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 ,


   !* 

1
12
15
22
27
41
49
55
64
77
81
84
94

11
14
21
26
40
48
54
63
76
80
83
93
109

(malnutrition)

2
2


1. (inadequate nutrient intake)

2. (maldigestion malabsorption)

3.

4.

Starvation
(macronutrient)
(protein-energy malnutrition) starvation

(micronutrient)
1

Semistarvation

Fasting total fasting (complete delivery
of dietary energy) fasting starvation
overnight fast
Cachexia starvation
(wasting) (metabolic stress)
cytokine-induced malnutrition starvation
(metabolic stress)

(body responses to
starvation)
(metabolic responses to fasting)
(fed state)
basal post-absorptive state
(endogenous fuel)

post-absorptive state
8-10 /.
50

(glycogenolysis)
(gluconeogenesis)
12-24 gluconeogenesis

gluconeogenesis

(oxidation)
2-3
gluconeogenesis
gluconeogenic amino acid ()
40-50

:

4-7
30-40
2 3-5
2

gluconeogenesis
2
10-12 / 62.5 - 75
lean tissue mass 250-300
3
(adaptation) 7-10 2-3
50

gluconeogennesis
(resting energy expenditure RMR)
15 2 25-35 3-4

1.
(prealbumin)
(retinol binding protein RBP)

2.
(extracellular fluid)

3. 50
4. gastric emptying time 4

4 . 5 3 .
5
2 3 1 3
lean tissue mass

(anti-natriuretic action) (2-3
/) (3-4 /)
lean tissue mass (19-25 /) 2
lean tissue mass
(survival in prolonged fasting)
lean tissue mass 50
(survival)
60
lean tissue mass 1
3
382

100-150
50 ( protein
sparing effect )
(natural adaptation) 7-10


4

(hypoalbuminemic malnutrition kwarshiokor)

7-10
3

(body responses to protein

deficiency)
(adaptation)

lean
tissue mass (accommodation)
lean tissue mass


(adaptation)
(protein turnover)

7-10

0.45 /./

(protein
conservation)

(energy expenditure)

(labile protein)



(labile protein)
3

3-5

labile pool

(adaptation)

(metabolic response to protein energy deficiency)

2 3
24
23
70 lean tissue
mass 24 60
6

(interstitial space)

(adaptation)
lean tissue mass

(dietary induced thermogenesis DIT)

lean tissue mass

1.

2.
3.

4.

5.
(micronutrient)

1.

2. (peripheral protein)


3.

4.

5.
(failed adaptation)

1.
2.
3.

4.

(Body response to
metabolic stress)
(metabolic response
to metabolic stress)

counter regulatory hormone,
cytokines

( catecholamines)
( antidiuretic hormone aldosterone
counter- regulartory hormones catecholamines
growth hormones (hyperglycemia of
stress)
cytokines
cytokines
interleukin1 (IL-1), tumor necrosis factors (TNF)
(parakine effect) (systemic effect)
IL-1 lymphocyte acute phase response
acute phase protein
(ceruloplasmin ) redistribution trace element


Redistribution trace element
IL-1 iron-binding protein lactoferrin

IL-1 counter-regulatory hormones

TNF

120-270 ./
15 70 .
40 60
10
cytokines
acute phase protein
(transcapillary escape rate)
(permeability)

1.
2.
3.
4. acute phase protein c- reactive protein, 1 acid
glycoprotein,
5.
6.
7.
(bacterial
translocation)
8.
9.

10

1. Biolo G, ToiGo G, Ciocchi B, Situlin R, Iscra F, Gullo A, Guarniere G. Metabolic

response to infury and sepsis: Change in protein metabolism. Nutrition 1997; 13
(suppl): 52S-7S.
2. Chiolero R, Revelly JP, Tappy L. Energy metabolism in sepsis and injury. Nutrition
1997; 13 (suppl): 45S-51S.
3. Hoffer J. Metabolic consequence of starvation. In: Shils ME, Olson JA, Shike M, Ross
AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams &
Wilkins, 1999: 645-65.

11

(Type of protein energy malnutrition)

(classification of PEM)

1. (primary PEM)

2. (secondary PEM)

(type of PEM)
1. Marasmus (total energy deficiency)

(skin and bone appearance)

2. Kwarshiokor (protein deficiency)


marasmus
3. Marasmic-kwarshiokor

12

2.1
2.1

Marasmus

Edematous malnutriton

cytokines

(central protein
visceral protein)

acute phase response

acute phase response

arm muscle
circumference

lean tissue
mass

lean tissue
mass

anorexia nervosa

counter
regulatory hormones, aldosterone
antidiuretic hormone

McMahon MM, Bistrian BR. The physiology of nutritional assessment and

therapy in protein-calorie malnutrition. Disease a Month.1990; 388.

13

(severity of PEM)
1. (body mass index BMI) 17.0-18.5 ./
.
2. 16.90-17 ./.
3. 16 ./.

17-18.5 /.
18 /.

5-7

1. Hoffer J. Metabolic consequence of starvation. In: Shils ME, Olson JA, Shike M, Ross
AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams &
Wilkins. 1999: 645-65.
2. McMahon MM, Bistrian BR. The physiology of nutritional assessment and therapy in
protein-calorie malnutrition. Disease a Month.1990; July: 384-417.

14

(Complication of protein energy malnutrition)

lean tissue mass

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

(adaptation)

3.1

15

3.1

- ( -
-
)
-
Growth
- -
-
-
hormone
-
-
-
Insulin like
- -
-
-
-
growth factors

-
-
(IGF)
-
-
- growth hormone

-
-
-
-

- -

-
-
- -
-

-
-
-
-
-
-
-

- (?)
-T4 -T4 - 5'
-
-T3
-
,
deiodinase
-T3
- reverse T3
Gonadotropins -
-
-
-
?
Torun B. and Chew F. Protein energy malnutrition. In: Modern of nutrition in health and
disease. 9th edition 1999, 963-988.

16

(red cell mass)

lean tissue mass

( functional anemia)

12

absolute cardiac
output

(venous return) (postural
hypotension)
(stroke volume)

3
1. (respiratory drive)
lean tissue mass

2. (respiratory pattern)
(tidal volume)

maximum ventilatory
ventilatioin (MVV)

(sigh frequency) functional residual
capacity

17

3. (parenchymatous change)

(emphysematous change)

(glomerular filtration rate GFR)

(cardiac output)

(intracellular electrolytes) (
)
(adenosine triphosphate ATP)
-

(medullary interstitial tissue)

(urine concentrating ability)
-

refeeding
syndromes

18

1.
2.
3.
4.

-
interleukin-1
classic alternative pathway
opsonic activity

5. (phagocytosis)
6.
(chemotaxis)
7. (intracellular killing)

8. (humeral immune response)

-
secretory Ig A

1. (motility)
(gastric secretion)
2.
(brush border enzymes)

3. (mucosal barrier)
4.
5.

1.

19

2.
(intestinal bacterial overgrowth)

(bacterial translocation)

acetyl co-A
(fatty liver steatosis) (protein
deficiency malnutrition)
(long chain
triglyceride)

(micronutrient deficiency)
micronutrients
1 6 12
(peripheral neuropathy) 1 6 12

gonadotropin

20

1. Hoffer J. Metabolic consequence of starvation. In: Shils ME, Olson JA, Shike M, Ross
AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams &
Wilkins. 1999: 645-65.
2. Torun B and Chew F. Protein-energy malnutrition. In: Shils ME, Olson JA, Shike M,
Ross AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams
& Wilkins.1999: 963-88.

21

(Principle of nutrition support in malnorished patients)

(Principle of nutrition support )

4.1
7-10

4.1

7-10

3-4

McMahon MM, Bistrian BR. The physiology of nutritional assessment and

therapy in protein-calorie malnutrition. Disease a Month.1990; July: 384-417.

22

1.

2. -

3.

4.

(refeeding effect)
refeeding

(antinatriuretic)

(RMR)

(refeeding diarrhea)

23

1.

2.
(refeeding
syndrome) 20
500-800 . 150-200
/ 2-3



(maintenance)
1
lean tissue mass

3. 1.5- 2 /
./

4.

(response to nutrition support)

marasmus
2-4 lean tissue
mass 60-180 edematous
hypoalbuminemic malnutrition

24

2-4

7-10

Baidao 10-13 ./.
( 16.5 ) ( 8.5 )
marasmus
(recovery phase)
edematous PEM
(9 )

(renal solute load)
( 8-13)

1. Collins B. Dietary treatment of severe malnutrition in adults. Am J Clin Nutr 1998;

68:193-9.
2. Hoffer J. Metabolic consequence of starvation. In: Shils ME, Olson JA, Shike M, Ross
AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams &
Wilkins. 1999: 645-65.
3. McMahon MM, Bistrian BR. The physiology of nutritional assessment and therapy in
protein-calorie malnutrition. Disease a Month.1990; July: 384-417.

25

4. Owen OE, Smalley KJ, D'Alessio DA, Mozzolo MA, and Dawson EK. Protein, fat and
carbohydrate requirements during starvation: anaplerosis and cataplerosis. Am J
Clin Nutr 1997; 68: 12-34.
5. Torun B and Chew F. Protein-energy malnutrition. In: Shils ME, Olson JA, Shike M,
Ross AC, eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams
& Wilkins. 1999: 963-88.

26

5
(Nutritional assessment)





(whole body)

1. (clinical assessment)
2. (anthropometric assessment)
3. (biochemical and laboratory
assessment)
4. (functional assessment)

27

(clinical nutritional
assessment)

(static assessment)
(dynamic assessment)

28

1. (weight change)

0.6
0.1 .
0.5 . /

(total starvation)
0.4 ./ 70
minimum survival weight
(semi-starvation)
48-55
2
(total weight loss) (rate of weight loss)
(prognostic index)

(% weight change) = - x 100

10
10-20
20

(clinical outcome) Studely

20 33
20 5
5.1

29

5.1

(significant
weight loss) ()

(severe weight loss) (

)

1-2

>2

>5

7.5

>7.5

10

>10

GL Blackburn, BR Bistrain, BS Maini, HT Schlamm, MF Smith. Nutritional and

metabolic assessment of the hospitalized patient. JPEN.1977;1:11-22.
2. (dietary change)

(strict vegetarian)
12 , 1 ,


1.


micronutrient
2.

micronutrient
3. (appetite, satiety
abdominal discomfort)
30

4.
(eating disorder)
anorexia nervosa
3. (GI tract symptoms)

4. (symptoms of nutrient deficiency)

4.1

4.2


4.3 trace element
(hypogausea)
5. (medical history)

5.1
(organ failure)

5.2

chronic atrophic gastritis

12

12

-

- ileum
12

31

- (short bowel syndrome)

trace element


5.3
-
-
-
-Fistula
- (hemodialysis) (peritoneal
dialysis) 6
-Draining abscess
-Nephrotic syndrome
5.4

- 1 13
-
- C

- (pregnancy lactation)

6.

-
- antacid
- barbiturates phenyltoin
12 , 6, , ,
-

12
32

- 6


- methotrexate, pyrimethamine, trimetroprim

- cholestiramine cholestipol bile acid exchange resin

(antibiotic associated diarrhea)
- (INH) 6
6
7.
(near total total
gastrectomy)
intrinsic factor 12
12 jejunum
bypass duodenum
8.

7 /
( empty calorie)
1,2,6,12

5.2

33

5.2

5.2

Head
Hair

Eyes

Mouth

- (wasted, skinny)

-Psoriasiform rash,eczematous scaling

-Follicular hyperkeratosis
-Perifollicular petechiae
-Flaky paint dermatitis
-Easy bruising
-Pigmentation changes
-Thickening and dryness of skin
-Nasolabial seborrhea
Temporal muscle wasting
-Sparse and thin, dyspigmentation,
easy to pull out
-Dry brittle hair
-Corkscrew hair
-Night blindness
-Photophobia,
xerosis,
Bitot's spots, keratomalacia
-conjunctival inflammation
-Glossitis (smooth red tongue)
-Bleeding gums
-Cheilosis
34

-
-
- 12
-
-
-
-
-
-
- 6

-
-
-
-
-
- A
-
6,12
-
- 6

Neck
Chest
Heart
Abdomen
Extremities

Nails
Neurologic

-Angular stomatitis
-Hypogeusia
-Scarlet and raw tongue or tongue
fissuring
-Tongue atrophy
-Enamel loss
-Goiter
-Parotid enlargement
-Respiratory muscle weakness
-High output failure
-Ascites
-hepatomegaly
-Edema
-Muscle wasting and weakness
-Bone pain
-Spooning
-Transverse lines
-Tetany
-Paresthesias
-Loss of reflexes,wrist drop, foot drop
-Loss of vibratory and position sense
-Peripheral neuropathy
-Dementia
-Disoriention
-Nystagmus
Opthalmoplegia

- 6
-
-
-
-
-
-
-
-
-
-
-
-e
-
-
-
-
- 12
-
- 12
- 6
- 12
-
-
-

Haisted CH, Van Hoozen CM, Ahmed B. Preoperative nutritional

assessment. In: Quigley EM, eds. The gastrointestinal surgical patient; preoperative and
postoperative care. Baltimore: William&Wilkins. 1994:27-49.

35

(Subjective global assessment

SGA)
(subjective global assessment
SGA)


5
4
6 2

( functional status)

(metabolic demand)
0 = 1+ = 3+ =

(mid-axillary line)
deltoids quadriceps

SGA 5.3
SGA
(clinical outcome)

36

5.3

A.
1.
6 : ________. _____; _____ .
2

2. ()

______





;

________ /
3. ( 2 )





4.

_____ :
5.
__________________________________________________________
stress
stress
stress
stress
B. ( 0 = , 1+ = , 2+ = , 3+ = )

___
___ (, , )
___
___

___
___
___
___

C. SGA rating

Jeejeebhoy KN. Clinical and functional assessment. In: Shils ME, Olson JA,
Shike M, eds. Modern nutrition in health and diseases. 8th ed. Philadelphia:
Lea&Febiger. 1994:805-811.
37

(functional assessment)
(body
structure) (body composition)

1. cognitive function
2. (disease response)
3. (reproductive competence)
4. (physical activity)
5. (social/behavioral performance)

(functional assessment)
. Skeletal muscle function

1. Maximum voluntary muscle strength

1.1 Hand grip strength hand dynamometry

hand
dynamometry

1.2 Peak expiratory inspiratory flow rate

maximum voluntary muscle strength

2. Muscle stimulation test adductor pollicis

(force frequency curve)
38

(maximum relaxation rate

. visceral protein

. (immunologic test)

1. total lymphocyte count (1500-4000/)
total lymphocyte count
2. (delayed hypersensitivity response
(DHR)) PPD Candida
(anergy)

39

1. Blackburn GL, Bistrain BR, Maini BS , HT Schlamm, MF Smith. Nutritional and

metabolic assessment of the hospitalized patient. JPEN.1977;1: 11-22.
2. Elia M. Assessment of nutritional status and body composition. In: Rombeau JL,
Rolnadelli RH, eds. Clincal nutrition: Enteral and tube feeding. 3rd ed. Philadelphia: W.B
Saunders company. 1997:155-73.
3. Haisted CH, Van Hoozen CM, Ahmed B. Preoperative nutritional assessment. In:
Quigley EM, eds. The gastrointestinal surgical patient; preoperative and postoperative
care. Baltimore: William&Wilkins. 1994:27-49.
4. Jeejeebhoy KN. Clinical and functional assessment. In: Shils ME, Olson JA, Shike M,
eds. Modern nutrition in health and diseases. 8th ed. Philadelphia: Lea& Febiger
1994:805-11.
5. Smith LC and Mullen JL. Nutritional assessment and indications for nutritional support.
Surg Clin North Am 1991; 71:449-457.

40

6

(Anthropometric assessment)
(anthropometry)
(body composition)
lean body mass
2
1.

2.
1

1. (weight height stature) (body

mass index)
2. (subcutaneous skinfold)
3. (arm muscle area)

(body weight)
(desirable ideal body
weight)
90-110

80-90

70-79

69

48-55

6.1 . .

40

6.1 .
(.)
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
189
180

50.0
50.7
51.4
51.8
52.2
52.7
53.2
53.7
54.1
55.0
55.9
56.5
57.1
57.7
58.6
59.5
60.1
60.7
61.4
62.3
63.2
63.8
64.4
65.0
65.9
66.8

53.6
54.3
55.0
55.5
56.0
56.4
56.6
57.2
57.7
58.5
59.5
60.1
60.7
61.4
62.3
63.2
63.8
64.4
65.0
65.9
66.8
67.5
68.2
69.0
69.9
70.9

58.2
58.8
59.5
60.0
60.5
60.9
61.5
62.1
62.7
63.4
64.1
64.8
65.6
66.4
67.5
68.6
69.2
69.8
70.5
71.4
72.3
72.9
73.5
74.1
75.3
76.4

43.2
43.7
44.1
44.6
45.1
45.5
46.2
46.8
47.3
47.8
48.2
48.9
49.5
50.0
50.5
50.9
51.5
52.1
52.7
53.6
54.5
55.1
55.7
56.4
57.3
58.2
58.8
59.4
60.0
60.9
61.8
62.4
63.0
63.6
64.5
65.5

45.9
46.6
47.3
47.7
48.1
48.6
49.3
50.0
50.5
51.0
51.4
52.3
53.2
53.6
54.0
54.5
55.3
56.1
56.8
57.7
58.6
59.2
59.8
60.5
61.4
62.2
62.8
63.4
64.1
65.0
65.9
66.5
67.1
67.7
68.6
69.5

50.5
51.2
51.7
52.2
52.7
53.2
54.0
54.5
55.0
55.5
55.9
56.8
57.7
58.3
58.9
59.5
60.1
60.7
61.4
62.3
63.2
63.8
64.4
65.0
65.9
66.8
67.4
68.0
68.6
69.8
70.9
71.7
72.5
73.2
74.1
75.0

(body frame) = (.)

(.)
6.1 .
(body frame)
(small frame)
(medium frame)
(large frame)

>10.4
9.6-10.4
<9.6

>10.9
9.9-10.9
<9.9

6 . 6 . Smithgall JM. Anthropometric measurements:

Body frame size. In: Atlas of nutritional support techniques. Rombeau
JL. et al. eds. Boston. Little Brown and company. 1989:41.

41

1.
2.

(body mass index)

[(.)/2(.2)]

30
/2
25.0-29.9
/2

20-24.9
/2
18.5-19.9
/2

17.5-18.49 /2

16.0-17.49 /2
16
/2

(fat reserve)
(subcutaneous fat)
50
(skinfold thickness) 6.1
4
1. Triceps skinfold
3. Suprailiac skinfold
2. Biceps skinfold
4. Subscapular skinfold
triceps skinfold

Triceps skinfold acromion olecranon

process ulnar 6.2 6.2
6.3 . 6.3 .

42

6.

Lee RD, Nieman DC. Anthropometry. In: Nutritional

assessment. Lee RD, Nieman DC. eds. Dubuque: Wm. C.
Publishers. 1993:139.

6.1 triceps
skinfold

Lee RD, Nieman DC. Anthropometry. In: Nutritional assessment.

Lee RD, Nieman DC. eds. Dubuque: Wm. C. Publishers. 1993:140.

6.2 (midarm circumference MAC)

Lee RD, Nieman DC. Anthropometry. In: Nutritional assessment. Lee RD, Nieman DC. Eds.
Dubuque: Wm. C. Publishers. 1993:170.

43

somatic protein
muscle area skinfold thickness

Upper arm circumference (AC)

acromion olicrinon process

Arm muscle circumference (AMC)

total muscle mass
Arm muscle circumference (MAMC) = mid- arm circumference - x triceps skinfold
6
Arm muscle area (AMA)
valid body muscle mass arm muscle circumference

Arm muscle area (AMA)

= mid arm circumference -( x triceps skinfold)2
4
7
skinfold thickness, arm muscle circumference arm muscle area
median ( percentile 50)
90-110 median
80-90 median
60-80 median
60 median
percentile
percentile 0-5

percentile 5-15

percentile 15-85
percentile 85-95
percentile 95-100

44

anthropometry
fluid status

6.2 Triceps skinfold

(.)

SD
th
th
th
th

5
10
15
25
50th
75th
85th
90th
95th

18-74
18-24
25-34
35-44
45-54
55-64
65-74

12.9
11.6
12.9
13.8
13.5
13.2
12.7

6.7
6.5
7.0
7.1
6.7
6.3
6.1

SD

18-74
18-24
25-34
35-44
45-54
55-64
65-74

24.9
20.7
23.6
26.3
27.5
27.2
25.7

9.8
8.6
9.9
9.8
9.7
9.5
9.0

5.0
4.5
4.5
5.0
5.5
5.0
5.0

6.0
5.0
5.5
6.0
6.5
6.0
6.0

6.5
6.0
6.5
7.0
7.0
7.5
7.0

8.0
6.5
7.5
9.0
9.0
9.0
9.0

12.0
10.0
11.5
12.5
12.0
12.0
11.5

16.0
15.0
16.5
17.0
16.5
16.0
16.0

19.5
17.5
20.0
20.0
20.0
19.5
18.5

22.0
20.0
23.0
23.0
22.0
21.5
21.0

25.5
24.5
26.0
27.0
25.5
25.5
25.0

85th

90th

95th

35.1
29.5
33.5
37.0
38.0
27.0
35.0

38.0
32.0
36.6
40.5
40.5
40.0
37.6

43.0
37.0
43.5
44.5
45.0
43.6
42.0

5th

10th

15th

25th
50th
75th

11.0
10.0
10.0
12.0
12.5
12.0
12.0

13.0
11.5
13.0
14.5
15.0
15.0
14.5

15.0
12.5
14.0
16.5
17.0
17.5
16.5

17.5
15.0
16.5
19.5
20.5
21.0
19.0

24.0
19.0
22.0
25.0
27.0
26.5
25.0

31.0
25.0
29.0
32.6
34.0
33.0
31.0

Lee RD, Nieman DC. Appendix L. Triceps skinfold norms from the second national health and
nutrition examination survey. In: Nutritional assessment. Lee RD, Nieman DC. eds. Dubuque: Wm.
C. Publishers, 1993:375-376.

45

6.3 arm muscle area

(.)

SD

18-24.9
25.0-29.9
30.0-30.9
35.0-39.9
40.0-44.9
45.0-49.9
50.0-54.9
55.0-59.9
60.0-64.9
65.0-69.9
70.0-74.9

550.5
54.1
55.6
56.5
56.6
55.6
55.0
54.7
52.8
49.8
47.8

11.6
11.9
12.1
12.4
11.7
12.3
12.5
11.8
11.7
11.6
11.5

SD

18-24.9
25.0-29.9
30.0-30.9
35.0-39.9
40.0-44.9
45.0-49.9
50.0-54.9
55.0-59.9
60.0-64.9
65.0-69.9
70.0-74.9

29.8
31.1
32.8
34.2
35.2
34.9
35.6
37.1
36.3
36.3
36.0

8.4
9.1
10.4
11.5
13.3
11.8
11.0
13.3
11.3
11.3
10.8

10

15

25
50th
75th

34.2
36.6
37.9
38.5
38.4
37.7
36.0
36.5
34.5
31.4
29.7

37.3
39.9
40.9
42.6
42.1
41.3
40.0
40.8
38.7
35.8
33.8

39.6
42.4
43.4
44.6
45.1
43.7
42.7
42.7
41.2
38.4
36.1

42.7
46.0
47.3
47.9
48.7
47.9
46.6
46.7
44.9
42.3
40.2

57.1
61.4
63.2
64.0
64.0
63.3
62.7
61.9
60.0
57.3
54.6

61.8
66.1
67.6
69.1
68.5
68.4
67.0
66.4
64.8
61.2
59.1

65.0
68.9
70.8
72.7
71.6
72.2
70.4
69.6
67.5
64.3
62.1

72.0
74.5
76.1
77.6
77.0
76.2
77.4
75.1
71.6
69.4
67.3

85th

90th

95th

36.4
38.5
41.2
43.1
45.8
44.7
46.1
47.3
45.6
46.3
46.4

39.0
41.9
44.7
46.1
49.5
48.4
49.6
52.1
49.1
49.6
49.2

44.2
47.8
51.3
54.2
55.8
56.1
55.6
58.8
55.1
56.5
54.6

th

th

th

th

49.4
53.0
54.4
55.3
56.0
55.2
54.0
54.3
52.1
49.1
47.0

5th

10th

15th

25th
50th
75th

19.5
20.5
21.1
21.1
21.3
21.6
22.2
22.8
22.4
21.9
22.2

21.5
21.9
23.0
23.4
23.4
23.1
24.6
24.8
24.5
24.5
24.4

22.8
23.1
24.2
24.7
25.5
24.8
25.7
26.5
26.3
26.2
26.0

24.5
25.2
26.3
27.3
27.5
27.4
28.3
28.7
29.2
28.9
28.8

28.3
29.4
30.9
31.8
32.3
32.5
33.4
34.7
34.5
34.6
34.3

33.1
34.9
36.8
38.7
39.8
39.5
40.4
42.3
41.1
41.6
41.8

85th

90th

95th

Lee RD, Nieman DC. Appendix L. Triceps skinfold norms from the second national
health and nutrition examination survey. In: Nutritional assessment. Lee RD, Nieman DC. eds.
Dubuque: Wm. C. Publishers, 1993:382-383.

46

1. Lee RD, Nieman DC. Anthropometry. In: Nutritional assessment. Lee RD, Nieman
DC. eds. Dubuque: Wm. C. Publishers. 1993:121-63.
2. Lee RD, Nieman DC. Asessment of the hospitalized patirnt. In: Nutritional
assessment.. Lee RD, Nieman DC. eds. Dubuque: Wm. C. Publishers. 1993:165-91.
3. Smithgall JM. Anthropometric measurements: Body frame
size. In: Atlas of nutritional support techniques. Rombeau
JL, Caldwell MD, Forlaw L, Guenter PA. eds. Boston: Little
Brown and company. 1989:3-46.

47

(Laboratory assessment)
(laboratory assessment)
objective
(subclinical malnutrition)
2
static
static 2


metabolites

static
metabolite


(diurnal or
nocturnal variation)

1.
2.
3.
4.
48

5.

70 . 1013 . 7.1

7.1

22

20

18

17

6
Gibson RS. Assessment of protein status. In Nutritional assessment
: A laboratory manual. Oxford university press 1993;105-113

visceral protein pool

1. visceral protein status (central protein)

2. somatic protein status (peripheral protein)
3.
4.
(
functional)
5.

49

visceral protein reserve

1. (serum protein)
2. (serum albumin)
3. (transferrin)
4. (serum prealbumin transtyretin)
5. serum retinal binding protein
6. serum IGF-1
7.

stress

retinol binding protein IGF-1

7.2
7.2

(/
)
45 (35-50)

()
14-20

Comments

oncotic

(carrier)

- hypothyroidism,
stress
- (nephrotic
syndrome) (protein losing
enteropathy)
- stress
- fluid overload
-body pool 3-5 /.

50

2.3 (2.03.2)

8-9

thyroid
binding
prealbumin

transtyretin

0.3 (0.20.5)

2-3

Retinol
binding
protein (RBP)

0.03720.0073

0.5

IGF-1
0.83
somatomedin- (0.55C
1.4)IU/ml

0.1-0.3

1.82+0.16 0.5-1

-

-

- protein losing
enteropathy, nephropathy,
uremia acute catabolic state
-body pool < 0.1 /.

-

- acute catabolic state,
retinol-binding
tissue trauma, sepsis, hyperthyroidism
protein

- energy
balance nitrogen balance
energy repletion

-body pool 0.01 / .

- catabolize
A
-
- A
acute
catabolic state, hyperthyrodism
-body pool 0.002 /.
-

hypothyroidism

- acute catabolic state
opsonic
-
glycoprotein
chemotaxis -

51

Lee RD, Nieman DC. Laboratory assessment of nutritional status. In: Nutritional
assessment. Lee RD, Nieman DC. eds. Dubuque: Wm. C. Publishers. 1993:223-252.
somatic protein reserve
anthropometric study
(creatinine) 24 3-methylhistidine
fat free mass bioelectrical impedance assay (BIA),
isotopic method
somatic protein reserve
24 . (24-hour
creatinine excretion
(creatinine height index) lean tissue mass

Creatinine excretion creatinine-height index

lean body mass
23 /./ 18
././
lean tissue mass
lean tissue mass (.) = 7.138 + 0.02908 x (. )
creatinine height index 10.
24-hr urine creatinine (mg) x 100
Creatinine height index (CHI) =
expected 24-hr urine creatinine (mg)
80 60-80
60

52

7.3 24
(.)
147.3
149.9
152.4
157.5
160.0
162.6
165.1
167.6
170.2
172.7
175.3
177.8
180.3
182.9
185.4
188.0
190.5
193.0

(.)

1288
1325
1359
1386
1426
1467
1513
1555
1596
1642
1691
1739
1785
1831
1891

(.)
830
851
875
925
949
977
1006
1044
1076
1109
1141
1174
1206
1240

Lee RD, Nieman DC. Laboratory assessment of nutritional status. In: Nutritional assessment. Lee
RD, Nieman DC. eds. Dubuque: Wm. C. Publishers. 1993:223-252.

1. Lee RD, Nieman DC. Laboratory assessment of nutritional status. In: Nutritional
assessment. Lee RD, Nieman DC. eds. Dubuque: Wm. C. Publishers. 1993:223-52.
2. McMahon MM, Bistrian BR. The physiology of nutritional assessment and therapy in
protein-calorie malnutrition. Dis a Month.1990; July 379-417.
3. Smith LC and Mullen JL. Nutritional assessment and indications for nutritional support.
Surg Clin North Am 1991; 71:449-57.
53

8
(Nutrition support)

2
(maintenance treatment)
(repletion treatment) 2
1. (enteral nutrition support)
2. (parenteral nutrition support)
(indication for nutrition support)
8.1 8.2
8.1 (established
indication)

10-14

Souba WW. Nutritional support. N Engl J Med 1997; 330 (1): 41-48.

54

8.2

-
10

AIDS

(branch chain amino acid)

-
- (Crohn's disease)
- fistula

inflammatory
bowel disease

(
)
7-10

Souba WW. Nutritional support. N Engl J Med 1997; 330 (1): 41-48.

55

(nutrient requirement)

[ (indirect
calorimetry) (nitrogen balance study) ]
(estimation)
(metabolic demand)
(caloric requirement)
(total
energy expenditure TEE)
3
1. [basal energy expenditure (BEE) basal
metabolic rate (BMR)]
10 .
65-70
2. (dietary induced thermogenesis DIT)
(
) 5-10

3. (activity energy expenditure AEE)

15-40


cold induced
thermogenesis
[resting energy expenditure (REE)
resting metabolic rate (RMR)]

REE = BEE + DIT
TEE = REE + AEE

56

1. (estimation)
HarrisBenedict (Harris- Benedict equation)

BEE = 66 + (13.7 x weight [kg] + (5 x height [cm] ) - (6.8 x age)

BEE = 655 + (9.6 x weight [kg] + (1.7 x height [cm]) - (4.7 x age)

(recent weight)
TEE = BEE x activity factor x stress factor
Activity factor

= 1.0

= 1.2

= 1.3
Stress factor

= 0.7
=1
= 1.0-1.05
= 1.0

= 1.15

= 1.15

= 1.2

0-20

20-40

40-100

= 1.0
= 1.2-1.3
= 1.4-1.5
= 1.0-1.5
= 1.5-1.8
= 1.8-2.0

8090 50
57

2.
2.1 indirect calorimetry (oxygen consumption
VO2) (CO2 production VCO2)
2 . 20-30
M
= 5.02 VO2
M 1 VO2

( 0
760 . )

Brouwer (Brouwer's equation)
M
= 3.87 VO2 + 1.20 VCO2 -1.43 N
N (urinary nitrogen) 1

20-33

2.2
(pulmonary artery catheter) cardiac output
thermodilution oxygen saturation mixed venous blood
Fix (Fix's equation)
REE = cardiac output x hemoglobin x (Sa O2 - Sv O2) x 95.18
indirect calorimetry
(low tissue perfusion) 50
3000
(caloric load)
( 80-85
)
(total calorie)
non protein calorie nonprotein calorie
non-protein calorie

58

non-protein calorie

50-60 25-40 12-20
(protein requirement)

1. /./ 8.3
8.3
stress

(/./)

0.8

0.8-1.4

1.4-2.0

2.0-4.0

Lee RD, Nieman DC. Assessment of the hospitalized patient. In Lee RD, Nieman DC.
eds : Nutritional assessment. Dubuque: Wm. C. Brown Publishers. 1993:179.

2. non-protein calorie : 8.4

8.4 nonprotein calorie:
stress

nonprotein calorie: g nitrogen

250-350:1

150-200:1

100-150:1

80-100:1

Lee RD, Nieman DC. Assessment of the hospitalized patient. In Lee RD, Nieman DC.
(eds) : Nutritional assessment, Dubuque: Wm. C. Brown Publishers. 1993:180

59

3.
N balance =
() - UUN- 4
6.25
UUN 24 4

trace element
trace element recommended
dietary allowance (RDA) 8.5

(fiber)
2 (soluble fiber)
(insoluble fiber) soluble fiber

(soluble fiber) (pectin) (gum)

(short chain fatty)


(insoluble fiber)
( intestinal transit
time )

(soy fiber) (oat fiber) 2025
60

8.5 (national and international

recommended dietary reference values)

19-64
> 64
19-54
>54

( 750
750
750
750
+0
+ 450
)
(.)
1.1
0.9
0.8
0.7
+ 0.2
+ 0.4
(.)
1.7
1.3
1.2
1.0
+ 0.3
+ 0.5
(. 19
16
13
11
+2
+5
)
(.)
1.3-1.9
1.0-1.5
0.9-1.4
0.8-1.1
+ 0.1
+ 0.7-0.8
()
200
200
200
200
+ 200
+ 150
12 () 2.0
2.0
2.0
2.0
+ 1.0
+ 0.5
(.)
40
40
30
30
+ 30
+ 45
10.0
7.0
7.0
+0
+ 2.5
(. - 10.0
tocopheral equivalents)
(.)
12
12
12
12
+4
+6
(.)
7.0
7.0
12.0-16.0 5.0-7.0
+ 10.0-20.0 + 0
()
150
150
120
120
+ 30
+ 50
(.)
320
320
270
270
+ 30
+ 70
(.)
800
800
800
1000
+ 300
+ 400
(.)
1000
1000
1000
1000
+ 200
+ 200
()
85
85
70
70
+ 10
+ 15
()
40-140
40-140
40-140
40-140
+0
+0
(.)
920-2300 920-2300 920-2300 920-2300
()
50-140
50-140
50-140
50-140
+0
+0
(.)
1950-5460 1950-5460 1950-5460 1950-5460
()
55
55
45
45
+6
+ 16
Bloch AS, Shils M. Appendix contents. In: Shils ME, Olson JA, Shike M, Ross AC. Eds. Modern
Nutrition in Health and disease 9th edition. Baltimore: Williams & Wilkins. 1999:A41.

61

1. Bloch AS, Shils M. Appendix contents. In: Shils ME, Olson JA, Shike M, Ross AC. Eds.
Modern Nutrition in Health and disease. 9th edition. Baltimore: Williams & Wilkins. 1999:
A41.
2. Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association
technical review on tube feeding for enteral nutrition. Gastroenterology 1995;108:1282301.
3. Lee RD, Nieman DC. Assessment of the hospitalized patient. In Lee RD, Nieman DC.
eds : Nutritional assessment. Dubuque: Wm. C. Brown Publishers 1993: 165-191.
4. Poehlman ET, Horton ES. Energy needs: Assessment and requirements in humans. In:
Shils ME, Olson JA, Shike M, Ross AC. eds. Modern Nutrition in Health and disease. 9th
edition. Baltimore: Williams & Wilkins. 1999: 95-104.
5. Roberfroid M. Dietary fiber, inulin, and oligofructose: a review comparing their
physiological effects. Crit Rev Foods Sci Nutri 1993; 33(2): 103-48.
6. Shike M. Enteral feeding. In: Shils ME, Olson JA, Shike M, Ross AC. eds. Modern
Nutrition in Health and disease. 9th edition. Baltimore: Williams & Wilkins. 1999:1643-56.

62

(Enteral nutrition support)

(enteral nutrition support)

1.
3.
1.1 (cerebrovascular
3.1
3.2 (inflammatory bowel
accident)
1.2
diseases)
1.3
3.3 (short bowel syndrome)
1.4

1.5 demyelination
(malabsorption syndromes)
1.6
3.4 fistula
1.7 anorexia nervosa
2. 4.
4.1
2.1
4.2
2.2
2.3
4.3 (AIDS)
4.4
4.5
63

1. (complete intestinal obstruction)

2. severe intestinal pseudo-obstruction
3.
4. (severe maldigestion or
malabsorption syndrome)
5. bowel ileus
6. high flow fistula
7.

(defined formula diet)

1 .
2
1.

2. (enteral tube feeding)
2
nasogastric tube nasoenteric
tube feeding gastrostromy,
duodinostomy jejunostomy tube feeding

64

(maintenance treatment)

(repletion treatment)

Defined formula diet

Protein isolate diet

tube enterostomy

nasoenteric tube feeding

nasoduodinal
nasojejunal tube feeding

nasogastric feeding

PPN

Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of enteral nutrition in: Rombeau
JC, Rolandelli RH. eds. Enteral and tube feeding 3rd edition. Philadelphia: W.B. Saunders Company. 1997:240-67.

65

1. nasogastric nasoenteral
Levin
polyethylene
polyvinylchloride (PVC)


content
French
8-16
lower esophageal sphincter

(stylet guide- wire)

tungsten (tungsten
weighted tube)

(enteric feeding) 36
(nasogastric tube) 42
(nasogastric nasoenteric tube)
nasogastric nasoenteric tube
gastrostomy jejunostomy tube

Y-connector content
9.1

gastric content

9.1

66

9.1 nasoentric tube Y- connector content

Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of enteral nutrition in: Rombeau
JC, Rolandelli RH. eds. Enteral and tube feeding 3rd edition. Philadelphia: W.B. Saunders Company. 1997:250.

9.1

PVC

gastric content

Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of

enteral nutrition in: Rombeau JC, Rolandelli RH. Eds. Enteral and tube feeding 3rd edition 1997:240267.

gastric content
content

67

nasogastric nasoenteric feeding

1. (aspiration)

nasoenteric feeding enteric tube feeding
ligament of Treize 9.2
2.

(gastroparesis) content

9.2 nasoenteric tube ligament of

Treize
Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of enteral nutrition in: Rombeau
JC, Rolandelli RH. eds. Enteral and tube feeding 3rd edition. Philadelphia: W.B. Saunders Company. 1997:250.

68

1.
2.
3. 45
4.
xyphoid process 8-10 .

5.
6. 1

7.

8. nasopharynx
9.
10. nasopharynx

11. gastric content

x-ray
12.
13.
metochopramide plasil R


8-24 .
endoscope
fluoroscope

69

nasogastric nasoenteral feeding

2

1.
2.
3.
4.
(sinusitis)

2. gastrostomy enterostomy



( gastrostomy) ( enterostomy)
gastrostomy feeding (residual
content) (post-pyloric
feeding)
gastrostomy / enterostomy
1. (surgical gastrostomy surgical enterostomy)

70

2. endoscope
percutaneous
endoscopic gastrostomy (PEG) percutaneous endoscopic
jejunostomy (PEJ) enterostomy PEGs



9.3

1. (continuous feeding)

2. (intermittent feeding)
1/2-2 . stable

9.3
Kirby DF, Delegge MH, Fleming CR. American Gastrienterological
Association technical review on tube feeding for enteral
nutrition.Gastroenterology 1995;108:1282-301.

71

intermittent continuous feeding
(gastric continuous feeding)
gastric distention

postprandial glucose (oxygen
consumption) (CO2 production)
(dietary induced thermogenesis DIT)
intermittent 24 . 16-18
. 16

(gastric intermittent feeding)

3-6


3 . 30 ./ .
45 . 2 . 1 . 90 . 1.
2 .
(enteric feeding)

jejunum



-

72

(initiation of feeding and titration)

isotonic
hypotonic

690 /.
9.2
9.2 (intermittent feeding)
(continuous feeding)

Intermittent feeding

Continuous feeding

120 . isotonic 30-40 ./. isotonic

formula formula
30 .

50-100 . 12- 40-60 ./

24 .
12 .

500./

4 .
150 . ( 100
.

gastrostomy)
2 .

150 ./.

Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of

enteral nutrition in: Rombeau JC, Rolandelli RH. Eds. Enteral and tube feeding 3rd edition 1997:240267. Zarling EJ, Parmar JR, Mobarhan S, Clapper M. Effect of enteral formula infusion rate,
osmolality and chemical composition upon clinical tolerance and carbohydrate absorption in normal
subjects. JPEN 1986; 10:588.

73

1.

2.

3.
3.1


3.2
3.3

3.4
3.5 13
4.

refeeding syndrome
5.
6.

74

1. Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of

enteral nutrition in: Rombeau JC, Rolandelli RH. eds. Enteral and tube feeding. 3rd
edition. Philadelphia: W.B. Saunders Company. 1997:240-67.
2. Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association
technical review on tube feeding for enteral nutrition. Gastroenterology 1995;108:1282301.
3. Shike M. Enteral feeding. In: Shils ME, Olson JA, Shike M, Ross AC. eds. Modern
nutrition in health and disease. 9th edition. Baltimore: Williams & Wilkins. 1999:1643-56.
4. Zarling EJ, Parmar JR, Mobarhan S, Clapper M. Effect of enteral formula infusion rate,
osmolality and chemical composition upon clinical tolerance and carbohydrate
absorption in normal subjects. JPEN 1986; 10:588.

75

 10

10

(feeding solution)
1. (blenderlized diet)
(

)


2. (commercial formula)

3.

. Polymeric solution

(long chain
triglyceride LCT) (medium chain
triglyceride MCT)
76

 10

12-20
40-60 30-40 :
150-200:1 75:1

micronutrient 1500-2000

1 .
300-450 /
650

(lactose free formula)

1. (standard formula) 4555 30-48 12-15

1.1 MCT Ensure
1.2 MCT Panenteral, Isocal, Fresubin
1.3 Jevity
2. 2 . Ensureplus Isocal HCN
3.

(cachexia) Traumacal (1.5
.) Sustacal ( ) 24-26
. Oligomeric solution
LCT MCT

Pregestimil Nutramigen

77

 10

. Monomeric solution

1. 5-8 Elental Vivonex
2. 30-35 Peptamen

(short bowel syndrome)
monomeric
polymeric

1.
1.5
/ 1. 22-25 Traumacal
Sustacal
2.
Nepro
3. (ventilatory problem)

0.7

Pulmicare Respalor
4.
25 (branch chain
amino acid BCAA) (leucine) (isoleucine)
(valine) (aromatic amino acid
78

 10

AAA) (phenylalanine) (tyrosine)

(tryptophan) (Aminoleban
enteral)
5. (DM formula)

-
6. (immune formula)
(fish oil)

1. Gottschlich MM, Shronts EP, Hutchins AM. Defined formula diets. In: Rombeau JC,
Rolandelli RH. eds. Enteral and tube feeding. 3rd edition. Philadelphia: W.B.
Saunders Company. 1997:207-39.
2. Guenter P, Jones S, Sweed MR, Ericson M. Delivery systems and administration of
enteral nutrition. In: Rombeau JC, Rolandelli RH. eds. Enteral and tube feeding. 3rd
edition. Philadelphia: W.B. Saunders Company. 1997:240-67.

79

 11

11

(Parenteral nutrition support)

(peripheral parenteral nutrition)
(central parenteral nutrition)

(peripheral parenteral nutrition)

(partial
parenteral nutrition)
(peripheral
total parenteral nutrition)

600 900


1.
2.
3.

4. 2

5. lipid emulsion
lipid
emulsion

80

 11

1.
(mechanical
complication of catheter insertion)
subclavian
2. catheter related infection
3.

1.
2. (thrombophelebitis)
3. (partial
parenteral nutrition)

(central venous parenteral nutrition)

(central venous
catheter)

superior vena cava (SVC) inferior vena

cava (IVC) SVC

1. Subclavian vein

2. Internal jugular vein subclavian vein

subclavian catheter
subclavian vein
81

 11

3. Peripherally inserted central catheterization (PICC)

cephalic basillic vein SVC

subclavian
subclavian approach TPN

4. venesecton cutdown
venesection

IVC femoral
vein

1. Mizock BA, Troglia S. Nutritional support of the hospitalized patient. Disease a

Month 1997; 43: 351-426.
2. National Advisory Group on Standards and Practice Guidelines for Parenteral
Nutrition. Safe practices for parenteral nutrition formulations. JPEN 1998;22(2):49-71.
3. Pelham LD. Rational use of intravenous fat emulsions. Am J Hosp Pharm. 1981; 38:
198-208.
4. Shils ME, Brown RO. Parenteral nutrition. In: Shils ME, Olson JA, Shike M, Ross AC.
eds. Modern nutrition in health and disease. 9th edition. Baltimore: Williams & Wilkins.
1999:1657-88.

82

 12

12

(Parenteral nutrition solution)

(macronutrient)
micronutrient

16

(primary energy source)

sorbitol
lipid emulsion
3.4 1 4 1
5-50%

(intravenous lipid intravenous lipid emulsion)

lipid emulsion (cottonseed oil)
lipid emulsion
lipid emulsion medium chain triglyceride
long chain triglyceride lipid emulsion
(structured lipid) physical
backbone glycerol
Particle lipid emulsion
(core)
cholesteryl ester
phytosterol lipid emulsion
83

 12

particle lipid emulsion apoprotein lipid emulsion

particle
(phospholipid rich particle) liposome lipoprotein X
lipoprotein X
lipid emulsion
10 %
20 %
lipid emulsion
lipid emulsion
lipid emulsion
apo CII CIII, E A IV HDL apo CII CIII
receptor
apo CIII E receptor
LDL cholesteryl ester lipid emulsion particle lipid
emulsion particle LDL HDL
hydrolysis emulsion VLDL
(endothelium)

activity activity
activity tumor necrotic factor (TNF)-

hydrolysis negative
feedback activity
hydrolysis
hydrolysis
medium chain hydrolyze long chain
lipid emulsion lipid emulsion
hydrolysis
hydrolysis lipid emulsion particle
HDL LDL cholestryl ester neutral lipid transfer
cholestryl ester transfer protein
84

 12

medium chain
long chain
hydrolysis neutral lipid transfer lipid particle
remnant particle cholesteryl ester
n-3 remnant particle (remnant receptor)
lipid emultion hepatic lipase apo E

remnant receptor
lipid emulsion 2
1. (linoleic)
2-4 - (- linoleinic)
0.2-0.4
10% emulsion 500-1000 .

2. (non protein calorie)

25-40
50-60 fat
overload syndrome
Lipid clearance
clearance intravenous lipid 2-4 / ./
6 / ./
Clearance lipid emulsion
clearance
(low tissue perfusion)
(multiple organ dysfunction failure syndrome: MODS
MOFS) clearance intravenous lipid emulsion lipid emulsion
non receptor pathway reticulo-endothelial system

lipid emulsion load

85

 12

lipid emulsion
1. lipid emulsion
lipid
emulsion
2. wheeezing

3.
fat overload syndrome
4 /./
4. transminase enzyme
cholestasis
5.
5.1 lipid emulsion diffusion capacity
intrapulmonary shunt

5.2 (platelet dysfunction)

lipid emulsion
lipid emulsion

lipid emulsion
1. atherosclerotic disease
2.
3. (coagulation defect)
4.
5. acute respiratory distress
syndrome
6.

86

 12

(dosage)
25-40 2.5 / ./
4 / ./

lipid emulsion 0.5-1 / (0.1 ./)

80-100 ./
monitor lipid emulsion

6 . 300 ./.
350-400 ./. lipid emulsion

3-15 %
1. (standard amino acid solution)
(essential amino acid) (non essential
amino acid) sorbitol

2. (branch chain amino acid )

hepatic encephalopathy
3. (essential amino acid solution)

60-100 (/)
60-100 (/)

87

80-120 (/)
20-30 (/)

 12

5-10 (/)
5-7.5 (/)

0-60

(/)

(3
4.4

Trace element
Trace element





trace element
TPN
(iron)
1 ./

0.28-1.4 ./
(iron deficiency) iron
dextran 25-50 ./ 2-4
anaphylaxis
home parenteral
nutrition (HPN)
1-2 ./

88

 12

(iodine)
4


1 .//

ultratrace element
xanthine oxidase xanthine dehydrogenase




200-300
trace element
12.1

89

 12

12.1 Trace element TPN

Trace element

2.5-4 .

2 .

12 ./
small bowel content
17 ./
ileostomy content
5
20

*
0.3-0.5

10-15
*
60-100
40-80
#
#
0
**
1-2 .
Shils ME, Brown RO. Parenteral nutrition. In: Shils ME, Olson JA, Shike M,
Ross AC. Eds. Modern Nutrition in Health and disease 9th edition. Baltimore: Williams &
Wilkins. 1999:1657-88.
* (severe cholestasis)
#

** TPN

12.2

(sunlight)

pH 5-6

90

 12

12.2 TPN

( 1)
( 2)
( 3)

( 5)
( 6)
( 12)

3 .
3.6 .
40 .
400
15 .
4 .
5
60
100 .
3300 IU
200 IU
10 IU
1 ./ 2-5 /

National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition.
Safe practices for parenteral nutrition formulations. JPEN 1998;22(2):49-71.

1. Carpentier YA, Simoens C, Siderova V, Makadi L, Vanweyenberg V, Eggerickx D,

and Deckelbaum RJ. Recent development in lipid emulsions: Relevance to intensive
care. Nutrition 1997;13 (suppl): 73S-8S.
2. Intravenous lipid emulsions. Nutrition in Clinical Practice 1987;2(3) 96-107.
3. Mizock BA, Troglia S. Nutritional support of the hospitalized patient. Disease a
Month 1997; 43: 351-426.
4. National Advisory Group on Standards and Practice Guidelines for Parenteral
Nutrition. Safe practices for parenteral nutrition formulations. JPEN 1998;22:49-71.
5. Pelham LD. Rational use of intravenous fat emulsions. Am J Hosp Pharm. 1981;38:
198-208.
91

 12

6. Shils ME, Brown RO. Parenteral nutrition. In: Shils ME, Olson JA, Shike M, Ross AC.
eds. Modern nutrition in health and disease 9th edition. Baltimore: Williams & Wilkins,
1999:1657-88.

92

 13

13

(Complication of parenteral nutrition)

1. (central venous
catheter)
2.
2.1
2.2
2.3
3.

subclavian
1. (pneumothorax)
2. subclavian (arterial puncture)
3. Air embolism
4. thoracic duct (thoracic duct injury)
5. brachial plexus (brachial plexus injury)
6. (hemothorax)
7. (venous thrombosis)

18 ./.
internal jugular peripherally inserted central catheter


TPN
93

 13

(exit site)

1. (tunnel site infection)

2. TPN ( hub contamination)
3. (infusate contamination)
4. (seeding of other site of infection)
13.1
13.1 catheter related infection

Mermel LA. Prevention of intravascular catheterrelated infection. Ann Intern Med. 200; 132:391-402

94

 13

catheter related infection (CRI)

1. (site) internal jugular vein
femoral vein subclavian vein
2. venesection

3. PICCs (peripherally inserted central catheterization)

subclavian vein subclavian
innominate vein SVC
4. multi-lumen catheters CRI single lumen catheter

5. (presence of infectious focus)

CRI
6. (presence of bacteremia) CRI
7. subvlavian (subclavian thrombosis)

8. (tracheostomy)
9. (hyperglycemia)
10. cathter (duration of catheterization)

11. (type of dressing)

1. Coagulase negative Staphylococcus (CoNS)

2. Staphylococcus aureus
3. Candida spp.
4. E. coli, K. pneumoniae

95

 13

CRI
CRI
1. Localized catheter related infection
2. Catheter related bloodstream infection (CBI)
3. catheter colonization
4. catheter contamination

1. single lumen catheter

multilumen catheter
3 (three way stopcock)
2. subclavian vein
PICC femoral vein
internal jugular vein
3.
(maximum barrier precaution )
3.1
3.2
3.3 (local antiseptic)
chlorhexidine CRI 70 % providone
iodine
3.4 drape
3.5
3.6

maximum barrier
precaution CBI 6
4. (transparency dressing)
colinize


96

 13

(prevention of extraluminal contamination)
5. (catheter and catheter-site care)
(prevention of intraluminal
contamination)
5.1 single lumen catheter 3
TPN central venous
pressure multilumen catheter
TPN TPN

5.2
manipulation

5.3
CRI
5.4 (cutaneous antiseptis)

5.5
providone iodine
5.6 CRI


6.
(aseptic
technique) TPN
(routine catheter change)
(specialized personal)
CRI
1.
2. (examination of tunnel site)

97

 13

3. guidewire

(documented CRI)
4. (catheter tip)
100
96.5 semi-quantitative culture
5. (central and peripheral line
blood culture)
6. empirical antibiotic
vancomycin aminoglycoside
7.
7.1 exit tunnel site infection
7.2 (sepsis)
7.3 48
7.4
7.5
7.6

(metabolic complication)

1. refeeding (refeeding syndrome)
2. (electrolyte imbalance)
3. (dysglycemia)
4. overfeeding (overfeeding syndromes)
5. (fluid imbalance)
6. (dyslipidemia)
7. (liver complication)
8. (nutrient deficiency)

98

 13

refeeding (refeeding syndrome)

refeeding
1.

2. (respiratory
acidosis)

(oxygen consumption)
(carbondioxide production)
3.

refeeding

4.
5.
refeeding
refeeding

(glucose based formula)

refeeding
1.
2.
3. (
REE) 1 3
2 3
99

 13

1 3 5-7 1 3 5-7
2
4.
(dysglycemia)

(occult infection)



4 (capillary glucose monitoring CBGM)


6 .
120-220 ./.
2/3

220 ./.

1-2

100

 13

(postinfusion hypoglycemia)
10%
Overfeeding syndrome
refeeding
( work of
breathing) 3
8 respiratory quatient 1





(dyslipidemia)
lipid emulsion (lipid emulsion)

lipid emulsion
lipid emulsion (fat overload)
1.
2.
activity
3.
(fatty acid oxidation)
(multiple
organ failure syndrome)

101

 13

lipid emulsion
300 ./. lipid emulsion 4-6 .
350-400 ./. lipid emulsion
lipid emulsion ( 1-2 )
lipid emulsion
lipid emulsion 10 % LDL
lipid emulsion 20%
(lipoprotein X) subfraction LDL
10% lipid emulsion 20%

(TPN related liver complication)
(biochemical change)
(pathological change)
(biochemical change)
1-4
1. Transaminase 25-90
2. Alkaline phosphatase
3. Bilirubin 40
(pathological change)
13.1
Steatosis
transaminase
2 alkaline phosphatase bilirubin
TPN portal
system panlobular cetrilobular fat deposition

steatosis

5 ./. steatosis
lipid emulsion

102

 13

13.1
related liver complication)

1. Chlestasis

1. Steatosis

2. biliary sludge

2. Steatohepatitis

3. Distended gall bladder

3. Cholestasis

4. fibrosis

4. Biliary sludge

5. Cirrhosis

5. Cholelithiasis

6. Cholelithiasis

6. Acalculous cholecystistis

(TPN

7. Fibrosis
8. Micronodular cirrhosis
Quigley EMM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complication
of total parenteral nutrition. Gastroenterology 1993;104:286-301.
Cholestasis
bilirubin alkaline
phosphatase intracellular canalicular cholestasis
portal inflammation periportal fibrosis
cholestasis .

TPN
1.
2.
3.
3.1
3.2 (inflammatory bowel disease)
103

 13

3.3 ileum
Gallbladder biliary complication
acalculous cholecystitis, biliary sludge, gallbladder
distention TPN
cholecystokinin

13.2
13.2

Steatosis

Cholestasis

TPN

-
-
- Glucose intolerance

-
-
-

-
-
-
(dietary
protective factor)
-

- Immaturity

- enteric
stimulation
-
- (
)
- disturbed enteroheoatic
circulation
- small intestinal bacterial
overgrowth
-

-
- TPN

- serine
- methionine
- taurine
- L-glutamine
- E, selenium
- bacterial translocation
- lithocholate toxicity

104

 13

Cholestasis

- enteric
TPN
- :
stimulation

-
- TPN
-
- bacterial translocation
ileum
- L-glutamine
-
-
-inflammatory bowel
- lithocholate toxicity
disease
-
- bacterial overgrowth
- lithocholate toxicity
Gallbladder
enteric

disease
stimulation
gallbladder

Quigley EMM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complication of total
parenteral nutrition. Gastroenterology 1993; 104:286-301.

1.
2. 4 ././
lipid emulsion 20-30
3.
4.
5. cyclic TPN TPN (continuous TPN
administration)
6. bacterial overgrowth
lithocholate cholestasis

105

 13

(essential fatty acid deficiency EFAD)

glucose based TPN
glucose based TPN lipid emulsion
( 10 )
glucose based TPN lipid emulsion
2 lipid emulsion 10 %
20%
(thiamine deficiency) TPN
TPN

(electrolyte incompatibility)
(nutrient instability)
(electrolyte incompatibility)

-


microvascular pulmonary embolism

1.
2. - dibasic
form triphasic form 13.2
3. -

4.

5.

106

 13

6.

2H3PO4
pH < 5.0
2H2PO-4

+2H+

2 Ca 2+ +

2HPO2-4

+2H+

2CaHPO42H2
(crystalline)

3 Ca 2+ +

2PO3-4

+2H+

2CaHPO42H2
(amorphous)

pKa2 =7.2

13.2

Allwood MC. Kearney MCJ. Compatibility and stability of additives in parenteral nutrition
admixtures. Nutriton 1998;14: 697-706.

( 12) lipid emulsion TPN (total nutrient admixture)
ferric,
2
107

 13

1. (creaming) lipid
emulsion total nutrient admixture

2. (coalescence) emulsion particle

droplet 5-50

1. Allwood MC. Kearney MCJ. Compatibility and stability of additives in parenteral

nutrition admixtures. Nutrition 1998;14(9): 697-706.
2. National Advisory Group on Standards and Practice Guidelines for Parenteral
Nutrition. Safe practices for parenteral nutrition formulations. JPEN 1998;22(2):49-71.
3. Pearson ML, Hospital Infection Control Practices Advisory Committee. Guideline for
Prevention of Intravascular Device- Related Infections. Infec Control Hosp Epidemiol
1996;17:438-73.
4. Quigley EMM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complication of total
parenteral nutrition. Gastroenterology 1993;104:286-301.

108