Basic tswvyim
Parenteral khoom noj khoom haus (PN) yog cov khoom noj khoom haus los ntawm cov hlab ntsha raws li kev noj zaub mov noj ua ntej thiab tom qab phais thiab rau cov neeg mob hnyav. Tag nrho cov khoom noj khoom haus yog muab los ntawm niam txiv, hu ua total parenteral nutrition (TPN). Txoj hauv kev ntawm cov khoom noj khoom haus parenteral suav nrog cov khoom noj khoom haus peripheral intravenous thiab central intravenous khoom noj khoom haus. Parenteral khoom noj khoom haus (PN) yog cov khoom noj khoom haus uas xav tau los ntawm cov neeg mob, suav nrog calories (carbohydrates, rog emulsions), qhov tseem ceeb thiab tsis tseem ceeb amino acids, vitamins, electrolytes, thiab kab kawm. Parenteral khoom noj khoom haus tau muab faib ua tiav cov khoom noj khoom haus parenteral thiab ib nrab ntxiv cov khoom noj parenteral. Lub hom phiaj yog ua kom cov neeg mob tswj hwm kev noj zaub mov zoo, nce qhov hnyav thiab kho qhov txhab txawm tias lawv tsis tuaj yeem noj ib txwm, thiab cov menyuam yaus tuaj yeem loj hlob thiab loj hlob ntxiv. Txoj kev txhaj tshuaj infusion thiab cov txheej txheem infusion yog qhov tsim nyog tau lees paub rau kev noj zaub mov zoo rau niam txiv.
Cov lus qhia
Cov lus qhia yooj yim rau kev noj zaub mov parenteral yog cov neeg uas muaj plab hnyuv lossis tsis ua haujlwm, suav nrog cov uas xav tau kev txhawb nqa khoom noj hauv tsev parenteral.
Cov nyhuv tseem ceeb
1. Kev mob plab hnyuv
2. Absorption dysfunction ntawm gastrointestinal ib ntsuj av tau: ① Short plob tsis so tswj syndrome: extremities me me resection>70% ~ 80%; ② Cov kab mob me me: kab mob tiv thaiv kab mob, plab hnyuv ischemia, ntau lub plab hnyuv fistulas; ③ Radiation enteritis, ④ mob raws plab, ntuav tsis pom kev deev > 7 hnub.
3. Tus mob pancreatitis: Thawj qhov kev txhaj tshuaj los cawm kev poob siab lossis MODS, tom qab cov cim tseem ceeb tau ruaj khov, yog tias cov plab hnyuv tsis tau tshem tawm thiab cov khoom noj nkag mus tsis tuaj yeem zam tau tag nrho, nws yog ib qho kev qhia rau kev noj zaub mov hauv parenteral.
4. Lub xeev catabolic siab: kev kub nyhiab heev, kev raug mob hnyav, kis kab mob, thiab lwm yam.
5. Kev noj zaub mov tsis zoo: Protein-calorie deficiency malnutrition feem ntau nrog rau lub plab zom mov tsis zoo thiab tsis tuaj yeem tiv taus cov khoom noj nkag mus.
Kev them nyiaj yug yog siv tau
1. Perioperative lub sij hawm ntawm kev phais loj thiab kev raug mob: Kev txhawb nqa khoom noj khoom haus tsis muaj txiaj ntsig zoo rau cov neeg mob uas muaj zaub mov zoo. Ntawm qhov tsis sib xws, nws tuaj yeem ua rau muaj kev kis kab mob ntau ntxiv, tab sis nws tuaj yeem txo cov teeb meem tom qab phais rau cov neeg mob uas tsis muaj zaub mov txaus. Cov neeg mob uas tsis muaj zaub mov txaus xav tau kev noj zaub mov noj rau 7-10 hnub ua ntej kev phais; rau cov neeg uas xav tias yuav tsis rov qab ua haujlwm ntawm plab hnyuv hauv 5-7 hnub tom qab kev phais loj, kev txhawb nqa kev noj haus ntawm niam txiv yuav tsum tau pib ua ntej 48 teev tom qab kev phais kom txog thaum tus neeg mob tuaj yeem muaj khoom noj khoom haus txaus. Kev noj zaub mov zoo lossis kev noj zaub mov noj.
2. Enterocutaneous fistulas: Nyob rau hauv cov xwm txheej ntawm kev tiv thaiv kab mob thiab kev tso dej kom txaus, kev noj zaub mov tuaj yeem ua rau ntau tshaj li ib nrab ntawm cov kab mob enterocutaneous fistulas kho lawv tus kheej, thiab kev phais kom zoo tau dhau los ua kev kho mob kawg. Kev txhawb nqa kev noj zaub mov ntawm Parenteral tuaj yeem txo cov kua dej hauv plab hnyuv thiab fistula ntws, uas muaj txiaj ntsig zoo los tswj kev kis kab mob, txhim kho kev noj zaub mov zoo, txhim kho tus nqi kho, thiab txo qis kev phais thiab kev tuag.
3. Cov kab mob plab hnyuv: Crohn's kab mob, ulcerative colitis, plab hnyuv tuberculosis thiab lwm cov neeg mob nyob rau hauv lub active kab mob theem, los yog muaj teeb meem nrog plab abscess, plab hnyuv fistula, plab hnyuv ob leeg thiab los ntshav, thiab lwm yam., parenteral noj zaub mov yog ib qho tseem ceeb txoj kev kho mob. Nws tuaj yeem txo cov tsos mob, txhim kho cov khoom noj khoom haus, so lub plab hnyuv, thiab pab kho cov hnyuv mucosa.
4. Cov neeg mob qog nqaij hlav hnyav heev: Rau cov neeg mob lub cev poob qis ≥ 10% (lub cev hnyav li qub), kev txhawb nqa parenteral lossis enteral khoom noj khoom haus yuav tsum tau muab 7 mus rau 10 hnub ua ntej kev phais, kom txog rau thaum nkag mus rau hauv cov khoom noj los yog rov qab los noj tom qab phais. mus txog thaum.
5. Tsis txaus ntawm lub cev tseem ceeb:
① Daim siab tsis txaus: cov neeg mob uas muaj daim siab cirrhosis nyob rau hauv cov khoom noj khoom haus tsis zoo vim kev noj zaub mov tsis txaus. Thaum lub sij hawm perioperative ntawm daim siab cirrhosis los yog daim siab qog, hepatic encephalopathy, thiab 1 mus rau 2 lub lis piam tom qab hloov daim siab, cov neeg uas tsis tuaj yeem noj los yog tau txais cov khoom noj khoom haus enteral yuav tsum tau muab cov khoom noj khoom haus parenteral kev txhawb nqa.
② Lub raum tsis txaus: mob catabolic kab mob (kab mob, raug mob lossis ntau lub cev tsis ua haujlwm) ua ke nrog rau mob raum tsis ua haujlwm, mob raum tsis ua haujlwm rau cov neeg mob uas tsis muaj zaub mov noj, thiab xav tau kev txhawb nqa parenteral vim lawv tsis tuaj yeem noj lossis tau txais cov khoom noj nkag mus. Thaum lub sijhawm lim ntshav rau lub raum tsis ua haujlwm ntev, cov khoom noj khoom haus parenteral sib xyaw tuaj yeem ua rau lub sijhawm tso ntshav mus rau hauv cov ntshav.
③ Lub plawv thiab lub ntsws tsis txaus: feem ntau ua ke nrog cov protein-zog sib xyaw cov khoom noj tsis txaus. Kev noj zaub mov zoo tuaj yeem txhim kho kev kho mob thiab kev ua haujlwm ntawm plab hnyuv hauv cov kab mob ntsws ntev (COPD) thiab tuaj yeem pab cov neeg mob plawv tsis ua haujlwm (cov pov thawj tsis muaj). Qhov zoo tshaj plaws piv ntawm cov piam thaj rau cov rog hauv cov neeg mob COPD tseem tsis tau txiav txim siab, tab sis qhov sib piv ntawm cov rog yuav tsum tau nce ntxiv, tag nrho cov piam thaj thiab infusion tus nqi yuav tsum tau tswj, protein lossis amino acids yuav tsum tau muab (tsawg kawg li lg / kg.d), thiab glutamine txaus yuav tsum tau siv rau cov neeg mob uas muaj mob ntsws loj. Nws muaj txiaj ntsig zoo los tiv thaiv alveolar endothelium thiab cov kab mob hauv plab uas cuam tshuam nrog lymphoid cov ntaub so ntswg thiab txo cov kab mob ntsws. ④Inflammatory adhesive intestinal obstruction: perioperative parenteral food support rau 4 mus rau 6 lub lis piam yog qhov zoo rau kev rov ua haujlwm ntawm plab hnyuv thiab pab kom muaj kev cuam tshuam.
Contraindications
1. Cov neeg uas muaj lub plab zom mov ua haujlwm, yoog rau cov khoom noj khoom haus nkag mus lossis rov ua haujlwm ntawm plab hnyuv hauv 5 hnub.
2. Kev kho tsis tau, tsis muaj kev cia siab ntawm kev ciaj sia, tuag lossis cov neeg mob coma irreversible.
3. Cov neeg uas xav tau kev phais xwm txheej ceev thiab tsis tuaj yeem siv cov khoom noj khoom haus ua ntej kev phais.
4. Kev ua haujlwm ntawm lub plawv lossis cov kab mob metabolic hnyav yuav tsum tau tswj hwm.
Txoj kev noj zaub mov
Kev xaiv ntawm txoj kev tsim nyog ntawm cov khoom noj khoom haus parenteral nyob ntawm cov yam ntxwv xws li tus neeg mob lub vascular puncture keeb kwm, venous anatomy, coagulation status, xav kom lub sij hawm ntawm parenteral khoom noj khoom haus, qhov chaw zov me nyuam (tsev kho mob los yog tsis), thiab qhov xwm ntawm tus kab mob. Rau cov neeg mob hauv tsev kho mob, lub sij hawm luv luv peripheral venous lossis central venous intubation yog qhov kev xaiv ntau tshaj plaws; rau cov neeg mob mus sij hawm ntev nyob rau hauv qhov chaw tsis yog tsev kho mob, peripheral venous lossis central venous intubation, lossis subcutaneous infusion thawv feem ntau yog siv.
1. Peripheral intravenous parenteral noj zaub mov txoj kev
Cov lus qhia: ① Cov khoom noj khoom haus luv luv (<2 lub lis piam), cov khoom noj khoom haus osmotic siab tsawg dua 1200mOsm/LH2O; ② Central venous catheter contraindication lossis ua tsis tau; ③ Catheter kab mob los yog sepsis.
Qhov zoo thiab qhov tsis zoo: Txoj kev no yog qhov yooj yim thiab yooj yim rau kev siv, tuaj yeem zam qhov teeb meem (mechanical, kab mob) cuam tshuam rau hauv nruab nrab venous catheterization, thiab yooj yim los kuaj xyuas qhov tshwm sim ntawm phlebitis thaum ntxov. Qhov tsis zoo yog tias lub siab osmotic ntawm cov infusion yuav tsum tsis txhob siab dhau, thiab yuav tsum tau rov ua dua, uas ua rau phlebitis. Yog li ntawd, nws tsis haum rau kev siv mus ntev.
2. Parenteral noj zaub mov ntawm cov hlab ntsha hauv nruab nrab
(1) Cov lus qhia: parenteral khoom noj khoom haus rau ntau tshaj 2 lub lis piam thiab cov as-ham zoo osmotic siab siab tshaj 1200mOsm/LH2O.
(2) Catheterization txoj kev: los ntawm cov hlab ntsha hauv jugular, cov hlab ntsha subclavian los yog cov hlab ntsha peripheral ntawm sab qaum mus rau qhov zoo tshaj vena cava.
Qhov zoo thiab qhov tsis zoo: Lub subclavian leeg catheter yooj yim txav thiab tu, thiab qhov teeb meem tseem ceeb yog pneumothorax. Catheterization los ntawm cov hlab ntsha sab hauv jugular txwv lub jugular txav thiab hnav khaub ncaws, thiab ua rau muaj teeb meem me ntsis ntawm cov hematoma hauv zos, mob hlab ntsha thiab kab mob catheter. Peripheral vein-to-central catheterization (PICC): Cov hlab ntsha muaj nuj nqis yog qhov dav thiab yooj yim rau ntxig tshaj li cov hlab ntsha cephalic, uas tuaj yeem zam cov teeb meem loj xws li pneumothorax, tab sis nws ua rau muaj qhov tshwm sim ntawm thrombophlebitis thiab intubation dislocation thiab ua haujlwm nyuaj. Txoj kev noj zaub mov tsis zoo ntawm cov parenteral yog cov hlab ntsha sab nraud thiab cov leeg femoral. Lub qub muaj qhov siab ntawm qhov chaw tsis raug, thaum lub tom kawg muaj tus nqi siab ntawm kev kis mob.
3. Infusion nrog subcutaneously embedded catheter los ntawm central venous catheter.
Khoom noj khoom haus system
1. Parenteral khoom noj khoom haus ntawm cov tshuab sib txawv (multi-bottle serial, all-in-one thiab diaphragm hnab):
①Multi-bottles serial kis tau tus mob: Ntau lub fwj tshuaj muaj peev xwm muab sib xyaw thiab serially kis tau los ntawm "peb-txoj kev" los yog Y-shaped infusion raj. Txawm hais tias nws yooj yim thiab yooj yim rau kev siv, nws muaj ntau yam tsis zoo thiab yuav tsum tsis txhob tawm tsam.
②Tag nrho cov as-ham (TNA) los yog tag nrho-hauv-ib (AIl-in-One): aseptic mixing technology ntawm tag nrho cov as-ham yog muab tag nrho cov parenteral khoom noj khoom haus txhua hnub cov khoom xyaw (qabzib, rog emulsion, amino acids, electrolytes, vitamins thiab kab kawm) sib tov rau hauv ib lub hnab thiab ces infused. Txoj kev no ua rau cov tswv yim ntawm cov khoom noj khoom haus parenteral yooj yim dua, thiab cov tswv yim ib txhij ntawm ntau cov as-ham yog tsim nyog rau anabolism. Tiav Vim tias cov roj-soluble plasticizer ntawm polyvinyl chloride (PVC) hnab tuaj yeem ua rau qee yam tshuaj lom, polyvinyl acetate (EVA) tau siv los ua cov khoom siv tseem ceeb ntawm cov hnab khoom noj khoom haus parenteral tam sim no. Txhawm rau kom muaj kev ruaj ntseg ntawm txhua qhov kev daws teeb meem hauv TNA, kev npaj yuav tsum tau ua raws li qhov kev txiav txim tau teev tseg (saib Tshooj 5 kom paub meej).
③ Diaphragm hnab: Nyob rau hauv xyoo tas los no, cov thev naus laus zis tshiab thiab cov khoom siv tshiab yas (polyethylene / polypropylene polymer) tau siv rau hauv kev tsim cov hnab ntim khoom noj khoom haus ua tiav parenteral. Cov khoom noj khoom haus tshiab tag nrho (ob chav chamber bag, peb chav chamber bag) tuaj yeem khaws cia hauv chav sov li 24 lub hlis, zam qhov teeb meem muaj kuab paug ntawm kev daws teeb meem hauv tsev kho mob. Nws tuaj yeem siv tau yooj yim dua thiab yooj yim siv rau kev noj zaub mov hauv parenteral los ntawm cov hlab ntsha hauv nruab nrab lossis cov hlab ntsha peripheral hauv cov neeg mob uas xav tau kev noj zaub mov sib txawv. Qhov tsis zoo yog tias tus kheej ntawm tus qauv tsis tuaj yeem ua tiav.
2. Muaj cov tshuaj parenteral khoom noj khoom haus
Raws li tus neeg mob xav tau kev noj haus thiab muaj peev xwm metabolic, tsim cov khoom noj khoom haus npaj.
3. Tshwj xeeb matrix rau parenteral khoom noj khoom haus
Cov khoom noj khoom haus niaj hnub no siv cov kev ntsuas tshiab los txhim kho cov khoom noj khoom haus ntxiv los txhim kho cov neeg mob siab ntev. Txhawm rau ua kom tau raws li cov kev xav tau ntawm kev noj zaub mov zoo, cov khoom noj khoom haus tshwj xeeb tau muab rau cov neeg mob tshwj xeeb txhawm rau txhim kho tus neeg mob lub cev tsis muaj zog, txhim kho txoj hnyuv ua haujlwm, thiab txhim kho lub cev muaj peev xwm antioxidant. Cov kev npaj zaub mov tshwj xeeb tshiab yog:
①Fat emulsion: suav nrog cov qauv roj emulsion, cov saw ntev, nruab nrab cov saw roj emulsion, thiab cov roj emulsion nplua nuj nyob rau hauv omega-3 fatty acids, thiab lwm yam.
② Amino acid npaj: suav nrog arginine, glutamine dipeptide thiab taurine.
Table 4-2-1 Lub zog thiab cov protein xav tau ntawm cov neeg mob phais
Tus neeg mob lub zog Kcal/(kg.d) protein g/(kg.d) NPC: N
Ib txwm-nruab nrab malnutrition 20 ~ 250.6 ~ 1.0150: 1
Kev ntxhov siab 25 ~ 301.0 ~ 1.5120: 1
High metabolic stress 30 ~ 35 1.5 ~ 2.0 90 ~ 120: 1
Hlawv 35 ~ 40 2.0 ~ 2.5 90 ~ 120: 1
NPC: N tsis muaj protein ntau calorie rau nitrogen piv
Parenteral noj zaub mov pab txhawb rau cov kab mob siab ntev thiab hloov daim siab
Lub zog tsis muaj protein ntau Kcal / (kg.d) protein lossis amino acid g / (kg.d)
Kev them nyiaj cirrhosis25 ~ 35 0.6 ~ 1.2
Decompensated cirrhosis 25 ~ 35 1.0
Hepatic encephalopathy 25 ~ 35 0.5 ~ 1.0 (nce qhov piv ntawm branched-chain amino acids)
25 ~ 351.0 ~ 1.5 tom qab hloov daim siab
Cov teeb meem xav tau kev saib xyuas: qhov ncauj lossis kev noj zaub mov zoo feem ntau nyiam; Yog tias nws tsis zam, cov khoom noj khoom haus parenteral yog siv: lub zog yog tsim los ntawm cov piam thaj [2g / (kg.d)] thiab nruab nrab-ntev-ntev-cov saw roj emulsion [1g / (kg.d)], roj nyiaj rau 35 ~ 50% calories; nitrogen qhov chaw yog muab los ntawm compound amino acids, thiab hepatic encephalopathy tsub kom qhov feem ntawm branched-chain amino acids.
Parenteral noj zaub mov txhawb rau mob catabolic mob nyuaj nrog mob raum tsis ua haujlwm
Lub zog tsis muaj protein ntau Kcal / (kg.d) protein lossis amino acid g / (kg.d)
20 ~ 300.8 ~ 1.21.2 ~ 1.5 (cov neeg mob lim ntshav txhua hnub)
Cov teeb meem xav tau kev saib xyuas: qhov ncauj lossis kev noj zaub mov zoo feem ntau nyiam; Yog tias nws tsis zam, cov khoom noj khoom haus parenteral yog siv: lub zog muaj cov piam thaj [3 ~ 5g / (kg.d)] thiab roj emulsion [0.8 ~ 1.0g / (kg.d) )]; Cov amino acids tsis tseem ceeb (tyrosine, arginine, cysteine, serine) ntawm cov neeg noj qab haus huv tau dhau los ua cov amino acids tseem ceeb nyob rau lub sijhawm no. Cov ntshav qab zib thiab triglycerides yuav tsum tau saib xyuas.
Table 4-2-4 Pom zoo txhua hnub tus nqi ntawm tag nrho cov khoom noj khoom haus parenteral
Zog 20 ~ 30Kcal / (kg.d) [Dej muab 1 ~ 1.5ml ib 1Kcal/(kg.d)]
Glucose 2 ~ 4g / (kg.d) Rog 1 ~ 1.5g / (kg.d)
Nitrogen ntsiab lus 0.1 ~ 0.25g / (kg.d) Amino acid 0.6 ~ 1.5g / (kg.d)
Electrolytes (qhov nruab nrab txhua hnub yuav tsum tau rau cov neeg laus noj zaub mov noj) Sodium 80 ~ 100mmol Potassium 60 ~ 150mmol Chlorine 80 ~ 100mmol Calcium 5 ~ 10mmol Magnesium 8 ~ 12mmol Phosphorus 10 ~ 30mmol
Fat-soluble vitamins: A2500IUD100IUE10mgK110mg
Cov dej-soluble vitamins: B13mgB23.6mgB64mgB125ug
Pantothenic Acid 15mg Niacinamide 40mg Folic Acid 400ugC 100mg
Cov kab mob: tooj liab 0.3mg iodine 131ug zinc 3.2mg selenium 30 ~ 60ug
Molybdenum 19ug Manganese 0.2 ~ 0.3mg Chromium 10 ~ 20ug Hlau 1.2mg
Post lub sij hawm: Aug-19-2022