1. 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

3. Parenteral Nutrition

4. Formulations Amino acids Dextrose Lipids Electrolytes Trace elements
Vitamins

5. 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.

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

7. Dosing of fluid
30-40 CC/kg

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

9. Energy Needs
Never more than two times of BMR

10. Energy Needs
Amino acids
Dextrose
Fat

11. Dextrose
5% to 70%

12. 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

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

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

15. LIPIDS
10%
20%
30%

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

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

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

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

20. Electrolytes

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

22. Electrolytes

23. Trace element formulations

24. Trace element formulations

25. In Iran
Addamel
Tracutil

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

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

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

29. Vitamins

30. Soluvit N Vitamin B1 2.5 mg Vitamin B2 3.6 mg Nicotinamide 40 mg
Pantothenic acid mg
Vitamin C mg
Biotin μg
Folic acid mg
Cyanocobalamin μg

31. 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 …

32. 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 …

33. Glutamine
0.3‐0.5 g/kg/d

34. 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

35. 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.

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

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

38. CONTRAINDICATIONS Amino acids :
Hypersensitivity to one or more amino acids

39. 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.

40. 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.

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

42. 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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