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- 2. A method offeeding patients by infusing a mixture of all necessary nutrients into the circulatory system, thus bypassing the GIT. Also called as: Intravenous nutrition, Parenteral alimentation, and Artificial nutrition.
- 3. The gut shouldalways be the preferred route for nutrient administration. indicated generally when there is severe gastro-intestinal dysfunction (patients who cannot take sufficient food or feeding formulas by the enteral route) .
- 4. If enteralfeeding is completely stopped or ineffective, Total Parenteral Nutrition is used (TPN). If enteral feeding is just “not enough” , supplementation with Partial Parenteral Nutrition (PPN) is indicated.
- 5. Short-term use Bowelinjury, surgery, major trauma or burns Bowel disease (e.g. obstructions, fistulas) Severe malnutrition (Intractable malabsorption) Nutritional preparation prior to surgery. Malabsorption - bowel cancer, risk of aspiration Severe pancreatitis Poly trauma Bone marrow transplantation Prolonged mechanical ventilation Long-term use (HOME PN) Prolonged Intestinal Failure Crohn’s Disease Bowel resection
- 6. PPN canbe used to supplement Ordinary or Tube feeding esp. in malnourished patients. Indications: Short bowel syndrome Malabsorption disorders Critical illness or wasting disorders
- 7. Long termparenteral nutrition is a life-saving procedure. Enteral nutrition has lower % of infectious complications. Parenteral nutrition has been shown to lead to changes in intestinal morphology and higher % of bacterial translocation
- 8. Energy: Glucose Lipid Amino acids (Nitrogen) Water and electrolytes Vitamins Trace elements
- 9. Energy Basal energyrequirements Hospitalized adults require approximately 25-30 kcal/ kg BW/day. Requirements may be greater in patients with injury or infection.
- 10. Energy Sources:Glucose Readily metabolized in most patients, Reduces gluconeogenesis and spares endogenous protein. 1 gm = 4 Kcal. Insulin resistance in critically ill patients may lead to hyperglycemia, insulin should be incorporated acc. to blood sugar levels.
- 11. Energy Sources:Glucose Route Higher concentrations require a central venous line. 20, 25, or even 50 % solutions are needed volume administration.
- 12. Energy Sources:Lipid Fat mobilization is a major response to stress and infection. Need to be restricted in patients with hypertriglyceridemia.
- 13. Energy Sources:Lipid Essential fatty acids are the building blocks for many of the hormones involved in the inflammatory process as well as the hormones regulating other body functions. Ideally, energy from fat should not exceed 40% of the total (usually 20-30%).
- 14. Energy Sources:Lipid Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted patients. They are available in 10, 20 and 30% preparations. Calorific value of lipid emulsions is 10Kcal/g due to the contents of glycerol and phospholipids.
- 15. Protein: Healthy individuals require0.8 g/kg/day. Lost with weakness & muscle mass wasting. Critically ill patients requirement 1.5-2.5 g/kg/day (major trauma or burn > infection or after surgery > standard) The amount should be reduced in patients with kidney or liver disease
- 16. Nitrogen Daily Proteinrequirements ConditionCondition ExampleExample requirementrequirement Basic requirementsBasic requirements Normal personNormal person 0.5-1g/Kg0.5-1g/Kg Slightly increasedSlightly increased requirementsrequirements Post-operative, cancer,Post-operative, cancer, inflammatoryinflammatory 1.5g/Kg1.5g/Kg Moderately increasedModerately increased requirementsrequirements Sepsis, polytraumaSepsis, polytrauma 2g/Kg2g/Kg Highly increasedHighly increased requirementsrequirements Peritonitis, burns,Peritonitis, burns, 2.5g/Kg2.5g/Kg Reduced requirementsReduced requirements Renal failure, hepaticRenal failure, hepatic encephalopathyencephalopathy 0.6g/Kg0.6g/Kg
- 17. Protein : Parenteral amino acid solutions provide all known essential amino acids. Available preparations are 3.5 - 15 % (ie contains 3.5-15 gms of protein 1gm of protein = 0.16 gm of N2.
- 18. Fluids andelectrolytes 20–40 mL/kg - daily – young adults 30 mL/kg – daily – older adults Sodium, potassium, chloride, calcium, magnesium, and phosphorus ( as per the table) Daily lab tests to monitor electrolyte status
- 19. Fluids andelectrolytes NutrientNutrient Requirements (Requirements (/Kg/day)/Kg/day) WaterWater 20-40 mL20-40 mL SodiumSodium 0.5-1.0 mmol0.5-1.0 mmol PotassiumPotassium 0.5-1.0 mmol0.5-1.0 mmol MagnesiumMagnesium 0.1-0.2 mmol0.1-0.2 mmol CalciumCalcium 0.05-0.15mmol0.05-0.15mmol PhosphatePhosphate 0.2-0.5mmol0.2-0.5mmol Chloride/AcetateChloride/Acetate So a to maintain acid-base balanceSo a to maintain acid-base balance (normally(normally 0.5 mmol for Cl0.5 mmol for Cl-- , & 0.1mEq for Acetate), & 0.1mEq for Acetate)
- 20. Vitamins Multivitamin -12vitamins at levels estimated to provide daily requirements. Trace minerals These are essential component of the parenteral nutrition regimen. May be toxic at high doses. Iron is excluded, as it alters stability of other ingredients. So it is given by separate injection (iv or IM).
- 21. Trace minerals minerals excreted via the liver, such as copper and manganese, should be used with caution in patients with liver disease or impaired biliary function. MineralMineral Recommended dietaryRecommended dietary allowance (RDA) for dailyallowance (RDA) for daily oral intake (mg)oral intake (mg) Suggested dailySuggested daily intravenous intakeintravenous intake (mg)(mg) ZincZinc 1515 2.5-52.5-5 CopperCopper 2-32-3 0.5-1.50.5-1.5 ManganeseManganese 2.5-52.5-5 0.15-0.80.15-0.8 ChromiumChromium 0.05-0.20.05-0.2 0.01-0.0150.01-0.015 IronIron 10 (males)-18 (females)10 (males)-18 (females) 33
- 22. The Solution Manually mixed in hospital pharmacy or nutrition-mixing service. premixed solutions, Separate administration for every element alone in a separate line.
- 23. Venous access PPN: (<900 m.osmol/L): a peripheral line can be enough. TPN: Central venous access is fundamental, Ideally, the venous line should he used exclusively for parenteral nutrition. Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of the high rate of associated infection), or a long catheter placed in an arm vein and threaded into the central venous system (a peripherally inserted central catheter line) Once the correct position of the catheter has been established (usually by X ray), the infusion can begin.
- 25. Initiation ofTherapy TPN infusion is usually initiated at a rate of 25 to 50 mL/h. This rate is then increased by 25 mL/h until the predetermined final rate is achieved. Administration • Infusion pump - infusion over 22-24 h/day.
- 26. Monitor: 1- Efficacy: electrolytes(S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar, body weight, Hb. 2- Complications: ALT, AST, Bil, BUN, total proteins and fractions. 3- General: Input- Output chart. 4- Detection of infection: - Clinical (activity, temp, symptom - WBC count (total & differential) - Cultures
- 27. Sepsis Pneumothorax Air embolism Clotted catheter line Catheter displacement Fluid overload Hyperglycemia Rebound Hypoglycemia
- 28. I)Catheter-related complications oCatheter sepsis:localized or systemic (skin portal, malnutrition, poor immunity). s/s: fever, chills, ±drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip). TX:1- exclusion of other causes of fever 2- short course of anti-bacterial and antifungal therapy (acc. to C&S) 3- Catheter removal may be required
- 29. Catheter sepsis (Cont.): Prevention:a rigorous program of catheter care: Only I.V nutrition solutions are administered through the catheter no blood may be withdrawn from the catheter. Catheter disinfection and redressing 2 to 3 times weekly. The entrance site is inspected for signs of infection and if present, culture is taken or the catheter is removed. Other catheter-related complications: Thromboembolism, pneumothorax, vein or artery perforation, and superior vena cava thrombosis
- 30. II) Metabolic Complications 1)Hyperglycemia: o It can result in an osmotic diuresis (abnormal loss of fluid via the kidney) o Dehydration o Hyperosmolar coma. TX: - decrease the amount of infused glucose (to<4 mg/kg/min) -insulin can be administered (either S.C. inj. or incorporation in the infusion bag).
- 31. Metabolic Complications 2) Hypertriglyceridemia(High S. Triglycerides) Infusion of both glucose and fat emulsion in excess may result in pulmonary insufficiency. Excess glucose infusion –> excess carbon dioxide (CO2) production a result of glucose metabolism. Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce the diffusion capacity of respiratory gases.
- 32. Metabolic Complications 3)Liver toxicity (cholestasis): • severe cholestatic jaundice • Elevation of transaminases • Irreversible liver damage and cirrhosis. TX: There is no specific treatment, other than anticholestatic therapy. 4) Intestinal bacterial translocation: sepsis Prevention is to provide a minimal enteral nutrition supply to avoid or minimize this risk.
- 33. Metabolic Complication Othermetabolic complications: Electrolyte imbalance, mineral imbalance, acid-base imbalance, toxicity of contaminants of the parenteral solution.
- 34. III) Mechanical Complications Cathetersand tubing may become clotted or twist and obstruct. Pumps may also fail or operate improperly.
- 35. Switch fromcontinuous TPN to cyclic TPN should be gradually done by several hours per day and signs of glucose overload and fluid imbalance should be monitored