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DINH DNG NG TNH MACH HOAN TOAN

I. AI CNG:
Dinh dng ng tnh mach hoan toan la a cac chat dinh dng qua
ng tnh mach vao mau e nuoi dng c the. Cac chat dinh dng bao
gom: protein, carbohydrate, lipid, nc, muoi khoang va cac chat vi lng.
II. CH NH:
Khi co chong ch nh dinh dng ng tieu hoa:
- Giai oan sm hau phau ng tieu hoa.
- Suy ho hap co ch nh giup th (giai oan au).
- Xuat huyet tieu hoa.
- Hon me kem co giat.
Khi dinh dng qua ng tieu hoa khong hieu qua: hoi chng ruot
ngan, hoi chng kem hap thu.
III. NGUYEN TAC:
Cung cap ay u nang lng va cac chat dinh dng.
Cac chat dinh dng c a vao c the phai cung luc, cham va eu
an trong ngay.
IV. CAC BC TIEN HANH:
1. anh gia benh nhan:
Dau hieu sinh ton.
Can nang.
Tnh trang dinh dng hien tai.
Benh ly hien tai va benh nen: suy gan, suy than, suy ho hap.
2. Xet nghiem: CTM, em tieu cau, ion o, ng huyet.
3. Tnh nhu cau nang lng can thiet
Nhu cau nang lng tre bnh thng
Can nang
Nhu cau nang lng
10 Kg
100 Kcal/kg
> 10 20 Kg 1000 + 50 Kcal moi Kg tren 10
> 20 Kg
1500 + 20 Kcal moi Kg tren 20
Nhu cau nang lng :
Trong nhng ngay au ch can cung cap 40 - 50% nhu cau nang lng
c ban (nhu cau c ban # 55 65 Kcalo/kg), tang dan trong nhng ngay
sau.
4. Tnh nhu cau dch can thiet (A):
Nhu cau dch hang ngay tre bnh thng :
Can nang
Nhu cau nang lng
Dch
10 Kg
100 Kcal/kg
100 ml/Kg
> 10 20 Kg 1000 + 50 Kcal moi Kg tren 10
1000 + 50 ml moi Kg tren 10

Can nang
> 20 Kg

Nhu cau nang lng


1500 + 20 Kcal moi Kg tren 20

Dch
1500 + 20 ml moi Kg tren 20

Tuy theo tnh trang benh ly, nhu cau dch thay oi so vi nhu cau c ban
(NCCB)
Benh ly
Khong hoat ong the lc
Suy than
Tang tiet ADH
Th may
Bong
Sot

Lng dch cung cap


0,7
0,3 + nc tieu
0,7
0,75
1,5
+ 12% NCCB cho moi o tang tren 38oC

V du: Benh nhan 3 tuoi viem nao, CN = 10 kg


Lng dch hang ngay = (10 100 ml) 0,7 = 700 ml
5. Tnh thanh phan Protein (B), Lipid (C):
Protein: bat au vi lieu thap 1,5 g/Kg/ng, tang dan e at lieu toi a
2,5 3 g/Kg/ng vao N3.
Lipid: bat au vi lieu thap 1 g/Kg/ng, tang dan e at lieu toi a 3
g/Kg/ng vao N3.

Protein

Ngay 1
g/Kg/ng
1,5

Ngay 2
g/Kg/ng
2

Lipid
Glucose

1
5

2
10

6. Tnh the tch ien giai :


Nhu cau ien giai
mEq / 100 ml dch
3
Natri
2
Kali
0.5 - 1
Calci

T ngay 3 at t le
San pham
g/Kg/ng
%E
2,5 3
1016 % Aminoplasma 10%
Moriamin, Cavaplasma
3
40 %
Lipofuldin10%,20%
15
4450 % Dextrose 10%, 30%

San pham
NaCl 17.4%
Kalichlorua 10%
Calcichlorua 10%, Calcigluconate 10%

7. Tnh the tch Glucose (D):


The tch Glucose = Tong the tch (The tch Protein + The tch Lipid)
e n gian khong can tr lng the tch ien giai v t
1. Tnh thanh phan Glucose 30 % va Glucose 10% e hon hp dung dch
Glucose Acid amin at c nong o Glucose la 10 12,5%

9. Tnh

Thc te hien nay viec dinh dng TM hoan toan qua ng TM trung
tam con rat nhieu han che, chu yeu la qua ng TM ngoai bien. V
the khi tnh toan phai am bao nong o Glucose trong chai dch truyen
la < 12,5%
T le the tch Glucose 30% va Glucose 10% e at nong o Glucose
tren la : 1/6
Trng hp co ng TM trung tam th co the truyen dung dch co
nong o Glucose cao hn.
Osmol cua hon hp dung dch Glucose Acid amin ien giai
Ch tnh Osmol cua hon hp dung dch Glucose Acid amin v Lipid
c truyen rieng
Cong thc:
ALTT (moms/L) = (% dextrose 50) + (% amino acid 100)
+ 2(Na mEq/L + K mEq/L + Ca mEq/L)

e truyen qua TM ngoai bien, Osmol phai < 1100 mOsmol/L


10. Tnh nang lng thc te cung cap :
Tnh tong nang lng thc te cung cap
Tong K.calo/kg/ngay = so gam Acid amin kg/ngay 4
+ so gam Lipid/kg/ngay
10
+ so gam Glucose/kg/ngay 4
Tnh t le % nang lng thc te cung cap so vi nang lng ly thuyet
Tnh nang lng Protein so vi tong nang lng thc te (%)
Nang lng Protein

So gam AA 4 (Kcalo/g) 100


Tong nang lng thc te

Nang lng Protein : 10 20% tong nang lng

Tnh nang lng Lipide so vi tong nang lng thc te (%)


Nang lng Lipid

So gam Lipid 10 (Kcalo/g)


100
Tong nang lng thc te

Nang lng Lipid : 30 40% tong nang lng

V. CACH TRUYEN TNH MACH CAC DUNG DCH DINH DNG :


1. Cach pha dch:
DD am va ng , ien giai co the pha chung.

DD lipid phai c truyen rieng. Co the truyen cung luc dung dch
Lipid vi dung dch am-ng qua ba chia.
2. Chon tnh mach truyen:
Tnh mach ngoai bien (TM mu ban tay, TM co tay, TM khuyu tay, TM
co chan): truyen dung dch < 1100 mOsm/L.
Tnh mach trung tam (TM canh trong, canh ngoai, di on) : truyen
dung dch > 1100 mOsm/L hoac dung dch Dextrose >12,5%. Xem xet
ch nh at Implantrofix trong trng hp can dinh dng TM trung
tam dai ngay.
3. Toc o truyen:
DD am va ng, ien giai nen c truyen lien tuc suot 24 gi.
DD lipid thng c truyen t 12 18 gi (co thi gian ngh e anh
gia tnh trang hap thu cua c the).
4. Dinh dng TM ban phan :
Sm chuyen sang dinh dng TM ban phan khi benh nhan het chong
ch nh nuoi an ng tieu hoa, hoac dinh dng hoan toan ng
tieu hoa.
5. Yeu to vi lng va Vitamin :
Neu benh nhan c nuoi an tnh mach tren 2 tuan can bo sung cac
yeu to vi lng va vitamine qua ng tnh mach
Yeu to vi lng :

Yeu to
Sat
Kem
ong
Iodin
Manganese
Chlonium
Selenium

Nhu cau
0.1 0.2 mg/Kg
100 g/Kg
20 g/Kg
3 5 g/Kg
2 10 g/Kg
0.14 0.2 g/Kg
2 3 g/Kg

Vitamin
* Tan trong dau:
Vitamin A
Vitamin D
Vitamin E
Vitamin K
* Tan trong nc:
Vitamin C
Vitamin B1

Nhu cau

Vitamin :

700 g/Kg
10 g/Kg
7 g/Kg
40 g/Kg
80 mg/Kg
1.2 mg/Kg

Vitamin B6
Vitamin B12
Riboflavin
Niacin
Pantothenate
Biotin
Folate

1mg/Kg
1 g/Kg
1.4 mg/Kg
17 mg/Kg
5mg/Kg
20 g/Kg
140 g/Kg

LU O THC HANH DINH DNG TNH MACH HOAN TOAN

Tnh tong the tch dch (A)

Tnh lng Protein


The tch Protein (B)

Tnh lng Lipid


The tch lipid (C)

Tnh lng, the tch ien giai


(Na, K, Ca)

Tnh the tch Glucose (D)


D = A (B + C)

Tnh thanh phan Glucose 10%,


30%
T le the tch G30% va G10% =
1/6

Tnh Osmol
DD Glucose Acid amin

Tnh nang lng :


* Thc te / ly thuyet (%)
* Protein / tong nang lng thc te (%)
* Lipid / tong nang lng thc te (%)

6. V du: benh nhan 3 tuoi, viem nao,


mach hoan toan.
Ngay 1
Tong nang
400 500
lng can
(40 50% NLCB)
(Kcalo/ngay)
700
Tong dch
(NCCB 0,7)
Acid amin
15 g (150 ml)
(10%)
(1,5 g/kg/ng)
10 g (50 ml)
Lipid (20%)
(1 g/kg/ng)
30 mEq :
*24 mEq
Natri
(8 ml NaCl 17,4%)
*6 mEq (AA 10%)
20 mEq :
*16 mEq
Kali
(12 ml KCl 10%)
*4 mEq (AA 10%)
10 mEq
Calci
(7ml CaCl2 10|%)
The tch
500 ml
Glucose
The tch (ml)
Glucose 30%
70
Glucose 10%
430
Nong o
Glucose
9,8%
(DDGlucoseAA)
Nong o AA
2,3%
ALTT (mOsm/L)
840
Tong NL thc te
416 (41,6 %)
(% NCCB)
NL AA (% tong
14,42%
NL thc te)
NL Lipid (%
24%
tong NL thc te)
V. THEO DOI:
1. Lam sang:

can nang 10 Kg, can dinh dng tnh


Ngay 2
500 600
(5060% NLCB)

T ngay 3
600 -700
(6070% NLCB)

700
(NCCB 0,7)
20 g (200 ml)
(2 g/kg/ng)
20 g (100ml)
(2 g/kg/ng)
30 mEq :
*21 mEq
(7 ml NaCl 17,4%)
*9 mEq (AA 10%)
20 mEq :
*15 mEq
(11 ml KCl 10%)
*5 mEq (AA 10%)
10 mEq
(7ml CaCl2 10|%)

700
(NCCB 0,7)
25 g (250ml)
(2,5 g/kg/ng)
30 g (150 ml)
(3 g/kg/ng)
30 mEq :
*19 mEq
(6 ml NaCl 17,4%)
*11 mEq (AA 10%)
20 mEq :
*14 mEq
(10 ml KCl 10%)
*6 mEq (AA 10%)
10 mEq
(7ml CaCl2 10|%)

400 ml

300 ml

60
340

45
255

8,7%

7,1%

3,3%
885

4,5%
925

488 (48,8 %)

556 (55,6 %)

16,4%

18%

41%

54%

Dau hieu sinh ton, lng xuat nhap / hang ngay.


Can nang / hang tuan.
2. Can lam sang:
Xet nghiem
Tuan au
Giai oan on nh
CTM
Hang tuan
Hang tuan
Ion o
Hang ngay
Hang tuan
ng huyet
Hang ngay
Hang tuan
Ure, Creatine/mau.
1 lan / tuan
Hang tuan
SGOT, SGPT,Bilirubin
1 lan / tuan
Hang tuan
Protein, Albumin
1 lan / tuan
Hang tuan
Triglycerides,cholesterol
1 lan / tuan
Hang tuan
Kh mau
1 lan / tuan
Hang tuan
ng nieu.
Hang ngay
Hang tuan
3. Theo doi cac bien chng;
Cho tiem truyen: nhiem trung, hoai t, viem tnh mach.
Ha ng huyet, tang ng huyet.
Roi loan ien giai.
Toan chuyen hoa.
DUNG DCH DUNG TRONG DINH DNG TNH MACH HOAN TOAN
Dung dch

Glucose
(g/dL)

Protide
(g/dL)

Lipide
(g/dL)

ien giai
(mEq/dL)
Na Ka
Ca

Dextrose 30%
Dextrose 10%
Aminoplasma 10%
Lipofundine 20%
Natrichlorua 17,4%

30
10

10

20

4,3

Kalichlorua 10%

Calcichlorua 10%

2,5

30
0
13
4

ALTT
(mOsmol/L)

1500
1000
1000
380

180