Parenteral nutrition (PN), also known as total parenteral nutrition (TPN), involves delivering nutrients directly into the bloodstream when oral or enteral nutrition is not possible or sufficient. PN can be delivered via either a peripheral or central line. It provides nutrients such as glucose, lipids, amino acids, electrolytes, vitamins and minerals to meet nutritional needs when the gastrointestinal tract cannot be used. The gut is always preferred when possible due to risks of infection and other complications with PN. It is indicated when enteral nutrition cannot meet nutritional requirements for over 7-10 days or in cases of severe gastrointestinal dysfunction. Careful monitoring is required when on PN therapy.

2. TOTAL
PARENTRAL
NUTRITION

5. ENTERAL NUTRITION
 Enteral nutrition is also
called "tube feeding,“
 Enteral nutrition is a
mixture of all the
needed nutrients.
 It is thicker than
parenteral nutrition and
sometimes it looks like
a milk shake.
 It is given through a
tube into the stomach
or small intestine.

6. PARENTERAL NUTRITION
 Parenteral nutrition (PN) is an appropriate
route of
nutrition support when patients with identified
malnutrition or significant risk of malnutrition
cannot
meet their nutritional requirements through the
Gastrointestinal (GI) tract.

7. THE GOLDEN RULE OF NUTRITION
The gut should always be the preferred
route for nutrient administration.
 Therefore, parenteral nutrition is indicated
generally when there is severe gastro-
intestinal dysfunction

8. INDICATION FOR PARENTERAL NUTRITION
 In well-nourished adults, 7 - 10 days of
starvation with conventional intravenous
support (using 5% dextrose solutions) is
generally accepted.
 If the period of starvation is to extend beyond
this time, or the patient is not well-nourished,
Total Parenteral Nutrition (TPN) is necessary
to prevent the potential complications of
malnutrition.

9. IDENTIFYING THE
MALNOURISHED PATIENT
HISTORY:
 Eaten little or nothing for more than 5 days and/or
are likely to eat little or nothing for 5 days or longer.
 A poor absorptive capacity.
 High nutrient losses.
 Increased nutritional needs
from causes such as catabolism
 Unintentional weight loss

10. EXAMINATION:
 NO FAT BETWEEN FOLDS OF SKIN
 SKIN HANGING

11.  ROUGH HAIR
MOUTH SORES

12.  CALCULATE BMI <2O kg/m²

14. ROUTES OF PARENTERAL
NUTRITION

15. ADMINISTRATION OF PARENTERAL
NUTRITION
PERIPHERAL ROUTE:
 Peripheral administration should be
considered first line for parenteral feeding
 No requirements for a chest x-ray to confirm
placement
 A mid-line should be considered as a
peripheral line as it doesnot reach the central
circulation
 sometimes complicated or delayed by
phlebitis

16. CENTRAL ROUTE
 The central venous route is indicated when
 longer term feeding is anticipated
 high tonocity formulations
 peripheral route is inaccessible
 A range of single, double, triple &
quadruple lumen central lines are available.
 These lines require skillful insertion, usually
into the jugular or subclavin vein, confirm
their positions by X-ray
 Tunnelling of the line to an appropriate exit
site facilitates line care and may reduce the
incidence of significant line sepsis

17. PERIPHERALLY INSERTED CENTRAL
CATHETERS (PICCs)
 PICCs are typically inserted
into a peripheral vein, usually
into cephalic or basilic in the
upper arm, with exit tip in the
superior vena cava just
above the right atrium
 They are used for the central
administration of infusions
 Insertion is less invasive
then for conventional central
lines

18. CATEGORIES
OF
PARENTERAL
NUTRITION
PARTIAL
PARENTERAL
NUTRITION
TOTAL
PARENTERAL
NUTRITION

19.  If enteral feeding is just “not enough” ,
supplementation with Partial Parenteral
Nutrition (PPN) is indicated
Indications:
 Short bowel syndrome
 Malabsorption disorders
 Critical illness or wasting disorders

20.  If enteral feeding is completely
stopped or ineffective, Total
Parenteral Nutrition is used (TPN).

22. TPN
WELL
NOURISHED
7-10 DAYS
MILD OR
MODERATE
MALNUTRITION
5-7 DAYS
SEVERE
MALNUTRITION
3-5 DAYS

23. TPN INDICATIONS FOR
CHILDREN
 Congenital or acquired anomalies if the G.I.
tract: gastroschisis, bowel fistulas, intestinal
obstruction, atresias, short gut syndrome.
 Chronic or recurrent diarrhea: malabsorption
syndrome, inflammatory bowel disease.
 Preterm infants
 Malnutrition (cystic fibrosis, cancer, anorexia
nervosa, hypermetabolic states, e.g., burns).
 Patient who are Nill Per OS (or who will be NPO)
for sufficient periods of time to cause a significant
decrease in caloric intake (e.g., post-operative
patients).

24. TPN INDICATIONS FOR
ADULTS
SHORT-TERM USE
 Bowel injury, surgery, major trauma or burns
 Bowel disease (e.g. obstructions, fistulas)
 Severe malnutrition
 Nutritional preparation prior to surgery.
 Malabsorption - bowel cancer
 Severe pancreatitis
 Malnourished patients who have high risk of
aspiration
LONG-TERM USE (HOME PN)
 Prolonged Intestinal Failure
 Crohn’s Disease
 Bowel resection

25. COMPONENTS OF
PARENTERAL NUTRITION

26. COMPONENTS OF
PARENTERAL NUTRITION
MACRO
NUTRIENT
S
MICRO
NUTRIENTS

27. MACRO NUTRIENTS
ENERGY AMINOACIDS WATER

28. MICRO NUTRIENTS
VITAMINS
ELECTROLYTES
TRACE ELEMENTS

29. ENERGY

30. DAILY ENERGY
REQUIREMENTS IN ADULTS
Gender Energy
(Kcal)
MALE 2900 Kcal
FEMALE 2200 Kcal

31. DAILY ENERGY
REQUIREMENTS IN
INFANTS
Age ( Months) Energy (Kcal/kg)
0-3 116
3-6 99
6-9 95
9-12 101

32. ENERGY
 Hospitalized adults require approximately 25-
30 kcal/ kg /day.
 However, these requirements may be greater
in patients with injury or infection.

33. ENERGY REQUIREMENTS IN
DISEASE CONDITIONS
Patient condition Approximate energy
Requirement
(kcal/kg/day)
No postoperative
complications, GIT
fistula without infection
25-30
Mild peritonitis, malnourished 30-35
Severe injury or infection 35-45
Burn 40-100% of total body
surface
45-80

34. DUAL ENERGY
 Energy should be sourced from a combination of
lipid and glucose.
 Dual energy minimizes the risk of complications.

35. GLUCOSE
LIPIDS
DUAL
ENERGY

36. GLUCOSE

37. GLUCOSE
 Most common source of parenteral energy
supply.
 1 gm of glucose gives 4 Kcals.

38. • Most stable patients tolerate rates of 4-5
mg.kg-1.Min-1, but insulin resistance in
critically ill patients may lead to
hyperglycemia even at these rates, so
insulin should be incorporated according
to blood sugar levels.
•Do not advance dextrose doses until
Potassium and Phosphate levels are
corrected.

39.  More Potassium , Phosphates and Magnesium
are required during insulin therapy.
 Minimum dextrose dose per day is 100-
120g/day.

40.  Glucose in 5% solution can be safely
administered via a peripheral vein, but higher
concentrations require a central venous line.
 20, 25, or even 50 % solutions are needed to
administer meaningful amounts of energy to
most patients for proper volume
administration.

42. LIPIDS
 Used as a source of energy and for the
provision of the essential fatty acids, linoleic
acid and α- linolenic acid .
 FA which are the building blocks for many of
the hormones involved in the inflammatory
process as well as the hormones regulating
other body functions.
 Provide 10 Kcal energy per gram of oil.

43.  They are energy rich and can be infused
directly into the peripheral veins.
 Patients receive upto 2.5 g lipid/Kg/day.

44.  20% lipid emulsions are used in paediatrics as
they contain less phospholipids than the 10%
emulsions.
 Lipid clearance monitoring is important in
patients who are hyperlipidaemic, clearance
impaired,diabetic and have impaired renal or
hepatic function.

45. AMINO ACIDS
(PROTEINS)

46. PROTEINS
 Protein (or amino acids, the building blocks of
proteins) is the functional and structural
component of the body.
 Special amino acid solutions are also available
including valine, leucine and isoleucine.
 Other amino acids are essential for neonates,
infants and children including histidine, proline,
tyrosine, taurine.

47. COMMERCIAL SOLUTIONS
OF AMINO ACIDS
 Commercially available licensed solutions of
amino acids are available:
 Aminoplex
 Intrafusin
 Synthamin
 Vamin

48. DAILY REQUIREMENTS OF
PROTEINS

49.  With disease, poor food intake, body protein is
lost with the resultant weakness and muscle
mass wasting.

50. PROTEIN REQUIREMENTS IN
DISEASE CONDITIONS
PATIENT CONDITIONS PROTEIN
REQUIREMENTS
g/Kg/day
Healthy, nonstressed 0.8
Bone marrow transplant 1.4- 1.5
Pregnancy 1.3- 1.5
Renal failure 0.6- 1.0
Liver disease 1.0- 1.5

51. DOSE OF AMINO ACID IN
PN
Day : 1 0.5g /Kg/d
Day :2 1 g / Kg/d
Day : 3 1.2- 1.7 g/Kg/d

52.  Amino acid solutions are hypertonic to blood
and should not be administered alone into the
peripheral circulation.

53. WATER

54. WATER
 Water is the principal component of the body
and accounts for approximately 60% and 55%
of total body weight in men and women.
 Homeostasis maintains appropriate fluid
levels and electrolyte balance.
 An adult patient will require 20- 40 ml/Kg/day
fluid.

55. FACTORS AFFECTING
WATER REQUIREMENTS:
 Abnormal GI loss (vomiting, dehydration).
 High environmental temperature.
 Acute anabolic state.
 Burns or open wounds.

56. MICRO-NUTRIENTS
 Micronutrients are nutrients required by
humans and other organisms throughout life in
small quantities to orchestrate a range of
physiological functions

57. MICRONUTRIENTS INCLUDES
1. Vitamins
2. Minerals
a. Macrominerals
b. microminerals

58. FACTORS AFFECTING
MICRONUTRIENTS REQUIREMENTS
 Increased loss
 Increased requirements
 Organ dysfunction

59. Importance of micronutrients
 Affect of micronutrients
deficiencies

61. VITAMINS

62. WATER SOLUBLE VITAMINS
 It includes Vitamin B-complex group and vitamin C
 Thiamin (vitamin B1), Riboflavin (vitamin B2), Niacin
(vitamin B3), Pantothenic acid (vitamin B5) , Pyridoxine
(vitamin B6), Biotin (vitamin B7), Folic acid (vitamin B9),
Cobalamin (vitamin B12).
 water-soluble vitamins dissolve in water and are not
stored by the body. with the exception of B12 and folate
i-e B9, which are stored in the liver. a continuous daily
supply in our diet is required.

64. FAT SOLUBLE VITAMINS
 It includes Vitamin A, D, E and K
 Dissolve in fat before they are absorbed in the
bloodstream to carry out their functions. Excesses
of these vitamins are stored in the liver, and are not
needed every day in the diet
 It generally posses a greater risk for toxicity when
consumed in excess than water-soluble vitamins.

66. ELECTROLYTES
 Electrolytes are minerals in your blood and other
body fluids that carry an electric charge.
 Electrolytes affect the amount of water in your
body, the acidity of your blood (pH), your muscle
function, and other important processes. You lose
electrolytes when you sweat. You must replace
them by drinking fluids.

68. TRACE ELEMENTS
 A chemical element required in minute
quantities by an organism to maintain proper
physical functioning.
 REQUIREMENT: Less than 100mg

70. Application:
 The Solution
 Manually mixed in hospital
pharmacy or nutrition-
mixing service,
 premixed solutions,
 Separate administration for
every element alone in a
separate line.
Osmolality, compatibility,
stability, sterility, ease of
preparation, and
completeness of formula
The easy-to-use PINNACLE
TPN Manager Software automates
calculations and streamlines the
process from order entry to infusion,
from physician to pharmacist to
patient.
THE AMERICAN HOSPIAL,UAE 2009

71.  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.
 Cyclic infusion;
 Consider cyclic PN infusion in:
 • Stable inpatients
 • Patients involved in daytime acute care therapy or
 transferring to rehabilitative services/facilities
 • Otherwise ambulatory patients whose mobility is
 hindered by infusion equipment
 • Patients anticipated to receive PN long term at home
 – Some may prefer daytime infusion due to frequent
 nocturnal urination
 – Portable pumps can help increase mobility for
 patients receiving dayyime infusion or longer
 infusion duration.
.

72. Catheter
 Catheters are medical devices that
can be inserted in the body to
treat diseases or perform a
surgical procedure.
 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

73. CATHETER CONNECTOR
NEDDLES: 18,19,20,22G
CANOLLA SIZE:
TUBE: POLYETHYLENE
PREPERATION: Silicon & plastic
PRECAUTIONS
PARTS OF CATHETER:

74.  Initiation of Therapy
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
To ensure that the solution is administered at a continuous
rate, an infusion pump is utilized to administer the
solution. In hospitalized patients, infusion usually occurs
over 22-24 h/day. In ambulatory home patients,
administration usually occurs overnight (12-16 h).

75.  AutoComp6-XP High Speed TPN
Compounder.
 for accurate, high speed compounding
from a reliable
 cost-effective.
 lightweight system with safety and
simplicity you can trust.
 HEALTHMARK CANCER HOSPITAL, in
Northwest Florida,2011
TPN COMPOUNDING

76. TPN CALCULATING SOFTWERE
Berlin,1992

77. Monitoring
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,
symptoms)
WBC count (total &
differential)
CulturesPolicy: to monitor:
Sapphire Parenteral Nutrition Pump
Use With All Liquid Solutions.
Ambulatory Treatment.

78. Monitoring
Monitoring

79. GUIDELINES FOR TOTAL PARENTERAL NUTRITION (TPN)
• TPN Indications
• How much calories with TPN
• Fluid Considerations
• TPN, Lipid, and IV Drugs Compatibility
• Tapering and Discontinuation
When the primary reason for starting TPN is
resolving (i.e. mucositis, diarrhea,
vomiting…etc), taper
TPN by reducing the rate into half for one
hour then DC TPN.
Discontinuation of TPN will stimulate the
appetite further.

80. Team Responsibilities
Physician:
• Orders: Start TPN, taper TPN, DC TPN, total fluid intake in ml/hour, designates
desired IV maintenance with TPN. (Note that new start TPN orders are accepted daily
excluding weekends. Any TPN order written after 1600 will be processed next day).
• Consults with TPN Pharmacist on medical circumstances requiring special
consideration in TPN nutrients.
• Enters ordered laboratory orders (by TPN pharmacist) into Integrated Clinical
Information System (ICIS).
• Orders all TPN related medications: Spironolactone, Triamterene, Ranitidine, Insulin,
electrolytes boluses, if required before next TPN bag arrives.

81.  TPN Pharmacist:
• Nutritional assessment of the patient, in conjunction with the
dietitian.
• TPN formula design to meet nutritional needs.
• Daily writing of TPN orders to include lab evaluation, fluid needs,
caloric and protein needs.
• Daily calculation of calories and protein (to include all sources of
glucose from IVPB, IV fluids, etc.)
• Daily order of necessary laboratory orders.
• Monitor drug-nutrient and lab-nutrient interactions.
• 24-hour on call

82. Nursing staff:
• Draws blood (turn off for one full minute before drawing all labs and avoid
contamination of the drawn blood with TPN).
• Determines adequacy of oral intake.
• TPN monitoring: Daily weights, intake and output, TPN infusion rates and times.
• Ensure safe drug administration in regard to compatibility of drugs with TPN and
lipids.

84. Infectious complication
Mechanical complications
Metabolic Complications
COMPLICATIONS OF TOTAL
PARENTERAL NUTRITION

86.  Parenteral nutrition
imposes a chronic
breech in the body's
barrier system.
 The infusion
apparatus from
container to catheter
tip may prove a
source for the
introduction of
bacterial or fungal
organisms.

87. INFECTIOUS COMPLICATION:
 Parenteral nutrition solutions can easily
become contaminated during the preparation
process
 Infection is one of the two most common
problems that arise after central venous
access is established

88. SEPSIS
 The most common organisms to
cause sepsis in TPN patients are
Staphylococcus epidermidis and Staph
aureus. Other common bacteria include:
Streptococcus, gram-negative organisms and
Candida. Catheter site infections also occur.

89. FUNGEMIA
 The most common type, also known as
Candidemia, caused by Candida species, but
infections by other fungi, including
Saccharomyces, Aspergillus and
Cryptococcus, are also called fungemia.
 TPN is strongly associated with with fungemia
, sometime unusal fungi such as Malassezia
furfur associated with use of intravenous lipid
infusion due to growth requirement of this
organism for fatty acid

90. MECHANICAL
COMPLICATION
Catheter
related
complication
Site
related
Line
occulusio
n

91. CATHETER RELATED
COMPLICATION
1. Catheter related infection
2. Venous thrombosis
3. Pneumothorax, vessel damage, thrombosis,
occlusion, catheter breakage, infection.

92. CATHETER RELATED INFECTION
 Infection can occur at the exit
site, and in the subcutaneous
tissue through which the
catheter is placed.
 The two most common routes
for transmission of micro-
organisms in CR infection are
 Contamination from the skin
at the catheter exit site,
 Contamination of the hub
connections on the catheter or
catheter tubing

93. VENOUS THROMBOSIS
 Central venous
thrombosis (CVT)
potentially fatal
complications in children
receiving prolonged PN
 CVT tends to develop
after several weeks of
PN.
 It may result in facial
swelling, prominent
superficial veins or pain
on commencing PN

94.  CVT are associated with recurrent CVC
infection, proximal location of the CVC tip in
the superior vena cava, frequent blood
sampling, concentrated glucose solutions,
chemotherapeutic agents or may be idiopathic.
 Carers should look for any distress of the child,
breathlessness, redness or swelling in the
neck or limbs, leakage from the exit site or
stiffness of the CVC on flushing and for any
increase in pressure of the infusion pumps.

95. LINE OCCLUSION
 Line occulusion may be
caused by number of
factors
1. Fibrin sheath forming
arround the line
2. Thrombosis blocking
the tip
3. Internal blockage of
lipid
4. Salt or drug precipitate

96. PNEUMOTHORAX
 A pneumothorax is air
that is trapped between a
lung and the chest wall.
 Pneumothorax is the
most frequent
complication associated
with subclavin vein
catheter placement
REASON:
 close proximity of the
lung apex to the
subclavain vessels

97. METABOLIC
COMPLICATION
Hyperglycemia
or
hypoglycemia
Cholestas
is
Hyperlipidemia
Hepatic
complication
Refeeding
syndrome

98. HYPERGLYCEMIA
 Hyperglycemia is a higher
than normal level of sugar in
the blood.
Causes
 It can occur when the TPN is
infused too fast or if the body
cannot tolerate the sugar.

99. HYPOGLYCEMIA
Hypoglycemia is a lower than normal level of sugar
in the blood
Causes
 It can be caused by stopping the TPN infusion
abruptly without a “taper down,” or too much
insulin in the TPN bag.
 When the body is receiving a large amount of
sugar, it produces more insulin. When the TPN
infusion stops suddenly, the insulin takes longer to
stop being produced. The result is a drop in the
blood sugar below normal.

100. HYPERLIPIDEMIA
 Hyperlipidemia in patients receiving PN usually
manifests as increased serum triglyceride levels
 Hypertriglyceridemia associated with PN is mainly
the result of
 excessive fat synthesis from dextrose overfeeding,
 excessive lipid infusion, or
 impaired lipid clearance
 In patients receiving PN, several factors cause
reduction in lipid emulsion clearance, including
sepsis, , obesity, diabetes , liver disease , and
medications that alter fat metabolism

101. REFEEDING SYNDROME

102. Hepatic complications
 Include liver
dysfunction, painful
hepatomegaly, and
hyperammonemia.
They can develop at
any age but are most
common among
infants, particularly
premature ones
(whose liver is
immature).

103.  Liver dysfunction may be transient, evidenced
by increased transaminases, bilirubin, and
alkaline phosphatase; it commonly occurs
when TPN is started.
 Delayed or persistent elevations may result
from excess amino acids.
 Pathogenesis is unknown
 but cholestasis and inflammation may
contribute.

104. CHOLESTASIS
 PN-associated
cholelithiasis is the result of
decreased gallbladder
contractility during fasting.
 In the absence of oral
intake or enteral
stimulation, there is
decreased secretion of
cholecystokinin (CCK), a
peptide hormone secreted
by the duodenum in
response to meals to
induce gallbladder
contractility .

105.  Fasting PN patients have been observed to
have a distended gallbladder and absence of
gallbladder contractions, a finding not
observed in enterally fed patients.
 As a result of bile stasis, bile accumulation in
the biliary tract facilitates cholesterol gallstone
formation and calcium bilirubinate precipitation
in the form of sludge.

106. Metabolic Complications
o Other metabolic complications:
Electrolyte imbalance, mineral imbalance,
acid-base imbalance, toxicity of contaminants
of the parenteral solution.

107. Fluid and electrolyte complications
 Electrolyte management is one of the most
difficult aspects of PN therapy. Often
electrolytes are outside of the normal range
based on an underlying cause rather than
directly related to the PN solution

109. HYPERNATREMIA
 Dehydration
 Excess sodium intake
HYPONATREMIA
 Excess Fluid

111. TREATMENT
OF
INFECTION AND
SEPSIS

112. Local infections
 Require removal of the catheter
 Local antiseptic treatment of the exit site
 And in some cases antibiotics

113. Tincture of iodine

114. SYSTEMIC INFECTION
 DIAGNOSIS
 Blood cultures
 from paired peripheral vein blood samples
 and from inside the central catheter
 Another procedure includes rubbing the
catheter tip in bloody agar.

115. TREATMENT
 Catheter removal may be required
 If removal is not consider in patients on long-
term TPN, then the antibiotics were
administered through the contaminated
catheter
 Short course of anti-bacterial and antifungal
therapy (acc. to C&S)

116. PREVENTIVE MEASURES
 Changing the dressing routinely (every 48-72
hours) or when it becomes soiled, wet or
loose.

117. PREVENTIVE MEASURES
 The care-giver should wear a mask and gloves
while changing the dressing

118. Other Preventive Measures
Include:
 Extending the application of antimicrobial solution at
least 1 inch beyond the final dressing.
 Placing a sterile sponge over the catheter, then placing
an occlusive dressing.
 Inspecting the site for tenderness, erythema, edema, or
drainage.
 Changing the TPN intravenous tubing every 48 hours.
 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.

119. FUNGEMIA TREATMENT
 Diagnosis is difficult, as routine blood
cultures have poor sensitivity.
 Treatment involves use of antifungals such as
 Amphocetrin and
 Fluconazole

120. 1. Amphotericin B
 Amphotericin B is a polyene antifungal drug,
often used intravenously for systemic fungal
infections. It was originally extracted
from Streptomyces nodosus
 Dose: 0.25 mg/kg per day IV

121. AMPHOTERICIN B
MECHANISM OF ACTION

122. Adverse effects Of AMPHOTERICIN B
 Fever and chills

123. Adverse effects Of AMPHOTERICIN B
Renal impairement Hypotension

124. 2. Fluconazole
 Triazoles group
 Available both Orally and parentrally
 Treatment and prophylaxis of infections
 Highly effective in treatment of Cryptococcus
infection Cryptococcus neoformans
 Dose:150–300 mg once weekly

125. MECHANISM OF ACTION
 Inhibit an enzyme, reulting in cell membrane
leaking
 Lead to altered cell membrane
 Result fungal death
 The drug is excreted via the kidney, and doses
must be reduced in patients with comprised
renal function

126. MECHANISM OF ACTION

127. VENOUS THROMBOSIS
DIAGNOSIS
 Ultrasound

128. VENOGRAPHY

129. ANTICOAGULANT TREATMENT
 Removal or replacement of the Central vein
catheter
 Patients under long-term TPN will typically
receive a periodic HEPARIN flush to dissolve
such clots before they become dangerous.
 (Maintenance doses of heparin are considered
to be 10 - 25 units/kg per hour)

130. Pulmonary embolism
 DIAGNOSIS
 Ultrasound
 Venography
 TREATMENT
 Anticoagulant Therapy
 Fogarty catheter may occasionally be
successful

131. LINE OCCLUISON TREATMENT
 Thrombolytic therapy with low dose Tissue
plasminogen activator or Urokinase
 After 2-h treatment with 2 mg per 2 mL
recombinant tissue plasminogen activator
(Alteplase), function was restored to 74% in
the alteplase After another dose (2 mg per 2
mL), function was restored in 90% of patients.

132. PNEUMOTHORAX
 DIAGNOSIS: Chest x-ray
 TREATMENT

133. Metabolic Complications
o HYPERGLYCEMIA TREATMENT
o Decrease the amount of infused glucose (to<4
mg/kg/min)
o Insulin can be administered,
was suggested for
serum glucose concentrations
exceeding 200 mg/dL

134. Hypoglycemia Treatment
 In general,patients who are undergoing surgery
while receiving TPN should have the rate of
infusion reduced to 50 ml/h.
 Sudden discontinuation of TPN being
administered at a high rate should be
countered by administering a 10% dextrose
solution in the interim.

135. Hypertriglyceridemia Treatment
 Niacin
Omega3 Fatty acid
Statins

136. Hepatic and biliary dysfunction
 TPN-associated cholestasis occurs more
frequently in infants.
 TREATMENT
 Cycling of TPN
 Avoidance of over-feeding (435 kcal/kg
BW/day),
 Avoidance of high glucose infusion (45 g/kg
BW/day),

137. CHOLECYSTECTOMY
 There is no specific treatment
 For most patients diagnosed with acute
cholecystitis, the definitive treatment is
surgical removal of the gallbladder,
cholecystectomy
 Oral administration of ursodeoxycholic
(Actigall) may improve cholestasis

138. Treatment Of Fluid And Electrolyte
Abnormalities
 Minimized by careful monitoring.
 At least 50 mEq of sodium,
 40mEq of potassium,
 90±100 mEq of phosphorus,
 and 28±32 mEq of magnesium and calcium
 should be administered daily to all patients
receiving parenteral nutrition

139. HYPERNATREMIA
 TREATMENT
 Replace fluid deficit
 Check for excess sodium intake

140. HYPONATREMIA
 TREATMENT
 Decrease fluid intake
 Check for causes of fluid retention
 Check for causes of sodium loss
 Administer sodium if patient at risk for seizures

141. REFEEDING SYNDROM
 TREATMENT
 Correct electrolyte abnormalities
 Administer volume and energy slowly
 Monitor pulse, electrolytes closely
 Provide appropriate vitamin supplementation
 Avoid overfeeding
 Parentral phosphate administration( eg
18mmoldl)
 MILK

142. REFEEDING SYNDROM
 On average, patients should receive 2-4
mmol/kg/day potassium, 0.3-0.6 mmol/kg/day
phosphate, and 0.2 mmol/kg/day intravenous
or 0.4 mmol/kg/day oral magnesium
 For Gastrointestinal disturbance during
refeeding, domperidone or metoclopramide
 As well as acid suppressants such as
omeprazole

143. CASE HISTORY

144. CASE
 A 64- year- old women
 Recovering slowly from major abdominal
surgery
 Fed by total parenteral nutrition (TPN)
 Ten days into her course of TPN she develops
a high fever and rigors
 Antibiotics are commenced
 But after 48 hours there is no response
 Blood cultures have remained negative

145. CASE (cont.)
 Fungal infection is suspected
 Fluconazole is commenced
 Likely fungal cause would be candida albicans
or a related species
 And because amphotericin was not felt to be
suitable for a frail patient with compromised
renal function
 The temperature coming down a little
 She continue to feel unwell

146. CASE (cont.)
 The cannula is then removed
 The patient’s fever returns to normal within 24
hours
 She feels much better.
 What might have happened????

147. ANSWER
 Colonized cannula
 Blood culture negative, cannula tip grew
nothing
 Because there is the possibility that this was
an infection with flucazole-resistant strain of
candida
 Malassezia furfur didnot grow on conventional
culture media; it has growth requirement for
fatty acids which are not present in routine lab
media

148. Detection Of Malassezia furfur

151. HEALTH IS WEALTH
&
STAY BLESSED