問題病患消化不良或是拉肚子一般會在配方上或是卡數上做什麼樣的調整? 如使用米湯啦或者什麼配方的介入? ICU 病人高血糖及腎功能不佳, 會建議醫師加胰島素, 營養給腎低的配方, 但 ICU 醫師都說要先供糖尿病配方, 請問在配方上要如何調整? RCW 病人給的熱量都是 >35 大卡, 甚至

重症營養暨營養診斷實務分享馬偕醫院許碧惠 2016/05/28

問題病患消化不良或是拉肚子一般會在配方上或是卡數上做什麼樣的調整? 如使用米湯啦或者什麼配方的介入? ICU 病人高血糖及腎功能不佳, 會建議醫師加胰島素, 營養給腎低的配方, 但 ICU 醫師都說要先供糖尿病配方, 請問在配方上要如何調整? RCW 病人給的熱量都是 >35 大卡, 甚至 40 卡 /KGBW 或是 45, 但醫師認為還是要加熱量, 個案就是很瘦才 40 幾公斤,... 給這麼高的熱量及蛋白質, 病人一樣呼吸器脫離不掉, 反而越養越胖? RCW 個案 82 歲, 熱量漸進給予到 40kcal/kg, 蛋白質給予 1.9g/kg, 消化佳, 體重無變化, 沒有其他特殊問題但半年來 Alb 一直拉不起來 (2.9-2.9-2.8), Hb( 平均 9-10) 還有其他建議? 長者多重慢性病 BMI 低消化不佳半罐 / 餐 ( 已給予雙卡 *3/ 天 ) 體位無法上升有什麼營養建議嗎?? 給予單體配方?? 增加次數?? 長者的熱量供應有建議到多少嗎?? 因為用現由體位 *35KG 都上不去會乘到 40 以上才有成效那有上限嗎?? 有 DM 及 CKD 病史 (STAGE-4) 且身上傷口又多建議配方給予可以再給高蛋白嗎病人入院診斷 : 肺炎臥床 - 給 DM 配方有 DM 病史已有再用藥跟打胰島素但血醣仍起伏大例如每天清晨 AC100~187 mg/dl 這種情況下配方還需要再一直做調整嗎還是可以就維持給 DM 配方持續 F/U 即可當病人患有糖尿病及腎臟病時但血糖控制不佳 Cr 又高時是要給予控制熱量還是給予低蛋白飲食? 一般急性病房營養篩檢最簡單且有效的方法? 是否有評估工具可參考? 管灌食病患傷口多, 除了給予足夠熱量蛋白質外, 臨床上還可給予哪些 support 讓傷口癒合更快 (Glutamine 成本高 )?

Stress responses Hyper metabolism Hyper catabolism Persistent lean body mass wasting Hyperglycemia Fluid accumulation 3

Physiologic change associated with stress response Response Physiologic Benefit Potential Physiologic risk Protein catabolism Ensure adequate substrate for acute phase response, gluconeogenesis, wound healing, immune function Functional tissue loss hypoalbuminemia hyperglycemia Ensure substrate availability Hyperglycemia Immune dysfunction Osmotic diuresis Hyperosmolarity Protein glycosylation Sodium and water retention Maintain intravascular volume Hyponatremia Hypervolemia Pulmonary edema Cogestive heart failure Hypomagnesemia Increase heart rate and cardiac output Maintain organ perfusion Increase cardiac work Increase myocardial ischemia Arrhythmias Hyper coagulability; Increase platelet aggregation Hemostasis Micravascular thrombosis Deep venous thrombosis Pulmonary embolus Increase sympathetic tone Increase cardiac output Increase substrate availability (glycogenolysis, lipolysis) Increase myocardialb irritability Hyperglycemia Inhibits insulin Shunting of blood flow to central organs, away from gut 4

The metabolic alterations of the stress response Metabolic parameters Rate compared to normal Resting energy expenditure Increase Oxygen consumption Increase Carbohydrate metabolism Blood sugar concentration Increase Gluconeogenesis Increase Glycogenolysis Increase Tissue glucose uptake/oxidation Increase Fat metabolism Ketogenesis No change/decrease Lipolysis Increase Tissue uptake/oxidation Increase Protein metabolism Net synthesis Decrease Net breakdown Increase Hepatic synthesis Increase Muscle synthesis Decrease Ureagenesis Increase 5

營養評估工具迷你營養評估量表 Mini Nutritional Assessment; MNA 主觀性整體評估表 (Subjective Global Assessment; SGA) 營養不良通用篩檢工具 (Malnutrition Universal Screening Tool; MUST) 營養不良篩選表 MST Malnutrition Screening Tool; MST 老人營養風險指標 Geriatric Nutritional Risk Index; GNRI

重症營養評估 NRS 2002 NUTRIC score Nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. High nutrition risk identifies those patients most likely to benefit from early EN therapy. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

Nutritional risk screening; NRS 2002

NUTRIC score

NUTRIC Score 的相關研究作者受試者年齡人數方法 Heyland DK et al., 2011 18 歲. 597 位病人. 入 ICU > 24 小時. 211 位入 ICU 3 天. 年齡 baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, interleukin-6, CRP, BMI, 進食量, 3 個月體重減輕, procalcitonin (PCT). 28 天死亡率. 28 天內無使用呼吸器天數. NUTRIC score: 含年齡 baseline APACHE II, baseline SOFA score, number of NUTRIC score:comorbidities, days from hospital admission to ICU admission, interleukin-6. NUTRIC score 分數高增加 28 天死亡率及 28 天內呼吸器使用天數. 高風險的病人增加營養攝取可降低死亡率 Heyland DK et al., 2015 18 歲. 多國家研究. 入 ICU > 96 小時. 使用灌食 > 96 小時. 3390 位病人. NUTRIC score. 評估及收集 12 天熱量及蛋白質需求及攝取. 分析死亡率 ICU 及總住院天數呼吸器使用天數. NUTRIC score 較高分者及住 ICU>7 天者接受 EN 的時間較晚 (41.3 vs. 35.5 小時, P<0.001) Rahman A et al., 2015 18 歲. 歐洲及北美共 40 個 ICU 研究. 入 ICU >5 天. 1199 位病人. NUTRIC score ( 無 IL-6). NUTRIC score 及 28 天死亡率. 28 天死亡率為 29% 平均 NUTRIC score 為 5.5±1.6 分. NUTRIC score 每增加 1 分 28 天死亡率之 OR 值 1.4(95% CI, 1.3-1.5). 對 NUTRIC score 高分者足夠營養攝取與 28 天有很強的正相關. NUTRIC score 高分者有較高的 6 個月死亡率 (P<0.0001). 368 位病人. 使用呼吸器 > 24 小時. NUTRIC-1 score ( 無 IL-6). NUTRIC-2 score (CRP) 比較相者之性能. 可以用 CRP 值來取代 IL-6 以提高 NUTRIC score 的篩檢性能 Moretti D et al., 2014 結果

需積極營養支持者 Starvation-related malnutrition chronic disease-related malnutrition acute disease or injury-related malnutrition 5/13/16 12

Association between nutritional state according to BMI (kg/m 2) and length of hospital stay. The box plots represent the 10th, 25th, 50th, 75th, and 90th percentiles. Clinical Nutrition, Volume 25, Issue 4, August 2006, Pages 563-572 13

aggressive fluid resuscitation, vasopressor therapy, mechanical ventilation and early antibiotic therapy Amino acids and other key substrates are mobilized from various body storage sites, particularly muscle, to provide rapidly available energy and other key substrates for the immune system and other key organ systems as the patient (or water buffalo) fights to survive Phased metabolic/inflammatory response to critical illness and injury. This phased response may also be true for the hormonal, bioenergetics, and immune response. Derived from personal communication with Mervyn Singer. Crit Care. 2013; 17(Suppl 1): S7.

重症病人熱量需求每日總能量消耗組成 JPEN. 2013; 37: 705-13.

問題病患消化不良或是拉肚子一般會在配方上或是卡數上做什麼樣的調整? 如使用米湯啦或者什麼配方的介入? ICU 病人高血糖及腎功能不佳, 會建議醫師加胰島素, 營養給腎低的配方, 但 ICU 醫師都說要先供糖尿病配方, 請問在配方上要如何調整? RCW 病人給的熱量都是 >35 大卡甚至 40 卡 /KGBW 或是 45 但醫師認為還是要加熱量個案就是很瘦才 40 幾公斤... 給這麼高的熱量及蛋白質病人一樣呼吸器脫離不掉反而越養越胖? RCW 個案 82 歲熱量漸進給予到 40kcal/kg 蛋白質給予 1.9g/kg 消化佳, 體重無變化沒有其他特殊問題但半年來 Alb 一直拉不起來 (2.9-2.9-2.8) Hb( 平均 9-10) 還有其他建議? 長者多重慢性病 BMI 低消化不佳半罐 / 餐 ( 已給予雙卡 *3/ 天 ) 體位無法上升有什麼營養建議嗎?? 給予單體配方?? 增加次數?? 長者的熱量供應有建議到多少嗎?? 因為用現由體位 *35 Kcal 都上不去會乘到 40 以上才有成效那有上限嗎?? 有 DM 及 CKD 病史 (STAGE-4) 且身上傷口又多建議配方給予可以再給高蛋白嗎病人入院診斷 : 肺炎臥床 - 給 DM 配方有 DM 病史已有再用藥跟打胰島素但血醣仍起伏大例如每天清晨 AC100~187 mg/dl 這種情況下配方還需要再一直做調整嗎還是可以就維持給 DM 配方持續 F/U 即可當病人患有糖尿病及腎臟病時但血糖控制不佳 Cr 又高時是要給予控制熱量還是給予低蛋白飲食? 一般急性病房營養篩檢最簡單且有效的方法? 是否有評估工具可參考? 管灌食病患傷口多, 除了給予足夠熱量蛋白質外, 臨床上還可給予哪些 support 讓傷口癒合更快 (Glutamine 成本高 )?

熱量計算公式 The best method: IC published predictive equation 25~30 kcal/kg/day American College of Chest Physicians equation 25 weight If BMI 16 25 kg/m2 use usual body weight If BMI > 25 kg/m2 use ideal body weight If BMI < 16 kg/m2 use existing body weight for the first 7 10 d, then use ideal body weight Harris-Benedict equation Men: 66.4730 + (13.7516 weight)+ (5.0033 height) (6.755 age) Women: 655.0955 + (9.5634 weight) + (1.8496 height) (4.6756 age) Ireton-Jones 1992 equation 1925 (10 age) + (5 weight) + (281 if male) + (292 if trauma present) + (851 if burns present) Ireton-Jones 1997 equation (5 weight) (11 age) + (244 if male) + (239 if trauma present) + (840 if burns present) 1,784 Penn State 1998 equation56 (1.1 value from Harris-Benedict equation ) + (140 Tmax) + (32 V E) 5,340 Penn State 2003 equation56 (0.85 value from Harris-Benedict equation ) + (175 Tmax) +(33 V E) 6,433

結果以 BMI 分組 REE 與 HBEE 之比較 BMI < 20 ( n=32) Age (years) Height (cm) 20 BMI < 25 ( n=54) 77.7 ±11.8 159.3 ±8.4 25 BMI 30 BMI < 30 < 35 ( n=29) ( n=11) 73.8 ±12.2 160.8 ±9.3 BMI 35 ( n=7) 74.4 ±11.8 159.2 ±9.3 73.1 ±12.9 156.8 ±7.5 67.3 ±11.4 161.4 ±8.8 Weight (kg) 43.8 ±6.2 e 57.8 ±8.0d 67.9 ±8.5c 77.2 ±7.2b 99.2 ±11.3a BMI (kg/m2) 17.2 ±1.7e 22.2 ±1.4d 26.7 ±1.5c 311.3 ±1.5b 38.0 ±1.3a APACH II 25.6 ±6.9 26.1 ±6.1 26.0 ±6.1 25.6 ±7.2 21.3 ±5.9 HBEE_CBW (kcal) 969 ±131e 1174 ±168cd 1280 ±200bc 1366 ±193b 1718 ±305a HBEE_IBW (kcal) 1123 ±138 1165 ±145 1138 ±163 1117 ±136 1210 ±171 REE_IC (kcal) 1354 ±277bc 1560 ±365 1506 ±342b 1559 ±388 1994 ±439a RQ 0.80 ±0.11 0.80 ±0.07 0.80 ±0.07 0.81 ±0.07 0.81 ±0.07 IC/HBEE(CBW) 1.41 ±0.28b 1.34 ±0.31 1.18 ±0.22a 1.15 ±0.31 1.17 ±0.20 IC/HBEE(IBW) 1.22 ±0.25b 1.34 ±0.29 1.32 ±0.22 1.40 ±0.36 1.65 ±0.30a abcde 同列不同英文字母代表有顯著差異 One-way ANOVA, Scheffe s test 事後比較 P<0.05)

結論以 HB 公式來評估病人熱量需求 HBEE( 目前體重 ) 係數 (stress factor) 會因體位愈胖而愈小 (1.41-1.17) HBEE( 理想體重 ) 係數 (stress factor) 會因體位愈胖而愈大 (1.22-1.65)

ASPEN 指引 (2009) 在開始營養支持時即需有明確灌食目標 (C) 熱量需求評估可用預估公式或 indirect calorimetry (IC) 對肥胖病人使用預估公式會較不準確 (E) 在入院第一週內可達 > 50~65% 灌食目標量即可達臨床效益 (C) 在 EN 7~10 天後仍無法達目標量可考慮補充 PN(E) 需評估病人蛋白質攝取是否足夠不足時可以補充高蛋白奶粉 BMI< 30 者蛋白質需求為 1.2~2.0 g/kg 實際體重 (E) 肥胖病人可允許低熱量灌食 BMI> 30 者熱量給予建議不要超過 60~70% 目標量或者 11~14 kcal/kg ABW (22~25 kcal/kg IBW) 蛋白質需求 2.0 g/kg IBW (BMI 30~40) 2.5 g/kg IBW (BMI 40) 病人因 EN 而腹瀉需進一步評估改善 (E) 可選用含水溶性纖維配方或元素配方 (E)

obesity The goal of the EN regimen should not exceed 65 70% of target energy requirements. 11 14 kcal/kg actual body weight/day for patients with BMI in the range 30 50 22 25 kcal/kg ideal body weight/day for patients with BMI > 50 protein should be provided in a range from 2.0 g/kg ideal body weight/day for patients with BMI 30 40 2.5 g/kg ideal body weight/day for patients with BMI >= 40 patient with a history of bariatric surgery receive supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy. In addition, evaluation for and treatment of micronutrient deficiencies such as calcium, thiamin, vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, along with the trace minerals iron, selenium, zinc, and copper should be considered. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

ESPEN 指引 (2006) 剛開始灌食或急性期熱量給予 < 20~25 kcal/kg BW 恢復期熱量需求為 25~30 kcal/kg BW (C) 營養不良之病人 EN 供應需 > 25~30 kcal/kg/bw 若 EN 無法滿足需求則需補充 PN(C) 對 EN 攝取足夠之病人不建議再給予 PN 補充 (A) EN 配方選擇可用一般完整蛋白配方 (C) 嚴重感染病人不建議使用免疫調節配方 (B)

重症病人蛋白質需求 Ishibashi 等人 (1998 年 ): 蛋白質需求為 1.2 g/kg 未生病前體重無入院前體重者建議給予 1.0 克 / 公斤目前 Weijs 等人 (2012 年 ): BMI=20~30 kg/m2 需 1.2 g/kg 實際體重 (actual body weight; ABW) BMI < 20 kg/m2 1.2 g 身高 (m)2 20 BMI >30 kg/m2 1.2 g 身高 (m)2 27.5 ASPEN 指引 : BMI <30 kg/m2 1.2-2.0 克 / 公斤實際體重或非蛋白熱量 : 氮 =70:1~100:1 BMI >30 kg/m2 > 2.0 克 / 公斤理想體重 BMI >40 kg/m2 2.5 克 / 公斤理想體重每增加 1 公克正氮平衡病人存活率增加 21%(OR=1.211; CI: 1.017-1.443, P=0.03) 2003;19(11-12):909-16.

Nutrition support therapy in the form of early EN be initiated within 24 48 hours in the critically ill patient who is unable to maintain volitional intake. Trophic feeding (defined as 10 20kcal/hr or up to 500 kcal/day) for the initial phase of sepsis, advancing as tolerated after 24 48 hours to > 80% of target energy goal over the first week. We suggest delivery of 1.2 2 g protein/kg/day. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

Enteral feeding Early feeding ( within 48 hrs) Benefits: the effects of hypercatabolism and hypermetabolism More physiologic, cheaper, and safer than TPN Protective effects on gut mucosa and liver Lower rates of infections than TPN 5/13/16 25

Initiate EN 時需注意 P t weight loss Previous nutrient intake Level of disease severity Comorbid conditions GI tract function 5/13/16 26

Figure 1. Early enteral nutrition (EN) vs delayed EN, mortality. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. Copyright by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 4

Figure 2. Early enteral nutrition (EN) vs delayed EN, infectious complications. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. Copyright by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 5

total of 4,786 patients APACHE II: early feeding group: 20.6±7.0 late feeding group: 21.0± 8.0 (CHEST 2006; 129:960 967) 5/13/16 29

Figure 3. Enteral nutrition (EN) vs parenteral nutrition (PN), infectious complications. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. Copyright by 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 6

Kaplan Meier Estimates of the Time to Discharge from the Intensive Care Unit (ICU) and from the Hospital. Timing of the initiation of parenteral nutrition in whom caloric targets cannot be met by enteral nutrition alone. early-initiation group: 2312 patients, PN was initiated within 48 hours after ICU admission late-initiation group: 2328 patients, PN was not initiated before day 8 Casaer MP et al. N Engl J Med 2011;365:506-517. Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation.

Patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (eg, NRS 2002 3 or NUTRIC score 5) who cannot maintain volitional intake do not require specialized nutrition therapy over the first week of hospitalization in the ICU. Patients who are at high nutrition risk (eg, NRS 2002 5 or NUTRIC score 5, without interleukin 6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24 48 hours while monitoring for refeeding syndrome. Efforts to provide >80% of estimated or calculated goal energy and protein within 48 72 hours should be made to achieve the clinical benefit of EN over the first week of hospitalization. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

nutrition record: 12 days 2,772 mechanically ventilated patients BMI:25-30 BMI:30-35 5/13/16 Intensive Care Med. 2009 Oct;35(10):1728-37. 33

5/13/16 Predicted probability of 28-day mortality versus percent of caloric. Prescription received for patients with low (n = 114) and high (n = 97) NUTRIC score. Lines and shading are the predicted probability and 95% confidence intervals based on logistic regression. Circles and plus symbols indicate the observed values for the subgroup of 211 patients evaluable for assessment of nutritional adequacy. NUTRIC, Nutrition Risk in the Critically Ill Score. Heyland et al. Critical Care 2011 15:R268 doi:10.1186/cc10546 34

A metabolic model of critical illness description Acute critical illness Nutrition/metabolic intervention Permissive starvation Prioritize protein/amino acids, (nonprotein fuels may not be necessary) Prolonged acute critical illness Ensure adequate protein/amino acids Permissive nonprotein underfeeding Chronic critical illness Ensure adequate protein/amino acids Ensure adequate and consistent nutrition without overfeeding Recovery Conventional nutrition targets (25-35 kcal/kg/d) Nutr Clin Pract, Vol. 21, No. 6, 587-604 (2006) acute phase : insulin resistance (hypocaloric, high-protein) chronic phase: more aggressive calorie delivery recovery phase more aggressive calorie delivery 35

Either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) and those expected to have a duration of mechanical ventilation >= 72 hours, as these two strategies of feeding have similar patient outcomes over the first week of hospitalization. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

receive trophic or full enteral feeding for the first 6 days full-feeding : 25 to 30 kcal/kg per day of nonprotein calories and 1.2 to 1.6 g/kg per day of protein no differences : 60-day mortality, trophic feeding rate: 20 kcal/h ventilator-free day, infection 5/13/16 JAMA. 2012;307(8):795-803. 37

灌食後監測 NG Gj output Distention Pain Glycemic control Acidosis Hemodynamics Urine output; BP/HR 5/13/16 GRVs not be used as part of routine care to monitor ICU patients on EN Should be assessed for risk of aspiration switched to continuous infusion prokinetic medications (metoclopramide or erythromycin) Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. Refeeding Overfeeding 38

腸道營養 Risks: Aspiration risk Anastomotic leaks Not well tolerance Diarrhea Distention Gut ischemia in poorly resuscitated pt Difficult access 5/13/16 39

Prevalence of GI symptoms during the patients ICU stay 59.1% one GI symptom 36.2% more than one GI symptom 1. Reintam A, et al. Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiol Scand. 2009;53(3):318-324. 40

Diarrhea Definitions: 2 3 liquid stools per day > 250 g of liquid stool per day may contribute to acute diarrhea: type and amount of fiber in formula osmolality of formula delivery mode EN contamination medications (antibiotics, proton-pump inhibitors, prokinetics, glucose lowering agents, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, laxatives, and sorbitol-containing preparations, in particular infectious etiologies, including Clostridium difficile Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

Selection of appropriate enteral formula: use of a commercial mixed fiber-containing formulation if there is evidence of persistent diarrhea avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. use of small peptide formulations in the patient with persistent diarrhea, with suspected malabsorption, ischemia, or lack of response to fiber Use of a soluble fiber supplement added to a standard enteral formula would be a third alternative. 10 20 grams of a fermentable soluble fiber (pectin, FOS, inulin and guar gum) stimulate the growth of Bifidobacteria and Lactobacillus, often referred to as the healthy bacteria. In an supplement be given in divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

Effects of refeeding syndrome Hypophosphatemia Altered cardiac function Altered hematologic effects hepatic dysfunction Neuromuscular effects Respiratory effects Hypokalemia Cardiac effects Gastrointestinal effects Metabolic effects Neuromuscular effects Hypomagnesemia Cardiac effects Gastrointestinal effects Neuromuscular effects Glucose and fluid introlerance

chronically critically ill chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS > 21 days) be managed with aggressive high-protein EN therapy and, when feasible, that a resistance exercise program be used. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

營養支持可以改善病人的瘦體組織存量嗎? SRM: starvation-related malnutrition NS: nutrition support ADRM: acute disease- or injury-related malnutrition CDRM: chronic disease-related malnutrition From: 2007;66(1):16-24.

Nutrition goals in the chronic critical illness syndrome Substrate Total calories Protein Carbohydrate Lipid Goals 18-25 kcal/kg/d 1.2-1.5 g/kg/d Monitor serum levels of urea nitrogen and ammonia May require additional protein if ongoing loss (ie, decubiti, fistulas) 50%-60% total energy requirements (60%-70% of nonprotein calories) Advance carbohydrate to goal when euglycemia (blood glucose level of 80 to 110 mg/dl) is achieved 20%-30% total energy requirements (30%-40% of nonprotein calories) Nutr Clin Pract, Vol. 21, No. 6, 587-604 (2006) 48

Impact of overfeeding Hyperglycemia Phagocyte dysfunction Osmotic diuresis Increased risk of infection Intracellular shifts of electrolytes Excessive CO2 production Respiratory failure Prolonged mechanical ventilation requirements Organ system dysfunction Hepatic dysfunction (steatosis) Cardiac dysfunction (refeeding syndrome) Respiratory dysfunction (refeeding syndrome) Neurologic dysfunction (refeeding syndrome)

Phased-based approach to nutrition delivery in critical care. EN, enteral nutrition; GH, growth hormone; GLN, γ-linolenic acid. Crit Care. 2013; 17(Suppl 1): S7.

問題病患消化不良或是拉肚子一般會在配方上或是卡數上做什麼樣的調整? 如使用米湯啦或者什麼配方的介入? ICU 病人高血糖及腎功能不佳, 會建議醫師加胰島素, 營養給腎低的配方, 但 ICU 醫師都說要先供糖尿病配方, 請問在配方上要如何調整? RCW 病人給的熱量都是 >35 大卡甚至 40 卡 /KGBW 或是 45 但醫師認為還是要加熱量個案就是很瘦才 40 幾公斤... 給這麼高的熱量及蛋白質病人一樣呼吸器脫離不掉反而越養越胖? RCW 個案 82 歲熱量漸進給予到 40kcal/kg 蛋白質給予 1.9g/kg 消化佳, 體重無變化沒有其他特殊問題但半年來 Alb 一直拉不起來 (2.9-2.9-2.8) Hb( 平均 9-10) 還有其他建議? 長者多重慢性病 BMI 低消化不佳半罐 / 餐 ( 已給予雙卡 *3/ 天 ) 體位無法上升有什麼營養建議嗎?? 給予單體配方?? 增加次數?? 長者的熱量供應有建議到多少嗎?? 因為用現由體位 *35 Kcal 都上不去會乘到 40 以上才有成效那有上限嗎?? 有 DM 及 CKD 病史 (STAGE-4) 且身上傷口又多建議配方給予可以再給高蛋白嗎病人入院診斷 : 肺炎臥床 - 給 DM 配方有 DM 病史已有再用藥跟打胰島素但血醣仍起伏大例如每天清晨 AC 100~187 mg/dl 這種情況下配方還需要再一直做調整嗎還是可以就維持給 DM 配方持續 F/U 即可當病人患有糖尿病及腎臟病時但血糖控制不佳 Cr 又高時是要給予控制熱量還是給予低蛋白飲食? 一般急性病房營養篩檢最簡單且有效的方法? 是否有評估工具可參考? 管灌食病患傷口多, 除了給予足夠熱量蛋白質外, 臨床上還可給予哪些 support 讓傷口癒合更快 (Glutamine 成本高 )?

A target blood glucose range of 140 or 150 180 mg/dl for the general ICU population; ranges for specific patient populations (post-cardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline. Crit Care Med. 2016 Feb;44(2):390-438. JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.

重症營養 _DM 熱量需求 : 25~35 kcal/kg IBW 肥胖 : 用 ABW 注意 overfeeding hyperglycemia Hepatic steatosis RQ 及脂肪新生作用蛋白質需求 : 1.5 gm/kg BW ( 肝腎功能正常者 )

問題病患消化不良或是拉肚子一般會在配方上或是卡數上做什麼樣的調整? 如使用米湯啦或者什麼配方的介入? ICU 病人高血糖及腎功能不佳, 會建議醫師加胰島素, 營養給腎低的配方, 但 ICU 醫師都說要先供糖尿病配方, 請問在配方上要如何調整? RCW 病人給的熱量都是 >35 大卡甚至 40 卡 /KGBW 或是 45 但醫師認為還是要加熱量個案就是很瘦才 40 幾公斤... 給這麼高的熱量及蛋白質病人一樣呼吸器脫離不掉反而越養越胖? RCW 個案 82 歲熱量漸進給予到 40kcal/kg 蛋白質給予 1.9g/kg 消化佳, 體重無變化沒有其他特殊問題但半年來 Alb 一直拉不起來 (2.9-2.9-2.8) Hb( 平均 9-10) 還有其他建議? 長者多重慢性病 BMI 低消化不佳半罐 / 餐 ( 已給予雙卡 *3/ 天 ) 體位無法上升有什麼營養建議嗎?? 給予單體配方?? 增加次數?? 長者的熱量供應有建議到多少嗎?? 因為用現由體位 *35 Kcal 都上不去會乘到 40 以上才有成效那有上限嗎?? 有 DM 及 CKD 病史 (STAGE-4) 且身上傷口又多建議配方給予可以再給高蛋白嗎病人入院診斷 : 肺炎臥床 - 給 DM 配方有 DM 病史已有再用藥跟打胰島素但血醣仍起伏大例如每天清晨 AC 100~187 mg/dl 這種情況下配方還需要再一直做調整嗎還是可以就維持給 DM 配方持續 F/U 即可當病人患有糖尿病及腎臟病時但血糖控制不佳 Cr 又高時是要給予控制熱量還是給予低蛋白飲食? 一般急性病房營養篩檢最簡單且有效的方法? 是否有評估工具可參考? 管灌食病患傷口多, 除了給予足夠熱量蛋白質外, 臨床上還可給予哪些 support 讓傷口癒合更快 (Glutamine 成本高 )?

ICU patients with acute renal failure (ARF) or AKI be placed on a standard enteral formulation, and standard ICU recommendations for protein (1.2 2 g/kg actual body weight per day) and energy (25 30 kcal/kg/day) provision should be followed. If significant electrolyte abnormalities develop, a specialty formulation designed for renal failure (with appropriate electrolyte profile) may be considered. Patients receiving hemodialysis or CRRT receive increased protein, up to a maximum of 2.5 g/kg/day.

ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure Clinical Nutrition. 2006; 25: 295 310.

Clinical Nutrition. 2006; 25: 295 310.

營養攝取與預後相關研究作者研究架構結果 Heidegger et al.,2013 RCT SICU+MICU 入 ICU > 3d 1. EN: 152 人 2. EN+SPN( 第四天 ):153 人 EN vs. +SPN: Energy intake (day4-day8): 20 kcal /kg vs. 28 kcal/kg; P< 0.0001 Protein intake (day4-day8): 0.8 gm/kg vs. 1.2 gm/kg, P<0.0001 SPN vs. EN: Infection: 27% vs. 38%, HR=0.65 CI:0.43-0.97; p=0.0338 Antibiotics days: 11±8d vs. 13±9d; p=0.0257 MV: NS ICU stay and hospital stay: NS ICU and hospital mortality: NS Heyland et al., 2011 prospective observational study SICU+MICU Age > 18y 入 ICU > 24h MV > 72h 207 位病人平均攝取目標量 48.9% 熱量及 45.1% 蛋白質, 入 ICU 後 1.8 天開始接受 EN MVD: 平均 9.1 天 ICU stay: 平均 13.5 天 28 天死亡率 : 29% 72h 及 96h 感染率 :25.1% 及 21.7% 熱量及蛋白質攝取增加 infection rate 96h 後感染率 : 每增加 1000 kcal infection risk: OR=0.32, CI:0.101.02, p=0.054 每增加 30g protein infection risk: OR=0.40, CI:0.190.89, p=0.024 Casaer et al., 2011 Prospective, RCT Age > 18y Late PN (day 8):2328 人 Early PN (day1): 2312 人 Late PN vs. eaprly N: Median Insulin requirement: 31u vs. 58u BS: 102± 14 vs. 107±18 mg/dl ICU mortality: NS 90 days hospital mortality: NS Late PN vs. early PN: Alive from the ICU: HR=1.06, CI: 1.0-1.13; p=0.04) New infection: 22.8% vs. 26.2%, p=0.008 MVD: NS Tracgeostomy: NS Renal replacement therapy day: 7 vs. 10 day; p=0.008 Alive from hospital: HR=1.06, CI:1.00-1.13; p=0.04 Healthy care cost: 16,863 vs. 17,973, p=0.04

Comparison of Macronutrient Intake and Outcomes of Five Randomized, Controlled Trials Evaluating Nutrition during Critical Illness. 5/13/16 N Engl J Med. 2014 Mar 27;370(13):1227-36. 59

Case study 70 歲張老先生因食慾不振 fever SOB 多日至門診就診因肺炎收入院因 Hypoxic respiratory failure on MV 轉入 ICU 家屬反應他三餐只吃半碗白稀飯加少許海苔醬整日臥床休息不想動抽血生化值為 Alb:2.7 g/dl, chol: 90 mg/dl, TG:35 mg/dl, BG:80 mg/dl, BUN:6 mg/dl, Cr.:0.4 mg/dl, K:3.0 meq/dl, Na:131 meq/dl, Cl:100 meq/dl, GOT:40 IU/dL, GPT:22 IU/dL, CBC data: WBC:11.5 103/uL, Lym: 9.0% 張先生身高 166 公分目前體重 50 公斤約 3 個月前體重 58 公斤且生活活動自如請問如何營養評估? 如何營養支持? 需 monitor 那些 data? 60

個案討論營養評估營養攝取 < 250 卡 / 天體位資料 : BH:166cm, IBW=60.6kg BW:50kg (82.5% IBW) 80 ~ 90% Mild malnutrition BMI=18.1 kg/m2 chronic energy deficiency % UBW=86.2% 85%~95% mild malnutrition % BW change=13.8% severe change Lab. Datas: Alb:2.7 g/dl 2.1-2.8 moderate depletion Chol.: 90 mg/dl 熱量需求 (Goal): HBEE=1110 kcal 1.2~1.3=1332~1443 kcal IJEE=1508 kcal simplistic formulas:1250~1500 kcal 蛋白質需求 : 1.2~2.0 g/kg 60~100g 61

個案討論營養支持 EN: NG feeding 可先給 < 20 kcal/kg ( < 1000 kcal/day) goal 1500 kcal/day PN: Monitor I/O, Gj, electrolytes, BS, PaCO2, 62