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1、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,静脉营养的临床应用,2,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, intractable vomiting, acute pancreatitis,
2、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,Comprom
3、ised,No,Yes,Decision to Initiate Specialized Nutrition Support,Ref：JPEN 17 （Suppl 4）：7 SA, 1993,静脉营养的临床应用,3,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,静脉营养的临床应用,4,Protein Requirements （for Adult P
4、atients）,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,静脉营养的临床应用,5,Glucose Requirement,Initial TPN : 100-150 gm （or 200gm
5、） 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. 1998 2. Contemporary Nutrition Support Practice. 1998 3. Clinical Nutrition Parenteral Nu
6、trition 3 Edition; 2001,静脉营养的临床应用,6,Fat 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 fat initially at 1 ml/min 15-30 min 2-4of total calories must be from EFA,22nd Clinical Congress, ASPEN 1998,静脉营养的临床应
7、用,7,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 Electrolyt
8、e Metabolism ,5th , 1994 . b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed 1995 .,静脉营养的临床应用,8,Vitamin Formulation For Children Aged 11 Years, Older and Adults,静脉营养的临床应用,9,Essential Trace ElementsAMA/NAG Suggested Daily IV Intake,静脉营养的临床应用,10,Metabolic Complications of
9、PN,Steatosis Cholestasis, Gallbladder Stasis, and Cholelithiasis Gastrointestinal Atrophy Gastric Hypersecretion and Hyperacidity,Macronutrient related Complications Overfeeding Refeeding syndrome,静脉营养的临床应用,11,Metabolic Complications of PN Steatosis,Within 1-2 weeks after initiation of PN Elevations
10、 of Serum aminotransferases, alkaline phosphatase and bilirubin Fatty infiltration of liver cells Continuous glucose and/or excessive calorie loads Resolves in 10-15 days,静脉营养的临床应用,12,Metabolic Complications of PNCholestasis, Gallbladder Stasis, and Cholelithiasis,May occur 2-6 wks after initiation
11、PN Progressive increase total bilirubin and serum alkaline phosphatase minimize the risk Cyclic PN Restrictin of carbohydrate, Avoidance of overfeeding Early enteral stimulation,静脉营养的临床应用,13,Metabolic Complications of PNGastrointestinal Atrophy,Lack of enteral stimulation cause villus hypoplasia Col
12、onic mucosal atropy Decrease gastric function Impaired GI immunity Bacterial overgrowth Bacterial translocation Initiate enteral feedings as soon as possible,静脉营养的临床应用,14,Metabolic Complications of PNGastric Hypersecretion and Hyperacidity,Gastric secretions directly related to the amount of small b
13、owel resected Peptic ulcerations and hemorrhagic gastritis Histamine H2 receptor antagonists are used to decrease gastric output Added directly to the PN solution,静脉营养的临床应用,15,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 Acid
14、osis Metabolic Acidosis 避免靜脈營養停止時的低血糖症,J. Nutrition 1999: 129. 290S-294S,静脉营养的临床应用,16,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
15、 glucose Significant hyperglycemia,静脉营养的临床应用,17,胰島素於玻璃瓶PVC及靜脈管的吸附作用,Anesthesiology 40: 4, 400-404, 1974,静脉营养的临床应用,18,Hyperglycemia a. Hyperosmolar state b. Osmotic diuresis c. Dehydration d. Immunosuppression Hepatic steatosis Ventilatory alterations Increased resting energy expenditure,Ref： 1. Nutr
16、ition Support Theory and Therapeutics 1st Ed , P471；1997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.,The Potential Hazards of OverfeedingGlucose,静脉营养的临床应用,19,The Potential Hazards of OverfeedingLipid,TG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and
17、400mg/dl for continuous lipid infusion Immunosuppression （RES Blockade） Increased prostaglandin production Hypercholesterolemia Hyperlipidemia Impaired liver function Ventilatory alterations Reducing the dose and/or lengthening the infusion time,Ref： 1. The Metabolic Hazards of Overfeeding Criticall
18、y Ill Patients, ASPEN, 1997.,静脉营养的临床应用,20,The Potential Hazards of OverfeedingAmino 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
19、 Ill Patients, ASPEN, 1997.,静脉营养的临床应用,21,Metabolic Complications and TreatmentHyperglycemia,1. Slow infusion rate 2. Give insulin 0.1 U of insulin /g of dextrose/liter 3. Increase fat emulsion therapy,静脉营养的临床应用,22,Refeeding Syndrome,Cardiac insuficiency peripheral edema hyertension Excess glucose Hy
20、perglycemia Hypokalemia Hypophosphatemia hypomagnesemia,Ref：Nutrition in Critical Care. 1994,静脉营养的临床应用,23,TPN or PPN ?,静脉营养的临床应用,24,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,静脉营养的临床应用,25,静脉营养的临床应用,26,静脉营养的临床应用,27,Guidelines for Nutritiona
21、l Therapy in Liver Disease,静脉营养的临床应用,28,Recommended macronutrient intake for patients with ARFCRF requiring N S,静脉营养的临床应用,29,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,静脉营养的临床应用,30,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
22、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: 468-478,TPN的問題,全靜脈營養的第一選擇：周邊靜脈營養路徑,静脉营养的临床应用,31,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 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,静脉营养的临床应用,32,Protein Sparing Effect,胰島素,葡萄糖,肝醣,胺基酸
23、,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: 175-187,静脉营养的临床应用,33,The Importance: hypocaloric PPN Support Sufficient Protein in Postoperative,The regimen of partial PN support is better in achieving 1. Less negative nitrogen balance
24、 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,静脉营养的临床应用,34,Glycal-Amin (3% Amino Acid and 3% Glycerin injection with Electrolytes),静脉营养的临床应用,35,P0.02,氮平衡/4日,Glycal-Amin
25、,一般氨基酸加電解質,0,-5,5,-10,10,顯著的正氮平衡,Freeman:Surgery, Gyn 17: 468-478,First Choice for Total Parenteral Nutrition: The Peripheral Route 全靜脈營養的第一選擇：周邊靜脈營養路徑,静脉营养的临床应用,45,Glycal-Amin 3% Amino Acid and 3% Glycerin Injection With Electrolytes,已預混合PPN 減少藥局調製時間 減少汙染的發生 容易處方 醫護人員操作方便 經濟,較TPN少併發症 較TPN價格便宜 減低高血糖
26、素症 有無infusion pump均可 使用 不須要tapering,安全、方便、經濟,静脉营养的临床应用,46,糖尿病與癌症病患 維持與穩定血糖 COPD病患 避免Pulmonary stress 避免因SIRS引起的高血糖症 避免TPN結束時的低血糖症,Glycal-Amin 3% Amino Acid and 3% Glycerin injection with Electrolytes,静脉营养的临床应用,47,藥師 龐振宜,營養是生命的泉源,永遠是要考慮到 必須給予病患 足夠的營養以維持其生命,静脉营养的临床应用,48,永遠是要考慮到必須給予病患 足夠的營養以維持其生命,Echenique MM; Nutrition in Clinical Practice 1999; 14:p36-37,