医学精品课件胃肠外营养（parenteral nutrition pn ）

胃肠外营养 (Parenteral nutrition, PN ),浙江大学医学院附属邵逸夫医ICU 潘孔寒,1986年2月，上海周绮思女士因患急性肠扭转切除全部小肠，华瑞决定长期无偿向提供生存所需的全套全静脉营养产品.,1992年4月8日，历史将记住这一天。蔡惟成为世界上完全依靠人工全静脉营养孕育的第一人。周绮思母女的事例也因此被载入吉尼斯世界纪录。,References,History of parenteral nutrition. JPEN， 27:225-232, 2003 A.S.P.E.N. Board of Directors and the Clinical Guidelines Taskforce: Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN， 26(Suppl):1138,2002 Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. JPEN， 27:355373, 2003 危重患者营养支持指导意见（草案）(重症医学分会).中国危重病急救医学,10(18)：582590,2006 住院患者肠外营养支持的适应证（草案)(肠外肠内营养学分会).中国危重病急救医学,10(18)：591594,2006,循证医学：证据分级,A级以良好研究为基础的证据来支持指南(前瞻、随机试验) B级以较好研究为基础的证据来支持指南(设计较好但无随机化) C级依据专家观点和共识来制订指南,Contributors,Jonathan Evans Rhoads, MD, Surgical Nutritionist the Harrison Department of Surgery at the University of Pennsylvania Stanley Dudrick, MD, Henry Vars, PhD, Douglas Wilmore, MD, and others at the University of Pennsylvania The full development of parenteral nutrition, as we know it today, was dependent on endless hours of effort by dedicated nurses, pharmacists, and dietitians.,History,Complete parenteral or IV nutrition is a therapeutic method that has been available for approximately 50 years The successful development of this mode of therapy, in a modern sense, was initiated in the late 1930s, but its practical clinical use did not emerge until the 1960s.,History1,The discovery of the circulation of the blood by William Harvey in 1628 formed the basis for the rationale for IV injections and infusions. A decade later, an important contribution to the development of IV infusions was made during the severe cholera epidemic of 1831 to 1832 by the Scottish physician Latta. He was the first to infuse water and salts (saline) into a patient, who quickly recovered and survived.,History2,Edward Hodder, in Canada in 1873, infused fat in the form of milk into 3 cholera patients.Two of the patients recovered completely, but the third cholera patient did not survive despite the milk infusion.,History 3 STUDIES WITH GLUCOSE,It seems obvious in retrospect that the field of parenteral nutrition could not progress successfully before much more was known in the basic sciences. Arthur Beidl and Rudely Krauts, in 1896, were the first to infuse glucose IV in humans. The terms “glucose fever“ and “salt fever“,History4 STUDIES WITH GLUCOSE,In 1915, Woodyatt and co-workers reported studies on IV administration of glucose in humans. They reported that about 0.85 g of glucose/kg per hour could be supplied by IV without ensuing glucosuria. This classic early study predated glucose clamp investigations by more that 50 years. They stated: “IV nutrition with glucose is thus proved to be a feasible clinical proposition, and the way is opened for experiments with amino acids, polypeptides, etc.“,History5 STUDIES WITH GLUCOSE,Matas, in 1924, was the first to use a continuous drip infusion of glucose, and some years later, Zimmerman, in 1945, described the infusion of IV solutions through an IV catheter placed in the superior vena cava. This approach was used by Dennis and Dennis and Karlson, who reported the support of surgical patients with the continuous infusion of a solution of 20% glucose along with some vitamins, electrolytes, and 300 to 400 mL of plasma.,History6 STUDIES WITH GLUCOSE,The next major contribution was the infusion of hypertonic glucose and all necessary nutrients by Dudrick et al.,History 7 The Use of Plasma as a Protein Source,In 1946, Albright and his research team at the Massachusetts General Hospital in Boston investigated the metabolic fate of infused plasma protein in humans and demonstrated that such infusions contributed to positive nitrogen balance.,History8 PROTEIN HYDROLYSATES AND CRYSTALLINE AMINO ACIDS,Robert Elman, a surgeon who worked in St Louis In 1937, he published the first successful studies evaluating the IV infusion of amino acids in the form of a fibrinogen hydrolysate in man. This was an indisputable landmark in the development of IV nutrition . Undoubtedly, Elman deserves the complement given to him by Arvid Wretlind, who referred to him as the “father of IV nutrition.“,History9 Fat,It was realized early on that optimal use of the amino acids in solutions could only be achieved by simultaneously providing adequate amounts of necessary energy. In those days, glucose was the only available nonprotein source that could be given IV.,History10 Fat & parenteral nutrition,The first to develop a nontoxic readily available fat emulsion was the Swedish scientist Arvid Wretlind, who in 1961, introduced Intralipid together with O. Schuberth.For his many developmental contributions, it seems appropriate to call Arvid Wretlind the “father of complete parenteral nutrition“,History11 Parenteral nutrition,In 1962, one of the first symposiums on parenteral nutrition was held in Kungalv, Sweden. This was the first time details of a TPN program were presented.,