Parenteral Nutrition

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Something About Nutrition And Parenteral Nutrition.

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Parenteral Nutrition

  1. 1. By Dr Kaleem Ullah Bhatti House Surgeon
  2. 2. The taking in and metabolism of nutrients so that life is maintained andgrowth can take place.
  3. 3. Definition A disorder of nutrition it may be due to unbalanced or insufficient diet or to defective assimilation or utilization of foods.
  4. 4. Following are the types of nutrition Enteral Nutrition Parenteral Nutrition
  5. 5.  Definition It is administration of nutrition exclusively through intravenous route bypassing gastrointestinal tract
  6. 6. Either who are malnourishedHave the potential for developing malnutritionAre not candidates for enteral support
  7. 7. Parenteral nutrition is usually indicated in the following situations: Parenteral nutrition maybe indicated in theDocumented inability to absorb adequate following situations: nutrients via the gastrointestinal tract; this  Inflammatory bowel disease unresponsive may be due to: to medical therapy Massive small-bowel resection / Short  Hyperemesis gravidarum when nausea bowel syndrome (at least initially) and vomiting persist longer than 5 -7 Radiation enteritis  days and enteral nutrition is not possible Severe diarrhea ,Steatorrhea  Partial small bowel obstruction Complete bowel obstruction, or intestinal  Intensive chemotherapy / severe mucositis pseudo-obstruction  Major surgery/stress when enteral nutrition Severe catabolism with or without not expected to resume within 7-10 days malnutrition when gastrointestinal tract is  Intractable vomiting and jejunal access is not usable within 5-7 days not possible Inability to provide sufficient   Chylous ascites or chylothorax when nutrients/fluids enterally EN(with a very low fat formula) does Persistent GI hemorrhage  not adequately decrease output Acute abdomen/ileus Lengthy GI work-up requiring NPO status for several days in a malnourished patient High output enterocutaneous fistula and EN access cannot be obtained distal to the site.
  8. 8. HistoryPhysical ExaminationAnthropometric MeasurementsLaboratory Investigations
  9. 9. It should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems Significant weight loss within last 6 months ▪ > 15% loss of body weight ▪ compare with ideal weight ▪ Beware the patient with ascites/ oedema/amputations
  10. 10.  We will proceed step by step General Appereance Skin and appendages Eyes,Mouth Neurological
  11. 11. • Weight for Height comparison• Body Mass Index (<19, or >10% decrease)• Triceps-skinfold• Mid arm muscle circumference• Bioelectric impedance• Hand grip dynamometry• Urinary creatinine / height index
  12. 12.  Serum Albumins can provide useful information Low Level Serum Albumin+ raised C-reactive protein Low level of Serum Albumins+ normal C-reactive proteins Rising serum albumins levels
  13. 13. TEE = REE + Stress Factor + Activity FactorRest Energy Expenditure Adults (18-65) 20-30 kcal/kg Elderly (65+)  kcal/kg 25 For burns Patients 30-35kcal/kgOther factors: Pregnancy: Add 300 kcal/day Lactation: Add 500 kcal/day Obese or Super obese 15-20 kcal/kg
  14. 14. peritonitis + 15%• soft tissue trauma + 15%• fracture + 20%• fever (per oC rise) + 13%• Moderate infection + 20%• Severe infection + 40%• <20% BSA Burns + 50%• 20-40% BSA Burns + 80%• >40% BSA Burns + 100%
  15. 15.  ESTIMATING ADULT FLUID REQUIREMENTS 1. By caloric intake : 1ml/calorie Ex: 1800 calorie diet = 1800 calories x 1ml= 1800ml 2. By body weight and age : Age Fluid requirements 16-55 years 35 ml/kg/day 56-65 years 30 ml/kg/day > 65 years 25 ml/kg/day
  16. 16.  Macronutrients Micronutrients
  17. 17.  Requirement 2g/kg/day 1grams=5kcal/g 40-50 percent of total nutrition
  18. 18.  Requirement 3 g/kg/day 1 gram= 9kcal/g 30-40 percent of nutrition
  19. 19.  Carbohydrate and fat,usually in lipid:carbohydrate ratio of 60:40 or vice versa
  20. 20.  Requirement 0.2-0.5g/kg/day 1 gram= 4kcal/g 15-20 percent of nutrition Mild stress 1.0 -1.2 g/kg Moderate stress (most ICU patients) 1.5-2.0 g/kg Severe Obesity 1.5 g – 2.0 g/kg IBW Severe stress, catabolic, burns 2.0 –2.5 g/kg
  21. 21. Nitrogen Balance = N input - N output6.25 g protein provides 1 g of nitrogen,as 100grams contains 16 g nitrogenN input = (protein in g / 6.25)N output = 24h urinary urea nitrogen + non-urinary N losses +4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to – 1: Net catabolism
  22. 22.  Sodium 70 – 100 mEq/day Chloride 70 – 100 mEq/day Potassium 70 – 100 mEq/day Calcium 10 – 20 mEq/day Magnesium 15 – 20 mEq/day Phosphorus 40-60 mEq/day Acetate 0 – 60 mEq/day
  23. 23.  Vitamin A 3300 IU Vitamin D 200 IU Vitamin E 10 IU Vitamin K - 150 mcg Ascorbic acid 100 mg Folic Acid 0.4 mg Niacin 40 mg Riboflavin (B2) 3.6 mg Thiamin (B1) 3 mg Pyridoxine (B6) 4 mg Cyanocobalamin (B12) 5 mcg Pantothenic acid 15 mg Biotin 60 mcg
  24. 24.  Zinc 2.5-4 mg Copper 0.5-1.5mg Chromium 10-15 mcg Selenium 20-60 mcg Manganese 150-800 mcg
  25. 25.  It can be achieved either by peripheral line indirectly or central line directly Every route have its own advantages and disadvantages
  26. 26.  Short term PN may be  Long term access can provided centrally via be achieved by the subclavian or  Peripheral internal jugular vein. Peripherally Inserted Central CatheterLine (PICC line), which is passed via the antecubital vein  Non Cannulated catheters(Hickman and Groshong line)
  27. 27. ADVANTAGES DISADVANTAGES Bed side technique  Trained personnel is Avoids complications of needed central venous catheter  Line blockage Avoid multiple venous  Mal position cannulations  Phlebitis Hyperonic solutions can be  Line sepsis given  thrombosis
  28. 28. ADVANTAGES DISADVANTAGES Central access needed  Inserted in theatre Multiple lumina can be  Increase infection rate used in acute emergency  Multiple complications Hypertonic solutions can be given Can be placed for than 6 weeks
  29. 29. ADVANTAGES DISADVANTAGES Convenient exit site  Removal needs surgical Long lasting than non dissection tunnels  Catheter related sepsis Hypertonic solutions can  Other complications be given
  30. 30.  Once the route is decided then we will calculate daily requirements and proceed
  31. 31. Determine Total Fluid Volume Determine Non- Caloric needs Determine Protein requirements Determine Electrolyte andTrace element requirements Determine need for additives
  32. 32.  Full Blood Count  weekly, unless indicated  daily until stable, then 2x/wk Renal Function Test Ca++, Mg++, PO42-  daily until stable, then 2x/wk Liver Function Test  weekly Iron Panel  weekly Lipid Panel  1-2x/wk Nitrogen Balance  weekly
  33. 33. Mechanical Complications Of TPNinfectious metabolic
  34. 34. Related to vascular Access Related to catheter in situ• Pneumothorax • Venous thrombosis• Air embolism • catheter occlusion• Bleeding• Brachial plexus injury• Catheter malplacement• Catheter embolism• Thoracic duct injury
  35. 35. Electrolyte • Hypo/hyperglycemia • Hyponatremia,hypokalemia etcimbalance • Hepatic steatosis Hepatic • Acalculous cholecystitisAcid BaseDisorders
  36. 36. Insertion siteContamination • improper insertion technique Catheter • use of catheter for non-feeding purposes • contaminated TPN solutionContamination • contaminated tubing • septicemia SecondaryContamination
  37. 37.  Adult Enteral and Parenteral Nutrition Handbook, 5th Ed Oxford Handbook Of Critical Care Internet

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