Case conference- Early feeding s/p gastrectomy 萬芳醫院 張靜怡 營養師 2005/11/22

全靜脈營養支持(total parenteral nutrition; TPN)，可降低手術後併發症 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) 2005/11/22 CYC

Protein-energy malnutrition in the gastrectomized patient (Papim 2002 ) 2005/11/22 CYC

腸道營養支持(early enteral feeding) 接受腹部手術後，儘早給予 腸道營養支持(early enteral feeding) 與只是全靜脈營養支持方式比較， 更有助於病患術後的恢復情況 (Huckleberry 2004 ) 2005/11/22 CYC

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 Early enteral Feeding 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 ) 2005/11/22 CYC

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 Early enteral Feeding 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 ) 2005/11/22 CYC

Treat adverse effects of EEN 1.Abdominal 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) (M. Braga et al 2002 ) 2005/11/22 CYC

Treat adverse effects of EEN 3.Vomiting : - treated by temporary stop of infusion followed by diagnostic procedures - if no intestinal obstruction was detected, infusion was 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 ) 2005/11/22 CYC

Case report

個案基本資料 性別：男性 年齡：78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 2005/11/22 CYC

個案基本資料 1. HTN 2. Old CVA 3. Old TB 4. CRI 5. PU (about 3 years ago) Medication histories ： 1. HTN 2. Old CVA 3. Old TB 4. CRI 5. PU (about 3 years ago) 6. Thalassemia (病患自述 ) 2005/11/22 CYC

入院摘要 入院時間：94/10/12 科別： 一般外科 主訴症狀： 診斷： Gastric cancer UGI massive bleeding (about 2000c.c.) 8 days ago then admitted in TVGH (Dx: Gastric ca by PES & CT study) 診斷： Gastric cancer 2005/11/22 CYC

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*4.5cm Method : 1.Radical B-Ⅱsubtotal 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 2005/11/22 CYC

Nutrition support progress Date TPN order Energy/AA Date (Kcal / g ) EN Energy/PT (Kcal / g ) 10/12 A160 c.c./hr+ 20% lipofundin 200ml 1399 / 50 10/12 NPO - 10/14 A260 c.c./hr+ 1840 / 63 10/13 As tolerance 10/14 500 / 20 10/16 10/17 CLD NPO 10/19 NPO ED ¼ s rate 20c.c./hr * 18hr 10/21 A2300 c.c./hr+ 10/20 ED ½ s →FS rate 30c.c./hr * 18hr 10/24 TPN DC 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) 12days OP day on 10/18 25 / 1 NPO 300 / 16 1385 / 32 NPO 540 / 28 NPO 720 / 38 NPO 800 / 42 500 / 0 NPO 530 / 22 10/25 Kabiben run 60c.c./hr 1037 / 34 NPO 10/28 oral :CLD 11/2 Soft diet 2005/11/22 CYC Diarrhea

TPN 處方箋 Infuvita Trace element Fat emulsion : 20 % Lipofundin 100ml/BT 代碼 品項 Glucose gm/L AA Electrolyte (mEq/L) TPN A1 Standard 163 35 46 37 12 8 6 71 694 TPN A2 High stress 187 44 50 40 15 36 77 812 TPN A3 Hepatic failure 239 38 60 47 965 TPN A4 Renal failure 333 23 - 1224 TPN B1 Aminomix 200 30 5 100 1000 Total Kcal/L Na K P Mg Ca Cl Acetate 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 2005/11/22 CYC

Nutrition support (Energy) MBD 11/7 OP day Early enteral Feeding TER BEE TPN+EN PPN + EN 2005/11/22 CYC 10/26NPO Diarrhea

Nutrition support (Protein) MBD 11/7 OP day Early enteral Feeding PT req. TPN+EN PPN + EN 2005/11/22 CYC 10/26NPO

Nutrition Status (10/18) 10/19 Alb 1 BT bid*2days Admission 2005/11/22 OP (10/18) Admission 10/19 Alb 1 BT bid*2days 2005/11/22 CYC

Nutrition Status OP (10/18) Admission 174 2005/11/22 CYC

Nitrogen Balance OP (10/18) 10/12 10/25 10/31 10/17 2005/11/22 CYC

Nutrition Status BW loss 6.7% in 2 weeks MBD 2005/11/22 CYC (10/18) OP (10/18) MBD (11/7) Admission BW loss 6.7% in 2 weeks 11/20 2005/11/22 CYC

Nutrition Status OP (10/18) Admission 2005/11/22 CYC

Hb (14-18) / Hct (42-52) 10/17 10/19 10/25 11/ 3 10/31 2005/11/22 CYC OP (10/18) 2005/11/22 CYC

Discussion

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？ 2005/11/22 CYC

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 2005/11/22 CYC

Thanks for your attention