静脉营养的临床应用.ppt

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1、靜脈營養的臨床應用靜脈營養的臨床應用 Parenteral NutritionParenteral Nutrition 營養評估與營養需求營養評估與營養需求 靜脈營養支持注意要點靜脈營養支持注意要點 靜脈營養的適應症靜脈營養的適應症v 全靜脈營養全靜脈營養TPNTPNv 周邊靜脈營養周邊靜脈營養PPNPPN 癌症與營養癌症與營養 龐振宜龐振宜 藥師藥師Clinical Decision Algorithm營養評估營養評估消化道功能消化道功能YesNo腸道營養腸道營養胃腸功能胃腸功能胃腸功能胃腸功能靜脈營養靜脈營養靜脈營養靜脈營養短期短期長期或須限水時長期或須限水時Peripheral PNPe

2、ripheral PNCentral PNCentral PN胃腸功能恢復胃腸功能恢復胃腸功能恢復胃腸功能恢復標準配方標準配方特殊配方特殊配方(Obstruction,peritonitis,intractable vomiting,acute pancreatitis,short-bowel syndrome,ileus)短期短期 Nasogastric Nasoduodenal Nasojejunal長期長期 Gastrostomy JejunostomyNutrient ToleranceAdequateProgress toOral FeedingsInadequatePN Suppl

3、ementationAdequateProgress to MoreComplex Diet andOral FeedingsAs ToleratedProgress to Total Enteral FeedingsNormalCompromisedNoYesDecision to Initiate Specialized Nutrition SupportRef：JPEN 17（Suppl 4）：）：7 SA,1993靜脈營養靜脈營養 建議攝取量建議攝取量Critically Ill Critically Ill(Stress)(Stress)StableFormula Formula g

4、/Lg/L (葡萄糖葡萄糖葡萄糖葡萄糖-A.A.-Fat)-A.A.-Fat)150-50-30150/200-40-30蛋白質蛋白質蛋白質蛋白質g/kg/d1-1.50.8 1.0糖類糖類糖類糖類mg/kg/min2-3.54-5脂肪脂肪脂肪脂肪g/kg/d11-2總熱量總熱量總熱量總熱量kcal/kg/d25 3030-35水分水分水分水分mL/kg/dMin.needed30-40ASPENnutritionsupportpracticemanual9-2,1998nMaintenance levels of electrolytesnStandard doses of multivit

5、amins and trace elementsProteinRequirements（for Adult Patients）1.1525ofTotalCalories2.Non-proteinCalorietoNitrogenRatio 80-100kcal：1/gm.NSevereStress 150-200kcal：1/gm.NModerateStress3.Nutritional vs.Metabolic Support 22ndClinicalCongress,ASPEN 1998Glucose RequirementnInitial TPN:100-150 gm（or 200gm）

6、nCan be increased by 50-75 gm/d (blood glucose levels are stable but less than 200 mg/dl)n the maximum glucose infusion rate be4 mg/kg/min(22-25Kcal/kg/day)Ref：1.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001F

7、at Requirementsn Maximum capacity：1.0-2.0 gm/kg/dayn Critically ill the maximum recommended infusion rate：1.0 gm/kg/dayn 10-25of total caloriesn Run fat initially at 1 ml/min 15-30 minn 2-4of total calories must be from EFA22ndClinicalCongress,ASPEN 1998 ElectrolytesRequirements for Adult Patients1.

8、Sodium 30 55 mEq/liter2.Potassium6090mEq/day3.Chloride 30 55 mEq/liter4.Calcium612mEq/day5.Magnesium1620mEq/day6.Acetate4570mEq/day7.Phosphorus1828mM/dayRef：a.MaxwellKleeman,sClinicalDisordersofFluidandElectrolyteMetabolism,5th,1994.b.AllinI.Arieff,M.D.Fluid,Electrolyte,andAcid-BaseDisorders.2ndEd19

9、95.VitaminsVitaminsAdult RDA Adult RDA in USAin USAAMA AMA RecommendedRecommendedRecommendatioRecommendation nFor the Critically For the Critically IllIllVitamin AVitamin A（IUIU）Vitamin DVitamin D（IUIU）4000-500040033002002500 10000400Vitamin EVitamin E（IUIU）Vitamin CVitamin C（mgmg）12-154510.0100.040

10、01000Folic acidFolic acid（mcgmcg）NiacinNiacin（mgmg）40012-20400.040.02000200Vitamin B2Vitamin B2（mgmg）Vitamin B1Vitamin B1（mgmg）1.1 1.81.0 1.53.63.01010Vitamin B6Vitamin B6（mgmg）Vitamin B12Vitamin B12（mcgmcg）1.6 2.034.05.02020 mgPantothenicPantothenic acidacid（mgmg）BiotinBiotin（mcmcg g）5 10150-30015.

11、060.01005 mgVitamin KVitamin K（mgmg）1.1 10 mg/wk2.Antibiotics 10 mg/3-4daysVitamin Formulation For Children Aged 11 Years,Older and AdultsFor Children Aged 11 Years,Older and AdultsEssential Trace ElementsAMA/NAG Suggested Daily IV IntakeAMA/NAG Suggested Daily IV IntakeElementStableAcute CatabolicG

12、I LossesZn2.5 4.0 mgAdditional2 mgAdd 12.2 mg/L small Bowel fluid lost；17.1 mg/kg of stool or ileostomy outputCu0.5 1.5 mg-Cr10 15 mcg-20 mcgMn1.150.8 mg-Metabolic Complications of PNnSteatosisnCholestasis,Gallbladder Stasis,and CholelithiasisnGastrointestinal AtrophynGastric Hypersecretion and Hype

13、racidityMacronutrientrelatedComplicationsOverfeedingRefeedingsyndromeMetabolic Complications of PN Steatosisn Within 1-2 weeks after initiation of PNnElevations of Serum aminotransferases,alkaline phosphatase and bilirubinnFatty infiltration of liver cellsn Continuous glucose and/or excessive calori

14、e loadsnResolves in 10-15 daysMetabolic Complications of PNCholestasis,Gallbladder Stasis,and CholelithiasisnMay occur 2-6 wks after initiation PNnProgressive increase total bilirubin and serum alkaline phosphatasenminimize the risknCyclic PNnRestrictin of carbohydrate,nAvoidance of overfeeding nEar

15、ly enteral stimulation Metabolic Complications of PNGastrointestinal AtrophynLack of enteral stimulation cause nvillus hypoplasianColonic mucosal atropynDecrease gastric functionnImpaired GI immunitynBacterial overgrowthnBacterial translocationnInitiate enteral feedings as soon as possibleMetabolic

16、Complications of PNGastric Hypersecretion and HyperaciditynGastric secretions directly related to the amount of small bowel resectednPeptic ulcerations and hemorrhagic gastritisnHistamine H2 receptor antagonists are used to decrease gastric outputnAdded directly to the PN solution適當靜脈營養支持注意要點適當靜脈營養支

17、持注意要點v 預防高血糖症預防高血糖症 血糖的穩定血糖的穩定v 電解質的平衡電解質的平衡 鉀鉀、鎂、磷、鎂、磷 的監測的監測v 酸鹼平衡酸鹼平衡Nutrition Support Overfeeding Respiratory AcidosisParenteral Nutrition Acidosis Metabolic Acidosisv 避免靜脈營養停止時的低血糖症避免靜脈營養停止時的低血糖症J.Nutrition 1999:129.290S-294SSystemic Inflammatory Response Syndrome(SIRS)Current Opinion in Clinic

18、al Nutrition and Metabolic Care 1999,2:69-78n n抑制抑制抑制抑制c centralentral Insulin action Insulin actionn nIncrease Increase gluconeogenesisgluconeogenesisn nPeripheral insulin Peripheral insulin resistanceresistancen nReduce uptake of glucoseReduce uptake of glucosen nSignificant hyperglycemiaSignifica

19、nt hyperglycemiaOPOP 246810 12 14 16 18 20Postoperative DayRelative insulin sensitivity(%)10080604020胰島素於玻璃瓶胰島素於玻璃瓶PVC及靜脈管的吸附作用及靜脈管的吸附作用Anesthesiology 40:4,400-404,1974RL GLASSRL PVCD5RL GLASSD5RL PVC0 05 5101015152020MINUTESMINUTES20203030404050506060%INSULIN LOSSINSULIN LOSSn Hyperglycemia a.Hyper

20、osmolar state b.Osmotic diuresis c.Dehydration d.Immunosuppressionn Hepatic steatosisn Ventilatory alterationsn Increased resting energy expenditureRef：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.The Potential Hazards of Ov

21、erfeedingGlucoseGlucoseThe Potential Hazards of OverfeedingLipidLipidnTG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion vv ImmunosuppressionImmunosuppression （RES BlockadeRES Blockade）vv Increased prostaglandin production Increased prostaglandin

22、 productionvv Hypercholesterolemia Hypercholesterolemiavv HyperlipidemiaHyperlipidemiavv Impaired liver function Impaired liver function vv Ventilatory Ventilatory alterationsalterationsn nReducing the dose and/or lengthening the infusion timeRef：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatien

23、ts,ASPEN,1997.The Potential Hazards of OverfeedingAmino AcidAmino Acidn Ureagenesisn Hyperchloremic acidosisn Ventilatory alterationsn Increased resting energy expenditure1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.Metaboli

24、c Complications and TreatmentHyperglycemian1.Slow infusion raten2.Give insulin 0.1 U of insulin/g of dextrose/litern3.Increase fat emulsion therapyRefeeding SyndromenCardiac insuficiency peripheral edema hyertensionnExcess glucoseHyperglycemia HypokalemiaHypophosphatemiahypomagnesemiaRef：Nutritionin

25、CriticalCare.1994TPN or PPN?全靜脈營養全靜脈營養的適應症的適應症Total Parenteral Nutrition營養有危機的人營養有危機的人體重過輕的病人體重過輕的病人短時間內體重下降超過短時間內體重下降超過10%10%有有1010天以上無法經口進食天以上無法經口進食胃腸道消化吸收有困難胃腸道消化吸收有困難嚴重外傷、燒傷嚴重外傷、燒傷嚴重敗血症嚴重敗血症 Hicaliq I TeruAmino 12X Hicaliq II TeruAmino 12XStress-II 一天一天1.5袋袋 總總 液液 量量 ml120012001800 總總 熱熱 量量 Kcal

26、80710271541 Glucose gm140206309 Xylitol gm 25 25 37.5 Amino Acid gm56.8 56.885.2 Na mEq75 75 112.5 K mEq30 30 45 Ca mEq8.5 8.512.75 Mg mEq101015 Cl mEq 7575112.5 Acetate mEq 252537.5 P mM 4.854.857.28 Zn mg0.70.71.05併併總總 液液 量量 ml10250 ml 145010250 ml 145010250 ml 2050 ml用用總總 熱熱 量量 Kcal108013021816脂脂

27、Non-Protein Kcal85510751475肪肪Non-P Kcal/N94118108 STD-ISTD-II 總總 液液 量量 ml1900 一日一日 2 袋袋1900 一日一日 1 袋袋 總總 熱熱 量量 Kcal12871727 Glucose gm282411 Xylitol gm2525 Amino Acid gm56.856.8 Non-Protein Kcal10601500 Non-Protein K/N117165 Na mEq7575 K mEq6060 Ca mEq 1717 Mg mEq2020 Cl mEq 7575 Acetate mEq5050 P m

28、M 9.79.7 Zn mg1.41.4併併總總 液液 量量 ml20250 ml 215010250 ml 2150用用總總 熱熱 量量 Kcal17872002脂脂Non-Protein Kcal15601775肪肪Non-Protein K/N172195Guidelines for Nutritional Therapy in Liver DiseaseProteingm/kg/dEnergyKcal/kg/dCHOFatNutritional GoalHepatits acute or chronic1.0-1.530-4067-8020-33Prevent malnutrition

29、Enhance regenerationCirrhosis uncomplicated1.0-1.530-4067-8020-33Same as aboveCirrhosis-complicated Malnutrition Cholestasis1.0-1.81.0-1.540-5030-407273-802820-27Restore normal nutritional statusPrevent malnutritionTreat fat malabsorptionEncephalopathy Grade 1 or 2 Grade 3 or 40.5-1.20.525-4025-4075

30、752525Provide nutritional needs without precipitating encephalopathyRecommended macronutrient intake for patients with ARFCRF requiring N S ARF or CRF Patients（HD treatments about three times/week）CVVH/CVVHD（in hypercatabolic ARF or CRF patients）Protein or Amino acidAbout 1.2 g/kg/d of mixed essenti

31、al and nonessential amino acids or protein1.5 2.5 g/kg/d of mixed essential and nonessential amino acids or proteinEnergy30 45 kcal/kg/d30 45 kcal/kg/dFat（of total energy）20-30 if not septic20-30 if not septicWaterAs toleratedAs tolerated 病人預期病人預期NPO 5-7NPO 5-7天天 不適當的胃腸功能維持在不適當的胃腸功能維持在5-75-7天天 轉移至口服

32、管灌期轉移至口服管灌期 中央靜脈輸入是禁忌時中央靜脈輸入是禁忌時 營養不良病患營養不良病患 預期須給予數日的預期須給予數日的NPONPO 高新陳代謝性病患高新陳代謝性病患 使用使用PPNPPN即可符合病患熱量及蛋白質的須求時即可符合病患熱量及蛋白質的須求時PPNPPN的適應症的適應症全靜脈營養與周邊靜脈營養全靜脈營養與周邊靜脈營養n5.7%嚴重的併發症嚴重的併發症n包括動脈出血及氣胸包括動脈出血及氣胸n9%導管性併發症導管性併發症n包括導管移除的未注意及中央靜脈栓包括導管移除的未注意及中央靜脈栓塞塞n6.5%與中央靜脈導管有關的菌與中央靜脈導管有關的菌血症血症Payne-James,JPEN

33、1993;17:468-478TPN的問題的問題全靜脈營養的第一選擇：周邊靜脈營養路徑全靜脈營養的第一選擇：周邊靜脈營養路徑g 無法或不必要用下腔頸靜脈插管無法或不必要用下腔頸靜脈插管 提供高滲透壓溶液時提供高滲透壓溶液時g 因菌血症而須將中心靜脈插管拆除因菌血症而須將中心靜脈插管拆除g 下腔靜脈先前的插管引起靜脈炎下腔靜脈先前的插管引起靜脈炎g 無專業人員無專業人員周邊靜脈營養周邊靜脈營養Peripheral Parenteral NutritionPeripheral Parenteral NutritionPPNPPN輕度至中度營養缺乏輕度至中度營養缺乏無法經口服或不易經由中央靜脈輸入無

34、法經口服或不易經由中央靜脈輸入或不需要時的一種有效的營養支持療法或不需要時的一種有效的營養支持療法Protein Sparing EffectProtein Sparing Effect胰島素胰島素胰島素胰島素葡萄糖葡萄糖肝醣肝醣胺基酸胺基酸蛋白質蛋白質酮體酮體脂肪酸脂肪酸脂肪脂肪ADP能量ATP能量代謝氧氣O2二氧化碳二氧化碳二氧化碳二氧化碳,水水水水,尿素尿素尿素尿素升糖激素Epin,Norepin,GH類固醇Blackburn;Am.J Clin Ntutr,1974:27:175-187The Importance:hypocaloric PPN Support Sufficient

35、Protein in Postoperativen nThe regimen of partial PN support is better in The regimen of partial PN support is better in achievingachieving 1.Less negative nitrogen balance 2.Improved visceral protein levels 3.Greater total lymphocyte count Protein source contribution at least 1g/kg/dayRef：Tsann-Lon

36、gHwangetal,JPEN：1993；Vol17,No.3P254-256Glycal-AminGlycal-Amin(3%Amino Acid and 3%Glycerin injection(3%Amino Acid and 3%Glycerin injection(3%Amino Acid and 3%Glycerin injection(3%Amino Acid and 3%Glycerin injection with Electrolytes)with Electrolytes)with Electrolytes)with Electrolytes)P0.02氮氮平平衡衡/4日

37、日 Glycal-AminGlycal-Amin 一般氨基酸加電解質一般氨基酸加電解質0-55-1010顯著的正氮平衡顯著的正氮平衡Freeman:Surgery,Gyn&Obs.Vol.156:p625-631,19833%3%Amino Acid and 3%Glycerin injection Amino Acid and 3%Glycerin injection with Electrolyteswith Electrolytes3211 12 23 34 45 51 12 23 34 45 54080120160200240胰島素胰島素依賴型糖尿病依賴型糖尿病非胰島素非胰島素依賴型糖

38、尿病依賴型糖尿病一般氨基酸一般氨基酸+葡萄糖葡萄糖Glycal-AminGlycal-Amindaysdaysdaysdays1 12 23 34 45 51 12 23 34 45 5P Pl la as sm ma a G Gl lu uc co os se e,m mg g/d dl lD Do os se e o of f i in ns su ul li in n I I.V V.,U U/h hF 不依賴胰島不依賴胰島素素FF 抗酮體抗酮體FF 穩定血糖穩定血糖FF 避免體液流失避免體液流失FF 減少併發症減少併發症Glycal-AminA.LevRan:JPEN 11:271-2

39、74,1987Peripharal Peripharal TPNTPN686827271818N=41P0.001葡萄糖葡萄糖基劑的基劑的PPNPPNGlycal-AminGlycal-Amin 一般靜脈注射一般靜脈注射一般靜脈注射一般靜脈注射(生理食鹽水生理食鹽水生理食鹽水生理食鹽水)靜脈炎之比較靜脈炎之比較靜脈炎之比較靜脈炎之比較50505050100100100100Eric B.Rypin:The Am.J.of Surg.159,p222-225,19903%3%Amino Acid and 3%Glycerin injection Amino Acid and 3%Glycerin

40、 injection with Electrolyteswith Electrolytes碳水化合物的代謝障礙碳水化合物的代謝障礙37%37%的癌症病人的癌症病人血糖不耐性問題血糖不耐性問題CachexiaCachexia不正常葡萄糖耐受性不正常葡萄糖耐受性飢餓狀態下的血糖飢餓狀態下的血糖可以上昇維持至可以上昇維持至110-120 110-120 mg/dlmg/dl控制葡萄糖利用的控制葡萄糖利用的GLUT-4 TransporterGLUT-4 Transporter受損受損持續減低的葡萄糖利用率持續減低的葡萄糖利用率Nutritional Oncology 1999 Chapter 36

41、p.519-536癌症惡體質的糖類代謝癌症惡體質的糖類代謝J.Am,College of Nutrition 445-456,1992葡萄糖利用性不良葡萄糖利用性不良A.S.P.E.N.23rd Clinical Congress p.244,1999宿主宿主宿主宿主CytokineCytokineCytokineCytokineProductionProductionProductionProduction腦腦無食慾無食慾?脂肪酸脂肪酸脂肪脂肪脂肪酸脂肪酸 甘油甘油 釋出釋出脂肪儲存脂肪儲存腫瘤腫瘤生長生長乳酸乳酸葡萄糖葡萄糖氨基酸氨基酸三酸甘油脂三酸甘油脂肝臟肝臟葡萄糖生成葡萄糖生成蛋白質

42、合成蛋白質合成肌肉肌肉合成合成合成合成分解分解分解分解氨基酸氨基酸脂肪酸脂肪酸氨基酸氨基酸?Proposed mechanism of cancer cachexia無氧反應無氧反應(-2 ATP)Cori cycle(-4 ATP)TCA Cycle(-36 ATP)Loss more 300Kcal/dayKern&Norton:JPEN;1988.12:287 Premixed,ready-to use,Premixed,ready-to use,peripheral IV nutrition support peripheral IV nutrition support 使用甘油而非葡

43、萄糖為熱量來源使用甘油而非葡萄糖為熱量來源 提供氨基酸、碳水化合物及電解質提供氨基酸、碳水化合物及電解質 (包括鈉、鉀、鎂、鈣、鏻等包括鈉、鉀、鎂、鈣、鏻等)735 735 mOsmmOsm/L/LGlycal-AminGlycal-Amin3%amino acid 3%glycerol with electrolytes3%amino acid 3%glycerol with electrolytes3%amino acid 3%glycerol with electrolytes3%amino acid 3%glycerol with electrolytes2L+500mL10%脂肪乳脂

44、肪乳3L/+500mL20%脂肪乳脂肪乳總熱量總熱量1,0401,735蛋白質蛋白質(克克)5887脂肪脂肪(克克)50100鈉鈉(mEq)70105鉀鉀(mEq)4872鎂鎂(mEq)1015鈣鈣(mEq)69氯氯(mEq)82123磷磷(mmol)14.518醋酸醋酸(mEq)94141提供類似提供類似TPNTPN的完整靜脈營養的完整靜脈營養Kenneth Waxman:JPEN 16:p374-378,1992安全、方便、經濟J.Payne-James:JPEN 1993;17:468-478J.Payne-James:JPEN 1993;17:468-478First Choice f

45、or Total Parenteral Nutrition:First Choice for Total Parenteral Nutrition:The Peripheral RouteThe Peripheral Route全靜脈營養的第一選擇：周邊靜脈營養路徑全靜脈營養的第一選擇：周邊靜脈營養路徑Glycal-AminGlycal-Amin 3%3%3%3%Amino Acid and 3%Glycerin Injection With ElectrolytesAmino Acid and 3%Glycerin Injection With ElectrolytesAmino Acid

46、and 3%Glycerin Injection With ElectrolytesAmino Acid and 3%Glycerin Injection With Electrolytes v已預混合已預混合PPNPPNv減少藥局調製時間減少藥局調製時間v減少汙染的發生減少汙染的發生v容易處方容易處方v醫護人員操作方便醫護人員操作方便v經濟經濟 較較TPNTPN少併發症少併發症 較較TPNTPN價格便宜價格便宜 減低高血糖素症減低高血糖素症 有無有無infusion pumpinfusion pump均可均可 使用使用 不須要不須要taperingtapering安全、方便、經濟安全、方便、

47、經濟 糖尿病與癌症病患糖尿病與癌症病患 維持與穩定血糖維持與穩定血糖 COPDCOPD病患病患 避免避免Pulmonary stressPulmonary stress 避免因避免因SIRSSIRS引起的高血糖症引起的高血糖症 避免避免TPNTPN結束時的低血糖症結束時的低血糖症Glycal-AminGlycal-AminGlycal-AminGlycal-Amin 3%3%3%3%Amino Acid and 3%Glycerin injection with ElectrolytesAmino Acid and 3%Glycerin injection with ElectrolytesA

48、mino Acid and 3%Glycerin injection with ElectrolytesAmino Acid and 3%Glycerin injection with Electrolytes藥師藥師 龐振宜龐振宜營養是生命的泉源營養是生命的泉源永遠是要考慮到永遠是要考慮到必須給予病患必須給予病患足夠的營養以維持其生命足夠的營養以維持其生命永遠是要考慮到必須給予病患永遠是要考慮到必須給予病患足夠的營養以維持其生命足夠的營養以維持其生命EcheniqueEchenique MM;Nutrition in Clinical Practice 1999;14:p36-37 MM;Nutrition in Clinical Practice 1999;14:p36-37