重症患者营养支持.pptx

重症患者营养支持;概述;营养支持演变;危重病状态下代谢特点; 糖代谢变化;高分解代谢; Randomized trials have not shown a benefit from approaches that try to counteract the natural catabolic state that occurs in the acute phase of critical illness (i.e., forcing patients to reach their calculated caloric goals, through combinations of enteric and parenteral feedings).;;营养需要量;正常人体所需营养素;正常人体能量需求;正常成人蛋白质需求 ;不一样年纪精细能量消耗量;应激时能量日需要量（正常倍数）;蛋白与电解质日需要量;危重症营养支持 ;危重病人营养支持目 ;危重病人营养支持标准 ;营养支持途径;营养支持途径;营养支持途径选择标准;危重病人能量补充标准 ;?经验性估计： 轻度应激：20～30kcal/天/Kg； 中度应激：30～40kcal/天/Kg ； 重度应激：40～50kcal/天/Kg ； 特殊病例（严反复合伤、大面积烧伤、严重感染等）：60～80kcal/天/Kg 。;肠外营养支持（PN）;应用指征 ;应用指征;应用指征;肠外补充主要营养素 ;碳水化合物;脂肪乳剂 ;脂肪乳剂;氨基酸/蛋白质 ;水、电解质补充 ;维生素与微量元素 ;肠外营养支持途径;肠内营养（EN） 与 全胃肠外营养(TPN);Enteral nutrition is preferable to total parenteral nutrition, which is associated with nosocomial infections. A meta-analysis of 6 randomized trials (n=498) comparing enteral with parenteral nutrition suggested TPN almost doubled the infection rate compared to tube feedings. JPEN J Parenter Enteral Nutr. 2023 Sep-Oct;27(5):355-73.;第38页;Many critically ill patients have reduced gut motility and fail to tolerate enteral feedings in the amounts calculated to meet their theoretical caloric needs. For these patients, there appears to be no benefit to starting total parenteral nutrition in the first week after impaired gut motility occurs, and doing so may increase the risk for nosocomial infection. Providing no nutritional support or dextrose infusions are as good or better than early TPN for critically ill patients who can’t tolerate tube feedings. That being said, early parenteral nutrition has never been shown to increase mortality from critical illness.;;;If a patient cant tolerate enteral liquid feedings via a tube, what would you do？ ;A huge trial (n=4,640) published in NEJM in 2023 showed no benefit and potential harm from providing TPN at day 3, rather than day 8 of failing enteric feeds. N Engl J Med. 2023 Aug 11;365(6):506-17 A large observational trial also did no