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1、靜脈營養的臨床應用靜脈營養的臨床應用 Parenteral Nutrition Parenteral Nutrition 營養評估與營養需求營養評估與營養需求 靜脈營養支持留意要點靜脈營養支持留意要點 靜脈營養的適應症靜脈營養的適應症 全靜脈營養全靜脈營養TPNTPN 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ClinicalDecisionAlgorithm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PeripheralPNPeriph
2、eralPNCentralPNCentralPN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,intractablevomiting,acutepancreatitis,short-bowelsyndrome,ileus)短期短期NasogastricNasoduodenalNasojejunal長期長期GastrostomyJejunostomyNutrientToleranceAdequateProgresstoOralFeedingsInadequatePNSupplementationAdequateP
3、rogresstoMoreComplexDietandOralFeedingsAsToleratedProgresstoTotalEnteralFeedingsNormalCompromisedNoYesDecisiontoInitiateSpecializedNutritionSupportRef：JPEN17Suppl4：7SA,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 g/L Formula g/L ( (葡萄糖葡萄糖葡萄糖葡萄糖-A.A.- Fat)-A.A.-
4、Fat)150-50-30150/200-40-30蛋白質蛋白質蛋白質蛋白質g/kg/dg/kg/d1 - 1.50.8 1.0糖類糖類糖類糖類mg/kg/minmg/kg/min2 - 3.54 - 5脂肪脂肪脂肪脂肪g/kg/dg/kg/d11-2總熱量總熱量總熱量總熱量kcal/kg/dkcal/kg/d25 3030 - 35水分水分水分水分mL/kg/dmL/kg/dMin. needed30 - 40ASPEN nutrition support practice manual 9-2, 1998nMaintenance levels of electrolytesnStandar
5、d doses of multivitamins and trace elementsProtein Requirements for Adult Patients 1. 15 25 of Total Calories 2. Non-protein Calorie to Nitrogen Ratio 80 - 100 kcal ： 1 / gm . N Severe Stress 150 - 200 kcal ： 1 / gm . N Moderate Stress3. Nutritional vs. Metabolic Support 22nd Clinical Congress, ASPE
6、N 1998Glucose RequirementnInitial TPN : 100-150 gm or 200gmnCan be increased by 50-75 gm/d n (blood glucose levels are stable but less than 200 mg/dl)n the maximum glucose infusion rate ben4 mg/kg/min (22-25Kcal/kg/day)Ref：1. The ASPEN Nutrition Support Practice Manual. 1998 2. Contemporary Nutritio
7、n Support Practice. 1998 3. Clinical Nutrition Parenteral Nutrition 3 Edition; 2001Fat Requirementsn Maximum capacity：n 1.0-2.0 gm/kg/dayn Critically ill the maximum recommended n 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
8、be from EFA22nd Clinical Congress, ASPEN 1998ElectrolytesRequirementsforAdultPatients1.Sodium3055mEq/liter2.Potassium6090mEq/day3.Chloride3055mEq/liter4.Calcium612mEq/day5.Magnesium1620mEq/day6.Acetate4570mEq/day7.Phosphorus1828mM/dayRef：a. Maxwell Kleeman,s Clinical Disorders of Fluid and Electroly
9、te Metabolism ,5th , 1994 . b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed 1995 .VitaminsVitaminsAdult RDA Adult RDA in USAin USAAMA AMA RecommendedRecommendedRecommendatioRecommendation nFor the Critically For the Critically IllIllVitamin AVitamin AIUIUVitamin DVitam
10、in DIUIU4000-50004003300200250010000400Vitamin EVitamin EIUIUVitamin CVitamin Cmgmg12-154510.0100.04001000Folic acidFolic acidmcgmcgNiacinNiacinmgmg40012-20400.040.02000200Vitamin B2Vitamin B2mgmgVitamin B1Vitamin B1mgmg1.11.81.01.53.63.01010Vitamin B6Vitamin B6mgmgVitamin B12Vitamin B12mcgmcg1.62.0
11、34.05.02020mgPantothenic acidPantothenic acidmgmgBiotinBiotinmcgmcg510150-30015.060.01005mgVitamin KVitamin Kmgmg1.110mg/wk2.Antibiotics10mg/3-4daysVitamin Formulation For Children Aged 11 Years, Older and AdultsEssential Trace ElementsAMA/NAG Suggested Daily IV IntakeElementStableAcute CatabolicGI
12、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、racidityMacronutrient related ComplicationsOverfeeding Refeeding syndromeMetabolic 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 c
14、alorie 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 overfeed
15、ing nEarly 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 possibleMe
16、tabolic 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適當靜脈營養支持留意要
17、點適當靜脈營養支持留意要點v預防高血糖症預防高血糖症v血糖的穩定血糖的穩定v電解質的平衡電解質的平衡v鉀、鎂、磷鉀、鎂、磷的監測的監測v酸鹼平衡酸鹼平衡vNutritionSupportOverfeeding RespiratoryAcidosisvParenteralNutritionAcidosis MetabolicAcidosisv防止靜脈營養停顿時的低血糖症防止靜脈營養停顿時的低血糖症J.Nutrition1999:129.290S-294SSystemic Inflammatory Response Syndrome (SIRS)CurrentOpinioninClinicalNu
18、tritionandMetabolicCare1999,2:69-78n n抑制抑制抑制抑制central Insulin actioncentral Insulin actionn nIncrease gluconeogenesisIncrease gluconeogenesisn nPeripheral insulin Peripheral insulin resistanceresistancen nReduce uptake of glucoseReduce uptake of glucosen nSignificant hyperglycemiaSignificant hypergl
19、ycemiaOPOP 246810 12 14 16 18 20PostoperativeDayRelativeinsulinsensitivity(%)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Anesthesiology40:4,400-404,1974RLGLASSRLPVCD5RLGLASSD5RLPVC0 05 5101015152020MINUTESMINUTES20203030404050506060%INSULINLOSS%INSULINLOSSn Hyperglycemian a. Hyperosmolar staten b.
20、 Osmotic diuresisn c. Dehydrationn d. Immunosuppressionn Hepatic steatosisn Ventilatory alterationsn Increased resting energy expenditureRef：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.The Potential Hazards of OverfeedingGl
21、ucoseThe Potential Hazards of OverfeedingLipidnTG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion n Immunosuppression RES Blockaden Increased prostaglandin productionn Hypercholesterolemian Hyperlipidemian Impaired liver function n Ventilatory al
22、terationsnReducing the dose and/or lengthening the infusion timeRef：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.The Potential Hazards of OverfeedingAmino Acidn Ureagenesisn Hyperchloremic acidosisn Ventilatory alterationsn Increased resting energy expenditure 1. Nutrition Supp
23、ort Theory and Therapeutics 1st Ed , P471；1997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997. Metabolic Complications and TreatmentHyperglycemian1. Slow infusion raten2. Give insulin n 0.1 U of insulin /g of dextrose/litern3. Increase fat emulsion therapyRefeeding Synd
24、romenCardiac insuficiency n peripheral edeman hyertensionnExcess glucosenHyperglycemian HypokalemianHypophosphatemianhypomagnesemiaRef：Nutrition in Critical Care. 1994TPN or PPN ?全靜脈營養的適應症全靜脈營養的適應症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
25、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 12XHicaliqIITeruAmino12XStress-II 一天一天1.5袋袋總總液液量量ml120012001800總總熱熱量量Kcal80710271541Glucosegm140206309Xylitolgm252537.5AminoAcidgm56.856.885.2NamEq7575112.5KmEq303045CamEq8.58.512.75MgmEq101015ClmEq7575112.5AcetatemEq252537.5PmM4.854.
26、857.28Znmg0.70.71.05併併總總液液量量ml10 250ml145010 250ml145010 250ml2050ml用用總總熱熱量量Kcal108013021816脂脂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Kcal12871727Glucosegm282411Xylitolgm2525AminoAcidgm56.856.8Non-ProteinKcal10601500Non-ProteinK/N117165Nam
27、Eq7575KmEq6060CamEq1717MgmEq2020ClmEq7575AcetatemEq5050PmM9.79.7Znmg1.41.4併併總總液液量量ml20 250ml215010 250ml2150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/d CHO FatNutritional GoalHepatits acute or
28、 chronic1.0-1.530-4067-8020-33PreventmalnutritionEnhanceregenerationCirrhosis uncomplicated1.0-1.530-4067-8020-33SameasaboveCirrhosis-complicated Malnutrition Cholestasis1.0-1.81.0-1.540 - 5030 - 407273 - 802820 - 27RestorenormalnutritionalstatusPreventmalnutritionTreatfatmalabsorptionEncephalopathy
29、 Grade 1 or 2 Grade 3 or 40.5 - 1.20.525 - 4025 - 4075752525ProvidenutritionalneedswithoutprecipitatingencephalopathyRecommended macronutrient intake for patients with ARFCRF requiring N S ARF or CRF PatientsHD treatments about three times/week CVVH/CVVHDin hypercatabolic ARF or CRF patientsProtein
30、or Amino acidAbout 1.2 g/kg/d of mixed essential and nonessential amino acids or protein1.52.5g/kg/dofmixedessentialandnonessentialaminoacidsorproteinEnergy3045kcal/kg/d30 45 kcal/kg/dFatof total energy20 - 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
31、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 轉移至口服管灌期轉移至口服管灌期 中央靜脈輸入是忌中央靜脈輸入是忌讳讳時時 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 运用运用PPNPPN即可符合病患熱量及蛋白質的即可符合病患熱量及蛋白質的須求時須求時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包括導管移除的未留意及中央靜包括導管移除的未留意及中央靜脈栓塞脈栓塞n6.5%與中央靜脈導管有
32、關的菌與中央靜脈導管有關的菌血症血症Payne-James,JPEN1993;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 無法或不用要用下腔頸靜脈插管無法或不用要用下腔頸靜脈插管g 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撤除因菌血症而須將中心靜脈插管撤除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
33、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法經口服或不易經由中央靜脈輸入或不需求時的一種有效的營養支持療法或不需求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 I
34、mportance: hypocaloric PPN Support Sufficient Protein in Postoperativen nThe regimen of partial PN support is better in The regimen of partial PN support is better in achievingachievingn n 1. Less negative nitrogen balance 1. Less negative nitrogen balancen n 2. Improved visceral protein levels 2. I
35、mproved visceral protein levelsn n 3. Greater total lymphocyte count 3. Greater total lymphocyte countn n Protein source contribution at least 1g/kg/day Protein source contribution at least 1g/kg/dayRef：Tsann-LongHwangetal,JPEN：1993；Vol17,No.3P254-256Glycal-AminGlycal-Amin(3% Amino Acid and 3% (3% A
36、mino Acid and 3% Glycerin injection with Glycerin injection with Electrolytes)Electrolytes)P0.02氮氮平平衡衡/ /4 4日日 Glycal-Amin Glycal-Amin普通氨基酸加電解質普通氨基酸加電解質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% Amino Acid and 3% Glycerin injection 3% Amino Acid and 3% Glycerin injection
37、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尿病依賴型糖尿病普通氨基酸普通氨基酸+ +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
38、 li in n I I. .V V. ., , U U/ /h hF 不依賴胰島不依賴胰島素素F 抗酮體抗酮體F 穩定血糖穩定血糖F 防止體液流防止體液流失失F 減少併發症減少併發症Glycal-AminA.LevRan:JPEN11:271-274,1987PeripharalTPNPeripharalTPN686827271818N=41P0.001葡萄糖葡萄糖基劑的基劑的PPNPPNGlycal-AminGlycal-Amin普通靜脈注射普通靜脈注射普通靜脈注射普通靜脈注射( ( ( (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
39、較50505050100100100100EricB.Rypin:TheAm.J.ofSurg.159,p222-225,19903% Amino Acid and 3% Glycerin injection 3% Amino Acid and 3% Glycerin 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
40、 mg/dl110-120 mg/dl控控制制葡葡萄萄糖糖利利用用的的GLUT-4 GLUT-4 TransporterTransporter受受損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 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,CollegeofNutrition445-456,1992葡萄糖利用性不良葡萄糖利用性不良A.S.P.E.N.23rdClinicalCongressp.244,1999宿主宿主宿主宿主CytokineCytokineCytokineCytokineProdu
41、ctionProductionProductionProduction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? ?Proposedmechanismofcancercachexia無氧反應無氧反應(-2ATP)Coricycle(-4ATP)TCACycle(-36ATP)Lossmore300Kcal/dayKern&Norton:JPEN;1988
42、.12:287 Premixed, ready-to use, peripheral IV nutrition support 运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 (包括鈉、鉀、鎂、鈣、鏻等) 735 mOsm/LGlycal-AminGlycal-Amin3% amino acid 3% glycerol with electrolytes3% amino acid 3% glycerol with electrolytes2L+500mL10%脂肪乳脂肪乳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
43、)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的完好靜脈營養的完好靜脈營養KennethWaxman:JPEN16:p374-378,1992平安、方便、經濟J. Payne-James: JPEN 1993; 17: 468-478J. Payne-James: JPEN 1993; 17: 468-478First Choice for Total Parenteral Nutrition:First Choice for Tota
44、l 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-Amin3% Amino Acid and 3% Glycerin Injection With 3% Amino Acid and 3% Glycerin Injection With Electrolytes 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
45、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價格廉价價格廉价 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 运用运用 不須要不須要taperingtapering平安、方便、經濟平安、方便、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 COPD COPD病患病患 防止防止Pulmonary stressPulmonary stress 防止因防止因SIRSSIRS引起的高血糖症引起的高血糖症 防止防止TPNTPN結束時的低血糖症結束時的低血糖症Glycal-AminGlyca
46、l-AminGlycal-AminGlycal-Amin3% Amino Acid and 3% Glycerin injection with Electrolytes3% Amino Acid and 3% Glycerin injection with Electrolytes3% Amino Acid and 3% Glycerin injection with Electrolytes3% Amino 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足夠夠的營養以維持其生命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足夠夠的營養以維持其生命的營養以維持其生命EcheniqueMM;NutritioninClinicalPractice1999;14:p36-37EcheniqueMM;NutritioninClinicalPractice1999;14:p36-37
