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Nutritional Support
Nutritional Support
Nutritional Support
Nutritional Support
Nutritional Support
Nutritional Support
Nutritional Support
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Nutritional Support

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nutritional support

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  • 1. Nutritional Support in Critical illness Tianjin Medical University General Hospital Emergency Center Shou songtao
  • 2. <ul><ul><li>Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets. </li></ul></ul>Definition
  • 3. ‘ A slender and restricted diet is always dangerous in chronic and in acute diseases’ Hippocrates 400 B.C.
  • 4. <ul><li>Malnutrition occurs in approx.40% of hospitalized patients </li></ul><ul><li>Can lead to increased morbidity and mortality </li></ul><ul><ul><li>Impairment of skeletal, cardiac, respiratory muscle function </li></ul></ul><ul><ul><li>Impairment of immune function </li></ul></ul><ul><ul><li>Atrophy of GIT </li></ul></ul><ul><ul><li>Impaired healing </li></ul></ul>
  • 5. <ul><li>1970s: TPN - separate CH, AAs and Lipids </li></ul><ul><li>2500-3000kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulin </li></ul><ul><li>Single lumen C/Lines, no pumps </li></ul><ul><li>Urinary urea measured, N calculated </li></ul><ul><li>1980s: Scientific studies of metabolism: recognition of overfeeding </li></ul><ul><li>1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials </li></ul><ul><li>2000s: glucose control, specific nutrients </li></ul>
  • 6. ICU Nutrition through the ages Overfeeding 1980s
  • 7. <ul><li>4 basic questions to be answered: </li></ul><ul><ul><li>Who? </li></ul></ul><ul><ul><li>When? </li></ul></ul><ul><ul><li>How much? </li></ul></ul><ul><ul><li>How? </li></ul></ul>
  • 8.  
  • 9.  
  • 10. Organisation of Nutrition Support 3. NICE Guidelines for Nutrition Support in Adults 2006 Screen Recognise Treat Oral Enteral Parenteral Monitor & Review
  • 11. Screen <ul><li>Various nutritional screening tools </li></ul><ul><li>Low risk: routine clinical care </li></ul><ul><li>Medium risk: observe </li></ul><ul><li>High risk: treat- refer to dietitian/local protocols </li></ul>
  • 12. Screening in ICU <ul><li>Almost all patients require artificial nutrition- cannot ‘observe’ </li></ul><ul><li>Needs adaptation using NICE Guidelines </li></ul><ul><li>Adapted MUST for ICU: Uses BMI/weight loss/food intake + refeeding risk assessment; linked to feeding flowchart </li></ul>
  • 13. Nutritional Assessment <ul><li>History – 10% weight loss or more suggests protein malnutrition </li></ul><ul><li>Exam – Weight/Ideal body weight (<85% predicted), temporal muscle wasting, anthropometrics </li></ul><ul><li>Nutritional markers </li></ul><ul><li>- daily weight – more a measure of fluid status than nutritional status </li></ul><ul><li>-24 hour urine urea nitrogen (cannot be used in renal failure) </li></ul><ul><li>-albumin (<30mg/dl,t 1/2 21), prealbumin(<12mg/dl, 2), transferrin(<150mmol/L, 7) </li></ul><ul><li>-albumin influenced by fluid status, acute phase response </li></ul>
  • 14. Nutritional Assessment <ul><li>Immune function – skin testing, anergy,total lymphocyte count<1800/mm 3 </li></ul><ul><li>Anthropometric measures </li></ul><ul><ul><li>> 10 % loss of ‘well’ body weight </li></ul></ul><ul><ul><li>Body mass index : weight (kg)/ height 2 (m 2 ) </li></ul></ul><ul><ul><ul><li><18 kg/m 2 assoc. With prolonged ICU, increased post-operative complications, higher readmission rates </li></ul></ul></ul><ul><ul><li>Mid-arm circumference, skin fold thickness </li></ul></ul><ul><ul><ul><li>Poor accuracy, specificity, reproducibility </li></ul></ul></ul>
  • 15. Nutritional assessment <ul><li>Serum proteins </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><ul><li>Reflects synthesis, degradation, losses, exchange between intracellular and extracellular compartments </li></ul></ul></ul><ul><ul><ul><li>Half life 21 days – limited ability to reflect acute changes </li></ul></ul></ul><ul><ul><ul><li>< 3.5 g/dL assoc. increased morbidity </li></ul></ul></ul>
  • 16. Nutritional assessment <ul><li>Serum proteins </li></ul><ul><ul><li>Transferrin (1/2 life 7 days), Pre-albumin (1/2 life 2 days) </li></ul></ul><ul><ul><li>More accurately reflect acute changes </li></ul></ul><ul><ul><li>Limited by erratic responses to stress, sepsis, cancer </li></ul></ul>
  • 17. Nutritional assessment <ul><li>Nitrogen balance </li></ul><ul><ul><li>= N intake – N loss </li></ul></ul><ul><ul><li>= (dietary protein x 0.16) – (urea nitrogen (urine) + 4 g (stool/skin) ) </li></ul></ul><ul><ul><li>Positive balance indicates anabolic state </li></ul></ul><ul><ul><li>Negative balance indicates catabolic state </li></ul></ul><ul><ul><li>Aim to provide non-protein sources of fuel to allow protein to be used for anabolic processes </li></ul></ul>
  • 18. How much to give in ICU? <ul><li>Schofield equation/Harris Benedict </li></ul><ul><li>e.g. for 65 year old woman: BMR = (9.2x weight in kg) + 687, = requirement in Kcal/24hr </li></ul><ul><li>Add Activity and Stress factors e.g. 10% for bedbound + 20-60% for sepsis/burns </li></ul><ul><li>For 65kg ventilated woman with sepsis: 1670 Kcal = approx 25 Kcal/kg/d </li></ul><ul><li>No dietitian? Rough guide: 25 Kcal/kg/day total energy. Increase to 30 as patient improves </li></ul>
  • 19. How much to give? <ul><li>0.2g/Kg/day of Nitrogen (1.25g/kg/day protein) </li></ul><ul><li>30 – 35ml fluid/kg/24 hours baseline </li></ul><ul><li>Add 2-2.5ml/kg/day of fluid for each degree of temperature </li></ul><ul><li>Account for excess fluid losses </li></ul><ul><li>Adequate electrolytes, micronutrients, vitamins </li></ul><ul><li>Avoid overfeeding </li></ul><ul><li>Obesity: feed to BMR, add stress factor only if severe i.e. burns/trauma </li></ul>
  • 20. Types of nutrition support <ul><li>Routes of nutrition support </li></ul><ul><ul><li>Enteral nutrition </li></ul></ul><ul><ul><li>Parenteral nutrition </li></ul></ul>
  • 21. Enteral nutrition <ul><li>In general, the preferred method of choice </li></ul>
  • 22. Enteral Nutrition <ul><li>Nutrition delivered via the gut </li></ul><ul><li>Includes oral feedings and tube feedings </li></ul>
  • 23. Indications for Enteral Nutrition <ul><li>Malnourished patient expected to be unable to eat >5-7 days </li></ul><ul><li>Normally nourished patient expected to be unable to eat >7-9 days </li></ul><ul><li>Adaptive phase of short bowel syndrome </li></ul><ul><li>Increased needs that cannot be met through oral intake (burns, trauma) </li></ul><ul><li>Inadequate oral intake resulting in deterioration of nutritional status or delayed recovery from illness </li></ul>ASPEN. The science and practice of nutrition support. A case-Based Core curriculum. 2001; 143
  • 24. Contraindications for EN <ul><li>Severe acute pancreatitis </li></ul><ul><li>High output proximal fistula </li></ul><ul><li>Inability to gain access </li></ul><ul><li>Intractable vomiting or diarrhea </li></ul><ul><li>Aggressive therapy not warranted </li></ul>ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143
  • 25. Contraindications for EN <ul><li>Inadequate resuscitation or hypotension; hemodynamic instability </li></ul><ul><li>Ileus </li></ul><ul><li>Intestinal obstruction </li></ul><ul><li>Severe G.I. Bleed </li></ul><ul><li>Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished </li></ul>
  • 26. <ul><ul><ul><li>Long-term nutrition </li></ul></ul></ul><ul><ul><ul><ul><li>Gastrostomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Jejunostomy </li></ul></ul></ul></ul><ul><ul><ul><li>Short-term nutrition </li></ul></ul></ul><ul><ul><ul><ul><li>Nasogastric feeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nasoduodenal feeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nasojejunal feeding </li></ul></ul></ul></ul>Enteral nutrition
  • 27.  
  • 28. Diagram of enteral tube placement.
  • 29. With/without endoscopic Long time with endoscopic operation Gastric tube duodenal tube gastrostomy Gastrostomy Duodenum feeding Jejunostomy feeding Decision of Selecting The Modes of Administration Enteral Nutrition Short time Tube Percutaneous tube
  • 30.  
  • 31.  
  • 32.  
  • 33. Enteral Formulas <ul><li>Liquid diets intended for oral use or for tube feeding </li></ul><ul><li>Ready-to-use or powdered form </li></ul><ul><li>Designed to meet variety of medical and nutrition needs </li></ul><ul><li>Can be used alone or given with foods </li></ul>
  • 34. Formula Selection <ul><li>The suitability of a feeding formula should be evaluated based on </li></ul><ul><li>Functional status of GI tract </li></ul><ul><li>Digestion and absorption capability of patient </li></ul><ul><li>Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity) </li></ul><ul><li>Macronutrient ratios </li></ul><ul><li>Specific metabolic needs </li></ul><ul><li>Contribution of the feeding to fluid and electrolyte needs or restriction </li></ul><ul><li>Cost effectiveness </li></ul>
  • 35. Enteral Formulas <ul><li>Determine best choice by medical and nutrition assessment </li></ul><ul><li>Meet specific nutrition needs </li></ul>
  • 36. Enteral Formula Categories <ul><li>Polymeric </li></ul><ul><li>Monomeric </li></ul><ul><li>Fiber-containing </li></ul><ul><li>Disease-specific </li></ul><ul><li>Rehydration </li></ul><ul><li>Modular </li></ul>
  • 37. Enteral Formula Categories Polymeric <ul><li>Whole protein nitrogen source </li></ul><ul><li>For use in patients with normal or near normal GI function </li></ul><ul><ul><li>Protein isolate formulas </li></ul></ul><ul><ul><ul><ul><li>Protein that has been separated from a food (casein from milk, albumin from egg) </li></ul></ul></ul></ul><ul><ul><li>Blenderized formulas </li></ul></ul><ul><ul><ul><li>May contain pureed meat, vegetables, fruits, milk, starches with v/m added </li></ul></ul></ul><ul><ul><ul><li>Made at home or purchased commercially </li></ul></ul></ul>
  • 38. Enteral Formula Categories Polymeric
  • 39. Enteral Formula Categories Monomeric <ul><li>Elemental/hydrolyzed </li></ul><ul><li>Predigested nutrients </li></ul><ul><li>Free amino acids and/or short peptide chains </li></ul><ul><li>Has low fat content or high percentage of MCT, LCT, structured lipids </li></ul>
  • 40. Enteral Formula Categories Monomeric
  • 41. Enteral Formula Categories Monomeric <ul><li>Use in patients with compromised digestive and/or absorptive capacity </li></ul><ul><li>More expensive than standard formulas </li></ul><ul><li>Tend to be more hyperosmolar because of small particle size </li></ul>
  • 42. Enteral Formula Categories Fiber-Containing <ul><li>Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients </li></ul><ul><li>Soy polysaccharide is the most common fiber additive in enteral feedings </li></ul>ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
  • 43. Enteral Formula Categories Fiber-Containing <ul><li>Soluble fiber (guar gum, oat fiber, pectin) may exert trophic effect on colonic mucosa and be useful in normalizing bowel function </li></ul><ul><li>Patients with impaired gastric emptying should not be fed fiber-containing formula into the stomach </li></ul>ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
  • 44. Enteral Formula Categories Fiber-Containing
  • 45. Enteral Formulas: Calorie Dense <ul><li>May be used in fluid-restricted or volume-sensitive patients </li></ul><ul><li>Calorie density ranges from 1.3 to 2 kcals/ml </li></ul><ul><li>Monitor fluid/hydration status </li></ul>
  • 46. Enteral Formulas: Calorie Dense
  • 47. Enteral Formula Categories Disease Specific <ul><li>Designed for patients with specific disease states. </li></ul><ul><li>Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise. </li></ul>
  • 48. Enteral Formula Categories Disease Specific
  • 49. Disease Specific Formulas Diabetic <ul><li>Amount and type of CHO modified to reduce blood glucose response </li></ul><ul><li>Increased fat content (may have increased monounsaturated fats) </li></ul><ul><li>May be worth trying diabetes formulas in patients who have failed to achieve good blood glucose control on standard formulas </li></ul>
  • 50. Disease Specific Formulas: Diabetic
  • 51. Disease Specific Formulas Hepatic <ul><li>Generally have reduced aromatic amino acids and increased branched chain amino acids </li></ul><ul><li>More expensive than standard products </li></ul><ul><li>Often lower in protein than standard formulas (may be too low for most liver patients) </li></ul>
  • 52. Disease Specific Formulas Renal <ul><li>Typically are calorie dense (2.0 kcal/cc) products with relatively low protein levels and modified electrolytes </li></ul><ul><li>Generally too low in protein for dialyzed patients and acutely ill patients </li></ul><ul><li>May be useful for short term use as supplement or calorie source in pre-dialysis chronic renal failure patients </li></ul>
  • 53. Disease-Specific Formulas Renal Novasource Renal
  • 54. Disease Specific Formulas Immune-Enhancing <ul><li>Have added “immune-enhancing” nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides) </li></ul><ul><li>Meta-analysis suggests that they might be most beneficial in surgical patients </li></ul>
  • 55. Immune-Enhancing Formulas
  • 56. Disease-Specific Formula Pulmonary <ul><li>Contain higher percentage of total calories from fat to reduce respiratory quotient and make it easier to wean from respirator </li></ul><ul><li>High fat gastric feedings may cause delayed emptying in critically ill patients </li></ul>
  • 57. Disease-Specific Formulas: Pulmonary
  • 58. Enteral Formula Nutrient Sources Carbohydrate <ul><li>CHO content ranges from 40-90% of total calories </li></ul><ul><li>Fiber: soy polysaccharide (most common) guar gum, oat fiber, pectin </li></ul>
  • 59. Enteral Formula Nutrient Sources Lipids <ul><li>Fat provides isotonic, concentrated energy source </li></ul><ul><li>Corn and soybean oil common </li></ul><ul><li>May include MCTs; more easily digested and absorbed </li></ul><ul><li>Fat content ranges from <10% to >50% of calories </li></ul>ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
  • 60. Enteral Formulas Nutrient Sources Protein <ul><li>Whole protein, hydrolyzed protein, free amino acids </li></ul><ul><li>Casein, soy protein, lactalbumin, whey, egg white albumin </li></ul><ul><li>Small peptides absorbed as efficiently as free amino acids </li></ul><ul><li>Free amino acids are more hyperosmolar </li></ul>
  • 61. Initiation of Feeds <ul><li>Approaches </li></ul><ul><ul><li>Bolus vs continuous feeds </li></ul></ul><ul><ul><li>Full feeds vs graded regimens </li></ul></ul>
  • 62. Assessment of Clinical Response <ul><li>Anthropometric measurements </li></ul><ul><li>Feeding tolerance </li></ul>
  • 63. Enteral nutrition <ul><li>Complications </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Mechanical </li></ul><ul><li>Metabolic </li></ul><ul><li>Formula related </li></ul>
  • 64. GI Complications <ul><li>Vomiting </li></ul><ul><li>Diarrhea </li></ul><ul><li>Constipation </li></ul><ul><li>Abdominal pain / bloating </li></ul><ul><li>Gastric irritation </li></ul><ul><li>Aspiration </li></ul>
  • 65. Mechanical Complications <ul><li>Tube occlusion </li></ul><ul><li>Nasopharyngeal effects </li></ul><ul><li>Tube fractures </li></ul><ul><li>Leakage </li></ul><ul><li>Obstruction </li></ul><ul><li>Irritation </li></ul>
  • 66. Metabolic Complications <ul><li>Hypovolemia </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Hypophosphatemia </li></ul><ul><li>Hypertonic dehydration </li></ul><ul><li>Fluid overload </li></ul>
  • 67. Formula Complications <ul><li>Incompatibility with medications </li></ul><ul><li>Hyperosmolality </li></ul><ul><li>Contamination </li></ul>
  • 68. Application Criterion of EN <ul><li>“ When the gut works, and can be used safely, use it ” </li></ul>
  • 69. Parenteral Nutrition
  • 70. Parenteral Nutrition <ul><li>Allows greater caloric intake </li></ul><ul><li>BUT </li></ul><ul><li>Is more expensive </li></ul><ul><li>Has more complications </li></ul><ul><li>Needs more technical expertise </li></ul>
  • 71. Who Will Benefit From Parenteral Nutrition? <ul><li>Patients with/who </li></ul><ul><ul><li>Abnormal gut function </li></ul></ul><ul><ul><li>Cannot consume adequate amounts of nutrients by enteral feeding </li></ul></ul>
  • 72. Two Main Forms of Parenteral Nutrition <ul><li>Peripheral Parenteral Nutrition </li></ul><ul><li>Central (Total) Parenteral Nutrition </li></ul><ul><li>Both differ in </li></ul><ul><ul><li>composition of feed </li></ul></ul><ul><ul><li>primary caloric source </li></ul></ul><ul><ul><li>potential complications </li></ul></ul><ul><ul><li>method of administration </li></ul></ul>
  • 73. Peripheral Parenteral Nutrition <ul><li>Given through peripheral vein </li></ul><ul><li>Short term use </li></ul><ul><li>Mildly stressed patients </li></ul><ul><li>Low caloric requirements </li></ul><ul><li>Contraindications to central TPN </li></ul>
  • 74. What to Do Before Starting TPN <ul><li>Nutritional Assessment </li></ul><ul><li>Venous access evaluation </li></ul><ul><li>Baseline weight </li></ul><ul><li>Baseline lab investigations </li></ul>
  • 75. Venous Access for TPN <ul><li>Need venous access to a “large” central line </li></ul><ul><li>with fast flow to avoid thrombophlebitis </li></ul>Superior Vena Cava <ul><li>Subclavian approach </li></ul><ul><li>Internal jugular approach </li></ul><ul><li>External jugular approach </li></ul>
  • 76.  
  • 77. Baseline Lab Investigations <ul><li>Full blood count </li></ul><ul><li>Coagulation screen </li></ul><ul><li>Ca ++ , Mg ++ , PO 4 2- </li></ul><ul><li>Lipid </li></ul><ul><li>Other tests when indicated </li></ul>
  • 78. Steps to Ordering TPN Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Determine Electrolyte and Trace element requirements Determine need for additives
  • 79. Steps to Ordering TPN Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Determine Electrolyte and Trace element requirements Determine need for additives
  • 80. How Much Volume to Give? <ul><li>Cater for maintenance & on going losses </li></ul><ul><li>Normal maintenance requirements </li></ul><ul><ul><li>By body weight </li></ul></ul><ul><ul><li>alternatively, 30 to 50 ml/kg/day </li></ul></ul><ul><li>Add on going losses based on I/O chart </li></ul><ul><li>Consider insensible fluid losses also </li></ul><ul><ul><li>e.g. add 10% for every o C rise in temperature </li></ul></ul>
  • 81. Steps to Ordering TPN Determine Total Fluid Volume Determine Caloric needs Determine Protein requirements Decide how much fat & carbohydrate to give Determine Electrolyte and Trace element requirements Determine need for additives
  • 82. Caloric Requirements <ul><li>Based on Total Energy Expenditure </li></ul><ul><ul><li>Can be estimated using predictive equations </li></ul></ul><ul><ul><ul><li>TEE = REE + Stress Factor + Activity Factor </li></ul></ul></ul><ul><ul><li>Can be measured using metabolic cart </li></ul></ul>
  • 83. <ul><li>Stress Factor </li></ul>Caloric Requirements Malnutrition - 30% Peritonitis + 15% Soft tissue trauma + 15% Fracture + 20% Fever (per o c rise) + 13% Moderate infection + 20% Severe infection + 40% <20% BSA burns + 50% 20-40% BSA burns + 80% >40% BSA burns + 100%
  • 84. <ul><li>Activity Factor </li></ul><ul><li>Bed-bound + 20% </li></ul><ul><li>Ambulant + 30% </li></ul><ul><li>Active + 50% </li></ul>Caloric Requirements
  • 85. How Much CHO & Fats? <ul><li>“ Too much of a good thing causes problems” </li></ul><ul><ul><li>Not more than 4 mg / kg / min Dextrose </li></ul></ul><ul><ul><ul><li>(less than 6 g / kg / day) </li></ul></ul></ul><ul><ul><li>Not more than 0.7 mg / kg / min Lipid </li></ul></ul><ul><ul><ul><li>(less than 1 g / kg / day) </li></ul></ul></ul>
  • 86. <ul><li>Fats usually form 25 to 30% of calories </li></ul><ul><ul><li>Not more than 40 to 50% </li></ul></ul><ul><ul><li>Increase usually in severe stress </li></ul></ul><ul><ul><li>Aim for serum TG levels < 350 mg/dl or 3.95 mmol/L </li></ul></ul><ul><li>CHO usually form 70-75 % of calories </li></ul>How Much CHO & Fats?
  • 87. Steps to Ordering TPN Determine Total Fluid Volume Determine Caloric needs Determine Protein requirements Decide how much fat & carbohydrate to give Determine Electrolyte and Trace element requirements Determine need for additives
  • 88. How Much Protein to Give? <ul><li>Based on calorie : nitrogen ratio </li></ul><ul><li>Based on degree of stress & body weight </li></ul><ul><li>Based on Nitrogen Balance </li></ul>
  • 89. Calorie : Nitrogen Ratio <ul><li>Normal ratio is </li></ul><ul><li>150 cal : 1g Nitrogen </li></ul><ul><li>Critically ill patients </li></ul><ul><li>85 to 100 cal : 1 g Nitrogen in </li></ul>
  • 90. Based on Stress & BW <ul><li>Non-stress patients 0.8 g / kg / day </li></ul><ul><li>Mild stress 1.0 to 1.2 g / kg / day </li></ul><ul><li>Moderate stress 1.3 to 1.75 g / kg / day </li></ul><ul><li>Severe stress 2 to 2.5 g / kg / day </li></ul>
  • 91. Based on Nitrogen Balance <ul><li>Aim for positive balance of </li></ul><ul><li>1.5 to 2g / kg / day </li></ul>
  • 92. Steps to Ordering TPN Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Protein requirements Determine Non-N Caloric needs Determine Electrolyte and Trace element requirements Determine need for additives
  • 93. Electrolyte Requirements <ul><li>Cater for maintenance + replacement needs </li></ul><ul><li>Na + 1 to 2 mmol/kg/d (or 60-120 meq/d) </li></ul><ul><ul><li>K + 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d) </li></ul></ul><ul><ul><li>Mg ++ 0.35 to 0.45 meq/kg/d (or 10 to 20 meq /d) </li></ul></ul><ul><ul><li>Ca ++ 0.2 to 0.3 meq/kg/d (or 10 to 15 meq/d) </li></ul></ul><ul><ul><li>PO 4 2- 20 to 30 mmol/d </li></ul></ul>
  • 94. Trace Elements <ul><li>Total requirements not well established </li></ul><ul><li>Commercial preparations exist to provide RDA </li></ul><ul><ul><li>Zn 2-4 mg/day </li></ul></ul><ul><ul><li>Cr 10-15 ug/day </li></ul></ul><ul><ul><li>Cu 0.3 to 0.5 mg/day </li></ul></ul><ul><ul><li>Mn 0.4 to 0.8 mg/day </li></ul></ul>
  • 95. Steps to Ordering TPN Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Protein requirements Determine Non-N Caloric needs Determine Electrolyte and Trace element requirements Determine need for additives
  • 96. Other Additives <ul><li>Vitamins </li></ul><ul><ul><li>Give that recommended for oral intake </li></ul></ul><ul><ul><li>1 ampoule MultiVit per bag of TPN </li></ul></ul><ul><ul><li>MultiVit does not include Vit K </li></ul></ul><ul><ul><ul><li>can give 1 mg/day or 5-10 mg/wk </li></ul></ul></ul>
  • 97. Other Additives <ul><li>Medications </li></ul><ul><li>Insulin </li></ul><ul><ul><li>0.1 u per g dextrose in TPN </li></ul></ul><ul><ul><li>10 u per litre TPN initial dose </li></ul></ul><ul><li>Other medications </li></ul>
  • 98. TPN Monitoring <ul><li>Clinical Review </li></ul><ul><li>Lab investigations </li></ul><ul><li>Adjust TPN order accordingly </li></ul>
  • 99. Clinical Review <ul><li>Clinical examination </li></ul><ul><li>Vital signs </li></ul><ul><li>Fluid balance </li></ul><ul><li>Catheter care </li></ul><ul><li>Sepsis review </li></ul><ul><li>Blood sugar profile </li></ul><ul><li>Body weight </li></ul>
  • 100. Lab investigations <ul><li>Full Blood Count </li></ul><ul><li>Renal Panel # 1 </li></ul><ul><li>Ca++, Mg++, PO42- </li></ul><ul><li>Liver Function Test </li></ul><ul><li>Iron Panel </li></ul><ul><li>Lipid Panel </li></ul><ul><li>Nitrogen Balance </li></ul><ul><li>weekly, unless indicated </li></ul><ul><li>daily until stable, then 2x/wk </li></ul><ul><li>daily until stable, then 2x/wk </li></ul><ul><li>weekly </li></ul><ul><li>weekly </li></ul><ul><li>1-2x/wk </li></ul><ul><li>weekly </li></ul>
  • 101. Complications Related to TPN <ul><li>Mechanical Complications </li></ul><ul><li>Metabolic Complications </li></ul><ul><li>Infectious Complications </li></ul>
  • 102. Mechanical Complications Related to vascular access technique <ul><li>pneumothorax </li></ul><ul><li>air embolism </li></ul><ul><li>arterial injury </li></ul><ul><li>bleeding </li></ul><ul><li>brachial plexus injury </li></ul><ul><li>catheter malplacement </li></ul><ul><li>catheter embolism </li></ul><ul><li>thoracic duct injury </li></ul>
  • 103. Mechanical Complications Venous thrombosis Catheter occlusion Related to catheter in situ
  • 104. Metabolic Complications <ul><li>Abnormalities related to excessive or inadequate administration </li></ul><ul><ul><li>hyper / hypoglycaemia </li></ul></ul><ul><ul><li>electrolyte abnormalities </li></ul></ul><ul><ul><li>acid-base disorders </li></ul></ul><ul><ul><li>hyperlipidaemia </li></ul></ul>
  • 105. Metabolic Complications <ul><li>Hepatic complications </li></ul><ul><li>Biochemical abnormalities </li></ul><ul><li>Cholestatic jaundice </li></ul><ul><ul><li>too much calories (carbohydrate intake) </li></ul></ul><ul><ul><li>too much fat </li></ul></ul><ul><li>Acalculous cholecystitis </li></ul>
  • 106. Infectious Complications <ul><li>Insertion site contamination </li></ul><ul><li>Catheter contamination </li></ul><ul><ul><li>improper insertion technique </li></ul></ul><ul><ul><li>use of catheter for non-feeding purposes </li></ul></ul><ul><ul><li>contaminated TPN solution </li></ul></ul><ul><ul><li>contaminated tubing </li></ul></ul><ul><li>Secondary contamination </li></ul><ul><ul><li>septicaemia </li></ul></ul>
  • 107. Stopping TPN <ul><li>Stop TPN when enteral feeding can restart </li></ul><ul><li>Wean slowly to avoid hypoglycaemia </li></ul><ul><li>Monitor during wean </li></ul><ul><ul><li>Give IV Dextrose 10% solution at previous infusion rate for at least 4 to 6h </li></ul></ul><ul><ul><li>Alternatively, wean TPN while introducing enteral feeding and stop when enteral intake meets TEE </li></ul></ul>
  • 108. Approach to Nutritional Support Nutritional Assessment Maintenance Repletion GI Tract Functional YES NO Enteral Nutrition Parenteral Nutrition
  • 109. Advantages - Enteral vs PN <ul><li>Preserves gut integrity </li></ul><ul><li>Possibly decreases bacterial translocation </li></ul><ul><li>Preserves immunological function of gut </li></ul><ul><li>Reduces costs </li></ul><ul><li>Fewer infectious complications in critically ill patients </li></ul><ul><li>Safer and more cost effective in many settings </li></ul>ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 147 ADA EAL, Critical Illness, accessed 8-07
  • 110. Single nutrient supplementation <ul><li>L-glutamine </li></ul><ul><ul><li>Used in purine, pyrimidine, lymphocyte and macrophage function, gut integrity and gut barrier function </li></ul></ul><ul><ul><li>If given, reduces nitrogen loss </li></ul></ul><ul><ul><li>Reduced length of stay, following colorectal surgery in elective setting </li></ul></ul><ul><ul><li>Other studies shown reduced risk of pneumonia, bacteraemia, sepsis following major trauma </li></ul></ul><ul><ul><li>? Role in short gut syndrome – improving GI absorbtion </li></ul></ul>
  • 111. Single nutrient supplementation <ul><li>Essential fatty acids </li></ul><ul><ul><li>Variety of functions, key role in maintaining membrane structure and function </li></ul></ul><ul><ul><li>Alter immune function (n-3 FA suppress immune function) </li></ul></ul><ul><ul><li>Preliminary studies using n-3 FA in inflammatory bowel disease showed improvement in histological appearance, reduction in disease activity, decreased steroid requirement </li></ul></ul>
  • 112.  
  • 113. Importants: <ul><li>Definition of nutritional support </li></ul><ul><li>Routs of nutritional support </li></ul><ul><li>Advantages of EN </li></ul><ul><li>Common complications of TPN </li></ul>
  • 114. Maintains Stimulates the environment defences <ul><li>FEEDING </li></ul><ul><li>Provides energy </li></ul>
  • 115. Thank you !!
  • 116. <ul><li>Essential Nonessential </li></ul><ul><li>Arginine Alanine </li></ul><ul><li>Histidine Asparagine </li></ul><ul><li>Isoleucine Aspartate </li></ul><ul><li>Leucine Cysteine </li></ul><ul><li>Lysine Glutamate </li></ul><ul><li>Methionine Glutamine </li></ul><ul><li>Phenylalanine Glycine </li></ul><ul><li>Threonine Proline </li></ul><ul><li>Tryptophan Serine </li></ul><ul><li>Valine Tyrosine </li></ul>

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