靜脈營養(yǎng)的臨床應(yīng)用

靜脈營養(yǎng)的臨床應(yīng)用第1頁/共49頁靜脈營養(yǎng)的臨床應(yīng)用

ParenteralNutrition營養(yǎng)評估與營養(yǎng)需求靜脈營養(yǎng)支持注意要點靜脈營養(yǎng)的適應(yīng)癥全靜脈營養(yǎng)TPN周邊靜脈營養(yǎng)PPN癌癥與營養(yǎng)龐振宜藥師第2頁/共49頁ClinicalDecisionAlgorithm

營養(yǎng)評估消化道功能YesNo腸道營養(yǎng)胃腸功能靜脈營養(yǎng)短期長期或須限水時PeripheralPNCentralPN胃腸功能恢復(fù)標(biāo)準(zhǔn)配方特殊配方(Obstruction,peritonitis,intractablevomiting,acutepancreatitis,short-bowelsyndrome,ileus)短期

NasogastricNasoduodenalNasojejunal長期

GastrostomyJejunostomyNutrientToleranceAdequateProgresstoOralFeedingsInadequatePNSupplementationAdequateProgresstoMoreComplexDietandOralFeedingsAsToleratedProgresstoTotalEnteralFeedingsNormalCompromisedNoYesDecisiontoInitiateSpecializedNutritionSupportRef：JPEN17（Suppl4）：7SA,1993第3頁/共49頁靜脈營養(yǎng)建議攝取量CriticallyIll(Stress)StableFormulag/L

(葡萄糖-A.A.-Fat)150-50-30150/200-40-30蛋白質(zhì)g/kg/d1-1.50.8–1.0糖類mg/kg/min2-3.54-5脂肪g/kg/d11-2總熱量kcal/kg/d25–3030-35水分mL/kg/dMin.needed30-40ASPENnutritionsupportpracticemanual9-2,1998MaintenancelevelsofelectrolytesStandarddosesofmultivitaminsandtraceelements第4頁/共49頁ProteinRequirements

（forAdultPatients）

1.15–25﹪ofTotalCalories2.Non-proteinCalorietoNitrogenRatio

80-100kcal：1/gm.NSevereStress

150-200kcal：1/gm

.NModerateStress3.Nutritionalvs.MetabolicSupport

22ndClinicalCongress,ASPEN1998第5頁/共49頁GlucoseRequirementInitialTPN:100-150gm（or200gm）Canbeincreasedby50-75gm/d

(bloodglucoselevelsarestablebutlessthan200mg/dl)

themaximumglucoseinfusionratebe4mg/kg/min(22-25Kcal/kg/day)Ref：1.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001第6頁/共49頁FatRequirements

Maximumcapacity：1.0-2.0gm/kg/day

Criticallyillthemaximumrecommended

infusionrate：1.0gm/kg/day

10-25﹪oftotalcalories

Runfatinitiallyat1ml/min×15-30min

2-4﹪oftotalcaloriesmustbefromEFA22ndClinicalCongress,ASPEN1998第7頁/共49頁

ElectrolytesRequirements

forAdultPatients

1.Sodium30–55mEq/liter2.Potassium60–90mEq/day3.Chloride30–55mEq/liter4.Calcium6–12mEq/day5.Magnesium16–20mEq/day6.Acetate45–70mEq/day7.Phosphorus18–28mM/dayRef：a.Maxwell＆Kleeman,sClinicalDisordersofFluidandElectrolyteMetabolism,5th,1994.b.AllinI.Arieff,M.D.Fluid,Electrolyte,andAcid-BaseDisorders.2ndEd1995.第8頁/共49頁VitaminsAdultRDAinUSAAMARecommendedRecommendationFortheCriticallyIllVitaminA（IU）VitaminD（IU）4000-500040033002002500–10000400VitaminE（IU）VitaminC（mg）12-154510.0100.04001000Folicacid（mcg）Niacin（mg）40012-20400.040.02000200VitaminB2（mg）VitaminB1（mg）1.1–1.81.0–1.53.63.01010VitaminB6（mg）VitaminB12（mcg）1.6–2.034.05.02020mgPantothenicacid（mg）Biotin（mcg）5–10150-30015.060.01005mgVitaminK（mg）1.1–10mg/wk2.Antibiotics–10mg/3-4daysVitaminFormulation

ForChildrenAged11Years,OlderandAdults第9頁/共49頁EssentialTraceElements

AMA/NAGSuggestedDailyIVIntakeElementStableAcuteCatabolicGILossesZn2.5–4.0mgAdditional2mgAdd12.2mg/LsmallBowelfluidlost；17.1mg/kgofstoolorileostomyoutputCu0.5–1.5mg--Cr10–15mcg-20mcgMn1.15–0.8mg--第10頁/共49頁MetabolicComplicationsofPNSteatosisCholestasis,GallbladderStasis,andCholelithiasisGastrointestinalAtrophyGastricHypersecretionandHyperacidityMacronutrientrelatedComplicationsOverfeedingRefeedingsyndrome第11頁/共49頁MetabolicComplicationsofPN

SteatosisWithin1-2weeksafterinitiationofPNElevationsofSerumaminotransferases,alkalinephosphataseandbilirubinFattyinfiltrationoflivercells

Continuousglucoseand/orexcessivecalorieloadsResolvesin10-15days第12頁/共49頁MetabolicComplicationsofPN

Cholestasis,GallbladderStasis,andCholelithiasisMayoccur2-6wksafterinitiationPNProgressiveincreasetotalbilirubinandserumalkalinephosphataseminimizetheriskCyclicPNRestrictinofcarbohydrate,AvoidanceofoverfeedingEarlyenteralstimulation

第13頁/共49頁MetabolicComplicationsofPN

GastrointestinalAtrophyLackofenteralstimulationcause

villushypoplasiaColonicmucosalatropyDecreasegastricfunctionImpairedGIimmunityBacterialovergrowthBacterialtranslocationInitiateenteralfeedingsassoonaspossible第14頁/共49頁MetabolicComplicationsofPN

GastricHypersecretionandHyperacidityGastricsecretionsdirectlyrelatedtotheamountofsmallbowelresectedPepticulcerationsandhemorrhagicgastritisHistamineH2receptorantagonistsareusedtodecreasegastricoutputAddeddirectlytothePNsolution第15頁/共49頁適當(dāng)靜脈營養(yǎng)支持注意要點預(yù)防高血糖癥

血糖的穩(wěn)定

電解質(zhì)的平衡

鉀、鎂、磷的監(jiān)測酸鹼平衡NutritionSupportOverfeedingRespiratoryAcidosisParenteralNutritionAcidosisMetabolicAcidosis避免靜脈營養(yǎng)停止時的低血糖癥J.Nutrition1999:129.290S-294S第16頁/共49頁SystemicInflammatoryResponseSyndrome(SIRS)CurrentOpinioninClinicalNutritionandMetabolicCare1999,2:69-78抑制centralInsulinactionIncreasegluconeogenesisPeripheralinsulinresistanceReduceuptakeofglucoseSignificanthyperglycemiaOP2468101214161820PostoperativeDayRelativeinsulinsensitivity(%)10080604020第17頁/共49頁胰島素於玻璃瓶PVC及靜脈管的吸附作用Anesthesiology40:4,400-404,1974RLGLASSRLPVCD5RLGLASSD5RLPVC05101520MINUTES2030405060%INSULINLOSS第18頁/共49頁

Hyperglycemiaa.Hyperosmolarstateb.Osmoticdiuresisc.Dehydrationd.Immunosuppression

Hepaticsteatosis

Ventilatoryalterations

IncreasedrestingenergyexpenditureRef：1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.ThePotentialHazardsofOverfeeding

Glucose第19頁/共49頁ThePotentialHazardsofOverfeeding

LipidTG<250mg/dl4hrsafterlipidinfusionforpiggybackedlipidsand<400mg/dlforcontinuouslipidinfusion

Immunosuppression（RESBlockade）IncreasedprostaglandinproductionHypercholesterolemiaHyperlipidemiaImpairedliverfunctionVentilatoryalterationsReducingthedoseand/orlengtheningtheinfusiontimeRef：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.第20頁/共49頁ThePotentialHazardsofOverfeeding

AminoAcid

UreagenesisHyperchloremicacidosisVentilatoryalterationsIncreasedrestingenergyexpenditure1.NutritionSupportTheoryandTherapeutics1stEd,P471；19972.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.

第21頁/共49頁MetabolicComplicationsandTreatment

Hyperglycemia1.Slowinfusionrate2.Giveinsulin

0.1Uofinsulin/gofdextrose/liter3.Increasefatemulsiontherapy第22頁/共49頁RefeedingSyndromeCardiacinsuficiencyperipheraledemahyertensionExcessglucoseHyperglycemiaHypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCriticalCare.1994第23頁/共49頁TPNorPPN?第24頁/共49頁全靜脈營養(yǎng)的適應(yīng)癥

TotalParenteralNutrition營養(yǎng)有危機(jī)的人體重過輕的病人短時間內(nèi)體重下降超過10%有10天以上無法經(jīng)口進(jìn)食胃腸道消化吸收有困難嚴(yán)重外傷、燒傷嚴(yán)重敗血癥第25頁/共49頁

HicaliqITeruAmino12X

HicaliqIITeruAmino12XStress-II一天1.5袋總液量ml120012001800總熱量Kcal80710271541

Glucosegm140206309

Xylitolgm252537.5

AminoAcidgm56.856.885.2

NamEq7575112.5

KmEq303045

CamEq8.58.512.75

MgmEq101015

ClmEq7575112.5

AcetatemEq252537.5

PmM4.854.857.28

Znmg0.70.71.05併總液量ml10﹪250ml145010﹪250ml145010﹪250ml2050ml用總熱量Kcal108013021816脂Non-ProteinKcal85510751475肪Non-PKcal/N94118108第26頁/共49頁

STD-ISTD-II

總液量ml1900一日2袋1900一日1袋總熱量Kcal12871727

Glucosegm282411

Xylitolgm2525

AminoAcidgm56.856.8

Non-ProteinKcal10601500

Non-ProteinK/N117165

NamEq7575

KmEq6060

CamEq1717

MgmEq2020

ClmEq7575

AcetatemEq5050

PmM9.79.7

Znmg1.41.4併總液量ml20﹪250ml215010﹪250ml2150用總熱量Kcal17872002脂Non-ProteinKcal15601775肪Non-ProteinK/N172195第27頁/共49頁GuidelinesforNutritionalTherapyinLiverDiseaseProteingm/kg/dEnergyKcal/kg/d﹪CHO﹪FatNutritionalGoalHepatits

－acuteorchronic1.0-1.530-4067-8020-33－Preventmalnutrition－EnhanceregenerationCirrhosis－uncomplicated1.0-1.530-4067-8020-33－SameasaboveCirrhosis-complicatedMalnutritionCholestasis1.0-1.81.0-1.540-5030-407273-802820-27－Restorenormalnutritionalstatus－Preventmalnutrition－TreatfatmalabsorptionEncephalopathy

Grade1or2Grade3or40.5-1.20.525-4025-4075752525－Providenutritionalneeds

withoutprecipitatingencephalopathy第28頁/共49頁RecommendedmacronutrientintakeforpatientswithARF＆CRFrequiringNS

ARForCRF

Patients（HDtreatmentsaboutthreetimes/week）

CVVH/CVVHD（inhypercatabolicARForCRFpatients）ProteinorAminoacidAbout1.2g/kg/dofmixedessentialandnonessentialaminoacidsorprotein1.5–2.5g/kg/dofmixedessentialandnonessentialaminoacidsorproteinEnergy30–45kcal/kg/d30–45kcal/kg/dFat（﹪oftotalenergy）20-30﹪ifnotseptic20-30﹪ifnotsepticWaterAstoleratedAstolerated第29頁/共49頁

病人預(yù)期NPO5-7天不適當(dāng)?shù)奈改c功能維持在5-7天

轉(zhuǎn)移至口服管灌期中央靜脈輸入是禁忌時

營養(yǎng)不良病患

預(yù)期須給予數(shù)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(zhì)的須求時PPN的適應(yīng)癥第30頁/共49頁全靜脈營養(yǎng)與周邊靜脈營養(yǎng)5.7%嚴(yán)重的併發(fā)癥包括動脈出血及氣胸9%導(dǎo)管性併發(fā)癥包括導(dǎo)管移除的未注意及中央靜脈栓塞6.5%與中央靜脈導(dǎo)管有關(guān)的菌血癥Payne-James,JPEN1993;17:468-478TPN的問題全靜脈營養(yǎng)的第一選擇：周邊靜脈營養(yǎng)路徑第31頁/共49頁

無法或不必要用下腔頸靜脈插管提供高滲透壓溶液時

因菌血癥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(yè)人員周邊靜脈營養(yǎng)PeripheralParenteralNutritionPPN輕度至中度營養(yǎng)缺乏無法經(jīng)口服或不易經(jīng)由中央靜脈輸入或不需要時的一種有效的營養(yǎng)支持療法第32頁/共49頁ProteinSparingEffect胰島素葡萄糖肝醣胺基酸蛋白質(zhì)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.JClinNtutr,1974:27:175-187第33頁/共49頁TheImportance:hypocaloricPPNSupport

SufficientProteininPostoperativeTheregimenofpartialPNsupportisbetterinachieving1.Lessnegativenitrogenbalance2.Improvedvisceralproteinlevels3.Greatertotallymphocytecount

Proteinsourcecontributionatleast1g/kg/dayRef：Tsann-LongHwangetal,JPEN：1993；Vol17,No.3P254-256第34頁/共49頁Glycal-Amin(3%AminoAcidand3%GlycerininjectionwithElectrolytes)第35頁/共49頁P<0.02氮平衡/4日

Glycal-Amin?一般氨基酸加電解質(zhì)0-55-1010顯著的正氮平衡Freeman:Surgery,Gyn&Obs.Vol.156:p625-631,19833%AminoAcidand3%GlycerininjectionwithElectrolytes第36頁/共49頁32112345123454080120160200240胰島素依賴型糖尿病非胰島素依賴型糖尿病一般氨基酸+葡萄糖Glycal-Amindaysdays1234512345PlasmaGlucose,mg/dlDoseofinsulinI.V.,U/h

不依賴胰島素抗酮體穩(wěn)定血糖避免體液流失減少併發(fā)癥Glycal-AminA.LevRan:JPEN11:271-274,1987PeripharalTPN第37頁/共49頁682718N=41P<0.001葡萄糖基劑的PPNGlycal-Amin?一般靜脈注射(生理食鹽水)靜脈炎之比較50100EricB.Rypin:TheAm.J.ofSurg.159,p222-225,19903%AminoAcidand3%GlycerininjectionwithElectrolytes第38頁/共49頁碳水化合物的代謝障礙37%的癌癥病人血糖不耐性問題Cachexia不正常葡萄糖耐受性飢餓狀態(tài)下的血糖可以上昇維持至110-120mg/dl控制葡萄糖利用的GLUT-4Transporter受損持續(xù)減低的葡萄糖利用率NutritionalOncology1999Chapter36p.519-536第39頁/共49頁癌癥惡體質(zhì)的糖類代謝J.Am,CollegeofNutrition445-456,1992第40頁/共49頁葡萄糖利用性不良A.S.P.E.N.23rdClinicalC