Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.
Total Parenteral Nutrition
By
Dr Waseem Ashraf
Moderator:-
Dr Rouf Ahmad Wani
Deptt of General Surgery
What is TPN?
Parenteral nutrition: process of supplying nutrie
nts via the intravenous route
– Total parenteral nutrition ...
Indications
Patients whose GI tract is not functional.
– e.g. 50% of metabolic needs met for < 7 days
Undernourished patie...
The gut should always be the preferred route for nutrient administrat
ion.
Therefore, parenteral nutrition is indicated ge...
Goals
To decrease the adverse effects of catabolis
m
Support ongoing metabolism
To improve immune function, cardiac and re...
Nutritional Content
Water
– 30 to 40 mL/kg/day
Energy
– 30 to 60 kcal/kg/day (depending on energy expenditure)
Amino acids...
Requirements:
Energy
 Basal energy requirements are a function of the individual's
weight, age, gender, activity level a...
Energy Requirements
Patient condition Basal metabolic
rate
Approximate energy
Requirement
(kcal/kg/day)
No postoperative
c...
Requirements:
Energy Sources: Glucose
The most common source of parenteral energy supply is glucos
e, being:
 Readily me...
Energy Sources: Glucose
 Low calorie value
 Requires large volume
 Hyperglycemia
 More CO2 production
 Thrombophlebit...
Requirements:
Energy Sources: Lipid
 Fat mobilization is a major response to stress and infect
ion.
 Triacylglycerols a...
Requirements:
Energy Sources: Lipid
Lipids are also a source for the essential fatty acid
s which are the building blocks...
Requirements:
Energy Sources: Lipid
Fat emulsions can be safely administered via perip
heral veins, provide essential fat...
Advantages
Energy Sources: Lipid
high calorie
Prevents hyperglycemia
Less co2 production
Less insulin production
14
Disadvantages
Energy Sources: Lipid
 Hypertriglyceridemia
 Sepsis
 Fat embolism
 Fat overload
 Hepatic dysfunction
 ...
Requirements:
Nitrogen
 Protein (or amino acids, the building blocks of protei
ns) is the functional and structural comp...
Requirements:
Nitrogen
 With disease, poor food intake, and inactivity, body prot
ein is lost with the resultant weaknes...
Requirements:
Nitrogen
Daily Protein requirements
Condition Example requirement
Basic requirements Normal person 0.5-1g/K...
Requirements:
Nitrogen
Nitrogen Balance =
Protein intake in grams ÷ 6.25 – UUN (in grams) + 3
 The nitrogen lost in urin...
Requirements:
Nitrogen
• Parenteral amino acid solutions provide all known esse
ntial amino acids.
• Available a.a. prepa...
Requirements:
Nitrogen
• Special a.a. solutions are also available containing
higher levels of certain a.a.s, most common...
Requirements:
Nitrogen
 Arginine was added to enteral formulae claiming po
sitive effects on immune function and length ...
Requirements:
Fluids and electrolytes
• 20–40 mL/kg - daily – young adults
• 30 mL/kg – daily – older adults
• Sodium, po...
Requirements:
Fluids and electrolytes
Nutrient Requirements (/Kg/day)
Water 20-40 mL
Sodium 0.5-1.0 mmol
Potassium 0.5-1....
Requirements:
Fluids and electrolytes
• Normalization of acid-base balance is a priority and
constant concern in the mana...
Requirements:
Vitamins
 These requirements are usually met when standard vol
umes of a nutrient mix are provided.
 Incr...
Requirements:
Vitamins
Multivitamin formulations for parenteral use for adult
patients usually contain 12 vitamins at lev...
Requirements:
Trace minerals
 These are essential component of the parenteral n
utrition regimen.
 A multi-element solu...
Requirements:
Trace minerals
minerals excreted via the liver, such as copper and
manganese, should be used with caution i...
Osmolarity:
PPN: Maximum of 900 milliosmoles / liter
TPN: as nutrient dense as necessary (>900
m.osmol and up as high as 3...
The Solution
Manually mixed in hospital pharmacy or nutrit
ion-mixing service
premixed solutions,
Separate administration ...
What to do before starting TPN
 Nutritional Assessment
 Venous access evaluation
 Baseline weight
 Baseline lab invest...
Nutritional Assessment
 History
 Physical examination
 Anthropometric measurements
 Laboratory investigations
Nutritional Assessment
History
 Dietary history
 Significant weight loss within last 6 months
 > 15% loss of body weigh...
Physical Examination
• Evidence of muscle wasting
• Depletion of subcutaneous fat
• Peripheral oedema, ascites
• Features ...
Anthropometry
• Weight for Height comparison
• Body Mass Index [BMI <19]
• Triceps-skinfold (index of body fat)
• Mid arm ...
Lab investigations
• albumin < 30 mg/dl
• pre-albumin <12 mg/dl
• transferrin < 150 mmol/l
• total lymphocyte count < 1800...
38
Special Considerations
 Patients who have renal insufficiency and are
not receiving dialysis or who have liver failure re...
Venous access
 PPN: (<900 m.osmol/L): a peripheral line can be en
ough.
 TPN: Central venous access is fundamental,
 Id...
Venous Access for TPN
Needs venous access to a “large” cent
ral line with fast flow to avoid thrombophle
bitis
• Long peri...
Types of CVC
Single/multi-lumen CVC.
Peripherally inserted central catheters (
PICC lines).
Tunneled catheters.
Implanted ...
Central Venous Catheters
Catheters used for delivering TPN shoul
d be employed for that sole use.
Single/multi-lumen CVC
Usually short term.
Percutaneous insertion using jugular, su
bclavian or femoral routes.
Multi-lume...
Peripherally inserted central catheters (PICC
Lines)
PICC lines are designed to provide ven
ous access for short to long p...
Tunneled CVC
Hickman and Broviac CVC : right atrial c
entral catheters that are surgically insert
ed into the chest.
The c...
Implanted CVC
Port-a-cath : a surgically inserted centra
l line that does not have an external exit
site, uses a subcutane...
Peripheral Parenteral nutrition
It differs from central TPN in
• composition of feed
• primary caloric source
• potential ...
Formulations
Two Types of TPN:
 Solutions with lipids (3-in-1)
 Solutions without lipids (2-in-1)
Advantages of (3-in-1)...
Formulations
Disadvantages to 3-in-1
 Precipitants cannot be seen
 Not stable as long as TPNs without lipids
Expiration ...
53
Steps in ordering TPN
Determine Total Fluid Volume
Determine Non-N Caloric needs
Determine Protein requirements
Decide how...
Steps in ordering TPN
Determine Total Fluid Volume
Determine Caloric needs
Determine Protein requirements
Decide how much ...
How much volume to give?
Cater for maintenance & on going losse
s
Normal maintenance requirements
 By body weight (25-35 ...
Steps in ordering TPN
Determine Total Fluid Volume
Determine Non-N Caloric needs
Determine Protein requirements
Decide how...
Caloric requirements
Based on Total Energy Expenditure
 Can be estimated using predictive equation
s
TEE = REE + Stress F...
Caloric requirements
REE (BMR) Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W in kg) + (5H in cm) ...
Caloric requirements
Stress Factor
•Post op. pat. + 10%
•Malnutrition + 30%
•peritonitis + 15%
•soft tissue trauma +
15%
•...
Caloric requirements
Activity Factor
Bed-bound + 20%
Ambulant + 30%
Active + 50%
How much CHO & Fats?
“Too much of a good thing causes pro
blems”
 Not more than 4 mg / kg / min Dextrose
(less than 6 g /...
How much CHO & Fats?
Fats usually form 25 to 30% of calories
 Not more than 40 to 50%
 Increase usually in severe stress...
How much protein to give?
 Based on calorie : nitrogen ratio
 Based on degree of stress & body weig
ht
 Based on Nitrog...
How much protein to give?
Calorie : Nitrogen Ratio
Normal ratio is
150 cal : 1g Nitrogen
Critically ill patients
85 to 100...
How much protein to give?
Based on Stress & BW
Condition Example requirement
Basic requirements Normal person 0.5-1g/Kg
Sl...
How much protein to give?
Based on Nitrogen Balance
Aim for positive balance of
1.5 to 2g / kg / day
Nitrogen Balance
Every gram of negative NB represents l
oss of approx. 30gms of lean muscle m
ass
For daily negative nitro...
Nitrogen Balance
Nitrogen Balance = N input - N output
1 g N = 6.25 g protein
N input = (protein in g / 6.25)
N output = 2...
Approx. Nitrogen Balance
and lean muscle mass loss
Procedure N-loss Muscle los
s
(gms/day)
Herniotomy 3 90
Appendisectomy ...
Steps to ordering TPN
Determine Total Fluid V
olume
Determine Protein requir
ements
Determine Non-N Calori
c needs
Decide ...
Electrolyte Requirements
Cater for maintenance + replacement nee
ds
Na+ 1 to 2 mmol/kg/d (or 60-120 meq/d)
K+ 0.5 to 1 mmo...
Trace Elements
Total requirements not well established
Commercial preparations exist to provide
RDA
 Zn 2-4 mg/day
 Cr 1...
Steps to ordering TPN
Determine Total Fluid V
olume
Determine Protein requir
ements
Determine Non-N Calori
c needs
Decide ...
Other Additives
Vitamins
 Give 2-3x that recommended for oral intak
e
 use 1 ampoule multivitamin per bag of TPN
 Multi...
Other Additives
Medications
 Insulin
 can give s/c initially based on sliding scale
 once stable, give 2/3 total requir...
The Solution
Manually mixed in hospital pharmacy or nutrit
ion-mixing service,
premixed solutions,
Separate administratio...
Caloric content of TPN
Parenteral glucose contains 3.4 kcal/g
Protein contains 4 kcal/g
Lipid contains 9 kcal/g
TPN for a 70 kg man
80
Example Calculation
For 70 kg man
 Caloric requirement : 30 x 70 = 2100 kcal
 Protein requirement : 1.5 x 70 = 105 g
 P...
Example Calculation
Make up the difference with dextrose :
1260 / 3.4 = 370 g dextrose
Final volume :
 Amino acids ( 10% ...
Example Water Rx Calculation
Fluid needs for 70kg man :
70 x 30 = 2100 + 600 = 2700
TPN Rx provides 1813 ml fluid per day
...
84
85
Practice Calculation
You are now ready to order a TPN on 60
kg man with trauma
Monitoring for Complications
Malnourished patients at risk for refeeding sy
ndrome should have serum phosphorus, mag
nesiu...
Monitoring for Complications
Serum electrolytes (sodium, potassium, chlori
de, and bicarbonate) should be monitored fre
qu...
Acute Inpatient PN Monitoring
Parameter Daily
Frequency
3x/week Weekly
Glucose Initially √
Electrolytes Initially √
Phos, ...
Inpatient Monitoring PN
Parameter Daily
Frequency
Weekly PRN
Body Weight Initially √
Nitrogen Balance Initially √
HGB, HCT...
Monitor—cont’d
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly...
Monitoring: Nutrition
Serum Hepatic Proteins
Parameter t ½
Albumin 19 days
Transferrin 9 days
Prealbumin 2 – 3 days
Retino...
Less than 5%
Technical
Biochemical
Others
93
Complications
Complications
Technical
– Air embolism
– Pneumothorax
– bleeding
– Infection
– Arterial puncture
– Catheter displacement
–...
Complications
Glucoseabnormalities are common.
– Hyperglycemia can be avoided by monitoring blood
glucose often, adjusting...
Complications
Abnormalities of serumelectrolytes and minerals
– should be corrected by modifying subsequent infu
sions or,...
Complications
Volume overload (suggested by > 1 kg/day weight gain)
– may occur when high daily energy requirements requir...
Complications
Adverse reactions to lipidemulsions
 dyspnea, cutaneous allergic reactions, nausea, headache, ba
ck pain, s...
Complications
Hepaticcomplications
– liver dysfunction
– painful hepatomegaly
– hyperammonemia.
– Transient liver dysfunct...
– Contributing factors probably include cholestasis an
d inflammation.
– Progressive fibrosis occasionally develops.
 Red...
Gallbladder complications
– include cholelithiasis, gallbladder sludge, and cholecystitis.
– These complications can be ca...
Refeeding Syndrome
Patients at risk are malnourished, partic
ularly marasmic patients
Can occur with enteral or parenteral...
Refeeding Syndrome
Reduced serum levels of magnesium, p
otassium, and phosphorus
Hyperglycemia and hyperinsulinemia
Inters...
Refeeding Syndrome Prevention/Treatment
Monitor and supplement electrolytes, vitamins
and minerals prior to and during inf...
Defense Against PN Complications
Select appropriate patients to receive PN
Aseptic technique for insertion and site care o...
Stopping TPN
Stop TPN when enteral feeding can rest
art
Wean slowly to avoid hypoglycemia
 Give IV Dextrose 10% solution ...
THANK YOU
Total parental nutrition
Total parental nutrition
Total parental nutrition
Nächste SlideShare
Wird geladen in …5
×

Total parental nutrition

10.427 Aufrufe

Veröffentlicht am

Total parental nutrition

Veröffentlicht in: Gesundheit & Medizin
  • Als Erste(r) kommentieren

Total parental nutrition

  1. 1. Total Parenteral Nutrition By Dr Waseem Ashraf Moderator:- Dr Rouf Ahmad Wani Deptt of General Surgery
  2. 2. What is TPN? Parenteral nutrition: process of supplying nutrie nts via the intravenous route – Total parenteral nutrition (TPN) – Peripheral parenteral nutrition (PPN) TPN may reduce morbidity and mortality after m ajor surgery, severe burns, and head trauma, es pecially in patients with sepsis. TPN is often used in hospital, long term care, an d sub-acute care, and infrequently is used in the home care setting.
  3. 3. Indications Patients whose GI tract is not functional. – e.g. 50% of metabolic needs met for < 7 days Undernourished patients who cannot ingest large volu mes of oral feedings and are being prepared for surge ry, radiation therapy, or chemotherapy. Disorders requiring complete bowel rest – Crohn's disease – ulcerative colitis – severe pancreatitis Pediatric GI disorders – congenital anomalies – prolonged diarrhea
  4. 4. The gut should always be the preferred route for nutrient administrat ion. Therefore, parenteral nutrition is indicated generally w hen there is severe gastro-intestinal dysfunction (p atients who cannot take sufficient food or feeding form ulas by the enteral route) .
  5. 5. Goals To decrease the adverse effects of catabolis m Support ongoing metabolism To improve immune function, cardiac and res piratory function Maintain glycogen reserve Maintain acid, base and electrolyte metabolis m 5
  6. 6. Nutritional Content Water – 30 to 40 mL/kg/day Energy – 30 to 60 kcal/kg/day (depending on energy expenditure) Amino acids – 1 to 2.0 g/kg/day (depending on the degree of catabolism) Essential fatty acids Vitamins, and minerals Children who need TPN may have different fluid requireme nts and need more energy (120 kcal/kg/day) and amino aci ds (2.5 to 3.5 g/kg/day).
  7. 7. Requirements: Energy  Basal energy requirements are a function of the individual's weight, age, gender, activity level and the disease process.  The estimation of energy requirements for parenteral nutrition r elies on predictive equations.  Hospitalized adults require approximately 25-30 kcal/ kgBW/da y.  However, these requirements may be greater in patients with inj ury or infection.
  8. 8. Energy Requirements Patient condition Basal metabolic rate Approximate energy Requirement (kcal/kg/day) No postoperative complications, GIT fistula without infection Normal 25-30 Mild peritonitis, long-bone fractur e, mild to moderate injury, malno urished 25% above nor mal 30-35 Severe injury or infection 50% above nor mal 35-45 Burn 40-100% of total body surf ace Up to 100% abo ve normal 45-80
  9. 9. Requirements: Energy Sources: Glucose The most common source of parenteral energy supply is glucos e, being:  Readily metabolized in most patients,  provides the obligatory needs of the substrate , thus reducin g gluconeogenesis and sparing endogenous protein.  1 gm of glucose gives 4 Kcals. Most stable patients tolerate rates of 4-5 mg.kg-1.Min-1, but ins ulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin should be incorporated acc. to bl ood sugar levels.
  10. 10. Energy Sources: Glucose  Low calorie value  Requires large volume  Hyperglycemia  More CO2 production  Thrombophlebitis in conc above 10% 10 Requirements:
  11. 11. Requirements: Energy Sources: Lipid  Fat mobilization is a major response to stress and infect ion.  Triacylglycerols are an important fuel source in those co nditions, even when glucose availability is adequate.  Need to be restricted in patients with hypertriglycerid emia.
  12. 12. Requirements: Energy Sources: Lipid Lipids are also a source for the essential fatty acid s which are the building blocks for many of the hor mones involved in the inflammatory process as wel l as the hormones regulating other body functions. Ideally, energy from fat should not exceed 40% of t he total (usually 20-30%).
  13. 13. Requirements: Energy Sources: Lipid Fat emulsions can be safely administered via perip heral veins, provide essential fatty acids, and are c oncentrated energy sources for fluid-restricted pati ents. They are available in 10, 20 and 30% preparations. Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is 10Kcal/g due to the cont ents of glycerol and phospholipids.
  14. 14. Advantages Energy Sources: Lipid high calorie Prevents hyperglycemia Less co2 production Less insulin production 14
  15. 15. Disadvantages Energy Sources: Lipid  Hypertriglyceridemia  Sepsis  Fat embolism  Fat overload  Hepatic dysfunction  pancreatitis 15
  16. 16. Requirements: Nitrogen  Protein (or amino acids, the building blocks of protei ns) is the functional and structural component of the body, so fulfilling patient’s caloric needs with non-pr otein calories (fat and glucose) is essential.  Protein requirements for most healthy individuals ar e 0.8 g/kg/day.
  17. 17. Requirements: Nitrogen  With disease, poor food intake, and inactivity, body prot ein is lost with the resultant weakness and muscle mass wasting.  Critically ill patients may need as high as 1.5-2.5 g prote in/kg/day depending on the disease process: (major trauma or burn > infection or after surgery > standard) • The amount should be reduced in patients with kidney o r liver disease.
  18. 18. Requirements: Nitrogen Daily Protein requirements Condition Example requirement Basic requirements Normal person 0.5-1g/Kg Slightly increased requirem ents Post-operative, cancer, inflam matory 1.5g/Kg Moderately increased requi rements Sepsis, polytrauma 2g/Kg Highly increased requirem ents Peritonitis, burns, 2.5g/Kg Reduced requirements Renal failure, hepatic enceph alopathy 0.6g/Kg
  19. 19. Requirements: Nitrogen Nitrogen Balance = Protein intake in grams ÷ 6.25 – UUN (in grams) + 3  The nitrogen lost in urine derives primarily from ami no acids released by protein breakdown in respons e to catabolic mediators that include stress hormon es (corticosteroids, catecholamines) and cytokines.  It is a way to assess the sufficiency of protein intake for the patient.
  20. 20. Requirements: Nitrogen • Parenteral amino acid solutions provide all known esse ntial amino acids. • Available a.a. preparations are 3.5 - 15 % (ie contai ns 3.5-15 gms of protein or a.a.s/100 mL solution). • 1gm of protein = 0.16 gm of N2.
  21. 21. Requirements: Nitrogen • Special a.a. solutions are also available containing higher levels of certain a.a.s, most commonly the br anched-chain ones (valine, leucine and isoleucine), aimed at the management of liver diseases, sepsis and other stress conditions. • Conversely, solutions containing fewer a.a.s (primar ily the essential ones) are available for patients with renal failure.
  22. 22. Requirements: Nitrogen  Arginine was added to enteral formulae claiming po sitive effects on immune function and length of hosp ital stay.  In some clinical trials, glutamine-enriched solutions i mproved nitrogen balance and gut morphology.
  23. 23. Requirements: Fluids and electrolytes • 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
  24. 24. Requirements: Fluids and electrolytes Nutrient Requirements (/Kg/day) Water 20-40 mL Sodium 0.5-1.0 mmol Potassium 0.5-1.0 mmol Magnesium 0.1-0.2 mmol Calcium 0.05-0.15mmol Phosphate 0.2-0.5mmol Chloride/Acetate So a to maintain acid-base balance (nor mally 0.5 mmol for Cl- , & 0.1mEq for Acetate)
  25. 25. Requirements: Fluids and electrolytes • Normalization of acid-base balance is a priority and constant concern in the management of critically ill patients. • Most electrolytes can be safely added to the parent eral amino acid/dextrose solution. • Sodium bicarbonate in high concentrations will tend to generate carbon dioxide at the acidic pH of the a mino acid/glucose mix.
  26. 26. Requirements: Vitamins  These requirements are usually met when standard vol umes of a nutrient mix are provided.  Increased amounts of vits are usually provided to sever ely ill patients.  Vitamins are either fat soluble (A,D,E,K) or water solubl e (B,C). Separate multivitamin commercial preparations are now available for both.
  27. 27. Requirements: Vitamins Multivitamin formulations for parenteral use for adult patients usually contain 12 vitamins at levels estimate d to provide daily requirements. Additional amounts can be provided separately when indicated. Most adult vitamin formulae do not contain vitamin K, which is added according to the patient’s coagulation status.
  28. 28. Requirements: Trace minerals  These are essential component of the parenteral n utrition regimen.  A multi-element solution is available commercially, and can be supplemented with individual minerals.  may be toxic at high doses.  Iron is excluded, as it alters stability of other ingred ients. So it is given by separate injection (iv or im).
  29. 29. Requirements: 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. Mineral Recommended dietary all owance (RDA) for daily or al intake (mg) Suggested daily intr avenous intake (mg) Zinc 15 2.5-5 Copper 2-3 0.5-1.5 Manganese 2.5-5 0.15-0.8 Chromium 0.05-0.2 0.01-0.015 Iron 10 (males)-18 (females) 3
  30. 30. Osmolarity: PPN: Maximum of 900 milliosmoles / liter TPN: as nutrient dense as necessary (>900 m.osmol and up as high as 3000). Amino acids (10 m.osmol/gm), dextrose (5 m. osmol/gm) and electrolytes (2 m.osmol /mEq) contribute most to the osmolarity, while lipids give 1.5 m.osmol/gm.
  31. 31. The Solution Manually mixed in hospital pharmacy or nutrit ion-mixing service premixed solutions, Separate administration for every element al one in a separate line.
  32. 32. What to do before starting TPN  Nutritional Assessment  Venous access evaluation  Baseline weight  Baseline lab investigations
  33. 33. Nutritional Assessment  History  Physical examination  Anthropometric measurements  Laboratory investigations
  34. 34. Nutritional Assessment History  Dietary history  Significant weight loss within last 6 months  > 15% loss of body weight  compare with ideal weight  Beware in patient with ascites/ oedema IBW
  35. 35. Physical Examination • Evidence of muscle wasting • Depletion of subcutaneous fat • Peripheral oedema, ascites • Features of Vitamin deficiency • eg nail and mucosal changes • Echymosis and easy bruising • Easy to detect if >15% loss Nutritional Assessment
  36. 36. Anthropometry • Weight for Height comparison • Body Mass Index [BMI <19] • Triceps-skinfold (index of body fat) • Mid arm muscle circumference(muscle mass) • Bioelectric impedance • Hand grip dynamometry • Clinical Assessment score(SGA) score of history and clinical examination Nutritional Assessment
  37. 37. Lab investigations • albumin < 30 mg/dl • pre-albumin <12 mg/dl • transferrin < 150 mmol/l • total lymphocyte count < 1800 / mm3 • tests reflecting specific nutritional deficits • eg Prothrombin time • Skin anergy testing • Urinary creatinine / height index Nutritional Assessment
  38. 38. 38
  39. 39. Special Considerations  Patients who have renal insufficiency and are not receiving dialysis or who have liver failure requi re solutions with reduced protein content and a hig h percentage of essential amino acids.  For patients with heart or kidney failure, volume (l iquid) intake must be limited.  For patients with respiratory failure, a lipid emulsi on must provide most of non-protein calories to min imize CO2 production by carbohydrate metabolism.  Neonates require lower dextrose concentrations (1 7 to 18%).
  40. 40. Venous access  PPN: (<900 m.osmol/L): a peripheral line can be en ough.  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 as sociated infection), or a long catheter placed in an arm vei n and threaded into the central venous system (a peripher ally inserted central catheter line)  Once the correct position of the catheter has been e stablished (usually by X ray), the infusion can begin.
  41. 41. Venous Access for TPN Needs venous access to a “large” cent ral line with fast flow to avoid thrombophle bitis • Long peripheral line • subclavian approach • internal jugular approach • external jugular approach Superior Vena Cava
  42. 42. Types of CVC Single/multi-lumen CVC. Peripherally inserted central catheters ( PICC lines). Tunneled catheters. Implanted venous devices or vascular a ccess ports.
  43. 43. Central Venous Catheters Catheters used for delivering TPN shoul d be employed for that sole use.
  44. 44. Single/multi-lumen CVC Usually short term. Percutaneous insertion using jugular, su bclavian or femoral routes. Multi-lumen may have 2,3 or 4 lumens. Single-lumen catheters are preferred. Flush after every use. Dressing change 24 hrs after insertion a nd then as per policy.
  45. 45. Peripherally inserted central catheters (PICC Lines) PICC lines are designed to provide ven ous access for short to long periods req uiring iv therapy. Increasing being used for patients recei ving home care. Can be established in our wards without any difficulty. Lifetime of 4 to 6 weeks.
  46. 46. Tunneled CVC Hickman and Broviac CVC : right atrial c entral catheters that are surgically insert ed into the chest. The catheter is tunneled under the ches t tissue after it exits the vein so that exit site is a distance from skin exit site. For long-term use.
  47. 47. Implanted CVC Port-a-cath : a surgically inserted centra l line that does not have an external exit site, uses a subcutaneous port. Catheter ends in a reservoir that has a r ubber diaphragm for a top that is implan ted under the skin.
  48. 48. Peripheral Parenteral nutrition It differs from central TPN in • composition of feed • primary caloric source • potential complications • method of administration
  49. 49. Formulations Two Types of TPN:  Solutions with lipids (3-in-1)  Solutions without lipids (2-in-1) Advantages of (3-in-1)  Lower cost of preparation  Less administration time for nurses  Potentially reduced risk of sepsis
  50. 50. Formulations Disadvantages to 3-in-1  Precipitants cannot be seen  Not stable as long as TPNs without lipids Expiration date for 2-in-1 is 21 days Expiration date for 3-in-1 is 7 days  Can remain at room temperature for 24 ho urs
  51. 51. 53
  52. 52. Steps in ordering TPN Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Decide how much fat & carbohy drate to give Determine Electrolyte and Trace element requirements Determine need for additives
  53. 53. Steps in ordering TPN Determine Total Fluid Volume Determine Caloric needs Determine Protein requirements Decide how much fat & carbohy drate to give Determine Electrolyte and Trace element requirements Determine need for additives
  54. 54. How much volume to give? Cater for maintenance & on going losse s Normal maintenance requirements  By body weight (25-35 ml/kg/day) Add on going losses based on I/O char t Consider insensible fluid losses also  e.g. add 10% for every 1oC rise in temperature
  55. 55. Steps in ordering TPN Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Decide how much fat & carbohy drate to give Determine Electrolyte and Trace element requirements Determine need for additives
  56. 56. Caloric requirements Based on Total Energy Expenditure  Can be estimated using predictive equation s TEE = REE + Stress Factor + Activity Factor  Can be measured using metabolic chart
  57. 57. Caloric requirements REE (BMR) Predictive equations Harris-Benedict Equation Males: REE = 66 + (13.7W in kg) + (5H in cm) - 6.8Age Females: REE= 65.5 + (9.6W in kg) + 1.8H in cm - 4.7Age Schofield Equation 25 to 30 kcal/kg/day
  58. 58. Caloric requirements Stress Factor •Post op. pat. + 10% •Malnutrition + 30% •peritonitis + 15% •soft tissue trauma + 15% •fracture+ 20% •fever (per oC rise) + 13% •Moderate infection + 20 % •Severe infection + 40% •<20% BSA Burns + 50 % •20-40% BSA Burns + 80 % •>40% BSA Burns + 100 %
  59. 59. Caloric requirements Activity Factor Bed-bound + 20% Ambulant + 30% Active + 50%
  60. 60. How much CHO & Fats? “Too much of a good thing causes pro blems”  Not more than 4 mg / kg / min Dextrose (less than 6 g / kg / day) Rosmarin et al, Nutr Clin Pract 1996,11:151-6  Not more than 0.7 mg / kg / min Lipid (less than 1 g / kg / day) Moore & Cerra, 1991
  61. 61. How much CHO & Fats? Fats usually form 25 to 30% of calories  Not more than 40 to 50%  Increase usually in severe stress  Aim for serum TG levels < 350 mg/dl CHO usually form 70-75 % of calories
  62. 62. How much protein to give?  Based on calorie : nitrogen ratio  Based on degree of stress & body weig ht  Based on Nitrogen Balance
  63. 63. How much protein to give? Calorie : Nitrogen Ratio Normal ratio is 150 cal : 1g Nitrogen Critically ill patients 85 to 100 cal : 1 g Nitrogen
  64. 64. How much protein to give? Based on Stress & BW Condition Example requirement Basic requirements Normal person 0.5-1g/Kg Slightly increased requirem ents Post-operative, cancer, inflam matory 1.5g/Kg Moderately increased requi rements Sepsis, polytrauma 2g/Kg Highly increased requirem ents Peritonitis, burns, 2.5g/Kg Reduced requirements Renal failure, hepatic enceph alopathy 0.6g/Kg
  65. 65. How much protein to give? Based on Nitrogen Balance Aim for positive balance of 1.5 to 2g / kg / day
  66. 66. Nitrogen Balance Every gram of negative NB represents l oss of approx. 30gms of lean muscle m ass For daily negative nitrogen balance of 1 0gms/day about 1.5kg of lean muscle m ass will be lost over a 5 day period
  67. 67. Nitrogen Balance Nitrogen Balance = N input - N output 1 g N = 6.25 g protein N input = (protein in g / 6.25) N output = 24h urinary urea nitrogen + no n-urinary N losses (estimated normal non-urinary Nitrogen lo sses about 3-4g/d)
  68. 68. Approx. Nitrogen Balance and lean muscle mass loss Procedure N-loss Muscle los s (gms/day) Herniotomy 3 90 Appendisectomy 6 180 Cholecystectomy 12 360 Esophagectomy 90 2700 Peritonitis 18 540 Sepsis 24 720
  69. 69. Steps to ordering TPN Determine Total Fluid V olume Determine Protein requir ements Determine Non-N Calori c needs Decide how much fat & carbohydrate to give Determine Electrolyte an d Trace element require ments Determine need for addit ives
  70. 70. Electrolyte Requirements Cater for maintenance + replacement nee ds Na+ 1 to 2 mmol/kg/d (or 60-120 meq/d) K+ 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d) Mg++ 0.35 to 0.45 meq/kg/d (or 10 to 20 meq /d) Ca++ 0.2 to 0.3 meq/kg/d (or 10 to 15 meq/d) PO4 2- 20 to 30 mmol/d
  71. 71. Trace Elements Total requirements not well established Commercial preparations exist to provide RDA  Zn 2-4 mg/day  Cr 10-15 ug/day  Cu 0.3 to 0.5 mg/day  Mn 0.4 to 0.8 mg/day
  72. 72. Steps to ordering TPN Determine Total Fluid V olume Determine Protein requir ements Determine Non-N Calori c needs Decide how much fat & carbohydrate to give Determine Electrolyte an d Trace element require ments Determine need for addit ives
  73. 73. Other Additives Vitamins  Give 2-3x that recommended for oral intak e  use 1 ampoule multivitamin per bag of TPN  Multivitamin does not include Vitamin K  can give 1 mg/day or 5-10 mg/wk
  74. 74. Other Additives Medications  Insulin  can give s/c initially based on sliding scale  once stable, give 2/3 total requirements in TPN & review daily  alternate regimes  0.1 u per g dextrose in TPN  10 u per liter TPN initial dose  Other medications
  75. 75. The Solution Manually mixed in hospital pharmacy or nutrit ion-mixing service, premixed solutions, Separate administration for every element al one in a separate line.
  76. 76. Caloric content of TPN Parenteral glucose contains 3.4 kcal/g Protein contains 4 kcal/g Lipid contains 9 kcal/g
  77. 77. TPN for a 70 kg man 80
  78. 78. Example Calculation For 70 kg man  Caloric requirement : 30 x 70 = 2100 kcal  Protein requirement : 1.5 x 70 = 105 g  Provide 20-30 % of calories as lipid : 2100 x 0.2 = 420 kcal  Then 420 / 9 = 47 g of lipid  Calories from amino acid : 105 x4 = 420 kc al  Remaining calories : 2100-420-420 = 1260 kcal
  79. 79. Example Calculation Make up the difference with dextrose : 1260 / 3.4 = 370 g dextrose Final volume :  Amino acids ( 10% stock solution) : 105g = 1050 ml • Dextrose (70% stock solution) : 370g = 528 ml • Lipids (20% stock solution) : 47g =235ml • Total volume = 1813ml/day
  80. 80. Example Water Rx Calculation Fluid needs for 70kg man : 70 x 30 = 2100 + 600 = 2700 TPN Rx provides 1813 ml fluid per day 2700 ml - 1813 ml = 887 ml additional st erile water needed
  81. 81. 84
  82. 82. 85
  83. 83. Practice Calculation You are now ready to order a TPN on 60 kg man with trauma
  84. 84. Monitoring for Complications Malnourished patients at risk for refeeding sy ndrome should have serum phosphorus, mag nesium, potassium, and glucose levels monit ored closely at initiation of SNS. (B) In patients with diabetes or risk factors for glu cose intolerance, SNS should be initiated with a low dextrose infusion rate and blood and uri ne glucose monitored closely. (C) Blood glucose should be monitored frequently upon initiation of SNS, upon any change in in sulin dose, and until measurements are stabl e. (B)
  85. 85. Monitoring for Complications Serum electrolytes (sodium, potassium, chlori de, and bicarbonate) should be monitored fre quently upon initiation of SNS until measurem ents are stable. (B) Patients receiving intravenous fat emulsions s hould have serum triglyceride levels monitore d until stable and when changes are made in the amount of fat administered. (C) Liver function tests should be monitored perio dically in patients receiving PN. (A)
  86. 86. Acute Inpatient PN Monitoring Parameter Daily Frequency 3x/week Weekly Glucose Initially √ Electrolytes Initially √ Phos, Mg, BUN, Cr, Ca Initially √ TG √ Fluid/Is & Os √ Temperature √ T. Bili, LFTs Initially √
  87. 87. Inpatient Monitoring PN Parameter Daily Frequency Weekly PRN Body Weight Initially √ Nitrogen Balance Initially √ HGB, HCT √ Catheter Site √ Lymphocyte Count √ √ Clinical Status
  88. 88. Monitor—cont’d Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly) Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)
  89. 89. Monitoring: Nutrition Serum Hepatic Proteins Parameter t ½ Albumin 19 days Transferrin 9 days Prealbumin 2 – 3 days Retinol Binding Protein ~12 hours
  90. 90. Less than 5% Technical Biochemical Others 93 Complications
  91. 91. Complications Technical – Air embolism – Pneumothorax – bleeding – Infection – Arterial puncture – Catheter displacement – Sepsis – blockage
  92. 92. Complications Glucoseabnormalities are common. – Hyperglycemia can be avoided by monitoring blood glucose often, adjusting the insulin dose in the TPN solution and giving subcutaneous insulin – Hypoglycemia can be precipitated by suddenly disc ontinuing constant concentrated dextrose infusions. 95
  93. 93. Complications Abnormalities of serumelectrolytes and minerals – should be corrected by modifying subsequent infu sions or, if correction is urgently required, by begin ning appropriate peripheral vein infusions. – Vitamin and mineral deficiencies are rare if solutio ns are given correctly. E – elevated BUN may reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein.
  94. 94. Complications Volume overload (suggested by > 1 kg/day weight gain) – may occur when high daily energy requirements require large fluid vo lumes. Metabolic bone disease, or bone demineralization (osteoporosis or ost eomalacia), – develops in some patients receiving TPN for > 3 mo. – Mechanism is unknown. – Advanced disease can cause severe periarticular, lower extremity, a nd back pain. – Temporarily or permanently discontinuing TPN is the only known trea tment.
  95. 95. Complications Adverse reactions to lipidemulsions  dyspnea, cutaneous allergic reactions, nausea, headache, ba ck pain, sweating, dizziness  uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/ kg/h.  Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure – treatment is usually not required.  Delayed adverse reactions to lipid emulsions include hepatom egaly, mild elevation of liver enzymes, splenomegaly, thrombo cytopenia, leukopenia, and, especially in premature infants wit h respiratory distress syndrome, pulmonary function abnormal ities. – Temporarily or permanently slowing or stopping lipid emulsion infusio n may prevent or minimize these adverse reactions.
  96. 96. Complications Hepaticcomplications – liver dysfunction – painful hepatomegaly – hyperammonemia. – Transient liver dysfunction, evidenced by increased transaminases, bilirubin, and alkaline phosphatase, is common with the initiation of TPN. – Delayed or persistent elevations may result from ex cess quantities of amino acids.
  97. 97. – Contributing factors probably include cholestasis an d inflammation. – Progressive fibrosis occasionally develops.  Reducing protein delivery may help. – Painful hepatomegaly suggests fat accumulation; c arbohydrate delivery should be reduced. – Hyperammonemia can develop in infants.  Signs include lethargy, twitching, and generalized seizures. Correction consists of arginine supplementation at 0.5 to 1.0 mmol/kg/day.  For infants who develop any hepatic complication , limiting amino acids to 1.0 g/kg/day may be nec essary. 100
  98. 98. Gallbladder complications – include cholelithiasis, gallbladder sludge, and cholecystitis. – These complications can be caused or worsened by prolon ged gallbladder stasis. – Stimulating contraction by providing about 20 to 30% of cal ories as fat and stopping glucose infusion several hours a day is helpful. – Oral or enteral intake also helps. – Treatment with metronidazole, ursodeoxycholic acid, phen obarbital, or cholecystokinin helps some patients with chole stasis. Complications
  99. 99. Refeeding Syndrome Patients at risk are malnourished, partic ularly marasmic patients Can occur with enteral or parenteral nut rition Results from intracellular electrolyte shif t
  100. 100. Refeeding Syndrome Reduced serum levels of magnesium, p otassium, and phosphorus Hyperglycemia and hyperinsulinemia Interstitial fluid retention Cardiac decompensation and arrest
  101. 101. Refeeding Syndrome Prevention/Treatment Monitor and supplement electrolytes, vitamins and minerals prior to and during infusion of P N until levels remain stable Initiate feedings with 15-20 kcal/kg or 1000 kc als/day and 1.2-1.5 g protein/kg/day Limit fluid to 800 ml + insensible losses (adjus t per patient fluid tolerance and status)
  102. 102. Defense Against PN Complications Select appropriate patients to receive PN Aseptic technique for insertion and site care of IV c atheters Do not overfeed  Maintain glycemic control <150-170 mg/dl  Limit lipids to 1 gm/kg and monitor TG levels  Adjust protein based on metabolic demand and organ fu nction Monitor fluid/electrolyte/mineral status Provide standard vitamin and trace element preps daily
  103. 103. Stopping TPN Stop TPN when enteral feeding can rest art Wean slowly to avoid hypoglycemia  Give IV Dextrose 10% solution at previous infusion rate for at least 4 to 6h  Alternatively, wean TPN while introducing enteral feeding and stop when enteral intak e meets TEE
  104. 104. THANK YOU

×