1. 標 準 化 T P N 處 方 臨 床 應 用 Indications for TPN therapy
Design of TPN regimen
Metabolic complications and treatments  Peripheral Parenteral nutritional support
藥師 龐振宜

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

3. 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.

4. 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.

5. A Standardized PN Sol,n： Rx, Use, Processing, and Material Cost Implications
a. 73 ﹪of pt,s receiving standardized TPN solution
b.  Prescribing error frequency was 0 ﹪
c.  Decreased processing and compounding time by 55 ﹪
d.  Decreased material cost by 19 ﹪
e.  70﹪-80﹪of adult patients tolerate
standardized solutions without adverse
metabolic complications
Hospital Pharmacy, 21;July 1986

6. Suggested Nutrient intake for Adult patients on PN
Critically Ill P’ts
Stable P’ts
Protein
g/kg/d
0.8 – 1.0
Carbohydrate
Not >4mg/kg/min
Not > 7mg/kg/min
Lipid
1g/kg/d
Total Calories
25 –30 kcal/kg/d
kcal/kg/d
Fluid
Min. needed to delivery adequate macronutrients
mL/kg/d
ASPEN nutrition support practice manual 9-2, 1998

7. Protein Requirements （for Adult Patients）
– 25 ﹪of Total Calories
2. Non-protein Calorie to Nitrogen Ratio
kcal ： 1 / gm . N Severe Stress
kcal ： 1 / gm . N Moderate St
3. Nutritional vs. Metabolic Support
22nd Clinical Congress, ASPEN 1998

8. Non-Protein Calories Requirements （G l u c o s e）
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
﹪of total calories
22nd Clinical Congress, ASPEN 1998

9. Non-Protein Calories Requirements （F a t）
1. Maximum capacity：
gm/kg/day
2. Critically ill the maximum recommended
infusion rate：1.0 gm/kg/day
﹪of total calories
4. Run fat initially at 1 ml/min × min
﹪of total calories must be from EFA
22nd Clinical Congress, ASPEN 1998

10. Electrolytes Requirements for Adult Patients
1. Sodium – mEq/liter
2. Potassium – mEq/day
3. Chloride – mEq/day
4. Calcium – mEq/day
5. Magnesium 16 – mEq/day
6. Acetate – mEq/day
7. Phosphorus – mM/day
Ref：a. Maxwell ＆ Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism ,5th ,
b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed

11. Vitamin Formulation For Children Aged 11 Years, Older and Adults
Vitamins
Adult RDA in USA
AMA Recommended
Recommendation
For the Critically Ill
Vitamin A（IU）
Vitamin D（IU）
400
3300
200
2500 – 10000
Vitamin E（IU）
Vitamin C（mg） 45
10.0
100.0
1000
Folic acid（mcg）
Niacin（mg）
400.0
40.0
2000
Vitamin B2（mg）
Vitamin B1（mg）
1.1 – 1.8
1.0 – 1.5
3.6
3.0 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
15.0
60.0
100
5 mg
Vitamin K（mg）
– 10 mg/wk
2. Antibiotics – 10 mg/3-4days

12. Essential Trace Elements NAG/AMA Suggested Daily IV Intake
Stable
Acute Catabolic
GI Losses Zn
2.5 – 4.0 mg
Additional
2 mg
Add 12.2 mg/L small Bowel fluid lost；
17.1 mg/kg of stool or ileostomy output Cu
0.5 – 1.5 mg - Cr
10 – 15 mcg
20 mcg Mn
1.15–0.8 mg

13. 適當靜脈營養支持注意要點: 預防高血糖症 電解質的平衡 酸鹼平衡 避免靜脈營養停止時的低血糖症 血糖的穩定 鉀、鎂、磷 的監測
鉀、鎂、磷 的監測
酸鹼平衡
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: S-294S

14. Guidelines to Maximize Benefits and Minimize Complications of PN（1）
1. Avoid calorie and glucose overload
a. 25 to 30 kcal/kg/day
b. 2 to 4 mg dextrose/kg/min
2. Avoid fat overload
a. ≦ 30﹪of total energy requirements
b. Provide as a continuous infusion

15. Guidelines to Maximize Benefits and Minimize Complications of PN（2）
3. Avoid protein catabolism
a to 2.0 gm protein/kg/day
b. BCAA-enriched formulations may offer
- Hepatic encephalopathy and significant RF
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

16. The Potential Hazards of Overfeeding （1） Glucose
1. Hyperglycemia
a. Hyperosmolar state
b. Osmotic diuresis
c. Dehydration
d. 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.

17. The Potential Hazards of Overfeeding （2） Lipid
1. Immunosuppression （RES Blockade）
2. Increased prostaglandin production
3. Hypercholesterolemia
4. Hyperlipidemia
5. Impaired liver function
6. Ventilatory alterations
Ref： 1. Nutrition Support Theory and Therapeutics 1st Ed , P471；1997
2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.

18. The Potential Hazards of Overfeeding （3） Amino Acid
1. Ureagenesis
2. Hyperchloremic acidosis
3. Ventilatory alterations
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.

19. Metabolic Complications and Treatment （1）Hyperglycemia
1. Slow infusion rate
2. Give insulin
0.1 U of insulin /g of dextrose/liter
3. Increase fat emulsion therapy

20. Peripheral – T P N (Patient Criteria for P-TPN)
1. Good venous access
2. Mild to moderate stress
3. Not fluid restricted
4. Able to tolerate fat emulsion
5. Expected to resume enteral feeding
within 5-7 days

21. 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
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

22. 3% Amino Acid and 3% Glycerin injection with Electrolytes
Glycal-Amin®
3% Amino Acid and 3% Glycerin injection with Electrolytes

23. Glycal-Amin® 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
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

24. Glycal-Amin® 安全、方便、經濟 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
3% Amino Acid and 3% Glycerin Injection With Electrolytes
安全、方便、經濟
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
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

25. First Choice for Total Parenteral Nutrition:
安全、方便、經濟
J. Payne-James: JPEN 1993; 17:
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