2006/09/091肠外营养支持2006/09/092患者Z，男，42岁，体重70kg，急性重症胰腺炎第3天。昨天体温39oC，胃液500ml，尿1500ml，血尿淀粉酶升高，血常规示WBC总数及中性WBC升高。如何进行营养支持？病例报告When?2006/09/093问题1谁需要营养支持？2006/09/094营养不良包括营养素摄入不足、营养素代谢障碍造成的如何营养状态紊乱，包括营养过度。流动门诊患者1-15%门诊留观患者25-60%住院患者35-65%营养不良2006/09/095增加发病率与死亡率延缓伤口愈合增加并发症延长住院时间增加医疗费用增加再次住院率营养不良NoComplicationNon-infectiousComplicationInfectiousComplicationTotalNotat-risk8888(2513)(2513)77(194)(194)55(141)(141)100100(2848)(2848)At-risk6969(903)(903)1717(226)(226)1414(183)(183)100100(1312)(1312)P<0.0012006/09/096营养筛查病史首测参数体重下降体重食欲、恶心身高摄食量BMI2006/09/097体质指数(BODYMASSINDEX,BMI)=体重(kg)/身高2(m2)等级BMI指数正常值18.5<=BMI<23.5蛋白质:热量营养不良I级17.0-18.4蛋白质:热量营养不良II级16.0-16.9蛋白质:热量营养不良III级<16营养筛查2006/09/098营养筛查BMI与死亡率<15kg/m2significantmortality<18.5kg/m2underweight>25kg/m2overweight>30kg/m2Obese;significantmortality2006/09/099体重过度降低或增加均可视为营养不良，其评判标准为在6个月内因非主观原因比平时体重降低或增加10%左右，或比过去1个月的体重降低或增加5%，或体重为理想体重的±20%。理想体重计算公式：男：（身高cm-80）×0.7±10%女：（身高cm-70）×0.6±10%营养筛查2006/09/0910等级理想体重的％正常值>90轻度营养不良80-90中度营养不良60-79重度营养不良<60营养筛查2006/09/09111.NutritionalRiksIndex2.Subjectiveglobalassessment3.MalnutritionUniversalScreeningTool(MUST)4.NutritionalRiskScreening(NRS2002)5.MNA(elderly)营养筛查2006/09/0912MUST0(LOW)0(LOW)1(MEDIUM)1(MEDIUM)2ormore(HIGH)2ormore(HIGH)ROUTINECLINICALCAREROUTINECLINICALCAREOBSERVEOBSERVETREATTREATAcutediseaseeffectAcutediseaseeffectAddaAddascoreof2scoreof2iftherehasiftherehasbeenorislikelytobenoorbeenorislikelytobenoornutritionalintakefor>5daysnutritionalintakefor>5daysHospitalHospital-refertodietitianor-refertodietitianorimplementlocalpolicies.implementlocalpolicies.GenerallyfoodfirstfollowedbyGenerallyfoodfirstfollowedbyfoodfortificationandsupplementsfoodfortificationandsupplementsCareHomesCareHomes(asforhospital)(asforhospital)CommunityCommunity(asforhospital)(asforhospital)BMI(kg/m2)BMI(kg/m2)0:>20.00:>20.01:=18.5-20.01:=18.5-20.02<18.52<18.5Weightlossin3-6monthsWeightlossin3-6months0:<5%0:<5%1:=5-10%1:=5-10%2:>10%2:>10%HospitalHospital-documentdietaryand-documentdietaryandfluidintakefor3daysfluidintakefor3daysCareHomesCareHomes(asforhospital)(asforhospital)CommunityCommunity-Repeatscreening,-Repeatscreening,e.g.from<1moto>6mo(withe.g.from<1moto>6mo(withdietaryadviceifnecessary)dietaryadviceifnecessary)RepeatscreeningRepeatscreeningHospitalHospital-everyweek-everyweekCareHomesCareHomes-everymonth-everymonthCommunityCommunity-everyyearfor-everyyearforspecialgroups,e.g.those>75yspecialgroups,e.g.those>75y2006/09/0913NRS20021.IsBMI<20.5?YesNo2.Hasthepatientlostweightwithinthelast3months?YesNo3.Hasthepatienthadareduceddietaryintakeinthelastweek?YesNo4.Isthepatientseverelyill?(e.g.ICU)YesNo→If“No“toallquestions,re-screenedatweeklyintervals.→If“Yes“toanyquestion,thefinalscreeningisperformed.AnswerAnswerInitialscreening2006/09/0914NRS2002Finalscreening(Finalscreening(ImpairednutritionalstatusImpairednutritionalstatus))AbsentScore0=NormalnutritionalstatusMildScore1Wtloss>5%in3monthsorFoodintake...
