第21章 创伤和手术病人的营养治疗背景知识 background n创伤(wound):是指机械损伤。Machine hurt. 创伤、手术 Wound Operation负氮平衡 negative nitrogen balance代谢需求 Metabolic demand保证手术、创伤后的营养需求，促进机体恢复。Keep nutrition demand of wound and operation .Promote recovery1. 严重创伤病人的营养治疗The nutritional therapy of serious wound2. 围手术期病人的营养治疗 The nutritional therapy of perioperative period 3. 短肠综合征病人的营养治疗 The nutritional therapy of short bowel syndrome 4. 肠瘘病人的营养治疗 The nutritional therapy of intestinal fistula 严重创伤和大手术的病人，高代谢状态，常伴 有免疫功能低下。Metabolic demand is increased during wound healing and operation. Depress immune function. 仅提供充足的能量和氮源的营养治疗方法，并 不能有效的恢复病人的免疫功能。Enough energy and nitrogen source only can not recover immune function effectively.一、营养代谢特点 Characteristic of nutrient metabolism 二、营养治疗与饮食指导 Nutrition therapy and dietary guidance 能量代谢Energy metabolism 糖代谢Glucose metabolism 蛋白质代谢Proteinmetabolism脂肪代谢Fat metabolism静息能量消耗 （rest energy expenditure, REE）增加。 儿茶酚胺分泌增加，血糖升高 Catecholamine secretion,blood glucose increased 分解增加，负氮平衡 Decomposition increased negative nitrogen balance 脂肪动员增加 Fat mobilization increase 早期使用肠外营养，病人肠道功能容许尽早使用肠内营养。parenteral nutrition should be used, patients who bowel function allowed should use enteral nutrition earlier. 膳食由流质饮食、半流质饮食、软质饮食向普通饮食过渡。 Diet transform from liquid diet, semi-liquid diet, soft diet diet to normal diet gradually.能 量 Energy早期，分解代谢，15001800kcal/d early period, catabolism 恢复，合成代谢，20002500kcal/d recovery, anabolic 能量需求基础能量消耗（BEE）活动系数体温系数应激系数男性BEE=66.4713.75体重（kg）5.00身高（cm）6.76年龄（岁）女性BEE=655.109.46体重（kg）1.85身高（cm）4.68年龄（岁）糖和脂肪 Carbohydrate and fat 蛋白质 Protein蛋白质供给量应达到23g/（kgd） 优质蛋白占50%以上。Protein supply should reach 2 3g / (kg d) High-quality protein, accounting for more than 50%.增加谷氨酰胺的供给量，促进恢复。 Increase the supply of glutamine to promote recovery.提供能量和必须脂肪酸。Provide energy and essential fatty acids.脂肪供能应占总能量的30%35%，其余所需能 量由碳水化合物和蛋白质提供。Fat account for 30% 35% total energy ,and the rest required providing by the carbohydrate and protein.矿物质与维生素 Minerals and vitamin 促进组织修复，胶原合成。由含以上营养素丰 富的食物提供，必要时也可使用相应制剂。Promote tissue recovery, collagen synthesis. Provide with food contained rich nutrients, if necessary, can also use corresponding agents. 一、营养代谢特点 Characteristic of nutrient metabolism 二、营养治疗与饮食指导 Nutrition therapy and dietary guidance 手术创伤初期，机体处于应激状态，表现 为交感-肾上腺髓质系统兴奋。 肾上腺素、去甲肾上腺素、糖皮质激素、 生长激素和胰高血糖素分泌增加，从而影响营 养物质的代谢 。At the initial surgical wound time, the body is in stress, manifested as sympathetic - adrenal system excited. Epinephrine, norepinephrine, glucocorticoid, growth hormone and glucagon secrete increasingly , and affecting the metabolism of nutrients.糖代谢Glucose metabolism 脂肪代谢Fat metabolism蛋白质代谢Proteinmetabolism水、电解质 代谢 Water and electrolyte metabolism 分解增加，负氮平衡 Decomposition increased negative nitrogen balance分解过度，必需脂肪酸缺乏 Over decomposition lack of essential fatty acids 儿茶酚胺分泌增加，血糖升高 Catecholamine secretion,blood glucose increased水、电解质代谢紊乱 Water, electrolyte metabolism disorder 手术前的营养治疗与饮食指导 Pre-operative nutritional therapy and dietary guidance 术前应尽量改善病人的血红蛋白、血清总蛋白及其他各项营 养指标， 最大限度地提高其手术耐受力。preoperative patients hemoglobin, serum total protein and other nutritional indicators should be tried to improve to maximize the tolerance of its operation.尽量采用肠内营养治疗， 严重营养不良消化吸收功能障碍者，可联合或单独使用肠外 营养治疗。Use of enteral nutrition therapy as far as possible, Digestion and absorption of severe malnutrition dysfunction may jointly or separately use of parenteral nutrition therapy. 能 量 Energy每日能量供给20002500kcal。 Daily energy supply ： 2000 2500kcal 碳水化合物为主要能量来源，占总能 量的65。 Carbohydrates as the main energy source, accounting for 65% of total energy. 脂肪、蛋白质 Fat and Protein脂肪供给量低于正常人，占总能量的 1520。 Lower than normal supply, Fat supply accounts for 15- 20% of total energy.蛋白质充足，优质蛋白占50。Adequate protein supply, high-quality protein, accounting for more than 50%.矿物质与维生素 Minerals and vitamin 每天供给维生素C100mg， 胡萝卜素3mg、 维生素B1、B2各56mg， 维生素PP5060mg， 有凝血机制障碍者加用维生素 K15mg。术前710天开始补充. Preoperative day 7 to 10 added 手术后的营养治疗与饮食指导 Post-operative nutritional therapy and dietary guidance以肠内营养为主，膳食多从要素营养制剂开 始，辅以营养免疫剂，逐步经过流质饮食、半 流质饮食、软质饮食向普通饮食过渡。通常采 用少食多餐的供餐方式，必要时可采用肠外营 养治疗，或肠内、肠外联合营养治疗。Enteral nutrition first. At the beginning, elements of nutrition diet should be supplied, supplemented with immune agents. Diet transition from a liquid diet, semi-liquid diet, soft to ordinary diet gradually. If necessary, parenteral nutrition or enteral, parenteral nutrition combined therapy can be treated.胃肠道手术Gastrointestinal surgery 禁食少渣半流食、半流食 软食 Fasting Semi-flow low residue food, semi -flow foodsoft diet 肝、胆、脾手术Liver, gallbladder, spleen surgery 低脂、高蛋白的半流饮食；肝硬化流质软食Low-fat, semi-flow high-protein diet; cirrhosis liquid diet. 口腔、咽喉部手术Mouth, throat surgery 禁食冷流质饮食 少渣半流食 软食 Fasting Cold liquid diet Semi-flow low residue foodsoft diet 其他部位手术Other parts of the operation 颅脑损伤和昏迷 管饲肠内营养 慢性消耗性疾病 高蛋白膳食 能 量 Energy卧床休息男性病人， 每日供给能量2000kcal，女性为1800kcal。 Male patient with bed rest, daily supply of