presentation on prarenteral nutrition in surgical patients

1. Parenteral nutrition
1

2. • Parenteral nutrition is the
provision of all nutritional
requirements by means of
the intravenous route.

3. 1913
1939
Henriques and
Anderson administered
hydrolysed protein in
an animal study
Elman and Weiner
reported the first
successful intravenous
administration of protein
hydrolysates in humans

4. Indications
• Inadequate Enteral intake
• Significant Multi organ system disease

5. Inadequate enteral intake
• Conditions that impair absorption of
nutrients
• Need for bowel rest
• Motility disorders
• Inability to maintain enteral access

6. Significant multi organ
system disease
• Significant renal, hepatic and
pulmonary diseases or critical illness
(MODS, severe head injury, burns,
etc) which prevents adequate oral or
EN

7. Contraindications
• If enteral nutrition meets or exceeds the calculated
nutritional requirements
• Good nutritional status who require short term
support
• Severe liver failure, cardiac failure, shock and
blood dycrasias
• Fluid-electrolyte imbalance

8. Energy requirement
1. Harris-Benedict equation -
• Men : BEE = 66 + 13.8 (wt in kg) + 5 (ht in cm) - 6.8 (age)
• Women : BEE = 655 + 9.6 (wt in kg) + 1.8 (ht in cm) - 4.7
(age)
2. Adjusted body weight = ideal body weight + 50% of difference
of actual body weight and ideal body weight.
• Baseline calorie need based on adjusted body weight is 25
kcal/kg/day
• Severe injury - 30 - 40 kcal /kg/day

9. Protein requirement
• Crystalline amino acids
• Initial starting rate: 0.16-0.24g of Nitrogen/kg/d
(1.0-1.5g/kg/d)
• Chronic renal failure - 0.6-0.8 gm/kg/day
• on Hemodialysis - 1.2-1.3 g/kg/day
• Acute hepatic encephalopathy - 0.6-0.8 g/kg/day

10. Carbohydrates
• Glucose requirement - 2g/kg/day
• maximum rate - 6 mg/kg/min
• Dextrose Monohydrate is the most common form
administered parenterally
• 1gm = 3.4 kcal

11. Lipids
• 1g lipid /kg/d
• Patients can receive 25 - 30% of calorie
requirement as lipids
• maximum infusion rate - 0.15 g/kg/hr

12. Micro nutrients
requirement

13. Venous access

14. Peripheral venous access
• Teflon / Plastic cannula
• Midlines into the basilic or cephalic
veins.

15. • Non-tunelled, non-cuffed catheters
(central lines)
• Peripherally Inserted Central
Catheters
• Tunnelled
Central venous access

19. Monitoring

21. • Mechanical
• Infective
• Metabolic
Complications

22. Mechanical
1. Improper placement of central venous catheter
• Pneumothorax
• Hemothorax
• Brachial Plexus injury
• Cardiac Arrhythmia
2. Venous thrombosis

23. Infective
1. Intestinal side effects
2. Related to placement technique and
catheter care

24. Metabolic
1. Early
• Volume overload
• Refeeding syndrome
• Hypokalemia, Hypophophatemia,
Hypomagnesemia and
Hyperchloremic acidosis.

25. 2. Late
• Essential fatty acid deficiency
• Trace mineral deficiency
• Vitamin deficiency
• Bone demineralisation - Oesteomalacia and
Osteoporosis
• Hepatic Complications - Fatty liver, steatohepatitis
and Decompensated liver disease
• Gall bladder complications - Cholestasis,
Cholecystitis, Cholelithiasis

26. Refeeding syndrome
• Severe fluid and electrolyte shifts in malnourished
patients undergoing refeeding
• Hypophosphatemia, hypocalcemia, hypokalaemia and
hypomagnesemia
• Altered myocardial functions, arrhythmia, liver
dysfunction, seizures, confusion, coma, tetany and
death
• Calorie delivery should be increased slowly and
vitamins administered regularly

30. Two chamber bags

31. Lipid emulsions