臺灣博碩士論文加值系統

加護病房（intensive care unit; ICU）使用呼吸器的重症病人普遍存在著營養不良的問題。然而多數使用呼吸器的重症病人有嚴重的臨床狀況，一般估算能量需要的公式並不一定能正確的估算出病人實際能量需要。因此本篇的研究目的為：1)評估病人的營養狀況。2)利用間接能量測定法測量使用呼吸器之重症病人的實際基本能量消耗。3)比較實際測量與公式估算出的能量需要的差異度並探討其相關性。
方法：本實驗受測者共有46位，依其使用營養支持的方式分為腸道營養（EN）、靜脈營養（TPN）以及合併腸道及靜脈營養（combined）。病人的營養狀況是利用體位測量、生化檢驗、營養素攝取及重症程度加以評估。病人的實際能量消耗是以DeltatracTM II MBM-200 Metabolic Monitor測量。另外病人的能量需要也利用Harris-Benedict，Kleiber，Liu，Ireton-Jones及Fusco等公式估算。
結果：病人的體位測量和生化檢驗除了ferritin之外都低於正常值。病人以間接能量測定法測出的基本能量消耗平均為1631 ± 345 kcal/d與病患的能量攝取量1822 ± 439 kcal/d有顯著差異。Harris-Benedict、Kleiber、Liu以及Ireton-Jones等公式所估算出的能量需要有低估、高估或適當估算病人的實際能量消耗的情形，然而在乘上預估的壓力因子1.2之後則無顯著差異。Fusco公式不論在乘上預估的壓力因子1.2之前或之後皆無顯著差異。病人的實際能量消耗與所有公式呈顯著正相關（r = 0.480-0.783；p < 0.01）。
結論：加護病房重症病人呈顯著營養不良的情形。間接能量測定是比較適宜用來評估重症病患能量需要的方法，但若無法以間接能量測定法測得病人的實際能量需要，將Harris-Benedict、Kleiber及Liu等公式乘上適當的壓力因子（1.2）或許可以作為估算重症病人能量需要的公式。

Background: The prevalence of malnutrition is a common problem in hospitalized patients, especially in critically ill patients. All most critically ill patients with mechanically ventilated have severe clinical conditions, estimated equations may not be useful for patients. Purpose: 1) to assess nutritional status; 2) to measure actual resting energy expenditure by using indirect calorimetry ; 3) to compare measured and estimated resting energy expenditure in mechanically ventilated critically ill patients.
Methods: Forty-six patients in the ICU were divided into enteral nutrition (EN), total parenteral nutrition (TPN) or combined nutrition (EN plus TPN) groups. Anthropometric and biochemical measurements, macronutrient intakes and medical status were assessed. The Deltatrac TM II MBM-200 Metabolic Monitor was used to measure actual energy expenditure of patients. Harris-Benedict, Kleiber, Liu, Ireton-Jones and Fusco equations were used to estimate energy requirements of patients.
Results: Patients had abnormal mean anthropometric and biochemical measurements. The mean measured actual energy expenditure (1631 ± 345 kcal/d) of patients was significant different from patients’ calories intake (1822 ± 439 kcal/d). The equations of Harris-Benedict, Kleiber, Liu, and Ireton-Jones underestimated, overestimated, or reasonably estimated REE in patients. The use of an estimated stress factor (1.2) times REE estimated by Harris-Benedict, Kleiber, and Liu equations were comparable to and correlated with the measured resting energy expenditure (MREE) in any groups. The Fusco equation did not show significant differences when compared with the values of MREE in 3 groups. The MREE of patients was significantly positively correlated with all equations (r = 0.480-0.783, p < 0.01).
Conclusions: Patients were in malnutrition. Measurement of metabolic rates by using indirect calorimetry in mechanically ventilated critically ill patients is generally not routine in the hospitals of Taiwan. Our results demonstrated that energy expenditure can be estimated in the critically ill patients by using Harris-Benedict, Kleiber, and Liu equations if the estimated stress factor is reasonable value (1.2).

中文摘要--------------------------------------------------- 1
英文摘要--------------------------------------------------- 3
壹、文獻回顧----------------------------------------------- 5
一、加護病房使用呼吸器的重症病人------------------------ 5
二、重症病患的營養需求---------------------------------- 6
能量------------------------------------------------ 6
總能量需要------------------------------------------ 6
能量測定-------------------------------------------- 8
1.直接能量測定法-------------------------------------- 8
2.間接能量測定法-------------------------------------- 9
3.呼吸商--------------------------------------------- 11
4.估算能量消耗的公式--------------------------------- 13
蛋白質及碳水化合物 -------------------------------- 16
脂質----------------------------------------------- 17
三、營養評估------------------------------------------- 18
體位測量------------------------------------------- 19
身高----------------------------------------------- 19
體重----------------------------------------------- 20
三頭肌皮層厚度及上臂圍----------------------------- 21
生化檢驗------------------------------------------- 22
白蛋白--------------------------------------------- 22
前白蛋白及總淋巴球數------------------------------- 23
運鐵蛋白及鐵蛋白----------------------------------- 24
氮平衡及肌酸酐身高指數----------------------------- 25
飲食攝取------------------------------------------- 26
營養狀況指標--------------------------------------- 27
預後營養指數（PNI）-------------------------------- 27
營養指數（MI）及營養危險指數（NRI）---------------- 28
疾病嚴重度（APACHE II score）---------------------- 29
四、結論-------------------------------------------------- 31
貳、研究目的 --------------------------------------------- 32
參、研究對象與方法 --------------------------------------- 33
能量測定---------------------------------------------- 34
間接能量測定------------------------------------------ 35
估算能量需要------------------------------------------ 36
營養評估---------------------------------------------- 38
體位測量---------------------------------------------- 38
生化檢驗及疾病嚴重度評估------------------------------ 40
營養狀況指標及飲食攝取-------------------------------- 41
統計分析---------------------------------------------- 42
肆、結果 ------------------------------------------------- 43
病患特性及疾病診斷------------------------------------ 43
生化檢驗及體位測量------------------------------------ 44
營養素攝取狀況及呼吸商-------------------------------- 45
能量需要---------------------------------------------- 46
營養指標---------------------------------------------- 49
表格-------------------------------------------------- 50
圖---------------------------------------------------- 61
伍、討論 ------------------------------------------------- 63
陸、結論 ------------------------------------------------- 72
柒、參考文獻 --------------------------------------------- 73
附錄
1. 病患轉入加護病房的原因 -------------------------------- 82
2. 疾病嚴重度（APACHE II score）-------------------------- 84
3. 格拉斯哥昏迷指數（Glasgow coma scale）----------------- 85
4. 間接能量測定公式的演算 -------------------------------- 86
5. 管灌配方 ---------------------------------------------- 87
6. 全靜脈營養配方 ---------------------------------------- 88
7. 周邊靜脈營養配方 -------------------------------------- 90

Askanazi J, Weissman C, Rosenbaum S H, Hyman A I, Milic-Emili J.
Nutrition and the respiratory system. Crit Care Med 1982; 10:
163-172
Bassili H R, Deitel M. Effect of nutritional support on weaning
patients of mechanical ventilators. JPEN 1981; 5: 161-163
Bishop M J. Hemodynamic and gas exchange effects of pancuronium
bromide in sedated patients with respiratory failure.
Anesthesiology 1984; 60: 369-371
Bistrian B R, Blackburn G L, Schrimshaw N S. Cellular immunity
in semi starved status in hospitalized adults. Am J Clin Nutr
1975; 28: 1148-1156
Bower R H. Nutritional and metabolic support of critically ill
patients. JPEN 1990; 14: 257s-259s
Brandi L S, Santoro D, Natali A, Altomonte F, Baldi S,
Frascerra S, Ferrrannini E. Insulin resistance of stress:
sites and mechanisms. Clin Sci 1993; 85: 525
Brown P E, McClave S A, Hoy N W, Short A F, Sexton L K. The acute physiology and chronic health evolution II classification system is a
valid marker for physiologic stress in the critically ill patients. Crit
Care Med 1993; 21: 363-367
Burgess E J, Fleck A. Inadequacy of urinary urea for the estimation of
nitrogen balance during total parenteral nutrition. Ann Clin Biochem
1990; 27: 163-164
Bursztein S, Elwyn D H, Askanazi J, Kinney J M. Energy Metabolism,
Indirect Calorimerty and Nutrition. Baltimore, Md: Williams and
Wilkins; 1989
Butte N F, Wong W W, Ferlic L, Smith E O, Klein P D, Garza C. Energy
expenditure and deposition of breast-fed and formula-fed infants during
early infancy. Pediatr Res 1990; 28: 631-640
Buzby G P, Mullen J L, Mathews D C, Hobbs C L, Rosato E F. Prognostic
nutritional index in gastrointestinal surgery. Am J Surg 1980; 139: 160-
67
Buzby G P, Williford W O, Peterson O L, Crosby L D, Page C P, Reinhardt
G F, Mullen J L. A randomized clinical trial of total parenteral nutrition
in malnourished surgical patients: the rationale and impact of previous
clinical trials and pilot study on protocol design. Am J Clin Nutr 1988a;
47: 357-365
Buzby G P, Knox L S, Crosby L O. Study protocol: a randomized clinical
trial of total parenteral nutrition in malnourished surgical patients. Am J
Clin Nutr 1988b; 47: 366-381
Calson D E. Nutrition for the Critically Ill. Wolf Rinke Associates, Inc.
1995; 9-32
Cerra F B. How nutrition intervention changes what getting sick means.
JPEN 1990; 14: 164s-168s
Chandra R K. Nutrition, immunity and infection: Present knowledge
and future direction. Lancet 1983; 1: 688-693
Chumlea W C, Roche A F, Mukherjee D. Nutritional Assessment of The
Elderly Through Anthropometry. Ross Laboratories, Columbus, Ohio.
1984
Christman J W, McCain R W. A sensible approach to the nutrition support
of mechanically ventilated critically ill patients. Intensive Care Med
1993; 19: 129-136.
Church J M, Hill G L. Assessing the efficacy of intravenous nutrition in
general surgical patients-dynamic nutritional assessment using plasma
proteins. JPEN 1987; 11: 135-141
Connelly K G, Repine J E, Seligman P A, Giclas P C, Moore F A, Moore E
E, Pharsons P E, Moss M. Serum ferritin as a predictor of the acute
respiratory distress syndrome. Am J Respir Crit Care Med 1997; 155:
21-25
Cook J D, Skikne B S. Serum ferritin: a possible model for the assessment
of nutrition stores. Am J Clin Nutr 1982; 35: 1180-1185
Cortes B, Nelson L D. Errors in estimating energy expenditure in critically
ill surgical patients. Arch Surg 1989; 124: 287-290
Covelli H D, Black J W, Olsen M S, Beekman J F. Respiratory failure
predicted by high carbohydrate loads. Ann Inter Med 1981; 95: 579-581
Cutts M E, Dowdy R P, Ellersieck M R, Edes T E. Predicting energy needs
in ventilator-dependent critically ill patients: effect of adjusting weight
for edema or adiposity. Am J Clin Nutr 1997; 66: 1250-1256
Dark D S, Pingleton S K, Kerby G R. Hypercapnia during weaning: a
comparison of nutritional support. Chest 1985; 88: 141-143
Davies P S W. Energy requirements and energy expenditure in infancy. Eur
J Clin Nutr 1992; 46 (suppl): s29-s35
de Jong PCM, Wesdorp RIC, Volovics A, Roufflart M, Greep F M,
Soeters P B. The value of objective measurements to select patients who
are malnourished. Clin Nutr 1985; 4: 61-66
Douville P, Talbot J, Lapointe R, Belanger L. Potential usefulness of serum
prealbumin in total parenteral nutrition. Clin Chem 1982; 28: 1706-1707
Driver A G, LeBrun M. Iatrogenic malnutrition in patients receiving
ventilatory support. JAMA 1980; 244: 2195-2196
Elia M, Livesey G. Theory and validity of indirect calorimetry during net
lipid synthesis. Am J Clin Nutr 1988; 47: 591-607
Ferrannini E. The theoretical basis of indirect calorimetry. Metabolism
1988; 37: 287-301
Feurer I D, Crosby L O, Mullen J L. Measured and predicted resting
energy expenditure in clinically stable patients. Clin Nutr 1984; 3: 27- 31
Flancbaum L, Choban P S, Sanbucco S, Verducci J, Burge J C. Comparison
of indirect calorimetry, the Fick method, and prediction equations in
estimating the energy requirements of critically ill patients. Am J Clin
Nutr 1999; 69: 461-466
Forbes G B. Human Body Composition: Growth, Aging, Nutrition and
Activity. New York, Springer-verlag, 1987
Frisancho A R. New standard of weight and body composition by frame
size and height for assessment of nutritional status of adults and the
elderly. Am J Clin Nutr 1984; 40: 808-819
Fuller N J, Jebb S A, Goldberg G R, Pullicino E, Adams C, Cole T J, Elia
M. Inter-observer variability in the measurement of body composition.
Eur J Clin Nutr 1991; 45: 43-49
Fusco M A, Mills M E, Nelson L D. Predicting caloric requirements with
emphasis on avoiding overfeeding. JPEN 1995; 19 (suppl): 18s (abstr)
Garrow J S. Energy Balance and Obesity in Man. 2nd Ed. New York, NY:
Elsevier/North Holland Biomedical Press; 1978
Guenst J M, Nelson L D. Predictors of total parenteral nutrition induced
lipogenesis. Chest 1994; 105: 553-559
Harris J A, Benedict F G. A Biometric Study of Basal Metabolism in Man.
Washington DC: Carnegie Institute, 1919. Publication No.279
Harvey K B, Moldawer L L, Bistrian B R, Blackburn G L. Biological
measures for the formulation of a hospital prognostic index. Am J Clin
Nutr 1981; 34: 2013-2022
Hayashida Y, Kido Y, Tsujinaka T, Abe Y, Kobayashi M, Nishi T, Ogawa
A, Tanaka T, Mori T. Increased energy expenditure after intra- venous
administration of amino acids. JPEN 1992; 16: 142-148
Hill J O, Heymsfield S B, Mcmanus C, Digirolamo M. Meal size and
thermic response to food in meal subjects as a function of aerobic
capacity. Metabolism 1984; 33: 743-749
Heymsfield S B, Head C A, McManus C B, Seitz S, Staton G W, Grossman
G D. Respiratory, cardiovascular, and metabolic effects of enteral
hyperalimentation: influence of formula dose and composition. Am J
Clin Nutr 1984; 40: 116-130
Huang Y C, Yen C L, Jih K S, Kan M N. Nutritional status of mechanically
ventilated critically ill patients: comparison of different types of
nutritional support. Clin Nutr 2000; 19: 101-107
Huang P C, Yu S L, Lin Y M. Body weight of Chinese adults by sex, age
and body height and criterion of obesity based on body mass index. J
Chinese Nutr Sec 1992; 17: 157-172
Hulthen L, Hallberg L, Lundberg P A, Lindstedt G. Effect of the mild
infection on serum ferritin concentration─Clinical and epidemiological
implication. Eur J Clin Nutr 1998; 52: 376-379
Hunter D C, Jaksic T, Lewis D, Benotti P N, Blackburn G L, Bistrian B R.
Resting energy expenditure in the critically ill patients: estimation
versus measurement. Br J Surg 1988; 75: 875-878
Hwang T L, Huang S L, Chen M F. The use of indirect calorimetry in
critically ill patients – the relationship of measured energy expenditure to
injury severity score, septic severity score, and APACHE II score. J
Trauma 1993; 34: 247-251
Ingelbleek Y, van den Schriek H G, De Nayer P, DeVisscher M. Albumin,
transferrin and the thyroxine-binding prealbumin/retinol binding protein
complex in assessment of malnutrition. Clin Chim Acta 1975; 63: 61-67
Ireton-Jones C S, Turner W W, Liepa G U, Baxter C R. Equation for
estimating energy expenditure in burn patients with special reference to
ventilatory status. J Burn Care Rehabil 1992; 13: 330-333
Jeejeebhoy K N, Meguid M M. Assessment of nutrition status in the
oncologic patient. Surg Clin North Am 1986; 66: 1077-1083
Jolliet P, Pichard C, Biolo G. Enternal nutrition in intensive care patients:
a practical approach. Intensive Care Med 1998; 24: 848-859
Kleiber M. The Fire of Life: An Introduction to Animal Energetics.
Huntington, Robert E. Krieger Publishing Co., 1975.
Knaus W A, Draper E A, Wanger D P, Draper E A, Zimmerman J E.
APACHE II: A severity of disease classification system critical care
medicine. 1985; 13: 818-829
Larca L, Greenbum D M. Effectiveness of intensive nutritional regimes
in patients who fail to wean from mechanical ventilation. Crit Care Med
1982; 10: 297-300.
Liggett S B, Renfro A D. Energy expenditure of mechanically ventilated
nonsurgucal patients. Chest 1990; 98: 682-686
Liu H Y, Lu Y F, Chen W J. Predictive equation for basal metabolic rate in
Chinese adults: a cross-validation study. J Am Diet Assoc 1995; 95:
1403-1408
Livesey G, Elia M. Estimation of energy expenditure, net carbohydrate
utilization, and net fat oxidation and synthesis by indirect calorimetry:
evaluation of errors with special reference to the detailed composition of
fuels. Am J Clin Nutr 1988; 47: 608-628
Long C L, Schaffel N, Geiger J W. Metabolic response to injury and
illness: Estimation of energy and protein needs from indirect calorimetry
and nitrogen balance. JPEN 1979; 3: 452-456
Makita K, Nunn J, Royston B. Evaluation of metabolic measuring
instrument for use in critically ill patients. Crit Care Med 1990; 18: 638-
644
Mann S, Westenskow D R, Houtchens B A. Measured and predicted caloric
expenditure in the acutely ill. Crit Care Med 1985; 13: 173-177
Manning E M C, Shenkin A. Nutritional assessment in critical ill. Crit Care
Clin 1995; 11: 603-634
McMahon M M, Franell M B, Murray M J. Nutritional support of critically
ill patients. Mayo Clin Proc 1993; 68: 911-920
Moroz C, Djaldetti M, Salman H, Zahavi I, Katz M, Bessler H. Elevated
serum ferritin level in acute myocardial infraction. Biomed
Pharmacother 1997; 51: 126-130
Nishiya K, Hashimoto K. Elevation of serum ferritin levels as a marker for
active systemic lupus erythematosus. Clin Exp Rheumatol 1997; 15: 39-
44
Oba K, Metori S, Nakano H, Suzuki T, Sasai K, Sato S, Okazaki K,
Yamashita N. High levels of serum ferritin in elderly patients with
non-insulin dependent diabetes mellitus. Nippon Ronen Igakkai Zasshi
1997; 34: 305-311
Pemberton C M: Mayo Clinic Diet Manual, 6th Ed. Philadelphia, BC
Decker, 1988; 588
Porter C, Cohen N H. Indirect calorimetry in critically ill patients: role of
the clinical dietitian in interpreting results. J Am Diet Assoc 1996; 96:
49-54
Quebbeman E J, Ausman R K, Schneider T C. A re-evaluation of energy
expenditure during parenteral nutrition. Ann Surg 1982; 195: 282-286
Reinhardt G F, Myscofski R D, Wilkens D. Incidence and motility of
hypoalbuminaemic patients in hospitalized veterans. JPEN 1980; 4: 357-
366
Rochester D F, Esau S A. Malnutrition and the respiratory system. Chest
1984; 85: 411-414
Roe C F, GoldbergM J, Blaw C S, Kinney J M. The influence of body
temperature on early postoperative oxygen consumption. Surgery 1966;
60: 85-92
Seltzer M H, Slocum B A, Cataldi-Belcher E L. Instant nutritional
assessment: Absolute weight loss and surgical mortality. JPEN 1982; 6:
218-221
Sharkey R A, Repine J E, Haslett C, Robertson C E, Connelly K G,
Donnelly S C. Initial serum ferritin levels in patients with multiple
trauma and the subsequent development of acute respiratory distress
syndrome. Am J Respir Crit Care Med 1999; 159: 1506-1509
Sherman M S. A predictive equation for determination of resting energy
expenditure in mechanically ventilated patients. Chest 1994; 105: 544-
549
Simonson D C, Defronzo R A. Indirect calorimetry: methodological and
interpretative problems. Am J Physiol 1990; 258: E399
Starker P M, Gump F E, Askanazi J, Elwyn D H, Kinney J M. Serum
albumin levels as an index of nutritional support. Surgery 1982; 91: 194-
199
Stettler N, Schutz Y, Micheli J-L, Jequier E. Energetic and metabolic
cost of growth in Gambian infants. Eur J Clin Nutr 1992; 46: 329-335
Swinamer D L, Phang P T, Jones R L, Grace M, King E G. Twenty-four
hour energy expenditure in critically ill patients. Crit Care Med 1987; 15:
637-643
Takala J, Keinanen O, Vaisanen P, Kari A. Measurement of gas exchange in
intensive care: laboratory and clinical validation of a new device. Crit
Care Med 1989; 17: 1041-1047
Tissot S, Delafosse B, Bertand O, Bouffard Y, Viale J P, Annat G. Clinical
validation of the Deltatrac monitoring system in mechanically ventilated
patients. Intensive Care Med 1995; 21: 149-153
Vicari J, Watson P, Fagan D, Jasnowski J, Lanspa S J. Measured resting
energy expenditure: relationship to APACHE II score and obesity. Nutr
Res 1995; 15: 777-784
Von Meyenfeldt M F, Meijerink W J HJ, Rouflart M MJ. Perioperative
nutrition support: A randomised clinical trial. Clin Nutr 1992; 11: 180
Weir J B de V. New methods for calculating metabolic rate with special
reference to protein metabolism. J Physiol 1949; 109: 1-9
Weissman C, Kemper M, Askanazi J, Hyman A I, Kinney J M. Resting
metabolic rate in the critically ill patient: Measured versus predicted.
Anesthesiology 1986a; 64: 673-679
Weissman C, Kemper M, Elwyn D H, Askanazi J, Hyman A I, Kinney J M.
The energy expenditure of the mechanically ventilated critically patient:
an analysis. Chest 1986b; 89: 254-259
Weissman C, Sardar A, Kemper M. An in vitro evaluation of an designed to
measure oxygen consumption and carbon dioxide production during
mechanical ventilation. Crit Care Med 1994; 22: 1995
Woo R, Daniels-Kush R, Horton E S. Regulation of energy balance. Ann
Rev Nurt 1985; 5: 411-433
Zaloga G P. Nutrition in Critical Care. Mosby: St. Louis. 1994; 167-191
金惠民、賴昭鴻、蔡秀悅、金美雲、王秀媛：疾病營養與膳食療養，華香園出版社，台北，1991
原著：Robinson, Lawler, Elizabeth, Chenoweth, Chenoweth. 主譯者: 連潔群、楊又才：新編實用營養學，第一版，藝軒圖書出版，台北，1998
唐高駿：加護病房之使用及成本效益。臨床醫學，1998; 41:434-437
楊雪松：實用急症處理手冊，合計圖書出版社，台北，1997
蔡淑芳、周聰成、陳冠如、陳雪美、陳麗真、彭巧珍、蔡秀玲、蔡淑芳：應用膳食療養學，第一版，藝軒圖書出版社，台北，1997
蔡秀玲、蔡佩芬、郭靜香：營養評估手冊，國興出版社，新竹，1993