Parenteral Nutrition/Total Parenteral Nutrition (TPN)

Parenteral Nutrition/Total Parenteral Nutrition (TPN)

Parenteral Nutrition/Total Parenteral Nutrition (TPN)

Lingaliro loyambira
Parenteral Nutrition (PN) ndi chakudya chochokera m'mitsempha monga chithandizo chamankhwala asanayambe kapena atatha opaleshoni komanso odwala omwe akudwala kwambiri.Zakudya zonse zimaperekedwa parenterally, yotchedwa total parenteral nutrition (TPN).Njira zopezera chakudya cham'mimba zimaphatikizanso kudya modutsa m'mitsempha komanso chakudya chapakati chodutsa m'mitsempha.Zakudya za makolo (PN) ndizomwe zimaperekedwa m'mitsempha ya zakudya zomwe zimafunikira kwa odwala, kuphatikizapo zopatsa mphamvu (zakudya, mafuta a emulsions), ma amino acid ofunikira komanso osafunikira, mavitamini, electrolytes, ndi kufufuza zinthu.Zakudya za makolo zimagawidwa m'magulu athunthu a zakudya zamagulu komanso zakudya zowonjezera zowonjezera.Cholinga chake ndikuthandizira odwala kukhala ndi thanzi labwino, kunenepa komanso kuchiritsa mabala ngakhale kuti sangathe kudya bwino, ndipo ana aang'ono akhoza kupitiriza kukula ndikukula.Njira zolowetsedwera m'mitsempha ndi njira zolowetsera ndi zitsimikizo zofunika pazakudya za makolo.

Zizindikiro

Zizindikiro zazikulu za kadyedwe ka makolo ndi omwe ali ndi vuto la m'mimba kapena kulephera, kuphatikizapo omwe amafunikira chithandizo chamankhwala chapakhomo.
Chochititsa chidwi
1. Kutsekeka kwa m'mimba
2. Kusagwira ntchito kwa m'mimba: ① Matenda a m'matumbo aang'ono: kutuluka kwa matumbo ang'onoang'ono > 70% ~ 80%;② Matenda a m'matumbo ang'onoang'ono: matenda a chitetezo cha mthupi, ischemia ya m'mimba, fistula yambiri ya m'mimba;③ Radiation enteritis, ④ Kutsekula m'mimba kwambiri, kusanza kosalekeza pogonana> masiku 7.
3. Pancreatitis yoopsa: Kulowetsedwa koyamba kuti mupulumutse kugwedezeka kapena MODS, zizindikiro zofunika zitakhazikika, ngati ziwalo za m'mimba sizichotsedwa ndipo zakudya zam'mimba sizingavomerezedwe mokwanira, ndi chizindikiro cha zakudya za makolo.
4. Mkulu wa catabolic state: kuyaka kwakukulu, kuvulala koopsa pawiri, matenda, etc.
5. Kuperewera kwa zakudya m'thupi kwambiri: Kuperewera kwa zakudya m'thupi la protein-calorie nthawi zambiri kumatsagana ndi kusagwira bwino ntchito kwa m'mimba ndipo sikungathe kulekerera chakudya cham'mimba.
Thandizo ndilovomerezeka
1. Nthawi yowonongeka ya opaleshoni yaikulu ndi kupwetekedwa mtima: Thandizo la zakudya zopanda thanzi silimakhudza kwambiri odwala omwe ali ndi thanzi labwino.M'malo mwake, zitha kukulitsa zovuta za matenda, koma zimatha kuchepetsa zovuta zapambuyo pa opareshoni kwa odwala omwe ali ndi vuto losowa zakudya m'thupi.Odwala omwe ali ndi vuto loperewera zakudya m'thupi amafunikira thandizo la zakudya kwa masiku 7-10 asanachite opaleshoni;kwa iwo omwe akuyembekezeka kulephera kuchira m'mimba mkati mwa masiku 5-7 pambuyo pa opaleshoni yayikulu, chithandizo chopatsa thanzi cha parenteral chiyenera kuyambika mkati mwa maola 48 pambuyo pa opaleshoni mpaka wodwalayo atha kukhala ndi chakudya chokwanira.Zakudya za m'mimba kapena kudya.
2. Enterocutaneous fistulas: Pansi pa chikhalidwe cha matenda opatsirana ndi madzi okwanira komanso oyenera, chithandizo cha zakudya chingapangitse oposa theka la fistula ya enterocutaneous kudzichiritsa okha, ndipo opaleshoni yotsimikizirika yakhala chithandizo chomaliza.Thandizo la zakudya za makolo likhoza kuchepetsa kutulutsa kwamadzimadzi m'mimba ndi kutuluka kwa fistula, zomwe zimapindulitsa kuthetsa matenda, kupititsa patsogolo kadyedwe kake, kupititsa patsogolo machiritso, ndi kuchepetsa zovuta za opaleshoni ndi imfa.
3. Matenda otupa matumbo: Matenda a Crohn, ulcerative colitis, chifuwa chachikulu cha m'mimba ndi odwala ena ali ndi matenda opatsirana, kapena ovuta ndi abscess m'mimba, matumbo a m'mimba, kutsekeka kwa m'mimba ndi magazi, etc., zakudya za parenteral ndi njira yofunikira yothandizira.Ikhoza kuthetsa zizindikiro, kusintha zakudya, kupuma m'mimba, ndikuthandizira kukonza m'mimba mucosa.
4. Odwala chotupa chosowa zakudya m'thupi: Kwa odwala omwe ali ndi kulemera kwa thupi ≥ 10% (kulemera kwa thupi lachibadwa), chithandizo cha parenteral kapena cholowa cham'mimba chiyenera kuperekedwa kwa masiku 7 mpaka 10 musanayambe opaleshoni, mpaka chakudya cham'mimba kapena kubwereranso kudya pambuyo pa opaleshoni.mpaka.
5. Kusakwanira kwa ziwalo zofunika:
① Kusakwanira kwa chiwindi: Odwala omwe ali ndi vuto la chiwindi amakhala ndi thanzi labwino chifukwa chosadya mokwanira.Pa nthawi ya perioperative ya chiwindi matenda enaake kapena chotupa chiwindi, kwa chiwindi encephalopathy, ndi 1 kwa 2 milungu chiwindi kumuika, amene sangathe kudya kapena kulandira cholowa zakudya ayenera kupatsidwa parenteral zakudya Thandizo lazakudya.
② Kulephera kwa aimpso: matenda owopsa kwambiri (matenda, kuvulala kapena kulephera kwa ziwalo zingapo) kuphatikiza kulephera kwaimpso, kulephera kwaimpso kwa odwala omwe ali ndi vuto la kuperewera kwa zakudya m'thupi, ndipo amafunikira thandizo lazakudya za makolo chifukwa sangathe kudya kapena kulandira zakudya zopatsa thanzi.Pa dialysis aakulu aimpso kulephera, parenteral zakudya osakaniza akhoza kulowetsedwa pa mtsempha magazi.
③ Kulephera kwa mtima ndi m'mapapo: nthawi zambiri kumaphatikizidwa ndi kuperewera kwa zakudya m'thupi ndi mapuloteni.Zakudya zam'mimba zimathandizira kuti pakhale matenda komanso m'mimba m'matenda osakhazikika a pulmonary (COPD) ndipo zitha kupindulitsa odwala omwe ali ndi vuto la mtima (umboni ulibe).Chiyerekezo choyenera cha shuga ndi mafuta mwa odwala COPD sichinadziwikebe, koma chiŵerengero cha mafuta chiyenera kuwonjezeka, chiwerengero chonse cha shuga ndi kulowetsedwa chiyenera kuyendetsedwa, mapuloteni kapena amino acid ayenera kuperekedwa (osachepera lg/kg. d), ndipo glutamine yokwanira iyenera kugwiritsidwa ntchito kwa odwala omwe ali ndi matenda oopsa a m'mapapo.Ndizopindulitsa kuteteza endothelium ya alveolar ndi minofu yokhudzana ndi matumbo a lymphoid ndikuchepetsa zovuta zam'mapapo.④Kutsekeka kwamatumbo otupa: Thandizo la perioperative parenteral Thandizo kwa masabata a 4 mpaka masabata a 6 ndilopindulitsa pakubwezeretsa matumbo ndi mpumulo wa kutsekeka.

Contraindications
1. Omwe ali ndi vuto la m'mimba, amazolowera zakudya zam'mimba kapena kuchira m'mimba mkati mwa masiku asanu.
2. Osachiritsika, palibe chiyembekezo chokhala ndi moyo, odwala chikomokere osachiritsika.
3. Omwe amafunikira opaleshoni yadzidzidzi ndipo sangathe kugwiritsa ntchito chithandizo cha zakudya asanachite opaleshoni.
4. Kugwira ntchito kwa mtima kapena zovuta za metabolic ziyenera kuyendetsedwa.

Njira yazakudya
Kusankhidwa kwa njira yoyenera ya zakudya za makolo kumadalira zinthu monga mbiri ya kuphulika kwa mitsempha ya m'mitsempha, venous anatomy, coagulation, kuyembekezera nthawi ya parenteral zakudya, malo a chisamaliro (ogonekedwa m'chipatala kapena ayi), komanso mtundu wa matenda omwe amayambitsa.Kwa odwala omwe ali m'chipinda chogona, njira yachidule ya venous kapena central venous intubation ndiyo njira yofala kwambiri;kwa odwala omwe ali ndi chithandizo chanthawi yayitali omwe si a chipatala, peripheral venous kapena central venous intubation, kapena mabokosi olowetsera a subcutaneous amagwiritsidwa ntchito kwambiri.
1. Njira yodutsa mtsempha wa mtsempha wa makolo
Zizindikiro: ① Zakudya zopatsa thanzi kwakanthawi kochepa (masabata 2), mphamvu ya osmotic yamphamvu yochepera 1200mOsm/LH2O;② Chapakati venous catheter contraindication kapena chosatheka;③ Matenda a catheter kapena sepsis.
Ubwino ndi kuipa: Njirayi ndi yosavuta komanso yosavuta kugwiritsa ntchito, imatha kupewa zovuta (makina, matenda) okhudzana ndi catheterization yapakati ya venous, ndipo ndizosavuta kuzindikira kupezeka kwa phlebitis koyambirira.Choyipa chake ndikuti kuthamanga kwa osmotic kwa kulowetsedwa sikuyenera kukhala kokwera kwambiri, ndipo kupukusa mobwerezabwereza ndikofunikira, komwe kumakonda kukhala ndi phlebitis.Choncho, sizoyenera kugwiritsidwa ntchito kwa nthawi yaitali.
2. Zakudya za makolo kudzera m'mitsempha yapakati
(1) Zizindikiro: parenteral zakudya zoposa 2 milungu ndi michere njira osmotic kuthamanga kuposa 1200mOsm/LH2O.
(2) Njira ya catheterization: kudzera m'mitsempha yamkati yamkati, mtsempha wa subclavia kapena mtsempha wapakatikati wopita kumtunda wapamwamba wa vena cava.
Ubwino ndi kuipa: Katheta ya subclavia vein ndiyosavuta kusuntha ndikusamalira, ndipo vuto lalikulu ndi pneumothorax.Kutsekula m'mitsempha ya m'kati mwa jugular kumachepetsa kuyenda ndi kuvala kwa jugular, ndipo kumabweretsa zovuta zina za hematoma yapafupi, kuvulala kwa mitsempha ndi matenda a catheter.Peripheral vein-to-central catheterization (PICC): Mtsempha wamtengo wapatali ndi wotakasuka komanso wosavuta kuyikapo kusiyana ndi mitsempha ya cephalic, yomwe ingapewe mavuto aakulu monga pneumothorax, koma imawonjezera kuchuluka kwa thrombophlebitis ndi intubation dislocation komanso kuvuta kugwira ntchito.Njira zosayenera zopatsa thanzi za makolo ndi mtsempha wakunja wa jugular ndi mtsempha wa chikazi.Yoyamba ili ndi chiwerengero chachikulu cha malo olakwika, pamene chotsatiracho chimakhala ndi vuto lalikulu la matenda opatsirana.
3. Kulowetsedwa ndi subcutaneously ophatikizidwa catheter kudzera chapakati venous catheter.

Dongosolo lazakudya
1. Zakudya zamakolo zamakina osiyanasiyana (mabotolo ambiri, onse-mu-modzi ndi matumba a diaphragm):
①Kupatsirana kwamabotolo ambiri: Mabotolo angapo a yankho la michere amatha kusakanizidwa ndikufalikira kudzera mu chubu cholowetsera cha "njira zitatu" kapena Y.Ngakhale kuti ndi yosavuta komanso yosavuta kugwiritsa ntchito, ili ndi zovuta zambiri ndipo siyenera kuilimbikitsa.
②Total nutrient solution (TNA) kapena all-in-one (AIl-in-One): Ukadaulo wosanganiza wa aseptic wa njira yonse yazakudya ndikuphatikiza zosakaniza zonse za tsiku ndi tsiku (shuga, emulsion yamafuta, ma amino acid, ma electrolyte, mavitamini ndi kufufuza. element) ) zosakaniza mu thumba kenako ndikulowetsedwa.Njirayi imapangitsa kuti zakudya za parenteral zikhale zosavuta, ndipo kulowetsedwa kwa zakudya zosiyanasiyana nthawi imodzi kumakhala koyenera kwa anabolism.Pomaliza Chifukwa matumba a polyvinyl chloride osungunuka ndi mafuta a polyvinyl chloride (PVC) amatha kuyambitsa poizoni, polyvinyl acetate (EVA) yakhala ikugwiritsidwa ntchito ngati zopangira zazikulu zamatumba azakudya za makolo pano.Pofuna kuonetsetsa kukhazikika kwa gawo lililonse mu yankho la TNA, kukonzekera kuyenera kuchitidwa motsatira ndondomeko yomwe yatchulidwa (onani Mutu 5 kuti mudziwe zambiri).
③Chikwama cha diaphragm: M'zaka zaposachedwa, matekinoloje atsopano ndi mapulasitiki atsopano (polyethylene/polypropylene polima) akhala akugwiritsidwa ntchito popanga matumba omalizidwa a zakudya zopatsa thanzi.Mankhwala atsopano amtundu wa michere (chikwama cha zipinda ziwiri, thumba la zipinda zitatu) akhoza kusungidwa kutentha kwa miyezi 24, kupewa vuto la kuipitsidwa kwa michere yokonzedwa m'chipatala.Itha kugwiritsidwa ntchito mosamala komanso moyenera pakulowetsedwa kwazakudya kwa makolo kudzera mtsempha wapakati kapena mtsempha wapakatikati mwa odwala omwe ali ndi zosowa zosiyanasiyana zazakudya.Choyipa ndichakuti kukhazikika kwa chilinganizo sikungakwaniritsidwe.
2. Mapangidwe a parenteral zakudya njira
Malinga ndi zakudya zomwe wodwalayo amafunikira komanso kagayidwe kachakudya kagayidwe kachakudya, pangani kapangidwe ka zakudya zokonzekera.
3. Special masanjidwewo kwa parenteral zakudya
Zakudya zamakono zamakono zimagwiritsa ntchito njira zatsopano zopititsira patsogolo zakudya zopatsa thanzi kuti zipititse patsogolo kulolerana kwa odwala.Kuti akwaniritse zosowa za chithandizo chamankhwala, magawo apadera azakudya amaperekedwa kwa odwala apadera kuti apititse patsogolo chitetezo chamthupi cha wodwalayo, kukonza zotchinga m'matumbo, ndikuwongolera mphamvu ya antioxidant ya thupi.Zokonzekera zatsopano zopatsa thanzi ndi izi:
①Fat emulsion: kuphatikiza mafuta emulsion opangidwa, unyolo wautali, emulsion yamafuta apakatikati, ndi emulsion yamafuta olemera omega-3 mafuta acid, ndi zina zambiri.
②Kukonzekera kwa amino acid: kuphatikiza arginine, glutamine dipeptide ndi taurine.
Table 4-2-1 Zofunikira za Mphamvu ndi mapuloteni a odwala opaleshoni
Mkhalidwe wa odwala mphamvu Kcal/(kg.d) mapuloteni g/(kg.d) NPC: N
Kuperewera kwa zakudya m'thupi mwachizolowezi 20~250.6~1.0150:1
Kupanikizika pang'ono 25 ~ 301.0 ~ 1.5120: 1
Kupanikizika kwakukulu kwa metabolic 30~35 1.5~2.0 90~120:1
Kuwotcha 35~40 2.0~2.5 90~120: 1
NPC: N calorie yopanda mapuloteni ku chiŵerengero cha nayitrogeni
Thandizo la zakudya za makolo pa matenda aakulu a chiwindi ndi kupatsirana kwa chiwindi
Mphamvu zopanda mapuloteni Kcal/(kg.d) mapuloteni kapena amino acid g/(kg.d)
Kulipidwa cirrhosis25~35 0.6~1.2
Decompensated cirrhosis 25-35 1.0
Hepatic encephalopathy 25 ~ 35 0.5 ~ 1.0 (kuwonjezera chiŵerengero cha nthambi za amino acid)
25 ~ 351.0 ~ 1.5 pambuyo pa kuika chiwindi
Mfundo zofunika kuziganizira: Zakudya zopatsa thanzi m'kamwa kapena zam'mimba nthawi zambiri zimakondedwa;ngati sichikuloledwa, chakudya cha makolo chimagwiritsidwa ntchito: mphamvu imapangidwa ndi shuga [2g/(kg.d)] ndi emulsion yamafuta apakati [1g/(kg.d)], mafuta amawerengera 35 ~ 50% ma calories;gwero la nayitrogeni limaperekedwa ndi ma amino acid apawiri, ndipo hepatic encephalopathy imakulitsa gawo la nthambi za amino acid.
Thandizo lazakudya la makolo pachimake matenda a catabolic ovuta ndi kulephera kwaimpso
Mphamvu zopanda mapuloteni Kcal/(kg.d) mapuloteni kapena amino acid g/(kg.d)
20 ~ 300.8 ~ 1.21.2 ~ 1.5 (tsiku ndi tsiku odwala dialysis)
Mfundo zofunika kuziganizira: Zakudya zopatsa thanzi m'kamwa kapena zam'mimba nthawi zambiri zimakondedwa;ngati sichikuloledwa, zakudya za parenteral zimagwiritsidwa ntchito: mphamvu imapangidwa ndi shuga [3 ~ 5g / (kg.d)] ndi mafuta emulsion [0.8 ~ 1.0g / (kg.d) )];ma amino zidulo osafunikira (tyrosine, arginine, cysteine, serine) athanzi amakhala ma amino acid ofunikira panthawiyi.Shuga wamagazi ndi triglycerides ziyenera kuyang'aniridwa.
Table 4-2-4 Analimbikitsa tsiku kuchuluka kwa okwana parenteral zakudya
Mphamvu 20~30Kcal/(kg.d) [Madzi 1~1.5ml pa 1Kcal/(kg.d)]
Glucose 2 ~ 4g/(kg.d) Mafuta 1-1.5g/(kg.d)
Nayitrojeni wa 0.1~0.25g/(kg.d) Amino asidi 0.6~1.5g/(kg.d)
Electrolytes (avereji tsiku zofunika parenteral zakudya akuluakulu) Sodium 80~100mmol Potaziyamu 60~150mmol Chlorine 80~100mmol Kashiamu 5~10mmol Magnesium 8~12mmol Phosphorus 10~30mmol
Mavitamini osungunuka mafuta: A2500IUD100IUE10mgK110mg
Mavitamini osungunuka m'madzi: B13mgB23.6mgB64mgB125ug
Pantothenic Acid 15mg Niacinamide 40mg Folic Acid 400ugC 100mg
Tsatani zinthu: mkuwa 0.3mg ayodini 131ug zinki 3.2mg selenium 30~60ug
Molybdenum 19ug Manganese 0.2~0.3mg Chromium 10~20ug Iron 1.2mg

 


Nthawi yotumiza: Aug-19-2022