Intravenous Therapy: IVF, Electrolytes, TPN

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

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

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

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

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

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

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

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

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

“ Third spacing” occurs in:
Ascites
Burns
Peritonitis
Bowel obstruction
Massive bleeding into body cavity or joints

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

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

Output of Fluid – vary due to following:
Increased temperature
Increased respiration
Draining wounds
Ostomies
Gastric suction

Sources of water:
Liquids
Water-containing foods
Metabolic activities or oxidation

Elimination of Fluid:
Sensible loss (measurable)
Insensible (not measurable, e.g. skin, lungs, feces)
INSENSIBLE WATER LOSS ?

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

Routes Gain and Losses:
Kidneys
Usual daily urine volume in adult = 1 – 2 L
General Rule: 1 ml/kg/hour in all age groups

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

Lungs
Normally eliminate water vapor (insensible loss)
Rate is at 300 – 400ml/day
Loss is greater with increased respiratory rate or depth

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

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

Laboratory Tests for Evaluating Fluid Status:
Osmolarity
Reflects the concentration of the solutions
Measured in milliosmoles per liter (mOsm/L)

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

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)

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

The Electrolytes:
Cations:
Sodium
Potassium
Calcium
Magnesium
Anions:
Chloride
Bicarbonate
Phosphate

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

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

Calcium (Ca ++ )
Has 2 forms:
Ionized (free) calcium – physiologically active
Ca bound to plasma proteins

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

Magnesium (Mg ++ )
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

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

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

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

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

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

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

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

Types of Fluid Balance and Imbalance:
Saline
ECF, reflects the volume of water and salt
Water
Osmolar proportion of water and salt (concentration)

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)

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

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

(ECF Volume)
Atrial Natriuretic Peptide:
Atrial distention (increase ECF)
Release Peptides
Acts on kidney
Increase renal excretion of Na + & water
Relieveing distention

(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

Saline Imbalance: Saline Deficit
ECF volume deficit
Isotonic contraction
Isosmotic dehydration
Hypovolemia
Extracellular volume depletion

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

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

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

Saline Imbalance: Saline Excess
ECF volume excess
Isotonic expansion
Hypervolemia
Circulatory overload

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)

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

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

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

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

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

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

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.

TYPES OF WATER IMBALANCE
WATER DEFICIT:
Hypernatremia
Water depletion
Hypertonicity
Hyperosmolar balance

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)

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

WATER DEFICIT
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)

WATER DEFICIT
Pathophysiology:
Decrease Water
Increase Osmolality
Osmosis
ICF
ECF
Attempt to restore osmolality
Cells shrivels
Cell dysfunction

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

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

TYPES OF WATER IMBALANCE
WATER EXCESS:
Hyponatremia (decrease serum Na - < 135mEq/L)
Water intoxication
Hypotonicity

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

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

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

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)

WATER EXCESS
Causes:
B. Gastrointestinal – due to water replacement not by salt
Nasogastric suction
Vomiting
Diarrhea
Hypotonic irrigation solutions

WATER EXCESS
Causes:
C. Others
Burns
Excessive sweating

WATER EXCESS
Pathophysiology
Increased Water
Decrease Osmolality
Osmosis
ECF
ICF
Attempt to restore Osmolality
Cell swollen
Cell dysfunction

WATER EXCESS
Decrease serum Na
Malaise
Headache
Confusion
Lethargy
Seizures
Coma

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 )

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

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

EDEMA
2. Decrease blood osmotic pressure
A. Decrease serum Albumin
Loss of albumin
Nephrotic Syndrome
Protein-losing enteropathies
Liver disease (Cirrhosis)

EDEMA
3. Increase fluid osmotic pressure
A. Increase capillary permeability
Burns
Inflammation
Hypersensitivity reactions
Toxins
Trauma

EDEMA
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

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

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)

Electrolytes:
Normal Routes of Exit:
Urine
Feces
Sweat
Abnormal Route:
Fistula drainage
Emesis
Gastric or intestinal suction
Paracentesis
Exudates

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

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

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

HYPOKALEMIA
Serum K < 3.5 mEq/L
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

HYPOKALEMIA
Serum K < 3.5 mEq/L
Note:
Decrease K is manifested in dysfunction of all 3 kinds of muscles:
Smooth
Skeletal
Cardiac

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

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

HYPERKALEMIA
Serum K > 5.0 mEq/L
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

HYPERKALEMIA
Serum K > 5.0 mEq/L
Interventions:
Diarrhea
Muscle weakness or flaccid paralysis
Decrease ability to function
Ineffective breathing
Decreased cardiac output

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])

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)

CALCIUM BALANCE & IMBALANCES
Facts:
Calcium ions in the body are mostly located in the bones and teeth
Small amount in cells of soft tissue
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

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

HYPOCALCEMIA
Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished
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

HYPOCALCEMIA
Interventions:
Neuromuscular irritability
Laryngospasm
Paresthesia and muscle cramps
Medical Therapy:
Replacement of Calcium – oral or IV

HYPOCALCEMIA
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

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

HYPERCALCEMIA
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

HYPERCALCEMIA
Interventions:
Constipation
Nausea and vomiting – nutrition
Aspiration
Fatigue
Pain
Muscle weakness
Decreased level of consciousness
Altered thought processes
Impaired social interaction
Renal calculi

HYPERCALCEMIA
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

HYPERCALCEMIA
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

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

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

HYPOPHOSPHATEMIA
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

HYPOPHOSPHATEMIA
Laboratory Values:
Alkalosis (increased in pH especially respiratory alkalosis)
Interventions:
Decreased level of consciousness
Respiratory muscle weakness

HYPOPHOSPHATEMIA
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

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

HYPERPHOSPHATEMIA
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

HYPERPHOSPHATEMIA
Laboratory Values:
Plasma calcium decreases
Hyperkalemia
Hypermagnesemia
Metabolic acidosis
Increase BUN
Increase creatinine
Interventions:
CaPO 4 precipitation in urinary tract
Pruritus

HYPERPHOSPHATEMIA
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

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

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

HYPOMAGNESEMIA
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

HYPOMAGNESEMIA
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)

HYPERMAGNESEMIA
Serum Mg > 2.5 mEq/L
Causes:
Increased Mg intake or absorption
Shift of Mg from bones to blood
Decreased Mg excretion

HYPERMAGNESEMIA
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

HYPERMAGNESEMIA
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

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

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

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).

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

Thank You ! Dr. Ronald Sanchez - Magbitang

BASIC INTRAVENOUS THERAPY TRAINING PROGRAM TOTAL PARENTERAL NUTRITION (TPN) Solutions Used in TPN

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

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

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

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

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

DIETARY ADVICE AND DECISION TO IMPROVE NUTRITIONAL SUPPORT
“ IS THE
GASTROINTESTINAL TRACT… FUNCTIONAL…?”

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
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 "hyperal" (hyperalimentation).
The term "hyperalimentation" is a misnomer because it incorrectly implies that nutrients are supplied in excess of needs.

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

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

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

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

NUTRITIONAL THERAPY
Planning Diet Therapy:
Assessment
Prescription
Care Plan

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

PARAMETERS TO ASSESS NUTRITIONAL STATUS:
Arm-muscle circumference
Mid-arm muscle circumference
Triceps skin-fold thickness
Plasma proteins

= π X triceps skin-fold thickness
(pi)

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

PARAMETERS TO ASSESS
NUTRITIONAL STATUS:
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

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

NUTRITIONAL THERAPY PRESCRIPTION
The design of individual regimen
The basal requirement for:
Protein
Energy
Water
Electrolytes and minerals
Essential biological elements
Vitamins

THE DESIGN OF INDIVIDUAL REGIMEN
BODY WEIGHT
Usual Body Weight (UBW)
Ideal or Desirable Body Weight (IBW / DBW)

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pneumothorax Hydrothorax
Air embolism Nerve injury
Central venous thrombosis arrhythmias
Partial catheterization

Sepsis
Catheter blockage
Air embolism

Hyperglycemia
Hypoglycemia
Respiratory distress

Hyperlipidemia
Essential fatty acid deficiency

Hyperammonemia
Metabolic acidosis

Dehydration and overhydration
Sodium imbalance
Potassium imbalance

Other Complications
Hypocalcemia
Hypophosphatemia
Hypomagnesemia
Trace elements deficiency
Liver enzeyme elevation

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.

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.

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.

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)

Thank You ! Dr. Ronald Sanchez - Magbitang

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Intravenous Therapy: IVF, Electrolytes, TPN

by Ronald Magbitang on Aug 18, 2008

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Intravenous Therapy: IVF, Electrolytes, TPN — Presentation Transcript