Parentral nutrition

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By Dr Ranjeet Patil

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Parentral nutrition

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

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