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Intravenous Therapy: IVF, Electrolytes, TPN
 

Intravenous Therapy: IVF, Electrolytes, TPN

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for the basic IV therapy for nursing practice, regards the discussion on intravenous fluids, electrolytes, and total parenteral nutrition

for the basic IV therapy for nursing practice, regards the discussion on intravenous fluids, electrolytes, and total parenteral nutrition

rsm, md

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Intravenous Therapy: IVF, Electrolytes, TPN Intravenous Therapy: IVF, Electrolytes, TPN Presentation Transcript

  • Dr. Ronald Sanchez – Magbitang
    • EDUCATIONAL ATTAINMENT
    • NEHS
    • UST – B.S. Biology (Pre-Med)
    • SLU – Doctor of Medicine (“Emeritus”)
    • TRAININGS
    • Dr. PJGMRMC – Internal Medicine
    • Children's Medical Center – Hematology
    • RITM – 1 st In-Country Training in HIV/AIDS
    • CONVENTIONS/SYMPOSIA
    • Philippine College of Physicians
    • Philippine Association of Hospital Administrators
    • Philippine Hospital Association
    • PRESENT POSITION
    • Chief of Hospital
    • Gov. Eduardo L. Joson Memorial Hospital
    • Daan Sarile, Cabanatuan City
    • ... was born on the 28th of July, year nineteen hundred and sixty-six, 10am at the Galang's Maternity Clinic in Batangas St., Santa Cruz, Manila, Philippines with a twin sister, Ruby, and they are the youngest among the four siblings. Dr. Magbitang is from Brgy. Bonifacio, San Leonardo, Nueva Ecija, Philippines, where presently he is living with his wonderful and loving family. He had his primary education from San Leonardo Central School where he graduated with honor. Then, had his secondary education from Nueva Ecija High School at Cabanatuan City. Thereafter, finished his Bachelor in Science, Biology from the University of Santo Tomas as preparatory course and subsequently obtained his Doctor of Medicine from the Saint Louis University in Baguio City and graduated "Emeritus". Subsequently, after his Internship at PJGMRMC he passed the Medical Board Examination on the following year. He had his Residency Training in the Department of Internal Medicine from Dr. Paulino J. Garcia Memorial and Research Center in Cabanatuan City, where he was the Chief Resident for the last 2 years of his training. And, became an Associate Fellow of The Philippine College of Physicians and member of the Philippine Association of Medical Specialists, Philippine Association of Hospital Administrators, and Philippine Hospital Association He had numerous positions in different prestigious medical and non-medical, and NGO's local and national associations and societies. He was once the Medical Section Head and the Chief of Clinics, and presently the Chief of Hospital of Eduardo L. Joson Memorial Hospital at Daan Sarile, Cabanatuan City.
    Dr. Ronald S. Magbitang Internal Medicine Chief of Hospital Gov. Eduardo L. Joson Memorial Hospital
  •  
  •  
  •  
  • BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FLUIDS AND ELECTROLYTES: Problems/Imbalances Common IV Solutions
  • ?
  •  
  • FLUIDS AND ELECTROLYTES
    • BODY FLUIDS
    • Refers to the body water in which electrolytes are dissolved
    • Described as “a sea within”
    • Water – is the largest single constituent of the body, representing 45% - 74% of the body weight, depending on age, gender and body fat
  •  
  • FLUIDS AND ELECTROLYTES
    • In the newborn infant – almost ¾ of the body weight is water, with the greatest percentage found in extracellular compartment
    • By adulthood
      • the young male’s body water is only 60% and 2/3 of this is in the intracellular compartment
      • In the average young female – only approximately 50% of body weight (due to increased amount of fat in women which is essentially water-free
  • FLUIDS AND ELECTROLYTES
    • Total Body water = 60% body weight
    Approximate size of body compartment in 70-kg adult Total = 42.5 L 0 100 200 300 1% 5% 14% 28 liters Transcellular 1L Plasma 3.5L Interstitial 10 liters Extracellular Water 20% BW Intracellular water 40% BW Osmolality – mOsm/L
  •  
  • FLUIDS AND ELECTROLYTES
    • Functions of Body Fluids:
      • Transport nutrients to the cells and carries waste products away from the cells
      • Maintains blood volume
      • Regulates body temperature
      • Serves as aqueous medium for cellular metabolism
      • Assists in digestion of food through hydrolysis
      • Acts as solvents in which solutes are available for cell function
      • Serves as medium for the excretion of waste products
  • FLUIDS AND ELECTROLYTES
    • Body Fluids are distributed in the body in 2 compartments:
      • Intracellular (ICF) – within the cell, approximately 2/3 of the body fluid; located primarily in the skeletal muscle mass, provides the aqueous medium for cellular function
      • 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells
      • a. Interstitial fluid – between the cells, fills spaces between most cells and comprises 15% of BW, e.g. lymph
    FLUIDS AND ELECTROLYTES
  • FLUIDS AND ELECTROLYTES
      • 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells
      • b. Intravascular fluid – in the blood vessels, the PLASMA (i.e. watery colorless fluid of lymph and blood in which RBC, WBC and platelets are suspended) comprises 5% of BW, approximately 3L of the average 6L of blood volume is made up of plasma and the remaining 3L is made up of other blood components
  • FLUIDS AND ELECTROLYTES
      • 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells
      • c. Transcellular – 1% to 3% of BW, the smallest division of the ECF compartment and contains approximately 1 – 2 L of fluid in any given time (e.g. CSF, pericardial, synovial, intraocular, pleural fluids, sweats, and digestive secretions
  •  
  • FLUIDS AND ELECTROLYTES
    • Total Body water = 60% body weight
    Approximate size of body compartment in 70-kg adult Total = 42.5 L 0 100 200 300 1% 5% 14% 28 liters Transcellular 1L Plasma 3.5L Interstitial 10 liters Extracellular Water 20% BW Intracellular water 40% BW Osmolality – mOsm/L
  • FLUIDS AND ELECTROLYTES
    • There is a continuous exchange of fluid between the fluid compartment , of these spaces only the plasma is directly influenced by the intake or elimination of fluid from the body
    • There is also the so called third space fluid shift or “third spacing” where there is a loss of ECF into a space that does not contribute to the equilibrium between ICF & ECF
  • FLUIDS AND ELECTROLYTES
    • “ Third spacing” occurs in:
      • Ascites
      • Burns
      • Peritonitis
      • Bowel obstruction
      • Massive bleeding into body cavity or joints
  • FLUIDS AND ELECTROLYTES
    • Pathophysiology:
      • The decrease in urine output despite adequate fluid intake (due to fluid shifts out of the intravascular space) + kidneys receive less blood and compensate by decreasing the urine output
  • FLUIDS AND ELECTROLYTES
    • Signs and Symptoms of Intravascular Fluid Volume Deficit are:
      • Increased heart rate
      • Decreased blood pressure
      • Decreased CVP
      • Edema
      • Decreased BW
      • Imbalances in fluid I & O
  • FLUIDS AND ELECTROLYTES
    • Output of Fluid – vary due to following:
      • Increased temperature
      • Increased respiration
      • Draining wounds
      • Ostomies
      • Gastric suction
  • FLUIDS AND ELECTROLYTES
    • Sources of water:
      • Liquids
      • Water-containing foods
      • Metabolic activities or oxidation
  • FLUIDS AND ELECTROLYTES
    • Elimination of Fluid:
      • Sensible loss (measurable)
      • Insensible (not measurable, e.g. skin, lungs, feces)
      • INSENSIBLE WATER LOSS ?
  • FLUIDS AND ELECTROLYTES
    • Water Balance I & O ( in adult eating 2500/day)
    Output 100 Feces 2500 Total 2500 Total 1400 Urine 300 Oxidation 500 Perspiration 1000 Food Intake 500 Breathing 1200 Liquids Amount of loss (ml) Route Amount of gain (ml) Route Intake
  • FLUIDS AND ELECTROLYTES
    • Routes Gain and Losses:
    • Kidneys
      • Usual daily urine volume in adult = 1 – 2 L
      • General Rule: 1 ml/kg/hour in all age groups
  • FLUIDS AND ELECTROLYTES
    • Routes of Gain & Losses:
    • Skin
      • Sensible perspiration or sweating
      • Chief solutes are Na, Cl, & K
      • Actual sweat losses vary from 0 – 1000ml or more every hour depending on environmental temperature
      • Conditions:
        • fever – increased water loss through skin and lungs
        • burns – natural skin barrier is destroyed
  • FLUIDS AND ELECTROLYTES
    • Routes of Gain & Losses:
    • Lungs
      • Normally eliminate water vapor (insensible loss)
      • Rate is at 300 – 400ml/day
      • Loss is greater with increased respiratory rate or depth
  • FLUIDS AND ELECTROLYTES
    • Routes of Gain & Losses:
    • Gastrointestinal Tract
      • Loss is at 100 – 200ml /day
      • Because the bulk of fluid is reabsorbed in the small intestine
        • diarrhea and fistulae are associated with large losses
  • FLUIDS AND ELECTROLYTES
    • Laboratory Tests for Evaluating Fluid Status:
    • Osmolality
      • Reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis
      • Measures the solute concentration per kilogram in blood and urine
      • Also measures the ability of a solution to create osmotic pressure and affects movement of water
      • Most reliable in measuring urine concentration
      • Reported as milliosmoles per kilogram of water (mOsm/kg)
      • Normal serum osmolality = 280 – 300 mOsm/kg
      • Normal urine osmolality = 50 – 1400 mOsm/kg
  • FLUIDS AND ELECTROLYTES
    • Laboratory Tests for Evaluating Fluid Status:
    • Osmolarity
      • Reflects the concentration of the solutions
      • Measured in milliosmoles per liter (mOsm/L)
  • FLUIDS AND ELECTROLYTES
    • Comparison of Serum & Urine Osmolality:
    Fluid volume excess Diabetes insipidus Fluid volume deficit SIADH Urine SIADH Renal Failure Diuretic use Adrenal insufficiency Free water loss Diabetes insipidus Sodium overload Hyperglycemia Uremia Serum Factors decreasing Factors increasing Fluid
  • FLUIDS AND ELECTROLYTES
    • ELECTROLYTES
      • Chemical compounds in solution that have the ability to conduct an electrical current
      • Distributed in different concentrations in the intracellular, intravascular, & interstitial
      • They break into ions:
        • Cations – positively charge (Na, K, Ca, Mg, H ions)
        • Anions – negatively charge (Cl, bicarbonate, phosphate, sulfate, proteinate ions)
  • FLUIDS AND ELECTROLYTES
    • General Functions of Electrolytes
      • Promote neuromuscular irritability
      • Maintain body fluid volume and osmolality
      • Distribute body water between compartments
      • Regulate acid-base balance
    • Approximate Major Electrolyte Content in Body Fluid
    * main electrolyte Cations: Cations: 17 Proteinate 5 Organic Acids 1 Sulfate (SO 4 -- ) 40 Proteinate 2 Phosphate (HPO 4 -- ) 10 Bicarbonate (HCO 3 - ) 26 Bicarbonate (HCO 3 - ) 150 Phosphates & Sulfates 103 Chloride (Cl - ) Anions: Anions: 2 Magnesium (Mg ++ ) 10 Sodium (Na + ) 5 Calcium (Ca ++ ) 40 Magnesium (Mg ++ ) 5 Potassium (K + ) 150 * Potassium (K + ) 142 * Sodium (Na + ) mEq/L Electrolytes mEq/L Electrolytes Intracellular Fluid (ICF) Extracellular Fluid (ECF) Plasma
  • FLUIDS AND ELECTROLYTES
    • The Electrolytes:
      • Cations:
        • Sodium
        • Potassium
        • Calcium
        • Magnesium
      • Anions:
        • Chloride
        • Bicarbonate
        • Phosphate
  • FLUIDS AND ELECTROLYTES
    • Sodium (Na + )
      • Normal concentration = 138 – 145 mEq/L
      • Most prevalent cation in the extracellular
      • Controls the osmotic pressure of the ECF compartment
      • Importance:
        • essential for neuromuscular functioning
        • helps in the maintenance of acid-base balance
  • FLUIDS AND ELECTROLYTES
    • Potassium (K + )
      • Normal concentration = 3.5 – 5.0 mEq/L
      • Major cation of the cell intracellularly
      • K enters the cell during anabolism (tissue formation) or glycogenesis
      • K goes out the cell during catabolism (tissue breakdown) – trauma, dehydration, starvation
      • Mostly located in intracellular compartment
      • Importance:
        • has a direct effect on the excitability of nerves and muscles
        • contributes most to the intracellular osmotic pressure
        • helps maintain acid-base balance and kidney function
  • FLUIDS AND ELECTROLYTES
    • Calcium (Ca ++ )
      • Normal concentration = 4.5 – 5.8 mEq/L
      • Has 2 forms:
        • Ionized (free) calcium – physiologically active
        • Ca bound to plasma proteins
  • FLUIDS AND ELECTROLYTES
    • Calcium (Ca ++ )
      • Free ionized Ca is needed for:
        • Blood coagulation
        • Muscle function (smooth, skeletal, cardiac)
        • Nerve function
        • Bone and teeth formation
      • Calcium level depends on 3 hormones:
        • Parathormone – decreased Ca & increase P
        • Vitamin D – from sunlight, for Ca absorption
        • Calcitonin – decreases Ca levels preventing bone resorption, opposes effects of PTH and Vit D on bones
  • FLUIDS AND ELECTROLYTES
    • Magnesium (Mg ++ )
      • Normal concentration = 1.5 – 2.5 mEq/L
      • About 50% is located in bones, 5% in ECF, and 45% in the ICF compartment
      • Vital for enzyme activation reactions, especially in carbohydrate metabolism
      • Has a sedative effect on CNS
  • Laboratory Values Used in Evaluating Fluid and Electrolyte Status 3.5-5.5 g/dL 3.5-5.5 g/dL Serum Albumin 3.9-6.1 mmol/L 70-110 mg/dL Serum Glucose Volume fraction: 0.39-0.47 Female: 39-47 % Volume fraction: 0.44-0.52 Male: 44-52 % Hematocrit 10:1 BUN/Creatinine ratio 62-133 mmol/L 0.7-1.5 mg/dL Serum creatinine 3.5-7 mmol/L of urea 10-20 mg/dL BUN 280-295 mmol/L 280-300 mOsm/kg Serum osmolality 24-30 24-30 Carbon Dioxide content 96-106 96-106 Serum Chloride 0.80-1.5 2.5-4.5 Serum Phosphorus 0.80-1.2 1.5-2.5 mEq/L Serum Mg 2.1-2.6 8.5-10.5 mg/dL Total serum Ca 3.5-5.5 3.5-5.5 mEq/L Serum K 135-145 mmol/L 135-145 mEq/L Serum Na SI Units Usual Reference Guide Test
  • Laboratory Values Used in Evaluating Fluid and Electrolyte Status < 6.6 < 6.6 typical urine 4.5-8.0 4.5-8.0 Urinary pH 500-800 500-800 mOsm/L typical urine 40-1400 mmol/kg 50-1400 mOsm/L extreme range Urine Osmolality 1.010-1.020 random specimen with normal intake Physiologic range after fluid restriction: 1.025-1.035 1.025-1.035 Urinary Specific Gravity 110-250 110-250 mEq/day Urinary Cl 40-80 40-80 mEq/day Urinary K 50-220 mmol/day 50-220 mEq/day Urinary Na SI Units Usual Reference Guide Test
  • FLUIDS AND ELECTROLYTES
    • Regulation of Body Fluid Compartments
      • Movement of particles through the cell membrane occurs via the following transport mechanisms:
        • Passive transport:
          • Osmosis
          • Diffusion
          • Filtration
        • Active transport
          • Na-K pump
    • Osmosis – movement of fluid to area of high concentration and gradual equalization of solute concentration
    • Diffusion – movement of fluid and solutes and equalization of solute concentration
    A B
  • FLUIDS AND ELECTROLYTES
    • OSMOSIS
      • The movement of water through a semipermeable membrane from a solution that has a low concentration of particles towards a solution that has a high concentration of particles
      • Normal serum osmolality = 280-300 mOsm/kg
      • Osmolality of ECF and ICF is always equal
  • FLUIDS AND ELECTROLYTES
    • DIFFUSION
      • Is the natural tendency of substance to move from an area of higher concentration to one of lower concentration
      • Occurs through the random movement of ions and molecules
      • Particles will distribute themselves evenly
      • Example: exchange of O 2 and CO 2 between pulmonary capillaries and alveoli
  • FLUIDS AND ELECTROLYTES
    • FILTRATION
      • The process by which water and diffusible substances move together in response to fluid pressure
      • This process is active in capillary beds
      • Example:
        • Passage of water and electrolytes from the arterial capillary bed to the interstitial fluid
  •  
  • FLUIDS AND ELECTROLYTES
    • ACTIVE TRANSPORT
      • The movement of substances across the cell membrane by chemical activity or energy expenditure, that allows cells to admit larger molecules
      • Example:
        • sodium-potassium pump – Na is pumped out of the cell, K is pumped in against pressure gradient
  •  
  • FLUIDS AND ELECTROLYTES
    • Regulation of Body Fluids
      • Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are:
        • Kidneys
        • Heart and Blood vessels
        • Lungs
        • Glands
        • Other Mechanisms
  • FLUIDS AND ELECTROLYTES
    • Regulation of Body Fluids
      • Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are:
        • Other mechanisms:
          • Baroreceptors
          • Renin-Angiotensin-Aldosterone System
          • ADH and thirst
          • Osmoreceptors
          • Release of Atrial Natriuretic Peptide
  • Types of Fluid Balance And Imbalance
  • FLUIDS AND ELECTROLYTES
    • Types of Fluid Balance and Imbalance:
    • Saline
      • ECF, reflects the volume of water and salt
    • Water
      • Osmolar proportion of water and salt (concentration)
  • FLUIDS AND ELECTROLYTES
    • Saline Balance
      • Refers to maintaining the proper volume of ECF and the three mechanisms involved in regulating saline balance
      • Aldosterone – a major regulator of saline balance (ECF volume)
  • FLUIDS AND ELECTROLYTES
    • Saline Imbalance
      • Changes in the volume of extracellular fluid compartment
      • Mechanisms in Regulating Saline Balance (ECF Volume):
        • Pituitary Gland - Aldosterone
        • Atrial Natriuretic Peptide
        • Neural Mechanism
  • FLUIDS AND ELECTROLYTES
    • Mechanisms in Saline Balance Regulation
    • (ECF Volume)
    • Pituitary Gland:
    • Ineffective blood volume (decrease blood circulation/ decrease ECF volume)
    • Stimulates adrenal cortex
    • Secrete aldosterone
    • Increase Na + reabsorption in distal tubule, collecting ducts
    • Increase saline retention
    • Increase in volume of water
    • Relieveing saline imbalance
  • FLUIDS AND ELECTROLYTES
    • Mechanisms in Saline Balance Regulation
    • (ECF Volume)
    • Atrial Natriuretic Peptide:
    • Atrial distention (increase ECF)
    • Release Peptides
    • Acts on kidney
    • Increase renal excretion of Na + & water
    • Relieveing distention
  • FLUIDS AND ELECTROLYTES
    • Mechanisms in Saline Balance Regulation
    • (ECF Volume)
    • Neural mechanism:
    • Decrease ECF volume
    • Stimulate renal sympathetic nerves
    • Release of Renin and stimulate the kidneys
    • Decrease renal secretion of saline
    • Increase ECF volume
    • Atrial distention
    • Mechano-receptors in the wall of left atrium
    • Decrease activity of sympathetic nerve
    • Increase excretion of saline by the kidney
  • FLUIDS AND ELECTROLYTES
    • Saline Imbalance: Saline Deficit
      • ECF volume deficit
      • Isotonic contraction
      • Isosmotic dehydration
      • Hypovolemia
      • Extracellular volume depletion
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Deficit
      • Causes:
        • Vomiting
        • Diarrhea
        • Extreme diaphoresis
        • Blood loss through hemorrhage
        • Burns
        • Bed rest
        • Fistula drainage
        • Salt wasting disorder
        • Third-space fluid accumulation
        • NGT suctioning
        • Excessive diuretic use
        • Intestinal decompression
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Deficit
      • Clinical Manifestations: - dehydration
        • Weight loss
        • Postural BP drop
        • Increased small vein filling time
        • Neck vein flat or collapsing with inspiration
        • Dizziness, syncope
        • Oliguria or anuria
        • Decreased CVP
        • Decreased skin turgor
        • Longitudinal furrow in the tongue
        • Dry mucous membrane
        • Hard, dry stools
        • Decreased tears and sweat
        • Sunken eyeballs
        • Hypovolemic shock
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Deficit
      • Laboratory Values:
        • Urinalysis – increased Cl
        • Blood studies – increased BUN, increased Hct, increased plasma protein, increased Na
      • Medical Therapy:
        • Saline replacement through IV related to complication of medical therapy
        • Dx – potential for injury related to complication
  • FLUIDS AND ELECTROLYTES
    • Saline Imbalance: Saline Excess
      • ECF volume excess
      • Isotonic expansion
      • Hypervolemia
      • Circulatory overload
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Excess
      • Causes:
        • Endocrine imbalance
          • Hyperaldosteronism
          • Cushing’s syndrome
          • Glucocorticoid therapy
        • Secondary to disease process
          • Chronic renal failure
          • CHF
          • Cirrhosis
        • Excess IV infusion of saline solutions (0.9% saline, Ringer’s)
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Excess
      • Clinical Manifestations:
        • Weight gain (0.5kg/day) – sign of volume expansion
        • Edema
        • Vascular expansion
        • Crackles or rales in lungs – fluid accumulation
        • Dyspnea, orthopnea due to volume overload
        • Increased CVP (5 – 10 cmH 2 0) – right atrium
  • FLUIDS AND ELECTROLYTES
    • Saline balance: Saline Excess
      • Laboratory Values:
        • Elevated CVP
        • Chest x-ray – fluid accumulation in the lungs
        • Blood studies – normal serum Na
        • Hematocrit – normal or decrease, depending on the cause, if occurs slowly the Hct remains normal
      • Treatment: treat the underlying cause
  •  
  • FLUIDS AND ELECTROLYTES
    • Water Balance and Imbalance
    • Refers to the maintenance of the proportion of salt to water in the blood
    • Important Facts:
      • Serum Na concentration is a useful measure of water balance (normal serum Na = 135 – 145 mEq/L in adults of all ages)
        • If the serum Na is decreased:
          • The osmolality of blood is decreased
          • Blood is less concentrated than normal
          • Blood has excess water relative to the amount of salt
        • If the serum Na is increased:
          • Osmolality of blood has increased
          • Blood is more concentrated
          • The blood has a deficit of water relative to the amount of salt
  • FLUIDS AND ELECTROLYTES
    • Normal and Abnormal Routes of Water Entry and Exit
    - Parenteral - Rectal 300 ml Metabolic water 1,200 ml Water in food 1,200 ml Drink Oral Gastrointestinal Average Volume (per 24 hours) Route of Entry
  • FLUIDS AND ELECTROLYTES
    • Normal and Abnormal Routes of Water Entry and Exit
    - Hemorrhage - Paracentesis procedures Others: - Drainage from lesions 600 ml Insensible perspiration Skin - Fistula - Emesis 100 ml Fecal Gastrointestinal 400 ml Respiratory 1,500 ml Renal Average Volume (per 24 hours) Route of Exit
  • FLUIDS AND ELECTROLYTES
    • Water Balance and Imbalance
    • The major regulators of oral water intake are:
        • Thirst
        • Habit patterns
        • Social influence
    • Three major mechanism of thirst:
        • Cellular dehydration thirst
        • Baroreceptor – mediated thirst
        • Angiotensin – mediated thrist
  • FLUIDS AND ELECTROLYTES
    • Water Balance and Imbalance
    • Cycle of Urine Excretion:
    • Increase in osmolality of blood
    • Hypothalamus
    • Pituitary Gland
    • Release of ADH
    • Collecting ducts of kidneys
    • Reabsorption of water back to the blood stream
    • Dilute the blood
    • Restore osmolalilty
    • Note: The excretion of urine (of water) is controlled by ADH.
  • FLUIDS AND ELECTROLYTES
    • TYPES OF WATER IMBALANCE
    • WATER DEFICIT:
      • Hypernatremia
      • Water depletion
      • Hypertonicity
      • Hyperosmolar balance
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Causes:
    • 1. Loss of water relative to salt
      • Renal
        • Dibetes insipidus (salt gain due to polyuria)
        • Osmotic diuresis (polyuria)
        • Renal concentrating disorder
        • Renal failure
      • Other sources:
        • Prolonged diarrhea without water replacement
        • Excessive sweating without water replacement
        • Dysfunctional humidifier of mechanical ventilators (dry air inhalation)
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Causes:
    • 2. Gain of salt relative to water
      • Decrease water intake
        • No access to water
        • Prolonged nausea
        • Difficulty swallowing fluid (Parkinson’s disease)
        • Inability to respond to thirst
      • Increase salt intake
        • By means of tube feeding
        • Half and half for ulcer diet
        • Excess hypertonic NaCl or NaHCO 3
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Clinical Manifestations:
      • Serum Na is above normal (blood is concentrated)
      • Thirst (due to lack of water)
      • Oliguria
      • Confusion
      • Lethargy
      • Mild muscle weakness
      • Seizures
      • Coma (varies in severity)
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Clinical Manifestations:
    • Pathophysiology:
    • Decrease Water
    • Increase Osmolality
    • Osmosis
    • ICF
    • ECF
    • Attempt to restore osmolality
    • Cells shrivels
    • Cell dysfunction
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Laboratory Values:
    • Urinalysis
      • Increase in specific gravity of urine > 1.030 (normal urine sp.gr. = 1.010 – 1.030)
    • Blood studies
      • Increase serum Na
      • Decrease serum protein
      • Decrease Hct
  • FLUIDS AND ELECTROLYTES
    • WATER DEFICIT
    • Medical Therapy:
    • Replacement of fluid loss by IVF or oral route
      • Institute or encourage oral fluid intake
      • Administer in small amount
      • Help patient in taking his I & O measurement
    • Complications:
      • Cerebral edema (therapy too rapid)
      • Rebound fluid excess (therapy excessive)
      • Infection
      • Infiltration
    Because of IV therapy
  • FLUIDS AND ELECTROLYTES
    • TYPES OF WATER IMBALANCE
    • WATER EXCESS:
      • Hyponatremia (decrease serum Na - < 135mEq/L)
      • Water intoxication
      • Hypotonicity
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • I. General etiology: Gain or water relative to salt
      • A. Endocrine:
        • Stimulation of ADH
          • Stressors
          • Post-surgical state
          • Nausea
          • Pain
        • Ectopic production of ADH
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • I.General etiology: Gain or water relative to salt
      • B. Iatrogenic – caused by medical therapy
        • Excessive tap water enema
        • Excessive infusion of D5W
        • Excessive use of ultrasonic nebulizer
        • Hypotonic irrigating solution (by process of osmosis)
        • Excessive water ingestion after poisoning
        • Excessive water ingestion before an UTZ examination
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • I. General etiology: Gain or water relative to salt
      • A. Others
        • Psychogenic polydipsia – excessive thrist
        • Excessive beer drinking
        • Near drowning in fresh water
        • Overdose of Barbiturates
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • II. General Etiology: Lost of salt related to water
      • A. Renal
        • Salt wasting renal disease
        • Use of many types of diuretics (Thiazides)
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • II. General Etiology: Lost of salt related to water
      • B. Gastrointestinal – due to water replacement not by salt
        • Nasogastric suction
        • Vomiting
        • Diarrhea
        • Hypotonic irrigation solutions
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Causes:
    • II. General Etiology: Lost of salt related to water
      • C. Others
        • Burns
        • Excessive sweating
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Clinical Manifestations:
    • Pathophysiology
    • Increased Water
    • Decrease Osmolality
    • Osmosis
    • ECF
    • ICF
    • Attempt to restore Osmolality
    • Cell swollen
    • Cell dysfunction
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Clinical Manifestations:
      • Decrease serum Na
      • Malaise
      • Headache
      • Confusion
      • Lethargy
      • Seizures
      • Coma
  • FLUIDS AND ELECTROLYTES
    • WATER EXCESS
    • Medical Therapy/ Management:
    • Restrict water intake below the daily insensible losses (1,000 ml)
    • The kidney will excrete the excess water
    • Administration of diuretic ( Furosemide )
    • Administration of ADH-blocking agent Demeclocycline or LiCO 3 )
  •  
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Fluid accumulation of the interstitial space
    • Maybe a sign of saline excess
    • Governed by the net result of the ff:
      • Blood hydrostatic pressure
      • Interstitial fluid hydrostatic pressure
      • Blood colloid osmotic and oncotic pressure
      • Interstitial fluid osmotic pressure
  •  
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Capillary Mechanism for Edema Formation
    • 1. Increase blood hydrostatic pressure
    • A. Increase capillary flow
          • Local infection
          • Inflammation
    • B. Venous congestion
          • External pressure
          • Venous thrombosis
          • Right heart failure
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Capillary Mechanism for Edema Formation
    • 2. Decrease blood osmotic pressure
    • A. Decrease serum Albumin
          • Loss of albumin
          • Nephrotic Syndrome
          • Protein-losing enteropathies
          • Liver disease (Cirrhosis)
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Capillary Mechanism for Edema Formation
    • 3. Increase fluid osmotic pressure
    • A. Increase capillary permeability
          • Burns
          • Inflammation
          • Hypersensitivity reactions
          • Toxins
          • Trauma
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Capillary Mechanism for Edema Formation
    • 4. Impaired lymphatic drainage
        • a. obstruction of the lymph node by tumors
        • b. Surgical removal of lymph nodes
        • c. Obstruction of lymph nodes by parasites
  • FLUIDS AND ELECTROLYTES
    • EDEMA
    • Medical Therapy and Interventions:
      • Use of elastic stockings to enhance venous return
      • Administration of diuretics or a Na-restricted diet
    • ELECTROLYTE BALANCE
    • AND
    • ELECTROLYTE IMBALANCES
  • FLUIDS AND ELECTROLYTES
    • ELECTROLYTE BALANCE AND IMBALANCES
    • Electrolytes:
      • Salts found in every body fluids
      • K, Ca, PO 3 , Mg (major electrolytes)
      • Enter the body primarily in the diet then enter the ECF and distributed to some other body electrolyte pool (bones/ inside cells)
  • FLUIDS AND ELECTROLYTES
    • Electrolytes:
    • Normal Routes of Exit:
      • Urine
      • Feces
      • Sweat
    • Abnormal Route:
      • Fistula drainage
      • Emesis
      • Gastric or intestinal suction
      • Paracentesis
      • Exudates
  • FLUIDS AND ELECTROLYTES
    • POTASSIUM BALANCE AND IMBALANCES
    • Normal range = 3.5 – 5.0 mEq/L
    • “ Kalium” – Latin word for potassium
    • Potassium Homeostasis:
      • Enters the cells through an active transport mechanism
      • Both insulin and epinephrine cause K to enter cells
      • Exercise causes K to exit cells initially
      • pH of ECF also affect the distribution
  • FLUIDS AND ELECTROLYTES
    • POTASSIUM BALANCE AND IMBALANCES
    • Normal range = 3.5 – 5.0 mEq/L
    • “ Kalium” – Latin word for potassium
    • Factors that causes K shift
    • A. Accumulation of carbonic acid
        • May cause a mild ECF shift
    • B. Accumulation of mineral acids
        • Causes significant extracellular K shift
    • C. Accumulation of organic acids
        • Does not in itself cause a K shift
  • FLUIDS AND ELECTROLYTES
    • HYPOKALEMIA
    • Serum K < 3.5 mEq/L
    • Causes:
    • Decrease K intake
      • Non-iatrogenic
        • Anorexia
        • Fad diets
        • Fasting
      • Iatrogenic
        • NPO orders
        • Prolonged IV therapy without K
    • Entry of K into cells
    • Increased K excretion
    • K loss by abnormal route
  • FLUIDS AND ELECTROLYTES
    • HYPOKALEMIA
    • Serum K < 3.5 mEq/L
    • Clinical Manifestations:
    • Serum K below normal
    • Postural hypotension
    • Abdominal distention
    • Diminished bowel sounds manifestation of unresponsive
    • Constipation GI smooth muscles
    • Skeletal muscle weakness
    • Flaccid paralysis
    • Polyuria, nocturia
    • Cardiac arrythmias
    • ECG changes: ST depression, inverted T-waves, U waves, QT prolongation
  • FLUIDS AND ELECTROLYTES
    • HYPOKALEMIA
    • Serum K < 3.5 mEq/L
    • Note:
      • Decrease K is manifested in dysfunction of all 3 kinds of muscles:
        • Smooth
        • Skeletal
        • Cardiac
  • FLUIDS AND ELECTROLYTES
    • HYPOKALEMIA
    • Serum K < 3.5 mEq/L
    • Interventions:
    • Constipation
    • Postural hypotension
    • Muscle weakness or flaccid paralysis
    • Ineffective breathing
    • K replacement therapy complications:
      • GI irritation or ulceration
      • Rebound hyperkalemia (if oliguria develops)
      • Cardiac arrhythmias (too rapid therapy)
      • Rebound hyperkalemia (excessive therapy)
      • Inflammation, infection, infiltration (out of vein)
    • Medical Therapy: Oral or IV Potassium replacement
  • FLUIDS AND ELECTROLYTES
    • HYPERKALEMIA
    • Serum K > 5.0 mEq/L
    • Excess of K in the ECF
    • Causes:
    • Increased K intake
    • Movement of K out of cells
    • Decreased K excretion
  • FLUIDS AND ELECTROLYTES
    • HYPERKALEMIA
    • Serum K > 5.0 mEq/L
    • Clinical Manifestations:
    • Serum K above normal
    • Intestinal cramping
    • Diarrhea
    • Skeletal muscle weakness
    • Flaccid paralysis
    • Cardiac arrhythmias
    • Cardiac arrest
    • ECG changes: peaked narrow T-waves, shortened QT intervals, widened QRS, sine wave
    • Laboratory values: acidosis
  • FLUIDS AND ELECTROLYTES
    • HYPERKALEMIA
    • Serum K > 5.0 mEq/L
    • Interventions:
      • Diarrhea
      • Muscle weakness or flaccid paralysis
      • Decrease ability to function
      • Ineffective breathing
      • Decreased cardiac output
  • FLUIDS AND ELECTROLYTES
    • HYPERKALEMIA
    • Serum K > 5.0 mEq/L
    • Medical Therapy:
      • To move K into cells (insulin, glucose, HCO 3 infusion)
      • To counteract the cardiac effects of hyperkalemia (IV Ca gluconate)
      • Remove K from the body (dialysis, diuretics, ion-exchange resins [Na polysterene sulfonate])
  • FLUIDS AND ELECTROLYTES
    • HYPERKALEMIA
    • Serum K > 5.0 mEq/L
    • Complications of Medical Therapy:
      • Hypoglycemia (insulin, glucose)
      • Hypercalcemia (Ca gluconate)
      • Metabolic alkalosis (IV HCO 3 )
      • Rebound hypokalemia (excessive therapy)
      • Inflammation, infection, or infiltration (IV therapy)
      • Aspiration pneumonitis (oral ion-exchange resin)
      • Constipation (oral ion-exchange resin without sorbitol)
      • Kayexalate – ion-exchange resin (Na polysterene sulfonate)
  • FLUIDS AND ELECTROLYTES
    • CALCIUM BALANCE & IMBALANCES
    • Facts:
    • Calcium ions in the body are mostly located in the bones and teeth
    • Small amount in cells of soft tissue
    • Normal concentration = 4.5 – 5.5 mEq/L
    • Calcium Homeostasis:
    • Major source of calcium intake:
      • Milk
      • Dairy products (cheese, cream, yogurt, ice cream)
      • Sea foods (clams)
    • Calcium is absorbed from the GIT by active transport mechanism requiring Vitamin D
    • Parathyroid hormone (PTH) increases activation of Vitamin D
  • FLUIDS AND ELECTROLYTES
    • HYPOCALCEMIA
    • Occurs if the serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished
    • Ionized hypocalcemia: total serum Ca maybe normal but ionized Ca concentration will be < normal
    • Causes:
    • Decreased Calcium intake or absorption
    • Decreased physiological availability of Calcium
    • Increased Calcium excretion
    • Calcium loss by abnormal route
  • FLUIDS AND ELECTROLYTES
    • HYPOCALCEMIA
    • Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished
    • Clinical Manifestations:
      • Decreased serum Ca (or decreased ionized Ca & normal total Ca)
      • Paresthesias (digital or perioral) – numbness or tingling sensation
      • *Chvostek ’s sign – tapping the Facial N. in front of the ear cause the mouth to draws up in a grimace, due to increased neuromuscular irritability
      • *Trousseau ’s sign – carpal spasm after occluding the arterial flow to the hand with sphygmomanometer for about 3 mins
      • Grimacing, muscle twitching, cramping
      • Hyperactive reflexes
      • Carpal, pedal spasm
      • Tetany – increased irritability
      • Laryngospasm (sudden involuntary muscular contraction of larynx)
      • Seizures
      • Cardiac arrhythmias
  • FLUIDS AND ELECTROLYTES
    • HYPOCALCEMIA
    • Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished
    • Interventions:
      • Neuromuscular irritability
      • Laryngospasm
      • Paresthesia and muscle cramps
    • Medical Therapy:
      • Replacement of Calcium – oral or IV
  • FLUIDS AND ELECTROLYTES
    • HYPOCALCEMIA
    • Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished
    • Complications of IV Calcium replacement:
      • Cardiac arrhythmias (therapy too rapid)
      • Rebound hypercalcemia (therapy excessive)
      • Inflammation, infection, infiltration
      • Tissue sloughing (after calcium infiltration)
      • Altered bowel elimination – constipation
    • Note: oral Ca salts are often administered with Vitamin D
  • FLUIDS AND ELECTROLYTES
    • HYPERCALCEMIA
    • Serum Ca > 5.5 mEq/L
    • Excess calcium in plasma may come from the bones or from external source
    • Causes:
    • Increased calcium intake or absorption
    • Release of calcium from bone
    • Decreased calcium excretion
  • FLUIDS AND ELECTROLYTES
    • HYPERCALCEMIA
    • Serum Ca > 5.5 mEq/L
    • Clinical Manifestations:
      • Increased serum Ca
      • Anorexia
      • Nausea, emesis
      • Constipation
      • Abdominal pain
      • Polyuria
      • Renal calculi
      • Fatigue
      • Muscle weakness
      • Impaired reflexes
      • Headache
      • Confusion, lethargy
      • Personality change
      • Psychosis
      • Cardiac arrest
      • ECG changes: shortened QT interval
  • FLUIDS AND ELECTROLYTES
    • HYPERCALCEMIA
    • Serum Ca > 5.5 mEq/L
    • Interventions:
      • Constipation
      • Nausea and vomiting – nutrition
      • Aspiration
      • Fatigue
      • Pain
      • Muscle weakness
      • Decreased level of consciousness
      • Altered thought processes
      • Impaired social interaction
      • Renal calculi
  • FLUIDS AND ELECTROLYTES
    • HYPERCALCEMIA
    • Serum Ca > 5.5 mEq/L
    • Notes:
      • Prune, cranberry juice or acid ash diet maybe use to acidify the urine
      • Hypercalcemia due to calcium withdrawal from bone results to weak bones
      • Hypercalcemia potentiates digitalis, may result to digitalis toxicity
      • Thiazide diuretics decrease calcium excretion which should be withheld if hypercalcemia develops
  • FLUIDS AND ELECTROLYTES
    • HYPERCALCEMIA
    • Serum Ca > 5.5 mEq/L
    • Medical Therapy:
      • Infusion of IV 0.9% Saline to induce saline diuresis
      • Calcitonin – used to decrease plasma calcium rapidly in emergency hypercalcemia
    • Complications of Therapy:
      • ECF volume excess (IV saline)
      • Inflammation, infection, infiltration (any IV agent)
      • Hypokalemia (diuretic therapy)
      • Hypersensitivity reaction (calcitonin)
      • Diarhhea (diphosphonates)
      • Nausea, vomiting (plicamysin)
      • Bone marrow suppression, liver damage, renal damage
  • FLUIDS AND ELECTROLYTES
    • PHOSPHATE BALANCE & IMBALANCES
    • An anion
    • Integral part of bones and are abundant inside cells
    • Normal serum concentration = 2.5 – 4.5 mg/dL
    • Serum PO 4 tends to decrease with age in both men and women
    • Phosphate Homeostasis:
      • Phosphate absorption occurs in small intestine
      • Maybe affected by Vitamin D
      • Magnesium, aluminum ions diarrhea decrease the absorption of PO 4 from GIT
      • PO 4 distribution distribution between the ECF and bones is under the influence of PTH which promotes bone resorption
      • PO 4 excretion occurs primarily in urine and feces
      • PTH increases renal excretion of PO 4
  • FLUIDS AND ELECTROLYTES
    • HYPOPHOSPHATEMIA
    • Serum concentration < 2.5 mg/dL
    • Mild hypophosphatemia is often asymptomatic
    • If serum level < 1.0mg/dL is a serious symptomatic hypophosphatemia
    • Causes:
      • Decreased phosphate intake or absorption
      • Movement of phosphate into cells
      • Increased phosphate excretion
      • Phosphate loss through abnormal route
  • FLUIDS AND ELECTROLYTES
    • HYPOPHOSPHATEMIA
    • Serum concentration < 2.5 mg/dL
    • Clinical Manifestations:
      • Serum level < 1.0 mg/dL
      • Anorexia, nausea
      • Malaise
      • Decreased reflexes
      • Muscle weakness, severe debility
      • Myalgia
      • Bone pain (long-term antacid use)
      • Irritability, apprehension
      • Paresthesias
      • Confusion
      • Stupor
      • Seizures
      • Coma
  • FLUIDS AND ELECTROLYTES
    • HYPOPHOSPHATEMIA
    • Serum concentration < 2.5 mg/dL
    • Laboratory Values:
      • Alkalosis (increased in pH especially respiratory alkalosis)
    • Interventions:
      • Decreased level of consciousness
      • Respiratory muscle weakness
  • FLUIDS AND ELECTROLYTES
    • HYPOPHOSPHATEMIA
    • Serum concentration < 2.5 mg/dL
    • Medical Therapy:
      • Mild cases of hypophosphatemia are monitored and allowed to return to normal spontaneously as precipitating factors are removed and corrected
      • IV PO 4 for severe symptomatic cases, followed with oral replacement
    • Complications of Therapy:
      • Hypocalcemia
      • Rebound hyperphosphatemia
      • Inflammation, infection, infiltration
    • Note: IV PO 4 may decreased the plasma Ca concentration rapidly
  • FLUIDS AND ELECTROLYTES
    • HYPERPHOSPHATEMIA
    • Serum concentration > 4.5 mg/dL
    • Major problem with excess phosphate in the blood is its interaction with calcium
    • Causes:
      • Increased phosphate intake
      • Release of phosphate from cells
      • Decreased phosphate excretion
  • FLUIDS AND ELECTROLYTES
    • HYPERPHOSPHATEMIA
    • Serum concentration > 4.5 mg/dL
    • Clinical Manifestations:
      • Serum Ca decrease as serum phosphate increases
      • Increased neuromuscular excitability
      • Conjunctivitis
      • Band keratopathy
      • Pruritus
      • Acute renal failure
      • Arthritis
    • The serum calcium does not fall resulting to precipitation of CaPO 4 salts in soft tissues of the body
  • FLUIDS AND ELECTROLYTES
    • HYPERPHOSPHATEMIA
    • Serum concentration > 4.5 mg/dL
    • Laboratory Values:
      • Plasma calcium decreases
      • Hyperkalemia
      • Hypermagnesemia
      • Metabolic acidosis
      • Increase BUN
      • Increase creatinine
    • Interventions:
      • CaPO 4 precipitation in urinary tract
      • Pruritus
  • FLUIDS AND ELECTROLYTES
    • HYPERPHOSPHATEMIA
    • Serum concentration > 4.5 mg/dL
    • Medical Therapy:
      • Restrict dietary PO 4
      • Fluid administration to increase urinary PO 4 excretion
      • PO 4 binder therapy – aluminum ions in antacids bind PO 4 in GI preventing its absorption, antacid to be taken during not after meals
      • MgAl antacid not to be used in renal failure, Mg is contraindicated
  • FLUIDS AND ELECTROLYTES
    • MAGNESIUM BALANCE & IMBALANCES
    • Most of Mg ions in the body are located in the bones
    • Rest of Mg is intracellular especially in the liver and skeletal muscles
    • Small amount of Mg in the blood
    • Normal Concentration = 1.5 – 2.5 mEq/L
    • Foods high in Mg content: whole grain cereals, dark green vegetables, dried beans and peas, soy products, nuts (except cashew and almonds), peanut butter, cocoa, chocolate, bananas, egg yolk, sea salt
  • FLUIDS AND ELECTROLYTES
    • HYPOMAGNESEMIA
    • Serum Mg < 1.5 mEq/L
    • Causes:
      • Decreased Mg intake or absorption
      • Decreased physiological availability of Mg
      • Increased Mg excretion
      • Mg loss by abnormal route
  • FLUIDS AND ELECTROLYTES
    • HYPOMAGNESEMIA
    • Serum Mg < 1.5 mEq/L
    • Clinical Manifestations:
      • Serum Mg < normal
      • Insomnia
      • Hyperreflexia
      • Chvostek ’s sign
      • Trosseau ’s sign
      • Leg and foot cramps
      • Grimacing
      • Dysphagia
      • Ataxia
      • Nystagmus
      • Tetany
      • Seizures and decrease level of consciousness
      • Cardiac arrhythmias
      • ECG changes: ST & T wave abnormalities
  • FLUIDS AND ELECTROLYTES
    • HYPOMAGNESEMIA
    • Serum Mg < 1.5 mEq/L
    • Laboratory Values:
      • Abnormal plasma concentration of other electrolytes
      • Hypokalemia
      • Hypocalcemia
      • Hypophosphatemia
      • Hyponatremia
    • Medical Therapy:
      • Mg replacement (oral or IV)
      • IV SO4 must be carefully administered
      • Check for adequate renal function and patellar reflexes before Mg administration (decreased or diminished reflexes may need to recheck if may have elevated)
  • FLUIDS AND ELECTROLYTES
    • HYPERMAGNESEMIA
    • Serum Mg > 2.5 mEq/L
    • Causes:
      • Increased Mg intake or absorption
      • Shift of Mg from bones to blood
      • Decreased Mg excretion
  • FLUIDS AND ELECTROLYTES
    • HYPERMAGNESEMIA
    • Serum Mg > 2.5 mEq/L
    • Clinical Manifestations:
      • Decreased neuromuscular excitability
      • Increased serum Mg
      • Hypotension
      • Flushing, diaphoresis
      • Drowsiness, lethargy
      • Diminished deep tendon reflexes
      • Flaccid paralysis
      • Respiratory depression
      • Bradycardia
      • Cardiac arrhythmias
      • Cardiac arrest
      • ECG changes
  • FLUIDS AND ELECTROLYTES
    • HYPERMAGNESEMIA
    • Serum Mg > 2.5 mEq/L
    • Medical Therapy:
    • Removal of excess Mg from plasma
      • With normal renal function, administer large amount of fluid to increased renal Mg excretion
      • In renal failure, hemodialysis maybe use
      • In severe hypermagnesemia, calcium salts maybe administered IV to counteract the cardiotoxicity of excess extracellular Mg
    • Complications:
      • Hypercalcemia
      • Tissue sloughing (infiltration)
      • Digitalis toxicity
    • ACID – BASE BALANCE
  • FLUIDS AND ELECTROLYTES
    • ACID – BASE IMBALANCE
    • Hydrogen ions are vital to life and health
    • The concentration of hydrogen ions in the body is less than that of other ions
    • Acid-base status of patient is obtained from sample of arterial blood (ABG)
        • Normal blood pH = 7.35 – 7.45
        • pCO 2 = 36 – 44 mmHg
        • HCO 3 = 22 – 26 mEq/L
    • pH < 7.35 is acidosis
    • pH > 7.45 is alkalosis
    • pH limit compatible to life 7.0 – 7.8
  • FLUIDS AND ELECTROLYTES
    • ACID – BASE IMBALANCE
    • Mechanisms regulating Acid-Base Balance:
    • A. Chemical buffers in cells and ECF
      • Instantaneous action
      • Combine acids or bases added to the system to prevent marked changes in pH
    • B. Respiratory system
      • Minutes to hours in action
      • Controls CO 2 concentration in ECF by changes in rate and depth of respiration
    • C. Kidneys
      • Hours to days in action
      • Increases or decreases quantity of NaHCO 3 in ECF
      • Combines HCO 3 or H with other substances and excreted in urine
  • FLUIDS AND ELECTROLYTES
    • ACID – BASE PNEMONIC: R – O – M – E
    • R – Respiratory
    • O – Opposite
    • pH increase pCO 2 decrease – alkalosis
    • pH decrease pCO 2 increase – acidosis
    • M – Metabolic
    • E – Equal
    • pH increase HCO 3 increase – alkalosis
    • pH decrease HCO 3 decrease – acidosis
  • FLUIDS AND ELECTROLYTES Elevate pH with IV NaHCO 3 Oral bicarbonate or citrate in chronic metabolic acidosis Improvement of ventilation through bronchodilators or mechanical support For severe type, infusion of NaHCO 3 to raise the pH toward normal THERAPY Decreased HCO 3 ion concentration, hyperventilation (compensatory mechanism), headache, abdominal pain, confusion, drowsiness, lethargy, stupor, coma, arrhythmias Increased pCO 2 , headache, blurred vision, disorientation, tachycardia, cardiac arrhythmias, lethargy, somnolence MANIFESTATIONS Acid accumulation by ingestion, by increased metabolic acid production, by utilization of abnormal or incomplete metabolic pathways, by impaired acid excretion, and primary decrease of HCO 3 Decreased gaseous exchange Impaired neuromuscular function Suppressed ventilatory mechanism on brain stem (medulla) CAUSE METABOLIC (Noncarbonic acid excess) RESPIRATORY (Carbonic acid excess) ACIDOSIS
  • FLUIDS AND ELECTROLYTES Directed toward treating the original cause and enhance the renal excretion of bicarbonate to correct imbalance Dialysis may be instituted if profound Correct the underlying disorder Monitor for its effectiveness and potential complications THERAPY Initial disorder, nausea, emesis, paresthesias, tetany, seizures, profound disorder, confusion, lethargy, coma Decreased pCO 2 , diaphoresis, lightheadedness, paresthesias (fingers, toes, circumoral), muscle cramps, Chvostek ’s and Trosseau ’s sign, carpopedal spasm, tetany, syncope, arrhythmias MANIFESTATIONS Decreased of acid Increased of base (bicarbonate ions) Hyperventilation CAUSE METABOLIC (Noncarbonic acid deficit) RESPIRATORY (Carbonic acid deficit) ALKALOSIS
  • FLUIDS AND ELECTROLYTES B. Isotonic Fluid: Osmolality = 240 – 340 mOsm/L, treat hypotension due to hypovolemia Ringer’s lactate, blood components, 0.9% NaCl C. Hypertonic Fluid: Osmolality 340 mOsm/L or higher 5% Dextrose in 0.45% NaCl, 5% Dextrose and 0.9% NaCl, 10% or 20% or 50% Dextrose, 3% and 5% NaCl, hyperalimentation Blood and blood products Stabilized human serum (SHS) Haemacel Human albumin Plasma protein fraction (PPF) A.Hypotonic Fluid: Osmolality < 240 mOsm/L, lowers serum Na 0.45% NaCl, 5% Dextrose Water, 0.2% NaCl Solutions that do not dissolved Not true solutions Increase intravascular colloid osmotic pressure True solutions Capable of passing through a semipermeable membrane COLLOID SOLUTIONS CRYSTALLOID SOLUTIONS TYPES OF INTRAVENOUS SOLUTIONS
  • Osmosis. Erythrocytes undergo no change in size in Isotonic solutions (A). There is increase in size in Hypotonic solutions (B) and decrease in size [shrink/crenate] in Hypertonic solution (C).
  • FLUIDS AND ELECTROLYTES
    • Exerts higher osmotic pressure than that of blood plasma
    • Increases solute concentration of plasma, drawing water out of cells into ECF compartment
    • Uses:
    • Electrolyte replacement
    • Expand intravascular compartment
    • Total parenteral nutrition
    • Caution:
    • Irritating to veins
    • May cause circulatory overload
    • Exerts the same osmotic pressure as that found in plasma
    • Use to expand ECF compartments
    • Do not affect the intracellular and interstitial compartments
    • Fluid does not alter serum osmolality
    • Can be used to treat hypotension caused by hypovolemia
    • Uses:
    • Expands intravascular compartment
    • Caution:
    • Can cause circulatory overload
    • Dilutes concentration of Hgb
    • Exerts less osmotic pressure than that of blood plasma
    • Cause dilution of plasma solute concentration, cause the fluid shift out of blood vessels and interstitial spaces where osmolality is higher
    • Hydrates cell while depleting circulatory system
    • Lowers serum Na
    • Not to give hypotonic solutions to hypotensive patients
    HYPERTONIC ISOTONIC HYPOTONIC
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  • Thank You ! Dr. Ronald Sanchez - Magbitang
  • BASIC INTRAVENOUS THERAPY TRAINING PROGRAM TOTAL PARENTERAL NUTRITION (TPN) Solutions Used in TPN
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  • PARENTERAL NUTRITION
    • NUTRITION
      • The science of foods, nutrients, and other substances therein; their actions, interactions and balance in relation to health and disease
      • The process by which an individual organism, ingest, digest, absorbs, transport, and utilizes nutrients and disposed of their end products
      • Also concern with the social, economic, cultural, and psychological implications of food and eating
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  • PARENTERAL NUTRITION
    • Nutritional Balance Scale
    • EXCESS NUTRITION
    • NORMAL NUTRITION
    • Primary DEFICIENCY Secondary
    • (Social) (Disease)
    • Tissue Depletion
    • Biochemical Lesions
    • Clinical signs
        • Normal nutrition implies a BALANCE that avoids deficiencies of intake or excessive intake
  • PARENTERAL NUTRITION
    • MALNUTRITION
      • Frequently accompanies acute and chronic diseases
      • 48 – 50% hospitalized to medical /surgical wards are found (in studies) undernourished
      • Consequences:
        • Disease complications
        • More susceptibility to infection
        • Poor/delayed wound healing and recovery
        • Higher mortality rates
  • PARENTERAL NUTRITION
    • Malnutrition in hospital is surprisingly common
    • Up to 50% of patients admitted to medical and surgical wards are undernourished or become so during their stay
    • They are more likely to suffer from complications, they are more susceptible to infection and they experience poor or delayed wound healing
    • Their mortality rates are higher and their stays in hospital longer
    • Mortality and morbidity are reduced when nutritional status is improved
    • Intravenous nutrition has now become the accepted method for the prevention or correction of malnutrition in patients who cannot be provided with adequate nutrition by the gastrointestinal route
  • PARENTERAL NUTRITION
    • Intravenous nutrition has now become the accepted method for the prevention or correction of malnutrition in patients who cannot be provided with adequate nutrition by the gastrointestinal route
  • PARENTERAL NUTRITION Hill et. al. (1977) Lancet 1: 687
  • PARENTERAL NUTRITION
    • DIETARY ADVICE AND DECISION TO IMPROVE NUTRITIONAL SUPPORT
    • “ IS THE
    • GASTROINTESTINAL TRACT… FUNCTIONAL…?”
  • PARENTERAL NUTRITION
    • What is the patient’s NUTRITIONAL STATUS ?
    • Ensure that adequate
    • Nutritional state is ADEQUATE INADEQUATE
    • Maintained.
    • Re-assess if appropriate Is active nutritional support indicated ?
    • NO YES
    • Is the GASTROINTESTINAL TRACT FUNCTIONAL ?
    • NO YES
    • PARENTERAL NUTRITION
    • Short-term Long-term ENTERAL NUTRITION
    • Support Support
    • Peripheral Line Central line
    • Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract.
    • Fluids are given into a vein to provide most of the necessary nutrients the body needs.
    • The method is used when a person cannot or should not receive feedings or fluids by mouth.
    • TPN is used for patients who cannot or should not get their nutrition through eating
    • TPN may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elements
    • The solution may contain all or some of these substances, depending on your condition.
    • Even though TPN often includes lipids, it will not make you fat
    • Everyone needs calories, protein, and fat, in addition to other substances, to stay healthy
    • Electrolytes include sodium, potassium, chloride, phosphate, calcium, and magnesium
    • Trace elements include zinc, copper, manganese, and chromium
    • Electrolytes are important for maintaining almost every organ in your body
    • They help your heart, muscles, and nerves to work properly and keep you from becoming dehydrated.
    • Total parenteral nutrition (TPN) is sometimes called central parenteral nutrition (CPN) or &quot;hyperal&quot; (hyperalimentation).
    • The term &quot;hyperalimentation&quot; is a misnomer because it incorrectly implies that nutrients are supplied in excess of needs.
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY
    • Objectives:
        • To prevent or treat malnutrition
        • Control diet related manifestation or disease
        • Delay progression of chronic disease
        • Provide support for other medical or surgical treatment
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY
    • Guiding Principles to Sound Diet Therapy:
        • Nutrition-related problem must be present
        • Diet therapy must be based on solid scientific rationale
        • Patient must be able and willing to eat and have a functional gastrointestinal system
        • Patient must adhere to the diet
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY
    • Decision Process for Using
    • PARENTERAL OR ENTERAL NUTRITION:
        • Knowledge of the potential benefits and risks of nutritional support
        • The ability to communicate the benefits and risks to the patient and family
        • Awareness of legal requirements pertinent to the issue
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY
    • Risk and Benefits of Nutrition Support:
        • The body’s need for continued existence must be met by EXOGENOUS foodstuffs or tissue catabolism
        • Adequate nutrient supply is necessary to avoid catabolism, BUT nutrient excess can be expensive and toxic, causing hypermetabolism, fatty liver, uremia, and encephalopathy
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY
    • Planning Diet Therapy:
        • Assessment
        • Prescription
        • Care Plan
  • PARENTERAL NUTRITION
    • FUNDAMENTALS OF NUTRITIONAL THERAPY:
        • Clinical history
        • Dietary history
        • Physical examination findings
        • Anthropometric measurements
        • Muscle function test
        • Biochemical data
        • Immunological test
  • PARENTERAL NUTRITION < 70% 70 – 79% 80 – 90% % ideal body weight anergy reactive reactive Cell – mediated immunity < 800 800 - 1199 1200 - 2000 Total lymphocyte count, mm 3 > 10% over 6 months > 7.5% over 3 months > 5% over 1 month Weight loss < 100 100 - 149 150 - 200 Transferrin, mg/dL < 2.1 2.1 – 2.7 2.8 – 3.4 Albumin, g/dL < 80% 80 – 89% 90 – 95% % usual body weight Severe Moderate Mild PROTEIN – CALORIE DEFICIENCY
  • PARENTERAL NUTRITION
    • PARAMETERS TO ASSESS NUTRITIONAL STATUS:
        • Arm-muscle circumference
        • Mid-arm muscle circumference
        • Triceps skin-fold thickness
        • Plasma proteins
  • PARENTERAL NUTRITION
    • PARAMETERS TO ASSESS NUTRITIONAL STATUS:
        • Arm-muscle circumference
        • = π X triceps skin-fold thickness
        • (pi)
  • PARENTERAL NUTRITION
    • PARAMETERS TO ASSESS NUTRITIONAL STATUS:
        • Arm-muscle circumference
        • Mid-arm muscle circumference (Adults)
        • Standard: male = 25.3 cm
        • female = 23.2 cm
        • Nutritional Depletion: mild = 90% standard
        • mod = 70 – 80% standard
        • severe = 60% standard
    Frisancho AR. Triceps skinfold and upper arm muscle size for assessment of nutritional status. Am J. Clin. Nutr. 1974; 27: 1052
  • PARENTERAL NUTRITION
    • PARAMETERS TO ASSESS
    • NUTRITIONAL STATUS:
        • Arm-muscle circumference
        • Mid-arm muscle circumference
        • Triceps skin-fold thickness
        • Standard: male = 12.5mm
        • female= 16.5mm
        • Nutritional Depletion: mild = 90% standard
        • mod = 70 – 80% standard
        • severe = 60% standard
    Dumin JV and Ramaman MM. The assessment of the amount of fat in the human body from measurement of skinfold thickness. Br. J. Nutr. 1967; 21:681
  • PARENTERAL NUTRITION
    • PARAMETERS TO ASSESS NUTRITIONAL STATUS:
        • Arm-muscle circumference
        • Mid-arm muscle circumference
        • Triceps skin-fold thickness
        • Plasma proteins: Half-lives and Levels
    Rothschild MA, et.al. Albumin Synthesis (1 st of two parts). N. Eng. J. Med. 1972; 286: 748 < 0.1 g/L 12 hours Retinal Binding Protein < 0.2 g/L 2 days Pre-albumin < 2.0 g/L 8 days Transferrin < 35 g/L 20 days Albumin Values in Malnutrition Half - life Plasma Proteins Half-lives and Levels in Malnutrition
  • PARENTERAL NUTRITION Bistrian BR, et.al. Cellular Immunity in semi-starved states in hospitalized adults. Am. J. Clin. Nutr. 1975; 28: 1148 Elwyn DH. Nutrional Requirements of Adult Surgical Patients: Crical Care Medicine 1980; Vol. 8, No. 1: 9-20 Lee HA. Methods of Assessment IN: Johnston IDA and Lee HA, eds Development in Clical Nutrion Tunbridge Wells. MCS Consultants 1979; 75-78 800 – 1200 /mm Moderate malnutrition < 800 /mm 1200 – 2000 /mm Severe malnutrition Mild malnutrition TOTAL LYMPHOCYTE COUNT 16 - 20 12 - 16 8 - 12 Nitrogen (gms) 2000 – 3000 2000 - 2500 1500 - 2000 Energy (kcals) Highly increased Moderately increased Normal Total Daily Body Requirement GUIDELINES TO ENERGY AND NITROGEN REQUIREMENTS
  • PARENTERAL NUTRITION
    • NUTRITIONAL THERAPY PRESCRIPTION
      • The design of individual regimen
      • The basal requirement for:
        • Protein
        • Energy
        • Water
        • Electrolytes and minerals
        • Essential biological elements
        • Vitamins
  • PARENTERAL NUTRITION
    • THE DESIGN OF INDIVIDUAL REGIMEN
    • BODY WEIGHT
      • Usual Body Weight (UBW)
      • Ideal or Desirable Body Weight (IBW / DBW)
  • PARENTERAL NUTRITION
    • BODY WEIGHT (BW)
    • 1. Infants:
    • 1 st 6 mos:
    • DBW (gm) = birth wt (gm) + age (mos) X 600
    • 7 – 12 mos:
    • DBW (gm) = birth wt (gm) + age (mos) X 300
    • 2. Children:
    • DBW (kg) = age (years) X 2 + 8
  • PARENTERAL NUTRITION
    • BODY WEIGHT (BW)
    • 3. Adolescents and Adults:
    • A. Tannhauser’s method:
    • DBW (kg) = height (cm) – 100, OR *Filipino stature DBW – 10%
    • = height (cm) X 2.54 – 100
    • B. Hamwi’s method:
    • Male: 5 ft = 106 lbs + 6 lbs in every inch > 5 ft
    • Female: 5 Ft = 105 + 5 lbs in every inch > 5 ft
    • C. NDAP Formula:
    • Male: 5 ft = 112 lbs + 4 lbs in every inch > 5 ft
    • Female: 5 ft = 106 lbs + 4 lbs in every inch > 5 ft
  • PARENTERAL NUTRITION
    • BODY WEIGHT (BW)
    • Adjusted Weight = IBW + (Actual body wt – IBW) X 0.25
    • The following Prescription Plan will be derived from the estimated BW:
        • Basal Energy Expenditure (BEE)
        • Total Energy Expenditure (TEE)/ Total Caloric Requirement (TER)
        • Energy Sources Requirements
        • Water / Fluid Requirements or Replacements
        • AND … Basal Daily Requirement of Micronutrients, Vitamins, Minerals
  • PARENTERAL NUTRITION
    • BASAL ENERGY EXPENDITURE (BEE)
    • Harris – Benedict Equation:
        • Male: 66 + (13.7 x weight, kg) + (5 x height, cm) – 6.8 x age
        • Female: 635 + (9.6 x weight, kg) + (1.85 x height, cm) – 4.7 x age
    • TOTAL ENERGY EXPENDITURE (TEE)
      • = BEE x activity factor x stress factor
    • TOTAL ENERGY REQUIREMENT (TER) or TOTAL CALORIC REQUIREMENT/day
    • = DBW x activity factor (kcals / kgDBW / day)
  • PARENTERAL NUTRITION = 110 – 120 kcal/kgDBW/day 1. Infants 45.0 heavy 40.0 moderate 35.0 light 30.0 sedentary 27.5 bed rest Kcal/kgDBW/day Activity Level: Kraus Method 4. Adults: * Average for both sexes = 50 kcals/kgDBW/day 45 50 16 – 19 years old 50 55 13 – 15 years old Girls Boys 3. Adolescents: = 1000 + (100 x age, years) 2. Children ACTIVITY FACTORS
  • PARENTERAL NUTRITION 1.30 – 1.80 Pancreatitis 1.30 – 1.55 Liver Failure 1.30 Acute Renal Failure 1.30 – 1.55 - with major operation 1.20 – 1.30 - with dialysis or sepsis 0.80 – 1.00 - without sepsis Cardioplulmonary Disease 1.20 – 1.30 Bone Marrow transplant 1.30 – 1.35 ARDS or Sepsis 1.05 – 1.25 Peritonitis or other infections 1.00 – 1.10 Elective Surgery 0.80 – 1.00 Starvation Stress Factor Clinical Conditions: DISEASE STRESS FACTORS
  • PARENTERAL NUTRITION Liver failure Severe burn 45 kcals/kgDBW/day Severe Stress Sever infection Fracture 35 kcals/kgDBW/day Moderate Stress Mild infection Elective surgery 25 kcals/kgDBW/day Mild Stress Examples Energy Requirement Simplified Estimate DAILY ENERGY EXPENDITURE
  • PARENTERAL NUTRITION
    • From the estimated ideal and desirable BW, will divide and compute for:
        • BEE
        • TER
        • Energy requirement for:
            • Carbohydrate
            • Fats/lipids
            • protein
        • Water and fluid requirement
        • Basal daily requirements for vitamins and minerals (including the trace elements)
  • PARENTERAL NUTRITION
    • ENERGY SOURCES / REQUIREMENTS
    • Caloric Allowances
        • 1 st to consider in writing a diet prescription
        • Base on patient's weight, height, age, sex, and the estimated activity or stress factor
    • Dietary Balances: Food Components
        • CARBOHYDRATE 50 – 60% TER ~ 4kcal/gm
        • PROTEIN 15 – 20% TER ~ 4kcal/gm
        • FAT 20 – 30% TER ~ 9 kcal/gm
  • PARENTERAL NUTRITION
    • THE FOOD EXCHANGE SYSTEM:
      • Grouped together different foods but containing the same amount of carbohydrates, proteins, and fat
      • Consist of 6 food groups ( by the American Dietetic Association, ADA, and US Public Health Service), or 7 food groups (by the Food and Nutrition Research Institute, FNRI)
  • PARENTERAL NUTRITION * Rice another food group added by FNRI 100 - 2 23 80 ½ cup *RICE 45 5 - - 5 1 tsp Fat 55 75 3 3 7 7 - - 30 30 1 ounce 1 ounce Meat, low fat Meat,med fat 70 - 2 15 varies Bread 40 - - 10 varies Fruit 25 - 2 5 100 ½ cup Vegetables 80 179 - 10 8 8 12 12 240 240 1 cup 1 cup Milk, non-fat Milk, whole Energy (kcal) Fat (gm) Protein (gm) Carbohydrate (gm) Weight (gm) Measure Food Exchange COMPOSITION OF FOOD EXCHANGE LIST
  • PARENTERAL NUTRITION
    • INTRAVENOUS NUTRITION
        • Reserved for malnourished patients who are likely to become, and the GIT is not functional or is not accessible
    • ENTERAL NUTRITION
        • Includes both the delivery of food and nutrients orally and via tube directly into the GIT
        • Oral supplements
  • PARENTERAL NUTRITION
    • Common Conditions where IV nutrition is often used:
        • Post-operative states where oral or tube feeding is contraindicated for > 4 – 5 days
        • Short bowel syndrome
        • Gastrointestinal fistulae
        • Prolonged paralytic ileus
        • Acute pancreatitis
        • Multiple injuries – involved the viscera
        • Major sepsis
        • Severe burn
        • Inflammatory bowel syndrome
    • Is the disease process likely to cause
    • NUTRITIONAL IMPAIRMENT ?
    • YES
    • Is the patient MALNOURISHED or the patient strongly AT-RISK for
    • malnutrition ?
    • YES
    • Would preventing or treating the malnutrition
    • NUTRITION SUPPORT will improve the
    • prognosis and quality of life ?
    • YES NO
    • What are the fluid, energy, and Risk and discomfort of the nutritional
    • vitamin requirement; and can these support would out-weigh potential
    • be provided ENTERALLY ? benefits.
    • Explain issue to patient and family.
    • YES NO Support the patient with general
    • measures including oral food and
    • Can requirements be met through Does the patient require TPN ? liquid supplements.
    • ORAL food & liquid supplements ?
    • YES NO NO YES
    • Calorie Count Feeding Tube CVL, PICC or CVL or PICC
    • Clin. Assessment Peripheral line
    • + Enteral nutrition
    • weeks months/years weeks months/years
    • nasally inserted percutaneous inserted Subclavian catheter or PICC Tunneled external line or
    • subcutaneous infusion port
  • PARENTERAL NUTRITION
    • ENERGY SOURCES FOR PARENTERAL NUTRITION: Protein
    • PROTEIN
    Elwyn DH. Nutrional Requirements of Adult Surgical Patients: Crical Care Medicine 1980; Vol. 8, No. 1: 9-20 Lee HA. Methods of Assessment IN: Johnston IDA and Lee HA, eds Development in Clical Nutrion Tunbridge Wells. MCS Consultants 1979; 75-78 16 - 20 12 - 16 8 - 12 Nitrogen (gms) 2000 – 3000 2000 - 2500 1500 - 2000 Energy (kcals) Highly increased Moderately increased Normal Total Daily Body Requirement PROTEIN: Amino Acids/ Nitrogen Requirement
  • PARENTERAL NUTRITION
    • Essential Amino Acids:
        • Threonine
        • Isoleucine
        • Lysine
        • Methionine – Cysteine
        • Histidine
        • Valine
        • Leucine
        • Tryptophan
        • Phenylalanine – Tyrosine
        • (Arginine)
    • Branched-chain Amino Acids:
      • Leucine
      • Isoleucine
      • Valine
      • Peripherally metabolized
      • Important in liver failure and encephalopathy
  • PARENTERAL NUTRITION
    • NITROGEN REQUIREMENT:
      • 12 – 16 gm
          • Administered daily with appropriate non-protein energy sources
      • 8 – 12 gm
          • Elderly, female, frail, and starved patient
      • >18 gm
          • Increased by youth, male sex, large body frame, weight loss, sepsis, and trauma
  • PARENTERAL NUTRITION
    • ENERGY SOURCES FOR PARENTERAL NUTRITION: Non – Protein Energy Sources
    • CARBOHYDRATE:
      • Glucose is the preferred IV carbohydrate
      • Problems associated with glucose as “single-energy system”:
          • Hyperglycemia
          • Fatty infiltration of the liver
          • Excessive CO 2 production
          • Excessive O 2 consumption
          • Essential fatty acid deficiency
  • PARENTERAL NUTRITION
    • ENERGY SOURCES FOR PARENTERAL NUTRITION: Non – Protein Energy Sources
    • FAT / LIPID
      • “ dual – energy system”
      • Lipid emulsions: Fatty acids
    • ESSENTIAL FA:
      • Linoleic Acid
      • Linolenic Acid
    • NON-ESSENTIAL FA:
      • Oleic acid
      • Palmitic acid
      • Stuaric acid
  • PARENTERAL NUTRITION 20.0 – 120.0 150.0 – 300.0 Molybdenum, μ g 15.0 – 30.0 50.0 – 200.0 Chromium, μ g 2.0 – 5.0 2.0 – 5.0 Manganese, mg 0.15 0.15 Iodine, mg 0.3 – 0.5 2.0 – 3.0 Copper, mg 3.0 – 12.0 15.0 Zinc, mg 1.0 – 2.0 10 Iron, mg 0.3 0.3 Magnesium, gm 3.0 – 4.0 2.0 – 3.0 Chloride, gm 1.0 – 3.0 1.0 – 3.0 Sodium, gm 3.0 – 4.0 2.0 – 5.0 Potassium, gm 0.4 – 0.8 0.8 – 1.2 Phosphorus, gm 0.2 – 0.4 0.8 – 1.2 Calcium, gm 2.0 – 4.0 1.0 – 2.0 Essential fatty acids, % kcal Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL
  • PARENTERAL NUTRITION 200.0 70.0 – 140.0 Vitamin K, μ g 10.0 – 15.0 8.0 – 10.0 Vitamin E, mg 5.0 – 10.0 10.0 Vitamin D, μ g 1000.0 1000.0 Vitamin A, μ g 3.0 3.0 Cobalamin, μ g 400.0 400.0 Folic acid, μ g 4.0 2.0 Pyridoxine, mg 15.0 5.0 Panthotenic acid, mg 60.0 60.0 Biotin, μ g 40.0 18.0 Niacin, mg 3.60 1.60 Riboflavin, mg 3.0 1.40 Thiamine, mg 100.0 60.0 Ascorbic Acid, mg 50.0 – 100.0 50.0 – 200.0 Selenium, μ g Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL
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  • TOTAL PARENTERAL NUTRITION
    • WATER AND FLUID REQUIREMENT
      • Base on the amount of daily water loss from individual body
      • Depends on activity and environmental temperature
      • Infants have high body surface area – high water content and needs for higher amount of water/fluid per day
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    • Total Body water = 60% body weight
    Approximate size of body compartment in 70-kg adult 0 100 200 300 1% 5% 14% 28 liters Transcellular 1L Plasma 3.5L Interstitial 10 liters Extracellular Water 20% BW Intracellular water 40% BW Osmolality – mOsm/L
  • TOTAL PARENTERAL NUTRITION
    • WATER AND FLUID REQUIREMENT
    = 700 ml Insensible loss = 1400 ml urine = 100 ml feces Average Fluid Intake = 2300 ml = 100 ml sweat 6600 ml 3300 ml 2300 ml Total: 100 ml 100 ml 100 ml Feces 5000 ml 1400 ml 1000 ml Sweat 500 ml 1200 ml 1400 ml Urine 650 ml 250 ml 350 ml Resp. Tract 350 ml 350 ml 350 ml Skin Insensible losses: Exercise Hot Temp Normal Temp
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  • PARENTERAL NUTRITION
    • DIETARY FIBERS
      • “ indigestible substance” – roughage, bulk, residue, cellulose, fibers
      • Non-nutritive substance - polysaccharides and lignin; mostly from plant sources
      • Important for maintenance of normal GIT physiology
      • The amount of fiber in the diet is not known
  • PARENTERAL NUTRITION
    • Effects of Dietary Fibers:
      • Maintains normal gastrointestinal physiology
      • Influence by the fiber’s characteristics, particle size, fiber interaction between them and other dietary components and the bacterial flora
          • Dietary fibers hold water – stool elimination
          • Increase motility of small intestine and colon – decrease transit time
          • Pectins, mucilage, and gums retard gastric emptying time, and chelate with bile acids and steroid materials
          • Pectins, hemicellulose, gums, and mucilage are partially fermented by the bacterial flora
          • High-fiber diet: reduce intraluminal pressure in colon and lowers coefficients of digestability
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  • PARENTERAL NUTRITION
    • CARE PLANNING
        • Involves the provision of specialized nutritional support need
        • Knowledge of the problem needing a scientific and rational nutritional therapy
        • Risks and benefits, including legal requirements
    • A continuous regular monitoring of the patient’s status to ensure that prescribed regimen meet the patient’s need, and avoid the possible toxicity and its complications
    • Is the disease process likely to cause
    • NUTRITIONAL IMPAIRMENT ?
    • YES
    • Is the patient MALNOURISHED or the patient strongly AT-RISK for
    • malnutrition ?
    • YES
    • Would preventing or treating the malnutrition
    • NUTRITION SUPPORT will improve the
    • prognosis and quality of life ?
    • YES NO
    • What are the fluid, energy, and Risk and discomfort of the nutritional
    • vitamin requirement; and can these support would out-weigh potential
    • be provided ENTERALLY ? benefits.
    • Explain issue to patient and family.
    • YES NO Support the patient with general
    • measures including oral food and
    • Can requirements be met through Does the patient require TPN ? liquid supplements.
    • ORAL food & liquid supplements ?
    • YES NO NO YES
    • Calorie Count Feeding Tube CVL, PICC or CVL or PICC
    • Clin. Assessment Peripheral line
    • + Enteral nutrition
    • weeks months/years weeks months/years
    • nasally inserted percutaneous inserted Subclavian catheter or PICC Tunneled external line or
    • subcutaneous infusion port
  • PARENTERAL NUTRITION
    • MONITORING
        • The need to re-assess the status of individual patient to have assurance of adequate specialized nutritional supportive regimen
        • Meets the benefits and needs of patient, and avoid or prevent occurrence of any toxicity and complication
  • PARENTERAL NUTRITION
    • MONITORING
    • General Parameters:
        • Clinical history
        • Dietary history
        • PE findings, includes V/S and anthropometric measurements
    • Standard Laboratory Test:
        • Albumin
        • Pre-albumin
        • Lymphocytic counts
        • Cell-mediated immunity
    • Special Studies:
        • Nitrogen balance determination
        • 24 o urine Urea Nitrogen
        • (Protein intake/ 6.25) – UUN / 0.8 + 2
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Metabolic Complications associated with Nutrients: Fat
      • Metabolic Complications associated with Nutrients: Amino Acid
      • Metabolic Complications associated with Fluid and Electrolyte Imbalance
      • Other Complications
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Pneumothorax Hydrothorax
      • Air embolism Nerve injury
      • Central venous thrombosis arrhythmias
      • Partial catheterization
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Sepsis
      • Catheter blockage
      • Air embolism
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Hyperglycemia
      • Hypoglycemia
      • Respiratory distress
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Metabolic Complications associated with Nutrients: Fat
      • Hyperlipidemia
      • Essential fatty acid deficiency
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Metabolic Complications associated with Nutrients: Fat
      • Metabolic Complications associated with Nutrients: Amino Acid
      • Hyperammonemia
      • Metabolic acidosis
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Metabolic Complications associated with Nutrients: Fat
      • Metabolic Complications associated with Nutrients: Amino Acid
      • Metabolic Complications associated with Fluid and Electrolyte Imbalance
      • Dehydration and overhydration
      • Sodium imbalance
      • Potassium imbalance
  • PARENTERAL NUTRITION
    • PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS
      • Complications of Catheterization
      • Catheter-related Complications
      • Metabolic Complications associated with Nutrients: Glucose
      • Metabolic Complications associated with Nutrients: Fat
      • Metabolic Complications associated with Nutrients: Amino Acid
      • Metabolic Complications associated with Fluid and Electrolyte Imbalance
      • Other Complications
    • Hypocalcemia
    • Hypophosphatemia
    • Hypomagnesemia
    • Trace elements deficiency
    • Liver enzeyme elevation
  • PARENTERAL NUTRITION
    • ENDING PARENTERAL NUTRITION
      • Decrease appetite
      • Lactase deficiency
      • “ sip” feeding
      • … in the past , parenteral nutrition involved a complicated infusion arrangement with at least 2 IV bottles with catheter for each administration lines
      • … recent advances , now provide a single stable admixture that supply all nutrients prepared in a 500 ml to 4-liter bag
    • TPN will drip through a needle or catheter placed in your vein for 10-12 hours, once a day or five times a week.
  • The preferred method of delivering TPN is with a medical infusion pump A sterile bag of nutrient solution, between 500 mL and 4 L is provided The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open Feeding schedules vary, but one common regimen ramps up the nutrition over a few hours, levels off the rate for a few hours, and then ramps it down over a few more hours, in order to simulate a normal set of meal times.
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  •  
    • Storing your medication
      • Your health care provider probably will give you a several-day supply of total parenteral nutrition at a time. You will be told to store it in the refrigerator or freezer.
      • Take your next dose from the refrigerator 4-6 hours before using it; place it in a clean, dry area to allow it to warm to room temperature.
      • If you are told to store additional total parenteral nutrition in the freezer, always move a 24-hour supply to the refrigerator for the next day's use.
      • Do not refreeze medications.
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  • Intravenous (IV) lines are often placed into a vein in the hand, foot, or scalp of babies who are too sick to get all of their feedings and fluids by mouth. The belly button also has a large vessel that may be used for intravenous fluids. Sometimes a large IV called a central line or PICC line is placed by sterile technique or by surgery to provide long-term, highly concentrated intravenous fluid.
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    • Sample Regimen for Parenteral Nutrition
  • SAMPLE REGIMEN FOR PARENTERAL NUTRITION: Osmolality = 720 mosmol/kg water (mmol) Non-protein kcal : Nitrogen = 202 : 1 20 80 35 3.0 7.5 55 65 100 200 9.4 1900 2150 (8.0 μ J) 3040 (9.0 μ J) Total = 9.4 gm N 1 vial Solivito N 10 Vitlipid N Adult 15 100 1100 1100 1000 Intralipid 10% 20 15 15 10 Addiphos 100 400 400 1000 Glucose 10% 20 20 10 KCl 15% 20 13 1.5 5 10 Addamel 55 1.5 2.5 20 50 - 100 9.4 400 650 1000 Vamin 9 gm Zn μ mol Cl P Mg Ca K Na Fat (gm) Glucose (gm) Nitrogen (gm) Non-protein Energy (kcal) Total Energy (kcal) Quantity (ml) Preparations A. PPN – 9 gm Nitrogen, 2200 kcal (1900 non-protein kcal)
  • SAMPLE REGIMEN FOR PARENTERAL NUTRITION: Osmolality = 720 mosmol/kg water (mmol) Non-protein kcal : Nitrogen = 142 : 1 20 135.5 37.5 3.8 8.8 92.5 97.5 100 250 14.1 2000 2375 (8.4 μ J) 3055 (9.9 μ J) Total = 14.1 gm N 1 vial Solivito N 20 Vitlipid N Adult 7.5 100 1000 1000 500 Intralipid 10% 30 22.5 22.5 15 Addiphos 100 400 400 1000 Glucose 10% 40 40 20 KCl 15% 20 13 1.5 5.0 10 Addamel 82.5 2.25 3.75 30 75 - 150 14.1 600 975 1500 Vamin 9 gm Zn μ mol Cl P Mg Ca K Na Fat (gm) Glucose (gm) Nitrogen (gm) Non-protein Energy (kcal) Total Energy (kcal) Quantity (ml) Preparations B. TPN – 9 gm Nitrogen, 2100 kcal (1800 non-protein kcal)
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  • Thank You ! Dr. Ronald Sanchez - Magbitang