Dr. Ronald Sanchez Magbitang is an esteemed physician with a B.S. in Biology and a Doctor of Medicine from reputable institutions, currently serving as the Chief of Hospital at Gov. Eduardo L. Joson Memorial Hospital. His extensive training includes a focus on internal medicine, hematology, and HIV/AIDS, alongside multiple leadership roles in various medical associations in the Philippines. The document elaborates on the essential concepts of body fluids and electrolytes, their functions, compartments, balance, and the physiological mechanisms involved in maintaining fluid and electrolyte homeostasis.

1. 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

2. ... 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

6. BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FLUIDS AND ELECTROLYTES: Problems/Imbalances Common IV Solutions

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9. 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

11. FLUIDS AND ELECTROLYTES 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

12. FLUIDS AND ELECTROLYTES 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

14. FLUIDS AND ELECTROLYTES 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

15. FLUIDS AND ELECTROLYTES 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

16. 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 FLUIDS AND ELECTROLYTES

17. FLUIDS AND ELECTROLYTES 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells 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

18. FLUIDS AND ELECTROLYTES 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells 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

20. FLUIDS AND ELECTROLYTES 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

21. FLUIDS AND ELECTROLYTES 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

22. FLUIDS AND ELECTROLYTES “ Third spacing” occurs in: Ascites Burns Peritonitis Bowel obstruction Massive bleeding into body cavity or joints

23. FLUIDS AND ELECTROLYTES 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

24. FLUIDS AND ELECTROLYTES 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

25. FLUIDS AND ELECTROLYTES Output of Fluid – vary due to following: Increased temperature Increased respiration Draining wounds Ostomies Gastric suction

26. FLUIDS AND ELECTROLYTES Sources of water: Liquids Water-containing foods Metabolic activities or oxidation

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

28. FLUIDS AND ELECTROLYTES 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

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

30. FLUIDS AND ELECTROLYTES 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

31. FLUIDS AND ELECTROLYTES Routes of Gain & Losses: Lungs Normally eliminate water vapor (insensible loss) Rate is at 300 – 400ml/day Loss is greater with increased respiratory rate or depth

32. FLUIDS AND ELECTROLYTES Routes of Gain & Losses: 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

33. FLUIDS AND ELECTROLYTES 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

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

35. FLUIDS AND ELECTROLYTES 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

36. FLUIDS AND ELECTROLYTES 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)

37. FLUIDS AND ELECTROLYTES General Functions of Electrolytes Promote neuromuscular irritability Maintain body fluid volume and osmolality Distribute body water between compartments Regulate acid-base balance

38. 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

39. FLUIDS AND ELECTROLYTES The Electrolytes: Cations: Sodium Potassium Calcium Magnesium Anions: Chloride Bicarbonate Phosphate

40. FLUIDS AND ELECTROLYTES 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

41. FLUIDS AND ELECTROLYTES 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

42. FLUIDS AND ELECTROLYTES Calcium (Ca ++ ) Normal concentration = 4.5 – 5.8 mEq/L Has 2 forms: Ionized (free) calcium – physiologically active Ca bound to plasma proteins

43. FLUIDS AND ELECTROLYTES 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

44. FLUIDS AND ELECTROLYTES Magnesium (Mg ++ ) Normal concentration = 1.5 – 2.5 mEq/L 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

45. 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

46. 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

47. FLUIDS AND ELECTROLYTES 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

48. 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

49. FLUIDS AND ELECTROLYTES 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

50. FLUIDS AND ELECTROLYTES 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

51. FLUIDS AND ELECTROLYTES 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

53. FLUIDS AND ELECTROLYTES 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

55. FLUIDS AND ELECTROLYTES 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

56. FLUIDS AND ELECTROLYTES 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

57. Types of Fluid Balance And Imbalance

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

59. FLUIDS AND ELECTROLYTES 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)

60. FLUIDS AND ELECTROLYTES 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

61. FLUIDS AND ELECTROLYTES 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

62. FLUIDS AND ELECTROLYTES Mechanisms in Saline Balance Regulation (ECF Volume) Atrial Natriuretic Peptide: Atrial distention (increase ECF) Release Peptides Acts on kidney Increase renal excretion of Na + & water Relieveing distention

63. FLUIDS AND ELECTROLYTES Mechanisms in Saline Balance Regulation (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

64. FLUIDS AND ELECTROLYTES Saline Imbalance: Saline Deficit ECF volume deficit Isotonic contraction Isosmotic dehydration Hypovolemia Extracellular volume depletion

65. FLUIDS AND ELECTROLYTES 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

66. FLUIDS AND ELECTROLYTES Saline balance: Saline Deficit 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

67. FLUIDS AND ELECTROLYTES Saline balance: Saline Deficit 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

68. FLUIDS AND ELECTROLYTES Saline Imbalance: Saline Excess ECF volume excess Isotonic expansion Hypervolemia Circulatory overload

69. FLUIDS AND ELECTROLYTES 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)

70. FLUIDS AND ELECTROLYTES Saline balance: Saline Excess 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

71. FLUIDS AND ELECTROLYTES Saline balance: Saline Excess 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

73. FLUIDS AND ELECTROLYTES 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

74. FLUIDS AND ELECTROLYTES 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

75. FLUIDS AND ELECTROLYTES 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

76. FLUIDS AND ELECTROLYTES Water Balance and Imbalance 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

77. FLUIDS AND ELECTROLYTES Water Balance and Imbalance 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.

78. FLUIDS AND ELECTROLYTES TYPES OF WATER IMBALANCE WATER DEFICIT: Hypernatremia Water depletion Hypertonicity Hyperosmolar balance

79. FLUIDS AND ELECTROLYTES 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)

80. FLUIDS AND ELECTROLYTES 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

81. FLUIDS AND ELECTROLYTES WATER DEFICIT Clinical Manifestations: 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)

82. FLUIDS AND ELECTROLYTES WATER DEFICIT Clinical Manifestations: Pathophysiology: Decrease Water Increase Osmolality Osmosis ICF ECF Attempt to restore osmolality Cells shrivels Cell dysfunction

83. FLUIDS AND ELECTROLYTES 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

84. FLUIDS AND ELECTROLYTES 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

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

86. FLUIDS AND ELECTROLYTES 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

87. FLUIDS AND ELECTROLYTES 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

88. FLUIDS AND ELECTROLYTES 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

89. FLUIDS AND ELECTROLYTES 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)

90. FLUIDS AND ELECTROLYTES WATER EXCESS Causes: II. General Etiology: Lost of salt related to water B. Gastrointestinal – due to water replacement not by salt Nasogastric suction Vomiting Diarrhea Hypotonic irrigation solutions

91. FLUIDS AND ELECTROLYTES WATER EXCESS Causes: II. General Etiology: Lost of salt related to water C. Others Burns Excessive sweating

92. FLUIDS AND ELECTROLYTES WATER EXCESS Clinical Manifestations: Pathophysiology Increased Water Decrease Osmolality Osmosis ECF ICF Attempt to restore Osmolality Cell swollen Cell dysfunction

93. FLUIDS AND ELECTROLYTES WATER EXCESS Clinical Manifestations: Decrease serum Na Malaise Headache Confusion Lethargy Seizures Coma

94. FLUIDS AND ELECTROLYTES 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 )

96. FLUIDS AND ELECTROLYTES 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

98. FLUIDS AND ELECTROLYTES 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

99. FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 2. Decrease blood osmotic pressure A. Decrease serum Albumin Loss of albumin Nephrotic Syndrome Protein-losing enteropathies Liver disease (Cirrhosis)

100. FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 3. Increase fluid osmotic pressure A. Increase capillary permeability Burns Inflammation Hypersensitivity reactions Toxins Trauma

101. FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 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

102. FLUIDS AND ELECTROLYTES EDEMA Medical Therapy and Interventions: Use of elastic stockings to enhance venous return Administration of diuretics or a Na-restricted diet

103. ELECTROLYTE BALANCE AND ELECTROLYTE IMBALANCES

104. FLUIDS AND ELECTROLYTES 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)

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

106. FLUIDS AND ELECTROLYTES 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

107. FLUIDS AND ELECTROLYTES 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

108. FLUIDS AND ELECTROLYTES 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

109. FLUIDS AND ELECTROLYTES HYPOKALEMIA Serum K < 3.5 mEq/L Clinical Manifestations: 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

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

111. FLUIDS AND ELECTROLYTES 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

112. FLUIDS AND ELECTROLYTES 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

113. FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Clinical Manifestations: 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

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

115. FLUIDS AND ELECTROLYTES 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])

116. FLUIDS AND ELECTROLYTES 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)

117. FLUIDS AND ELECTROLYTES CALCIUM BALANCE & IMBALANCES Facts: Calcium ions in the body are mostly located in the bones and teeth Small amount in cells of soft tissue Normal concentration = 4.5 – 5.5 mEq/L 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

118. FLUIDS AND ELECTROLYTES 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

119. FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Clinical Manifestations: 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

120. FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Interventions: Neuromuscular irritability Laryngospasm Paresthesia and muscle cramps Medical Therapy: Replacement of Calcium – oral or IV

121. FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished 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

122. FLUIDS AND ELECTROLYTES 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

123. FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Clinical Manifestations: 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

124. FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Interventions: Constipation Nausea and vomiting – nutrition Aspiration Fatigue Pain Muscle weakness Decreased level of consciousness Altered thought processes Impaired social interaction Renal calculi

125. FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L 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

126. FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L 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

127. FLUIDS AND ELECTROLYTES 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

128. FLUIDS AND ELECTROLYTES 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

129. FLUIDS AND ELECTROLYTES HYPOPHOSPHATEMIA Serum concentration < 2.5 mg/dL Clinical Manifestations: 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

130. FLUIDS AND ELECTROLYTES HYPOPHOSPHATEMIA Serum concentration < 2.5 mg/dL Laboratory Values: Alkalosis (increased in pH especially respiratory alkalosis) Interventions: Decreased level of consciousness Respiratory muscle weakness

131. FLUIDS AND ELECTROLYTES HYPOPHOSPHATEMIA Serum concentration < 2.5 mg/dL 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

132. FLUIDS AND ELECTROLYTES 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

133. FLUIDS AND ELECTROLYTES HYPERPHOSPHATEMIA Serum concentration > 4.5 mg/dL Clinical Manifestations: 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

134. FLUIDS AND ELECTROLYTES HYPERPHOSPHATEMIA Serum concentration > 4.5 mg/dL Laboratory Values: Plasma calcium decreases Hyperkalemia Hypermagnesemia Metabolic acidosis Increase BUN Increase creatinine Interventions: CaPO 4 precipitation in urinary tract Pruritus

135. FLUIDS AND ELECTROLYTES HYPERPHOSPHATEMIA Serum concentration > 4.5 mg/dL 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

136. FLUIDS AND ELECTROLYTES 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

137. FLUIDS AND ELECTROLYTES 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

138. FLUIDS AND ELECTROLYTES HYPOMAGNESEMIA Serum Mg < 1.5 mEq/L Clinical Manifestations: 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

139. FLUIDS AND ELECTROLYTES HYPOMAGNESEMIA Serum Mg < 1.5 mEq/L 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)

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

141. FLUIDS AND ELECTROLYTES HYPERMAGNESEMIA Serum Mg > 2.5 mEq/L Clinical Manifestations: 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

142. FLUIDS AND ELECTROLYTES HYPERMAGNESEMIA Serum Mg > 2.5 mEq/L 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

143. ACID – BASE BALANCE

144. FLUIDS AND ELECTROLYTES 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

145. FLUIDS AND ELECTROLYTES 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

146. FLUIDS AND ELECTROLYTES 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

147. 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

148. 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

149. 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

150. 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).

151. FLUIDS AND ELECTROLYTES 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

154. Thank You ! Dr. Ronald Sanchez - Magbitang

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

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158. 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

160. PARENTERAL NUTRITION 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

161. PARENTERAL NUTRITION 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

162. PARENTERAL NUTRITION 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

163. PARENTERAL NUTRITION 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

164. PARENTERAL NUTRITION Hill et. al. (1977) Lancet 1: 687

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

166. PARENTERAL NUTRITION 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 PARENTERAL NUTRITION Short-term Long-term ENTERAL NUTRITION Support Support Peripheral Line Central line

167. 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.

168. 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.

169. 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.

170. Total parenteral nutrition (TPN) is sometimes called central parenteral nutrition (CPN) or &quot;hyperal&quot; (hyperalimentation). The term &quot;hyperalimentation&quot; is a misnomer because it incorrectly implies that nutrients are supplied in excess of needs.

171. PARENTERAL NUTRITION 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

172. PARENTERAL NUTRITION 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

173. PARENTERAL NUTRITION 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

174. PARENTERAL NUTRITION 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

175. PARENTERAL NUTRITION NUTRITIONAL THERAPY Planning Diet Therapy: Assessment Prescription Care Plan

176. PARENTERAL NUTRITION FUNDAMENTALS OF NUTRITIONAL THERAPY: Clinical history Dietary history Physical examination findings Anthropometric measurements Muscle function test Biochemical data Immunological test

177. 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

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

179. PARENTERAL NUTRITION PARAMETERS TO ASSESS NUTRITIONAL STATUS: Arm-muscle circumference = π X triceps skin-fold thickness (pi)

180. PARENTERAL NUTRITION PARAMETERS TO ASSESS NUTRITIONAL STATUS: Arm-muscle circumference 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

181. PARENTERAL NUTRITION PARAMETERS TO ASSESS NUTRITIONAL STATUS: Arm-muscle circumference Mid-arm muscle circumference Triceps skin-fold thickness 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

182. PARENTERAL NUTRITION PARAMETERS TO ASSESS NUTRITIONAL STATUS: Arm-muscle circumference Mid-arm muscle circumference Triceps skin-fold thickness 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

183. 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

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

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

186. PARENTERAL NUTRITION 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

187. PARENTERAL NUTRITION 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

188. PARENTERAL NUTRITION 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

189. PARENTERAL NUTRITION 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)

190. 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

191. 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

192. 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

193. PARENTERAL NUTRITION 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)

194. PARENTERAL NUTRITION 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

195. PARENTERAL NUTRITION 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)

196. 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

197. PARENTERAL NUTRITION 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

198. PARENTERAL NUTRITION 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

199. 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

200. PARENTERAL NUTRITION 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

201. PARENTERAL NUTRITION 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

202. PARENTERAL NUTRITION 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

203. PARENTERAL NUTRITION 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

204. PARENTERAL NUTRITION 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

205. 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

206. 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

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208. 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

210. Total Body water = 60% body weight 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

211. 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

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213. PARENTERAL NUTRITION 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

214. PARENTERAL NUTRITION 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

216. PARENTERAL NUTRITION 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

217. 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

218. PARENTERAL NUTRITION 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

219. PARENTERAL NUTRITION 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

220. PARENTERAL NUTRITION 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

221. PARENTERAL NUTRITION PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS Complications of Catheterization Pneumothorax Hydrothorax Air embolism Nerve injury Central venous thrombosis arrhythmias Partial catheterization

222. PARENTERAL NUTRITION PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS Complications of Catheterization Catheter-related Complications Sepsis Catheter blockage Air embolism

223. PARENTERAL NUTRITION PROBLEMS RELATED TO NUTRITION OF CRITICALLY ILL PATIENTS Complications of Catheterization Catheter-related Complications Metabolic Complications associated with Nutrients: Glucose Hyperglycemia Hypoglycemia Respiratory distress

224. PARENTERAL NUTRITION 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 Hyperlipidemia Essential fatty acid deficiency

225. PARENTERAL NUTRITION 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 Hyperammonemia Metabolic acidosis

226. PARENTERAL NUTRITION 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 Dehydration and overhydration Sodium imbalance Potassium imbalance

227. PARENTERAL NUTRITION 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 Hypocalcemia Hypophosphatemia Hypomagnesemia Trace elements deficiency Liver enzeyme elevation

228. PARENTERAL NUTRITION 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

229. TPN will drip through a needle or catheter placed in your vein for 10-12 hours, once a day or five times a week.

230. 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.

233. 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.

236. 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.

238. Sample Regimen for Parenteral Nutrition

239. 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)

240. 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)

243. Thank You ! Dr. Ronald Sanchez - Magbitang