静脉营养的临床应用ppt课件

靜脈營養的臨床應用靜脈營養的臨床應用 Parenteral Nutrition 營養評估與營養需求 靜脈營養支持注意要點 靜脈營養的適應症 v 全靜脈營養 TPN v 周邊靜脈營養 PPN 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Yes No 腸道營養 胃腸功能胃腸功能 靜脈營養靜脈營養 短期 長期或須限水時 Peripheral PN Central PN 胃腸功能恢復胃腸功能恢復標準配方 特殊配方 (Obstruction, peritonitis, intractable vomiting, acute pancreatitis, short- bowel syndrome, ileus) 短期 Nasogastric Nasoduodenal Nasojejunal 長期 Gastrostomy Jejunostomy Nutrient Tolerance Adequate Progress to Oral Feedings Inadequate PN Supplementation Adequate Progress to More Complex Diet and Oral Feedings As Tolerated Progress to Total Enteral Feedings Normal Compromised NoYes Decision to Initiate Specialized Nutrition Support Ref： 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 (Stress) Stable Formula g/L (葡萄糖葡萄糖 -A.A.- Fat) 150-50-30 150/200-40-30 蛋白質蛋白質 g/kg/d 1 - 1.5 0.8 1.0 糖類糖類 mg/kg/min 2 - 3.5 4 - 5 脂肪脂肪 g/kg/d 1 1-2 總熱量總熱量 kcal/kg/d 25 30 30 - 35 水分水分 mL/kg/d Min. needed 30 - 40 ASPEN nutrition support practice manual 9-2, 1998 nMaintenance levels of electrolytes nStandard doses of multivitamins and trace elements Protein 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 Stress 3. Nutritional vs. Metabolic Support 22nd Clinical Congress, ASPEN 1998 Glucose Requirement nInitial TPN : 100-150 gm （ or 200gm ） 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 be 4 mg/kg/min (22-25Kcal/kg/day) Ref： 1. The ASPEN Nutrition Support Practice Manual. 1998 2. Contemporary Nutrition Support Practice. 1998 3. Clinical Nutrition Parenteral Nutrition 3 Edition; 2001 Fat Requirements n Maximum capacity： 1.0-2.0 gm/kg/day n Critically ill the maximum recommended infusion rate： 1.0 gm/kg/day n 10-25 of total calories n Run fat initially at 1 ml/min 15-30 min n 2-4 of total calories must be from EFA 22nd Clinical Congress, ASPEN 1998 Electrolytes Requirements for Adult Patients 1. Sodium 30 55 mEq/liter 2. Potassium 60 90 mEq/day 3. Chloride 30 55 mEq/liter 4. Calcium 6 12 mEq/day 5. Magnesium 16 20 mEq/day 6. Acetate 45 70 mEq/day 7. Phosphorus 18 28 mM/day Ref： a. Maxwell Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism ,5th , 1994 . b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed 1995 . Vitamins Adult RDA in USA AMA Recommended RecommendationFor the Critically Ill Vitamin A（ IU） Vitamin D（ IU） 4000 - 5000 400 3300 200 2500 10000 400 Vitamin E（ IU） Vitamin C（ mg） 12 - 1545 10.0100.0 4001000 Folic acid（ mcg） Niacin（ mg） 40012 - 20 400.040.0 2000200 Vitamin B2（ mg） Vitamin B1（ mg） 1.1 1.81.0 1.5 3.63.0 1010 Vitamin B6（ mg） Vitamin B12（ mcg） 1.6 2.03 4.05.0 2020 mg Pantothenic acid（ mg） Biotin（ mcg） 5 10150 - 300 15.060.0 1005 mg Vitamin K（ mg） 1. 1 10 mg/wk 2. Antibiotics 10 mg/3-4days Vitamin Formulation For Children Aged 11 Years, Older and Adults Essential Trace Elements AMA/NAG Suggested Daily IV Intake Element Stable Acute Catabolic GI Losses Zn 2.5 4.0 mg Additional2 mg Add 12.2 mg/L small Bowel fluid lost； 17.1 mg/kg of stool or ileostomy output Cu 0.5 1.5 mg - - Cr 10 15 mcg - 20 mcg Mn 1.150.8 mg - - Metabolic Complications of PN nSteatosis nCholestasis, Gallbladder Stasis, and Cholelithiasis nGastrointestinal Atrophy nGastric Hypersecretion and Hyperacidity Macronutrient related Complications Overfeeding Refeeding syndrome Metabolic Complications of PN Steatosis n Within 1-2 weeks after initiation of PN n Elevations of Serum aminotransferases, alkaline phosphatase and bilirubin n Fatty infiltration of liver cells n Continuous glucose and/or excessive calorie loads n Resolves in 10-15 days Metabolic Complications of PN Cholestasis, Gallbladder Stasis, and Cholelithiasis n May occur 2-6 wks after initiation PN n Progressive increase total bilirubin and serum alkaline phosphatase n minimize the risk n Cyclic PN n Restrictin of carbohydrate, n Avoidance of overfeeding n Early enteral stimulation Metabolic Complications of PN Gastrointestinal Atrophy nLack of enteral stimulation cause nvillus hypoplasia nColonic mucosal atropy nDecrease gastric function nImpaired GI immunity nBacterial overgrowth nBacterial translocation n Initiate enteral feedings as soon as possible Metabolic Complications of PN Gastric Hypersecretion and Hyperacidity n Gastric secretions directly related to the amount of small bowel resected n Peptic ulcerations and hemorrhagic gastritis n Histamine H2 receptor antagonists are used to decrease gastric output n Added directly to the PN solution 適當靜脈營養支持注意要點 v 預防高血糖症 血糖的穩定 v 電解質的平衡 鉀 、鎂、磷 的監測 v 酸鹼平衡 Nutrition Support Overfeeding Respiratory Acidosis Parenteral Nutrition Acidosis Metabolic Acidosis v 避免靜脈營養停止時的低血糖症 J. Nutrition 1999: 129. 290S-294S Systemic Inflammatory Response Syndrome (SIRS) Current Opinion in Clinical Nutrition and Metabolic Care 1999, 2:69-78 n 抑制抑制 central Insulin action n Increase gluconeogenesis n Peripheral insulin resistance n Reduce uptake of glucose n Significant hyperglycemia OP 2 4 6 8 10 12 14 16 18 20 Postoperative Day Relative insulin sensitivity (%)100 80 60 40 20 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, 1974 RL GLASS RL PVC D5RL GLASS D5RL PVC 0 5 10 15 20 MINUTES 20 30 40 50 60 % INSULIN LOSS n Hyperglycemia a. Hyperosmolar state b. Osmotic diuresis c. Dehydration d. Immunosuppression n Hepatic steatosis n Ventilatory alterations n Increased resting energy expenditure Ref： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471； 1997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997. The Potential Hazards of Overfeeding Glucose The Potential Hazards of Overfeeding Lipid n TG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion v Immunosuppression （ RES Blockade） v Increased prostaglandin production v Hypercholesterolemia v Hyperlipidemia v Impaired liver function v Ventilatory alterations n Reducing the dose and/or lengthening the infusion time Ref： 1. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997. The Potential Hazards of Overfeeding Amino Acid n Ureagenesis n Hyperchloremic acidosis n Ventilatory alterations n Increased resting energy expenditure 1. Nutrition Support Theory and Therapeutics 1st Ed , P471； 1997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997. Metabolic Complications and Treatment Hyperglycemia n 1. Slow infusion rate n 2. Give insulin 0.1 U of insulin /g of dextrose/liter n 3. Increase fat emulsion therapy Refeeding Syndrome nCardiac insuficiency peripheral edema hyertension nExcess glucose Hyperglycemia Hypokalemia Hypophosphatemia hypomagnesemia Ref： Nutrition in Critical Care. 1994 TPN or PPN ? 全靜脈營養 的適應症 Total Parenteral Nutrition 營養有危機的人 體重過輕的病人 短時間內體重下降超過 10% 有 10天以上無法經口進食 胃腸道消化吸收有困難 嚴重外傷、燒傷 嚴重敗血症 Hicaliq I TeruAmino 12X Hicaliq II TeruAmino 12X Stress-II 一天 1.5袋 總 液 量 ml 1200 1200 1800 總 熱 量 Kcal 807 1027 1541 Glucose gm 140 206 309 Xylitol gm 25 25 37.5 Amino Acid gm 56.8 56.8 85.2 Na mEq 75 75 112.5 K mEq 30 30 45 Ca mEq 8.5 8.5 12.75 Mg mEq 10 10 15 Cl mEq 75 75 112.5 Acetate mEq 25 25 37.5 P mM 4.85 4.85 7.28 Zn mg 0.7 0.7 1.05 併 總 液 量 ml 10 250 ml 1450 10 250 ml 1450 10 250 ml 2050 ml 用 總 熱 量 Kcal 1080 1302 1816 脂 Non-Protein Kcal 855 1075 1475 肪 Non-P Kcal / N 94 118 108 STD -I STD -II 總 液 量 ml 1900 一日 2 袋 1900 一日 1 袋 總 熱 量 Kcal 1287 1727 Glucose gm 282 411 Xylitol gm 25 25 Amino Acid gm 56.8 56.8 Non-Protein Kcal 1060 1500 Non-Protein K / N 117 165 Na mEq 75 75 K mEq 60 60 Ca mEq 17 17 Mg mEq 20 20 Cl mEq 75 75 Acetate mEq 50 50 P mM 9.7 9.7 Zn mg 1.4 1.4 併 總 液 量 ml 20 250 ml 2150 10 250 ml 2150 用 總 熱 量 Kcal 1787 2002 脂 Non-Protein Kcal 1560 1775 肪 Non-Protein K / N 172 195 Guidelines for Nutritional Therapy in Liver Disease Protein gm/kg/d Energy Kcal/kg/d CH O Fat Nutritional Goal Hepatits acute or chronic 1.0-1.5 30-40 67-80 20-33 Prevent malnutrition Enhance regeneration Cirrhosis uncomplicated 1.0-1.5 30-40 67-80 20-33 Same as above Cirrhosis-complicated Malnutrition Cholestasis 1.0 - 1.8 1.0 - 1.5 40 - 50 30 - 40 72 73 - 80 28 20 - 27 Restore normal nutritional status Prevent malnutrition Treat fat malabsorption Encephalopathy Grade 1 or 2 Grade 3 or 4 0.5 - 1.2 0.5 25 - 40 25 - 40 75 75 25 25 Provide nutritional needs without precipitating encephalopathy Recommended macronutrient intake for patients with ARF CRF requiring N S ARF or CRF Patients （ HD treatments about three times/week） CVVH/CVVHD （ in hypercatabolic ARF or CRF patients） Protein or Amino acid About 1.2 g/kg/d of mixed essential and nonessential amino acids or protein 1.5 2.5 g/kg/d of mixed essential and nonessential amino acids or protein Energy 30 45 kcal/kg/d 30 45 kcal/kg/d Fat（ of total energy） 20 - 30 if not septic 20 - 30 if not septic Water As tolerated As tolerated 病人預期 NPO 5-7天 不適當的胃腸功能維持在 5-7天 轉移至口服管灌期 中央靜脈輸入是禁忌時 營養不良病患 預期須給予數日的 NPO 高新陳代謝性病患 使用 PPN即可符合病患熱量及蛋白質的須求時 PPN的適應症的適應症 全靜脈營養與周邊靜脈營養 n5.7%嚴重的併發症 n包括動脈出血及氣胸 n9%導管性併發症 n包括導管移除的未注意及中央靜脈栓 塞 n6.5%與中央靜脈導管有關的菌 血症 Payne-James, JPEN 1993; 17: 468-478 TPN的問題 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 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 g 下腔靜脈先前的插管引起靜脈炎 g 無專業人員 周邊靜脈營養周邊靜脈營養 Peripheral Parenteral Nutrition PPN 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 或不需要時的一種有效的營養支持療法 Protein Sparing Effect 胰島素胰島素 葡萄糖 肝醣胺基酸蛋白質 酮體 脂肪酸 脂肪 ADP 能量 ATP 能量代謝 氧氣 O2 二氧化碳二氧化碳 , 水水 , 尿素尿素 升糖激素 Epin,Norepin , GH 類固醇 Blackburn; Am. J Clin Ntutr, 1974: 27: 175-187 The Importance: hypocaloric PPN Support Sufficient Protein in Postoperative n The regimen of partial PN support is better in achieving 1. Less negative nitrogen balance 2. Improved visceral protein levels 3. Greater total lymphocyte count Protein source contribution at least 1g/kg/day Ref： Tsann-Long Hwang et al, JPEN： 1993； Vol 17, No.3 P254-256 Glycal-Amin (3% Amino Acid and 3% Glycerin injection with Electrolytes) P0.02 氮平衡 /4日 Glycal-Amin 一般氨基酸加電解質 0 -5 5 -10 10 顯著的正氮平衡顯著的正氮平衡 Freeman:Surgery, Gyn 1988. 12:287 Prem