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Parentral nutrition

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By Dr Ranjeet Patil

By Dr Ranjeet Patil

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  • 1. Parenteral Nutrition
  • 2. Parenteral nutrition is defined as the infusion of complete nutrient solutions into the bloodstream via a peripheral vein or, more commonly, by central venous access to meet nutritional needs
    Definition
  • 3. Fluid Requirements
  • 4. Conditions requiring nutrition
  • 5. Central access
    —TPN both long- and short-term placement
    Peripheral or PPN
    —New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis
    <2000 kcal required or <10 days
    Routes of Parenteral Nutrition
  • 6. Venous access site
  • 7. Utilization of peripheral veins for the administration of nutrients
    A. Indications for use:
    PN necessary but no access to central vein
    2. Malnourished patients with frequent NPO for procedures/tests
    Peripheral Parenteral Nutrition (PPN)
  • 8. B. Contraindications:
    Patient can be fed enterally
    Pt. has weak peripheral veins
    C. Limitations
    Peripheral site more prone to inflammation/infection
    Catheter may need to be repeatedly inserted Poor choice for long-term nutrition
    Peripheral Parenteral Nutrition (PPN)
  • 9. Peripherally inserted central catheter
    Benefits
    Access to central vein
    Can accommodate hypertonic fluids
    Lower risk of phlebitis than PPN
    Easier to insert than central line
    PICC Line
  • 10. Provides nutrients when less than 2 to 3 feet of small intestine remains
    Allows nutrition support when GI intolerance prevents oral or enteral support
    Advantages- Parenteral Nutrition
  • 11. Costly
    Long term risk of liver dysfunction, kidney and bone disease, and nutrient deficiencies
    Disadvantages
  • 12. GI non functioning
    NBM >5 days
    GI fistula
    Acute pancreatitis
    Short bowel syndrome
    Malnutrition with >10% to 15 % weight loss
    Nutritional needs not met; patient refuses food
    Indications for Total Parenteral Nutrition
  • 13. Working GI tract
    Terminally ill
    Only needed briefly (<14 days)
    Contraindications
  • 14. Avoid excess kcal (> 40 kcal/kg)
    Adults
    kcal/kg BW
    Obese—use desired BMI range or an adjusted factor
    Calculating Nutrient Needs
  • 15. Carbohydrate
    glucose or dextrose monohydrate
    3.4 kcal/g
    Amino acids
    3, 3.5, 5, 7, 8.5, 10% solutions
    Fat
    10% emulsions = 1.1 kcal/ml
    20% emulsions = 2 kcal/ml
    Parenteral Components
  • 16. 1.2 to 1.5 g protein/kg IBW mild or moderate stress
    2.5 g protein/kg IBW burns or severe trauma
    Protein Requirements
  • 17. Max. 0.36 g/kg BW/hr
    Excess glucose causes:
    Increased minute ventilation
    Increased CO2 production
    Increased RQ
    Increased O2 consumption
    Lipogenesis and liver problems
    Carbohydrate Requirements
  • 18. 4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid
    Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg
    Lipid Requirements
  • 19. Fluid—30 to 50 ml/kg
    Electrolytes
    Use acetate or chloride forms
    to manage acidosis or alkalosis
    Vitamins
    Trace elements
    Other Requirements
  • 20. 1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L
    2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L
    3. Fat is isotonic and does not contribute to osmolarity.
    4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L
    Calculating the Osmolarity of a Parenteral Nutrition Solution
  • 21. Total nutrient admixture of amino acids, glucose, additives
    3-in-1 solution of lipid, amino acids, glucose, additives
    Compounding Methods
  • 22. Intralipid(separately by syringe pump via a 3-way connector)
    Aminoven+5% Dextrose50% Dextrose +MVI +Heparin (0.5 - 1unit/ml)+Add. electrolytes, as reqd
    Compounds
  • 23. Start slowly(1 L 1st day; 2 L 2nd day)
    Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)
    Cyclic give 12 to 18 hours per day
    Administration
  • 24. Infection
    Hemodynamic stability
    Catheter care
    Refeeding syndrome
    Monitoring and Complications
  • 25. Hypophosphatemia
    Hyperglycemia
    Fluid retention
    Cardiac arrest
    Refeeding Syndrome
  • 26. Weight(daily)
    BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUNCa+, P Plasma transaminases
    Monitor
  • 27. BloodTwice/week Ammonia Mg Plasma transaminasesWeeklyHgbProthrombin time Zn Cu Triglycerides
    Monitor—cont’d
  • 28. Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)
    Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)
    Monitor—cont’d
  • 29. PPNSite irritation
    TPN1. Catheter sepsis2. Placement problems3. Metabolic
    Problems
  • 30. Type of feeding formula and tube
    Method (bolus, drip, pump)
    Rate and water flush
    Intake energy and protein
    Tolerance, complications, and corrective actions
    Patient education
    Document in Chart
  • 31. Thankyou