1、1Case conference-Case conference-Early feeding s/p gastrectomyEarly feeding s/p gastrectomy萬芳醫院張靜怡 營養師2005/11/222005/11/22CYC2 手術前積極的給予手術前積極的給予7天以上之天以上之全靜脈營養支持全靜脈營養支持(total parenteral nutrition;TPN)，可降低手術後併發症可降低手術後併發症(如：感染率如：感染率)發生率發生率(Ikeda et al.2004)2005/11/22CYC3Protein-energy malnutrition in th
2、e gastrectomized patient(Papim 2002)2005/11/22CYC4接受腹部手術後，儘早給予接受腹部手術後，儘早給予腸道營養支持腸道營養支持(early enteralearly enteral feeding)feeding)與只是全靜脈營養支持方式比較，與只是全靜脈營養支持方式比較，更有助於病患術後的恢復情況更有助於病患術後的恢復情況 (Huckleberry 2004)Early enteral Feeding2005/11/22CYC5早期經由空腸造口給予之營養支持，可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以提高免疫系統力降低感
3、染發生率(Papim 2002)Early enteral Feeding2005/11/22CYC6 對於對於營養不良營養不良病患，給予病患，給予空腸造口空腸造口作作為腸道營養餵食途徑，可避免在手術後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原、延長住院天數與增加其感染發生率 (Papim 2002)Early enteral Feeding2005/11/22CYC7Treat adverse effects of EEN1.Abdomina
4、l 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,Biofermin)-infusion rate red
5、uced by 20 ml/h -temporary stopped for 6-12 hours and resumed at a lower rate(M.Braga et al 2002)2005/11/22CYC8Treat adverse effects of EEN3.Vomiting:-treated by temporary stop of infusion followed by diagnostic procedures -if no intestinal obstruction was detected,infusion was resumed at the same r
6、ate 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)9Case report2005/11/22CYC10個案基本資料個案基本資料性別：男性 年齡：78歲(民國16年10月27日)身高：1
7、63.5 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/dayTER=1700 1800 kcal/dayPT req.:73 80 g/day 2005/11/22CYC11個案基本資料個案基本資料Medication histories：1.HTN 2.Old CVA 3.Old TB 4.CRI 5.PU(about 3 years ago)6.Thalassemia(病患自述)2005/11/22CYC12入院摘要入院摘要入院時間：94/10/12科別：一般外科主訴症狀：UGI
8、 massive bleeding(about 2000c.c.)8 days ago then admitted in TVGH (Dx:Gastric ca by PES&CT study)診斷：Gastric cancer2005/11/22CYC13OperationDate:94/10/18 Pre-Dx:Gastric cancerClinical finding(10/13):ulcerative tumor at LCS(mid-body)with invasion to mesocolon 5.5*4.5cm Method:1.Radical B-subtotal gastr
9、ectomy 2.Cholecystectomy 3.Feeding jejunostomy 4.LN dissection No 1,3,4,5,6,7Biopsy:1.Adenocarcinoma,intestinal type 2.LN negative for metastic carcinoma 2005/11/22CYC14Nutrition support progressDateTPN orderEnergy/AA Date(Kcal/g)EN Energy/PT (Kcal/g)10/12A160 c.c./hr+20%lipofundin 200ml1399 /50 10/
10、12 NPO -10/14A260 c.c./hr+20%lipofundin 200ml1840/63 10/13As tolerance 10/14 500/20 10/16 10/17 CLD NPO 10/19 NPO ED s rate 20c.c./hr*18hr10/21A2300 c.c./hr+20%lipofundin 200ml 10/20 10/21 ED s FS rate 30c.c./hr*18hr10/24TPN DC 10/22 10/23-24 rate 40c.c./hr*18hr rate 50c.c./hr 6010/24 D10W run 60c.c
11、./hr 10/25 10/26 MD 50c.c./hr DC OralTF(Jejunostomy)NPOOP day on 10/181385/32NPONPONPONPONPO25/1300/16540/28720/38800/42530/2210/28 oral:CLD11/2 Soft diet10/25 Kabiben run 60c.c./hr 500/01037/34Diarrhea12days2005/11/22CYC15TPN 處方箋處方箋代碼品項Glucosegm/LAAgm/LElectrolyte(mEq/L)TPN A1Standard16335463712863
12、771694TPN A2High stress18744504015863677812TPN A3Hepatic failure23938504015866047965TPN A4Renal failure 33323-1224TPN B1Aminomix2005050301555100-1000NaKPMgCaClAcetateTotalKcal/LFat emulsion:20%Lipofundin 100ml/BT 20%Intralipid 100ml/BT 10%Lipovnous 500ml/BTInfuvita(Vit A,D E,B1,B2,B6,B12 VitC,Niacin
13、,Pathenol,Bioin,Folat)Trace elementZn,Cr,Cu,I,Mn2005/11/22CYC16Nutrition support (Energy)Energy)Early enteral FeedingPPN+ENTPN+ENBEE MBD 11/710/26NPODiarrheaOP dayTER2005/11/22CYC17Nutrition support(Protein)Protein)Early enteral FeedingPPN+ENTPN+ENPT req.MBD 11/710/26NPOOP day2005/11/22CYC18Nutritio
14、n StatusAlbumin(3.4-5.0)Albumin(3.4-5.0)3.23.22.72.93.13.42.52.72.93.13.33.510/1210/1510/1810/2110/2410/2710/3011/2日期g/dl OP(10/18)Admission10/19 Alb 1 BT bid*2days2005/11/22CYC19Nutrition StatusTransferrin(174-348)22418110813322205010015020025010/1210/1510/1810/2110/2410/2710/30日期日期mg/dlmg/dl OP(10
15、/18)Admission1742005/11/22CYC20Nitrogen Balance-1.45-1.2-5.8-6-4-20246公克/天公克/天10/1210/1510/1810/2110/2410/2710/30日期日期 OP(10/18)10/1210/1710/2510/312005/11/22CYC21Nutrition StatusBody weight(Kg)56606264.561.761.850525456586062646610/1210/1710/2210/2711/111/611/1111/16 日期日期 OP(10/18)Admission11/20MBD(
16、11/7)BW loss 6.7%in 2 weeks2005/11/22CYC22Nutrition StatusTotal lymphocyte count5517262161718559503020040060080010001200140016001800200010/1210/1510/1810/2110/2410/2710/3011/2 日期日期 OP(10/18)Admission2005/11/22CYC23Hb(14-18)/Hct(42-52)10.111.212.49.710.4931.131.132.737.53528.1515253510/1210/1510/1810/2110/2410/2710/3011/2HbHbHctHct OP(10/18)10/1710/1910/2510/3111/324Discussion 2005/11/22CYC25Diarrhea 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？2005/11/22CYC26胃切除手術後營養支持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 steatorrhea27Thanks for your attention
