????? ??????????? ??????F?

1
????? ??????????? ??????F?

• ???a?? ????a?
• ? ?e????????? ???????
• ?a?ep?st?µ??? ??????

2
?as???? ?a???a?
3
?a???a? se ?e??????????? as?e?e??
4
????? pa?e?te???? d?at??f?

• ?? d?ata?a??? t?? ????e?? se ?e???????????
  as?e?e?? ????? 2 ????a ?a?a?t???st???
• ?p???e??a ????
• t?? ?e?????????? ??s?? (a???e??a, ?µet??,
  d??????e? ??p)
• t?? pe?????sµ?? t?? t??f?? (e?et?se??, d?a?te?
  ??p)
• ?a? ta d??
• ?etaß?????? d?ata?a???
• t?? t?a?µat?? (stress/inflammation)
• a???µ???? ?ataß???sµ??
• e?att?µ???? a?aß???sµ??

5
??de??e?? ???

• ?p?dede??µ??e?
• S??
• ??e???e??t? d?sap???f?s?
• ???e??e???t??? se ?p???ept????? as?e?e??
• ??????? a??? µ? ap?dede??µ??e? ap? ????????
  µe??te?
• ?a???? p?s???te?
• ?ete??e???t???
• ??a?µa
• S???
• ??e?a pa???eat?t?da, ?pat??? a?ep???e?a
• ?e?t??s? t?? p???t?ta? t?? ????
• AIDS
• ?a??????

6
???? a???se? ? ???

• T?ept??? e?t?µ?s?
• ?p????? ?e?t????? f??ßa?
• ????sµa (Baseline ?S)
• ???ast???a?? (Baseline)

7
T?ept??? e?t?µ?s?

• ?st?????
• ??????? e??tas?
• ?????p?µet????? µet??se??
• ???ast???a??? e?et?se??

8
T?ept??? e?t?µ?s?

• ?S??????
• Dietary history
• Significant weight loss within last 6 months
• gt 15 loss of body weight
• compare with ideal weight
• Beware the patient with ascites/ oedema

9
T?ept??? e?t?µ?s?

• ??????? ?????S?
• Evidence of muscle wasting
• Depletion of subcutaneous fat
• Peripheral oedema, ascites
• Features of Vitamin deficiency
• eg nail and mucosal changes
• Echymosis and easy bruising
• Easy to detect gt15 loss

10
T?ept??? e?t?µ?s?

• SO???????????
• Weight for Height comparison
• Body Mass Index (lt19, or gt10 decrease)
• Triceps-skinfold
• Mid arm muscle circumference
• Urinary creatinine / height index

11
T?ept??? e?t?µ?s?

• ??G?S???????
• albumin lt 30 mg/dl
• pre-albumin lt12 mg/dl
• transferrin lt 150 mmol/l
• total lymphocyte count lt 1800 / mm3
• tests reflecting specific nutritional deficits
• eg Prothrombin time
• Skin anergy testing

12
?e?t???? ??aµµ?
?????G? ????????S G?????S

• ?s? sfa??t?da f??ßa
• ?p???e?d??? f??ßa
• ??? sfa??t?da f??ßa
• ????a?a f??ßa

?? F??ßa
13
????d?? ?a?et???asµ??

• ??s???? te????? ??a µ? ?µpe??? p??s?p???
• ???pe? ?a t?????ta? ???? ?? ?a???e? a?t?s???a?
• ???d???? !!!
• ??a??et??? ??s??e?t??? f???t?da aµ?s?? µet?

14
?a?et???asµ??
15
?as???? e??ast???a??? µet??se??

• Full blood count
• Coagulation screen
• Ca, Mg, PO42-
• Lipid Panel
• Other tests when indicated

16
??s?e?

• ???te??e?
• ??e??e?a aµ?????a (iso, leu, lys, met, phe, thr,
  trp, val)
• BCAA ??a ?pat?p??e?a ??at? µp????? ?a
  µetaß???s???? st??? µ?e? (valine, leucine,
  isoleucine)
• ???µat??? aµ?????a (Phe, Try, Trp)
• ??d??? p?????ta (Heptamine, Nephroamine, others)
• ?e? e??a? p??? e????e?a? ?a? de? ?p????????ta? ??
  ?e?µ?de?
• Glycine e??a? t? ????? aµ?????
• Glutamine a?a??a?? p??s?et?

17
??s?e?

• ?dat????a?e?
• Dextrose (D 5, D 10, D 20, D 35)
• 3,4 kcals/gram
• ????? ?dat????a?e? µetat??p??ta? p??? se ??p??
  ?a? CO2

18
??s?e?

• ??p?? (9 kcals/gram)
• ?p??e? ?a d??e?
• ?a??µe????
• ???e de?te?? ?µ??a
• ?ßd?µad?a?a (??a t?? a????e? t?? ESFA)
• 500 ml, 10 ??p??? d??e? 550 kcals (1.1 kcals/mL)
• 500 ml, 20 ??p??? d??e? 1,000kcals ( 2.0
  kcals/mL)
• ?a d?a??µata e??a? ?s?t??a (µp??e? ?a d????? ?a?
  ap? pe??fe???? f??ßa)
• ????a p??? ?e?µ?d?? µp??e? ?a f??se? ?a? st? 60
  t?? a?a???? se ?e?µ?de? a? ?p???e? a?????
• ?pa?a?t?ta ??pa?? ???a (EFAs)
• Omega-3 (?3) Linolenic acid
• Omega-6 (?6) Linoleic acid

19
??s?e?

• ??e?t????te?, ??taµ??e?, ????st???e?a,
• MVI ???e ?µ??a ? ???e de?te?? ?µ??a
• ??taµ??? K ?pa? eßd?µad?a???
• ??e?t????te? ?µe??s?e? a????e? ?a? ap??e?e? a???
  p??? ap? ??a ß?se? t?? e??ast???a???
• ?sß?st?? ?a? F?sf???? p??pe? ?a e??????µe ??a
  ???µata (precipitate formation)
• ????µ??e? a????e? se ß?taµ??? C ?a? Zinc
• ??e???eta? ß?taµ??? B

20
??s?e?

• F??µa?a
• ?a ap?fe????µe
• ?? te???? d????µa e??a? ?p??t??? ???? sta 1800
  mOsm/L
• ? ??? e??a? 700-900 mOsmols/L ?s? pe??p?? ? D 10
  ? D 12,5.

21
St?d?a pa?a??e??a? ???
22
????? ?????
23
How much volume to give?

• Cater for maintenance on going losses
• Normal maintenance requirements
• By body weight
• alternatively, 30 to 50 ml/kg/day
• Add on going losses based on I/O chart
• Consider insensible fluid losses also
• eg add 10 for every oC rise in temperature

24
???sd????sµ?? µ? p??te?????? ?e?µ?d??
25
??se? ?e?µ?de? ?a? p?se? p??te??e? ?a
??????s??µe

• Te?µ?de? 25-35 ?cal / Kg /?µ??a
• ???te??e? 1,5 -2 g/Kg/?µ??a

'do not overfeed !'

• ??????s? pe??ss?te??? ap? 35 Kcal/Kg s?et??eta?
  µe pe??ss?te?e? s?pt???? ?a? µetaß??????
  ep?p????? (Torrosian M. World J
  Surg.19923565-569)
• S??d??µ? epa?as?t?s??. ??a ep?p???? t??
  te???t?? d?at??f?? p?? ep?ß???e? t?? stad?a??
  epa?as?t?s? (Apovian et al. Crit Care Med.
  1990181030-33

26
Te?µ?de?

• ? ?p?????sµ?? ßas??eta? st? ???
• (Total Energy Expenditure)
• TEE REE Stress Factor Activity Factor
• ??S (? REE, resting energy expenditure ) x 25-35
  kcal/kg a?????a µe t?? s?ßa??t?ta t?? ??s??

27
?p?????sµ??

• ?S(kg).
• ?S x ?µe??s?e? a????e?
• (25-35 kcal/kg ?S)
• p?
• 87kg x 35 kcal/kg 3045
• 87kg x 45 kcal/kg 3915
• (pa?a??te?? ?p???, s?µe?a ?a?e?? de? pa???e?
  a?t?? t?? p?s?t?ta)
• ?????e? as?e????
• 3,045 kcal/day

28
REE (resting energy expenditure)

• ?a????sµ?? t?? REE µe t?? e??s?s?
  Harris-Benedict ßas?sµ??? se ???? (?), ?S (W)
  ?a? ?????a (A)
• Harris-Benedict Equation
• Males REE 66 (13.7W) (5H) - 6.8A
• Females REE 655 (9.6W) 1.8H - 4.7A
• Schofield Equation
• 25 to 30 kcal/kg/day

29
?pe????s? Harris-Benedict equation
30
Te?µ?de?

• Stress Factor

• ?p???e??a - 30
• pe??t???t?da 15
• ??. µa?a??? ?st?? 15
• ??ta?µa 20
• p??et?? (per oC rise) 13

• ?p?a ???µ??? 20
• S?ßa?? ???µ??? 40
• lt20 BSA ???a?µa 50
• 20-40 BSA ???a?µa 80
• gt40 BSA ???a?µa 100

31
Te?µ?de?

• Activity Factor

?ata?e???µµ???? 20 ????t?p???µ???? 30
??ast????? 50
32
??s? ??p?? ?a? ?dat????a?e?

• ?dat????a?e?
• ??? pe??ss?te?? ap? 4 mg/kg/min Dextrose
• (????te?? ap? 6 g/kg/?µ)
• Rosmarin et al, Nutr Clin Pract 1996,11151-6
• ??p??
• ??? pe??ss?te?? ap? 0,7 mg/kg/min ??p??
• (????te?? ap? 1 g/kg/?µ)
• Moore Cerra, 1991

33
??s? ??p?? ?a? ?dat????a?e?

• ?? ??p?? d??e? t? 25-30 t?? ?e?µ?d??
• ??? pe??ss?te?? ap? t? 40-50
• Se s?ßa?? s??? a????eta? t? p?s?st? se s?ßa??
  stress
• St???? ep?peda TG lt 350 mg/dl ? 3.95 mmol / l
• ?dat????a?e? s?????? 70-75 t?? ?e?µ?d??

34
???te??e?
35
???te??e?

• ?as??eta? st?? a?a????a Calorie / Nitrogen
• ?as??eta? st? Stress BS
• ?as??eta? st? ?s?????? ???t??

36
Calorie / Nitrogen a?a????a

• ? f?s???????? a?a????a e??a?
• 150 cal 1g Nitrogen
• ?a???? p?s???te?
• 85-100 cal 1 g Nitrogen

37
t? Stress BS

• Non-stress as?e?e?? 0.8 g/kg/day
• Mild stress gtgt 1,0-1,2 g/kg/day
• Moderate stress gtgt 1,3-1,75 g/kg/day
• Severe stress gtgt 2-2,5 g/kg/day

38
t? ?s?????? ???t??

• St???? ?et??? ?s?????? a??t??
• 1,5-2 g/kg/day

39
??e?t????te? ?a? ????st???e?a
40
??e?t????te?

• ?µe??s?e? a????e? ap??e?e?
• Na 1 - 2 mmol/kg/d (? 60-120 meq/d)
• K 0.5 - 1 mmol/kg/d (? 30 - 60 meq/d)
• Mg 0.35 - 0.45 meq/kg/d (? 10 to 20 meq /d)
• Ca 0.2 to 0.3 meq/kg/d (? 10 to 15 meq/d)
• PO42- 20 to 30 mmol/d

41
????st???e?a

• Total requirements not well established
• Commercial preparations exist to provide RDA
• Zn 2-4 mg/day
• Cr 10-15 ug/day
• Cu 0.3 to 0.5 mg/day
• Mn 0.4 to 0.8 mg/day

42
???s?eta
43
???s?eta

• ??taµ??e?
• 1 amp MVI se ???e s??? ???
• MVI de? ??e? ß?taµ??? K
• ??? µp??e? ?a d??e? se d?s? 1 mg/day ? 1 amp
  ( 5-10 mg)/wk

44
???a p??s?eta

• F??µa?a
• Insulin
• ?p??e?? ?a d?se?? ???sta????? ??s?????? s?µf??a
  µe ???µa?a µe dextrostick a?? 6h (???? t? lt11
  mmol/l)
• ????? sta?e?? d?se ta 2/3 ???? t?? a?a???? se
  ??s?????? st? s??? ??? ???e ?µ??a s???a??
• e?a??a?t???
• 0.1 u a?? g dextrose st?? ???
• 10 u a?? litre ??? a????? d?s?
• ???a
• H2 antagonists
• Heparin

45
???p?? ??????s??
46
???p?? ??????s??
47
?a?a???????s?
48
Parenteral Nutrition

• Allows greater caloric intake
• BUT
• Is more expensive
• Needs more technical expertise
• Has more complications

49
?p?p?????

• ?p?p?????
• ???a?????
• ?etaß??????
• ???µ??e??

50
Mechanical Complications
Related to vascular access technique

• brachial plexus injury
• catheter malplacement
• catheter embolism
• thoracic duct injury

• pneumothorax
• air embolism
• arterial injury
• bleeding

51
Mechanical Complications
Related to catheter in situ

• Venous thrombosis
• catheter occlusion

52
???a????? ep?p?????
53
Metabolic Complications

• Abnormalities related to excessive or
• inadequate administration
• hyper / hypoglycaemia
• electrolyte abnormalities
• acid-base disorders
• hyperlipidaemia

54
Metabolic Complications

• Hepatic complications
• Biochemical abnormalities
• Cholestatic jaundice
• too much calories (carbohydrate intake)
• too much fat
• Acalculous cholecystitis

55
Infectious Complications

• Insertion site contamination
• Catheter contamination
• improper insertion technique
• use of catheter for non-feeding purposes
• contaminated TPN solution
• contaminated tubing
• Secondary contamination
• septicaemia

56
Source of Infections

• Extralumenal (65)
• Patient skin
• Hands of personnel
• Intralumenal (30)
• Hands of personnel
• Hematogenous seeding
• Contaminated IV fluids

57
Infections with Intravenous Therapy in the United
States

• gt150 million vascular devices sold
• gt5 million central venous lines
• 200,000 cases of bloodstream infections
• -Most frequent cause of nosocomial bacteremia
• -15 mortality

Mermel LS Clin Inf Dis May, 2001
58
Microorganisms Associated with IV Therapy

• Staphylococcus non-aureus
• Staphylococcus aureus
• Enterococci
• Candida albicans
• Some Gram-negative rods

59
Biofilm with staphylococci
60
(No Transcript)
61
(No Transcript)
62
?a?????te? p?? p??d?a??t??? st?? a??pt??? ßa????
???µ????
63
??a??p? ???

• St?p ?ta? µp??e? ?a a???se? ? e?te???? s?t?s?
• ???? ??a ?a ap?fe???e? ? ?p?????a?µ?a
• ?a?a???????s? t?? sa?????? t?? a?µat?? ?at? t??
  d????e?a t?? d?ad??as?a? (dextrostick)
• Dextrose 10 ?v st?? ?d?? ???µ? ??a t??????st??
  4-6h
• ??a??a?t??? ep??????? µe t?? d?at??f? ap? t? st?µa

64
??a??p? ???

• ??µ?? 1
• ?? ? as?e??? de? µp??e? ?a s?t?ste? ?a?? (?a
  ?a???e? d??ad? t? 50 t?? ?µe??s??? a?a????)
  t?te p??pe? ?a ß????µe ?a?et??a s?t?s??.
• ??µ?? 2
• ??a??pt??µe t?? ??? stad?a?? ?a? ?ta? ? as?e???
  ?aµß??e? t??????st?? 70-75 t?? a?a???? t?? ap?
  t?? e?te???? ?d? (st?µa, ?a?et??a?)

65
Two main forms of parenteral nutrition

• Peripheral Parenteral Nutrition
• Central (Total) Parenteral Nutrition
• Both differ in

• composition of feed
• primary caloric source
• potential complications
• method of administration

66
(No Transcript)
67
????? pa?e?te???? d?at??f? (???)

• ????a p?e??e?t?µata
• ?a??? ??????s?
• ??e????a
• T?ept???? ??s?e?
• ????
• ???f??e? p????t?te?
• ????a µe???e?t?µata
• ??st??
• ?p?p?????

68
??? vs ???

• ???
• ?s?t??? d????µa
• ??a ta d?at??f??? st???e?a
• ?a ?ef?? p??pe? ?a d???e????
• ????? d????e?a 7-14 ?µ??e?
• ?a?? µe e?te???? d?at??f?
• ?ta? ? ??? de? e??a? d??at?

• ???
• ?e?t???? f??ßa
• ?????? s???e?t??se??-?p??t??a d?a??µata
• ?a??? ??????s?
• ?e???e? a????e?
• S?ßa?? ?p???e??a
• ???ß??µa ? ???µ??e??

69
?a?e?te???? d?at??f? st? sp?t?

• ??tetaµ??? efa?µ??? ?at ????? ??s??e?a? ?e????se
  st?? ?µe???? t?? de?aet?a t?? 80, µet? ap?
  ??µ??es?a p?? ????e ep?t??p?? ??a t?? ??e??? t??
  ??st??? ?a? e??d?? t?? ??s???µe??? , ta ?p??a
  ????pte t? s?st?µa ??e?a? (Medicare)
• ?p?t??esµa ?ta?
• ? µe??µ??? pa?aµ??? st? ??s???µe??
• ? a???µ???? a???µ?? ??????? as?e??? st? sp?t?
• ? a??pt??? t?? ?at ????? ?e?ape?a? / ??s??e?a?
  (d?µ?s???, ?d??t???? t?µ?a?
• ??st??? ???t???a ??a t?? ?????? as?e??? ??a ??
  ?a? ?? ,

70
?at ????? te???t? d?at??f? st?? ?.?.?

• ?? 1995
• 80.000 as?e?e?? ?ta? se pa?e?te???? ?at ?????
  d?at??f?
• ?a?
• 300.000 as?e?e?? ?ta? se e?te???? ?at ?????
  d?at??f?
• ?? a???µ?? a?t?? e??a? 4-10 f???? µe?a??te???
  s?????t??? µe ???e? ???e? t?? d?s??
• 
  Howard L. et al. 1995

71
?at ????? te???t? d?at??f? st?? ?????a

• ?? 1995
• 4 as?e?e?? / 1 e?at?µ???? ?at????? ?ta? se
  e?te???? ?at ????? d?at??f? (???? st??? 200
  as?e?e??)
• ?a?
• 40 as?e?e?? / 1 e?at?µ???? ?at????? ?ta? se
  e?te???? ?at ????? d?at??f? ( 2.000 as?e?e??)
• 
  Howard L. et al. 1995

72
?e??s? ??st???

• ?? ??st?? ?fe??eta? ?????? st?? a??a t??
  p?????t?? ?a? ????te?? st?? ??e?se?? ?p???es???,
  e?et?se?? ?t?.
• Reddy et al. 1997
• ?a???? t? ????? t?? ??st?? (60.000/ ?t?? st??
  ?????a, 100.000 / ?t?? st?? ???) ? ??????s?
  pa?e?te????? s?t?s?? st? sp?t? µe???e? t? ??st??
  50-70 se s??s? µe t? ??st?? pa?aµ???? st?
  ??s???µe??. ?s? pe??ss?te?? ?e? ? as?e??? t?s?
  pe??ss?te?? µe???eta? t? ??st??.
• ?? ??st?? t?? e?te????? d?at??f?? e??a? saf??
  µ????te?? ap? a?t? t?? pa?e?te????? (pe??p?? 5
  f???? )
• ? ??????s? e?te????? d?at??f?? ?at ????? µe???e?
  t? ??st?? ?at? 90 se s??s? µe t? ??st??
  pa?aµ???? st? ??s???µe??
• 
  Dickerson et
  al. 1998

73
??t?a ?at ????? te???t?? d?at??f?? st?? ?.?.?,
µeta?? 1985-1992
Howard et al. 1995
74
??t?a ?at ????? te???t?? d?at??f?? st?? ?????a
??st??? ???s?
ESPEN- Home Artificial Working Group, 1999
75
??t?a ?at ????? te???t?? d?at??f?? st?? ?????a
??te???? d?at??f?
76
?e???t? d?at??f? st?? ?at ????? ??s??e?a

• ??a? as?e??? ??e? ??de??? ??a te???t? d?at??f?
  ?ta? ?? ??ept???? a????e? p?? e??a? apa?a?t?te?
  ??a t?? ?p?st????? t?? ???? ?a? t? d?at???s? t??
  ?a??? ?at?stas?? t?? ??e?a? t??, de? µp????? ?a
  ?a??f???? µe f?s???????? ap? t?? st?µat??
  d?at??f? µe t?? s????e?? t??f?? ? ?a? ta
  s?µp????µata.
• 
  F. ?a?fa???t??? 2001

77
???t???a ep?????? as?e??? ??a ??????s? te???t??
d?at??f?? st? sp?t?

• ? as?e??? de? µp??e? ?a ?a???e? t?? ?µe??s?e?
  ??ept???? t?? a????e? µe ap? t?? st?µat??
  d?at??f? ? s?µp????µa
• ? ?at ????? d?at??f? e??a? asfa???, d??at? ?a?
  p?? ??a??p???t??? ap? t?? pa?atetaµ???
  e?d???s???µe?a?? ??s??e?a se s??s? µe t?? ????a
  p???s? t?? as?e??
• ??a p???? f???t?da? µp??e? ?a s?ed?as?e? ??a ?a
  ep?te???e? ? te????? st????
• ? as?e??? ? ?? s???e?e?? t?? e??a? se ??s? µe
  asf??e?a ?a ??????s??? te???t? d?at??f?
• ?a?a???????s? t?? as?e?? e??a? d??at? se ta?t?
  d?ast?µata
• 
  F. ?a?fa???t??? 2001

78
??a?????s? t?? as?e??? p?? µp????? ?a p?????
te???t? d?at??f? ?at ?????

• ?p???e? ?µ?da (?at???, ??s??e?t??, d?a?t??????,
  fa?µa??p????) p?? ?a a???????s??? t?? as?e??, ?a
  ap?fas?s??? ??a t?? ?e?ape?a , ?a ?a??d???s???
  t?? as?e?? ?a? t??? s???e?e?? t??, ?a? ?a
  s?µµet????? st?? pa?a???????s? t?? as?e??
• ? ?at?stas? t?? as?e?? e??a? s?et???
  sta?e??p???µ??? ?ste ?a e??a? d??at? ? ???d?? ap?
  t? ??s???µe?? ?a? ? f???t?da st? sp?t?
• ? as?e??? de? µp??e? ?a ?a???e? t?? ?µe??s?e?
  ??ept???? t?? a????e? µe ap? t?? st?µat??
  d?at??f? ? µe s?µp????µa
• Nancy Evans Stoner 1997

79
???t???a ep?????? t?? as?e??? p?? µp????? ?a
p????? te???t? d?at??f? ?at ?????

• ? as?e??? ?a? t? s???e???? pe??ß?????
  ?ata?aßa????? ?a? s?µf????? µe t?? ?at ?????
  s?t?s?, t??? ß?a??p???esµ??? ? µa???p???esµ???
  st????? t?? ?a? e??a? e??µe??? ??a t?? d????e?a,
  t? ??st?? ?a? t?? ?????? a?t?? t?? ??st??? ap?
  t?? asfa??st??? t??? f???a
• To s???e???? pe??ß????? ? ? as?e??? µp????? ?a
  ??????s??? µe asf??e?a e?te???? ? ?a? pa?e?te????
  d?at??f?
• ???at?t?ta µ???s??, d??at?t?ta s?µµ??f?s?? µe
  ?d???e?, ??a??p???t??? de???te???a, d??at?t?ta
  a?????s?? ?a? ?ept?? ?e???sµ??,d??aµ?, µ??µ?
• ?? pe??ß????? t?? as?e?? p??pe? ?a e??a?
  ?at?????? ??a t?? f??a?? ?a? t?? asfa?? ?e???sµ?
  t?? p?????t??
• ?e??, ??e?t????, ????, t???f???, ?a?a??? ?????,
  e????? p??sßas? se µp????
• 
  Nancy Evans
  Stoner 1997

80
?a????sµ?? ????? ?a? e??????

• ?s?e??? ? ???st??
• S???e???? pe??ß????? ? e?d??? ß????? ?
  ?e??p???s?/ f???t?da, pa?a???????s? ?a? e??µ???s?
  ?at???
• Te??p?? ?at??? ?G??µ?te?s?, s??ta?????f?s?,
  pa?a???????s?, te???? e?????
• ??a?t??????? ??at??f??? e?t?µ?s?, ep????? µa?? µe
  t?? ?at?? ?at??????? s?e?asµ?t?? e?pa?de?s?
  as?e?? / s???e???, pa?a???????s? / e?t?µ?s? ?a?
  e??µ???s? ?e??p??t?? ?at???
• ? ?a?? ? e??e?p?? e?pa?de?s? t?? as?e?? ?a? t??
  p??s?p?? p?? t?? f???t????? ??e? ?? ap?t??esµa
  t?? a???µ??e? ep?p????? ?a? t? a???µ??? ??st??
  ???? epa?e?sa????? st? ??s???µe??

81
?a????sµ?? ????? ?a? e??????

• ??s??e?t??? ?a??d???s? , e?pa?de?s? as?e??
  /s???e???
• Fa?µa??p???? ????? d?a??µ?t?? pa?e?te?????
  s?t?s??
• ?sfa??st??? f???a? ? ?????? ??st???
• Fa?µa?e?t??? eta??e?a ? S??e??as?a, e?t??es?
  pa?a??e???? , d?a??µ? ?at ????? p?????t?? ?a?
  s?s?e??? ?a? pa???? ??s??e?t???? ?p??es???,
  e??µ???s? se ?e??p??ta ?at??
• St?? ?????a ?a? st?? ??? ?p?????? standards ??a
  t?? eta??e?e? p?? pa?????? ?p??es?e? te???t??
  ?at ????? d?at??f?? ?p?? ??pa?de?s? t??
  as?e?? ?a? s???e????? p??s?p?? , ??apt?? ?d???e?
  ???s?? ?a? 24??? ??aµµ? e??p???t?s??

82
T?µata ??st??? ?a? taµe???

• ??a?????s? asfa??st???? f???a ?a? apa?t?se?? ??a
  s?st? ??????
• ??st???? ?a???e? p?? af????? t?? ???µate?se?? ?a?
  t?? as???e?e? p?? ?a??pt??ta? ap? t? taµe??
• ?p????? t??p?? p??µ??e?a? ?????? ?a? d?a??µ?t??
• ??a?????s? ?t? t? a????? ??st?? p????? f????
  p??pe? ?a ?a??f?e? ap? t?? as?e??, µ???? ?a
  e?????e? ? dap??? ap? t? taµe??
• 
  Nancy Evans Stoner 1997

83
?p????? as?e??? ??a µe????? d????e?a? ?at ?????
PN

• ?s?e?e?? µe µ? ?e?t??????? G? ?p??
• S??d??µ? ß?a???? e?t???? (lt100cm)
• ?s?a?µ???? ??s?? t?? e?t????
• ??ata?a??? t?? ????t???t?ta? t?? e?t????
• ??t????? e?te??t?da
• ??s?? t?? Crohn
• ?????a ap?f?a?t??? ??s?? t?? ??t? G?
• ?e?d? ap?f???e??
• ??te??p??e?a ?fe???µe?? se AIDS
• ?e?p??sµata (??? se te?e?ta??? stad??? as?e?e??)
• S???e?e?? ??s?? t?? G?
• S?ßa?? s??d??µa d?sap????f?s??
• Dickerson et al. 1998
  
  

84
?p????? as?e??? ??a ?at ????? te???t? EN

• ?s?e?e?? µe ?e?t??????? G? p?? de? µp????? ?a
  t?af??? ?a?????? ap? t? st?µa ? t? ?a??????
  fa??t? de? ?a??pte? t?? ?a??µe????? a????e?
• S?ßa?? a???e??a se s??d?asµ? µe ??????
  e?e??e?a??? ?a? p??te?????? a????e? (AIDS,
  ?a?????pa?e??)
• ??ata?a??? st?? ?at?p?s? (???efa????,
  ?e?????????? d?ata?a???, at??s?a ? st???s?
  ??s?f????, Ca ??s?f????, e??ef???? ? t?a?????,
  ap?f?a?? t?? ??? G?)
• Gast???? p??es?
• ?p?a? µ??f?? d?sap????f?s? p?? a?t?µet?p??eta? µe
  e?d??? d?a?ta
• (s??d??µ? ß?a???? e?t????, f?e?µ???de?? pa??se??
  t?? e?t????)
• ?s?e??? µe ??st??? ???s?
• S???e?e?? µetaß?????? d?ata?a??? (?????????s? ,
  ?pe???s??????sµ??,)
• ?????e? ?e???µ????? d?ata?a???, e??efa????
  pa????s?, a???e??a
• Dickerson et al. 1998

85
?p????? t??p?? ??????s?? te???t?? d?at??f??

• ?p????? ?a?et??a
• ?a?e?te???? d?at??f?
• ?p????? ?a?et??a ap? a??e?t??? ?????, µe
  ?p?d???e?? t???e? p?? ?a µe???e? t?? p??a??t?te?
  µ????s?? .
• ??te???? d?at??f?
• ?p????? ?G ?a?et??a ??a s?t?s? lt 2 µ???? (ap? PUR
  ? SIL - ??a??? ???e 2-3 eßd?µ?de?)
• ?p????? ?at? p??t?µ?s? ?ast??st?µ?a? (PEG, Button
  ? ?e????????? ?ast??st?µ?a) ??a pa?atetaµ???
  s?t?s? µe µe?a??te?? ?????µa ap? ??a ap??
  ???et??a s?t?s??, ?a? d??at?t?ta s?t?s?? ?at?
  bolus
• ?p????? ??st?d?st?µ?a? ??a pa???aµ?? t??
  st?µ????, µe??s? p??a??t?ta? e?s??f?s?, µe µ????
  ?????µa . ???at?t?ta p?????? e?te????? s?t?s??,
  a??? apa?a?t?t? ? ???s? a?t??a?

86
??µata ??a t?? ??????s? te???t?? d?at??f??

• ?a????sµ?? p????? s?t?s??
• S?st? ep????? p?????t?? ?a? s?s?e??? ??????s??
  e?????? st?? ???s?, p?? apa?t??? ?s? t? d??at?
  ????te???? ?e???sµ??? ap? t?? as?e?? ? t??
  s???e???? pe??ß?????
• ?a????sµ?? ??????s?? ??t?a ?e??? ?a? ß?taµ????
  (a? e??a? apa?a?t?te?)
• ?a????sµ?? d????e?a? s?t?s??/ ?µ??a . ??
  p????aµµa p??pe? ?a ta?????e? µe t?? ?a??µe?????
  as????e? t?? as?e?? . ?e?t???eta? ?ts? ? ap?d???
  (Compliance)
• ?? s?t?s? ?at? p??t?µ?s? t? ß??d? (12 ??e?) ??a
  t?? d??at?t?ta ????s?? ?a? a?e?a?t?s?a? t??
  as?e??
• 
  Nancy Evans Stoner 1997

87
??µata ??a t?? ??????s? te???t?? d?at??f??

• ?a????sµ?? p????? s?t?s??
• ?? ?at? bolus s?t?s?, µ?µ?s? ?a??µe????? ?e?µ?t??
• ?? s??e??? s?t?s?, ?at? p??t?µ?s? t? ß??d? (12
  ??e?) ? ?a ???s?µ?p??e?ta? e?d??? a?t??a p??
  ep?t??pe? t?? ????s? t?? as?e??
• ??pa?de?s? t?? as?e?? ?a? t?? s???e?????
  pe??ß?????t?? (?e?t?????a a?t??a?, pe??p???s??
  st?µ?a?, f??a?? ,p??et??µas?a ?a? ?e???sµ??,
  pa?a???????s? s?µpt?µ?t??, ap?f??? ?a?
  a?t?µet?p?s? ep?p?????, ep????????a µe t??ef?????
  ???t??, ?a??µe???? f???t?da, s??epe?? e?et?se??)
• ?a???? ????af?? ??????
• ?a????sµ?? t?? te????? st???? d?at??f????
  ?p?st?????? (s??????? d????e?a s?t?s??, ep?te???
  st????)
• ???at?t?ta a?a?e???s?? p????? a?????a µe
  p??ß??µata ? a????e?
• ?a?a???????s? as?e?? , ?a? e?t?µ?s? p??e?a? t??
  (e?et?se??, f?s???????? e?t?µ?s?, e?t?µ?s?
  ap?d???? t?? ?e?ape?a?)
• 
  Nancy Evans Stoner 1997

88
???ß??µata ?a? ep?p????? t?? µa???????a? ?at
????? PN

• ?????s? t?? ?a?et??a
• 1-4/1000?µ??e? s?t?s?? se pa?d?? , (0,3-1.3/
  1000?µ??e? s?t?s?? se e?????e?,?????te?? se
  s??s? µe ??s???µe??)
• ?pa?a?t?t? ? ap?µ?????s? se pe??pt?se??
  µ???t???? µ????se??,
• ?e?????? ep?p????? µeta????s? ? ?atast??f? t??
  ?a?et??a
• T??µß?s? (??????s? ?pa?????)
• ??ata?a??? st? ?s?????? ?????, ??e?t????t??
• ???e??e?? ß?taµ???? (Fo) ?a? µet????? (Fe, Zn)
• ??ata?a??? sta ep?peda t?? ????????
• ?etaß????? ??s?? t?? ?st?? (e?e??e?? se ß?taµ??e?
  ? µ?ta??a, a????s?a, fa?µa?e?t??? a???? ???? )
• ?pat???? d?ata?a??? (??????? ??????s? ?? a?t? ??a
  s??e??)

89
???ß??µata ?a? ep?p????? t?? µa???????a? ?at
????? PN

• Se ?e????? ??aµµ?? ?? pa?d?at????? as?e?e?? se
  HPN, ????? ?a??te?? p??ß????µ? ep?ß??s?? ?a?
  µe?a??te?? p??a??t?ta ?a ?e????s??? ?? µ?sa se 1
  ????? ap? ?t? ?? e?????e? as?e?e??, a???
  e?s????ta? µe µe?a??te?? s????t?ta st? ??s???µe??
  ??a s??? p?? s?s?et??eta? µe HPN.

90
???ß??µata ?a? ep?p????? t?? ?at ????? ??

• ?µet?? ?a? ??s??f?s? (??e?µ???a ap? e?s??f?s?)
• ?????? ???µ?? ??????s??, µe??µ??? ta??t?ta
  ade??sµat?? t?? st?µ????, ????? ?ast????
  ?p??e?µµa, ?ast?? ??s?fa???? pa???d??µ?s?,
  µe??µ??a a?ta?a??ast??? st?s? t?? as?e?? ?at? t??
  ??????s?, ?e?????????? d?ata?a???, µet??es? t??
  ???e?t??a s?t?s?? st?? ??s?f???

91
???ß??µata ?a? ep?p????? t?? ?at ????? ??

• ???????a
• ?????? ???µ?? ??????s??, ??????s? ?at? Bolus,
  a?t?ß??t??? ?e?ape?a, d?sap????f?s?, ? ?a?
  µ????s? t?? d?a??µat?? e?d??? a? e??a? pe?ast?
• ??s??????t?ta
• ?e??µ??? p??s???? se ?e??, ap??e?a f?t???? ????
  ap? t?? t??f?
• Gast?e?te????? d?ata?a??? (F??s??µa, ?a???a ?t?.)
• ???µ? ??????s??, ?????? ????? t??f??, ?a??
  ??????s? fa?µa?e?t???? a?????
• ??e??sµ?? st?? µ?t?, ??s?f???, st?µa??
• ?a?atetaµ??? ???s? ?????ast????? ?a?et??a

92
???ß??µata ?a? ep?p????? t?? ?at ????? ??

• ??ata?a??? st? ?s?????? ?????, ??e?t????t??,
  µet????? ?a? ß?taµ????
• ?e??µ??? p??s???? se ?e??, ??e?t????te?,
  a???µ??e? a????e? se ß?taµ??e?, d?sap????f?s?
  µet????? ?a? ß?taµ????, µetaß???sµ??
• ?etaß?????? d?ata?a??? (p?? sp???e? se sx?s? µe
  PN)
• ?f?d?t?s?, ?p??at?eµ?a (???? d??????a?),
  ?p?????a?µ?a
• ?????µa t?? ?a?et??a ? t?? s?s?e??? ??????s??
• ??????s? fa?µ???? ap? t?? ?a?et??a, ??p??µa t??
  ?a?et??a, a??a?? s?s?e??? a?? 24???, ??????s?
  pe?ast?? t??f??, ???e??? ?a?et??a, ??????s? µe
  ßa??t?ta, pe??e?t???t?ta se ??e?

93
????t?ta ???? se as?e?e?? µe ?at ????? ??

• ? p???t?ta e??a? µe??µ??? se s??s? µe t?? ?e????
  p????sµ? ?????? ???? ?p??e?µe??? ??s??
• ? p???t?ta ???? ße?t???eta? st?? ?at ????? ?? se
  s??s? µe t?? e?a??a?t??? t?? s??e???? pa?aµ????
  st? ??s???µe??.
• ?? ??e??e? de?????? ?t? ?? ???? as?e?e?? se ?at
  ????? ?? d??????? pe??ss?te?? ße?t??s? st??
  p???t?ta t?? ???? t??? se s??s? µe t???
  ??????µ?????.
• ?a?d?at????? as?e?e?? se ?at ????? ?? ????? t??
  d??at?t?ta ?a p??e s???e?? ?a? ?a s?µµet????? se
  sp??.
• ? p???t?ta t?? ?p??? s?????? ?e???te?e?e? e?
  a?t?a? ???te????? ????s?? ?a? s??a?e?µ?? t??
  a?t??a?
• ? ?? ep??e??e? ?????? t??? t?µe?? t?? ?p???, t??
  ta??d??? , t?? ?s??s?? ?a? t?? ?????????? ????

94
????t?ta ???? se as?e?e?? µe ?at ????? ??

• ? p???t?ta e??a? µe??µ??? se s??s? µe t?? ?e????
  p????sµ? ?????? ???? ?p??e?µe??? ??s??
• S?µf??a µe µa?t???e? s???e??? ?a? as?e??? ?
  p???t?ta ???? ße?t???eta? st?? ?at ????? ?? se
  s??s? µe t?? e?a??a?t??? t?? s??e???? pa?aµ????
  st? ??s???µe??.
• ?a? ??a a?t? ? t?p???t?s? t?? ?a?et???? s?t?s??
  p???a?e? d?sa??s??a ?a? e?????s?
• ???t?µ?ta? ? s?t?s? µ?s? st?µ?a? ? Button se
  as?e?e?? µe ????????? ??? p?? de? ep???µ??? ?a
  fa??eta? ? s????a?.
• ?e??µ??? d??at?t?ta ?????e?e?a??? ?e?µ?t??
  (s?µa?t??? st?? ?????e?e?a?? s??????)

95
???sd???µ? ep?ß??s?? as?e??? se te???t? d?at??f?
?at??????

• ??a?t?ta? ap? t?? ?p??e?µe?? ??s?.
• ?.?. ?s?e?e?? se ?? µe ??s?? t?? Crohn--gt
  µ????te?? ???s?µ?t?ta ap? ?a????? ?a? AIDS
• ?.?. ?s?e?e?? se ?? µe ?a????? ?a? d?ata?a???
  ?at?p?s??--gt ????? ???s?µ?t?ta

96
????? t?? d?a?t??????

• ??at??f??? e?t?µ?s? p??? ap? t?? ???d? t?? as?e??
  ap? t? ??s???µe??
• ?p????? d?at??f???? s??µat?? ?a? t??p?? ??????s??
  se s??e??as?a µe ?e??p??ta ?at??
• ??pa?de?s? as?e?? ?a? s???e???
• ?a?a???????s? p??e?a? as?e??, ep?p?????, a??a???
  t?? a?a???? ?a? p??sa?µ??? d?at??f???? s??µat??
• Stad?a?? ep?st??f? st?? ap? t?? st?µat?? s?t?s?