surgical nutrition

外科營養

手術後病患傷口的復原，端賴營養的補充。有些重症的病患又無法進食，主動的營養評估和給予變得相當重要。

1.        碳水化合物 Carbonhydrate

                            i.                Electron transport chain, Protein sparing effect, Brain tissue

                           ii.                循環中的葡萄糖約80kcal，肝臟glycogen約300kcal，肌肉中的glycogen約600kcal

                         iii.                4kcal/g，葡萄糖溶液中約3.4kcal/g，500ml D5W/S=85kcal

2.        脂肪 Lipid

                            i.                主要的儲存形式，9kcal/g, Fatty acid 脂肪酸，Beta-oxidation

                           ii.                腸道黏膜為必需脂肪酸(GLA, ALA, EPA)組成，兩三天就要更換（約網球場面積）

                         iii.                Fatty Acid 脂肪酸：<6 short, 6-12 medium, >12 long chain

1.         必需脂肪酸：自己無法合成，須仰賴食物供給（大都為不飽和脂肪酸）

Linoleic Acid (LA-Ω6), AlphaLinoleic Acid (ALA-Ω3)

                                                                            i.                Ω3-ALA, EPA (EicosaPentaenoic Acid), DHA (DocosaHexaenoic Acid)：亞麻油、胡桃油、綠葉蔬菜

                                                                           ii.                Ω6-LA, GLA (Gamma), AA (Arachidonic acid)：葵花、紅花、玉米、芝麻油

                                                                         iii.                Ω9-Oleic Acid (油酸)

2.         以前Ω6：Ω3=1:1，目前 30:1(Milk=40, Baby Milk=10)

溫帶植物油、加工食品（氫化）、深海魚少、胚芽少、糖增加（250%）

3.         Ω3的重要性：

甲、 DHA 腦中最需要的脂肪酸，為條件必需，素食者最缺乏

乙、 EPA 會轉成 PGE3 促使發炎反應、免疫、血液凝固、血管活力

4.         Ω6的重要性：

甲、 AA會促進腦部發育，但也會轉變成PGE2促成發炎反應

乙、 GLA會轉變成PGE1，抑制AA轉變成PGE2

                        iv.                Ketone bodies

                         v.                Cholesterol：每天製造3000mg(約等於一打雞蛋)

                        vi.                Phospholipid：礦物質加脂肪酸（一為飽和，另一為不飽和）

神經細胞膜, 卵磷脂（Letithin）

                      vii.                Glycerol: Gluconeogenesis - nerve and blood cell

                   viii.                500ml 10% Intrafat = 550 Kcal

3.        蛋白質 Protein

                            i.                4 Kcal/g, 1~1.5g/kg/day

                           ii.                Aromatic, Branched chain, Ammoniogenic, Essential (Cori cycle, Urea formation)

                         iii.                組織蛋白：肌肉（橫紋，平滑，心肌），循環（白/球蛋白，抗體），酵素

                        iv.                500ml 5.5% AA= 4.63 gm N/28.9g P

1.         70kg-15kg fat, 6kg protein

2.         Kilocalorie (kcal)=1 Calorie(Cal)=1000 calories

3.         蛋白質需求：1~1.5g/kg(loss 1g/kg/day)

4.         氮平衡：6.25g protein=1g body nitrogen

5.         ESRD/Cirrhosis ‾; sepsis/burn/surgery ­

6.         食物營養量

1.         Clear liquid diet 400~500 Kcal

2.         Liquid diet 1300~1500 Kcal

3.         Soft diet 1800~2000 Kcal

4.           Full diet 1800~2200 Kcal

7.           考慮因素

1.         Protein sparing effect: CHO 100gm/day

2.         Anabolic phase: calories/N=150~200

3.         PreOp malnutrition, trauma, sepsis

4.         Method

                                                                            i.                NG, Gastrostomy, Jejunostomy feeding

                                                                           ii.                Elemental diet

                                                                         iii.                Parental nutrition supply

1.         病史：體重，食慾，腸道症狀

2.         理學檢查：

                                        i.    肌肉流失、水腫、皮下組織、I/O balance

                                       ii.    Anthropometric measurement

²          Triceps skin fold, Midarm muscle circumference

3.         檢驗室檢查

                                        i.    Albumin, Transferrin, TIBC, Prealbumin

                                       ii.    Total lymphocyte count <1500/mm

1.         NG feeding

                            i.                Alert, Unwillingness, Unable eating patient

                           ii.                Infusion pump for large dose

                         iii.                Complication:

²     Discomfort, Pressure necrosis, Esophagitis, Otitis media

2.     Gastrostomy feeding

                            i.                Alert, Distal esophagus

                           ii.                Pyloric intact or not

                         iii.                Temporary - Stamm

                        iv.                Permanent - Glassman

3.         Esophagostomy feeding: Aspiration when bolus or not alert

4.         Jejunostomy feeding

                            i.                Temporary - Witzel

                           ii.                Permanent - Roux-en-Y

                         iii.                Start 12-18 hrs later

                        iv.                Diarrhea ( Hyperosmolarity, Bolus, Bacteria overgrowth)

                         v.                Administration: continuous

3~8% Aminoacid, 10% Fat emulsion, 5~10% Dextrose

>10% solution - phlebitis

短期使用，Glycalamin

1.         Indication: avoid GI tract through Central vein

2.         Component:

                                        i.    1 Kcal/ml, calorie : nitrogen = 150:1, 25% Dextrose

                                       ii.    Electrolyte, water, fat

                                     iii.    Vitamin (water and fat soluble)

                                    iv.    Trace metals: Cofacters (Zn, Cu, Mn, Se, Cr)

3.         Special condition:

                                        i.    ESRD: essential AA, higher Dextrose

                                       ii.    Liver cirrhosis: branched-chain AA (Encephalopathy)

4.         TPN-calculation

                                        i.    Harris-benedict equation, 1919, REE

1.         Male = (789*BSA)+137

2.         Female = (544*BSA)+414

                                       ii.    TPN for 70kg, 170cm male, Postoperation, 2200ml water

1.         REE=1557(BSA1.8), REE+20%1867 Kcal

2.         Protein=70*1.3=91gm=14.5 Nitrogen

                                                                                        i.    900ml 10% AA (15.1gm N)

                                                                                       ii.    500ml 10% Intrafat (550 Kcal)

                                                                                     iii.    800ml 50% Dextrose (1360 Kcal)

Total 1910 Kcal/2200ml water

5.         TPN的併發症

                                        i.    Catheter-related

1.         Sepsis: 溶液汙染、管道汙染

2.         Central line insertion

                                                                                        i.    Pneumohemothorax, Hydrothorax, Vein injury

                                                                                       ii.    Great vein thrombosis

                                       ii.    Metabolic

1.         HHNK, Hypoglycemia

2.         Volume overload

3.         Hepatic cholestasis

Pediatric patient