臺灣博碩士論文加值系統

全靜脈營養 (Total parenteral nutrition, TPN) 用於暫時無法經由腸道供給營養的住院病患營養支持。本研究收集一年期間使用TPN的77位成年患者，分析治療前後其營養狀況以及代謝性異常的發生，更進一步依照不同疾病類別、不同年齡層、使用TPN天數長短、是否恢復腸道營養、是否調整電解質配方以及使用不同TPN配方來分組，詳細探討其營養情況及代謝異常之差異。本研究結果顯示使用TPN後，體重與前白蛋白(Prealbumin, Pre-alb)有明顯增加，即使用TPN可明顯改善病患的營養狀況，而在代謝性異常部份，顯示肝功能異常發生率為21.57%、腎功能異常發生率為5.45%，電解質不平衡改善率為19.48%、脂質代謝異常改善率為2.60%。恢復腸道營養及使用標準配方兩組於營養狀況有明顯改善，代謝異常於TPN使用14天以上、未恢復腸道營養、有調整電解質及使用非標準配方的組別較高。但經由營養支持小組 (Nutrition support team, NST) 給予個人化的TPN營養配方，並經由適當的監測，有助於其營養狀況，並可預防代謝性併發症之發生。

Total parenteral nutrition (TPN) gives nutrient supports to many hospitalized patients who temporarily can’t get nutrition from intestine tracts. The research gathered and analyzed 77 adult patients using TPN within a year. It also investigated the nutrient status and the occurrence of metabolic abnormalities, and further classified patients into different groups according to different kinds of diseases, ages, length of using TPN, recovering nutrition of intestine tracts or not, modifying electrolyte formula or not and using different kinds of TPN formulae in order to examine the nutrient status and metabolic abnormalities in detail. This study showed that after using TPN, the weight and prealbumin of patients had increased significantly, and that using TPN improved patients’ nutrient status. However, in the ratio of metabolic abnormalities, the ratio of occurrence of liver malfunctions was 21.57%, and the renal function abnormalities was 5.45%, the ratio of improvement of the imbalance of electrolyte was 19.48% and the lipid metabolic abnormities was 2.60%. Through classifying into groups, the two groups, recovering nutrition of intestine tracts and using standard formulae, improved significantly in the nutrient status. The occurrence of metabolic abnormalities was higher in the groups using TPN over 14 days, not recovering intestine nutrition, modifying electrolyte and using non-standard formulae. However, after the Nutrition Support Team (NST) gave personal TPN formulae and suitable surveillance, the nutrient status became better and the potential abnormal symptoms of metabolic combinations could be avoided.

摘要 I
Abstract II
誌謝 IV
目錄 V
圖目錄 VII
表目錄 VIII
壹、緒論 1
一、前言 1
二、研究背景與動機 1
三、研究目的 2
四、研究重要性 2
五、研究限制 2
貳、文獻回顧 3
一、全靜脈營養介紹 3
二、全靜脈營養臨床上的適應症 4
(一)全靜脈營養之投予時機 4
(二)全靜脈營養臨床上的適應症 5
三、全靜脈營養的併發症 6
四、營養評估的方法 9
五、全靜脈營養成分建議量 16
參、材料與方法 22
一、研究流程 22
二、研究架構 23
三、實驗方法 24
(一)收集檢測評估指標 24
(二)體位測量 25
(三)採檢血液方法 25
(四)生化抽血檢查 25
四、實驗材料 32
(一)TPN調配使用材料 32
(二)TPN溶液配製儀器 32
(三)本院TPN處方標準含量 33
五、營養調配作業流程 33
六、營養評估的方法 40
七、本研究代謝性異常的定義 42
八、統計方法 42
肆、研究結果 43
一、基本資料分析 43
二、病患施打TPN之適應症 46
三、病患施打TPN熱量成份分析 46
四、所有病患營養狀況分析及代謝性異常探討 50
五、各類分組病患營養狀況分析及代謝性異常探討 55
(一)依疾病類別分兩組比較 55
(二)依年齡層分兩組比較 59
(三)依TPN使用天數長短分兩組比較 63
(四)依是否恢復腸道營養分組比較 67
(五)依是否調整電解質配方分組比較 71
(六)依使用不同TPN種類分兩組比較 75
伍、討論 79
一、所有病患之營養狀況分析及代謝性異常探討 79
(一)所有病患之營養狀況分析 79
(二)所有病患之代謝性異常探討 80
二、依照不同類別分組之營養狀況分析及代謝性異常探討 85
(一)依照不同類別分組之營養狀況分析 85
(二)依照不同類別分組之代謝性異常探討 85
(三)個人化調配處方之優缺點探討 86
陸、結論 87
參考文獻 88
作者簡介 96

丁冠玉、孔慶聞、吳淑如、張月萍、黃秀珠、黃淑俐、葉寶華、詹仲舒、鄭兆君、蕭千祐、戴瑄、鐘淑英。2002。實用膳食療養學。第一版。華格那企業有限公司。1-64。
尹彙文。2005。實用外科重症EEG臨床指引－營養篇。第一版。時新出版有限公司。
金惠民、賴昭鴻、蔡秀悅、金美雲、王秀媛。1991。疾病營養與膳食療養。華香園出版社。
吳英湘。2005。成人全靜脈營養簡介。成醫藥誌。第一版。15(4)。
唐麗英、王春和。2005。SPSS統計分析12.0中文版。第一版。儒林圖書公司。
高美丁、李蕙蓉、許文音、郭素娥、劉麗娟。2003。常用營養師手冊。第一版。華格那企業有限公司。
張明峰、徐學良。2004。全靜脈營養所引起的膽汁鬱滯併發症。中華民國靜脈暨腸道營養醫學會會訊。42。
陳國榮、陳碧華、牛亞蕾、李文欽、吳肇鑫、蕭志賢。2004。華盛頓內科學手冊。第一版。合記圖書出版社。26-55。
陳淑娟、尹彙文。2003。臨床營養學－膳食療養。第二版。合記書局有限公司。楊志良。1998。生物統計學新論。增修二版。巨流圖書公司。
章樂綺、殷梅津、彭巧珍。2001。實用膳食療養學。第一版。匯華圖書出版有限公司。
黃淑玲。1999。探討二合一包裝中央靜脈營養輸液於外科病人的臨床使用及對醫療費用的影響。台灣大學藥學研究所碩士論文。
楊榮森。2005。臨床營養學－靜脈暨腸道營養。第一版。時新出版有限公司。
蔡秀玲、蔡佩芬、郭靜香。1993。營養評估手冊。國興出版社。
蔡淑芳、周聰成、陳冠如、陳雪美、陳麗真、彭巧珍、蔡秀玲。1997。應用膳食療養學。第一版。藝軒圖書出版社。
鄭美麗、陳麗芳、侯清正。2003。全靜脈營養代謝性異常及併發症。台灣醫學 7:319-25。
鄭隆致、許秉毅、陳以書、康秀萍、黃秀華、曾碧萊、羅錦河、黎國洪、周慧姝、莫景棠。循環式營養法對接受全靜脈營養治療者肝功能異常之預防效果：一個前瞻性隨機研究。內科學誌。14:62-8。
賴鴻緒。2003。全靜脈營養中脂肪乳劑之新發展。台灣醫學 7:876-81。
Alverdy JC,Aoys E, Moss GS. 1988. Total parenteral nutrition promotes bacterial translocation from the gut. Surgery 104:185-190.
Alverdy JC, Chi HS, Sheldon GF. 1995. The effect of parenteral nutrition on gastrointestinal immunity. Ann. Surg. 202 (6) : 681-684.
Anderson CF, Wochos DN. 1982. The utility of serum albumin values in the nutritional assessment of hospitalized patients. Mayo Clinic Proceedings 57:181-4.
ASPEN: Board of Directors. 2002. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26 (suppl): 1SA-138SA.
AUBANIAC RL. 1952. Injection intraveineuse sous-claviculaire. Presse Med 60: 1456.
Bashir RM, Lipman TO. 1995. Hepatobiliary toxicity of total parenteral nutrition in adults. Gastroenterol Clin North Am 24:1003-25.
Bernstein LH, Leukhardt-Fairfield CJ, Pleban W, Rudolph R. 1989. Usefulness of data on albumin and prealbumin concentrations in determining effectiveness of nutritional support. Clin Chem 35:271-4.
Bear RA, Neil GA. 1983.A Clinical a approach to common electrolyte problems: 2. Potassium imbalances. Can Med Assoc J 129(4 Pt 2):28-31
Bear RA, Neil GA. 1983. A Clinical approach to common electrolyte problems: 1. Hyponatremia. Can Med Assoc J 128 (4 Pt 1): 1171-4.21.
Berkelhammer C, Bear RA. 1985. A clinical approach to common electrolyte problems: 4.Hypomagnesemia. Can Med Assoc J 132 (4 Pt 4):360-8.
Bienia R, Ratcliff S, Barbour GL, Kummer M. 1982. Malnutrition and hospital prognosis in the alcoholic patient. J Parenter Enter Nutr 6:301-3.
Bistrian BR, Blackburn GL, Schrimshaw NS. 1975. Cellular immunity in semi starved status in hospitalized adults. Am J Clin Nutr 28: 1148-1156.
Buchman A. 2002. Total parenteral nutrition-associated liver disease. JPEN 26(5 suppl 1): S43-S48.
Cavicchi M. 2000. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med 132:525-32.
Chandra RK. 1983. Nutrition, immunity and infection: Present knowledge and future direction. Lancet 1: 688-693.
Chernoff R. 2003. Nutrition and metabolism. In: McCabe BJ, Frankel EH, Wolfe JJ, editors. Handbook of food-drug interactions. Boca Raton (FL) : CRC Press 33-52.
Christman JW, McCain RW. 1993. A sensible approach to the nutrition support of mechanically ventilated critically ill patients. Intensive Care Med 19: 129-136.
ChrisAnderson D, Heimburger DC, Morgan SL. 1996. Metabolic complications of TPN:Effects of a nutrition support service. JPEN 20:206-10.
Church JM, Hill GL. 1987. Assessing the efficacy of intravenous nutrition in general surgical patients-dynamic nutritional assessment using plasma proteins. JPEN 11: 135-141
Cook JD, Skikne BS. 1982. Serum ferritin: a possible model for the assessment of nutrition stores. Am J Clin Nutr 35: 1180-1185.
Crook MA, Hally V, Panteli JV. 2001. The importance of refeeding syndrome. Nutrition 17:632-7.
Dalton MJ, Schepers G, Gee JP, et al. 1984.Consultative TPN teams: The effect on theincidence ofTPN-related complications. JPEN 8:146-52.
Dodds ES, John DM, Katherme MT. 2001. Metabolic occurrences in total parenteral nutrition patients managed by a nutrition support team: NutrClinPract 16:78-84.
Douville P, Talbot J, Lapointe R, Belanger L. 1982. Potential usefulness of serum prealbumin in total parenteral nutrition. Clin Chem 28: 1706-1707.
Dudrick SJ, Wilmore DW, Vars HM. 1968. Long-term TPN with growth, development, and positive nitrogen balance. Surgery. 64:134-42.
Erstad BL, Campbell DJ, Rollins CJ, Rappaport ED. 1994. Albumin and prealbumin concentrations in patients receiving postoperative parenteral nutrition. Pharmacotherapy 14:458-62.
Featherston WR, Rogers QR, Freedland RA. 1973. Relative importance of kidney and in synthesis of arginine by the rat. Am J Photosynthesis 224:127
Fisher GG, Opper FH. 1996. An interdisciplinarynutrition support team improves quality of care in a teaching hospital. J Am Diet Assoc 96:176-8.
Forbes GB. 1987. Human body composition: Growth, aging, nutrition and activity. New York, Springer-verlag.
Gales BJ, Riley DG. 1994. Improved TPN therapy management by a nutritional support team.Hosp Pharm 29:469-75.
Gettes LS. 1992. Electrolyte abnormalities underlying lethal and ventricular arrhythmias. Circulation 85:170-6.
Grant JP. 1992. Handbook of total parenteral nutrition 2nd ed. Philadelphia: WB Saunders.
Grant JP. 1994. Nutrition in surgical patients. In: Sabiston DC, Lyerly HK editors. Sabiston essentials of surgery. 2nd ed. PA: WB. Sauders. 97-107.
Harvey KB, Moldawer LL, Bistrian BR, Blackburn GL. 1981. Biological measures for the formulation of a hospital prognostic index. Am J Clin Nutr 34: 2013-2022.
Hickey MM, Munyer TO, Salem RB. 1979. Parenteral nutrition utilization: Evaluation of an educational protocol and consult service. JPEN 3:433-7.
Holcombe BJ. 1995. Adult parenteral nutrition. In: Young LY, Koda-Kimble MA, editors. Applied therapeutics: the clinical use of drugs. 6th ed. WA: Applied Therapeutics. 35-36.
Holcombe BJ, Gervasio JM. 2005. Adult parenteral nutrition. In: Applied therapeutics: the clinical use of drugs. 8th ed. Baltimore: Lippincott Williams & Wilkins. 37.1-37.23.
Ingelbleek Y, van den Schriek H G, De Nayer P, DeVisscher M. 1975. Albumin, transferrin and the thyroxine-binding prealbumin/retinol binding protein complex in assessment of malnutrition. Clin Chim Acta 63: 61-67.
Ingenbleek Y, Van Den Schrieck HG, De Nayer P, De Visscher M. 1975. The role of retinol-binding protein in protein-calorie malnutrition. Metabolism 24:633-41.
Ioannides-Demos LL, Liolios L, Topliss DJ, Mclean AJ. 1995. A prospective audit of total parenteral nutrition at a major teaching hospital. Med J Aust 163:233, 235-7.
Iyer KR. 2002. Organ transplant for intestinal failure. JPEN 26(5 suppl):S43-S48.
Jeejeebhoy KN, Meguid MM. 1986. Assessment of nutrition status in the oncologic patient. Surg Clin North Am 66: 1077-1083.
Jones ME. 1985. Conversion of glutamate to ornithine and proline: pyrro-line-5-carboxylate, a possible modulator of arginine requirem ents. J Nutr 115:509
Keohane PP, Jones BJ, Attrill H, et al. 1983. Effectof catheter tunneling and a nutrition nurse oncatheter sepsis during parenteral nutrition. A controlled trial. Lancet 2:1388-90.
Kopple JD. 1987. Uses and limitations of the balance technique. J Parenter Enter Nutr 11(5 suppl.): 79S-85S.
Li J, K udsk KA and Gocinski B. 1995. Effects of parenteral and enteral nutrition on gut-associated lymphoid tissue. J Traum a 39:44-52.
Mattox TW. 1997. Parenteral nutrition. In: DiPiro JT, editors. Pharmacotherapy: a pathophysiologic approach. 3rd ed. Stamford: Appleton & Lange. 2735-58.
Mattox TW. 2002. Parenteral nutrition. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: a pathophysiologic approach. 5th ed. New York: McGraw-Hill. 2475-94.
McEvoy GK. 2002. American hospital formulary service drug information. American society of health-system pharmacists.
Mirtallo JM. 2001. Introduction to parenteral nutrition. In: Gottschlich MM, editor: The science and practice of nutrition support. Kendall/Hunt.
Mirtallo JM, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P. 2004. Safe Practices for parenteral nutrition. JPEN. 28:S52-7.
Mullen JL, Gertner MH, Buzby GP, Goodhart GL, Rosato EF. 1979. Implications of malnutrition in the surgical patient. Arch Surg 114:121-5.
Nehme AE. 1980. Nutritional support of the hospitalized patient: The team concept. J Am Med Assn 243:1906-8.
Patricia W. 2004. Practical aspects of nutritional support-an advanced practice guide. In: Patricia W, Laurie R. editors: Administration and management of parenteral nutrition. 367-98. Saunders.
Rayfield EJ, Ault MJ, Keusch GT, et al. 1982. Infection and diabetes: The case for glucose control. Am J Med 72:439-50.
Reinhardt GF, Myscofski RD, Wilkens D. 1980. Incidence and motility of hypoalbuminaemic patients in hospitalized veterans. JPEN 4: 357- 366.
Rose WC. 1937.The nutritive significance of the amino acids and certain related compounds. Science 86:298-300.
Rosmarm DK, Wardlaw GM, Mirtallo J. 1996. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract l 1:151-6.
Ryan JA, Abel RM, Abbot WM, et al. 1974. Catheter complications in TPN. A prospectivestudy of 200 consecutive patients. N Engi J Med 290:757-61.
Reinhardt GF, Myscofski JW, Wilkens DB, Dobrin PB, Mangan JE, Stannard RT. 1980. Incidence and mortality of hypoalbuminemic patients in hospitalized veterans. J Parenter Enter Nutr 4:357-9.
Rudman D, Feller AG, Nagraj HS, Jackson DL, Rudman IW, Mattson DE. 1987. Relation of serum albumin concentration to death rate in nursing home men. J Parenter Enter Nutr 11:360-3.
Rosmarin DK, Wardlaw GM, Mirtallo J. 1996. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Prac 11:151-6.
Sax HC, Souba WW. 1998. Nutritional goals and macronutrient requirements. In: The ASPEN editors. The ASPEN nutrition support pratice manual. 2-1-5.
Sax HC. 1993. Complications of total parenteral nutrition and their prevention. In: Rombeau JL, editors. Clinical nutrition: parenteral nutrition. 2nd ed. Philadelphia: W.B. Saunders. 367-81.
Scott AS, Robert GM, Steven DS. 2002. Nutritional considerations in the intensive care unit. In: Gail AC, editors. Nutrition assessment and monitoring. ASPEN. 21-30.
Seidner DL. 2002. Parenteral nutrition-associated metabolic bone disease. JPEN 26(5 suppl): S37-S42.
Shattuck KA, Klein GL. 2001. Hepatobiliary complications of parenteral nutrition. In: Rombeau JL, Rolandelli RH, editors: Clinical nutrition: parenteral nutrition, ed 3, Philadelphia. WB Saunders.
Shronts EP, Fish JA, Pesce-Hammond K. 1998. Nutrition assessment. In: The A.S.P.E.N. editors. The A.S.P.E.N. nutrition support practice manual. p. 1-1-17.
Skipper A, Millikan KW. 1998. Parenteral nutrition implementation and management. In: The A.S.P.E.N. editors. The A.S.P.E.N. nutrition support practice manual. p. 9-1-9.
Skoutakis VA, Martinez DR, Miller WA, Dobbie RP. 1975.Team approach to total parenteral ntrition. Am J Hosp Pharm 32:693-7.
Spiekerman AM. 1993. Proteins used in nutritional assessment. Clinic In Lab Med 13:353-69.
The ASPEN Board of Directors. 1986. Guidelines of use of total parenteral nutrition in the hospitalized adult patient. J Parenter Enter Nutr 10:441-5.
Teasley-Strausburg KM, Anderson JD. 1997. Assessment of nutrition status and nutrition requirements. In: DiPiro JT, editors. Pharmacotherapy: a pathophysiologic approach. 3ed ed. Stamford: Appleton & Lange Norwalk. 2679-97.
Teasley-Strausburg KM. 1997. Prevalence and significance of malnutrition. In: DiPiro JT, editors. Pharmacotherapy: a pathophysiologic approach. 3ed ed. Stamford: Appleton & Lange Norwalk. 2699-709.
Van den Berghe G. 2001. Intensive insulin therapy in critically ill patients. N Engl J Med 345(19): 1359-67.
Von Meyenfeldt M F, Meijerink W J HJ, Rouflart M MJ. 1992. Perioperative nutrition support: A randomised clinical trial. Clin Nutr 11: 180.
Wagman LD, Newsome HH, Miller KB, et al. 1986. The effect of acute discontinuation of total parenteral nutrition. Ann Surg. 204:524-9.18.
Weinsier RL, Bacon J, Butterworth CE. 1982. Central venous alimentation: A prospective study on the frequency of metabolic abnormalities among medical and surgical patients. JPEN 6:421-5.
Winkler MF, Gerrior SA, Pomp A, Albina JE. 1989. Use of retinol-binding protein and prealbumin as indicators of the response to nutrition therapy. J Am Diet Assoc 89:684-7.
Winkler MF. 1995. Controlling blood glucose in parenteral and enteral nutrition. In: Proceedings of the 19 th Clinical Congress of A.S.P.E.N.
Yves Ingenbleek, Vernon Young. 1994. Transthyretin (prealbumin) in health and disease: nutritional implications. Annu Res Nutr 14:495-533.
Ziegler TR, Smith RJ. 1993. Parenteral nutrition in patients with diabetes mellitus. In: Rombeau JL, Caldwell MD, editors. Clinical nutrition: parenteral nutrition 2nd ed. Philadelphia: W.B. Saunders Company. 649-54.