2. DEFINITIONDEFINITION
Intravenous administration of calories,Intravenous administration of calories,
nitrogen and other nutrients in sufficientnitrogen and other nutrients in sufficient
quantities to achieve tissue synthesis andquantities to achieve tissue synthesis and
anabolism is calledanabolism is called Parenteral NutritionParenteral Nutrition..
3. HISTORYHISTORY
Willium harvey’sWillium harvey’s elucidation of the humanelucidation of the human
circulationcirculation
Arvid Wretlind & collegueArvid Wretlind & collegue (1961) – prepared fat(1961) – prepared fat
emulsionemulsion
Stanley Dudrick & Jonathan RhoadsStanley Dudrick & Jonathan Rhoads (1968) –(1968) –
develop TPNdevelop TPN
Solassol & JoyeuxSolassol & Joyeux (1976) – developed 3-in-1Bag(1976) – developed 3-in-1Bag
PN solutionPN solution
Shills & JeejeebhoyShills & Jeejeebhoy (1978) – developed HOME(1978) – developed HOME
PNPN
4. INTRODUCTIONINTRODUCTION
PNPN uses the vascular system to provide vitaluses the vascular system to provide vital
nutritional support to malnourished patients & itnutritional support to malnourished patients & it
supplies the nutrients in their elemental formssupplies the nutrients in their elemental forms
(carbohydrate, lipids, aminoacids, trace(carbohydrate, lipids, aminoacids, trace
elements & vitamins)elements & vitamins)
Two TypesTwo Types
1.1. TPNTPN – Total Parentral Nutrition– Total Parentral Nutrition
2.2. PPNPPN – Partial Parentral Nutrition– Partial Parentral Nutrition
Can be administered by two routesCan be administered by two routes
1.1. Large central veinLarge central vein (Central PN)(Central PN)
2.2. Peripheral veinPeripheral vein (Peripheral PN)(Peripheral PN)
5. When PN is required?When PN is required?
PPN is used to prevent or reduce theN is used to prevent or reduce the
adverse effects of malnutrition.adverse effects of malnutrition.
AAnd is used when entral nutrition (EN) isnd is used when entral nutrition (EN) is
unsafe or ineffective and this condition isunsafe or ineffective and this condition is
anticipated to last for 7 – 10 days.anticipated to last for 7 – 10 days.
6. INDICATIONS FOR PNINDICATIONS FOR PN
Extreme short bowel syndromeExtreme short bowel syndrome
Structural – resectionStructural – resection
Functional – Severe inflammationFunctional – Severe inflammation
Bowel RestBowel Rest -- Enterocutaneous fistula (Enterocutaneous fistula (high outputhigh output))
- Anastomotic leak- Anastomotic leak
Paralytic ileusParalytic ileus –– Major abdominal surgeryMajor abdominal surgery
-- Major abdominal traumaMajor abdominal trauma
Intestinal ObstructionIntestinal Obstruction –– Cancer, AdhesionsCancer, Adhesions
7. INDICATIONS OF PN CONTD….INDICATIONS OF PN CONTD….
PPreoperatively only in patients with severereoperatively only in patients with severe
malnutritionmalnutrition
MMulti-organ failure with sepsisulti-organ failure with sepsis
OOthersthers
Severe mucositis/oesophagitis/radiation entritisSevere mucositis/oesophagitis/radiation entritis
Inflammatory bowel disease with severeInflammatory bowel disease with severe
malnutritionmalnutrition
Intestinal Atresia /Motility disordersIntestinal Atresia /Motility disorders
Intractable vomitingIntractable vomiting (CT, Hyperemesis G.)(CT, Hyperemesis G.)
8. CONTRADICATIONS FOR PNCONTRADICATIONS FOR PN
CContradications for central lineontradications for central line (coagulopathies)(coagulopathies)
HHemodynamically unstable patientemodynamically unstable patient
PPulmonary edema/Fluid overloadulmonary edema/Fluid overload
AAnuria without dialysisnuria without dialysis
SSevere metabolic/electrolyte disturbencesevere metabolic/electrolyte disturbences
AAdvance cancer or terminal illnessdvance cancer or terminal illness
9. MERITS OF PNMERITS OF PN
Turns the catabolic state of patient intoTurns the catabolic state of patient into AnabolicAnabolic
statestate
ProvidesProvides rest to bowelrest to bowel ( in anastomosis / leaks)( in anastomosis / leaks)
PreventsPrevents wasting of muscleswasting of muscles
ImproveImprove healing of woundshealing of wounds
10. Assesment for MalnutritionAssesment for Malnutrition
BY HISTORYBY HISTORY
Weight lossWeight loss >10% of body weight>10% of body weight
Decresed food intakeDecresed food intake
G.I. SymptomsG.I. Symptoms
- Anorexia- Anorexia
- Dysphagia- Dysphagia
- Nasuea /Vomiting- Nasuea /Vomiting
- Chronic Diarrhoea- Chronic Diarrhoea
- Abdominal Pain- Abdominal Pain
11. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
BY PHYSICAL FINDINGSBY PHYSICAL FINDINGS
WeightWeight <90% of ideal wt.<90% of ideal wt.
AnthropometryAnthropometry (mid-arm circumference in cm.)(mid-arm circumference in cm.)
Loss of subcutaneous fatLoss of subcutaneous fat (skinfold thickness)(skinfold thickness)
Skin rashes/ occular changesSkin rashes/ occular changes
Mucus membrane changesMucus membrane changes for deficiency offor deficiency of
Neurological changesNeurological changes particular nutrientparticular nutrient
12. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
BY LABORATORYBY LABORATORY
SSerum Albumin <30g/Lerum Albumin <30g/L
TTotal lymphocyte Count <1800/cu mmotal lymphocyte Count <1800/cu mm
SSkin Test Reactivity (to asses immunekin Test Reactivity (to asses immune
system)system)
S.S. levels of vitamin A, D, Elevels of vitamin A, D, E
P.P. levels of iron/folic acidlevels of iron/folic acid
S.S. levels of Zn, Mg, Phosphoruslevels of Zn, Mg, Phosphorus
13. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
BY SPECIAL PROCEDURESBY SPECIAL PROCEDURES
1. Bioelectric Impedence Analysis (BIA)1. Bioelectric Impedence Analysis (BIA)
for measurement of – Body Fatfor measurement of – Body Fat
- FFM (Fat Free Mass)- FFM (Fat Free Mass)
- Total Body Water- Total Body Water
Lean Body MassLean Body Mass = Body wt. – Fat Mass= Body wt. – Fat Mass
= Total Body Water / 0.73= Total Body Water / 0.73
14. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
BY SPECIAL PROCEDUREBY SPECIAL PROCEDURE
2. Indirect Calorimetry2. Indirect Calorimetry – To measure REE– To measure REE
Harris & Benedicts FormulaHarris & Benedicts Formula
REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) -REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) -
6.7(Age in Yr) K cal / day6.7(Age in Yr) K cal / day
REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)
- 4.7 (Age in Yrs) K cal / day- 4.7 (Age in Yrs) K cal / day
TEE = REE + Stress Factor + Activity FactorTEE = REE + Stress Factor + Activity Factor
REE is 60% of TEEREE is 60% of TEE
Schofield equationSchofield equation – 25 to 30 K cal / Kg / day– 25 to 30 K cal / Kg / day
17. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
SPECIAL PROCEDURE….SPECIAL PROCEDURE….
2.2. Nitrogen balanceNitrogen balance = N input – N output= N input – N output
1 Gm N = 6.25 Gm Protien1 Gm N = 6.25 Gm Protien
N input = Protien in Gm x 6.25N input = Protien in Gm x 6.25
N output = 24 hr. Urinary Urea Nitrogen +N output = 24 hr. Urinary Urea Nitrogen +
Non-urinary N lossesNon-urinary N losses
(estimated non-urinary N losses ~ 3 - 4 Gm/day)(estimated non-urinary N losses ~ 3 - 4 Gm/day)
Aim of Positive N balance =Aim of Positive N balance = 1.5 – 2 G/Kg/day1.5 – 2 G/Kg/day
18. BEFORE STARTING PNBEFORE STARTING PN
CBCCBC
LFTLFT
RFTRFT
Serum Electrolytes (Na, K, Cl, Ca, Mg)Serum Electrolytes (Na, K, Cl, Ca, Mg)
PT & PTTPT & PTT
Lipid ProfileLipid Profile
19. BEFORE STARTING PN contd…BEFORE STARTING PN contd…
CALCULATION OF REQUIREMENTCALCULATION OF REQUIREMENT
A.A. Fluid RequirementFluid Requirement
Basic Need = 1500 + 20 ml/Kg body wt.Basic Need = 1500 + 20 ml/Kg body wt.
((If Wt. is >20 Kg)If Wt. is >20 Kg)
Total Need = Basic Need + LossesTotal Need = Basic Need + Losses
Losses like – Nasogastric aspirationLosses like – Nasogastric aspiration
- Vomit volume- Vomit volume
- Drain output- Drain output
- Fistula output- Fistula output
20. BEFORE STARTING PN contd…BEFORE STARTING PN contd…
CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
B.B. Protien RequirementProtien Requirement
Normal = 1.0 – 1.2 Gm / Kg / dayNormal = 1.0 – 1.2 Gm / Kg / day
In catabolic state = 2 Gm / Kg / dayIn catabolic state = 2 Gm / Kg / day
Catabolic states – PolytraumaCatabolic states – Polytrauma
- Severe Burns- Severe Burns
- Pt. taking Renal Replacement- Pt. taking Renal Replacement
therapytherapy
TPN contains Aminoacids in 3 – 15% concentrationTPN contains Aminoacids in 3 – 15% concentration
21. BEFORE STARTING PN contd…BEFORE STARTING PN contd…
CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
C.C. Energy RequirementEnergy Requirement
Normal = 25 – 30 K cal / Kg / dayNormal = 25 – 30 K cal / Kg / day
((Should be provided by non-protein calories i.e.Should be provided by non-protein calories i.e.
calculate it from carbohydrate & lipids only, tocalculate it from carbohydrate & lipids only, to
minimize nitrogen consumption)minimize nitrogen consumption)
Carbohydrate & lipid Ratio ~Carbohydrate & lipid Ratio ~ 70 : 3070 : 30
22. Contd….Contd….
CARBOHYDRATESCARBOHYDRATES
Commercial Dextrose – 5%, 25%, and 70% Conc.Commercial Dextrose – 5%, 25%, and 70% Conc.
TPN Dextrose - 50% to 70% Conc.TPN Dextrose - 50% to 70% Conc.
1 Gm Dextrose = 3.4 K cal.1 Gm Dextrose = 3.4 K cal.
Rate of infusion ~ < 5 – 7 mg / Kg / min.Rate of infusion ~ < 5 – 7 mg / Kg / min.
LIPIDSLIPIDS In 10% - 20% ConcentrationIn 10% - 20% Concentration
Infusion rate < 0.7 K cal / Kg / hr.Infusion rate < 0.7 K cal / Kg / hr.
10 – 15 ml / min for 20% sol.10 – 15 ml / min for 20% sol.
MULTIVITAMINMULTIVITAMIN – Given 1 amp / day i.v.– Given 1 amp / day i.v.
Vit. K 1 amp / day i.m.Vit. K 1 amp / day i.m.
ELECTROLYTEELECTROLYTE – Acc. to their serum levels– Acc. to their serum levels
24. BEFORE GIVING PNBEFORE GIVING PN
VENOUS ACCESSVENOUS ACCESS
1.1. Central VeinCentral Vein – Large Bore, High Flow– Large Bore, High Flow
- Preferred for TPN- Preferred for TPN
- For long term use- For long term use
(e.g. Subclavian /Int. jugular /Basilic /femoral)(e.g. Subclavian /Int. jugular /Basilic /femoral)
2.2. Peripheral VeinPeripheral Vein – For short term use– For short term use
- When central vein- When central vein
contraindicatedcontraindicated
Verify the tip of cannula by X ray before PNVerify the tip of cannula by X ray before PN
25. CATHETERSCATHETERS
FORFOR
Central Vein CannulationCentral Vein Cannulation – Single Lumen– Single Lumen
- Double Lumen- Double Lumen
- Multiple Lumen- Multiple Lumen
In Poly- Lumen CathetersIn Poly- Lumen Catheters
Medial/Proximal Lumen – PN infusionMedial/Proximal Lumen – PN infusion
Lateral/Distal Lumen - Other UsesLateral/Distal Lumen - Other Uses
27. INFUSION OF PNINFUSION OF PN
BY TWO WAYSBY TWO WAYS
ContinuousContinuous – For Short Term– For Short Term
- When Rapid Infusion Intolerable- When Rapid Infusion Intolerable
CyclicallyCyclically – When Used For Long Term– When Used For Long Term
- When Rapid Infusion Tolerable- When Rapid Infusion Tolerable
- Continuous administration for 8 – 12- Continuous administration for 8 – 12
hrs and then rest for next 12 hrshrs and then rest for next 12 hrs
- Freedom during day- Freedom during day
Use 3-in-1 TPN or 2-in1 PN with DextroseUse 3-in-1 TPN or 2-in1 PN with Dextrose
or AA/Lipid/Dextrose seperatelyor AA/Lipid/Dextrose seperately
31. Adverse Events To Be WatchedAdverse Events To Be Watched
2+ Glucose in Urine2+ Glucose in Urine
Mod. Ketones in UrineMod. Ketones in Urine
Persistent thirst/Excessive U.O.Persistent thirst/Excessive U.O.
Level of ConsciousnessLevel of Consciousness
HypoglycemiaHypoglycemia
Chills/Rigor/FeverChills/Rigor/Fever
Signs of PhlebitisSigns of Phlebitis
Skin rashesSkin rashes
Hyperventilation / HypotensionHyperventilation / Hypotension
32. Side Effects of LipidsSide Effects of Lipids
Back & Chest PainBack & Chest Pain
DiaphoresisDiaphoresis
Fever/Flushing/Chills/RigorFever/Flushing/Chills/Rigor
Nausea/VomitingNausea/Vomiting
UrticariaUrticaria
Shortness of BreathShortness of Breath
33. Care Of CVAD LineCare Of CVAD Line
EExamine the site for signs of infectionxamine the site for signs of infection
AAlt. day change the catheter dressinglt. day change the catheter dressing
PPeriodically check line for blockageeriodically check line for blockage
TTubes should be changed dailyubes should be changed daily
DDedicate one lumen for PN onlyedicate one lumen for PN only
AAvoid accidents like – Pullingvoid accidents like – Pulling
AAllow only one trained person to handlellow only one trained person to handle
34. Piggybacking of PNPiggybacking of PN
Should be freshly prepared.Should be freshly prepared.
Start slowly atStart slowly at 50ml/hr50ml/hr on day 1on day 1stst
..
Volume must not exceedVolume must not exceed 1000ml1000ml on day 1on day 1stst
..
From 2From 2ndnd
day volume should be increased byday volume should be increased by
1 lit./day1 lit./day
until goal reached.until goal reached.
Rate of infusion most not exceedRate of infusion most not exceed 125ml/hr125ml/hr..
35. Tapering of PNTapering of PN
Taper the infusion rate to half for 20 min.Taper the infusion rate to half for 20 min.
& again half the rate for other 20 min.& again half the rate for other 20 min.
Flush the line with 10-15 ml NS.Flush the line with 10-15 ml NS.
Flush the line withFlush the line with heparin lockheparin lock..
Clamp the line.Clamp the line.
Infuse 10% Dextrose at the same rate forInfuse 10% Dextrose at the same rate for
1 hr. through other line.1 hr. through other line.
Restart PN next day with aseptic tech…Restart PN next day with aseptic tech…
36. COMPLICATIONS OF PNCOMPLICATIONS OF PN
CATHETER RELATEDCATHETER RELATED
PneumothoraxPneumothorax
Air EmbolismAir Embolism
Venous ThrombosisVenous Thrombosis
Catheter OcclusionCatheter Occlusion
Catheter SepsisCatheter Sepsis
Catheter EmbolismCatheter Embolism
38. COMPLICATIONS contd…COMPLICATIONS contd…
GASTRO-INTESTINALGASTRO-INTESTINAL
FATTY LIVERFATTY LIVER
CHOLESTASISCHOLESTASIS
INTESTINAL MUCOSAL ATROPHYINTESTINAL MUCOSAL ATROPHY
To Avoid – Early use of GITTo Avoid – Early use of GIT
39. HOME PNHOME PN
Required in those who needs PN for long termRequired in those who needs PN for long term
IndicationsIndications – Short Bowel syndrome– Short Bowel syndrome
- Bowel Rest- Bowel Rest
- Severe Malnutrition- Severe Malnutrition
Patient SelectionPatient Selection
Clinically & Psychologically soundClinically & Psychologically sound
Family SupportFamily Support
Adequate FinanceAdequate Finance
40. TPN in Various illnessTPN in Various illness
ACUTE RENAL FAILUREACUTE RENAL FAILURE
Avoid- High Protein DietAvoid- High Protein Diet
Avoid NS / RLAvoid NS / RL
Restrict FluidRestrict Fluid
Protein RequirementProtein Requirement
Predialysis – LowPredialysis – Low (0.6-0.8 Gm/kg/day)(0.6-0.8 Gm/kg/day)
Dialysis - StandardDialysis - Standard (1- 1.2 Gm/Kg/day)(1- 1.2 Gm/Kg/day)
41. TPN in Various illness contd..TPN in Various illness contd..
BURNSBURNS
Resuscitation Phase (1Resuscitation Phase (1stst
24 – 48 hr.)24 – 48 hr.)
- Fluids with Crystalloids- Fluids with Crystalloids
Energy RequirementEnergy Requirement
- 25 Kcal/Kg/day + 20Kcal/ % of BSA- 25 Kcal/Kg/day + 20Kcal/ % of BSA
- Proteins – 2 Gm/Kg/day- Proteins – 2 Gm/Kg/day
42. TPN in Various illness contd…TPN in Various illness contd…
HEPATIC DISEASEHEPATIC DISEASE
High Caloric IntakeHigh Caloric Intake – 35 Kcal / Kg / day– 35 Kcal / Kg / day
Encephalopathy PresentEncephalopathy Present – Proteins 0.6 Gm/Kg/day– Proteins 0.6 Gm/Kg/day
Avoid Aromatic AAAvoid Aromatic AA
Use Branched Chain AAUse Branched Chain AA
Encephalopathy AbsentEncephalopathy Absent - Proteins 1- 1.2 Gm/Kg/day- Proteins 1- 1.2 Gm/Kg/day
Edema / Asicitis PresentEdema / Asicitis Present – Restrict Na– Restrict Na
43. TPN in Various illness contd…TPN in Various illness contd…
RESPIRATORY FAILURERESPIRATORY FAILURE
Calories 20 – 30 Kcal / Kg / dayCalories 20 – 30 Kcal / Kg / day
Give 30 to 35 % calorie as FATGive 30 to 35 % calorie as FAT
Avoid CARBOHYDRATESAvoid CARBOHYDRATES
Proteins 1 – 2 Gm / Kg / dayProteins 1 – 2 Gm / Kg / day
44. IMMUNONUTRITIONIMMUNONUTRITION
GLUTAMINEGLUTAMINE
–– Semi essential AASemi essential AA
- Improve Immune Functions- Improve Immune Functions
- Restore Protein Stores- Restore Protein Stores
ENTERAL GLUTAMINEENTERAL GLUTAMINE
- Increase Intestinal Mucosal Height- Increase Intestinal Mucosal Height
- Increase Enterocyte Protein Contents- Increase Enterocyte Protein Contents
45. Newer AgentsNewer Agents
Anabolic Androgen TherapyAnabolic Androgen Therapy
Increase the Muscle MassIncrease the Muscle Mass
Megestral AcetateMegestral Acetate – Appetite Stimulant– Appetite Stimulant
Growth HormonesGrowth Hormones
Increase the Muscle MassIncrease the Muscle Mass
Increase Visceral Protein StatusIncrease Visceral Protein Status
46. Enteral Vs ParentralEnteral Vs Parentral
CheaperCheaper
Maintain IntestinalMaintain Intestinal
MucosaMucosa
Easy to AdministerEasy to Administer
Less ComplicationsLess Complications
CostlyCostly
Causes IntestinalCauses Intestinal
AtrophyAtrophy
Require ProfessionalRequire Professional
More ComplicationsMore Complications
47. CONCLUSIONCONCLUSION
TPNTPN is life-saving tool &is life-saving tool &
should be given whenshould be given when
indicated. If conditionsindicated. If conditions
allow, switch the patientallow, switch the patient
over theover the Enteral NutritionEnteral Nutrition
as early as possible.as early as possible.