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![MONITOR ADEQUACY OF PROTEIN INTAKE BY NITROGEN BALANCE
NITROGEN BALANCE= NITROGEN INTAKE-NITROGEN LOSS
NITROGEN LOSS={[24-UREA NITROGEN + 4 ] X 6.25 }
POSITIVE NITROGEN BALANCE = ANABOLISM](https://image.slidesharecdn.com/totalparenteralnutrition1-210225170557/75/Total-parenteral-nutrition-1-1-2021-32-2048.jpg)
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Total parenteral nutrition 1.1.2021
- 2. TOTAL PARENTERAL NUTRITION -DR.RESHMI HARIKUMAR PILLAI -GUIDE:DR. NEERA SAMAR RNT MEDICAL COLLEGE AND MB GOVT HOSPITAL DEPARTMENT OF MEDICINE SEMINAR
- 3. SPECIALISED NUTRITIONAL SUPPORT OPTIMISED VOLUNTARY NUTRITIONAL SUPPORT FORCEDENTERAL NUTRITION PARENTERAL NUTRITION
- 4. OVERVIEW •DEFINITION •PRINCIPLES OF NUTRITION •PLANNINGOF PARENTERAL NUTRITION •ADVANTAGES •DISADVANTAGES •DELIVERING PARENTERAL NUTRITION •DESIGNING PARENTERAL NUTRITION FORMULA •INITIATION OF PN •MONITORING OF PN •TERMINATION OF PN •COMPLICATION •NUTRITIONALASPECTS OF SPECIFIC DISEASE
- 5. DEFINITION Total Parenteral Nutrition(TPN)is a modality of specialized nutritional support and it encompasses delivery of a complete nutritional regimen directly into the blood stream in the form of crystalline amino acids,dextrose,triglyceride emulsions,minerals ,electrolytes and micronutrients without the use of the gastrointestinal tract.
- 6. PRINCIPLES OF NUTRITION •Avoidmalnutrition •If the bowel is functioning,use it •Avoid overfeeding-hyperglycemia, hepatic steatosis, increased BUN, increased CO2 production •Limit protein wasting(Stress-Catabolic state) + Supply essential nutrients
- 7. EN IS PREFERREDOVER PN BECAUSE: •Maintains mucosal protection •EN Supplies gut preferred fuels •More physiological; liver is not by passed •Prevents cholelithiasis •Fewer serious complications •Less costly, low maintenance
- 8. CONTRAINDICATIONS TO ENTERALNUTRITION: •GI causes: Paralytic ileus, intestinal obstruction, severe GI bleed •Cardiac cause: Hemodynamic instabililty(GI Ischemia) •Lack of access: Unable to get safe access to GIT •Complications of enteral feeding: Aspiration,intestinal ischemia
- 9. ADVANTAGE OF PARENTERALNUTRITION OVER ENTERAL NUTRITION: •Ensured, desired volume of delivery of nutrition •Improved metabolic, electrolyte, micronutrient management •Better acid base manipulation •Drug delivery capability
- 10. CONTRAINDICATIONS TO PARENTERALNUTRITION GENERAL •Enteralnutrition meets/exceeds requirement •Good nutritional support(short term) •Severe liver failure, cardiac failure •Fluid and electrolyte imbalance DISEASE SPECIFIC •Avoid excess carbohydrate:compromised pulmonary function •Avoid lipid administration:TG>350mg/dl, severe sepsis •Hepatic encephalopathy/Renal failure
- 11. GOALS OF PARENTERALNUTRITION •To maintain or improve nutritional status by providing all nutrients •To minimize the deleterious effects of catabolism •To boost immune function and wound healing •To improve cardiac and respiratory muscle function by restoring glycogen storage •To maintain or correct acid base and electrolyte disturbances •To accelerate rehabilitation and improve the quality of life
- 12. PLANNING OF PARENTERALNUTRITION
- 13. 1. Selection ofpatient 2. Calculation of nutritional requirement 3. Select and establish appropriate route of administration 4. Prescribe parenteral nutrition 5. Administration, monitoring and avoiding complications of parenteral nutrition
- 14. INDICATIONS OF PARENTERALNUTRITION
- 15. •GENERAL INDICATIONS -Inadequate oral/ enteral nutrition for 7-10 days -Preexisting severe malnutrition •INADEQUATE ORAL/ENTERAL INTAKE -Conditions which impair nutrient absorption -Need for bowel rest -Motility disorder -Inability to achieve / maintain enteral access •SIGNIFICANT MULTIORGAN SYSTEM DISEASE
- 16. NUTRITIONAL REQUIREMENTS FLUID REQUIREMENT=Abnormal loss + Daily requirement (35ml/kg or 1500ml for 20ml/kg body weight + 20ml/kg for additional weight) ENERGY REQUIREMENT: 1. Calculation based on calories per kg body weight 2. Harris Benedict Equation(REE) + additional calories(activity/illness) 3. Energy expenditure with indirect calorimetry
- 18. TEE= REE XAF X DF X TF
- 19. ENERGYREQUIREMENTS OFAPATIENTON PN 50-70%Carbohydrate (1 gram dextrose= 3.4kcal) 20-30% Fat (1 gram lipid =9 kcal) 15-20% Protein (1 gram protein =4 kcal) Mixture- Glucose: Fat=70:30(reduces CO2 production and thereby work of breathing) The benefits of constraining glucose, lipid and fluid volume provision justify hypocaloric nutrition in the first 2 weeks of SNS. AVOID OVERFEEDING !
- 20. CARBOHYDRATE ADVANTAGE/FUNCTIONS: •Low cost •Supplies calories •Nitrogensparing effect DISADVANTAGE •Low calorie supply •Increased CO2 production •Thrombophlebitis MOST CPN USE 50-70% conc diluted to 15-30%
- 21. DEXTROSE INFUSIONAND MONITORING •Maxrate of dextrose oxidation = 5mg/kg/min(7.2g/kg/day) •Maintain blood glucose = 120-180 mg/dl •Avoid excess glucose: Hyperglycemia, Hepatic steatosis, excess CO2 presentation •Initial dose of glucose shouldnot exceed 200g/dayincrease dosing on a daily basis until requirement is met
- 22. •GLUCOSE INFUSION RATE: (Shouldnot exceed) -Non critically ill~ 500g(1700kcal)/day -Critically ill ~350g(1200kcal)/day •INSULIN:-Basal endogenous Insulin secretion= 30U/day • - Non diabetic-10U regular Insulin/ 100g dextrose -IDDM-Twice the -at home dosage -NIDDM-20U/100g dextrose
- 24. FAT •Lipid emulsion :IV source of fat, calories, EFA(linoleic/linolenic acid) •CONTENTS: Long chain triglycerides, egg yolk phospholipids, glycerin •CALORIC VALUE, PREPARATIONS AND REQUIREMENTS: •Richest source of calories(9kcal/g) •20-30% of total calories ; max dose 50g(500kcal)/day in critical illness ;infused 2-3 times weekly •Lipid emulsions are usually added after the first week
- 25. FUNCTION/ADVANTAGE: •Energy dense •Protein/ Glucosesparing •Less CO2 production •Prevents EFA deficicency •Reduced risk of thrombophlebitis DISADVANTAGE •Increased TG levels •Sepsis •Fat embolism •C/I:TG>350mg/dl, acidosis,anemia,DIC,obese
- 26. •To prevent EFAdeficiency: 3-4 days a week •Calorie source: Daily •Rate of Infusion : 0.7kcal/kg/hour iv over 12 hours •Monitor TG levels weeks Discontinue if TG>400mg/dl •Modified preparations: LCTs , MCTs
- 28. PROTEIN •Calorie supplied =4Kcal/g •6.25g protein contain 1 g nitrogen •Concentration of amino acids in standard made solutions : 3-15% •15-20% of total energy intake should come from protein •Protein requirement : 0.8-1.5g/kg/day -Lower- ckd, HE -Higher-massive burn,trauma,hypoproteinemia,protein losing enteropathy
- 30. ADVANTAGE •Calorie supplementation •Protein synthesis •Reducesrate of protein catabolism CONTRAINDICATIONS •Hepatic insufficiency: •Renal Failure: •Exacerbation of metabolic or respiratory alkalosis •Excess proteinexcess urea(hypertonic dehydration)
- 32. MONITOR ADEQUACY OFPROTEIN INTAKE BY NITROGEN BALANCE NITROGEN BALANCE= NITROGEN INTAKE-NITROGEN LOSS NITROGEN LOSS={[24-UREA NITROGEN + 4 ] X 6.25 } POSITIVE NITROGEN BALANCE = ANABOLISM
- 33.
- 34. DELIVERING PARENTERAL NUTRITION •ROUTES:Peripheral v/s Central •SYSTEMS:Multiple bottle solution v/s Three in one •DURATION: Continuous v/s cyclical
- 35. PERIPHERALPARENTERALNUTRITION Goal : Provideenough calories for a short period(<2 weeks) which can prevent malnutrition Composition : Osmolarity<900mOsm/L Low concentrated dextrose(5-10%),amino acids, calorie dense lipids(20%lipid emulsion)
- 36. Indication:-Requirement for shortperiod(<2 weeks);central venous catheterization not possible, Sepsis in patient with CPN Contraindication: High nutritional requirement, need fluid restriction, critically ill who cannot tolerate high vol of PPN
- 37. CENTRALPARENTERALNUTRITION •Goal: Provide maintenancenutrition and correct existing deficits •Composition: Variable. Dextrose(50-70%) and amino acids(8.5-10%); Osmolarity-1000-1900mOsm/L •Selection of catheter for CPN: Polyurethane-short term use/Silicone rubber(months to years)
- 38. Site of Insertionof Catheter for CPN 1. Short term central access: Infraclavicular approach to Subclavian vein 2. Long term central access: Tunneled catheter and implanted subcutaneous ports ;stable for long term use; Placed in the SCV/IJV and fed into theSVC
- 40. 3. Percutaneous insertedcentral catheter(PICC) For 1 week – 6 months; distance between site of skin entry and catheter tip minimizes risk of infection Catheter is inserted into a vein in the antecubital area and threaded in to the subclavian vein with the catheter tip in the superior vena cava
- 42. SYSTEMS OF DELIVERINGPARENTERALNUTRITION MULTIPLE BOTTLE SYSTEM •Separate bags infuse various required nutrients •Ease of adjustment to rapidly changing needs •Needs proper monitoring-risk of hyperglycemia/hypertriglyceridemi a,incompatibility due to improper mixing ‘THREE IN ONE’ SYSTEM •All the components are placed in a single bag •Time saving/cost saving /less handling/better assimilation due to slow rate of infusion •Less stability/flexibility/absence of transparent colour
- 45. DURATION OF DELIVERINGPARENTERALNUTRITION CONTINUOUS •Slow continuous infusion of PN by infusion pumps avoids volume overload •Avoids hyperglycemia,hypertriglyceridemi a •Provides requirement all day CYCLICAL •PN delivered over 8-10 hours •Free period of 12-16 hours •Safe for stable chronically ill patients who require long term nutrient support
- 46. DESIGNING PARENTERAL NUTRITION FORMULA 1.Calculation of daily requirement of PN 2. Convert Requirement into Prescription 3. To prepare PN solution as per prescription, or to select an optimal commercially available formula to deliver prescribed nutrients
- 47.
- 48. •Fluid requirement: ~35ml/kg So35(ml/kg) x 60(kg) = 2100 ml/day •Caloric requirement: ~25kcal/kg So 25(kcal/kg) x 60(kg) = 1500 kcal/day •Protein requirement:1g/kg body weight 1(g/kg) x 60(kg) =60gram/day 1gram=4kcal; 60gm60x4= 240kcal •Fat requirement: 30% of total calories 0.3x1500=450kcal , 1g fat=9kcal 450/9=50g fat Carbohydrate requirement:Total calorie-(fat + protein); 1500- (240+450)=810kcal810/4=202g dextrose
- 49. CONVERT REQUIREMENTS INTOPRESCRIPTION
- 50. (1).Determine vol oflipid emulsion : We will select 10% lipid emulsion Fluid volume(ml)=Amt of substance x 100 = 50x100 =500ml fat conc of substance 10 (2).Determine vol of amino acid infusion: We will select 10% amino acid inf Fluid volume(ml)=Amt of substance x 100 = 60x100 =600ml aa sol. conc of substance 10 (3).Selection of dextrose infusion Remaining solution=2100-(500+600)=1000ml Fluid volume(ml)=Amt of substance x 100 conc of substance 1000(ml)=202.5gmx 100 ; Conc of substance =20% conc of substance 1000ml of 20% dextrose
- 51. To prepare PNsolution or to select an optimal formula for prescription •PN solutions may be made as per prescription not always feasible •One or combination of more than one solution can be made from commercially available solutions
- 55. INITIATION OF PN •Initiateslowly: Use a volumetric infusion pump: 50% of goal on first day, 75%on day2 , and 100% on third to fourth day •PN solution: High in dextrose INITIATE SLOWLY.Allows pancreatic beta cells to adapt. •Severely malnourished : Precipitation of Refeeding Syndrome(MONITOR ELECTROLYTES)
- 56. MONITORING OF PN •Recordvitals Q4h •CXR: Check catheter placement •Serum biochemistry-prior to initiation, then daily ,biweekly/SOS thereafter •Daily weight monitoring •Catheter site care and dressing •Monitor for complication
- 57. TERMINATION OF PN •Oncepatient is able to take 50-60% energy intake orally /enterally PN may be stopped •Transition PNEN/oral nutrition should be gradual •Donot discontinue PN abruptly.Reduce infusion rate to 50% for 1-2 hours before discontinuing PN. •Need for abrupt discontinuation of PN ; D10 to be given (prevent hypoglycemia).
- 58. COMPLICATION MECHANICAL METABOLIC/GI INFECTIOUS FIRST48 HOURS MALPOSITION HAEMO/PNEUMOTHORAX AIR EMBOLISM BLOOD LOSS PUCTURE OF SCA FLUID OVERLOAD HYPERGLYCEMIA HYPERPHOSPHATEMIA HYPOKALEMIA HYPOMAGNESEMIA REFEEDING SYNDROME --- FIRST 2 WEEKS CATHETER DISPLACEMENT CATHETER THROMBOSIS CATHETER OCCLUSION AIR EMBOLISM HYPERGLYCEMIA COMA ACID BASE IMBALANCE ELECTROLYTE IMBALANCE CATHETER INDUCED SEPSIS EXIT SITE INFECTION 3 MONTHS ONWARDS FRACTURE/TEAR OF CATHETER CATHETER THROMBOSIS AIR EMBOLISM BLOOD LOSS EFA/VITAMIN/TRACE ELEMENT DEFICIENCY METABLIC BONE DISEASE TUNNEL INFECTION CATHETER INDUCED SEPSIS EXIT SITE INFECTION
- 60. •Hyperglycemia: Osmotic diuresis Osmotic diuresis and glycosuriaHyperosmolar dehydration Risk factor:excess/rapid administration/metabolic stress/obesity/DM Slow administration (2-3 mg/kg/min) and decreased amount (100-150 g/day) of initial infusion,reduced dextrose and increased lipid Target-120-180mg/dl; (20U Insulin per litre of PN solution OR Insulin drip 2- 5U/hour)
- 61. Hypoglycemia: Reactive hypoglycemia isuncommon Abrupt stoppage of high glucose ,no insulin containing formulations Prevention : Slowing the PN infusion rate to 50ml/hour (or replacing it with D10) Paitent’s metabolic stress (or glucocorticoid dose) decreases without appropriate downward adjustment of Insulin dose Artefactual Hyperglycemia and Hyperkalemia: Incorrect technique of blood sampling
- 62. Volume Overload: Hypertonic i.vdextroseIntense Insulin response Insulin:Antinatriuretic and antidiuretic hormonePotentiates sodium and water retention Prevention: Slower rate of dextrose infusion Limit sodium intake:20-30mmol/day
- 63. •Hyponatremia Cause: Excess hypotonicfluid,Adrenal insufficiency, CHF ,SIADH Treatment: Fluid restriction, diuretics Hypertriglyceridemia Rate of lipid infusion >Plasma triglyceride clearance capacity Factors reducing TG clearance:Renal failure,sepsis,diabetes,multiorgan failure
- 64. •Refeeding syndrome -Starvation :Body adapts to less carbohydrate and more fat metabolism -Carbohydrate refeeding Insulin Secretion(Antinatriuretic effect) Cellular uptake of electrolyte + ECFV expansion -Precipitation of left heart failure -Hallmark: Hypokalemia, hypomagnesemia, hypophosphatemia -C/F: Fluid overload, muscular weakness, glucose intolerance, cardiac arrhythmia
- 65. -Prevention: -Start PNgradually -Only 1/3 of basal energy needs should be given in first 24 hours -Glucose < 150g/day , Na < 20mEq /day , Total fluid< 800ml/day. -Monitor electrolytes
- 66. •Hepatic abnormality -Generally benignand temporary -Complication – Biochemical(Transaminitis) or Histological(steatosis) -Provide 20-40% calories as fat, reduce dextrose , cycling of infusion(stopping for atleast 8-10 hours per day)
- 67. •Catheter sepsis -M/c lifethreatening complication -15% -Femoral>IJV>SCV -Same organism is grown from catheter tip as is recovered from blood and C/F of infection resolve with removal of the catheter -Entry of organism at catheter site,contamination of tubings
- 68. CATHETER RELATED SEPSIS (1)Evaluateinsertion site and culture any drainage (2)Blood C/S from peripheral vein /CVC (3)Begin empiric antibiotic therapy Purulent discharge/abscess at insertion site : Remove the catheter ! -Aseptic,USG guided insertion technique,meticulous dressing , one port dedicated solely to PN
- 69. NUTRITIONALASPECTS OF SPECIFICDISEASE •Critical Illness •Cancer •Cardiac disease •Pulmonary disease •AKI •Liver Disease •Pancreatitis •IBD
- 70. CRITICAL ILLNESS •Metabolic Alterations:Hypermetabolism, hyperglycemia with Insulin resistance,accelerated lipolysis,net protein catabolism •Early PN –Severely catabolic states/EN not possible for 5-7 days •Nutrition- SUPPORTIVE NOT THERAPEUTICslows down net protein catabolism •Energy expenditure doesnot exceed 2000Kcal/day
- 71. NUTRITIONALREQUIREMENTS IN CRITICALLYILLANDSTABLE PATIENTS CITICALLY ILL PATIENTS STABLE PATIENTS PROTEIN 1.2-1.5g/kg/day 0.8-1g/kg/day CARBOHYDRATE Not>4mg/kg/min Not>7mg/kg/min LIPID 1g/kg/day 1g/kg/day TOAL CALORIES 25-30kcal/kg/day 30-35kcal/kg/day FLUID Min needed to deliver adequate macronutrients 30-40ml/kg/day
- 72. CANCER •Indication: Chemo/RT induced GItoxicity preventing oral/enteral intake for more than one week •Not used routinely. Provided only if clinical improvement with quality survival is expected
- 73. CARDIAC DISEASE •Indication :Postoperative complications which prevent the use of the GIT •Postop Cardiac surgery:Risk of volume overload, hyponatremia, metabolic alkalosis,uremia •Avoid CHF: Use max concentrated PN solutions ; fluid and salt restriction; Use of fat emulsion (9kcal/g) •On diuretics: Requirement of K, Mg, Zn increases
- 74. PULMONARY DISEASE ‘’DEATH FROMSTARVATION IS DEATH FROM PNEUMONIA’’ •MalnutritionProtein(skeletal muscle) catabolismmuscle wastingrespiratory failuredecreased ventilatory drive and hypoxia •Malnutritionreduced pulmonary defense mechanisminfection •Refeeding restores ventilatory drive
- 75. NUTRITIONALREQUIREMENTS •Recommended energy intake= 1.7x resting energy expenditure •Lipid-preferred source of energy ; provides more energy with less CO2 production- reduces work of breathing •Avoid overfeeding(Dextrose:lipid=70:30) •Low carbohydrate formula-weaning of patients •Protein intake=1g/kg/day •ARDS;fluid restriction if hemodynamic status necessitates •Avoid hypophosphatemia,hypocalcemia,hypomagnesemia
- 76. AKI ARF TREATED CONSERVATIVELY: •Adjust/restrict fluid intake as per urine output in oliguric individuals. Use of max concentrated PN solutions •Avoid hyperkalemia, hypermagnesemia, hyperphosphatemia •Energy requirement: -Uncomplicated ARF:25kcal/kg/day -Critically ill ARF: 25-35kcal/kg/day •Protein: -Uncomplicated ARF:0.8g/kg/day -Critically ill ARF: 1.5-1.8g/kg/day •Avoid greater supplementation of protein uremia+assoc complications
- 77. ARF TREATED WITHRENAL REPLACEMENT THERAPY: •Additional amino acid supply (compensates loss) : 0.2g/kg/day •After regular dialysis is established, conventional mixture is used. •Water soluble vitamin supplementation (Excess Viatmin C secondary oxalosis)
- 78. LIVER DISEASE •Energy requirements:-Compensatedcirrhosis:25-35kcal/kg/day -Decompensated cirrhosis:35-45kcal/kg/day •Protein requirements:-Compensated CLD:1g/kg/day -Decompensated CLD:0.5g/kg/day;Use of BCAA •Vitamin and micronutrient supplemenatation •Fluid and salt restriction
- 79. PANCREATITIS •80% cases aremild-can resume oral intake within 7 days •20% cases-develop severe disease- need EN/PN •Indications:-Paralytic ileus,pseudocyst,fistulae -Enteral feeding leads to exacerbation of abdominal pain •Start nutritional support within 48-72 hours of hospitalization ENERGY 25-35 kcal/kg/day PROTEIN 1.2-1.5 g/kg/day CARBOHYDRATE 4-6g/kg/day LIPID Up to 2g/kg/day
- 80. References 1. Practical Guidelineson Fluid Therapy , Sanjay Pandya ,2nd edition 2. Harrison’s Principles of Internal Medicine, 20th edition 3. Bailey and Love’s Short Practice of Surgery 4. Schwartz Principles of Surgery 11e 5. Paul Marino The ICU Book 4e
- 81.
Editor's Notes
- #56 The Roman Historian Flavius Josephus writing in the first century described classic symptoms of the syndrome among survivors of the siege of Jerusalem. He described the death of those who overindulged in food after famine, whereas those who ate at a more restrained pace survived