静脉营养的临床应用培训课件.pptx

1、Clinical Decision Algorithm消化道功能消化道功能YesNo腸道營養腸道營養短期短期長期或須限水時長期或須限水時標準配方標準配方特殊配方特殊配方(Obstruction,peritonitis,intractable vomiting,acute pancreatitis,short-bowel syndrome,ileus)短期短期 Nasogastric Nasoduodenal Nasojejunal長期長期 Gastrostomy JejunostomyNutrient ToleranceAdequateProgress toOral FeedingsInade

2、quatePN SupplementationAdequateProgress to MoreComplex Diet andOral FeedingsAs ToleratedProgress to Total Enteral FeedingsNormalCompromisedNoYesDecision to Initiate Specialized Nutrition SupportRef：JPEN 17（Suppl 4）：）：7 SA,1993150-50-30150/200-40-30g/kg/d1-1.50.8 1.0mg/kg/min2-3.54-5g/kg/d11-2kcal/kg

3、/d25 3030-35mL/kg/dMin.needed30-40ASPENnutritionsupportpracticemanual9-2,1998nMaintenance levels of electrolytesnStandard doses of multivitamins and trace elementsProteinRequirements（for Adult Patients）1.1525ofTotalCalories2.Non-proteinCalorietoNitrogenRatio 80-100kcal：1/gm.NSevereStress 150-200kcal

4、：1/gm.NModerateStress3.Nutritional vs.Metabolic Support 22ndClinicalCongress,ASPEN 1998Glucose RequirementnInitial TPN:100-150 gm（or 200gm）nCan be increased by 50-75 gm/d (blood glucose levels are stable but less than 200 mg/dl)n the maximum glucose infusion rate be4 mg/kg/min(22-25Kcal/kg/day)Ref：1

5、.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001Fat Requirementsn Maximum capacity：1.0-2.0 gm/kg/dayn Critically ill the maximum recommended infusion rate：1.0 gm/kg/dayn 10-25of total caloriesn Run fat initiall

6、y at 1 ml/min 15-30 minn 2-4of total calories must be from EFA22ndClinicalCongress,ASPEN 1998 ElectrolytesRequirements for Adult Patients 1.Sodium 30 55 mEq/liter 2.Potassium6090mEq/day 3.Chloride 30 55 mEq/liter 4.Calcium612mEq/day 5.Magnesium1620mEq/day 6.Acetate4570mEq/day 7.Phosphorus1828mM/dayR

7、ef：a.MaxwellKleeman,sClinicalDisordersofFluidandElectrolyteMetabolism,5th,1994.b.AllinI.Arieff,M.D.Fluid,Electrolyte,andAcid-BaseDisorders.2ndEd1995.4000-500040033002002500 1000040012-154510.0100.0400100040012-20400.040.020002001.1 1.81.0 1.53.63.010101.6 2.034.05.02020 mg5 10150-30015.060.01005 mg1

8、.1 10 mg/wk2.Antibiotics 10 mg/3-4daysElementStableAcute CatabolicGI LossesZn2.5 4.0 mgAdditional2 mgAdd 12.2 mg/L small Bowel fluid lost；17.1 mg/kg of stool or ileostomy outputCu0.5 1.5 mg-Cr10 15 mcg-20 mcgMn1.150.8 mg-Metabolic Complications of PNnSteatosisnCholestasis,Gallbladder Stasis,and Chol

9、elithiasisnGastrointestinal AtrophynGastric Hypersecretion and HyperacidityMacronutrientrelatedComplicationsOverfeedingRefeedingsyndromeMetabolic Complications of PN Steatosisn Within 1-2 weeks after initiation of PNnElevations of Serum aminotransferases,alkaline phosphatase and bilirubinnFatty infi

10、ltration of liver cellsn Continuous glucose and/or excessive calorie loadsnResolves in 10-15 daysMetabolic Complications of PNCholestasis,Gallbladder Stasis,and CholelithiasisnMay occur 2-6 wks after initiation PNnProgressive increase total bilirubin and serum alkaline phosphatasenminimize the riskn

11、Cyclic PNnRestrictin of carbohydrate,nAvoidance of overfeeding nEarly enteral stimulation Glycal-Amin提供氨基酸、碳水化合物及電解質1900 一日 2 袋Non-protein Calorie to Nitrogen RatioMay occur 2-6 wks after initiation PNDose of insulin I.足夠的營養以維持其生命150/200-40-3030 45 kcal/kg/dN Moderate Stress使用甘油而非葡萄糖為熱量來源10250 ml 14

12、50無法或不必要用下腔頸靜脈插管Potassium 60 90 mEq/dayInitial TPN:100-150 gm（or 200gm）可以上昇維持至110-120 mg/dl1900 一日 1 袋Compromisedvomiting,acute pancreatitis,short-避免因SIRS引起的高血糖症Metabolic Complications of PNGastrointestinal AtrophynLack of enteral stimulation cause nvillus hypoplasianColonic mucosal atropynDecrease

13、gastric functionnImpaired GI immunitynBacterial overgrowthnBacterial translocationnInitiate enteral feedings as soon as possibleMetabolic Complications of PNGastric Hypersecretion and HyperaciditynGastric secretions directly related to the amount of small bowel resectednPeptic ulcerations and hemorr

14、hagic gastritisnHistamine H2 receptor antagonists are used to decrease gastric outputnAdded directly to the PN solution適當靜脈營養支持注意要點適當靜脈營養支持注意要點v 預防高血糖症預防高血糖症 血糖的穩定血糖的穩定v 電解質的平衡電解質的平衡 鉀鉀、鎂、磷、鎂、磷 的監測的監測v 酸鹼平衡酸鹼平衡Nutrition Support Overfeeding Respiratory AcidosisParenteral Nutrition Acidosis Metabolic

15、Acidosisv 避免靜脈營養停止時的低血糖症避免靜脈營養停止時的低血糖症J.Nutrition 1999:129.290S-294SCurrent Opinion in Clinical Nutrition and Metabolic Care 1999,2:69-78246810 12 14 16 18 20Postoperative DayRelative insulin sensitivity(%)10080604020Anesthesiology 40:4,400-404,1974RL GLASSRL PVCD5RL GLASSD5RL PVCn a.Hyperosmolar st

16、ate b.Osmotic diuresis c.Dehydration d.Immunosuppressionn n n Ref：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.nTG 250mg/dl 4 hrs after lipid infusion for piggybacked lipids and 400mg/dl for continuous lipid infusion Ref：1.T

17、heMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.n Ureagenesisn Hyperchloremic acidosisn Ventilatory alterationsn Increased resting energy expenditure1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.Metabolic Comp

18、lications and TreatmentHyperglycemian1.Slow infusion raten2.Give insulin 0.1 U of insulin/g of dextrose/litern3.Increase fat emulsion therapyRefeeding SyndromenCardiac insuficiency peripheral edema hyertensionnExcess glucoseHyperglycemia HypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCritic

19、alCare.1994TPN or PPN?1900 一日 1 袋Glycal-AminKern&Norton:JPEN;1988.Zn mg總 液 量 mlRefeeding syndrome1 10 mg/wkAdult RDA in USAExcess glucoseAs Tolerated30 45 kcal/kg/dGastrointestinal Atrophy1 mg/kg of stool or ileostomy outputHyperglycemia290S-294SProgress tohyertensionGuidelines for Nutritional Thera

20、py in Liver DiseaseEnhance regenerationRecommended macronutrient intake for patients with ARFCRF requiring N S全靜脈營養全靜脈營養的適應症的適應症Total Parenteral Nutrition營養有危機的人營養有危機的人體重過輕的病人體重過輕的病人短時間內體重下降超過短時間內體重下降超過10%10%有有1010天以上無法經口進食天以上無法經口進食胃腸道消化吸收有困難胃腸道消化吸收有困難嚴重外傷、燒傷嚴重外傷、燒傷嚴重敗血症嚴重敗血症 Hicaliq I TeruAmino 12X

21、 Hicaliq II TeruAmino 12XStress-II 一天一天1.5袋袋 總總 液液 量量 ml120012001800 總總 熱熱 量量 Kcal80710271541 Glucose gm140206309 Xylitol gm 25 25 37.5 Amino Acid gm56.8 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併併

22、總總 液液 量量 ml10250 ml 145010250 ml 145010250 ml 2050 ml用用總總 熱熱 量量 Kcal108013021816脂脂Non-Protein Kcal85510751475肪肪Non-P Kcal/N94118108 STD-ISTD-II 總總 液液 量量 ml1900 一日一日 2 袋袋1900 一日一日 1 袋袋 總總 熱熱 量量 Kcal12871727 Glucose gm282411 Xylitol gm2525 Amino Acid gm56.856.8 Non-Protein Kcal10601500 Non-Protein K/N

23、117165 Na mEq7575 K mEq6060 Ca mEq 1717 Mg mEq2020 Cl mEq 7575 Acetate mEq5050 P mM 9.79.7 Zn mg1.41.4併併總總 液液 量量 ml20250 ml 215010250 ml 2150用用總總 熱熱 量量 Kcal17872002脂脂Non-Protein Kcal15601775肪肪Non-Protein K/N172195Guidelines for Nutritional Therapy in Liver DiseaseProteingm/kg/dEnergyKcal/kg/dCHOFatN

24、utritional GoalHepatits acute or chronic1.0-1.530-4067-8020-33Prevent malnutritionEnhance regenerationCirrhosis uncomplicated1.0-1.530-4067-8020-33Same as aboveCirrhosis-complicated Malnutrition Cholestasis1.0-1.81.0-1.540-5030-407273-802820-27Restore normal nutritional statusPrevent malnutritionTre

25、at fat malabsorptionEncephalopathy Grade 1 or 2 Grade 3 or 40.5-1.20.525-4025-4075752525Provide nutritional needs without precipitating encephalopathyRecommended macronutrient intake for patients with ARFCRF requiring N S ARF or CRF Patients（HD treatments about three times/week）CVVH/CVVHD（in hyperca

26、tabolic ARF or CRF patients）Protein or Amino acidAbout 1.2 g/kg/d of mixed essential and nonessential amino acids or protein1.5 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 t

27、oleratedAs tolerated 病人預期病人預期NPO 5-7NPO 5-7天天 不適當的胃腸功能維持在不適當的胃腸功能維持在5-75-7天天 轉移至口服管灌期轉移至口服管灌期 中央靜脈輸入是禁忌時中央靜脈輸入是禁忌時 營養不良病患營養不良病患 預期須給予數日的預期須給予數日的NPONPO 高新陳代謝性病患高新陳代謝性病患 使用使用PPNPPN即可符合病患熱量及蛋白質的須求時即可符合病患熱量及蛋白質的須求時全靜脈營養與周邊靜脈營養全靜脈營養與周邊靜脈營養n5.7%嚴重的併發症嚴重的併發症n包括動脈出血及氣胸包括動脈出血及氣胸n9%導管性併發症導管性併發症n包括導管移除的未注意及中央靜

28、脈栓塞包括導管移除的未注意及中央靜脈栓塞n6.5%與中央靜脈導管有關的菌血與中央靜脈導管有關的菌血症症Payne-James,JPEN 1993;17:468-478TPN的問題的問題全靜脈營養的第一選擇：周邊靜脈營養路徑全靜脈營養的第一選擇：周邊靜脈營養路徑g 無法或不必要用下腔頸靜脈插管無法或不必要用下腔頸靜脈插管 提供高滲透壓溶液時提供高滲透壓溶液時g 因菌血症而須將中心靜脈插管拆除因菌血症而須將中心靜脈插管拆除g 下腔靜脈先前的插管引起靜脈炎下腔靜脈先前的插管引起靜脈炎g 無專業人員無專業人員PPNPPN輕度至中度營養缺乏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無法經口服或不

29、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或不需要時的一種有效的營養支持療法葡萄糖葡萄糖肝醣肝醣胺基酸胺基酸蛋白質蛋白質酮體酮體脂肪酸脂肪酸脂肪脂肪ADP能量ATP能量代謝氧氣O2升糖激素Epin,Norepin,GH類固醇Blackburn;Am.J Clin Ntutr,1974:27:175-187 1.Less negative nitrogen balance 2.Improved visceral protein levels 3.Greater total lymphocyte count Protein source contribution at least 1g/

30、kg/dayRef：Tsann-LongHwangetal,JPEN：1993；Vol17,No.3P254-256DextroseGlycerin能能量量提提供供3.4kcal/克克4.3kcal/克克胰胰島島素素作作用用須須依依賴賴胰胰島島素素，產產生生葡葡萄萄糖糖不不耐耐性性體體內內代代謝謝不不須須胰胰島島素素，無無血血糖糖昇昇高高問問題題呼呼吸吸係係數數RespiratoryquotionRQ=1 易易產產生生VCO2增增高高，O2耗耗氧氧量量增增加加，引引起起肺肺窘窘迫迫RQ=0.87 較較不不易易引引起起肺肺窘窘迫迫，適適合合肺肺功功能能不不全全患患者者小小靜靜脈脈刺刺激激性性PH

31、=5.0 滲滲透透壓壓高高，易易引引起起靜靜脈脈炎炎PH=6.5 滲滲透透壓壓低低，靜靜脈脈炎炎發發生生機機率率較較低低熱熱安安定定性性不不安安定定，與與胺胺基基酸酸引引起起褐褐化化反反應應(Millard Reaction)安安定定，可可加加熱熱滅滅菌菌，減減少少藥藥局局混混合合時時的的污污染染P0.02氮平衡氮平衡/4日日 Glycal-AminGlycal-Amin 一般氨基酸加電解質一般氨基酸加電解質0-55-1010Freeman:Surgery,Gyn&Obs.Vol.156:p625-631,19833%3%Amino Acid and 3%Glycerin injection

32、Amino Acid and 3%Glycerin injection with Electrolyteswith Electrolytes3211 12 23 34 45 51 12 23 34 45 54080120160200240胰島素胰島素依賴型糖尿病依賴型糖尿病非胰島素非胰島素依賴型糖尿病依賴型糖尿病一般氨基酸一般氨基酸+葡萄糖葡萄糖Glycal-AminGlycal-Amindaysdaysdaysdays1 12 23 34 45 51 12 23 34 45 5Plasma Glucose,mg/dlPlasma Glucose,mg/dlDose of insulin I.

33、V.,U/hDose of insulin I.V.,U/hF A.LevRan:JPEN 11:271-274,1987N=41P0.001葡萄糖葡萄糖基劑的基劑的PPNPPNEric B.Rypin:The Am.J.of Surg.159,p222-225,19903%3%Amino Acid and 3%Glycerin injection Amino Acid and 3%Glycerin injection with Electrolyteswith ElectrolytesHyperchloremic acidosisProtein Sparing Effect總 液 量 mlM

34、etabolic Complications and TreatmentHyperglycemia提供氨基酸、碳水化合物及電解質20-30 if not septic20-30 if not septic150/200-40-30Central PNProtein source contribution at least 1g/kg/dayAMA RecommendedGlycal-Amin避免因SIRS引起的高血糖症Potassium 60 90 mEq/dayAdded directly to the PN solutionuncomplicatedGrade 3 or 4Progress

35、 to30 45 kcal/kg/dPlasma Glucose,mg/dl37%37%的癌症病人的癌症病人血糖不耐性問題血糖不耐性問題CachexiaCachexia不正常葡萄糖耐受性不正常葡萄糖耐受性飢餓狀態下的血糖飢餓狀態下的血糖可以上昇維持至可以上昇維持至110-120 110-120 mg/dlmg/dl控制葡萄糖利用的控制葡萄糖利用的GLUT-4 TransporterGLUT-4 Transporter受損受損Nutritional Oncology 1999 Chapter 36 p.519-536T Ty yp pe e I II Id di i a ab be et t e

36、 es s體體重重流流失失的的癌癌症症病病人人飯飯前前g gl l u uc co os se e增增加加正正常常飯飯前前 i i n ns su ul l i i n n增增加加減減少少或或增增加加I In ns su ul l i i n n 分分泌泌減減少少減減少少或或增增加加耐耐糖糖試試驗驗不不正正常常不不正正常常肝肝臟臟葡葡萄萄糖糖製製造造量量增增加加極極極極度度度度增增增增加加加加肌肌肉肉葡葡萄萄糖糖攝攝取取量量減減少少減減少少J.Am,College of Nutrition 445-456,1992Cancer type(n)Insulin(%of control)Glucos

37、e disposal Reference 頭頭 頸頸 部部(8)290 52%Tayek 1995 720 74%胃胃 腸腸 道道(11)500 65%M cCall 1992 胰胰 臟臟 (16)310 60%Permert 1994 630 81%胃胃 與與 大大 腸腸(15)430 73%Copeland 1987 大大 腸腸-直直 腸腸(10)240 62%Copeland 1987 淋淋 巴巴 瘤瘤 (6)430 55%M inn 1994 G I,Breast,Lung(12)680 49%Yoshikaw a 腦腦無食慾無食慾?脂肪酸脂肪酸脂肪脂肪脂肪酸脂肪酸 甘油甘油 釋出釋出

38、脂肪儲存脂肪儲存腫瘤腫瘤生長生長乳酸乳酸葡萄糖葡萄糖氨基酸氨基酸三酸甘油脂三酸甘油脂肝臟肝臟葡萄糖生成葡萄糖生成蛋白質合成蛋白質合成肌肉肌肉氨基酸氨基酸脂肪酸脂肪酸氨基酸氨基酸?無氧反應無氧反應(-2 ATP)Cori cycle(-4 ATP)TCA Cycle(-36 ATP)Loss more 300Kcal/dayKern&Norton:JPEN;1988.12:287 2L+500mL10%脂肪乳脂肪乳3L/+500mL20%脂肪乳脂肪乳總熱量總熱量1,0401,735蛋白質蛋白質(克克)5887脂肪脂肪(克克)50100鈉鈉(mEq)70105鉀鉀(mEq)4872鎂鎂(mEq)1

39、015鈣鈣(mEq)69氯氯(mEq)82123磷磷(mmol)14.518醋酸醋酸(mEq)94141Kenneth Waxman:JPEN 16:p374-378,1992J.Payne-James:JPEN 1993;17:468-478J.Payne-James:JPEN 1993;17:468-478First Choice for Total Parenteral Nutrition:First Choice for Total Parenteral Nutrition:The Peripheral RouteThe Peripheral Route全靜脈營養的第一選擇：周邊靜脈營

40、養路徑全靜脈營養的第一選擇：周邊靜脈營養路徑v已預混合已預混合PPNPPNv減少藥局調製時間減少藥局調製時間v減少汙染的發生減少汙染的發生v容易處方容易處方v醫護人員操作方便醫護人員操作方便v經濟經濟 較較TPNTPN少併發症少併發症 較較TPNTPN價格便宜價格便宜 減低高血糖素症減低高血糖素症 有無有無infusion pumpinfusion pump均均可可 使用使用 不須要不須要taperingtapering安全、方便、經濟安全、方便、經濟 糖尿病與癌症病患糖尿病與癌症病患 維持與穩定血糖維持與穩定血糖 COPDCOPD病患病患 避免避免Pulmonary stressPulmon

41、ary stress 避免因避免因SIRSSIRS引起的高血糖症引起的高血糖症 避免避免TPNTPN結束時的低血糖症結束時的低血糖症藥師藥師 龐振宜龐振宜營養是生命的泉源營養是生命的泉源TPN or PPN?bowel syndrome,ileus)Non-Protein KcalPeripharal TPNP mMa.UreagenesisCentral PNGuidelines for Nutritional Therapy in Liver DiseaseImpaired GI immunity735 mOsm/LGlycal-AminFormula g/LVentilatory alt

42、erationsPeripheral Parenteral NutritionZn mgDecision to Initiate Specialized Nutrition SupportRun fat initially at 1 ml/min 15-30 minHyperchloremic acidosis1900 一日 1 袋nutritional statusperipheral IV nutrition supportClinical Decision Algorithm消化道功能消化道功能YesNo腸道營養腸道營養短期短期長期或須限水時長期或須限水時標準配方標準配方特殊配方特殊配方

43、(Obstruction,peritonitis,intractable vomiting,acute pancreatitis,short-bowel syndrome,ileus)短期短期 Nasogastric Nasoduodenal Nasojejunal長期長期 Gastrostomy JejunostomyNutrient ToleranceAdequateProgress toOral FeedingsInadequatePN SupplementationAdequateProgress to MoreComplex Diet andOral FeedingsAs Toler

44、atedProgress to Total Enteral FeedingsNormalCompromisedNoYesDecision to Initiate Specialized Nutrition SupportRef：JPEN 17（Suppl 4）：）：7 SA,1993150-50-30150/200-40-30g/kg/d1-1.50.8 1.0mg/kg/min2-3.54-5g/kg/d11-2kcal/kg/d25 3030-35mL/kg/dMin.needed30-40ASPENnutritionsupportpracticemanual9-2,1998nMainte

45、nance levels of electrolytesnStandard doses of multivitamins and trace elementsRefeeding SyndromenCardiac insuficiency peripheral edema hyertensionnExcess glucoseHyperglycemia HypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCriticalCare.1994TPN or PPN?g 無法或不必要用下腔頸靜脈插管無法或不必要用下腔頸靜脈插管 提供高滲透壓溶液時

46、提供高滲透壓溶液時g 因菌血症而須將中心靜脈插管拆除因菌血症而須將中心靜脈插管拆除g 下腔靜脈先前的插管引起靜脈炎下腔靜脈先前的插管引起靜脈炎g 無專業人員無專業人員PPNPPN輕度至中度營養缺乏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或不需要時的一種有效的營養支持療法3211 12 23 34 45 51 12 23 34 45 54080120160200240胰島素胰島素依賴型糖尿病依賴型糖尿病非胰島素非胰島素依賴型糖尿病依賴型糖尿病一般氨基酸一般氨基酸+葡萄糖葡萄糖Glycal-AminGlycal-Amind

47、aysdaysdaysdays1 12 23 34 45 51 12 23 34 45 5Plasma Glucose,mg/dlPlasma Glucose,mg/dlDose of insulin I.V.,U/hDose of insulin I.V.,U/hF A.LevRan:JPEN 11:271-274,1987N=41P0.001葡萄糖葡萄糖基劑的基劑的PPNPPNEric B.Rypin:The Am.J.of Surg.159,p222-225,19903%3%Amino Acid and 3%Glycerin injection Amino Acid and 3%Glyc

48、erin injection with Electrolyteswith ElectrolytesThe Potential Hazards of OverfeedingGlucoseMg mEqCl mEq糖類mg/kg/minTPN or PPN?Glucose gm3%Amino Acid and 3%Glycerin injection with Electrolytes病人預期NPO 5-7天提供高滲透壓溶液時Refeeding SyndromeAs ToleratedPhosphorus 18 28 mM/dayPremixed,ready-to use,Progress toAc

49、ute CatabolicAmino Acid gmDecision to Initiate Specialized Nutrition SupportGastrointestinal AtrophyVitamin B6（mg）Hicaliq I TeruAmino 12XRecommended macronutrient intake for patients with ARFCRF requiring N SPlasma Glucose,mg/dlXylitol gm2nd Ed 1995.The Potential Hazards of OverfeedingAmino AcidGlyc

50、al-AminGlucose RequirementGlycal-AminDecision to Initiate Specialized Nutrition SupportMetabolic Complications of PNCholestasis,Gallbladder Stasis,and CholelithiasisLess negative nitrogen balanceIncreased prostaglandin productionLevRan:JPEN 11:271-274,1987c.Acetate mEqRecommendationProgress to Total