武功密笈

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j Decreased food intake because of anorexia, early satiety, nausea, vomiting,

and change of taste and smell

k Poor absorption of nutrients

l Food aversion, particularly in patients undergoing chemotherapy or irradiation

m Generalized weakness

n Type and site of the cancer

j Patients who have a 10-pound weight loss or a 10% decrease in body weight

2 months prior to assessment

k Patients with serum albumin less than 3.4 gm%

l Patients with anergy to 4 of 5 standard skin test antigens

m Patients with low total lymphocyte count (less than 1200)

n Patients who cannot or will not eat enough

1). Enteric Nutrition:

  Requirement for enteric nutrition: a functional GI track

  By the use of nasoenteric tube, gastrostomy tube, or jejunostomy tube.

  Advantages: being cost-effective, probably maintaining GI mucosa

integrity, providing a normal sequence of intestinal and hepatic

metabolism prior to systemic distribution, appearing to preserve normal

hormonal patterns, and avoiding the risk of sepsis.

  Complications: diarrhea, electrolyte imbalance, and glucose intolerance.

2). Parenteral Nutrition:

  The role of total parenteral nutrition (TPN) in the patients with cancer has

yet to be determined. It appears that parenteral nutrition improves a

patient’s tolerance of treatment and improves her nutritional state, yet it

has not been shown to improve survival or to affect morbidity and

mortality. The concern that TPN may stimulate tumor growth is

unfounded.

  Indications for TPN:

j Severely malnourished patients undergoing surgery

k Patients with postoperative complications that require nutritional

support

l Therapy induced complications that require nutritional support

Ú Routine use of TPN in patients with cancer is not indicated.

  Types of access:

j Peripheral vein:

- May be used only when short duration of isotonic TPN is anticipated

- Major complications: thrombophlebitis and infiltration

k Central vein (subclavian vein or major neck veins):

- Used in most situations

- Complications:

Infection, hyper- or hypoglycemia, hyperosmolarity, azotemia,

hypercholoremic metabolic acidosis, mineral electrolyte disorder,

liver enzyme elevations, and anemia.

  Monitoring the patient on TPN:

± Sense of well-being: symptoms suggesting fluid overload, high or low blood

± Strength as judged by graded activity: getting out of bed, walking, stair climbing.

± Vital signs: BP, TPR

± Fluid balance: weight, I/O

± Delivery equipment for parenteral nutrition: composition of nutrient solution,

± Laboratory data:

　

Plasma glucose	Qid until patient stable
Blood glucose, Na+, K+, Cl+, HCO3-, BUN	Qd until glucose infusion load and patient stable, then twice weekly
Serum albumin, transferrin (or TIBC), liver function studies, serum Cr, Ca2+, PO42-, Mg2+, Hb/Ht, WBC	Baseline, then twice weekly
PT, PTT, micronutrient tests as indicated	Baseline, then weekly

  Complications of TPN:

　

First 48 hours	First 2 weeks	3 months onward
MECHANICAL
Complications from catheter insertion: Cephalad displacement Pneumothroax Hemothorax Detachment of line at catheter hub with blood loss or air embolism	Catheter coming out of vein, more common if Silastic Detachment of line at catheter hub with blood loss or air embolism	Detachment of line at catheter hub with blood loss or air embolism Fractures or tears in catheter
METABOLIC
Fluid overload Hyperglycemia Hypophosphatemia Hypokalemia	Cardiopulmonary failure Hyperosmolar nonketotic hyperglycemic coma Acid-base imbalance Electrolyte imbalance	Essentially fatty acid deficiency Mineral deficiency Iron deficiency Vitamin deficiencies Refeeding edema TPN metabolic bone disease TPN liver disease
INFECTIOUS
	Catheter-induced sepsis	Catheter-induced sepsis Tunnel infections

1. Clinical Gynecologic Oncology, 5^th edition, DiSaia and Creasman

2. Harrison’s Principles of Internal Medicine, 13^th edition, Isselbacher, etc.