo zvakashata ndezvekuti iyo yega yega fomura haigone kuwanikwa.
2. Kuumbwa kwe parenteral nutrition solution
Zvinoenderana nezvinodiwa nemurwere zvinovaka muviri uye simba remetabolism, gadzira kuumbwa kwegadziriro yekudya.
3. Special matrix ye parenteral nutrition
Chikafu chemazuva ano chekiriniki chinoshandisa matanho matsva ekuwedzera kuvandudza maumbirwo ezvekudya kuvandudza kushivirira kwevarwere. Kuti zvizadzise zvinodikanwa zvekurapa kwehutano, zvakakosha zvinovaka muviri zvinopihwa kune varwere vakasarudzika kuti vavandudze immune system yemurwere, kuvandudza intestinal barriers basa, uye kuvandudza antioxidant simba remuviri. Izvo zvitsva zvakakosha zvekudya zvinovaka muviri ndezvi:
①Fat emulsion: inosanganisira yakarongeka mafuta emulsion, refu-chain, yepakati-cheni mafuta emulsion, uye mafuta emulsion akapfuma mu omega-3 fatty acids, nezvimwe.
②Amino acid kugadzirira: kusanganisira arginine, glutamine dipeptide uye taurine.
Tafura 4-2-1 Simba uye mapuroteni zvinodiwa zvevarwere vanovhiya
Mamiriro emurwere simba Kcal/(kg.d) protein g/(kg.d) NPC: N
Kushaya zvokudya zvinovaka muviri 20~250.6~1.0150:1
Kushungurudzika kuri pakati nepakati 25~301.0~1.5120:1
High metabolic stress 30~35 1.5~2.0 90~120:1
Kusvirwa 35~40 2.0~2.5 90~120: 1
NPC: N isiri-protein calorie kune nitrogen ratio
Kutsigira kwekudya kwevabereki kune chirwere chisingaperi chechiropa uye kuiswa kwechiropa
Simba risiri-protein Kcal/(kg.d) protein kana amino acid g/(kg.d)
Yakatsiviwa cirrhosis25~35 0.6~1.2
Decompensated cirrhosis 25~35 1.0
Hepatic encephalopathy 25~35 0.5 ~ 1.0 (kuwedzera chiyero chebranched-chain amino acids)
25 ~ 351.0 ~ 1.5 mushure mekudyarwa kwechiropa
Nyaya dzinoda kutarisirwa: Zvokudya zvokunwa kana kuti zvemukati zvinowanzodiwa; kana isingabvumirwi, kudya kwevabereki kunoshandiswa: simba rinoumbwa neglucose [2g / (kg.d)] uye yepakati-yakareba-chain-chain mafuta emulsion [1g / (kg.d)], mafuta anokwana 35 ~ 50% emakori; nitrogen sosi inopiwa nekomboni amino acids, uye hepatic encephalopathy inowedzera chikamu chebranched-chain amino acids.
Kutsigira kwekudya kwevabereki kune acute catabolic chirwere chakaomeswa neacute renal kukundikana
Simba risiri-protein Kcal/(kg.d) protein kana amino acid g/(kg.d)
20 ~ 300.8 ~ 1.21.2 ~ 1.5 (mazuva ose dialysis varwere)
Nyaya dzinoda kutarisirwa: Zvokudya zvokunwa kana kuti zvemukati zvinowanzodiwa; kana isingabvumirwi, kudya kwevabereki kunoshandiswa: simba rinoumbwa neglucose [3 ~ 5g / (kg.d)] uye mafuta emulsion [0.8 ~ 1.0g / (kg.d))]; asiri-akakosha amino acids (tyrosine, arginine, cysteine, serine) yevanhu vane hutano vanova mamiriro akakosha amino acids panguva ino. Shuga yeropa uye triglycerides inofanira kuongororwa.
Tafura 4-2-4 Yakakurudzirwa zuva rega rega yehuwandu hwevabereki chikafu
Simba 20~30Kcal/(kg.d) [Mvura 1~1.5ml pa1Kcal/(kg.d)]
Glucose 2~4g/(kg.d) Mafuta 1~1.5g/(kg.d)
Nitrogen content 0.1~0.25g/(kg.d) Amino acid 0.6~1.5g/(kg.d)
Electrolytes (avhareji yezuva nezuva inodiwa kune vabereki vanovaka muviri vakuru) Sodium 80~100mmol Potassium 60~150mmol Chlorine 80~100mmol Calcium 5~10mmol Magnesium 8~12mmol Phosphorus 10~30mmol
Mavhitamini anonyungudika mafuta: A2500IUD100IUE10mgK110mg
Mavhitaminzi anonyungudika mumvura: B13mgB23.6mgB64mgB125ug
Pantothenic Acid 15mg Niacinamide 40mg Folic Acid 400ugC 100mg
Tevera zvinhu: mhangura 0.3mg ayodhini 131ug zingi 3.2mg selenium 30~60ug
Molybdenum 19ug Manganese 0.2~0.3mg Chromium 10~20ug Iron 1.2mg
Nguva yekutumira: Aug-19-2022