静脉营养的临床应用课件.ppt

1、Tianjin Cancer Hospital2006 Head&Neck Department 營養評估與營養需求營養評估與營養需求 靜脈營養支持注意要點靜脈營養支持注意要點 靜脈營養的適應症靜脈營養的適應症v 全靜脈營養全靜脈營養TPNTPNv 周邊靜脈營養周邊靜脈營養PPNPPN 癌症與營養癌症與營養 Tianjin Cancer Hospital2006 Head&Neck DepartmentClinical 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

2、,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 ToleratedProgress

3、 to Total Enteral FeedingsNormalCompromisedNoYesDecision to Initiate Specialized Nutrition SupportRef：JPEN 17（Suppl 4）：）：7 SA,1993Tianjin Cancer Hospital2006 Head&Neck Department150-50-30150/200-40-30g/kg/d1-1.50.8 1.0mg/kg/min2-3.54-5g/kg/d11-2kcal/kg/d25 3030-35mL/kg/dMin.needed30-40ASPEN nutritio

4、n support practice manual 9-2,1998nMaintenance levels of electrolytesnStandard doses of multivitamins and trace elementsTianjin Cancer Hospital2006 Head&Neck DepartmentProtein Requirements （for Adult Patients）1.15 25 of Total Calories 2.Non-protein Calorie to Nitrogen Ratio 80-100 kcal：1/gm.N Severe

5、 Stress 150-200 kcal：1/gm.N Moderate Stress3.Nutritional vs.Metabolic Support 22nd Clinical Congress,ASPEN 1998Tianjin Cancer Hospital2006 Head&Neck DepartmentGlucose 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)

6、n the maximum glucose infusion rate be4 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 Nutrition 3 Edition;2001Tianjin Cancer Hospital2006 Head&Neck DepartmentFat Requirementsn Maximum c

7、apacity：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 initially at 1 ml/min 15-30 minn 2-4of total calories must be from EFA22nd Clinical Congress,ASPEN 1998Tianjin Cancer Hospital2006 Head&Neck Department Electrolytes Requirem

8、ents 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/dayRef：a.Maxwell Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism,5th,1994.b.Allin I.Ar

9、ieff,M.D.Fluid,Electrolyte,and Acid-Base Disorders.2nd Ed 1995.Tianjin Cancer Hospital2006 Head&Neck Department4000-500040033002002500 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 mg1.1 10 mg/wk2.Antibiotics 10 mg/3-4days

10、Tianjin Cancer Hospital2006 Head&Neck DepartmentElementStableAcute 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 Stasi

11、s,and CholelithiasisnGastrointestinal AtrophynGastric Hypersecretion and HyperacidityMacronutrient related ComplicationsOverfeeding Refeeding syndromeTianjin Cancer Hospital2006 Head&Neck DepartmentMetabolic Complications of PN Steatosis Within 1-2 weeks after initiation of PNElevations of Serum ami

12、notransferases,alkaline phosphatase and bilirubinFatty infiltration of liver cells Continuous glucose and/or excessive calorie loads Resolves in 10-15 daysTianjin Cancer Hospital2006 Head&Neck DepartmentMetabolic Complications of PNCholestasis,Gallbladder Stasis,and Cholelithiasis May occur 2-6 wks

13、after initiation PN Progressive increase total bilirubin and serum alkaline phosphatase minimize the riskCyclic PNRestrictin of carbohydrate,Avoidance of overfeeding Early enteral stimulation Tianjin Cancer Hospital2006 Head&Neck DepartmentMetabolic Complications of PNGastrointestinal AtrophyLack of

14、 enteral stimulation cause villus hypoplasiaColonic mucosal atropyDecrease gastric functionImpaired GI immunityBacterial overgrowthBacterial translocation Initiate enteral feedings as soon as possibleTianjin Cancer Hospital2006 Head&Neck DepartmentMetabolic Complications of PNGastric Hypersecretion

15、and Hyperacidity Gastric secretions directly related to the amount of small bowel resectedPeptic ulcerations and hemorrhagic gastritis Histamine H2 receptor antagonists are used to decrease gastric output Added directly to the PN solutionTianjin Cancer Hospital2006 Head&Neck Department適當靜脈營養支持注意要點適當

16、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 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-294STianjin Cancer Hospital2006 Head&Neck DepartmentCurrent Opinion i

17、n Clinical Nutrition and Metabolic Care 1999,2:69-782 46810 12 14 16 18 20Postoperative DayRelative insulin sensitivity(%)10080604020Tianjin Cancer Hospital2006 Head&Neck DepartmentAnesthesiology 40:4,400-404,1974RL GLASSRL PVCD5RL GLASSD5RL PVCTianjin Cancer Hospital2006 Head&Neck Departmentn a.Hyp

18、erosmolar state b.Osmotic diuresis c.Dehydration d.Immunosuppressionn n n Ref：1.Nutrition Support Theory and Therapeutics 1st Ed,P471；1997 2.The Metabolic Hazards of Overfeeding Critically Ill Patients,ASPEN,1997.Tianjin Cancer Hospital2006 Head&Neck DepartmentnTG 250mg/dl 4 hrs after lipid infusion

19、 for piggybacked lipids and 400mg/dl for continuous lipid infusion Ref：1.The Metabolic Hazards of Overfeeding Critically Ill Patients,ASPEN,1997.Tianjin Cancer Hospital2006 Head&Neck Departmentn Ureagenesisn Hyperchloremic acidosisn Ventilatory alterationsn Increased resting energy expenditure 1.Nut

20、rition Support Theory and Therapeutics 1st Ed,P471；1997 2.The Metabolic Hazards of Overfeeding Critically Ill Patients,ASPEN,1997.Tianjin Cancer Hospital2006 Head&Neck DepartmentMetabolic Complications and TreatmentHyperglycemian1.Slow infusion raten2.Give insulin 0.1 U of insulin/g of dextrose/lite

21、rn3.Increase fat emulsion therapyTianjin Cancer Hospital2006 Head&Neck DepartmentRefeeding SyndromenCardiac insuficiency peripheral edema hyertensionnExcess glucoseHyperglycemia HypokalemiaHypophosphatemiahypomagnesemiaRef：Nutrition in Critical Care.1994TPN or PPN?Tianjin Cancer Hospital2006 Head&Ne

22、ck Department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Tianjin Cancer Hospital2006 Head&Neck Department Hicaliq I TeruAmino 12X Hicaliq II TeruAmino 12XStress-II 一天一天1.5袋袋 總總 液

23、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併併總總 液液 量量 ml10250 ml 145010250 ml 145010250 ml 205

24、0 ml用用總總 熱熱 量量 Kcal108013021816脂脂Non-Protein Kcal85510751475肪肪Non-P Kcal/N94118108Tianjin Cancer Hospital2006 Head&Neck Department 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/N1

25、17165 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/N172195Tianjin Cancer Hospital2006 Head&Neck DepartmentGuidelines for Nutritional Therapy in Li

26、ver DiseaseProteingm/kg/dEnergyKcal/kg/dCHOFatNutritional 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 n

27、ormal nutritional statusPrevent malnutritionTreat fat malabsorptionEncephalopathy Grade 1 or 2 Grade 3 or 40.5-1.20.525-4025-4075752525Provide nutritional needs without precipitating encephalopathyTianjin Cancer Hospital2006 Head&Neck DepartmentRecommended macronutrient intake for patients with ARFC

28、RF 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 protein1.5 2.5 g/kg/d of mixed essential and nonessential amino acids or proteinEnergy30

29、 45 kcal/kg/d30 45 kcal/kg/dFat（of total energy）20-30 if not septic20-30 if not septicWaterAs toleratedAs toleratedTianjin Cancer Hospital2006 Head&Neck Department 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

30、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Tianjin Cancer Hospital2006 Head&Neck Department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脈栓包括導管移除的未注意及中央靜脈栓塞塞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

31、路徑全靜脈營養的第一選擇：周邊靜脈營養路徑Tianjin Cancer Hospital2006 Head&Neck Departmentg 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Tianjin Cancer Hos

32、pital2006 Head&Neck Department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,1974:27:175-187Tianjin Cancer Hospital2006 Head&Neck Department 1.Less negative nitrogen balance 2.Improved visceral protein levels 3.Greater total lymphocyte count Prot

33、ein source contribution at least 1g/kg/dayRef：Tsann-Long Hwang et al,JPEN：1993；Vol 17,No.3 P254-256 Tianjin Cancer Hospital2006 Head&Neck DepartmentDextroseGlycerin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

34、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=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Tianjin Cancer Hospital2006 Head&Neck DepartmentP0.02氮平衡氮平衡/4

35、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 Amino Acid and 3%Glycerin injection with Electrolyteswith ElectrolytesTianjin Cancer Hospital2006 Head&Neck Department3211 12 23 34 45 51 12 23 34 45 540801201602

36、00240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.V.,U/hDose of insulin I.V.,U/hF A.LevRan:JPEN 11:271-274,1987Tianjin Cancer Hospital2006 Head&Neck DepartmentN=41P

37、0.001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 ElectrolytesTianjin Cancer Hospital2006 Head&Neck Department37%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

38、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.519-536Tianjin Cancer Hospital2006 Head&Neck DepartmentT Ty yp pe e I II Id di i a ab be et t e 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

39、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 445-456,1992Tianjin Cancer Hospital2006 Head&Neck DepartmentCancer type(n)Insulin(%of control)Glucose disposal Ref

40、erence 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 A.S.P.E.N.23rd Clinical Congress p.244,1999Tianji

41、n Cancer Hospital2006 Head&Neck Department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;1988.12:287Tianjin Cancer Hospital2006 Head&

42、Neck Department Tianjin Cancer Hospital2006 Head&Neck Department2L+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)1015鈣鈣(mEq)69氯氯(mEq)82123磷磷(mmol)14.518醋酸醋酸(mEq)94141Kenneth Waxman:JPEN 16:p374-378,1992Tianjin Cancer Hospital2006 Head&Neck D

43、epartmentJ.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：周邊靜脈營養路徑全靜脈營養的第一選擇：周邊靜脈營養路徑Tianjin Cancer Hospital2006 Head&Neck Departmentv已預混合已預混合

44、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Tianjin Cancer Hospital2006 Head&Neck Department 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Pulmo

45、nary stressPulmonary 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Tianjin Cancer Hospital2006 Head&Neck Department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Tianjin Cancer Hospital2006 Head&Neck DepartmentTianjin Cancer Hospital2006 Head&Neck Department后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用资料仅供参考，实际情况实际分析T

46、ianjin Cancer Hospital2006 Head&Neck Department主要经营：课件设计，文档制作，网络软件设计、图文设计制作、发布广告等秉着以优质的服务对待每一位客户，做到让客户满意！致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求Tianjin Cancer Hospital2006 Head&Neck DepartmentThe user can demonstrate on a projector or computer,or print the presentation and make it into a film to be used in a wider field