靜脈營養(yǎng)的臨床應(yīng)用(已修改)
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【正文】 靜脈營養(yǎng)的臨床應(yīng)用 Parenteral Nutrition ? 營養(yǎng)評估與營養(yǎng)需求 ? 靜脈營養(yǎng)支持注意要點(diǎn) ? 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 Clinical Decision Algorithm 營養(yǎng)評估 消化道功能 Yes No 腸道營養(yǎng) 胃腸功能 靜脈營養(yǎng) 短期 長期或須限水時(shí) Peripheral PN Central PN 胃腸功能恢復(fù) 標(biāo)準(zhǔn)配方 特殊配方 (Obstruction, peritonitis, intractable vomiting, acute pancreatitis, short bowel syndrome, ileus) 短期 Nasogastric Nasoduodenal Nasojejunal 長期 Gastrostomy Jejunostomy Nutrient Tolerance Adequate Progress to Oral Feedings Inadequate PN Supplementation Adequate Progress to More Complex Diet and Oral Feedings As Tolerated Progress to Total Enteral Feedings Normal Compromised No Yes Decision to Initiate Specialized Nutrition Support Ref： JPEN 17 （ Suppl 4）： 7 SA, 1993 靜脈營養(yǎng) 建議攝取量 Critically Ill (Stress) Stable Formula g/L (葡萄糖 Fat) 1505030 150/2004030 蛋白質(zhì) g/kg/d 1 – 糖類 mg/kg/min 2 4 5 脂肪 g/kg/d 1 12 總熱量 kcal/kg/d 25 –30 30 35 水分 mL/kg/d Min. needed 30 40 ASPEN nutrition support practice manual 92, 1998 ?Maintenance levels of electrolytes ?Standard doses of multivitamins and trace elements Protein Requirements （ for Adult Patients） 1. 15 – 25 ﹪ of Total Calories 2. Nonprotein Calorie to Nitrogen Ratio 80 100 kcal ： 1 / gm . N Severe Stress 150 200 kcal ： 1 / gm . N Moderate Stress 3. Nutritional vs. Metabolic Support 22nd Clinical Congress, ASPEN 1998 Glucose Requirement ? Initial TPN : 100150 gm （ or 200gm） ? Can be increased by 5075 gm/d (blood glucose levels are stable but less than 200 mg/dl) ? the maximum glucose infusion rate be 4 mg/kg/min (2225Kcal/kg/day) Ref： 1. The ASPEN Nutrition Support Practice Manual. 1998 2. Contemporary Nutrition Support Practice. 1998 3. Clinical Nutrition Parenteral Nutrition 3 Edition。 2022 Fat Requirements ? Maximum capacity： gm/kg/day ? Critically ill the maximum remended infusion rate： gm/kg/day ? 1025﹪ of total calories ? Run fat initially at 1 ml/min 1530 min ? 24﹪ of total calories must be from EFA 22nd Clinical Congress, ASPEN 1998 Electrolytes Requirements 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/day Ref： a. Maxwell ＆ Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism ,5th , 1994 . b. Allin I. Arieff , . Fluid, Electrolyte, and AcidBase Disorders . 2nd Ed 1995 . Vitamins Adult RDA in USA AMA Remended Remendation For the Critically Ill Vitamin A（ IU） Vitamin D（ IU） 4000 5000 400 3300 200 2500 – 10000 400 Vitamin E（ I
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