關(guān)于腸外和腸內(nèi)營養(yǎng)的文獻(xiàn)TPN

IntroductiontoTPN新光吳火獅紀(jì)念醫(yī)院內(nèi)科部胃腸肝膽科柯威旭醫(yī)師第1頁NutritionSupportTeamPhysiciansClinicalpharmacistsNurse-CliniciansDietitiansLaboratoryresearchtechnicianWardnursingstaffInSKH:主任,執(zhí)行秘書,各科醫(yī)師,藥劑師,營養(yǎng)師第2頁SourceofNutritionEnteralnutritionParenteralnutritionCentralparenteralnutrition(CPN=TPN)Peripheralparenteralnutrition(PPN)Long-termhomeparenteralnutrition(HPN)第3頁ClinicaldecisionalgorithmrouteofnutritionsupportDecisiontoinstitutespecial

nutritionsupport

OralFeedingNutritionAssessmentFunctionalGITractEnteralNutritionParenteralNutritionGIfunctionPPNTPNGIfunctionreturnIntactNutrientsDefinedFormulaAdequateInadequatePNShort-term:NG,ND,NJLong-term:GastrostomyJejunostomyYESNONOYESAdequate第4頁P(yáng)PNHighriskofthrombophlebitisOsmolarity:lessthan800-900mOsm/kgShort-term:upto2weeksNottheoptimalchoiceforsignificantmalnutritionseveremetabolicstresslargenutrientorelectrolyteneeds(especiallypotassium,astrongvascularirritant)fluidrestrictiontheneedforprolongedintravenousnutritionsupport

第5頁IndicationsofTPNImpossibilityforenteralnutritionInadequacyforenteralnutritionIncrementoftheseverityofdiseasebyenteralnutritionPLUSAnticipatedtohavePNformorethan7days第6頁TPNinInternalMedicineAcutepancreatitisIntestinaldisease(IBD,NEC,radiationcolitis,ileus,intractablediarrhea/vomiting)CancerHepaticfailureRenalfailureShortbowelsyndromeEnterocutaneousfistulaAIDSPerioperativesupport第7頁TPNshouldnotbeusedinMalignancy:poorresponsetoR/TorC/TActivestageofIBDRelativepreservedGIfunctionHypertriglyceridemia(TG>400md/dl)第8頁ComponentsofTPNCarbohydrate,Aminoacid,Fat,Electrolyte,Water,Vitamin,TraceelementStandardsolutionDextrose,AminoacidElectrolyte(Na,K,Cl,Mg,Ca,P)Vitamin(A,B1,B2,Niacin,B6,Panthothenicacid,C,D,E,Zn,Cu,Mn,Cr)Lipidemulsion第9頁Dextrose-contentSolution1gglucose=3.4Kcal1gglucose=5mOsm/L第10頁Aminoacidsolution7%A.A.含essentialA.A.較高,適用於腎衰竭病患8%A.A.含高濃度branchchainA.A.,低濃度aromaticA.A.,可使肝衰竭病患之HE改善12%A.A.成人StandardSolution之A.A.來源第11頁Lipidemulsions10%intralipid20%intralipid10%lipofundinVolume500ml/B250ml/B100ml/BCalorie550Kcal/B500Kcal/B110Kcal/B第12頁TPNformulaB:standardsolutionD:8%A.A.,highBCAA,lowAAA;forhepaticdiseaseE:35%Dextrose,12%A.A.;forHDandwaterrestrictionF:29%Dextrose,12%&7%A.A.;forARFwithHDG:29%Dextrose,7%A.A.;forESRD第13頁TPNOrder第14頁VascularAccessforTPNCareComplicationInfectionSubclavianveinEasyHighLowInternaljugularveinHardLowHighFemoralveinHardLowHighestAntecubitalveinEasyLowHigh第15頁MechanicalcomplicationInsertion-of-catheterrelated:pneumothorax,brachialplexusinjury,subclavianandcarotidarterypuncture,hemothorax,thoracicductinjuryandchylothorax,cardiacperforation,cathetermalpositionAirembolismCatheterfragmentembolism第16頁MetaboliccomplicationFluidoverload/DehydrationfromosmoticdiuresisHypertriglyceridemiaHypocalcemiaHypomagnesemiaHypophosphatemiaHyperglycemia/ReboundhypoglycemiaonsuddencessationofTPNHyperammonemiaHyperchloremicmetabolicacidosisNKHS第17頁InfectiouscomplicationCatheter-relatedsepsis:Staph.epidermidisandaureus;solutioncontaminationGNBforimmunocompromiseDirectevidence:tipcultureorbloodcultureIndirectevidence:fever(upto38C,2times,every4hours),chills,abruptincreaseofbloodsugar,hypotension,tachycardia,leukocytosis第18頁HepaticcomplicationBiochemical:elevatedserumaminotransferaseandalkalinephosphataseHistological:steatosis,steatohepatitis,cholestasis,fibrosisandcirrhosisUsuallybenignandtransient,butsevereinTPNfor>16weeksAdditiveuseofCholine,GlutamineandCarnitinemaybehelpfulIfcholestasisispresent,CuandMgshouldbedeletedtopreventacculumationinliverandBG第19頁BiliarycomplicationAcalculouscholecystitis,GBsludge,cholelithiasisinTPNfor>3weeksDecreaseofbilesaltreabsorptionleadstoformationofGBstone;EncouragingenteralintaketostimulateGBcontraction第20頁IntestinalcomplicationVillousatrophy:decreasesingutweightandmucosalheight第21頁MetabolicbonediseasePresentinTPNfor>3monthsBonepain,bonefractureorasymptomaticbutdemineralizationinCxRPossiblemechanismsAluminumtoxicityVitaminDtoxicityNegativecalciumbalance第22頁RefeedingsyndromeThemetabolicandphysiologicconsequencesofthedepletion,repletion,compartmentalshiftsandinterrelationshipsofthefollowingsPhosphorus(<1mg/dl,deathwithinhours)PotassiumMagnesiumGlucosemetabolismVitamindeficiencyFluidresuscitation第23頁CaseHistory66y/ofemale,abdominalpainandanorexiafor6weekspersistentprofuse,yellow,waterydiarrheaafterconstructionanilealconduitforureteralobstructionlastingfor3monthsPE:BW36kg,70%ofIBW;afebrile,108,14,98/70anasarca,cachecticwithgeneralizedmusclewastage第24頁Hct38%,WBC17000,BUN/Cr22/1.0,K3.4,P3.4,HCO317,Sugar48,Alb.1.59HospitalCourseTPNwasstartedwith750gdextrose,120gAA,60mEqNa,20mEqK,15mmolPin3Lfluid24hrsafterstartofTPN,HR180,SBP50,CVP<3cmH2OP0.7,Na142,K1.4,HCO319,Mg1.8,Sugar1010,BUN/Cr27/1.3pH7.31,O259,CO224(O22L)第25頁ApneaandrespiratoryfailuredevelopedwithinonehourWithstoppingTPNandfluidreplacement,P6.9,K3.5andSugar45wereobtained.Inthefollowinghospitalization,bilateralpneumoniaandARDSwerecomplicated.Diedonthe6thdayAutopsy:ischemicenterocolitis,pneumonia,ARDSandperitonitisandtheheartwasunremarkable第26頁第27頁SequenceofeventsP,Sugar,K,Meta.acidosisGIbleeding,SepsisTachycardia,HypotensionApnea,MVsupportARDS,PneumoniaPersistentCardiopulmonaryInstabilityDeathWithin48hrsofstartingTPNAftercorrectionofhypophosphatemia第28頁P(yáng)hysiologyofStarvationWhenBMR=energyoutputtothelimitedintake,endogenousfuelsmustbeusedMajorstoragefuelisfatinformofTG(60-75days)Carbohydrate,incontrast,isquantitativelyinsignificantstoragefuel(1200kcal,1day’srestingER)Protein,12kg,2weeks’worthofcalories;butisfornonfuelfunction第29頁MetabolicResponsetoRefeedingAshiftfrombodyfattoCHOasmajorfuelsourceInsulinGlycogenolysis,gluconeogenesisandFAmobilizationfromadiposetissueisinhibitedCellularuptakeofglucose,K,P,andMgisenhancedbyinsulinAntinatriureticeffect(NaretentionandECFexpansion)第30頁P(yáng)atientofriskforrefeedi