静脉营养的临床应用

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YesNo腸道營養胃腸功能靜脈營養短期長期或須限水時PeripheralPNCentralPN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

GastrostomyJejunostomyNutrientToleranceAdequateProgresstoOralFeedingsInadequatePNSupplementationAdequateProgresstoMoreComplexDietandOralFeedingsAsToleratedProgresstoTotalEnteralFeedingsNormalCompromisedNoYesDecisiontoInitiateSpecializedNutritionSupportRef：JPEN17（Suppl4）：7SA,1993靜脈營養建議攝取量CriticallyIll(Stress)StableFormulag/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.needed30-40ASPENnutritionsupportpracticemanual9-2,1998MaintenancelevelsofelectrolytesStandarddosesofmultivitaminsandtraceelementsProteinRequirements

（forAdultPatients）

1.15–25﹪ofTotalCalories2.Non-proteinCalorietoNitrogenRatio

80-100kcal：1/gm.NSevereStress

150-200kcal：1/gm

.NModerateStress3.Nutritionalvs.MetabolicSupport

22ndClinicalCongress,ASPEN1998GlucoseRequirementInitialTPN:100-150gm（or200gm）Canbeincreasedby50-75gm/d

(bloodglucoselevelsarestablebutlessthan200mg/dl)

themaximumglucoseinfusionratebe4mg/kg/min(22-25Kcal/kg/day)Ref：1.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001FatRequirements

Maximumcapacity：1.0-2.0gm/kg/day

Criticallyillthemaximumrecommended

infusionrate：1.0gm/kg/day

10-25﹪oftotalcalories

Runfatinitiallyat1ml/min×15-30min

2-4﹪oftotalcaloriesmustbefromEFA22ndClinicalCongress,ASPEN1998

ElectrolytesRequirements

forAdultPatients

1.Sodium30–55mEq/liter2.Potassium60–90mEq/day3.Chloride30–55mEq/liter4.Calcium6–12mEq/day5.Magnesium16–20mEq/day6.Acetate45–70mEq/day7.Phosphorus18–28mM/dayRef：a.Maxwell＆Kleeman,sClinicalDisordersofFluidandElectrolyteMetabolism,5th,1994.b.AllinI.Arieff,M.D.Fluid,Electrolyte,andAcid-BaseDisorders.2ndEd1995.VitaminsAdultRDAinUSAAMARecommendedRecommendationFortheCriticallyIllVitaminA（IU）VitaminD（IU）4000-500040033002002500–10000400VitaminE（IU）VitaminC（mg）12-154510.0100.04001000Folicacid（mcg）Niacin（mg）40012-20400.040.02000200VitaminB2（mg）VitaminB1（mg）1.1–1.81.0–1.53.63.01010VitaminB6（mg）VitaminB12（mcg）1.6–2.034.05.02020mgPantothenicacid（mg）Biotin（mcg）5–10150-30015.060.01005mgVitaminK（mg）1.1–10mg/wk2.Antibiotics–10mg/3-4daysVitaminFormulation

ForChildrenAged11Years,OlderandAdultsEssentialTraceElements

AMA/NAGSuggestedDailyIVIntakeElementStableAcuteCatabolicGILossesZn2.5–4.0mgAdditional2mgAdd12.2mg/LsmallBowelfluidlost；17.1mg/kgofstoolorileostomyoutputCu0.5–1.5mg--Cr10–15mcg-20mcgMn1.15–0.8mg--MetabolicComplicationsofPNSteatosisCholestasis,GallbladderStasis,andCholelithiasisGastrointestinalAtrophyGastricHypersecretionandHyperacidityMacronutrientrelatedComplicationsOverfeedingRefeedingsyndromeMetabolicComplicationsofPN

SteatosisWithin1-2weeksafterinitiationofPNElevationsofSerumaminotransferases,alkalinephosphataseandbilirubinFattyinfiltrationoflivercells

Continuousglucoseand/orexcessivecalorieloadsResolvesin10-15daysMetabolicComplicationsofPN

Cholestasis,GallbladderStasis,andCholelithiasisMayoccur2-6wksafterinitiationPNProgressiveincreasetotalbilirubinandserumalkalinephosphataseminimizetheriskCyclicPNRestrictinofcarbohydrate,AvoidanceofoverfeedingEarlyenteralstimulation

MetabolicComplicationsofPN

GastrointestinalAtrophyLackofenteralstimulationcause

villushypoplasiaColonicmucosalatropyDecreasegastricfunctionImpairedGIimmunityBacterialovergrowthBacterialtranslocationInitiateenteralfeedingsassoonaspossibleMetabolicComplicationsofPN

GastricHypersecretionandHyperacidityGastricsecretionsdirectlyrelatedtotheamountofsmallbowelresectedPepticulcerationsandhemorrhagicgastritisHistamineH2receptorantagonistsareusedtodecreasegastricoutputAddeddirectlytothePNsolution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-294SSystemicInflammatoryResponseSyndrome(SIRS)CurrentOpinioninClinicalNutritionandMetabolicCare1999,2:69-78抑制centralInsulinactionIncreasegluconeogenesisPeripheralinsulinresistanceReduceuptakeofglucoseSignificanthyperglycemiaOP2468101214161820PostoperativeDayRelativeinsulinsensitivity(%)10080604020胰島素於玻璃瓶PVC及靜脈管的吸附作用Anesthesiology40:4,400-404,1974RLGLASSRLPVCD5RLGLASSD5RLPVC05101520MINUTES2030405060%INSULINLOSS

Hyperglycemiaa.Hyperosmolarstateb.Osmoticdiuresisc.Dehydrationd.Immunosuppression

Hepaticsteatosis

Ventilatoryalterations

IncreasedrestingenergyexpenditureRef：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.ThePotentialHazardsofOverfeeding

GlucoseThePotentialHazardsofOverfeeding

LipidTG<250mg/dl4hrsafterlipidinfusionforpiggybackedlipidsand<400mg/dlforcontinuouslipidinfusion

Immunosuppression（RESBlockade）IncreasedprostaglandinproductionHypercholesterolemiaHyperlipidemiaImpairedliverfunctionVentilatoryalterationsReducingthedoseand/orlengtheningtheinfusiontimeRef：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.ThePotentialHazardsofOverfeeding

AminoAcid

UreagenesisHyperchloremicacidosisVentilatoryalterationsIncreasedrestingenergyexpenditure1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.

MetabolicComplicationsandTreatment

Hyperglycemia1.Slowinfusionrate2.Giveinsulin

0.1Uofinsulin/gofdextrose/liter3.IncreasefatemulsiontherapyRefeedingSyndromeCardiacinsuficiencyperipheraledemahyertensionExcessglucoseHyperglycemiaHypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCriticalCare.1994TPNorPPN?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

HicaliqITeruAmino12X

HicaliqIITeruAmino12XStress-II一天1.5袋總液量ml120012001800總熱量Kcal80710271541

Glucosegm140206309

Xylitolgm252537.5

AminoAcidgm56.856.885.2

NamEq7575112.5

KmEq303045

CamEq8.58.512.75

MgmEq101015

ClmEq7575112.5

AcetatemEq252537.5

PmM4.854.857.28

Znmg0.70.71.05併總液量ml10﹪250ml145010﹪250ml145010﹪250ml2050ml用總熱量Kcal108013021816脂Non-ProteinKcal85510751475肪Non-PKcal/N94118108

STD-ISTD-II

總液量ml1900一日2袋1900一日1袋總熱量Kcal12871727

Glucosegm282411

Xylitolgm2525

AminoAcidgm56.856.8

Non-ProteinKcal10601500

Non-ProteinK/N117165

NamEq7575

KmEq6060

CamEq1717

MgmEq2020

ClmEq7575

AcetatemEq5050

PmM9.79.7

Znmg1.41.4併總液量ml20﹪250ml215010﹪250ml2150用總熱量Kcal17872002脂Non-ProteinKcal15601775肪Non-ProteinK/N172195GuidelinesforNutritionalTherapyinLiverDiseaseProteingm/kg/dEnergyKcal/kg/d﹪CHO﹪FatNutritionalGoalHepatits

－acuteorchronic1.0-1.530-4067-8020-33－Preventmalnutrition－EnhanceregenerationCirrhosis－uncomplicated1.0-1.530-4067-8020-33－SameasaboveCirrhosis-complicatedMalnutritionCholestasis1.0-1.81.0-1.540-5030-407273-802820-27－Restorenormalnutritionalstatus－Preventmalnutrition－TreatfatmalabsorptionEncephalopathy

Grade1or2Grade3or40.5-1.20.525-4025-4075752525－Providenutritionalneeds

withoutprecipitatingencephalopathyRecommendedmacronutrientintakeforpatientswithARF＆CRFrequiringNS

ARForCRF

Patients（HDtreatmentsaboutthreetimes/week）

CVVH/CVVHD（inhypercatabolicARForCRFpatients）ProteinorAminoacidAbout1.2g/kg/dofmixedessentialandnonessentialaminoacidsorprotein1.5–2.5g/kg/dofmixedessentialandnonessentialaminoacidsorproteinEnergy30–45kcal/kg/d30–45kcal/kg/dFat（﹪oftotalenergy）20-30﹪ifnotseptic20-30﹪ifnotsepticWaterAstoleratedAstolerated

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;17:468-478TPN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PeripheralParenteralNutritionPPN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,1974:27:175-187TheImportance:hypocaloricPPNSupport

SufficientProteininPostoperativeTheregimenofpartialPNsupportisbetterinachieving1.Lessnegativenitrogenbalance2.Improvedvisceralproteinlevels3.Greatertotallymphocytecount

Proteinsourcecontributionatleast1g/kg/dayRef：Tsann-LongHwangetal,JPEN：1993；Vol17,No.3P254-256Glycal-Amin(3%AminoAcidand3%GlycerininjectionwithElectrolytes)P<0.02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%AminoAcidand3%GlycerininjectionwithElectrolytes32112345123454080120160200240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-Amindaysdays1234512345PlasmaGlucose,mg/dlDoseofinsulinI.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:JPEN11:271-274,1987PeripharalTPN682718N=41P<0.001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50100EricB.Rypin:TheAm.J.ofSurg.159,p222-225,19903%AminoAcidand3%GlycerininjectionwithElectrolytes碳水化合物的代謝障礙37%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110-120mg/dl控制葡萄糖利用的GLUT-4Transporter受損持續減低的葡萄糖利用率NutritionalOncology1999Chapter36p.519-536癌症惡體質的糖類代謝J.Am,CollegeofNutrition445-456,1992葡萄糖利用性不良A.S.P.E.N.23rdClinicalCongress