کارگاه آموزشی تغذیه در آی سی یو – بخش سوختگی تغذیه پارنترال در آی سی یو سوختگی ارائه دهنده: ندا دهناد كارشناس تغذیه بالینی معاونت درمان دانشگاه علوم پزشکی قزوین 94/6/3 بر اساس اسلایدهای ارائه شده در کارگاه سوختگی وزارت متبوع

Parenteral Nutrition

Formulations Amino acids Dextrose Lipids Electrolytes Trace elements Vitamins

formulations 3 in 1 formulations (TNA): formulations that include intravenous fat emulsions (IVFE) 2 in 1 formulations are PN formulations that do not include IVFE.

Calculating 1- Calculation of volume 2- Calculation of total calorie 3- Calculation of protein & fat 4- Calculation of CHO

Dosing of fluid 30-40 CC/kg

Energy Needs Catabolic Phase IRETON-JONES EQUATION Simple Formula Anabolic Phase Toronto Formula

Energy Needs Never more than two times of BMR

Energy Needs Amino acids Dextrose Fat

Dextrose 5% to 70%

Dosing of CHO Up to 4 mg/kg/min in catabolic phase At least 100 g daily or 400 kcal daily Up to 7 mg/kg/min in anabolic phase 1g hydrated dextrose = 3.4 kcal >10% in TPN

Amino Acid Solutions are 3%, 4.5%, 5.5%, 8%, 10%,15%, 20% 15%, 20%= high protein 1g = 4 kcal

In Iran Aminoven 5, 10% Aminoplasmal 5, 10%

LIPIDS 10% 20% 30%

Dosing of Fat Monitor TG Contraindicated in TG> 400 Contraindicated in obese patients Infusion rate< 1 kcal/kg/h

In Iran Lipoven 10% Lipofundin 10% Lipofundin 20% SMOFlipid 20 %

Essential Fatty Acid Deficiency (EFAD) EFAD in adults after 20 days Children after 7-10 days Neonates after 2 days

Essential Fatty Acid Deficiency (EFAD) Alterations in platelet function Hair Loss poor wound healing Dry, scaly skin unresponsive to water miscible creams.

Electrolytes

Electrolytes Electrolytes, are generally added to the parenteral solution. Individualized Particular attention to Ca & P for formation of a precipitate

Electrolytes

Trace element formulations

Trace element formulations

In Iran Addamel Tracutil

Addamel N Contains: Iron Zinc Manganese Copper Chromium Sodium molybdate Sodium selenite Sodium fluoride Potassium iodide

Tracutil Contains: Iron Zinc Manganese Copper Chromium Sodium molybdate Sodium selenite Sodium fluoride Potassium iodide

Vitamins All patients receiving PN should receive a parenteral vitamin preparation on a daily basis. With & without vit K

Vitamins

Soluvit N Vitamin B1 2.5 mg Vitamin B2 3.6 mg Nicotinamide 40 mg Pantothenic acid 15.0 mg Vitamin C 100 mg Biotin 60 μg Folic acid 0.4 mg Cyanocobalamin 5.0 μg

In Iran Soluvit Daily Amp Folic Acid (5 mg) Weekly Amp Vit C (500mg) BD Amp Vit K (1 mg) Weekly Amp Vit A (50000 unit) Weekly Amp Vit D …

OR Amp B.Complex Daily Amp B12 (100 µg) Weekly Amp Folic Acid (5 mg) Weekly Amp Vit C (500mg) BD Amp Vit K (1 mg) Weekly Amp Vit A (50000 unit) Weekly Amp Vit D …

Glutamine 0.3‐0.5 g/kg/d

Important tips Beginning in low dose & gradually increase to goal Change tubing after each infusion Hang fat emulsion higher than other fluids (has low specific gravity and could run up into other lines) Infuse via pump using either peripheral or central venous line

Important tips Continuous or cyclic infusion for 12- 24 h with tapering up & tapering down period for prevention of hyperglycemia & hypoglycemia. The usual method used to cycle PN is to substract 4 hours each day from the administration time until the desired cycle length is achived without hyperglycemia or other complications.

CONTRAINDICATIONS Lipid-containing formulations: Hypersensitivity Severe egg allergy Severe soybean allergy Hyperlipidemia Severe liver damage Acute myocardial infarction Shock

CONTRAINDICATIONS Dextrose : Hypersensitivity to corn or corn products Hypertonic solutions in patients with intracranial or intraspinal hemorrhage

CONTRAINDICATIONS Amino acids : Hypersensitivity to one or more amino acids

MONITORING PARAMETERS Electrolytes: Na, K, chloride, and bicarbonate should be monitored frequently upon initiation and until stable; P: should be monitored closely in patients with pulmonary disease. Efficacy: Nutrition and outcome parameters should be measured serially.

MONITORING PARAMETERS Glucose: In diabetics or patients with glucose intolerance risk factors, monitor closely. Monitor frequently upon initiation of therapy and with any changes in insulin dose or renal function. Line site: Monitor for signs and symptoms of infection.

MONITORING PARAMETERS Liver function tests: Monitor periodically. Triglycerides: Before initiation of lipid therapy and at least weekly during therapy.

MONITORING PARAMETERS Bone densitometry: Perform upon initiation of long-term therapy. Vitamin A status: Should be carefully monitored in patients with chronic renal failure.

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