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,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
2、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 Spe
3、cialized 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 t
4、o 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
5、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/dayCr
6、itically 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. C
7、hloride 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 1
8、995 .,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
9、 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
10、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 sti
11、mulation,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
12、 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
13、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 ac
14、tion 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 alterationsIncrea
15、sed 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 infus
16、ion 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,Ref： 1. The Metabolic Hazar
17、ds of Overfeeding Critically Ill Patients, ASPEN, 1997.,The Potential Hazards of Overfeeding Amino Acid,UreagenesisHyperchloremic acidosisVentilatory alterationsIncreased resting energy expenditure,1. Nutrition Support Theory and Therapeutics 1st Ed , P471；19972. The Metabolic Hazards of Overfeeding
18、 Critically Ill Patients, ASPEN, 1997.,Metabolic Complications and Treatment Hyperglycemia,1. Slow infusion rate2. Give insulin 0.1 U of insulin /g of dextrose/liter3. Increase fat emulsion therapy,Refeeding Syndrome,Cardiac insuficiency peripheral edemahyertensionExcess glucose HyperglycemiaHypokal
19、emia Hypophosphatemia hypomagnesemia,Ref：Nutrition in Critical Care. 1994,TPN or PPN ?,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,Guidelines for Nutritional Therapy in Liver Disease,Recommended macronutrient intake for patients with ARFCR
20、F requiring N S,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,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: 468-478,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
21、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,Protein 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: 175-187,The Importance: hypocaloric PPN Suppo
22、rtSufficient Protein in Postoperative,The regimen of partial PN support is better in achieving1. Less negative nitrogen balance2. Improved visceral protein levels3. Greater total lymphocyte countProtein source contribution at least 1g/kg/day,Ref：Tsann-Long Hwang et al, JPEN：1993；Vol 17, No.3 P254-25
23、6,Glycal-Amin (3% Amino Acid and 3% Glycerin injection with Electrolytes),P0.02,氮平衡/4日,Glycal-Amin,一般氨基酸加電解質,0,-5,5,-10,10,顯著的正氮平衡,Freeman:Surgery, Gyn &Obs. Vol.156: p625-631, 1983,3% Amino Acid and 3% Glycerin injection with Electrolytes,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-Amin,A.LevRan: JPEN 11:271-2
24、74,1987,Peripharal TPN,68,27,18,N=41 P0.001,葡萄糖 基劑的PPN,Glycal-Amin,一般靜脈注射 (生理食鹽水),靜脈炎之比較,50,100,Eric B.Rypin: The Am. J. of Surg. 159, p222-225, 1990,3% Amino Acid and 3% Glycerin injection with Electrolytes,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110-120 mg/dl 控制葡萄糖利用的GLUT-4
25、Transporter受損 持續減低的葡萄糖利用率,Nutritional Oncology 1999 Chapter 36 p. 519-536,癌症惡體質的糖類代謝,J. Am,College of Nutrition 445-456, 1992,葡萄糖利用性不良,A.S.P.E.N. 23rd Clinical Congress p.244, 1999,宿主 Cytokine Production,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,葡萄糖生成 蛋白質合成,肌肉,合成 分解,氨基酸,脂肪酸,氨基酸,?,Propo
26、sed mechanism of cancer cachexia,無氧反應 (-2 ATP),Cori cycle (-4 ATP),TCA Cycle (-36 ATP),Loss more 300Kcal/day,Kern 1988. 12:287,Premixed, ready-to use, peripheral IV nutrition support使用甘油而非葡萄糖為熱量來源提供氨基酸、碳水化合物及電解質(包括鈉、鉀、鎂、鈣、鏻等)735 mOsm/L,Glycal-Amin 3% amino acid 3% glycerol with electrolytes,2L+500mL
27、,10%,脂肪乳,3L/+500mL,20%,脂肪乳,總熱量,1,040,1,735,蛋白質,(,克,),58,87,脂肪,(,克,),50,100,鈉,(mEq),70,105,鉀,(mEq),48,72,鎂,(mEq),10,15,鈣,(mEq),6,9,氯,(mEq),82,123,磷,(,mmol),14.5,18,醋酸,(mEq),94,141,提供類似TPN的完整靜脈營養,Kenneth Waxman: JPEN 16: p374-378, 1992,安全、方便、經濟,J. Payne-James: JPEN 1993; 17: 468-478,First Choice for T
28、otal Parenteral Nutrition: The Peripheral Route 全靜脈營養的第一選擇：周邊靜脈營養路徑,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素症有無infusion pump均可使用不須要tapering,安全、方便、經濟,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,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,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,
