Parenteral Nutrition (PN)

Approach to specialize Nutritional Support Nutritional Assessment Maintenance Repletion GI Tract Functional YES NO Enteral Nutrition Parenteral Nutrition

Definition nutrients directly into bloodstream intravenously. Parenteral nutrition is provision of nutrients directly into bloodstream intravenously.

PN Indications

Indications Inadequate enteral nutrition > 7-10 d Unavailable GIT, bowel rest: Intestinal obstruction Fistulas Hyper emesis/intractable vomiting Ileus Sepsis Inflammatory bowel disease Short bowel syndrome Hepatic disease Pancreatitis

Indications (cont) Acquired immune deficiency syndrome (AIDS) Respiratory failure Eating disorders severe malnutrition/ preoperative nutrition rehabilitation

PN Contraindications

Contraindications Functional GIT Nutrition support < 7 d Risks PN>benefits

Contraindications (cont) Aggressive nutrition support contraindicated   - not desired by patient - terminal illness, prognosis poor

Type of PN

Two main forms of PN Peripheral Parenteral Nutrition (PPN) Central Parenteral Nutrition (CPN)

Another Classification of PN Partially parenteral nutrition (PPN) Total parenteral noutrition (TPN)

Peripheral Parenteral Nutrition (PPN)

PPN Given through peripheral vein

PPN (cont 1) Short term use (14> day) Mildly stressed patients Low caloric requirements Needs large amounts of fluid

PPN (cont 2) Addition of heparin & hydrocortisone improve tolerance to PPN Osmolarity of PPN solution be limited to 900 mosm/l

Central Parenteral Nutrition (CPN)

CPN Long term use (>14 day) High caloric requirements Solution with greater osmolarity (>900 mosmol/l) may be administered via CPN

Venous Access for CPN Need venous access to a “large” central line with fast flow to avoid thrombophlebitis Long peripheral line subclavian approach internal jugular approach external jugular approach Superior Vena Cava

Type of central venous access in CPN

Type of central venous access Tunneled Catheter (TC): Placed in operating room Enter the vein on the upper chest wall & are tunneled away from the vein to an exit site With proper care can be left for several years TC available in single, double or triple lumen

TC

Type of central venous access (cont 1) 2) Implanted ports (IP) Similar to TC in that must be placed in operating room Suitable for long term access Unlike TC lie completely under skin Be accepted well by patient

Type of central venous access (cont 2) They are usually placed just below the clavicle on the chest wall Nursing intervention may be required to change needles used to gain access to these port

Type of central venous access (cont 3) 3) Short Term Access (STA): Is provided via a central catheter inserted percutaneously at bedside under local anesthesia These catheter available in single or multiple lumen Usually change every 5 days

Type of central venous access (cont 4) 4) Peripherally Inserted Central Catheter (PICC) PICC is a thin, flexible tube inserted into a vein near the bend of the elbow. The PICC is used to get samples of your blood. You can also get fluids, medicines and nutrients through it.

PICC

PICC (2)

Comparison between CPN & PPN

Differences between PPN & CPN Total amount delivered Osmolarity Duration Speed of delivery The total amount delivered is depend on the concentration and osmolarity of the fluids infused.

Advantage & disadvantages of CPN/PPN Disadv - central ++ Risk infection Invasive + Nursing care time More expensive More complications Needs more technical expertise Adv - central Hypertonic solution Meets nutrition requirements Long term use

Advantage & disadvantages of CPN/PPN (cont) Adv - peripheral Non-invasive Peripheral vein – risk infection Disadv – peripheral High volume of high mOsm/L to meet need short term use

Steps to ordering TPN

Steps to ordering TPN Determine Total Fluid Volume Determine Non-N Caloric needs Decide how much fat & carbohydrate to give Determine Protein requirements Determine vitamins, Electrolyte and Trace element requirements Determine need for additives

How much volume to give? Cater for maintenance & on going losses Normal maintenance requirements By body weight 25-55 year 35 cc/kg 56-65 year 30 cc/kg Add on going losses based on I/O chart Consider insensible fluid losses also add 13% for every oC rise in temperature

Based on Total Energy Expenditure Caloric requirements Based on Total Energy Expenditure Can be estimated using predictive equations TEE = BEE × Stress Factor × Activity Factor

Caloric requirements (cont1) Stress Factor Malnutrition 1.3 peritonitis 1.15 soft tissue trauma 1.15 fracture 1.2 fever (per oC rise) 1.13 Moderate infection 1.2 Severe infection 1.4 <20% BSA Burns 1.5 20-40% BSA Burns 1.8 >40% BSA Burns 2

Caloric requirements (cont2) Activity Factor Bedridden 1.2 Ambulant 1.3 Active 1.5

Caloric requirements (cont3) BEE Predictive equation 1) Harris-Benedict Equation: Males: BEE = 66.47 + (13.75×Wt) + (5×H) – (6.76×A) Females: BEE = 655.1 + (9.56×Wt) + (1.85×H) – (4.68×A) 2) Schofield Equation: 25 to 30 kcal/kg/day

Caloric requirements (cont4) Activity (Stress) Weight Low Moderate Severe Decrease 15 kcal/kg 20 kcal/kg 25 kcal/kg Maintenance 30 kcal/kg Increase 35 kcal/kg

How much CHO? CHO usually form 50-75 % of calories Commercial CHO consist anhydrous dextrose monohydrate in sterile water These are available in concentration ranging 5% to 70% & contain 3.4 kcal/g of dextrose Not more than 5 mg / kg / min Dextrose (less than 7 g / kg / day)

How much Fat? 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 s

How much Fat? (cont) Three concentration 10%, 20% & 30% are available Lipid emulsion 10% have 1.1 kcal/ml, 20% have 2 kcal/ml & 30% have 3 kcal/ml Not more than 50 cc/hr Lipid (less than 1 g / kg / day)

How much protein to give? Based on non pro calorie / nitrogen ratio Based on degree of stress & body weight (BW) Based on Nitrogen Balance (NB)

Non pro calorie / Nitrogen Ratio Normal ratio is 150-300 kcal : 1g Nitrogen Critically ill patients 85 to 100 kcal : 1 g Nitrogen

Based on Stress & BW Non-stress patients 0.8 to 1 g / kg / day Mild stress 1.25 g / kg / day Moderate stress 1.5 g / kg / day Severe stress 1.75 to 2 g / kg / day

Nutritional Balance NB = N input - N output 1 g N= 6.25 g protein N input = (protein in g / 6.25) N output = 24h urinary urea nitrogen + non-urinary N losses (estimated normal non-urinary Nitrogen losses about 3-4 g/d)

Electrolyte Requirements Cater for maintenance + replacement needs Na 1 to 2 meq/kg/d K+ 1 to 2 meq/kg/d Mg++ 0.35 to 0.45 meq/kg/d Ca++ 0.2 to 0.3 meq/kg/d PO42- 20 to 30 mmol/d

Trace Elements Requirements Zn 2.5-5 mg/day Cr 10-15 mg/day Cu 0.3 to 0.5 mg/day Mn 0.15 to 0.8 mg/day

Standard electrolytes solution Na 35 meq/L K 28.8 meq/L Ca 5 meq/L Phos 4.5 mmol/L Cl 35 meq/L Acetate 29.5 meq/L

Standard trace elements solution MTE-6 per cc have: Zn 1 mg Cu 0.4 mg Mn 0.1 mg Cr 4 mcg Se 20 mcg I 25 mcg

PN Vitamins Give 1 ampoule MultiVit per bag of TPN MultiVit does not include vit K Vit K Can give 1 mg/day or 5 - 10 mg/wk most institutes have a standard vitamin/mineral solution but can also order special formulations based on biochemical assessment and special needs

Vitamins Requirements Vitamin A 3300 IU Vitamin D 200 IU Vitamin E 10 IU Ascorbic acid 100 mg Folacin 400 µg Niacin 40 mg

Vitamins Requirements (cont 1) Riboflavin 3.6 mg Thiamine 3 mg B6 ( pyridoxine) 4 mg B12( cyanocobalamin) 5 µg Pantothenic acid 15 mg Biotin 60 µg

Standard vitamins solution MVI-2 include 2 ampoule Ampoule 1 per cc have: Vit A 660 IU Vit E 2 IU Vit B2 0.72 mg Vit B6 0.8 mg Vit C 20 mg Vit D 40 IU Vit B1 0.6 mg

Standard vitamins solution (cont) Vit B3 8 mg Vit B5 3 mg Ampoule 2 per cc have: Vit B9 80 µg Vit B12 1 µg Vit B8 12 µg Prescribed dose MVI-12: 10 CC/L

Medications can added to TPN Insulin alternate regimes 0.1 u per g dextrose in TPN 10 u per litre TPN initial dose Heparin often added to reduce complication of catheter occlusion Be added 1000 unit per lit

Medications can added to TPN (cont) H2-blockers: Famottidine: 20- 40 mg Ranitidine hydrochloride Cimitidine: 5g Albumin Aminophylline Steroids

Parenteral Nutrition Solutions

Parenteral Nutrition Solutions Every institute has its own standard solutions for both peripheral and central nutrition amino acids (crystalline and variable amounts) dextrose solutions (hydrous glucose) combined amino acid dextrose solutions lipid emulsions (10 and 20 % ) vitamin/mineral solutions electrolytes (amount to add in mmol)

Parenteral Nutrition Solutions Guidelines for amounts of each to provide: Protein: 15 - 20% of kcal Lipids: ~30% of kcal CHO: 50-75% of kcal Electrolytes, vitamins, trace elements: lower than DRI Fluid: 1.5 - 2.5 liters total Kcal: N ration: 125 kcal:1 gm N

Parenteral Nutrition Solutions Prepared aseptically & delivered 2 ways: “3 in 1” method: pro, fat, CHO in one bag and 1 pump is used to infuse solution “2 in 1” methodok: pro & CHO in 1 bag & lipid in glass bottle; solutions enter vein together Given continuously or cyclic (8-12 hrs/day)

Osmolarity of solution Calculated by adding the osmolarity of the solutions to be infused Estimation: Grams of dextrose × 5 ( per L) Grams of AA × 10 ( per L) electrolytes, vitamins, minerals add 300- 400 mOsm/L IV fat is isotonic

Example solution of 500 ml 50% dextrose and 500 ml 8.5% AA plus electrolytes, min and vitamins has osmolarity of: (50 × 5 × 5) + (8.5 × 5 × 10) + (300 to 400) = 1975 to 2075 mOsm/L

Available solution sample

Available solution sample DEXTROSE-SALINE DEXTROSE RINGER AMINO PLASMA ELECTROLITES

DEXTROSE-SALINE

DEXTROSE-SALINE (cont1)

DEXTROSE

DEXTROSE (cont1)

AMINO PLASMAL

AMINO PLASMAL (cont1)

LIPOFUNDIN

RINGER

RINGER (cont1)

ELECTROLITES

ELECTROLITES (cont1)

ELECTROLITES (cont2)

TPN Monitoring

TPN Monitoring Baseline Lab Investigations Complete blood count Coagulation tests Serums electrolytes Ca++, Mg++, PO42- TG, Hg, Hct Other tests when indicated

Adjust TPN order accordingly TPN Monitoring (cont1) Clinical Review Lab investigations Adjust TPN order accordingly

TPN Monitoring (cont2) Clinical Review clinical examination vital signs fluid balance catheter care sepsis review blood sugar profile Body weight

TPN Monitoring (cont3) Lab investigations blood glucose, BUN, Cr urinary glucose Alb & Pre Alb electrolytes, k, Na Body weight Alkaline phosphates, Chol, TG, Transferrin, PT chest x-ray, Ca, Mg daily ,then 3 times weekly :weekly daily Weekly daily, then 3 times weekly Daily weekly

TPN Monitoring (cont4) Lab investigations (cont) Weekly once stable Seum phophorus Serum selenium, amylase, lipase, bilirubin, serum ammonia, H&H, serum Fe, folacin, B12, AST, ALT, WBC, PCO2, PO2

Starting & stopping PN

What to do before starting PN Nutritional Assessment Venous access evaluation Baseline weight Baseline lab investigations

Starting PN variable 50 ml/hr day 1(not meet all requirements day 1-2) patient dependent volume dependent 50 ml/hr day 1(not meet all requirements day 1-2) 75 ml/hr day 2 125 ml/hr day 3    delivered in one system or piggy-back using y-joint

Stopping TPN Stop TPN when enteral feeding can restart 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 intake meets TEE

Transitional Feeding Examples: A process of moving from one type of feeding to another with multiple feeding methods used simultaneously Examples: parenteral feeding to enteral feeding parenteral feeding to oral feeding enteral feeding to oral feeding

Transitional Feeding parenteral to enteral Introduce enteral feeding – 30 cc/hr while giving parenteral If tolerated, gradually ↓ parenteral while increasing enteral Once pt tolerate 75% of needs enterally, d/c parenteral Process is called a stepwise decrease

Transitional Feeding parenteral to oral and enteral to oral Use step-wise decrease method; wait until pt accepting 75% oral and then decrease parenteral or enteral method But may need to: Some children & adults may continue on oral during the day and enteral at night

Complications of PN

Complications related to PN Mechanical Complications Metabolic Complications Infectious Complications

Mechanical Complications Related to vascular access technique Pneumothorax Air embolism Arterial injury Bleeding Catheter misplacement Catheter embolism Thoracic duct injury

Mechanical Complications (cont) Related to catheter Venous thrombosis Catheter occlusion

Metabolic Complications Abnormalities related to excessive or inadequate administration Hyper / hypoglycemia Electrolyte abnormalities Acid-base disorders Hyperlipidemia

Metabolic Complications (cont) Hepatic complications Biochemical abnormalities too much calories (carbohydrate intake) too much fat Calculus cholecystis

Infectious Complications Insertion site contamination Catheter contamination improper insertion technique use of catheter for non-feeding purposes contaminated TPN solution contaminated tubing Secondary contamination septicemia

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