1、Case conference- Early feeding s/p gastrectomy 萬芳醫院 張靜怡 營養師 2005/11/22 1 手術前積極的給予 7天以上之 全靜脈營養支持 (total parenteral nutrition; TPN)， 可降低手術後併發症 (如：感染率 )發生率 (Ikeda et al. 2004) 2 Protein-energy malnutrition in the gastrectomized patient (Papim 2002 ) 3 接受腹部手術後，儘早給予 腸道營養支持 (early enteral feeding) 與只是全靜脈營
2、養支持方式比較， 更有助於病患術後的恢復情況 (Huckleberry 2004 ) Early enteral Feeding 4 早期經由空腸造口給予之營養支持，可 以提高免疫系統力降低感染發生率 (Papim 2002 ) Early enteral Feeding 5 對於 營養不良 病患，給予 空腸造口 作 為腸道營養餵食途徑，可避免在手術後 避免因由口進食情況不佳，造成熱量及 蛋白質攝取不足，而影響傷口復 原、延長住院天數與增加其感染發生率 (Papim 2002 ) Early enteral Feeding 6 Treat adverse effects of EEN 1.Ab
3、dominal cramps : - traded first with non-steroid analgesic drug (Cataflam, Relifex) - with opioid as second choice (Morphine) - infusion rate reduced by 20 ml/h - temporary stopped for 6-12 hours and resumed at a lower rate 2.Abdominal bloating : - traded first with prokinetics drugs (Gascon, Biofer
4、min) - infusion rate reduced by 20 ml/h - temporary stopped for 6-12 hours and resumed at a lower rate (M. Braga et al 2002 ) 7 Treat adverse effects of EEN 3.Vomiting : - treated by temporary stop of infusion followed by diagnostic procedures - if no intestinal obstruction was detected, infusion wa
5、s resumed at the same rate 4.Diarrhea : - reduction of infusion rate by 20 ml/h - temporary stop for 6-12h and later with resumption at a lower rate - In patient with persistent diarrhea , Clostridium difficile infection was always ruled out (M. Braga et al 2002 ) 8 Case report 9 個案基本資料 性別：男性 年齡： 78
6、歲 (民國 16年 10月 27日 ) 身高： 163.5 公分 入院體重： 61.8公斤 (BW loss 20.8%) 通常體重： 78公斤 ( 6 months ago) 理想體重： 59 5.9公斤 BEE = 1190 kcal /day TER =1700 1800 kcal/day PT req. : 73 80 g/ day 10 個案基本資料 Medication histories ： 1. HTN 2. Old CVA 3. Old TB 4. CRI 5. PU (about 3 years ago) 6. Thalassemia (病患自述 ) 11 入院摘要 入院時
7、間： 94/10/12 科別： 一般外科 主訴症狀： UGI massive bleeding (about 2000c.c.) 8 days ago then admitted in TVGH (Dx: Gastric ca by PES & CT study) 診斷： Gastric cancer 12 Operation Date : 94/10/18 Pre-Dx : Gastric cancer Clinical finding(10/13) : ulcerative tumor at LCS (mid-body) with invasion to mesocolon 5.5*4.5
8、cm Method : 1.Radical B- subtotal gastrectomy 2. Cholecystectomy 3. Feeding jejunostomy 4. LN dissection No 1,3,4,5,6,7 Biopsy : 1. Adenocarcinoma, intestinal type 2. LN negative for metastic carcinoma 13 Nutrition support progress Date TPN order Energy/AA Date (Kcal / g ) EN Energy/PT (Kcal / g ) 1
9、0/12 A160 c.c./hr+ 20% lipofundin 200ml 1399 / 50 10/12 NPO - 10/14 A260 c.c./hr+ 20% lipofundin 200ml 1840 / 63 10/13 As tolerance 10/14 500 / 20 10/16 10/17 CLD NPO 10/19 NPO ED s rate 20c.c./hr * 18hr 10/21 A2300 c.c./hr+ 20% lipofundin 200ml 10/20 10/21 ED s FS rate 30c.c./hr * 18hr 10/24 TPN DC
10、 10/22 10/23-24 rate 40c.c./hr * 18hr rate 50c.c./hr 60 10/24 D10W run 60c.c./hr 10/25 10/26 MD 50c.c./hr DC Oral TF (Jejunostomy) NPO OP day on 10/18 1385 / 32 NPO NPO NPO NPO NPO 25 / 1 300 / 16 540 / 28 720 / 38 800 / 42 530 / 22 10/28 oral :CLD 11/2 Soft diet 10/25 Kabiben run 60c.c./hr 500 / 0
11、1037 / 34 Diarrhea 12days 14 TPN 處方箋 代碼 品項 Glucose gm/L AA gm/L Electrolyte (mEq/L) TPN A1 Standard 163 35 46 37 12 8 6 37 71 694 TPN A2 High stress 187 44 50 40 15 8 6 36 77 812 TPN A3 Hepatic failure 239 38 50 40 15 8 6 60 47 965 TPN A4 Renal failure 333 23 - - - - - - - 1224 TPN B1 Aminomix 200 5
12、0 50 30 15 5 5 100 - 1000 Na K P Mg Ca Cl Acetate Total Kcal/L Fat emulsion : 20 % Lipofundin 100ml/BT 20% Intralipid 100ml/BT 10% Lipovnous 500ml/BT Infuvita (Vit A, D E, B1, B2, B6 ,B12 VitC, Niacin , Pathenol, Bioin, Folat) Trace element Zn, Cr, Cu, I, Mn 15 Nutrition support (Energy) Early enter
13、al Feeding PPN + ENTPN+EN BEE MBD 11/7 10/26NPO Diarrhea OP day TER 16 Nutrition support (Protein) Early enteral Feeding PPN + ENTPN+EN PT req. MBD 11/7 10/26 NPO OP day 17 Nutrition Status OP (10/18 )Admission 10/19 Alb 1 BT bid*2days 18 Nutrition Status OP (10/18)Admission 174 19 Nitrogen Balance
14、OP (10/18) 10/12 10/17 10/25 10/31 20 Nutrition Status OP (10/18)Admission 11/20 MBD (11/7) BW loss 6.7% in 2 weeks 21 Nutrition Status OP (10/18)Admission 22 Hb (14-18) / Hct (42-52) OP (10/18) 10/17 10/19 10/25 10/31 11/ 3 23 Discussion 24 Diarrhea 配方轉換，適合嗎？ 元素 聚合？ 是否調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？ 25 胃切除手術後營養支持 如何增加熱量與蛋白質攝取？ 飲食評估資料： Diet record 體重追蹤 Diarrhea or steatorrhea 26 Thanks for your attention 27
