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    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . The Hitchhiker s Guide to Parenteral Nutrition Management for Adult Patients . ก. F ก F ก F (Introduction) ก F กF F F FF ก F ก ก F Enteral Parenteral กF F F F F ก F F ก F F ก กF F F F F ก F F ก (specialized nutrition support) ก ก ก F F F ก ก F ก ก F F Parnteral Nutrition F Fก ก F Fก F ก F Parenteral nutrition F กF F F F F (Indication) กก ก F (Nutrition support) Fก ก ก F F ก F F ก ก F F F F ก ก F infusion F F F ก 1 F Fก F กF F F ก ก F กF F F F F F F ก ก F ก F กF 1. ก F F (central parenteral nutrition; PN) ก Fก ก 1,2 กF กก F central venous catheter F F thrombosis ก F 2. ก F F (peripheral parenteral nutrition ; PPN) F F F (Indication) F F F (Contraindications) ก F 1 ก F (Patient assessment) ก F กF ก F PN F ก F ก ก F ก ก metabolic change F ก F F F F ก ก F F 2 ก ก F F ก ก F 1 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 1 Indications, Relative Indications Contraindications ก F (Parenteral Nutrition) F F F ก F Parenteral Nutrition o F F F F กF - Massive small-bowel resection/short bowel syndrome ( F F ก) - Radiation enteritis - Severe diarrhea - Untreatable steatorrhea/malabsorption ( F F ก ก F , small bowel bacterial overgrowth celiac disease) o ก F F pseudo-obstruction o Severe catabolism F F F 5-7 malnutrition F F Fก F o F Enteral F o F ก F F F Enteral F F o ก (Pacreatitis) F ก F F (abdominal pain ) กก F F jejunum o ก F F (Persistent GI hemorrhage) o F (Acute abdomen/ileus) o กก F F o Enterocutaneous fistula output ก ก F 500 ml F F F enteral F F F fistula F o F F F ก F ก Relative Indications ก F Parenteral Nutrition o Enterocutaneous fistula o Inflammatory bowel disease F Fก ก F ก F o ก กก ก F ก F F กก F 5-7 F F Enteral F o Partial small bowel obstruction o F F F / severe mucositis o Major surgery/stress F F FF ก F Enteral nutrition 7-10 o ก F ก F F Enteral nutrition F F F jejunum F o F (chyle) F ก (Chylous ascites) chylothorax ก 2 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . F enteral nutrition F ก F ก F F ก ก ก F F Contraindications ก F Parenteral Nutrition o F F ก o F F F F severe malnutrition F F ก ก Fก 5 o F F F (venous access) F o ก ก F F F F F F aggressive nutrition support o ก F F risk ก F PN กก F benefit 2 F F FF F Parenteral Nutrition o F ก ก ก F (Anthropometric Data) F กF - ก ก - F ก o F F ก (Lab values) F กF - F F ก ก ก metabolic panel (Comprehensive metabolic panel) - ก ก (Serum magnesium level - ก (Serum phosphorus) - triglycerides ก (Serum triglycerides) 18 o ก F ก F (Medical/Surgical History) - ก F F F (ostomies) - ก ก ก F (resections) - Pre-existing conditions F F F o ก ก F (Diet/Medication History) - ก F F - ก F - Special diets - / - F F ก F F F F ก F ก F ก F Physical stress, F F F ก F F F F F F ก ก ก ก F F ก 3 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . F ก F ก F F F ก F ก F ก กF F F F ก F กF F ก Fก กF F 3,4 F F ก F ก F stress, fever seizures ก F F ก ก F ก gold standard ก F ก F ก F indirect calorimetry ก ก F ก F F ก ก F ก F F F ก F ก - F FF ก F ก ก F ก F ก F F F F ก ก F ก F ก F Fก FF F F ก 3 F Guidelines ก ก F , F ก F ก F F F F nutrition support 5-8 3 guideline ก ก F F F F (Nutrient) ก ก ก ก ก ก (Acute Care ) (Critical Care) (Energy) 25 30 total kcals/kg/d 25 total kcals/kg/d - Refeeding 15 25 kcal/kg/d 15 25 kcal/kg/d - Obesity (≥ 130% IBW) 15 20 kcal/kg/d adjusted weight * 15 20 kcal/kg/d adjusted weight * (Protein) 0.8 1.0 g/kg/d maintenance 1.5 2.2 g/kg/d 1.2 2.0 g/kg/d catabolism Dextrose <7 g/kg/d <5 g/kg/d (Lipid) ** <2.5 g/kg/d 0.4 0.75 g/kg/d *Adjusted weight F ก F 50% correction factor ([usual weight ideal body weight] x 0.50) **ก F F PN กก F 3 F, F F 2% 4% F F ก IV fat emulsion (IVFE) F F F linoleic acid ก ก ก essential fatty acid deficiency (EFAD) ก F F (Venous access) Line F F กF F , F F F F F ก F ก F F ก 4 F F ก F ก F Parenteral nutrition support ก F F ก F ก ก F ก ก F 4 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . ก F F (Peripheral parenteral nutrition support;PPN) ก F F F F F ก F ( F กF 2 F) กก F ก F F ก F F ก ก F ก F PPN F ก , , , ก F F F (infusion rates) กก F 150 mL/hr F F ก ก thrombophlebitis F F F 12,14 osmolarity F ก F 600 900 mOsm/L ก osmolarity parenteral solutions F 5 6 osmolarity 600 900 mOsm Hypertonic F F poor peripheral access F F PPN ก F ก F F F กF ก FF F Central PN ก F peripheral protein-sparing IV fluids ก F 5% dextrose F ก F parenteral support F F F F enteral nutrition ก F F ก F F F IV fluids F F F F ก F PPN ก F F F parenteral support ก peripheral access 2-3 48 ก F F standard IV fluids F F F F F PPN ก ก ก heparin hydrocortisone PPN ( F F ก nitroglycerin patch F Fก )F catheter site F ก F ก F peripheral catheters F 16-18 ( 7) 4 Access Devices F ก F Nutritional Support10-13 Line type F F Peripheral Lines Peripheral Short - - F F ก line F , ก -ก F F กF phlebitis vein damage F - Fก ก catheter F - F F ก ก - กF F F ก nutrition ก ก ก ก F support F F (<1 week) - Lumen ก 1 lumen - F ก 48-72 - F ก osmolality 600 900 mOsm/L pH F 5-9 Peripheral Midline - F F ก F peripheral - F F F pH catheters guideline ก peripheral lines -ก F F ก F central lines - F F central line - F F F F F 5 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 4 Access Devices F ก F Nutritional Support ( F ) Line type F F Central Lines Peripherally Inserted - - ก F F ก F Central Lines Central Catheters osmolality >900 mOsm/L F PICC lines - trained RN F - ก Fก F F - ก anticubital position - F line F ก -ก ก F F F ก Multiple lumens* F - ก F F F กF - Fก CT contrast injection F - F ก F ก F - ก F กก F Hickman® - - F ก ก F ก Broviac® osmolality >900 mOsm/L F F - F Nutrition support IV route - F ก F F F - F line F ก ML* F -ก ก F กก F - F F -ก F F line F ก - locked F normal saline F F F F F Femoral Lines - F IV access กF F F - Fก ก F Multiple Lumen acute - ก - Fก care catheters trained RN F - F ก acute care F F F - F F F F ก F F Radiology F Port -ก F - ก F line ก F ก Fก F กF ก F F F ก F - F F F F - F ก access port F Huber - - ideal intermittent access needle Fก 6 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 5 ก Osmolarity IV Admixtures ก Osmolarity IV Admixtures o ก , mEq mL F F mOsm/Unit 6 o F F F F ก ก F F total mOsm Admixtures o formulation F F F o total mOsm F the total volume (Liters) F F mOsm/L formulation 6 Milliosmoles F F TPN formula15 F (Additive) mOsm/Unit Sterile Water 0.00 Dextrose Options (3.4 cal/g) Dextrose 5, 10, 30, 50, 70% ~5 mOsm/g Amino Acid Options (4 cal/g) Amino Acid 8.5, 10, 15% ~10 mOsm/g Intravenous Fat Emulsion (IVFE) Options 10% (1.1 cal/mL) 20% (2.0 cal/mL) ~0.280 mOsm/mL 30% (3.0 cal/mL) Micronutrients Calcium Gluconate 0.662 mOsm/mEq Magnesium Sulfate 1 mOsm/mEq Multi-trace Elements (MTE-5) 0.36 mOsm/ml MVI infusion Concentrate (MVI-12) 41.1 mOsm/dose Potassium Acetate 2 mOsm/mEq Potassium Chloride 2 mOsm/mEq Potassium Phosphate 2.47 mOsm/mM Sodium Acetate 2 mOsm/mEq Sodium Chloride 2 mOsm/mEq Sodium Phosphate 4.0 mOsm/mM 7 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 7 Vein Protector ก F Peripheral Parenteral Nutrition Vein Protector ก F Peripheral Parenteral Nutrition F กF o Hydrocortisone 15 mg o Heparin 1500 units o F ก transdermal nitroglycerin (NTG) patch 0.1 mg/hour Peripheral lines ก 48-72 F F ก ก ก 13 thrombophlebitis Fก F PPN F F central venous access F F F F ก F Nutrition support criteria F 8 F F F intravenous nutrition support F ก criteria ก F PPN F F F Nutrition support central PN 8 criteria F ก F Peripheral Parenteral Nutrition criteria F ก F Peripheral Parenteral Nutrition F กF o F ก F ก F 1800 kcals F o F F ก F intravenous nutrition support F ก 10-14 o F ( peripheral veins) ก F o F ก F 1 intravenous line F ก ก intravenous fat emulsion (IVFE) F piggyback infusion o F F F ก ก ก F Fixed concentration PPN product F ก F ก F ก F ก F dextrose F F F F F กF 5% 10% 3% glycerol amino acids F F F 3% - 4.25% F F electrolytes F ก F F PPN formulations F F intravenous fat emulsions (IVFE) electrolytes F F F F ก F F F F ก IVFE F F F IVFE F F 10% 20% F F piggyback F IVFE F isotonic osmolarity ก F osmolarity F F F F F ก กก F 70 % F F F ก F F ก F 1 gm/kg/day ก Fก ก immune function Fก ก F infusion long chain triglycerides19 ก ก ก Fat Overload Syndrome F F IVFE ก / ก ก ก ก F F กF hypertriglyceridemia, ,F clotting disorders, hepatosplenomegaly variable end organ 8 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . dysfunction F ก ก ก ก F F ก F F ก F IVFE ก ก 20,21 F ก F F ก ก ก F ก F anesthesia sedation propofol 10% IVFE F ก F F F ก (Central nutrition support) ก F Central venous catheters F F F F ก F 2 6 L/min ก ก F F nutrition formulations osmolarities กก F 900 mOsm/L (~1500 2800 mOsm/L) F ก F F ก Central venous access F กF Groshong®, Hickman®, Hohn®, multiple lumen catheters, peripherally inserted central catheter (PICC) lines implanted intravenous port devices ก central catheters multiple lumens single lumen ก F F PN F 22 distal lumen ก lumen F ก F F ก ก blood transfusions ก ก F (blood sampling) Central catheters route of choice F F ก ก F F congestive heart failure (CHF) F renal failure F , F peripheral venous access F ก F F F PN กก F 10-14 ก ก ก F TPN (Designing the formulation) Macronutrients F (Carbohydrate) F F ก F 60 % กF F ก F F ก ก F F ก ก F กF F dextrose F F F ก 7.2 g/kg/day (5 mg/kg/minute) ก 23 ก fatty liver hyperglycemia F ก F F ก F F FF ก ก F กก F F F F F F dextrose กก F 5 mg/kg/minute F F F ก F ก maintenance ก ก ก (Protein) (Amino acids) F F F 1.5 g protein/kg/day Fก stress catabolism ก F F F ก (Critical care), F F F ก F (post-surgical), F Burn, F F dialysis F ก ก F ก F 1.2 2 g/kg/day F F severe catabolic states F ก ก 2 2.5 g/kg/day24 F Acute renal failure ก F ก 1.5 1.6 g/kg/day ก 25 ก ก F glomeruli กก dialysis ก F renal insufficiency renal failure F F F ก ก F F urea nitrogen ก ก 9 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 26 F F 0.8 gm/kg F ก ก ก กF กก ก F F ก F F ก ก protein utilization F glucose F F , ก ก endogenous protein (lean body mass) F Fก F กก F ก F F ก F Nitrogen F 25% ก ก 1.3 g/kg/day 1 g/kg/day F ก 75 ก ก F F F 22 g/day GI bleeding, hyperglycemia trauma/sepsis Fก ก กF 22 g/day F F standard practice ก ก F liver failure F ก F ก F F ก Fก ก F Fก กF F F FF ก ก ก ก hepatic Encephalopathic F F ก F ก ก ก ก ก F F F F กF 27 28 9 ก ก F amino acid ก F F F ก F (To Count, or Not to Count Protein as Calories?) F (Total calories) ก F F ก ก F ก F F F tube feeding ก ก ก ก F PN protein non-protein calories F F F ก29,30 ก F nonprotein calories ก ก F ก ก ก protein utilization F F Amino acid กF F catabolic (catabolic patient) F ก ก ก oxidation amino acid กก F Fก ก infusion amino acid ก F amino acid ก F ก pathways ก ก utilization substrate F F F ก F 1 pathway Mixed fuel utilization ก ก F F relative amounts F substrate ก ก (Fat) Intravenous fat emulsions (IVFE) กF กก F lipid emulsions ก F F กF F F F 20-30 F F F F F ก F F F ก กF กก F F กF ก F hypertrigly-ceridemia ก F F infusions propofol (vehicle propofol 10% IVFE F essential fatty Acids, (1.1 cal/mL infused) vitamin K)31 F 10 lipid emulsions ก F F ก K F ก F F ก F K F F Fก F F F lipid emulsion F F ก safflower oil K F กF F F ก soybean oil ก ก F F F lipid emulsion ก F F F K F F F K F F F lipid emulsion 32-34 ก 10% 20% F 10 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 9 Crystalline Amino Acid ก F ก F / F F F F F Aminosyn II™ Standard 3.5%, 4.25%, 5%, 7%, 8.5%, 10% Travasol™ Standard 3.5%, 4.25%, 5.5%, 8.5%, 10% Aminosyn II™ Standard/fluid restriction 15% Clinisol™ Standard/fluid restriction 15% Novamine™ Standard/fluid restriction 15% Prosol™ Standard/fluid restrictions 20% Hepatamine™ Hepatic failure 8% Hepatasol™ Hepatic failure 8% Aminosyn HBC™ Metabolic stress 7% Freamine HBC™ Metabolic stress 6.9% Branchamin™ ( F ก F Metabolic stress 4% leucine, isoleucine valine F ก Standard amino acid base) Amino PF™ Pediatric 7%, 10% Trophamine™ Pediatric 6%, 10% * Aminess™ (EAA + histidine) Renal 5.2% Aminosyn RF™ (EAA+ arginine) Renal 5.2% Nephramine™ (EAA+ histidine) Renal 5.4% Renamin™ (EAA non-EAA ) Renal 6.5% * EAA= Essential amino acids ก Barber JR, Miller SJ, Sacks GS. Parenteral feeding formulations. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.;2001: 251 268 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety. Micronutrients ก ก F PN Fก F ก F , ก metabolism กก F F F F F F 11 F ก F 11 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . ก FF F parenteral ก ก F ก ก , กก ก GI suction, กก surgical drains, F ( ), (emesis), F (diarrhea) F F F ก PN IV Solutions 12 ก F F ก F F ก 32-35 10 K Intravenous fat emulsions (IVFE) F Lipid Emulsion F Soybean Oil Safflower Oil K (Kcals/mL*) (g/L) (g/L) (mcg/dL) Intralipid 10% 1.1 100 0 30.8 Intralipid 20% 2 200 0 67.5 Intralipid 30% 3 300 0 93 Liposyn II 10% 1.1 50 50 13.2 Liposyn II 20% 2 100 100 26 Liposyn III 10% 1.1 100 0 31 Liposyn III 20% 2 200 0 62 Liposyn III 30% 2.9 300 0 93 * F ก F ก ก lipid F glycerol F ก IVFE 11 F ก F ก ก , ก ก F ก F Parenteral Enteral36- 38 Electrolyte Normal Serum Range* Parenteral Intake Range Adult Enteral Requirements Sodium 135 145 mM/L 0 200 mEq/L 100 150 mEq/day Chloride As needed to maintain acid-base balance Potassium 3.5 5.1 mM/L 0 240 mEq/day 60 120 mEq/day Acetate** As needed to maintain acid-base balance Phosphate 2.3 4.7 mg/dl 0 60 mM/day 15 30 mM/day Magnesium 1.7 2.5 mEq/L 0 48 mEq/day 8 24 mEq/day Calcium 9.2 11.0 mg/dl (ionized calcium 0.8 1.2 mEq/L) 0 25 mEq/day 9 22 mEq/day *Note: F ก ก F ก ก F ก ก F F ก F ก **Acetate ก bicarbonate 12 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 36 12 ก F F ก F Body fluids F ก F/ F (mL/d) ก F (mEq/L) Na K HCO3 Cl 500 2000 2 10 20 30 30 8 18 ก 2000 2500 pH<4 60 10 90 pH>4 100 10 100 F 1000 140 5 90 75 1500 140 5 35 100 F ก 3500 100 15 25 100 F ก 60 30 75 1000 4000 60 30 45 45 1500 40 0 20 1500 50 5 55 Reprinted from Matarese LE. Metabolic complications of parenteral nutrition therapy. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001;269-286, with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety. F F ก ก ก Prepared multivitamin trace metal ก F กF cocktails F ก F ก F ก ก ก F F F 13 F F ก ก parenteral multivi- tamin injections Fก 39 (FDA) ก F Parenteral nutrition F ( F กF 1 F) F F FF F K F ก F F Parenteral nutrition กก F 1 F 1 F FF F K 40,41 2 4 mg/ F F ก F F F ก F F Infuvite® (Baxter Healthcare Inc, Deerfield, IL) MVI-Adult® (Mayne Pharma (USA), Paramus, NJ) F standards F FDA F ก K F Mayne Pharma F F F K F ก (MVIAdult without vitamin K®) Fก F F F F ก F F F F F warfarin ก F F K F F ก ก K ก F F wafarin F F K F ก F F F F ก F ก F anticoagulant 13 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 42 Fก กF F กF F ( 10 ) F IVFEs ก K F ก Fก oils F F ก , ก infusion F F lipid emulsion 10 39 13 Intravenous Vitamins F F F 1 FDA/AMA/NAG* / Thiamin (B1) 6 mg Riboflavin (B2) 3.6 mg Pyridoxine (B6) 6 mg Cyanocobalamin (B12) 5 mcg Niacin 40 mg Folic Acid 600 mcg Pantothenic acid 15 mg Biotin 60 mcg Ascorbic acid (C) 200 mg Vitamin A 3300 IU Vitamin D 5 mg Vitamin E 10 IU Vitamin K 150 mcg *National Advisory Group on Standards and Practice Guidelines for PN (ASPEN) F F 1 F 14 F manganese F F ก FF F PN F F F ก 44 ก F F ก manganese ก multivitamins trace elements F F ก F ก F F cholestatic liver disease F manganese copper 45, 47 F 14 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 43 14 Intravenous Trace Minerals F 1 F F F F F (Trace element) / Chromium 10 15 mcg Copper 0.3 0.5 mg Manganese 60 100 mcg Selenium 20-60 mcg Zinc* 2.5 5.0 mg *Note: zinc F F ostomy stool output lost: 12.2mg/L small bowel fluid 17.1mg/kg stool / ileostomy Adapted from Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. J Parenter Enteral Nutr, 2004; 28:S39 S70 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety (Medications) PN F F F ก F กF H2- 48 antagonists F กF F F ก F F (Insulin) Hyperglycemia กF F F F F PN ก ก regular Insulin (RI) PN F F F F F F FกF F F ก RI 1 unit F 10 ก dextrose F F PN F fasting blood glucose F F ก F PN กก F 200 mg/dL F RI F F F F RI 1.5 2 units F 10 g dextrose F ก F sliding scale F RI กก F 1 rapid acting insulin analogs F insulin lispro (Humalog®) insulin aspart (Novolog®) medication regimen F F PN F ก F F F ก F ก F ก insulin analogs F F F F F PN F PN F RI F PN F F ก F F 15 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . duration ก F ก ก ก F ก F F F Fก ก FF F PN ก F F F sliding scale insulin F ก F PN กF F ก ก F F ก Fก ก F , F F F F กก F enteral กF F F F F F ก ก ก ก ก ก F PN F ก F F F ก RI F F ก F 2 units F 10 ก dextrose F ก Fก ก F F ก F F F ก ก F กก ก F F ICU ก Fก ก F ก ก F F ก F F F F 80 130 mg/dL49 ก F IV drip ก F sliding scale insulin regimen F F ก F ก ก hypoglycemia, F FF ก PN admixture F ก ก ก ก F IV drip ก F กF F F PN F F กก 2/3 infusion F ก F PN กF F ก F ก กF ก bioavailability PN ก F ก F F Dextrose F ก ก F F ก F Fก F F ก ก F ก F ก ก FF F dextrose F F F IVFE FF F ก F F ก dextrose ก F F ก F ก F PN กF F F ก 50 F ก ก F ก ก F F F F ก ก F F 15 ก ก ก ก ก ก F F ก ก ก ก F , stress activity F F ก F ก ก F F 16 ก F ก F 16 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 51, 52 15 F Fก Hyperglycemia Fก Hypoglycemia Corticosteroids Flouroquinolones Diuretics - Gatifloxacin Adrenergic agents Insulin Cyclosporin Alcohol Tacrolimus Sulfonylureas Sandostatin Methandrostenolone Phenytoin Clofibrate Phenobarbital Cypionate Lithium B-blockers Calcitonin Monoamine Oxidase Inhibitors (MAOI) Rifampin 16 ก ก ก ก F กF o F FF F ก ก o F ก ก dextrose TPN F F ก 150 mg/ day o ก IV dextrose F F F ก CVVHD, กก peritoneal dialysis, กก antibiotic drips F ก dextrose F F F o unit ก F sliding scale o ก ก ก ( ก 4-6 ) o drips o ก F TPN กF F 24 F F กF F ก F H2-antagonists F F F ก ก ก ก Gastrointestinal stress ulcer ก F ก F H2- antagonists PN F famotidine F F F 72 53 3-in-1 admixtures F ก F F 20 mg ก 12 17 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 40 mg PN 24-hour bag F ก Famotidine ก ก F clearance F ก F 50 mg/min 50% ก ก famotidine F ranitidine ก PN F F ก 54 3-in-1 admixtures F 24 F F ก กก F F 10 F 48 ranitidine F F F F 200 300 mg F F Fก 400 mg 50 mg F F F creatinine clearance F ก F 50 mg/min55 ก F F ก F proton pump inhibitor F F F F F F F ก F H2-antagonist ก ก (Iron) Chronic home PN patients F F F F Iron supplement F F F ก ก ก F F 6 ก ก ก ก กก ก F F PN F F 56 ก supplement ก F 2 ก F Iron dextran 2-in-1 PN formulations 10 75 57,58 mg/day F F Fก ก F F F F ก F ก ก ก ก ก F Fก ก Iron dextran 3-in-1 PN admixtures58 ก ก F Anaphylaxis ก F F ก ก ก ก F supplement กF ก PN F F ก F F Ferrlecit® (Na ferric gluconate complex) Schein Venofer® (iron sucrose iron saccharate complex) American Regent ก F ก Fก F supplement ก ก F ก ก PN F ก F PN formulations F F ก ก F F F PN F F F ก ก ก ก compatibility F ก F PN ก F F F ก F ก ก F F ก F PN (Frequently asked questions in the clinical setting) F PN ? F (How Should PN Be Initiated?) FF ก F Infusion PN ก F ก F Fก F F F F F F Fก ก refeeding F F F PN F F กก F F ก F F ก F ก F ก F ก F F ก ก F F ก ก F F ก F PN F F PN ก F F F PN F ก F F F F ก ก ก ก F metabolism F F F F overfed F Hyperglycemia ก ก ก utilization F ก PN formulation ก ก F Overfeeding กF F FF F F F F ก dextrose macronutrient F F ก ก F PN F ก F ก 18 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . ก F dextrose F F F F F F F ก F ก ก F F ก PN ก F ก refeeding hyperglycemia ก F F F F ก ก ก F PN ก F PN F F F ก ก F F F reformulation ก F Fก F F ก F ก F Fก F F กF F F F F PN ? (When Should PN Be Discontinued?) F F F ก ก F enteral nutrition ก F F PN F F ก F F กก F enteral feeding F ก F PN F F F F F F enteral feedings กก F F 50 F F กก F F enteral กก ก F F Fก F F ก ก F F F F กก F PN F ก กF F Fก F F enteral ก F F F กก F ก F (enteral ก ) F ก F F 50 F F ก FF ก F PN F ก 2-3 ก ก ก F ก F PN F ก F F กF F F F ก กF F F F ก F hyperglycemia ก ก ก F PN F F F F FFก F PN therapy ก glucose tolerance test กF F PN F ? (How Should PN Be Tapered?) F ก F ก F F ก PN formulations กF ก FF ก F PN ก F PN FF ก hypoglycemia F F Rebound hypoglycemia ก F F Fก ก ก ก F 59-61 F F PN Fก ก hypoglycemia F ก Fก F ก F F ก ก ก ก hypoglycemia F F F ก ก ก F ก F PN ก ก F drips F half-life Regular Insulin 5 ( F ) ก F PN F F F ก F F ก F F F F F กF F F ก hypoglycemia F ก F PN F 1-2 กF F ก ก ก hypoglycemia ก F F ก ก Refeeding? (When Should I Be on the Lookout for Refeeding?) F ก ก ก ก ก F กก F ก ก F F PN F F F ก F ก F ก ก ก 19 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . refeeding refeeding ก F Refeeding syndrome ก ก F , ก / ก ก กก ก F F ก ก F FF ก F ก ก F ก / ก refeeding syndrome F กF ก Fก F F ก F F ก / ก กF F F F กF F F F ก ก F supplement ก F F 62 F F Stable F F F F PN F F F ก F F PN ก ก ? (What Happens If the Patient is Overfed?) ก F ก F F F ก ก ก F ก (hyperalimen- tation) F parenteral F ก F catabolic (catabolic patients) ก F ก ก (overfeeding) F ก F ก กF F Fก F กก F Fก F F ก F F ก F ก obligatory hypercatabolism F Fก กF F F ก F feeding63 ก FF ก F F ก 64,65 ก (overfeeding) F F ก F , F ก F ก F PN F ก F F F F F ก ก ก F 30 35 kcal/kg F ก F indirect calorimetry ก F F F ก F F ก ก F F F ก ก F F F ก 66 ก (overfeeding) F 3-in-1 ก 2-in-1 formulation F ก F ก ? (Which is Best? 3-in-1 versus 2-in-1) F F ก กก F Traditional 2- in-1 PN admixtures 3-in-1 admixture 3- in-1 admixture ก IVFE amino acid/dextrose ก IVFE ก F F ก ก F F F ก F F ก F ก ก 17 Hang Time IVFE (Intravenous Fat Emulsion Hang Time) CDC F F F F F 3-in-1 solutions F ก infusion F กF F F ก 24 ก F ก ก ก ก IVFE F F ก F 2-in-1 solutions F IVFE F F F ก 12 20 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 17 F F Total Nutrient Admixture (3-in-1) System F Total Nutrient Admixture (3-in-1) System F กF o F ก ก F ก ก F ก o ก ก ก F ก ก F F ก o F ก ก ก F o Fก F o F nursing time 1 bag/day F F F piggyback o F ก F F FF F F F pump IV tubing o ก ก ก ก F Fก ก home care settings o Glucose venous access tolerance ก F ก F o F ก F F F ก ก o cost-effective ก F F Total Nutrient Admixture (3-in-1) System F กF o ก particle lipid emulsion F F F F F ก 0.22- (ก bacteria-eliminating) F F F ก pore size ก F 1.2 F o ก lipid emulsion F F F ก ก ก F ก ก F o F F ก Fก F ก ก F ก F o Fก ก ก F ก F ก o ก ก incompatibility F ( F ก admixture F ) ก F lipid emulsion o ก ก Catheter F F o F ก ก F pediatric settings ก ก ก ก pH compatibility Reprinted from Barber JR, Miller SJ, Sacks GS. Parenteral feeding formulations. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001: 251 268 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety Series Editor s Note: . . 1982 The Centers for Disease Control and Prevention F F FF 69 ก Infusion lipid emulsions F 12 ก F F 70 ก ก . . 1996 CDC F F ก lipid 3-in-1 solution F 24 21 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 71 F ก ก F IV lipid emulsions F 12 ก ก ก ก F F ก ก F ก F lipid emulsions 3-in-1 solution ก ก F IV lipid Emulsions 24 ก ก F F F ก F F ก ก กF ก ก ก F F ก F F F lipid emulsion ก F 72 ก CDC F ก F กก ก invitro กก F กF F Fก F F ก ก ก กก F F F 24 F F ก F 12 F ก ก ก ก F line F ก ก ก ก ก ก ก F ก ก hang-time F lipid emulsions ก F ก F ก ก ก ก ก F ก Serum Electrolyte (What is the Best Way to Manage Serum Electrolyte Abnormalities?) ก ก F ก ก ก F parenteral formulations F ก F ก F F F , organ function, oral/enteral intake F F F F F ก F F F ก F F F F F F ก ก ก F F F PN F ก ก F serum electrolyte กก F F F Serum electrolyte กF F F กก ก F ก ก F F ก ก ก F PN F F F F ก ก ก ก F F F PN ก F ก F PN F ก ก guidelines ก Fก ก F ก F ก F 44,67,68 F F F ? (How Often Should Labs Be Checked?) F ก ก F PN ก F ก ก ก ก ก F กก F PN ก F ก F ก F Fก Guidelines ก F F ก F (Guidelines for appropriate lab monitoring) 18 ก F กก F PN (Long-term Complications) กF กก F PN F กF fatty liver, cholestasis, metabolic bone disease, electrolyte/ vitamin/mineral depletion electrolyte/ vitamin/mineral toxicity46 ก F F F PN ก ก ก F กก F PN F Fก F กF 22 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . ก ก longterm complications ก F PN F F ก ก F 47 19 กF ก F PN 18 F ก F F ก (Lab value) F F Parenteral Nutrition F ก Baseline ก F F ก F ก ก F PN F ก F ก - CBC with differential ก F ก F - PT, PTT ก F ก F - Basic chemistry-Na, K, Cl, CO2, BUN, Creatinine ก 3 ก 1-2 F F - ก , 1 ก F - Serum triglycerides 1 - Serum glucose ก ก 1-2 F F - Capillary glucose ก6 hr 2 3 / กF <150 mg/dl* - ก ก ก 2-3 F F - Intake and output ก ก - ALT, AST, ALP, total 1 ก F ก - Bilirubin, Nitrogen Balance * F F F 80-130 mg/dl ก Mirtallo JM. Introduction to parenteral nutrition. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.;2001: 211 223, with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety. 9, 36 19 กF ก F PN 23 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . ก ก ก /ก ก Fatty Liver F F F F LFTs - ก F overfeeding F ก F ก ก F Overfee- - F F macronutrients ding dextrose / total ก ( 3) calories ก F overfeeding - FF F , EFAD, ก carnitine enteral F choline F F - F Enteric antibiotics - Taurine PN Cholestasis F F F F alkaline phosphatase - ก F overfeeding F ก F ก ก total bilirubin - F F macronutrients F F ก ก F ก ก ( 3) Fก - FF F ก F , ก F overfeeding enteral F glucose, lipid / amino acids, F F toxic tryptophan metabolites - F Enteric antibiotics ก choline GI Atrophy ก villi in vivo: enteric bac- - FF F EN F ก enteral nutrients teremia sepsis F F Gottschlich MM, Ed. Nutrition Support Dietetics Core Curriculum. 2nd edition. American Society of Parenteral and Enteral Nutrition. Silver Spring, MD: 1993. 24 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . F Fก F ก F ก ก (What Should You Do When the Labs on Your PN Patient Look Like This?!!) Fก F ก 4.00 . Sodium 125 Potassium 6.7 Chloride 101 CO2 17 BUN 12 Creatinine 0.7 Glucose 896 Triglycerides 684 Magnesium 3.5 ก F ก F F F o F F F (20 units SQ) sodium polystyrene resin (Kayexalate®) 30 mL enema STAT o F F F endocrine o fingerstick glucose กF ก F ก ก FF F F F ก ก ก F ก F PN ก F draws ก central line F ก ก flushing F ก ก F Fก F PN, ก line flushing , ก initial aspirate F ก ก draw F ก F ก F ก F PN F F F F ก F PN / ก flushing F Fก draw ก F F ก F ก ก ก F ก F ก ก, potassium triglyceride F ก ก F PN ก ก F F ก F ก ก F ก finger stick blood sugar ก F F ก ก ก ก F F (Conclusion) ก F PN F F ก ก ก ก F F ก ก F ก F F F F F F F ก F nutrition Support กF ก F F - ก กF F ก F F F กF F F กF unfeedable. F F ก 20 (summary guidelines) ก F PN 25 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 20 (summary guidelines) (summary guidelines) ก F PN F กF o F indication ก ก F PN F o F (medical/surgical history, review drug/medication profile, anthropometric data lab values) o F F F F PN F F( (7-10 )) o F ก , F o 20 30 kcal/kg o 0.8 1.5 gm/kg ( ก F F severe catabolic states) o F กF F ก 30% o ก F ก ก ,F F o ก ก ก F ก PN formulation F ก F H2-antagonists o F o F ก ก refeeding syndrome o Glucose intolerance ( F ก F dextrose F กF F F กF F F ก F F F 24- 48 ) o F ก enteral F F F F F F ก ก F Acknowledgment Gordon S. Sacks, Pharm.D., BCNSP, FCCP Clinical Associate Professor Schools of Medicine and Pharmacy University of Wisconsin Madison ก F (References) 1. Lipman TO. The chicken soup paradigm. J Parenter Enteral Nutr, 2003; 27:93-99. 2. Braunschweig CL, Levy P, Sheean PM, et al. Enteral compared with parenteral nutrition: a meta- analysis. Am J Clin Nutr, 2001;74:534 542. 3. Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med, 1991;22;325(8):525-532. 4. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parent Enteral Nutr, 2003;27(5):355-373. 5. American College of Chest Physicians Consensus Statement. Chest, 1997;111(3):769-777. 26 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 6. National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition. J Parent Enteral Nutr, 1998;22(2):49-66. 7. Krenitsky J. Adjusted body weight, pro: evidence to support the use of adjusted body weight in calculating calorie requirements. Nutr Clin Pract, 2005;20:468-473. 8. Frankenfield D. Energy and macrosubstrate requirements. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:36. 9. Von Allmen D, Fisher JF. Metabolic Complications. In: Fischer JF (ed). Total Parenteral Nutrition. 2nd Ed. Boston, MA: Little Brown Company; 1991. 10. Krzywda EA, Andris DA, Edmiston CE, et al. Parenteral Access Devices. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:230. 11. Jerome L, Cookson ST, McArthur MA, et al. Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Ann Inter Med, 1999; 131(5):340-347. 12. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infusion Nursing,2006;29(1S):75. 13. O Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR, 2002;51(RR-10):1-29. 14. Mirtallo JM. Introduction to Parenteral Nutrition. In: Gottschlich MM, Ed. The Science and Practice of Nutrition Support: A Case- Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:217. 15. Adapted from information gathered from calculating osmolarity of an IV admixture viewed 05/31/2006 on http://rxkinetics.com/ iv_osmolarity.html 16. Tighe MJ, Wong C, Martin IG, et. al. Do heparin, hydrocortisone, and glyceryl trinitrate influence thrombophlebitis during full intravenous nutrition via a peripheral vein? J Parent Enteral Nutr, 1995;19(6):507-509. 17. Roongpisuthipong C, Puchaiwatananon O, Songchitsomboon S, et al. Hydrocortisone, heparin, and peripheral intravenous infusion. Nutrition, 1994;10(3):211-213. 18. Khawaja HT, Williams JD, Weaver PC. Transdermal glyceryl trinitrate to allow peripheral total parenteral nutrition: a doubleblind placebo controlled feasibility study. J Royal Soc Med, 1991; 84:69-72. 19. Grimm H, Tibell A, Norrlind B, Blecher C, et al. Immunoregulation by parenteral lipids: impact of the n-3 to n-6 fatty acid ratio. J Parent Enteral Nutr, 1994;18(5):417-421. 20. Haber LM, Hawkins EP, Seilheimer DK, et al. Fat overload syndrome. An autopsy study with evaluation of the coagulopathy. Am J Clin Pathol, 1988; 90(2):223-227. 27 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 21. Dahlstrom KA, Goulet OJ, Roberts RL, et al. Lipid tolerance in children receiving long-term parenteral nutrition: a biochemical and immunologic study. J Pediatr, 1988;113(6): 985-990. 22. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. J Parent Enteral Nutr, 2004;28(6):S39-S70. 23. Wolfe RR, O Donnell TF Jr, Stone MD, et al. Investigation of factors determining optimal glucose infusion rate in total parenteral nutrition. Metabolism, 1980;29:892-900. 24. Frankenfield D. Energy and macrosubstrate requirements. In: Gottschlich MM, Ed. The Science and Practice of Nutritional Support: A Case Based Core-Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:234. 25. Macias WL, Alaka KJ, Murphy MH, et al. Impact of nutritional regimen on protein catabolism and nitrogen balance in patients with acute renal failure. J Parent Enteral Nutr, 1996;20:56-62. 26. Druml W. Nutritional management of acute renal failure. Am J Kidney Dis, 2001; 37(1 Suppl 2):S89-S94. 27. Krenitsky J. Nutrition in Renal Failure: Myths and Management. Pract Gastroenterol, 2004; 28(9):40. 28. Krenitsky J. Nutritional Guidelines for Patients with Hepatic Failure. Pract Gastroenterol, 2003; 27(6):23. 29. Van Way CW. Total calories vs nonprotein calories. Nutr Clin Pract, 2001;16:271-272. 30. Miles JM, Klein J. Should protein calories be included in caloric calculations for a TPN prescription? Point- counterpoint. Nutr Clin Pract, 1996;11:204-206. 31. Devlin JW, Lau AK, Tanios MA. Propofol-associated hypertriglyceridemia and pancreatitis in the intensive care unit: an analysis of frequency and risk factors. Pharmacother, 2005; 25(10):1348-1352. 32. MacLaren R, Wachsman BA, Swift DK, et al. Warfarin resistance associated with intravenous lipid administration: discussion of propofol and review of the literature. Pharmacotherapy, 1997; 17:1331-1337. 33. Chambrier C, Leclercq M, Saudin F, et al. Is vitamin K1 supplementation necessary in long-term parenteral nutrition? J Parent Enteral Nutr, 1998; 22:87-90. 34. Lennon C, Davidson KW, Sadowski JA, et al. The vitamin K content of intravenous lipid emulsions. J Parent Enteral Nutr, 1993; 17:142-144. 35. Duerksen DR, Papineau N. Prevalence of coagulation abnormalities in hospitalized patients receiving lipid-based parenteral nutrition. J Parent Enteral Nutr, 2004;28(1):30-33. 36. Matarese LE. Metabolic Complications of Parenteral Nutrition Therapy. In: Gottschlich MM, Ed. The Science of Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.; 2001:275. 37. Faber MD, Schmidt RJ, Bear RA, et al. Management of fluid, electrolyte, and acid-base disorders in surgical patients. In: Narins RG (ed). Clinical Disorders of Fluid and Electrolyte Metabolism. 5th ed. New York: McGraw-Hill; 1987:1424. 38. Grant JP. Handbook of Total Parenteral Nutrition. 2nd ed. WB Saunders; Philadelphia, PA; 1992:174. 28 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 39. Parenteral multivitamin products; drugs for human use; drug efficacy study implementation; amended (21 CFR 5.70). Federal Register, 2000; 65:21200-21201. 40. Boosalis MG. Micronutrients. In: Gottschlich MM, Ed. The Science and Practice of Nutritional Support: A Case Based Core- Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co. 2001:94. 41. Helphingstine CJ, Bistrian BR. New food and drug administration requirements for inclusion of vitamin K in adult parenteral nutrition. J Parent Enteral Nutr, 2003; 27(3): 220-224. 42. Nutescu EA, Shapiro NL, Ibrahim S, et al. Warfarin and its interactions with foods, herbs and other dietary supplements. Expert Opin Drug Saf, 2006;5(3):433-451. 43. Safe Practices for Parenteral Nutrition Formulations. National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition. J Parenter Enteral Nutr, 1998; 22(2);49-66. 44. Btaiche IF, Khalidi N. Metabolic complications of parenteral nutrition in adults, part 2. Am J Health-Syst Pharm, 2004;61: 2050-2057. 45. Wardle CA, Forbes A, Roberts NB, et al. Hypermanganesemia in long-term intravenous nutrition and chronic liver disease. J Parenter Enteral Nutr, 2004; 28:S39-S70. 46. Fessler TA. Trace Element Monitoring and Therapy For Adult Patients Receiving Long Term Total Parenteral Nutrition. Pract Gastroenterol, 2005;29(3):44. 47. Jeejeebhoy KN. Management of PN-induced Cholestasis. Pract Gastroenterol, 2005; 29 (2):62. 48. Sacks G. Drug-nutrient considerations in patients receiving parenteral and enteral nutrition. Pract Gastroenterol, 2004; 28(7):39. 49. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med, 2001;345:1359- 1367. 50. Rossetti L, Giaccari A, DeFronzo RA. Glucose toxicity. Diabetes Care, 1990;13(6):610-630. 51. Frothingham R. Glucose homeostasis abnormalities associated with use of gatifloxicin. Clin Infect Dis, 2005;41(9):1269- 1276. 52. Stausburg KM. Drug interactions in nutrition support. In: McCabe JM, Frankel EH, Wolfe JJ, ed. Handbook of Food-Drug Interactions. Boca Raton, Fl: CRC Press; 2003: 145-166. 53. Montoro JB, Pou L, Salvador P, et al. Stability of famotidine 20 and 40 mg/L in total nutrient admixtures. Am J Hosp Pharm, 1989;46(11):2329-2332. 54. Hatton J, Luer M, Hirsch J, et al. Histamine receptor antagonists and lipid stability in total nutrient admixtures. J Parenter Enteral Nutr, 1994;18(4):308-312. 55. Product information: Ranitidine package insert, Bedford Laboratories, May 20. 29 ………………………………………………………………………………………………………......
    • . ..The Hitchhiker s Guide to Parenteral Nutrition Management . . 56. Khaodhiar L, Keane-Ellison M, Tawa NE, et al. Iron deficiency anemia in patients receiving home total parenteral nutrition. J Parenter Enteral Nutr, 2002;26:114-119. 57. Kwong KW, Tsallas G. Dilute iron dextran formulation for addition to parenteral nutrient solutions. Am J Hosp Pharm, 1980; 37(2):206-210. 58. Vaughan LM, Small C, Plunkett V. Incompatibility of iron dextran and a total nutrient admixture. Am J Hop Pharm, 1990; 47:1745-1746. 59. Eisenberg PG, Gianino S, Clutter WE, et al. Abrupt discontinuation of cycled parenteral nutrition is safe. Dis Colon Rectum, 1995; 38 (9):933-939. 60. Krzywda EA, Andris DA, Whipple JK, et al. Glucose response to abrupt initiation and discontinuation of total parenteral nutrition. J Parent Enteral Nutr, 1993;17:64-67. 61. Nirula R, Yamada K, Waxman K. The effect of abrupt cessation of total parenteral nutrition on serum glucose: a randomized trial. Am Surg, 2000;66(9):866-869. 62. McCray S, Walker S, Parrish CR. Much ado about refeeding. Pract Gastroenterol, 2005; 23:26-44. 63. Plank LD, Connolly AB, Hill GL. Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis. Ann Surg, 1998;228(2):146-158. 64. Klein CJ, Stanek GS, Wiles CE. Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc, 1998;98(7):795-806. 65. Bu JA, Klish WJ, Walding WJ, et al. Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. Am J Clin Nutr, 2001;74(5):664-669. 66. McClave SA, McClain CJ, Snider HL. Should indirect Calorimetry be used as a part of nutritional assessment? J Clin Gastroenterol, 2001;33(1):14-19. 67. Piazza-Barnett R, Matarese LE. Electrolyte management in total parenteral nutrition. Support Line, 1999;21(2):8-15. 68. Kraft MD, Btaiche IF, Sacks GS, et al. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health- Syst Pharm, 2005;62:1663-1682. 69. Anonymous. CDC Guideline for Prevention of Intravenous Therapy-related Infections. Infection Control, 1982; 3: 52-72. 70. Melly MA, Meng HC, Schaffer W. Microbial growth in lipid emulsions used in parenteral nutrition. Arch Surg, 1975; 110: 314-318. 71. Pearson ML. Hospital Infection Control Practices Advisory Committee: Guideline for prevention of intravascular device-related infections. Infection Control Hosp. Epidemiology, 1996; 17: 438-473. 30 ………………………………………………………………………………………………………......