手術(shù)前積極的給予7天以上之全靜脈營養(yǎng)支持totalparenteralnutrition課件

Caseconference-

Earlyfeedings/pgastrectomy萬芳醫(yī)院張靜怡營養(yǎng)師2005/11/221Caseconference-

Earlyfeeding手術(shù)前積極的給予7天以上之全靜脈營養(yǎng)支持(totalparenteralnutrition;TPN)，可降低手術(shù)後併發(fā)癥(如：感染率)發(fā)生率

(Ikedaetal.2004)2005/11/222CYC手術(shù)前積極的給予7天以上之2005/11/222CYCProtein-energymalnutritioninthegastrectomizedpatient

(Papim2002)2005/11/223CYCProtein-energymalnutritionin接受腹部手術(shù)後，儘早給予腸道營養(yǎng)支持(earlyenteralfeeding)與只是全靜脈營養(yǎng)支持方式比較，更有助於病患術(shù)後的恢復情況

(Huckleberry2004)EarlyenteralFeeding2005/11/224CYC接受腹部手術(shù)後，儘早給予EarlyenteralFeed早期經(jīng)由空腸造口給予之營養(yǎng)支持，可以提高免疫系統(tǒng)力降低感染發(fā)生率

(Papim2002)EarlyenteralFeeding2005/11/225CYC早期經(jīng)由空腸造口給予之營養(yǎng)支持，可以提高免疫系統(tǒng)力降低感染發(fā)

對於營養(yǎng)不良病患，給予空腸造口作為腸道營養(yǎng)餵食途徑，可避免在手術(shù)後避免因由口進食情況不佳，造成熱量及蛋白質(zhì)攝取不足，而影響傷口復原、延長住院天數(shù)與增加其感染發(fā)生率

(Papim2002)EarlyenteralFeeding2005/11/226CYC對於營養(yǎng)不良病患，給予空腸造口作為腸道營養(yǎng)餵食途徑，可TreatadverseeffectsofEEN1.Abdominalcramps:-tradedfirstwithnon-steroidanalgesicdrug(Cataflam,Relifex)-withopioidassecondchoice(Morphine)-infusionratereducedby20ml/h-temporarystoppedfor6-12hoursandresumedatalowerrate

2.Abdominalbloating:

-tradedfirstwithprokineticsdrugs(Gascon,Biofermin)-infusionratereducedby20ml/h-temporarystoppedfor6-12hoursandresumedatalowerrate(M.Bragaetal2002)2005/11/227CYCTreatadverseeffectsofEEN1.TreatadverseeffectsofEEN3.Vomiting:-treatedbytemporarystopofinfusionfollowedbydiagnosticprocedures-ifnointestinalobstructionwasdetected,

infusionwasresumedatthesamerate

4.Diarrhea:

-reductionofinfusionrateby20ml/h-temporarystopfor6-12handlaterwithresumptionatalowerrate-Inpatientwithpersistentdiarrhea,Clostridiumdifficileinfectionwasalwaysruledout(M.Bragaetal2002)2005/11/228CYCTreatadverseeffectsofEEN3.Casereport9Casereport9個案基本資料性別：男性

年齡：78歲(民國16年10月27日)身高：163.5公分入院體重：61.8公斤(BWloss20.8%)通常體重：78公斤(6monthsago)理想體重：595.9公斤BEE=1190kcal/dayTER=1700~1800kcal/dayPTreq.:73~80g/day2005/11/2210CYC個案基本資料性別：男性2005/11/2210C個案基本資料Medicationhistories：1.HTN2.OldCVA3.OldTB4.CRI5.PU(about3yearsago)6.Thalassemia(病患自述)2005/11/2211CYC個案基本資料Medicationhistories：20入院摘要入院時間：94/10/12科別：一般外科主訴癥狀：UGImassivebleeding(about2000c.c.)8daysagothenadmittedinTVGH(Dx:GastriccabyPES&CTstudy)診斷：Gastriccancer2005/11/2212CYC入院摘要入院時間：94/10/122005/11/2212COperationDate:94/10/18

Pre-Dx:GastriccancerClinicalfinding(10/13)

:

ulcerativetumoratLCS(mid-body)withinvasiontomesocolon5.5*4.5cmMethod:1.RadicalB-Ⅱsubtotalgastrectomy2.Cholecystectomy

3.Feedingjejunostomy

4.LNdissectionNo1,3,4,5,6,7Biopsy:1.Adenocarcinoma,intestinaltype2.LN→negativeformetasticcarcinoma2005/11/2213CYCOperationDate:94/10/182005/1NutritionsupportprogressDateTPNorderEnergy/AADate(Kcal/g)

EN

Energy/PT(Kcal/g)10/12A160c.c./hr+20%lipofundin200ml1399/5010/12NPO-10/14A260c.c./hr+20%lipofundin200ml1840/6310/13Astolerance

10/14

500/2010/1610/17CLDNPO10/19NPOED?srate20c.c./hr*18hr10/21A2300c.c./hr+20%lipofundin200ml10/20

10/21ED?s→FSrate30c.c./hr*18hr10/24TPNDC10/22

10/23-24rate40c.c./hr*18hrrate50c.c./hr→6010/24D10Wrun60c.c./hr

10/25

10/26

MD50c.c./hrDCOralTF(Jejunostomy)NPOOPdayon10/181385/32NPONPONPONPONPO25/1300/16540/28720/38800/42530/2210/28oral:CLD11/2Softdiet10/25Kabibenrun60c.c./hr500/01037/34Diarrhea12days2005/11/2214CYCNutritionsupportprogressDateTPN處方箋代碼品項Glucosegm/LAAgm/LElectrolyte(mEq/L)TPNA1Standard16335463712863771694TPNA2Highstress18744504015863677812TPNA3Hepaticfailure23938504015866047965TPNA4Renalfailure33323-------1224TPNB1Aminomix2005050301555100-1000NaKPMgCaClAcetateTotalKcal/LFatemulsion:20%Lipofundin100ml/BT20%Intralipid100ml/BT10%Lipovnous500ml/BTInfuvita(VitA,DE,B1,B2,B6,B12VitC,Niacin,Pathenol,Bioin,Folat)TraceelementZn,Cr,Cu,I,Mn2005/11/2215CYCTPN處方箋代碼品項GlucoseAAElectrolytNutritionsupport(Energy)EarlyenteralFeedingPPN+ENTPN+ENBEE

MBD11/710/26NPODiarrheaOPdayTER2005/11/2216CYCNutritionsupport(Energy)EarNutritionsupport(Protein)EarlyenteralFeedingPPN+ENTPN+ENPTreq.

MBD11/710/26NPOOPday2005/11/2217CYCNutritionsupport(Protein)EarNutritionStatus

OP(10/18)Admission10/19Alb1BTbid*2days2005/11/2218CYCNutritionStatusOPAdmissioNutritionStatus

OP(10/18)Admission1742005/11/2219CYCNutritionStatusOPAdmissioNitrogenBalance

OP(10/18)10/1210/1710/2510/312005/11/2220CYCNitrogenBalanceOP10/1210/NutritionStatus

OP(10/18)Admission11/20MBD(11/7)BWloss6.7%in2weeks2005/11/2221CYCNutritionStatusOPAdmissioNutritionStatus

OP(10/18)Admission2005/11/2222CYCNutritionStatusOPAdmissioHb(14-18)/Hct(42-52)

OP(10/18)10/1710/1910/2510/3111/32005/11/2223CYCHb(14-18)/Hct(42-52)ODiscussion

24Discussion24Diarrhea

配方轉(zhuǎn)換，適合嗎？元素→聚合？是否調(diào)整元素配方濃度或灌食速度可改善腹瀉情況？探討腹瀉原因？2005/11/2225CYCDiarrhea配方轉(zhuǎn)換，適合嗎？2005/11/2225胃切除手術(shù)後營養(yǎng)支持如何增加熱量與蛋白質(zhì)攝??？

飲食評估資料：Dietrecord體重追蹤Diarrheaorsteatorrhea2005/11/2226CYC胃切除手術(shù)後營養(yǎng)支持如何增加熱量與蛋白質(zhì)攝?。?005/11Thanksforyourattention27Thanksforyourattention27Caseconference-

Earlyfeedings/pgastrectomy萬芳醫(yī)院張靜怡營養(yǎng)師2005/11/2228Caseconference-

Earlyfeeding手術(shù)前積極的給予7天以上之全靜脈營養(yǎng)支持(totalparenteralnutrition;TPN)，可降低手術(shù)後併發(fā)癥(如：感染率)發(fā)生率

(Ikedaetal.2004)2005/11/2229CYC手術(shù)前積極的給予7天以上之2005/11/222CYCProtein-energymalnutritioninthegastrectomizedpatient

(Papim2002)2005/11/2230CYCProtein-energymalnutritionin接受腹部手術(shù)後，儘早給予腸道營養(yǎng)支持(earlyenteralfeeding)與只是全靜脈營養(yǎng)支持方式比較，更有助於病患術(shù)後的恢復情況

(Huckleberry2004)EarlyenteralFeeding2005/11/2231CYC接受腹部手術(shù)後，儘早給予EarlyenteralFeed早期經(jīng)由空腸造口給予之營養(yǎng)支持，可以提高免疫系統(tǒng)力降低感染發(fā)生率

(Papim2002)EarlyenteralFeeding2005/11/2232CYC早期經(jīng)由空腸造口給予之營養(yǎng)支持，可以提高免疫系統(tǒng)力降低感染發(fā)

對於營養(yǎng)不良病患，給予空腸造口作為腸道營養(yǎng)餵食途徑，可避免在手術(shù)後避免因由口進食情況不佳，造成熱量及蛋白質(zhì)攝取不足，而影響傷口復原、延長住院天數(shù)與增加其感染發(fā)生率

(Papim2002)EarlyenteralFeeding2005/11/2233CYC對於營養(yǎng)不良病患，給予空腸造口作為腸道營養(yǎng)餵食途徑，可TreatadverseeffectsofEEN1.Abdominalcramps:-tradedfirstwithnon-steroidanalgesicdrug(Cataflam,Relifex)-withopioidassecondchoice(Morphine)-infusionratereducedby20ml/h-temporarystoppedfor6-12hoursandresumedatalowerrate

2.Abdominalbloating:

-tradedfirstwithprokineticsdrugs(Gascon,Biofermin)-infusionratereducedby20ml/h-temporarystoppedfor6-12hoursandresumedatalowerrate(M.Bragaetal2002)2005/11/2234CYCTreatadverseeffectsofEEN1.TreatadverseeffectsofEEN3.Vomiting:-treatedbytemporarystopofinfusionfollowedbydiagnosticprocedures-ifnointestinalobstructionwasdetected,

infusionwasresumedatthesamerate

4.Diarrhea:

-reductionofinfusionrateby20ml/h-temporarystopfor6-12handlaterwithresumptionatalowerrate-Inpatientwithpersistentdiarrhea,Clostridiumdifficileinfectionwasalwaysruledout(M.Bragaetal2002)2005/11/2235CYCTreatadverseeffectsofEEN3.Casereport36Casereport9個案基本資料性別：男性

年齡：78歲(民國16年10月27日)身高：163.5公分入院體重：61.8公斤(BWloss20.8%)通常體重：78公斤(6monthsago)理想體重：595.9公斤BEE=1190kcal/dayTER=1700~1800kcal/dayPTreq.:73~80g/day2005/11/2237CYC個案基本資料性別：男性2005/11/2210C個案基本資料Medicationhistories：1.HTN2.OldCVA3.OldTB4.CRI5.PU(about3yearsago)6.Thalassemia(病患自述)2005/11/2238CYC個案基本資料Medicationhistories：20入院摘要入院時間：94/10/12科別：一般外科主訴癥狀：UGImassivebleeding(about2000c.c.)8daysagothenadmittedinTVGH(Dx:GastriccabyPES&CTstudy)診斷：Gastriccancer2005/11/2239CYC入院摘要入院時間：94/10/122005/11/2212COperationDate:94/10/18

Pre-Dx:GastriccancerClinicalfinding(10/13)

:

ulcerativetumoratLCS(mid-body)withinvasiontomesocolon5.5*4.5cmMethod:1.RadicalB-Ⅱsubtotalgastrectomy2.Cholecystectomy

3.Feedingjejunostomy

4.LNdissectionNo1,3,4,5,6,7Biopsy:1.Adenocarcinoma,intestinaltype2.LN→negativeformetasticcarcinoma2005/11/2240CYCOperationDate:94/10/182005/1NutritionsupportprogressDateTPNorderEnergy/AADate(Kcal/g)

EN

Energy/PT(Kcal/g)10/12A160c.c./hr+20%lipofundin200ml1399/5010/12NPO-10/14A260c.c./hr+20%lipofundin200ml1840/6310/13Astolerance

10/14

500/2010/1610/17CLDNPO10/19NPOED?srate20c.c./hr*18hr10/21A2300c.c./hr+20%lipofundin200ml10/20

10/21ED?s→FSrate30c.c./hr*18hr10/24TPNDC10/22

10/23-24rate40c.c./hr*18hrrate50c.c./hr→6010/24D10Wrun60c.c./hr

10/25

10/26

MD50c.c./hrDCOralTF(Jejunostomy)NPOOPdayon10/181385/32NPONPONPONPONPO25/1300/16540/28720/38800/42530/2210/28oral:CLD11/2Softdiet10/25Kabibenrun60c.c./hr500/01037/34Diarrhea12days2005/11/2241CYCNutritionsupportprogressDateTPN處方箋代碼品項Glucosegm/LAAgm/LElectrolyte(mEq/L)TPNA1Standard16335463712863771694TPNA2Highstress18744504015863677812TPNA3Hepaticfailure23938504015866047965TPNA4Renalfailure33323-------1224TPNB1Aminomix2005050301555100-1000NaKPMgCaClAcetateTotalKcal/LFatemulsion:20%Lipofundin100ml/BT20%Intralipid100ml/BT10%Lipovnous500ml/BTInfuvita(VitA,DE,B1,B2,B6,B12VitC,Niacin,Pathenol,Bioin,Folat)TraceelementZn,Cr,Cu,I,Mn2005/11/2242CYCTPN處方箋代碼品項GlucoseAAElectrolytNutritionsupport(En