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Journal of Korean Society of Health-System Pharmacists

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1. 전문약사

1) 시행 : 2010년 제1회 전문약사 시험

2) 목표 : 치료 성과 및 환자의 건강 개선에 기여하기 위해 해당 전문 분야에 통달하고 약물요법에 관해 보다 전문적인 자질과 능력을 갖춘 임상약사를 배양 3) 분야 : 종양약료, 심혈관계질환약료, 영양약료, 중

환자약료, 장기이식약료, 내분비질환약료

2. 영양약료 전문약사

1) 실무경력 : 고영양 수액제 조제 및 NST (Nutrition Support Team)업무 수행

2) 교육과정 지정기준 : 이론교육 : 강좌 당 1인 이상 / 실무실습지도 : 학생 5인 당 1인 이상

4. 시험시간 및 점수비중 1) 총 시험시간 : 3시간

2) 공통영역(의학통계 및 의학논문비평) 점수비중 : 100점 중 10점 배정

3) 전공과목 영역 점수비중 : 100점 중 90점 배정

영양약료

김귀숙 서울대학교병원 약제부

3. 전문약사 교육과정 이수시간 (2013. 10. 18 개정)

공통과목 전문약사의 역할 및 정책 전문약사역할론 12시간 6시간

임상약학연구 의약통계, 연구 12시간 6시간

약물치료학 질환별 약물치료학 168시간 140시간

임상약동학 임상약동학 전반 48시간 24시간

의약정보학 약물의 치료학적 정보 전반 48시간 24시간

전공이론과목 전문분야별 전공이론과목 144시간 80시간

전공실습과목 전문분야별 전공실습과목 120시간 80시간

총 교육 시간 552시간 360시간

세부내용

소과목 개정 전 개정 후

특집 - 전문약사 자격시험

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5. 제출유형

1) 공통영역 (10%) : 객관식으로 출제하되 multiple choice와 단답식 형식

2) 전공과목 영역 (90%) : 영양약료 부문

① 주관식 50% / 객관식 40%

② Case 문항중 problem list, SOAP 작성

③ 최신 연구결과의 이해 및 해석, 임상 case에서 의 적용

6. 출제범위

1) 정맥영양 : 성인, 소아, 신생아 2) 경장영양 : 약물과의 상호작용 중점 7. 출제문항

1) 영양상태 평가, 영양요구량 산정, 영양지원 계획 및 영양공급량 계산, 경로선택 및 주입

2) 모니터링과 중재, TPN 관련 합병증

3) 정맥영양 제제(TPN, 아미노산수액, 지방유제, 미 량원소, 비타민 등)의 종류 및 특징, 안정성 4) 약물과의 상호작용 및 compatibility

5) 정맥영양과 경장영양의 적응증, 주요 질환별 영양 지원

6) 최신 연구결과의 이해 및 해석, 임상 case에서의 적용

8. 참고문헌

1) Merritt R, eds. The A.S.P.E.N. Nutrition Support Practice Manual.2nd ed. Silver Spring, MD:

American Society for Parenteral and Enteral Nutrition (2005)

2) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

JPEN J Parenter Enteral Nutr, 33, 277-316 (2009)

3) ESPEN Guidelines on Parenteral Nutrition:

Intensive care. Clinical Nutrition, 28, 387-00 (2009) 4) A.S.P.E.N. Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer J and in Hematopoietic Cell Transplantation.

JPENJ Parenter Enteral Nutr, 33, 472-500 (2009) 5) A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. JPENJ Parenter Enteral Nutr, 35, 16-24 (2011)

6) A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child. JPENJ Parenter Enteral Nutr, 33, 260-276 (2009)

7) Enhancing Parenteral Nutrition Therapy for the Neonate. Nutr Clin Pract, 22, 183-193 (2007) 8) ESPEN Guidelines on Parenteral Nutrition:

Gastroenterology. Clinical Nutrition, 28, 415-27 (2009)

9) Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med, 365, 506-517 (2011) 10) A.S.P.E.N. Position Paper: Recommend ations

for Changes in Commercially Available Pa- renteral Multivitamin and Multi-race Element Products. NutrClin Pract, 27, 440-491 (2012) 11) A.S.P.E.N. Clinical Guidelines : Nutrition Support

of Adult Patients With Hypergly cemia. JPENJ Parenter Enteral Nutr. 37, 23-36 (2013)

<세부 내용>

1. 영양평가

1) BMI (Body Mass Index)

Underweight <18.5

Normal 18.5-24.9

Overweight 25-29.9

Obesity, class Ⅰ 30-34.9 Obesity, class Ⅱ 35-39.9

Obesity, class Ⅲ ≥40

Obesity Class BMI, kg/m2

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2) IBW (Ideal Body Weight)

3) 비만도와 혈청 albumin

2. 체중 : 비만시 체중 보정식

보정체중 = 표준체중+0.25x[현재체중-표준체중]

3. 영양요구량

1) Harris Benedict Equation(resting metabolic rate)

① 남자 : 66 + 13.75x(weight in kg) + 5x(height in cm) - 6.8x(age)

② 여자 : 655 + 9.6x(weight in kg) + 1.8(height in cm) - 4.7x(age) 2) 상태에 따른 열량

4. 검사결과

1) 검사항목의 정상범위

2) Calcium 보정식

Corrected Ca = total Serum Calcium + 0.8 x (4.0 - measured Serum Albumin)

5. 투여경로

1) 투여기간 : 단기 vs 장기

2주 이상 정맥영양 투여시 -> 중심정맥 2) Osmolarity 계산

6. 면역영양소 extreme underweight <69

severe underweight 70-79

underweight 80-89

normal 90-110

overweight ~120

obesity >120

serious obesity >200

Class % IBM (ABW/IBW)

Calcium 8.8-10.5 mg/dL

Phosphorus 2.5-4.5 mg/dL

Glucose, fasting 70-100 mg/dL BUN (Blood Urea Nitrogen) 10-26 mg/dL

Creatinine 0.7-1.4 mg/dL

Uric acid 3.0-7.0 mg/dL

Total protein 6.0-8.0 g/dL

Albumin 3.3-5.2 g/dL

Total Bilirubin 0.2-1.2 mg/dL

Cholesterol 0-240 mg/dL

Alkaline phosphatase 30-115 IU/L

AST(GOT) 0-40 IU/L

ALT(GPT) 0-40 IU/L

Sodium 135-145 mmol/L

Potassium 3.5-5.5 mmol/L

Total CO2 24-31 mmol/L

WBC (White Blood Cell) 4.0-10.0 x103/mcL

Hemoglobin 12-16 g/dL

Hct (Hematocrit) 36-48 %

항목 참고치

ICU (Intensive Care Unit) 25

Basal energy needs 25-30

Ambulatory with weight maintenance 30-35 Malnutrition with mild stress 35-40 Severe injuries and sepsis 40-45

Extensive burns 50+

Status Kcal/kg

※ IBW 남: (키,m)x(키,m)x22, 여: (키,m)x(키,m)x21

Dextrose(g/kg) 50 mOsm/%

Protein(g/kg) 100 mOsm/%

Na(mEg/kg) 2 mOsm/mEg

K(mEg/kg) 2 mOsm/mEg

P(mmol/kg) 2 mOsm/mEg

Ca(mEq/kg) 1.4 mOsm/mEg

Mg(mEg/kg) 1 mOsm/mEg

성분 삼투압

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7. 부작용

1) Infection

① Catheter related infection is a frequent cause of sepsis

② 말초정맥 카테터는 보통 72-96시간마다 교체

2) Thrombosis

① Thrombosis is associated catheter mis- placement and use of hyperosmolar solu- tions (말초 : 900 mOsm/L 이하)

3) Metabolic complication

① Hyper-or hypo-glycemia

② Refeeding syndrome (K, P, Mg)

③ Electrolyte disturbance

④ Hepatic function test disturbance

=> reduce lipid

⑤ Metabolic bone disease 8. 모니터링

1) Blood sugar test 안정상태 유지 : 180 mg/dL

미만으로 유지

2) LFT, lipid panel (Triglyceride level 포함) 3) BUN/Serum creatinine

4) Electrolytes (Mg 포함) 5) Intake/Output 및 체중변화 9. 질환별 영양공급

1) Pulmonary failure : high lipid, low carbohy- drate formula fluid restricted calorically dense formula

2) Renal failure : significant electrolyte abnor- mality => special formulation amino acid loss in CRRT (Continuous Renal Replacement Therapy) : 10-15 g/day => 1.5-2.0 g/kg/day

3) Hepatic failure : EN (Enteral Nutrition) pre- ferred route of nutrition therapy Use of BCAA Glutamine

Arginine

Omega-3 fatty acids(EPA+DHA)

- Nutrient for immune cells, improves gut barrier function - Nonessential amino acid, but

"conditionally essential" after critical illness, stress and injury - High does or parenteral

GLN(>0.25 to 0.3 g/kg/day IV or 30g/day PO) demonstrates the great potential for benefit Precursor for nitric oxide, enhances T lymphocyte numbers and function

Anti-inflammatory by suppressing pro-inflammatory cytokine production Immunonutrient Mode of action

Chemistry screen (Ca, Mg, LFTs, P) Electrolytes, BUN/Scr Serum triglycerides

*CBC

**PT, ***PTT

Weight

Intake/Output

If possible Daily 2-3회/week

Daily Glucose

Yes 2-3회/week weekly

Yes Daily 1-2회/week

Yes weekly weekly

Yes weekly weekly

Yes weekly weekly

3회/day

3회/day (until consistently

<200 mg/dL)

3회/day (until consistently

<200 mg/dL)

Daily unless fluid status in assessed by physical exam Daily

Parameters Baseline Critically ill

patients Stable patients

*CBC : Complete Blood Count

** PT : Prothrombin Time

** PTT : Partial Thromboplastin Time

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(Branched Chain Amino Acid) in hepatic encephalopathy improve coma grade 10. CASE

Q) 영양평가 및 영양요구량

A.T.는 38세 여성으로 항암치료중 호흡부전과 늑막흉 통으로 내원했다. 지난 5개월간 역류, 구토, 식욕저하로 체중 감소가 계속 심해져서, 5개월 전 체중이 59.1kg이 었는데 내원 시 체중은 44.5kg, 키는 162.6cm이다.

입원 시 임상검사 수치는 Na: 135 mEq/L, K: 4.0 mEq/L, Cl: 100 mEq/L, HCO3-: 25 mEq/L, BUN: 4 mg/dL, Serum creatinine: 0.6 mg/dL, glucose: 87 mg/dL, Ca: 8.2 mg/dL, Mg: 2.0 mg/dL, P: 3.0 mg/dL, total protein: 6.0 g/dL, albumin: 3.5 g/dL, prealbumin: 15 mg/dL이다. 백혈구 수치는 6,800 /mm3이다.

A) ① 열량 : “중등도 스트레스, 영양실조 상태(BMI 16.9)”범주이므로 25�30 kcal/kg/day

② 단백질 : 1.2�1.5 g/kg/day

③ 지방 : 비단백질 열량 30%

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