静脉营养的临床应用.ppt

靜脈營養的臨床應用ParenteralNutrition,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全靜脈營養TPN周邊靜脈營養PPN癌症與營養,龐振宜藥師,ClinicalDecisionAlgorithm,營養評估,消化道功能,Yes,No,腸道營養,胃腸功能,靜脈營養,短期,長期或須限水時,PeripheralPN,CentralPN,胃腸功能恢復,標準配方,特殊配方,(Obstruction,peritonitis,intractablevomiting,acutepancreatitis,short-bowelsyndrome,ileus),短期NasogastricNasoduodenalNasojejunal,長期GastrostomyJejunostomy,NutrientTolerance,AdequateProgresstoOralFeedings,InadequatePNSupplementation,AdequateProgresstoMoreComplexDietandOralFeedingsAsTolerated,ProgresstoTotalEnteralFeedings,Normal,Compromised,No,Yes,DecisiontoInitiateSpecializedNutritionSupport,Ref：JPEN17（Suppl4）：7SA,1993,靜脈營養建議攝取量,ASPENnutritionsupportpracticemanual9-2,1998,MaintenancelevelsofelectrolytesStandarddosesofmultivitaminsandtraceelements,ProteinRequirements（forAdultPatients）,1.1525ofTotalCalories2.Non-proteinCalorietoNitrogenRatio80-100kcal：1/gm.NSevereStress150-200kcal：1/gm.NModerateStress3.Nutritionalvs.MetabolicSupport,22ndClinicalCongress,ASPEN1998,GlucoseRequirement,InitialTPN:100-150gm（or200gm）Canbeincreasedby50-75gm/d(bloodglucoselevelsarestablebutlessthan200mg/dl)themaximumglucoseinfusionratebe4mg/kg/min(22-25Kcal/kg/day),Ref：1.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001,FatRequirements,Maximumcapacity：1.0-2.0gm/kg/dayCriticallyillthemaximumrecommendedinfusionrate：1.0gm/kg/day10-25oftotalcaloriesRunfatinitiallyat1ml/min15-30min2-4oftotalcaloriesmustbefromEFA,22ndClinicalCongress,ASPEN1998,ElectrolytesRequirementsforAdultPatients,1.Sodium3055mEq/liter2.Potassium6090mEq/day3.Chloride3055mEq/liter4.Calcium612mEq/day5.Magnesium1620mEq/day6.Acetate4570mEq/day7.Phosphorus1828mM/day,Ref：a.MaxwellKleeman,sClinicalDisordersofFluidandElectrolyteMetabolism,5th,1994.b.AllinI.Arieff,M.D.Fluid,Electrolyte,andAcid-BaseDisorders.2ndEd1995.,VitaminFormulationForChildrenAged11Years,OlderandAdults,EssentialTraceElementsAMA/NAGSuggestedDailyIVIntake,MetabolicComplicationsofPN,SteatosisCholestasis,GallbladderStasis,andCholelithiasisGastrointestinalAtrophyGastricHypersecretionandHyperacidity,MacronutrientrelatedComplicationsOverfeedingRefeedingsyndrome,MetabolicComplicationsofPNSteatosis,Within1-2weeksafterinitiationofPNElevationsofSerumaminotransferases,alkalinephosphataseandbilirubinFattyinfiltrationoflivercellsContinuousglucoseand/orexcessivecalorieloadsResolvesin10-15days,MetabolicComplicationsofPNCholestasis,GallbladderStasis,andCholelithiasis,Mayoccur2-6wksafterinitiationPNProgressiveincreasetotalbilirubinandserumalkalinephosphataseminimizetheriskCyclicPNRestrictinofcarbohydrate,AvoidanceofoverfeedingEarlyenteralstimulation,MetabolicComplicationsofPNGastrointestinalAtrophy,LackofenteralstimulationcausevillushypoplasiaColonicmucosalatropyDecreasegastricfunctionImpairedGIimmunityBacterialovergrowthBacterialtranslocationInitiateenteralfeedingsassoonaspossible,MetabolicComplicationsofPNGastricHypersecretionandHyperacidity,GastricsecretionsdirectlyrelatedtotheamountofsmallbowelresectedPepticulcerationsandhemorrhagicgastritisHistamineH2receptorantagonistsareusedtodecreasegastricoutputAddeddirectlytothePNsolution,適當靜脈營養支持注意要點,預防高血糖症血糖的穩定電解質的平衡鉀、鎂、磷的監測酸鹼平衡NutritionSupportOverfeedingRespiratoryAcidosisParenteralNutritionAcidosisMetabolicAcidosis避免靜脈營養停止時的低血糖症,J.Nutrition1999:129.290S-294S,SystemicInflammatoryResponseSyndrome(SIRS),CurrentOpinioninClinicalNutritionandMetabolicCare1999,2:69-78,抑制centralInsulinactionIncreasegluconeogenesisPeripheralinsulinresistanceReduceuptakeofglucoseSignificanthyperglycemia,胰島素於玻璃瓶PVC及靜脈管的吸附作用,Anesthesiology40:4,400-404,1974,Hyperglycemiaa.Hyperosmolarstateb.Osmoticdiuresisc.Dehydrationd.ImmunosuppressionHepaticsteatosisVentilatoryalterationsIncreasedrestingenergyexpenditure,Ref：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.,ThePotentialHazardsofOverfeedingGlucose,ThePotentialHazardsofOverfeedingLipid,TG250mg/dl4hrsafterlipidinfusionforpiggybackedlipidsand400mg/dlforcontinuouslipidinfusionImmunosuppression（RESBlockade）IncreasedprostaglandinproductionHypercholesterolemiaHyperlipidemiaImpairedliverfunctionVentilatoryalterationsReducingthedoseand/orlengtheningtheinfusiontime,Ref：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.,ThePotentialHazardsofOverfeedingAminoAcid,UreagenesisHyperchloremicacidosisVentilatoryalterationsIncreasedrestingenergyexpenditure,1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.,MetabolicComplicationsandTreatmentHyperglycemia,1.Slowinfusionrate2.Giveinsulin0.1Uofinsulin/gofdextrose/liter3.Increasefatemulsiontherapy,RefeedingSyndrome,CardiacinsuficiencyperipheraledemahyertensionExcessglucoseHyperglycemiaHypokalemiaHypophosphatemiahypomagnesemia,Ref：NutritioninCriticalCare.1994,TPNorPPN?,全靜脈營養的適應症TotalParenteralNutrition,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,GuidelinesforNutritionalTherapyinLiverDisease,RecommendedmacronutrientintakeforpatientswithARFCRFrequiringNS,病人預期NPO5-7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,全靜脈營養與周邊靜脈營養,5.7%嚴重的併發症包括動脈出血及氣胸9%導管性併發症包括導管移除的未注意及中央靜脈栓塞6.5%與中央靜脈導管有關的菌血症,Payne-James,JPEN1993;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,無法或不必要用下腔頸靜脈插管提供高滲透壓溶液時因菌血症而須將中心靜脈插管拆除下腔靜脈先前的插管引起靜脈炎無專業人員,周邊靜脈營養PeripheralParenteralNutrition,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,ProteinSparingEffect,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,水,尿素,升糖激素,Epin,Norepin,GH,類固醇,Blackburn;Am.JClinNtutr,1974:27:175-187,TheImportance:hypocaloricPPNSupportSufficientProteininPostoperative,TheregimenofpartialPNsupportisbetterinachieving1.Lessnegativenitrogenbalance2.Improvedvisceralproteinlevels3.GreatertotallymphocytecountProteinsourcecontributionatleast1g/kg/day,Ref：Tsann-LongHwangetal,JPEN：1993；