精品資料精品資料第四節(jié)腸內(nèi)營養(yǎng)的應(yīng)用一、腸內(nèi)營養(yǎng)的適應(yīng)癥Patientswithafunctionalgastrointestinal(GI)tractwhowillnot,cannot,orshouldnoteat,andarecandidatesfornutritionalsupport,shouldbefedenterally.腸內(nèi)營養(yǎng)的可行性主要取決于小腸是否具有一定的吸收功能，腸內(nèi)營養(yǎng)的主要適應(yīng)癥如下。（一）不能經(jīng)口進(jìn)食、攝食不足或有攝食禁忌者難者。AIDS覺喪失而不能吞咽者。（二）胃腸道疾病多數(shù)原發(fā)性胃腸道疾病病人應(yīng)用腸內(nèi)營養(yǎng)制劑可以改善營養(yǎng)狀況。腸內(nèi)營養(yǎng)制劑中各類營養(yǎng)素搭配合理，易消化吸收，此外還有改變腸道菌群、無渣、無乳糖以及對腸道和胰腺外分泌刺激較輕等優(yōu)點(diǎn)。體營養(yǎng)素需要量時(shí)，方可停止腸外營養(yǎng)。以上功能良好的小腸的小腸瘺，可由胃內(nèi)喂養(yǎng)。必要時(shí)可與腸外營養(yǎng)結(jié)合應(yīng)用。利于防止腸道粘膜萎縮，改善腸粘膜屏障功能，防止菌群移位?；加形詹涣季C合征、小腸憩室炎及各種疾病導(dǎo)致的頑固性腹瀉如AIDS有助于疾病的恢復(fù)和營養(yǎng)狀況的改善。胰腺外分泌并補(bǔ)充營養(yǎng)素。內(nèi)營養(yǎng)制劑可降低菌群失調(diào)和感染，從而使手術(shù)危險(xiǎn)性降低，檢查結(jié)果更準(zhǔn)確，術(shù)后護(hù)理更方便。復(fù)。（三）胃腸道外疾病2病人早日恢復(fù)。其它手術(shù)后需要補(bǔ)充營養(yǎng)時(shí)，只要胃腸道允許，均可采用腸內(nèi)營養(yǎng)。（心、嘔吐、腹瀉、味覺改變或肝臟毒害等），腸粘膜對氨基酸及低聚肽的吸收能力不受太大影響。代謝引起的體細(xì)胞群損失，提供足夠的能量與蛋白質(zhì)以滿足代謝需要，預(yù)防其它并發(fā)癥的發(fā)生。8助于合成體蛋白。1000kcal/d乏這種氨基酸的腸內(nèi)營養(yǎng)制劑，從而減少疾病對機(jī)體的損害，如苯丙酮尿癥。TPN養(yǎng)過渡到經(jīng)口進(jìn)食。二、腸內(nèi)營養(yǎng)的禁忌證Theonlyabsolutecontraindicationtoenteralfeedingismechanicalobstructionofthegut.Inaddition,enternutritionshouldbeavoidedinpatientswithactiveGIbleeding.ContraindicationsforenterostomyaccessaresummarizedinBox9.2.Box9.4.1ContraindicationsforgastrostomytubeplacementBox9.4.1ContraindicationsforgastrostomytubeplacementDisturbedcoagulationNeoplasmsinthestomachMorbidobesityGastricvarices只要腸道有功能，就可以實(shí)施腸內(nèi)營養(yǎng)支持。腸內(nèi)營養(yǎng)的絕對禁忌證是腸道梗阻。另外，下列情況不宜應(yīng)用腸內(nèi)營養(yǎng)：重癥胰腺炎急性期。嚴(yán)重應(yīng)激狀態(tài)、麻痹性腸梗阻、上消化道出血、頑固性嘔吐、嚴(yán)重腹瀉或腹膜炎。4～63完全性腸梗阻及胃腸蠕動嚴(yán)重減慢的病人；。下列情況應(yīng)慎用腸內(nèi)營養(yǎng)支持：嚴(yán)重吸收不良綜合征及長期少食衰弱的病人。小腸缺乏足夠吸收面積的空腸瘺病人。休克、昏迷的病人。三、腸內(nèi)營養(yǎng)并發(fā)癥的預(yù)防及處理Complicationsassociatedwithenteraltubefeedingmaybeofmechanical,gastrointestinal,ormetabolicnature.Complicationsassociatedwiththeproceduresofenterostomytubeareinfrequent,butincludereactiontoanethesia,perforationofadjacentorgans,bleeding,andinfection.Specialprecautionsshouldbetakenwhenfeedingintothesmallbowelduetothelackofgastricvolumeoracidity.ThemostcommoncomplicationsofenteralfeedingandadviceabouthowtominimizethemareshowninTable9.4.1.Table9.4.1PossiblecomplicationsofenteraltubefeedingComplicationComplicationProbablecausesActions/adviceMechanicalcomplications:TubecloggingDisplacementorkinkintubeChecktubefordisplacementsorkinks,changetubeifAdministrationofmedicationsnecessaryDiameteristoosmallAdvisetoflushthetubewithwaterwhenmedicationisNutritionalresidueadheringadministeredtotubeAdviselargerdiameterwhenhighlyviscousformulasareusedAdvisetoflushthetubefrequently,every4hwithwaterTubedisplacementCoughing,Sneezing,vomitingRepositionoftubeMigrationoftubeReplacetubeandconsiderplacementofatubewithalargerDislodgementbypatientdiameterInadequatetapingoftubeReplacetube,ifnecessaryrestrainpatientConsiderotherfeedingroute.ReplacetubeandfastenproperlyIrritationsofnose,TubediameteristoolargeAdviseatubewithasmallerdiameterthroatandesophagusTubeisstiffAdviseaflexibletubeImproperpositioningoftubeRepositionthetubeproperly.ReplacetubethroughotherTubeisplacedtoolongnostrilInadequatetapingoftubeConsiderotherfeedingroutesTapetubeproperly.ThetubeshouldbeabletomoveduringswallowingGastrointestinalcomplications:ProblemsintheoralDecreasedornostimulationofAdvisetorinsethemouthregularlyorsipfluidsifpossible.cavity salivaryDrymouth

Advisetochewonsugar-freegumorpeppermintsifAdvisepropermouthcareandregularrinsingofthemouthTimeperiodoftubeplacingisReplacetubeorconsiderotherfeedingtoolongNauseaorvomiting Formulaistoocold AdviseonlytoadministerenteralformulasatRateofinfusionistoohightemperatureVolumeistoohighFormulaistoo

DecreaserateofinfusionDecreasevolume,consideramoreconcentratedformulaDisturbedgastricemptyingNoDecreaseconcentrationofformulabowelmovementsIleusDislocationoftube

Checkgastricresiduals.Monitorfordiseasesordrugsmayinfluencegastricmotility.AdviseprokineticsifPossiblelactoseintolerancepossible.ConsidernasoenteralfeedingInfectiousorigin Advisetoexcludeanileus.Ifindicated,advisetostimulatebowelmovementswithaclysmaImmediatelystopenteralfeeding.IfindicatedparenternutritionReplacetubeandconfirmSwitchtolactose-freeformulaCheckperformanceofinfectioncontrolprotocolAspiration Delayedgastric Checkgastricresiduals.MonitorfordiseasesordrugsemptyingPatientonlyinlyingmayinfluencemotility.AdviseprokineticsifpossiblepositionAdministrationoffeedingHighinfusionrateDisplacedfeedingtubeConstipation InadequatefluidMedicationInactivityInadequatefiberintake

Elevateheadofbedwith30degreesAlterbolustocontinuefeedingordecreasebolusDecreaseinfusionrate.ConsiderconcentratedsolutionsReplacetube.ConsidernasoenteralfeedingMonitorfluidbalance,ifnecessaryincreaseadministrationCheckmedicationusewhichcancauseadecreaseinmotilityAdvisemorephysicalactivityifpossibleConsiderformularichindietaryfiberDiarrhea FormulatoocoldInfusionratetooHyperosmolarformulaBolusfeedingInfectiousoriginMalabsorptionLactoseintoleranceIncreasedbowel

AdviseonlytoadministerformulaatroomtemperatureDecreaseinfusionrateChangetoisotonicformulaDecreasebolusvolumeorchangetocontinuousEvaluatetubefeedinghandlingandinfectioncontrolstrategiesMonitormalasbsorption,changetoelementalformulaindicatedmotilityExtremelylowalbuminSwitchtolactose-freeformulalevelsMedications Reviewpossibleeffectsofmedicationordiseasesonbowelmotility.IfpossibleadvisetostartwithmedicationsslowbowelmotilitySinceadequateenteralfeedingisdifficulttoachieve,adviseparenteralnutrition.Ifpossible,asmallamountenteraltubefeedingcanbeadministeredMonitormedicationswhichmayinducediarrheasuchantibioticsMetaboliccomplications:Dehydration Inadequatewatersupply Monitorfluidbalancewithspecialinterestinkidneyfunction,serumvaluesofelectrolytes,urea,andcreatinine.Checkchangesinbodyweight.IfindicatedincreaseHyper-/hypoglycemia Feedingandinsulintherapyincompatible

Adjustfeedingorinsulintherapy.Considerationsaboutorcontinuousfeedingdependsoninsulintherapy.Monitorbloodsugarfrequently.IfnecessarystopnutritinSerumelectrolyteandDiseaserelatedmineraldisturbances

Adjustenteralformulatoabnormalities,ifindicatedDeficienciesofessentialnutrients

InsufficientsupplyofnutrientsLossesofnutrientsDisease-relateddeficiencies

Administertherecommendeddailyallowcesofallessentialnutrients.Ifindicated,advisesupplyMonitornutrientlosses.CheckserumvaluesandsupplementationifnecessaryChckdeficiencieswhentheycanbeexpectedandadvisesupplythemifindicatedSource:MichaelJ.Gibney,MarinosElia,OlleLjungqvist,etal.ClinicalNutrition,2005.腸內(nèi)營養(yǎng)的并發(fā)癥主要有胃腸道并發(fā)癥、代謝并發(fā)癥、感染并發(fā)癥和置管并發(fā)癥等。（一）胃腸道并發(fā)癥胃腸道并發(fā)癥是腸內(nèi)營養(yǎng)最常見的并發(fā)癥，主要表現(xiàn)為腹瀉、惡心、嘔吐。腹瀉營養(yǎng)制劑選擇不當(dāng)：營養(yǎng)制劑中脂肪含量相差較大，低脂肪營養(yǎng)液脂肪提供能量僅占0.9%～2%，高脂肪營養(yǎng)液脂肪提供能量達(dá)9%～31%，前者僅供給必需脂肪酸，而后者除提供必需脂肪酸外，還提供能量。對于脂肪吸收不良的病人，高脂肪較易引起腹瀉，因此，在選用腸內(nèi)營養(yǎng)制劑時(shí)應(yīng)熟悉各品種的營養(yǎng)素的質(zhì)和量及滲透壓，對某種產(chǎn)品不耐受者，可選用另一種產(chǎn)品。300mOsm/L營養(yǎng)液進(jìn)入腸腔后，腸粘膜吸收水分障礙，反向腸腔內(nèi)分泌水分而引起腹瀉，如水樣便。預(yù)防辦法為第l40～50ml/h，24h使用各種改善措施后仍無效，可改為腸外營養(yǎng)。營養(yǎng)液溫度過低：營養(yǎng)液溫度應(yīng)維持在40人。一般應(yīng)在體外復(fù)溫到室溫下再輸注入腸。從冰箱取出的配制營養(yǎng)液一定要復(fù)溫到室溫才可輸入。復(fù)溫可使用小型電熱杯、熱水袋或暖水瓶加熱。應(yīng)用腸內(nèi)營養(yǎng)輸液泵時(shí)，應(yīng)在輸液器近導(dǎo)管口端夾上保溫夾，可保持進(jìn)入體內(nèi)的液體溫度在38℃左右。嚴(yán)重營養(yǎng)不良、低蛋白血癥，尤其血漿白蛋白低于30g/Ll～2（如抗生素使?fàn)I養(yǎng)液中大量未水解的乳糖進(jìn)入腸腔，造成腸腔內(nèi)滲透壓驟然增高而引起腹瀉。目前商品用腸內(nèi)營養(yǎng)制劑中乳糖含量均極低，使用這類營養(yǎng)制劑時(shí)一般不會出現(xiàn)腹瀉。程度，因此應(yīng)針對病因處理，或改用腸外營養(yǎng)，待全身情況穩(wěn)定再開始應(yīng)用腸內(nèi)營養(yǎng)。此外，營養(yǎng)