By Dr Ranjeet Patil

1. Parenteral Nutrition

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 Definition

3. Fluid Requirements

4. Conditions requiring nutrition

5. Central access —TPN both long- and short-term placement Peripheral or PPN —New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis <2000 kcal required or <10 days Routes of Parenteral Nutrition

6. Venous access site

7. Utilization of peripheral veins for the administration of nutrients A. Indications for use: PN necessary but no access to central vein 2. Malnourished patients with frequent NPO for procedures/tests Peripheral Parenteral Nutrition (PPN)

8. B. Contraindications: Patient can be fed enterally Pt. has weak peripheral veins C. Limitations Peripheral site more prone to inflammation/infection Catheter may need to be repeatedly inserted Poor choice for long-term nutrition Peripheral Parenteral Nutrition (PPN)

9. Peripherally inserted central catheter Benefits Access to central vein Can accommodate hypertonic fluids Lower risk of phlebitis than PPN Easier to insert than central line PICC Line

10. Provides nutrients when less than 2 to 3 feet of small intestine remains Allows nutrition support when GI intolerance prevents oral or enteral support Advantages- Parenteral Nutrition

11. Costly Long term risk of liver dysfunction, kidney and bone disease, and nutrient deficiencies Disadvantages

12. GI non functioning NBM >5 days GI fistula Acute pancreatitis Short bowel syndrome Malnutrition with >10% to 15 % weight loss Nutritional needs not met; patient refuses food Indications for Total Parenteral Nutrition

13. Working GI tract Terminally ill Only needed briefly (<14 days) Contraindications

14. Avoid excess kcal (> 40 kcal/kg) Adults kcal/kg BW Obese—use desired BMI range or an adjusted factor Calculating Nutrient Needs

15. Carbohydrate glucose or dextrose monohydrate 3.4 kcal/g Amino acids 3, 3.5, 5, 7, 8.5, 10% solutions Fat 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml Parenteral Components

16. 1.2 to 1.5 g protein/kg IBW mild or moderate stress 2.5 g protein/kg IBW burns or severe trauma Protein Requirements

17. Max. 0.36 g/kg BW/hr Excess glucose causes: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems Carbohydrate Requirements

18. 4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg Lipid Requirements

19. Fluid—30 to 50 ml/kg Electrolytes Use acetate or chloride forms to manage acidosis or alkalosis Vitamins Trace elements Other Requirements

20. 1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L 2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L 3. Fat is isotonic and does not contribute to osmolarity. 4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L Calculating the Osmolarity of a Parenteral Nutrition Solution

21. Total nutrient admixture of amino acids, glucose, additives 3-in-1 solution of lipid, amino acids, glucose, additives Compounding Methods

22. Intralipid(separately by syringe pump via a 3-way connector) Aminoven+5% Dextrose50% Dextrose +MVI +Heparin (0.5 - 1unit/ml)+Add. electrolytes, as reqd Compounds

23. Start slowly(1 L 1st day; 2 L 2nd day) Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV) Cyclic give 12 to 18 hours per day Administration

24. Infection Hemodynamic stability Catheter care Refeeding syndrome Monitoring and Complications

25. Hypophosphatemia Hyperglycemia Fluid retention Cardiac arrest Refeeding Syndrome

26. Weight(daily) BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUNCa+, P Plasma transaminases Monitor

27. BloodTwice/week Ammonia Mg Plasma transaminasesWeeklyHgbProthrombin time Zn Cu Triglycerides Monitor—cont’d

28. Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly) Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed) Monitor—cont’d

29. PPNSite irritation TPN1. Catheter sepsis2. Placement problems3. Metabolic Problems

30. Type of feeding formula and tube Method (bolus, drip, pump) Rate and water flush Intake energy and protein Tolerance, complications, and corrective actions Patient education Document in Chart

31. Thankyou