Parenteral nutrition, PN

1
????? (Parenteral nutrition, PN )

• ?????????????ICU ???

2
1986?2?,????????????????????,?????????????????????
????.
3
1992?4?8?,????????????????????????????????????????
????????????????
4
References

• History of parenteral nutrition. JPEN,
  27225-232, 2003
• A.S.P.E.N. Board of Directors and the Clinical
  Guidelines Taskforce Guidelines for the use of
  parenteral and enteral nutrition in adult and
  pediatric patients. JPEN, 26(Suppl)1138,2002
• Canadian Clinical Practice Guidelines for
  Nutrition Support in Mechanically Ventilated,
  Critically Ill Adult Patients. JPEN, 27355373,
  2003
• ????????????(??)(???????????).?????????,10(18)582
  -590,2006
• ??????????????(??)(??????????????).?????????,10(18
  )591-594,2006

5
????????

• A?
• ????????????????
• (???????)
• B?
• ????????????????
• (?????????)
• C?
• ??????????????

6
Contributors

• Jonathan Evans Rhoads, MD, Surgical Nutritionist
• the Harrison Department of Surgery at the
  University of Pennsylvania
• Stanley Dudrick, MD, Henry Vars, PhD, Douglas
  Wilmore, MD, and others at the University of
  Pennsylvania
• The full development of parenteral nutrition, as
  we know it today, was dependent on endless hours
  of effort by dedicated nurses, pharmacists, and
  dietitians.

7
History

• Complete parenteral or IV nutrition is a
  therapeutic method that has been available for
  approximately 50 years
• The successful development of this mode of
  therapy, in a modern sense, was initiated in the
  late 1930s, but its practical clinical use did
  not emerge until the 1960s.

8
History1

• The discovery of the circulation of the blood by
  William Harvey in 1628 formed the basis for the
  rationale for IV injections and infusions.
• A decade later, an important contribution to the
  development of IV infusions was made during the
  severe cholera epidemic of 1831 to 1832 by the
  Scottish physician Latta.
• He was the first to infuse water and salts
  (saline) into a patient, who quickly recovered
  and survived.

9
History2

• Edward Hodder, in Canada in 1873, infused fat in
  the form of milk into 3 cholera patients.
• Two of the patients recovered completely, but
  the third cholera patient did not survive despite
  the milk infusion.

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History 3 STUDIES WITH GLUCOSE

• It seems obvious in retrospect that the field of
  parenteral nutrition could not progress
  successfully before much more was known in the
  basic sciences.
• Arthur Beidl and Rudely Krauts, in 1896, were the
  first to infuse glucose IV in humans.
• The terms "glucose fever" and "salt fever"

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History4 STUDIES WITH GLUCOSE

• In 1915, Woodyatt and co-workers reported studies
  on IV administration of glucose in humans.
• They reported that about 0.85 g of glucose/kg per
  hour could be supplied by IV without ensuing
  glucosuria.
• This classic early study predated glucose clamp
  investigations by more that 50 years.
• They stated "IV nutrition with glucose is thus
  proved to be a feasible clinical proposition, and
  the way is opened for experiments with amino
  acids, polypeptides, etc."

12
History5 STUDIES WITH GLUCOSE

• Matas, in 1924, was the first to use a continuous
  drip infusion of glucose, and some years later,
  Zimmerman, in 1945, described the infusion of IV
  solutions through an IV catheter placed in the
  superior vena cava.
• This approach was used by Dennis and Dennis and
  Karlson, who reported the support of surgical
  patients with the continuous infusion of a
  solution of 20 glucose along with some vitamins,
  electrolytes, and 300 to 400 mL of plasma.

13
History6 STUDIES WITH GLUCOSE

• The next major contribution was the infusion of
  hypertonic glucose and all necessary nutrients by
  Dudrick et al.

14
History 7 The Use of Plasma as a Protein Source

• In 1946, Albright and his research team at the
  Massachusetts General Hospital in Boston
  investigated the metabolic fate of infused plasma
  protein in humans and demonstrated that such
  infusions contributed to positive nitrogen
  balance.

15
History8 PROTEIN HYDROLYSATES AND CRYSTALLINE
AMINO ACIDS

• Robert Elman, a surgeon who worked in St Louis
• In 1937, he published the first successful
  studies evaluating the IV infusion of amino acids
  in the form of a fibrinogen hydrolysate in man.
• This was an indisputable landmark in the
  development of IV nutrition . Undoubtedly, Elman
  deserves the complement given to him by Arvid
  Wretlind, who referred to him as the "father of
  IV nutrition."

16
History9 Fat

• It was realized early on that optimal use of the
  amino acids in solutions could only be achieved
  by simultaneously providing adequate amounts of
  necessary energy.
• In those days, glucose was the only available
  nonprotein source that could be given IV.

17
History10 Fat parenteral nutrition

• The first to develop a nontoxic readily available
  fat emulsion was the Swedish scientist Arvid
  Wretlind, who in 1961, introduced Intralipid
  together with O. Schuberth.
• For his many developmental contributions, it
  seems appropriate to call Arvid Wretlind the
  "father of complete parenteral nutrition"

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History11 Parenteral nutrition

• In 1962, one of the first symposiums on
  parenteral nutrition was held in Kungalv, Sweden.
  
• This was the first time details of a TPN program
  were presented.

19
History12 Parenteral nutrition

• In 1968, a new landmark in the history of
  parenteral nutrition was passed by Dudrick et al,
  who demonstrated that
• a catheter placed in the superior vena cava
  could be used
• over extended periods of time
• to administer a solution of concentrated glucose,
  along with all other essential nutrients.

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History13 Parenteral nutrition

• Dudrick et al's regimen Glucose system
• The Swedish regimen Fat system
• Rhoads Hyperalimentation

21
History14 Parenteral nutrition HPN

• A contemporary parenteral feeding program
  consists of water, energy (carbohydrates and
  fat), amino acids, vitamins, and trace elements.
• It is extremely important that these nutrients
  are administered together.
• An improvement, aimed to simplify the infusions,
  was the introduction of the "All-in-One" system,
  where all nutrients are mixed in 1 bag at the
  local pharmacy or at a pharmaceutical company.
• The method was introduced by Solassol et al in
  1972.

22
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23
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24
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25
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• ?? ???? ?? ??
  ??
• ?? () gt90 8090
  6079 lt60
• ???? 18.523 1718.4 1616.9
  lt16
• TSF() gt90 8090
  6080 lt60
• ????() gt90 8090 6079
  lt60
• CHI() gt95 8594
  7084 lt70
• ???(g/l) gt30 3025 24.920
  lt20
• ????(g/l) 2.04.0 1.52.0 1.01.5
  lt1.0
• ????(g/l) gt2 1.62.0 1.21.5
  lt1.2
• ?LC(109/l) gt1500 12001500 8001200
  lt800
• ???(g/l) 1 5 10 10
  15 lt15

26
????

• ?????? subjective globe assessment,SGA
• ?????? mini nutritional assessment, MNA
• ????????2002 nutrition risk screening NRS2002

27
SNS???

• SNS
• ??????,???????????????
• EN
• ????????? ????????
• PN
• ????????
• ??
• ?????,???????????????

28
SNS???

• ?????PN?EN??????
• ?????EN????????????????(translocation of
  intestinal flora)?????????,????????(inflammatory
  pathways)?
• ?? ??????????????????????????????????,???????????
  ????
• EN ??????????????????

29
SNS???

• ???????????????????????EN?PN???????????,??????????
  ??EN?PN????
• ??????PN?EN??????????,??????????????,??PN??????SN
  S?

30
SNS???

• ????
• ??SNS?????
• ??????????EN???????,??????
• ????6-12h?EN??????,?????????,???????????

31
SNS???

• ????PN
• ??,???????
• ??????,??????
• 2???
• ???????1014??????SNS??
• ???????,???????,???????
• ????SNS
• ??714???????
• ???714??????????

32
SNS??????

• SNS???????????????????(B)
• ??SNS?,EN??PN ?(B)
• ??SNS?,PN?????????????????EN????????????
  (B)
• ????714??????????714?????????????SNS ?
  (B)

33
??????

• SNS???????????????????????
• ???????????????,??,????,????,?????,???????????
• ????EN?PN???
• ????????????????????

34
??????

• ??????????????????,??????????????,???????????
• ????????
• 2035kcal/kg/d ( 85145kj/kg/d)
• ?lt7g/kg/d, ??lt2.5g/kg/d(lt1g/kg/d iv icu
  patients)
• ???
• 0.8g/kg/d (?????????????)
• 2.0g/kg/d (??????)
• ??????
• ???
• ??3040ml/kg?1.01.5ml/kcal
• ?????????????

35
??????

• ??????
• (??cm-100)0.9
• gt165cm??-100
• lt165cm
• Male ??-105
• Female ??-100

36
??????

• ?????????
• Harris-Benedict??
• ?BEE(kcal/d)66.473013.7513W5.0033H-6.7750A
  
• ?BEE(kcal/d)655.09559.5634W1.8496H-4.6756A
  
• ?????3570??????,lt7g/kg?
• ??2030??????,??????50,lt2g/kg?

37
??????

• ????
• ???????? 1.0-1.1
• ?????????? 1.25
• ????/??/???? 1.3-1.6
• ????gt????40 2.0
• ?????? 1.1-1.25
• ??
  1.05-1.10/?

38
??????

• ????????
• 1g?6.25g???
• ???????? ?1g/kg/d
• ?????????,????
• ??? ????(kcal)/150????, ?1150??(?150kcal??????
  ?1g)

39
??????

• ??????60?
• TPN??????4-5mg/kg/min
• ??TPN?21????
• ????????400-500g/d
• DM?COPD??????
• ?????????????????,????????

40
??????

• ??3-30
• ????????40-50?
• ??????? ?????? 7030

41
???????????

• PN????????????????????? (A)
• ???????,????????????????????
  
  (B)
• ?????????????????? (B)
• ?????Chlorhexidine ????
  (B)
• ???????hub???
  (C)
• ???????????
  (A)
• ???????????(????)????????(B)
• ???????????????
  (B)
• ???????????????PN??????????
• 
  (B)
• 
  
  
• 
  
  

42
????????

• ?SNS?????????????(?????????????)?????(????????????
  ??????????)?(B)
• ????????/?????SNS????,?????????
  (C)

43
??????????

• ?????? ?????????????
• ?????????
• ??????
• ???????
• ????????

44
??????????

• ?????(PN)
• ?????
• ??????(PN)
• ???????(EN)
• ????????(EN)
• ???????

45
?????????

• ??SNS?,??????(refeeding syndrome)?????????????????
  ????????? (B)
• ??????????????????SNS?,?????????,????????????
  
• (C)
• ????SNS,???????????????????
  (B)
• ??SNS?,??????????(??????????)?????
  (B)

46
?????????

• ?????????????????????????????? (C)
• ??PN??????????? (A)
• ??SNS?,???????????? (C)
• ??EN??????????,???????????
  (C)

47
??????????

• ????(gt65?)??????????,???????
  (B)
• ????????????????????????
  (C)
• ?????????????????????-???????
  (B)
• ??????????SNS???,???????????????
  (B)
• ?????55-60???B-12?B-6?C????????30ml/kg?
  ??1500ml/d?

48
??????????

• ??????????????,???????(B)
• ?????,?????????????????????,??,?????????????,?????
  ?(?Harris-Benedict??)????????
  (B)
• ????????????????,???????(?????1g/kg IBW) ?
  (A)

49
???????????

• ???????????????,???????
  (A)
• ??????????????100-200mg/dl???
  (A)
• ?????????EN?PN????????????,???????????
  
• (B)
• PN0.1u RI/1g?

50
???????????

• ?????(cardiac cachexia) ????????NYHA??????????(CH
  F)?????????????????????(????????)?????????????????
  ???????
• ?????????CPB??????????????????,???????(B)
• PN??????????????????????? (C)
• ????????EN?????????????
  (C)

51
??????????

• COPD?ARDS????????????,???????(B)
• ????????????????????????CO2????(B)
• ????????????????????-????????(B)
• ???n-3?????????????????ARDS?????(B)
• ??????????????????????????ARDS???(B)
• ????????????????(A)

52
??????????

• ??????????????,???????(B)
• ???????????????A?D?E?K?Zinc?(B)
• ???????4-6??????????(B)
• ?????????????????????(1.0g/kg/d)?(A)
• ???????????SNS???????????????????(B)
• ????????????????????????????(A)

53
?????????????

• ???????SBS????????????,???????(B)
• SBS???????????????????-????????(A)
• ??????gt100cm????????VitB-12?(A)
• ????EN????SBS??????,???PN?(A)

54
??????????

• ????????????????????,?????????(0.6-0.8g/kg/d)
  ?(A)
• CRF???????????1.2-1.3g???/kg/d?(B)
• ARF????SNS?,????????????????(???)??????? (A)
• ???????????1.0g???/kg/d?(B)

r
55
??????????

• ??????????????ARF?????1.5-1.8g???/kg/d? (B)
• ??????????????(A)

56
??????????????

• ???????????(TBI)???????SNS?(B)
• ??SNS????,???EN?(C)
• ?????????,???????,???????????????????(B)

57
???????????

• SNS???????????????? (B)
• EN??????SNS???????,????PN???????(A)
• PN?????????SNS???????EN???(B)
• ???????????????????,????????????lt400mg/dl?(B)

58
???????????

• ???????5-10??????????????,????SNS?(B)
• EN??????SNS???????(B)
• PN???SNS??????EN??(C)

59
A Conceptual Framework Speciallized
nutrition(Immune enhanced nutrition)
60
Immune enhanced nutrition

• Glutamine supplemented PN is associated with a
  significant reduction in mortality in critically
  ill patients.
• Glutamine supplemented PN may reduce infectious
  complications in critically ill patients.

61
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