Transcript Practice Guidelines Malnutrition A.S.P.E.N. BOARD OF DIRECTORS

標 準 化 T P N 處 方
臨 床 應 用
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Indications for TPN therapy
Design of TPN regimen
Metabolic complications and treatments
Peripheral Parenteral nutritional support
藥師 龐振宜
Practice Guidelines Malnutrition
A.S.P.E.N. BOARD OF DIRECTORS
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Inadequate nutrient for ≧ 7 days
Weight loss ≧ 10 ﹪
口服無法維持適當營養需先考慮給予管灌方式
Enteral tube feeding and PN should be combined
Parenteral nutrition should be used alone
1. PN support cannot, should not, or will not eat adequately
to maintain their nutrient stores.
2. PPN may be used in selected patients
3. TPN support is necessary
JPEN 17（Ssuppl 4）：6 SA,1993
Practice Guidelines Parenteral Nutrition
（PPN used in selected patients）
• a. Partial or total nutrition support for up
to 2 weeks in patients
• b. Who cannot ingest or absorb oral nutrients
• c. When central parenteral nutrition
is not feasible.
J P E N 17 （Suppl 4）：10 SA, 1993.
Practice Guidelines Parenteral Nutrition
（T P N support ）
• a. Parenteral feeding is indicated for
longer than 2 weeks
• b. Peripheral venous access is limited
• c. Nutrient needs are large
• d. Fluid restriction is required
• e. The benefits of TPN support outweigh
the risks.
Ref： J P E N 17 （Suppl 4）：10 SA, 1993.
A Standardized PN Sol,n： Rx, Use, Processing,
and Material Cost Implications
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73 ﹪of pt,s receiving standardized TPN solution
Prescribing error frequency was 0 ﹪
Decreased processing and compounding time by 55 ﹪
Decreased material cost by 19 ﹪
70﹪-80﹪of adult patients tolerate
standardized solutions without adverse
metabolic complications
Hospital Pharmacy, 21;July 1986
Suggested Nutrient intake for Adult
patients on PN
Critically Ill P’ts
Stable P’ts
Protein
1.2 - 1.5 g/kg/d
0.8 – 1.0
Carbohydrate
Not >4mg/kg/min
Not > 7mg/kg/min
Lipid
1g/kg/d
1g/kg/d
Total
Calories
Fluid
25 –30 kcal/kg/d
30 - 35 kcal/kg/d
Min. needed to delivery
adequate macronutrients
30 - 40 mL/kg/d
ASPEN nutrition support practice manual 9-2, 1998
Protein Requirements
（for Adult Patients）
1. 15 – 25 ﹪of Total Calories
2. Non-protein Calorie to Nitrogen Ratio
80 - 100 kcal ： 1 / gm . N Severe Stress
150 - 200 kcal ： 1 / gm . N Moderate St
3. Nutritional vs. Metabolic Support
22nd Clinical Congress, ASPEN 1998
Non-Protein Calories Requirements
（G l u c o s e）
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1. Maximum capacity：
7 mg/kg/min or 10 gm/kg/day
2. Optimal infusion rate：
4 mg/kg/min or 5.76 gm/kg/day
3. Critically ill the recommended infusion
rate： 5 gm/kg/day
4. 50-60﹪of total calories
22nd Clinical Congress, ASPEN 1998
Non-Protein Calories Requirements
（F a t）
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1. Maximum capacity：
1.0-2.0 gm/kg/day
2. Critically ill the maximum recommended
infusion rate：1.0 gm/kg/day
3. 10-25﹪of total calories
4. Run fat initially at 1 ml/min × 15-30 min
5. 2-4﹪of total calories must be from EFA
22nd Clinical Congress, ASPEN 1998
Electrolytes Requirements for Adult Patients
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Sodium
Potassium
Chloride
Calcium
Magnesium
Acetate
Phosphorus
30 – 55
60 – 90
30 – 55
6 – 12
16 – 20
45 – 70
18 – 28
mEq/liter
mEq/day
mEq/day
mEq/day
mEq/day
mEq/day
mM/day
Ref：a. Maxwell ＆ Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism ,5th , 1994 .
b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed 1995 .
Vitamin Formulation
For Children Aged 11 Years, Older and Adults
Adult RDA
in USA
AMA Recommended
Recommendation
For the Critically Ill
Vitamin A（IU）
Vitamin D（IU）
4000 - 5000
400
3300
200
2500 – 10000
400
Vitamin E（IU）
Vitamin C（mg）
12 - 15
45
10.0
100.0
400
1000
Folic acid（mcg）
Niacin（mg）
400
12 - 20
400.0
40.0
2000
200
Vitamin B2（mg）
Vitamin B1（mg）
1.1 – 1.8
1.0 – 1.5
3.6
3.0
10
10
Vitamin B6（mg）
Vitamin B12（mcg）
1.6 – 2.0
3
4.0
5.0
20
20 mg
Pantothenic acid（mg）
Biotin（mcg）
5 – 10
150 - 300
15.0
60.0
100
5 mg
Vitamins
Vitamin K（mg）
1. 1 – 10 mg/wk
2. Antibiotics – 10 mg/3-4days
Essential Trace Elements
NAG/AMA Suggested Daily IV Intake
Element
Stable
Acute Catabolic
GI Losses
Add 12.2 mg/L small
Bowel fluid lost；
17.1 mg/kg of stool or
ileostomy output
Zn
2.5 – 4.0 mg
Additional
2 mg
Cu
0.5 – 1.5 mg
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Cr
10 – 15 mcg
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20 mcg
Mn
1.15–0.8 mg
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適當靜脈營養支持注意要點:
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預防高血糖症
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電解質的平衡
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鉀、鎂、磷 的監測
酸鹼平衡
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血糖的穩定
Nutrition Support Overfeeding  Respiratory Acidosis
Parenteral Nutrition Acidosis  Metabolic Acidosis
避免靜脈營養停止時的低血糖症
J. Nutrition 1999: 129. 290S-294S
Guidelines to Maximize Benefits and
Minimize Complications of PN（1）
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1. Avoid calorie and glucose overload
a. 25 to 30 kcal/kg/day
b. 2 to 4 mg dextrose/kg/min
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2. Avoid fat overload
a. ≦ 30﹪of total energy requirements
b. Provide as a continuous infusion
Guidelines to Maximize Benefits and
Minimize Complications of PN（2）
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3. Avoid protein catabolism
a. 1.5 to 2.0 gm protein/kg/day
b. BCAA-enriched formulations may offer
- Hepatic encephalopathy and significant RF
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4. Avoid micronutrient deficiencies
a. 10 ml of MVI-12/day
b. 3 ml of trace minerals（MTE-5）
c. 10 mg Vitamin K/week
Ref：1. Cerra FB. Diet, nutrition and immunity, 1994：39-50
2. Nutrition Support Theory and Therapeutics , 1997
The Potential Hazards of Overfeeding
（1） Glucose
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1. Hyperglycemia
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Hyperosmolar state
Osmotic diuresis
Dehydration
Immunosuppression
2. Hepatic steatosis
3. Ventilatory alterations
4. Increased resting energy expenditure
Ref： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471；1997
2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.
The Potential Hazards of Overfeeding
（2） Lipid
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Immunosuppression （RES Blockade）
Increased prostaglandin production
Hypercholesterolemia
Hyperlipidemia
Impaired liver function
Ventilatory alterations
Ref： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471；1997
2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.
The Potential Hazards of Overfeeding
（3） Amino Acid
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1. Ureagenesis
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2. Hyperchloremic acidosis
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3. Ventilatory alterations
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4. Increased resting energy expenditure
1. Nutrition Support Theory and Therapeutics 1st Ed , P471；1997
2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.
Metabolic Complications and Treatment
（1）Hyperglycemia
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1. Slow infusion rate
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2. Give insulin
0.1 U of insulin /g of dextrose/liter
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3. Increase fat emulsion therapy
Peripheral – T P N
(Patient Criteria for P-TPN)
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1. Good venous access
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2. Mild to moderate stress
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3. Not fluid restricted
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4. Able to tolerate fat emulsion
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5. Expected to resume enteral feeding
within 5-7 days
PPN的適應症
病人預期NPO 5-7天
不適當的胃腸功能維持在5-7天
轉移至口服管灌期
中央靜脈輸入是禁忌時
營養不良病患
預期須給予數日的NPO
高新陳代謝性病患
使用PPN即可符合病患熱量及蛋白質的須求時
Glycal-Amin®
3% Amino Acid and 3% Glycerin injection with Electrolytes
能量提供
胰島素作用
呼吸係數
Respiratory
quotion
小靜脈刺激性
Glycerin
3.4kcal/克
4.3kcal/克
須依賴胰島素，產生葡萄糖不 體內代謝不須胰島素，無血
耐性
糖昇高問題
RQ=1 易產生 VCO2 增高，O2 RQ=0.87 較不易引起肺窘
耗氧量增加，引起肺窘迫
迫，適合肺功能不全患者
PH=5.0 滲透壓高，易引起靜 PH=6.5 滲透壓低，靜脈炎發
脈炎
熱安定性
Dextrose
生機率較低
不安定，與胺基酸引起褐化反 安定，可加熱滅菌，減少藥
應(Millard Reaction)
局混合時的污染
Glycal-Amin®
3% Amino Acid and 3% Glycerin injection with Electrolytes
 糖尿病與癌症病患
維持與穩定血糖
COPD病患
避免Pulmonary stress
 避免因SIRS引起的高血糖症
避免TPN結束時的低血糖症
Glycal-Amin®
3% Amino Acid and 3% Glycerin Injection With Electrolytes
安全、方便、經濟
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較TPN少併發症
較TPN價格便宜
減低高血糖症
有無infusion pump均可
使用
不須要tapering
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已預混合PPN
減少藥局調製時間
減少汙染的發生
容易處方
醫護人員操作方便
經濟
安全、方便、經濟
J. Payne-James: JPEN 1993; 17: 468-478
First Choice for Total Parenteral Nutrition:
The Peripheral Route
全靜脈營養的第一選擇：周邊靜脈營養路徑