1. Parenteral NS Fluid and electrolyte requirements. Calculate enteral and parenteral formulations.

2. PNS Routes Peripheral access Short-term central access Long-term central access

3. Peripheral Access Veins in limbs Cannot exceed 800-900 mOsm/kg PICC - enter at peripheral but end of tube at subclavian vein

4. Central Access Figure 20-3 here Cephalic vein Subclavian vein Internal jugular vein Superior vena cava

5. Fig. 20-3. Central access

6. Central Access Short-term –percutaneous technique Long-term –implanted vascular devices

7. PNS Time frame for use of PNS –5 days or less is short-term Total nutrients needed Capacity of pt to handle fluid

8. PNS Condition of peripheral veins If can take adequate oral intake in 5 day - DO NOT do central line

9. PNS Components Protein –crystalline amino acids –3% to 15% solutions –10% = 100g protein/L –4 kcal/g protein –NPC non-protein calories

10. PNS Components Carbohydrate –dextrose monohydrate –5% to 70% solutions –D50W = 50% solution –10% solution = 100g/L –3.4 kcal/g dextrose

11. PNS Components Lipid –soybean or safflower oil –10%, 20% & 30% solutions –10% = 1.1 kcal/ml –20% = 2.0 kcal/ml –30% = 3.0 kcal/ml

12. PNS Components Lipid –10% kcal/day every day will provide 4% of kcal need to prevent EFA deficiency –if have long chain fatty acids

13. PNS Components Electrolytes, vitamins, minerals

14. PNS PPN –less than 8.5% AA –5-10% dextrose –lipid not more than 1g/kg/day

15. PNS PPN –Rule of thumb for PPN –D5W or D10W with 8.5% AA –D20W with 5% AA and lipid at 125 ml/hr

16. PNS Compounding methods –mix the dextrose and AA –‘piggy’ back the lipid and filter before mix with dextrose and AA

17. PNS Initiating TPN –start less than 50 ml/hr and 1 L/day –advance 12 - 24 hr intervals

18. PNS Monitoring –amount receiving –Na –K –BUN –prealbumin

19. PNS Monitoring –cholesterol –TG –I & O –body wt –blood glucose

20. McClaren 165. Essential fatty acid deficiency.

21. McClaren 166. Same pt. 165 after EFA supplementation.

22. Complications TPN Catheter in wrong place Sepsis Deficiencies –EFA def –trace minerals - added routinely

23. Complications TPN Metabolic complications –overloading –imbalances

24. Complications TPN Overloading –solute or fluid - meas. Serum osmolality –CHO, fat, amino acids

25. Complications TPN Imbalances –glucose intolerance –hypokalemia –reactive hypoglycemia –hypophosphatemia –hypo or hypermagnesemia

26. Refeeding Syndrome Too aggressive administration after ‘starving’ Hypokalemia Hypophosphotemia

27. Transition Feeding Parenteral to enteral –start enteral slow –keep TPN going & decrease as increase enteral –receive 75% from enteral before stop TPN

28. Transition Feeding Parenteral to oral –start oral and slowly decrease TPN –be careful of hyperosmolality of common clear liquids –receive 75% of needs before stop TPN

29. Transition Feeding Enteral to oral –?? –mOsm/kg for different clear liquids be careful not too high

30. TPN END Questions? Now for calculations