齐鲁医学静脉营养的临床应用

1、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2021/9/301Clinical Decision Algorithm營養評估消化道功能YesNo腸道營養胃腸功能靜脈營養短期長期或須限水時Peripheral PNCentral PN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

2、期 Nasogastric Nasoduodenal Nasojejunal長期 Gastrostomy JejunostomyNutrient ToleranceAdequateProgress toOral FeedingsInadequatePN SupplementationAdequateProgress to MoreComplex Diet andOral FeedingsAs ToleratedProgress to Total Enteral FeedingsNormalCompromisedNoYesDecision to Initiate Specialized Nutr

3、ition SupportRef：JPEN 17 （Suppl 4）：7 SA, 19932021/9/302靜脈營養 建議攝取量Critically Ill (Stress)StableFormula g/L (葡萄糖-A.A.- Fat)150-50-30150/200-40-30蛋白質g/kg/d1 - 1.50.8 1.0糖類mg/kg/min2 - 3.54 - 5脂肪g/kg/d11-2總熱量kcal/kg/d25 3030 - 35水分mL/kg/dMin. needed30 - 40ASPEN nutrition support practice manual 9-2, 199

4、8Maintenance levels of electrolytesStandard doses of multivitamins and trace elements2021/9/303Protein 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. Nutritio

5、nal vs. Metabolic Support 22nd Clinical Congress, ASPEN 19982021/9/304Glucose RequirementInitial 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 be4 mg/kg/min (22-25Kcal/kg/day)Ref：1. The ASPEN Nutr

6、ition Support Practice Manual. 1998 2. Contemporary Nutrition Support Practice. 1998 3. Clinical Nutrition Parenteral Nutrition 3 Edition; 20012021/9/305Fat Requirements Maximum capacity： 1.0-2.0 gm/kg/day Critically ill the maximum recommended infusion rate：1.0 gm/kg/day 10-25of total calories Run

7、fat initially at 1 ml/min 15-30 min 2-4of total calories must be from EFA22nd Clinical Congress, ASPEN 19982021/9/306 Electrolytes Requirements for Adult Patients 1. Sodium 30 55 mEq/liter2. Potassium 60 90 mEq/day3. Chloride 30 55 mEq/liter4. Calcium 6 12 mEq/day5. Magnesium 16 20 mEq/day6. Acetate

8、 45 70 mEq/day7. Phosphorus 18 28 mM/dayRef：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 .2021/9/307VitaminsAdult RDA in USAAMA RecommendedRecommendationFor the Critically

9、 IllVitamin A（IU）Vitamin D（IU）4000 - 500040033002002500 10000400Vitamin E（IU）Vitamin C（mg）12 - 154510.0100.04001000Folic acid（mcg）Niacin（mg）40012 - 20400.040.02000200Vitamin B2（mg）Vitamin B1（mg）1.1 1.81.0 1.53.63.01010Vitamin B6（mg）Vitamin B12（mcg）1.6 2.034.05.02020 mgPantothenic acid（mg）Biotin（mcg）

10、5 10150 - 30015.060.01005 mgVitamin K（mg）1. 1 10 mg/wk2. Antibiotics 10 mg/3-4daysVitamin Formulation For Children Aged 11 Years, Older and Adults2021/9/308Essential Trace ElementsAMA/NAG Suggested Daily IV IntakeElementStableAcute CatabolicGI LossesZn2.5 4.0 mgAdditional2 mgAdd 12.2 mg/L small Bowe

11、l fluid lost；17.1 mg/kg of stool or ileostomy outputCu0.5 1.5 mg-Cr10 15 mcg-20 mcgMn1.150.8 mg-2021/9/309Metabolic Complications of PNSteatosisCholestasis, Gallbladder Stasis, and CholelithiasisGastrointestinal AtrophyGastric Hypersecretion and HyperacidityMacronutrient related ComplicationsOverfee

12、ding Refeeding syndrome2021/9/3010Metabolic Complications of PN Steatosis Within 1-2 weeks after initiation of PNElevations of Serum aminotransferases, alkaline phosphatase and bilirubinFatty infiltration of liver cells Continuous glucose and/or excessive calorie loadsResolves in 10-15 days2021/9/30

13、11Metabolic Complications of PNCholestasis, Gallbladder Stasis, and CholelithiasisMay occur 2-6 wks after initiation PNProgressive increase total bilirubin and serum alkaline phosphataseminimize the riskCyclic PNRestrictin of carbohydrate, Avoidance of overfeeding Early enteral stimulation 2021/9/30

14、12Metabolic Complications of PNGastrointestinal AtrophyLack of enteral stimulation cause villus hypoplasiaColonic mucosal atropyDecrease gastric functionImpaired GI immunityBacterial overgrowthBacterial translocationInitiate enteral feedings as soon as possible2021/9/3013Metabolic Complications of P

15、NGastric Hypersecretion and HyperacidityGastric secretions directly related to the amount of small bowel resectedPeptic ulcerations and hemorrhagic gastritisHistamine H2 receptor antagonists are used to decrease gastric outputAdded directly to the PN solution2021/9/3014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

16、平衡 鉀、鎂、磷 的監測 酸鹼平衡Nutrition Support Overfeeding Respiratory AcidosisParenteral Nutrition Acidosis Metabolic Acidosis 避免靜脈營養停止時的低血糖症J. Nutrition 1999: 129. 290S-294S2021/9/3015Systemic Inflammatory Response Syndrome (SIRS)Current Opinion in Clinical Nutrition and Metabolic Care 1999, 2:69-78抑制central

17、Insulin actionIncrease gluconeogenesisPeripheral insulin resistanceReduce uptake of glucoseSignificant hyperglycemiaOP2468101214161820Postoperative DayRelative insulin sensitivity (%)100806040202021/9/3016胰島素於玻璃瓶PVC及靜脈管的吸附作用Anesthesiology 40: 4, 400-404, 1974RL GLASSRL PVCD5RL GLASSD5RL PVC05101520M

18、INUTES2030405060% INSULIN LOSS2021/9/3017 Hyperglycemia a. Hyperosmolar state b. Osmotic diuresis c. Dehydration d. Immunosuppression Hepatic steatosis Ventilatory alterations Increased resting energy expenditureRef： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471；1997 2. The Metabolic Ha

19、zards of Overfeeding Critically Ill Patients, ASPEN, 1997. The Potential Hazards of OverfeedingGlucose2021/9/3018The Potential Hazards of OverfeedingLipidTG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion Immunosuppression （RES Blockade） Increase

20、d prostaglandin production Hypercholesterolemia Hyperlipidemia Impaired liver function Ventilatory alterationsReducing the dose and/or lengthening the infusion timeRef： 1. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997. 2021/9/3019The Potential Hazards of OverfeedingAmino

21、Acid Ureagenesis Hyperchloremic acidosis Ventilatory alterations 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. 2021/9/3020Metabolic Complications and TreatmentHypergly

22、cemia1. Slow infusion rate2. Give insulin 0.1 U of insulin /g of dextrose/liter3. Increase fat emulsion therapy2021/9/3021Refeeding SyndromeCardiac insuficiency peripheral edema hyertensionExcess glucoseHyperglycemia HypokalemiaHypophosphatemiahypomagnesemiaRef：Nutrition in Critical Care. 19942021/9

23、/3022TPN or PPN ?2021/9/3023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2021/9/3024 Hicaliq I TeruAmino 12X Hicaliq II TeruAmino 12XStress-II 一天1.5袋 總 液 量 ml120012001800 總 熱 量 Kcal80710271541 Glucose gm140206309 Xylitol gm 25 25 37.5 Amino Acid gm5

24、6.8 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併總 液 量 ml10250 ml 145010250 ml 145010250 ml 2050 ml用總 熱 量 Kcal108013021816脂Non-Protein Kcal85510751475肪Non-P Kcal / N941181082021/9/3025 STD -ISTD -II 總

25、 液 量 ml1900 一日 2 袋1900 一日 1 袋 總 熱 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 mM 9.79.7 Zn mg1.41.4併總 液 量 ml20250 ml 215010250 ml 2150用總 熱 量 Kcal1787200

26、2脂Non-Protein Kcal15601775肪Non-Protein K / N1721952021/9/3026Guidelines for Nutritional Therapy in Liver DiseaseProteingm/kg/dEnergyKcal/kg/dCHOFatNutritional GoalHepatits acute or chronic1.0-1.530-4067-8020-33Prevent malnutritionEnhance regenerationCirrhosis uncomplicated1.0-1.530-4067-8020-33Same

27、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 - 4075752525Provide nutritional needs without precipitatin

28、g encephalopathy2021/9/3027Recommended 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 essential and nonessential amino acids or prote

29、in1.5 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 tolerated2021/9/3028 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

30、病患熱量及蛋白質的須求時PPN的適應症2021/9/3029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, JPEN 1993; 17: 468-478TPN的問題全靜脈營養的第一選擇：周邊靜脈營養路徑2021/9/3030 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Peripheral Parenteral NutritionPPN輕度至中度營養缺乏無法經口服或不易經由中央靜脈輸

31、入或不需要時的一種有效的營養支持療法2021/9/3031Protein Sparing Effect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. J Clin Ntutr, 1974: 27: 175-1872021/9/3032The Importance: hypocaloric PPN Support Sufficient Protein in PostoperativeThe regimen of partial PN support is better in

32、 achieving 1. Less negative nitrogen balance 2. Improved visceral protein levels 3. Greater total lymphocyte count Protein source contribution at least 1g/kg/dayRef：Tsann-Long Hwang et al, JPEN：1993；Vol 17, No.3 P254-256 2021/9/3033Glycal-Amin(3% Amino Acid and 3% Glycerin injection with Electrolyte

33、s)2021/9/3034P0.02氮平衡/4日 Glycal-Amin一般氨基酸加電解質0-55-1010顯著的正氮平衡Freeman:Surgery, Gyn &Obs. Vol.156: p625-631, 19833% Amino Acid and 3% Glycerin injection with Electrolytes2021/9/303532112345123454080120160200240胰島素依賴型糖尿病非胰島素依賴型糖尿病一般氨基酸+葡萄糖Glycal-Amindaysdays1234512345Plasma Glucose, mg/dlDose of insuli

34、n I.V., U/h 不依賴胰島素 抗酮體 穩定血糖 避免體液流失 減少併發症Glycal-AminA.LevRan: JPEN 11:271-274,1987Peripharal TPN2021/9/3036682718N=41P0.001葡萄糖基劑的PPNGlycal-Amin一般靜脈注射(生理食鹽水)靜脈炎之比較50100Eric B.Rypin: The Am. J. of Surg. 159, p222-225, 19903% Amino Acid and 3% Glycerin injection with Electrolytes2021/9/3037碳水化合物的代謝障礙37%

35、的癌症病人血糖不耐性問題Cachexia不正常葡萄糖耐受性飢餓狀態下的血糖可以上昇維持至110-120 mg/dl控制葡萄糖利用的GLUT-4 Transporter受損持續減低的葡萄糖利用率Nutritional Oncology 1999 Chapter 36 p. 519-5362021/9/3038癌症惡體質的糖類代謝J. Am,College of Nutrition 445-456, 19922021/9/3039葡萄糖利用性不良A.S.P.E.N. 23rd Clinical Congress p.244, 19992021/9/3040宿主CytokineProduction腦無食慾 ?脂肪酸脂肪脂肪酸 甘油 釋出脂肪儲存腫瘤生長乳酸葡萄糖氨基酸三酸甘油脂肝臟葡萄糖