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全靜脈營養TPN周邊靜脈營養PPN癌症與營養,龐振宜 藥師,Clinical Decision Algorithm,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,Peripheral PN,Central PN,胃腸功能恢復,標準配方,特殊配方,(Obstruction, peritonitis, intractablevomiting, acute pancreatitis, short-bowel syndrome, ileus),短期NasogastricNasoduodenalNasojejunal,長期GastrostomyJejunostomy,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,No,Yes,Decision to Initiate Specialized Nutrition Support,Ref：JPEN 17 （Suppl 4）：7 SA, 1993,靜脈營養 建議攝取量,ASPEN nutrition support practice manual 9-2, 1998,Maintenance levels of electrolytes Standard doses of multivitamins and trace elements,Protein Requirements （for Adult Patients）,1. 15 25 of Total Calories 2. Non-protein Calorie to Nitrogen Ratio80 - 100 kcal ： 1 / gm . N Severe Stress150 - 200 kcal ： 1 / gm . N Moderate Stress3. Nutritional vs. Metabolic Support,22nd Clinical Congress, ASPEN 1998,Glucose Requirement,Initial TPN : 100-150 gm （or 200gm） Can be increased by 50-75 gm/d (blood glucose levels are stable but less than 200 mg/dl)the maximum glucose infusion rate be 4 mg/kg/min (22-25Kcal/kg/day),Ref：1. The ASPEN Nutrition Support Practice Manual. 19982. Contemporary Nutrition Support Practice. 1998 3. Clinical Nutrition Parenteral Nutrition 3 Edition; 2001,Fat Requirements,Maximum capacity：1.0-2.0 gm/kg/dayCritically ill the maximum recommended infusion rate：1.0 gm/kg/day10-25of total caloriesRun fat initially at 1 ml/min 15-30 min2-4of 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 .,Vitamin Formulation For Children Aged 11 Years, Older and Adults,Essential Trace Elements AMA/NAG Suggested Daily IV Intake,Metabolic Complications of PN,Steatosis Cholestasis, Gallbladder Stasis, and Cholelithiasis Gastrointestinal Atrophy Gastric Hypersecretion and Hyperacidity,Macronutrient related Complications Overfeeding Refeeding syndrome,Metabolic Complications of PN Steatosis,Within 1-2 weeks after initiation of PN Elevations of Serum aminotransferases, alkaline phosphatase and bilirubin Fatty infiltration of liver cellsContinuous glucose and/or excessive calorie loads Resolves in 10-15 days,Metabolic Complications of PN Cholestasis, Gallbladder Stasis, and Cholelithiasis,May occur 2-6 wks after initiation PN Progressive increase total bilirubin and serum alkaline phosphatase minimize the risk Cyclic PN Restrictin of carbohydrate, Avoidance of overfeeding Early enteral stimulation,Metabolic Complications of PN Gastrointestinal Atrophy,Lack of enteral stimulation cause villus hypoplasia Colonic mucosal atropy Decrease gastric function Impaired GI immunity Bacterial overgrowth Bacterial translocation Initiate enteral feedings as soon as possible,Metabolic Complications of PN Gastric Hypersecretion and Hyperacidity,Gastric secretions directly related to the amount of small bowel resected Peptic ulcerations and hemorrhagic gastritisHistamine H2 receptor antagonists are used to decrease gastric output Added directly to the PN solution,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 Nutrition Support Overfeeding Respiratory Acidosis Parenteral Nutrition Acidosis Metabolic Acidosis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,抑制central Insulin action Increase gluconeogenesis Peripheral insulin resistance Reduce uptake of glucose Significant hyperglycemia,胰島素於玻璃瓶PVC及靜脈管的吸附作用,Anesthesiology 40: 4, 400-404, 1974,Hyperglycemiaa. Hyperosmolar stateb. Osmotic diuresisc. Dehydrationd. ImmunosuppressionHepatic steatosisVentilatory alterationsIncreased resting energy expenditure,Ref： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471；19972. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.,The Potential Hazards of Overfeeding Glucose,The Potential Hazards of Overfeeding Lipid,TG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion Immunosuppression （RES Blockade）Increased prostaglandin productionHypercholesterolemiaHyperlipidemiaImpaired liver function Ventilatory alterations Reducing the dose and/or lengthening the infusion time,