靜脈營養(yǎng)的臨床應用培訓課件

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胃腸功能恢復標準配方特殊配方(Obstruction,peritonitis,intractablevomiting,acutepancreatitis,short-bowelsyndrome,ileus)短期

NasogastricNasoduodenalNasojejunal長期

GastrostomyJejunostomyNutrientToleranceAdequateProgresstoOralFeedingsInadequatePNSupplementationAdequateProgresstoMoreComplexDietandOralFeedingsAsToleratedProgresstoTotalEnteralFeedingsNormalCompromisedNoYesDecisiontoInitiateSpecializedNutritionSupportRef：JPEN17（Suppl4）：7SA,1993ClinicalDecisionAlgorithm

營養(yǎng)1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靜脈營養(yǎng)建議攝取量CriticallyIllSta2ProteinRequirements

（forAdultPatients）

1.15–25﹪ofTotalCalories2.Non-proteinCalorietoNitrogenRatio

80-100kcal：1/gm.NSevereStress

150-200kcal：1/gm

.NModerateStress3.Nutritionalvs.MetabolicSupport

22ndClinicalCongress,ASPEN1998ProteinRequirements3GlucoseRequirementInitialTPN:100-150gm（or200gm）Canbeincreasedby50-75gm/d

(bloodglucoselevelsarestablebutlessthan200mg/dl)

themaximumglucoseinfusionratebe4mg/kg/min(22-25Kcal/kg/day)Ref：1.TheASPENNutritionSupportPracticeManual.19982.ContemporaryNutritionSupportPractice.19983.ClinicalNutritionParenteralNutrition3Edition;2001GlucoseRequirementInitialTPN4FatRequirements

Maximumcapacity：1.0-2.0gm/kg/day

Criticallyillthemaximumrecommended

infusionrate：1.0gm/kg/day

10-25﹪oftotalcalories

Runfatinitiallyat1ml/min×15-30min

2-4﹪oftotalcaloriesmustbefromEFA22ndClinicalCongress,ASPEN1998FatRequirementsMaximumcap5

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.ElectrolytesRequirements6VitaminsAdultRDAinUSAAMARecommendedRecommendationFortheCriticallyIllVitaminA（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,OlderandAdultsVitaminsAdultRDA7EssentialTraceElements

AMA/NAGSuggestedDailyIVIntakeElementStableAcuteCatabolicGILossesZn2.5–4.0mgAdditional2mgAdd12.2mg/LsmallBowelfluidlost；17.1mg/kgofstoolorileostomyoutputCu0.5–1.5mg--Cr10–15mcg-20mcgMn1.15–0.8mg--EssentialTraceElements

AMA/N8MetabolicComplicationsofPNSteatosisCholestasis,GallbladderStasis,andCholelithiasisGastrointestinalAtrophyGastricHypersecretionandHyperacidityMacronutrientrelatedComplicationsOverfeedingRefeedingsyndromeMetabolicComplicationsofPNS9MetabolicComplicationsofPN

SteatosisWithin1-2weeksafterinitiationofPNElevationsofSerumaminotransferases,alkalinephosphataseandbilirubinFattyinfiltrationoflivercells

Continuousglucoseand/orexcessivecalorieloadsResolvesin10-15daysMetabolicComplicationsofPN

10MetabolicComplicationsofPN

Cholestasis,GallbladderStasis,andCholelithiasisMayoccur2-6wksafterinitiationPNProgressiveincreasetotalbilirubinandserumalkalinephosphataseminimizetheriskCyclicPNRestrictinofcarbohydrate,AvoidanceofoverfeedingEarlyenteralstimulation

MetabolicComplicationsofPN

11Glycal-Amin提供氨基酸、碳水化合物及電解質(zhì)1900一日2袋Non-proteinCalorietoNitrogenRatioMayoccur2-6wksafterinitiationPNDoseofinsulinI.足夠的營養(yǎng)以維持其生命150/200-40-3030–45kcal/kg/dNModerateStress使用甘油而非葡萄糖為熱量來源10﹪250ml1450無法或不必要用下腔頸靜脈插管Potassium60–90mEq/dayInitialTPN:100-150gm（or200gm）可以上昇維持至110-120mg/dl1900一日1袋Compromisedvomiting,acutepancreatitis,short-避免因SIRS引起的高血糖癥MetabolicComplicationsofPN

GastrointestinalAtrophyLackofenteralstimulationcause

villushypoplasiaColonicmucosalatropyDecreasegastricfunctionImpairedGIimmunityBacterialovergrowthBacterialtranslocationInitiateenteralfeedingsassoonaspossibleGlycal-AminMetabolicComplicat12MetabolicComplicationsofPN

GastricHypersecretionandHyperacidityGastricsecretionsdirectlyrelatedtotheamountofsmallbowelresectedPepticulcerationsandhemorrhagicgastritisHistamineH2receptorantagonistsareusedtodecreasegastricoutputAddeddirectlytothePNsolutionMetabolicComplicationsofPN

13適當靜脈營養(yǎng)支持注意要點預防高血糖癥

血糖的穩(wěn)定

電解質(zhì)的平衡

鉀、鎂、磷的監(jiān)測酸鹼平衡NutritionSupportOverfeedingRespiratoryAcidosisParenteralNutritionAcidosis

MetabolicAcidosis避免靜脈營養(yǎng)停止時的低血糖癥J.Nutrition1999:129.290S-294S適當靜脈營養(yǎng)支持注意要點預防高血糖癥J.Nutriti14SystemicInflammatoryResponseSyndrome(SIRS)CurrentOpinioninClinicalNutritionandMetabolicCare1999,2:69-78抑制centralInsulinactionIncreasegluconeogenesisPeripheralinsulinresistanceReduceuptakeofglucoseSignificanthyperglycemiaOP2468101214161820PostoperativeDayRelativeinsulinsensitivity(%)10080604020SystemicInflammatoryResponse15胰島素於玻璃瓶PVC及靜脈管的吸附作用Anesthesiology40:4,400-404,1974RLGLASSRLPVCD5RLGLASSD5RLPVC05101520MINUTES2030405060%INSULINLOSS胰島素於玻璃瓶PVC及靜脈管的吸附作用Anesthesiol16

Hyperglycemiaa.Hyperosmolarstateb.Osmoticdiuresisc.Dehydrationd.Immunosuppression

Hepaticsteatosis

Ventilatoryalterations

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

GlucoseHyperglycemiaRef：1.Nutriti17ThePotentialHazardsofOverfeeding

LipidTG<250mg/dl4hrsafterlipidinfusionforpiggybackedlipidsand<400mg/dlforcontinuouslipidinfusion

Immunosuppression（RESBlockade）IncreasedprostaglandinproductionHypercholesterolemiaHyperlipidemiaImpairedliverfunctionVentilatoryalterationsReducingthedoseand/orlengtheningtheinfusiontimeRef：1.TheMetabolicHazardsofOverfeedingCriticallyIllPatients,ASPEN,1997.ThePotentialHazardsofOverf18ThePotentialHazardsofOverfeeding

AminoAcid

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

ThePotentialHazardsofOverf19MetabolicComplicationsandTreatment

Hyperglycemia1.Slowinfusionrate2.Giveinsulin

0.1Uofinsulin/gofdextrose/liter3.IncreasefatemulsiontherapyMetabolicComplicationsandTr20RefeedingSyndromeCardiacinsuficiencyperipheraledemahyertensionExcessglucoseHyperglycemiaHypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCriticalCare.1994RefeedingSyndromeCardiacinsu21TPNorPPN?TPNorPPN?221900一日1袋Glycal-Amin?Kern&Norton:JPEN;1988.Znmg總液量mlRefeedingsyndrome1–10mg/wkAdultRDAinUSAExcessglucoseAsTolerated30–45kcal/kg/dGastrointestinalAtrophy1mg/kgofstoolorileostomyoutputHyperglycemia290S-294SProgresstohyertensionGuidelinesforNutritionalTherapyinLiverDisease－EnhanceregenerationRecommendedmacronutrientintakeforpatientswithARF＆CRFrequiringNS全靜脈營養(yǎng)的適應癥

TotalParenteralNutrition營養(yǎng)有危機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)口進食胃腸道消化吸收有困難嚴重外傷、燒傷嚴重敗血癥1900一日1袋全靜脈營養(yǎng)的適應癥

TotalPa23

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/N94118108HicaliqIT24

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/N172195STD-ISTD-II總液量25GuidelinesforNutritionalTherapyinLiverDiseaseProteingm/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

withoutprecipitatingencephalopathyGuidelinesforNutritionalThe26RecommendedmacronutrientintakeforpatientswithARF＆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﹪ifnotsepticWaterAstoleratedAstoleratedRecommendedmacronutrientinta27

病人預期NPO5-7天不適當?shù)奈改c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(yǎng)不良病患

預期須給予數(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的適應癥病人預期NPO5-7天PPN的適應癥28全靜脈營養(yǎng)與周邊靜脈營養(yǎng)5.7%嚴重的併發(fā)癥包括動脈出血及氣胸9%導管性併發(fā)癥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)路徑全靜脈營養(yǎng)與周邊靜脈營養(yǎng)5.7%嚴重的併發(fā)癥Payne-Ja29

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)支持療法無法或不必要用下腔頸靜脈插管周邊靜脈營養(yǎng)PPN30ProteinSparingEffect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,1974:27:175-187ProteinSparingEffect胰島素葡萄糖肝醣31TheImportance:hypocaloricPPNSupport

SufficientProteininPostoperativeTheregimenofpartialPNsupportisbetterinachieving1.Lessnegativenitrogenbalance2.Improvedvisceralproteinlevels3.Greatertotallymphocytecount

Proteinsourcecontributionatleast1g/kg/dayRef：Tsann-LongHwangetal,JPEN：1993；Vol17,No.3P254-256TheImportance:hypocaloricPP32Glycal-Amin(3%AminoAcidand3%GlycerininjectionwithElectrolytes)Glycal-Amin33P<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%GlycerininjectionwithElectrolytesP<0.02氮平衡/4日Glycal-Amin?一般氨基3432112345123454080120160200240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:JPEN11:271-274,1987PeripharalTPN32112345123454080120160200240胰35682718N=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%GlycerininjectionwithElectrolytes682718N=41葡萄糖Glycal-Amin?一般靜脈注36HyperchloremicacidosisProteinSparingEffect總液量mlMetabolicComplicationsandTreatment

Hyperglycemia提供氨基酸、碳水化合物及電解質(zhì)20-30﹪ifnotseptic20-30﹪ifnotseptic150/200-40-30CentralPNProteinsourcecontributionatleast1g/kg/dayAMARecommendedGlycal-Amin避免因SIRS引起的高血糖癥Potassium60–90mEq/dayAddeddirectlytothePNsolution－uncomplicatedGrade3or4Progressto30–45kcal/kg/dPlasmaGlucose,mg/dl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.519-536Hyperchloremicacidosis碳水化合物的代37癌癥惡體質(zhì)的糖類代謝J.Am,CollegeofNutrition445-456,1992癌癥惡體質(zhì)的糖類代謝J.Am,CollegeofNut38葡萄糖利用性不良葡萄糖利用性不良39宿主CytokineProduction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(zhì)合成肌肉合成分解氨基酸脂肪酸氨基酸?Proposedmechanismofcancercachexia無氧反應(-2ATP)Coricycle(-4ATP)TCACycle(-36ATP)Lossmore300Kcal/dayKern&Norton:JPEN;1988.12:287宿主腦無食慾?脂肪酸脂肪脂肪酸甘油釋出腫瘤乳酸葡萄糖肝40

Premixed,ready-touse,peripheralIVnutritionsupport

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(zhì)(包括鈉、鉀、鎂、鈣、鏻等)735mOsm/LGlycal-Amin3%aminoacid3%glycerolwithelectrolytesPremixed,ready-touse,Glyca412L+500mL10%脂肪乳3L/+500mL20%脂肪乳總熱量1,0401,735蛋白質(zhì)(克)5887脂肪(克)50100鈉(mEq)70105鉀(mEq)4872鎂(mEq)1015鈣(mEq)69氯(mEq)82123磷(mmol)14.518醋酸(mEq)94141提供類似TPN的完整靜脈營養(yǎng)KennethWaxman:JPEN16:p374-378,19922L+500mL10%脂肪乳3L/+500mL20%脂肪乳42安全、方便、經(jīng)濟J.Payne-James:JPEN1993;17:468-478FirstChoiceforTotalParenteralNutrition:ThePeripheralRoute全靜脈營養(yǎng)的第一選擇：周邊靜脈營養(yǎng)路徑安全、方便、經(jīng)濟J.Payne-James:JPEN143Glycal-Amin?3%AminoAcidand3%GlycerinInjectionWithElectrolytes

已預混合PPN減少藥局調(diào)製時間減少汙染的發(fā)生容易處方醫(yī)護人員操作方便經(jīng)濟

較TPN少併發(fā)癥較TPN價格便宜減低高血糖素癥有無infusionpump均可使用不須要tapering安全、方便、經(jīng)濟Glycal-Amin?已預混合PPN較TPN少併發(fā)癥安全44

糖尿病與癌癥病患維持與穩(wěn)定血糖

COPD病患

避免Pulmonarystress

避免因SIRS引起的高血糖癥避免TPN結束時的低血糖癥Glycal-Amin?3%AminoAcidand3%GlycerininjectionwithElectrolytes糖尿病與癌癥病患Glycal-Amin?45藥師龐振宜營養(yǎng)是生命的泉源永遠是要考慮到必須給予病患足夠的營養(yǎng)以維持其生命藥師龐振宜營養(yǎng)是生命的泉源永遠是要考慮到46TPNorPPN?bowelsyndrome,ileus)Non-ProteinKcalPeripharalTPNPmMa.UreagenesisCentralPNGuidelinesforNutritionalTherapyinLiverDiseaseImpairedGIimmunity735mOsm/LGlycal-Amin?Formulag/LVentilatoryalterationsPeripheralParenteralNutritionZnmgDecisiontoInitiateSpecializedNutritionSupportRunfatinitiallyat1ml/min×15-30minHyperchloremicacidosis1900一日1袋nutritionalstatusperipheralIVnutritionsupport永遠是要考慮到必須給予病患足夠的營養(yǎng)以維持其生命EcheniqueMM;NutritioninClinicalPractice1999;14:p36-37TPNorPPN?永遠是要考慮到必須給予病患Echen47ClinicalDecisionAlgorithm

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胃腸功能恢復標準配方特殊配方(Obstruction,peritonitis,intractablevomiting,acutepancreatitis,short-bowelsyndrome,ileus)短期

NasogastricNasoduodenalNasojejunal長期

GastrostomyJejunostomyNutrientToleranceAdequateProgresstoOralFeedingsInadequatePNSupplementationAdequateProgresstoMoreComplexDietandOralFeedingsAsToleratedProgresstoTotalEnteralFeedingsNormalCompromisedNoYesDecisiontoInitiateSpecializedNutritionSupportRef：JPEN17（Suppl4）：7SA,1993ClinicalDecisionAlgorithm

營養(yǎng)48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靜脈營養(yǎng)建議攝取量CriticallyIllSta49RefeedingSyndromeCardiacinsuficiencyperipheraledemahyertensionExcessglucoseHyperglycemiaHypokalemiaHypophosphatemiahypomagnesemiaRef：NutritioninCriticalCare.1994RefeedingSyndromeCardiacinsu50TPNorPPN?TPNorPPN?51

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

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