Safety and feasiblity of parenteral nutrition in clinical practice 張維國 三軍總醫院 腸胃科

Case presentation 常先生、 58 ys Ischemic bowel disease s/p operation Short bowel syndrome TPN 2 months Lab: GOT 180, GPT 127, Total Bil 2.5

靜脈營養 Parenteral Nutrition Indications for TPN therapy Design of TPN regimen Access Monitoring Complications and treatments

靜脈營養 Parenteral Nutrition 消化道瘺管 發炎性腸疾患 腸管大量切除 消化道阻塞 消化道出血 手術前後營養管理 重度外傷、燒傷 嚴重的感染症 惡性腫瘤 胰臟炎

靜脈營養 Parenteral Nutrition Indications for TPN therapy Design of TPN regimen Access Monitoring Complications and treatments

Electrolytes Requirements 1. Sodium 30 – 55 mEq/liter 2. Potassium 60 – 90 mEq/day 3. Chloride 30 – 55 mEq/day 4. Calcium 6 – 12 mEq/day 5. Magnesium 16 – 20 mEq/day 6. Acetate 45 – 70 mEq/day 7. Phosphorus 18 – 28 mM/day

Vitamin Formulation Vitamins RDA in USAAMA Recommended Recommendation For the Critically Ill Vitamin A （ IU ） Vitamin D （ IU ） – Vitamin E （ IU ） Vitamin C （ mg ） Folic acid （ mcg ） Niacin （ mg ） Vitamin B2 （ mg ） Vitamin B1 （ mg ） 1.1 – – Vitamin B6 （ mg ） Vitamin B12 （ mcg ） 1.6 – mg Pantothenic acid （ mg ） Biotin （ mcg ） 5 – mg Vitamin K （ mg ） 1. 1 – 10 mg/wk 2. Antibiotics – 10 mg/3-4days

靜脈營養 Parenteral Nutrition Indications for TPN therapy Design of TPN regimen Access Monitoring Complications and treatments

High PN osmolarity to peripheral vein Peripheral vein did not tolerate > 900 mOsm/L Local phlebitis reactions after 4  3 hrs. PN 1044 mOsm/L; 91% phlebitis after 2.8 days

Prediction equations to Osmolarity of PN formulations Equation 1 = Amino acids (g/L) × 8 + Glucose (g/L) × 7 + Sodium (mEq/L) × 2 + Phosphate (mg/L) × 0.2 – 50 Equation 2 = Amino acids (%) × Glucose (%) × 50 + Calcium (mEq/L) × Magnesium (mEq/L) × 1 + Potassium (mEq/L) × 2 + Sodium (mEq/L) × 2 Equation 3 = Dextrose (g/L) × 5 + Amino acids (g/L) × 10 + Fat (g/L) × Electrolytes (mEg/L) × 1 Equation 4= × Brix value – Chang WK et al; Parenter Enter Nutr 2011

Case presentation 常先生、 58 ys Ischemic bowel disease s/p operation Short bowel syndrome TPN 2 months Fever 38.8C Lab: WBC 18,000/ul; N/L 90/10

Case presentation 常先生、 58 ys Ischemic bowel disease s/p operation Short bowel syndrome TPN 2 months Lab: GOT 180, GPT 127, Total Bil 2.5

PN associated liver disease (PNALD) 1.History of PN > 14 days 2.Liver enzyme (ALT, AST, AlK.P,  -GT) 1.5  Fold 3.Conjugated bilirubin > 1.5 mg/dl, >50% 4.Absence of other causes of liver injury

CHO 400 ml X 30% = 120 gm

Gut Disuse: Loss of Structural Integrity

靜脈營養 Parenteral Nutrition Indications for TPN therapy Design of TPN regimen Access Monitoring Complications and treatments