In this presentation i have tried to explain in details about the Total Parenteral Nutrition (TPN) , what is it, who needs it, and how to prepare it and the necessary procedure with instructions. It is very useful for the individuals from Nutrition, Nursing, Pharmacists, and Medical background.
Early Enteral Nutrition in Critically Ill Patients is the best for helping early recovery, decreasing hospital stay and decreasing malnutrition in ICU
How? When? Formulas used? Access forms?
Early Enteral Nutrition in Critically Ill Patients is the best for helping early recovery, decreasing hospital stay and decreasing malnutrition in ICU
How? When? Formulas used? Access forms?
Parenteral Nutrition for the oral and maxillofacial surgery patientMaxfac Center
Nutritional deficit that occurs after starvation or trauma and the various nutritional supplementation given parenterally to minimise morbidity and mortality. This topic covers the Parental Nutrition.
Mentor: Dr Saikat Saha MDS, OMFS, SIliguri, West Bengal, India
Address: MAXFAC Center for Oral and Maxillofacial and Head & Neck Surgery, Siliguri
Email : maxfacmail@gmail.com
Enteric nutrition part 1 ( In Maxillofacial, Head and Neck Surgery )Maxfac Center
An introduction to enteric nutrition and the indications, contraindications, nutritional formulations and various parameters in choosing such formulations.
Mentor: Dr Saikat Saha MDS, OMFS, SIliguri, West Bengal, India
Address: MAXFAC Center for Oral and Maxillofacial and Head & Neck Surgery, Siliguri
Email : maxfacmail@gmail.com
The Emerging Role of Pharmacists in Public Health.pptxDr. Ankit Gaur
The Emerging Role of Pharmacists in Public Health: Opportunities and Challenges
General system theory, steven's system model, Pharmacists in india, Disaster management and emergency care, rational use of medicine, RNTCP programme. National Aids Control Programme.
This presentation is about Stress and its impact on health. I have tried to cover everything related to it, stressors, coping mechanisms, tools, types etc.
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
In this presentation I have tried to discuss in brief about obsessive compulsive disorder and its treatment both pharmacological and non pharmacological.
In this presentation I have tried to explain in brief about pain management, different types of pain, its diagnostic criteria, its physiology, and its treatment approaches both pharmacological and non pharmacological
Respiratory Tract Infections- A Pharmacotherapeutic ApproachDr. Ankit Gaur
In this presentation I have tried to explain the types, etiology, pathophysiology of respiratory tract infections such as bronchitis, pnemonia, otitis media, sinusitis, pharyngitis, and their treatment
In this presentation I have tried to explain in brief about the dosage adjustment in renal disorders, how to carry out this process and the important formulae which are used in it.
In this presentation i have tried to explain in brief about nomograms and their applications, the general approach to individualise doage regimen by using pharmacokinetic data
In this presentation I have tried to explain in detail about tablets, their different types, ingredients which are used to prepare them, and the procedure to prepare them as well. This presentation is very useful for pharmacy students.
in this presentation i have tried to briefly discuss about diuretics (water pills), their classification, mechanism of action, pharmacokinetics and pharmacodynamics of these drugs
In this presentation i have tried to explain in brief about CPR, how and when it has to be done and the important things to be kept in mind while doing it. This ppt is very helpful for every individual who is looking for the info regarding CPR.
In this presentation i have tried to explain in detail about the nux vomica and khurchi bark. This presentation is useful for the individuals who are looking for information on this topic especially for those students who are studying Pharmacognosy.
In this presentation i have tried to explain in detail about the measurements of the outcomes which are used in epidemiology such as prevalence, incidence, fatality rate, crude death rate etc.
In this presentation i tried to explain in detail about cohort studies, their types, how to conduct them, their outcomes, and how to calculate sample size of these studies.
In this presentation i have tried to thoroughly discuss about the concept of Drug induced kidney disease or injury, the mechanism behind it, its classification and how to access it.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
2. Human nutrition is the provision to obtain the
essential nutrients necessary to support life
and health
Nutrients are the substances that are not
synthesized in sufficient quantity in the body
and therefore must be supplied from diet
Macronutrients mainly carbohydrates, fats,
protein, dietary fiber and water
Micronutrients: vitamins, minerals and trace
elements
3. Protein (Amino acids)
Fat
Carbohydrate
Dietary fiber
Water and electrolytes
Vitamins
minerals
Trace elements
4. Pts should be assessed for PEM as well as specific
nutrient deficiencies
History: assess for change in diet pattern (size,
number and content of meals)
Unintentional weight loss
Evidence of malabsorption
Symptoms of specific nutrient deficiencies
Look for factors which may increase metabolic
stress (infection, inflammation, malignancy)
Functional status (bed ridden, suboptimally
active, fully active)
5. By WHO criteria, pts can be classified by BMI as
underweight (<18.5),
normal weight (18.5-24.9),
overweight (25-29.9),
class I obesity(30-34.9),
class II obesity(35-39.9)
class III obesity(>40)
Pts who are extremely underweight (BMI<14
kg/m2) or those with rapid, severe weight loss
have high risk of death and should be considered
for admission to the hospital for nutritional
support
6. Look for tissue depletion(loss of body fat and
skeletal muscle wasting)
Assess muscle function (strength testing of
individual muscle groups)
Fluid status: dehydration or fluid overload
Look for sources of protein or nutrient losses:
large wounds, burns, nephrotic syndrome,
chronic diseases, GI losses of nutrients,
surgical drains.
Lab parameters: plasma albumin, electrolytes,
vitamins and minerals
7.
8. Critical illness induces anorexia and the inability
to eat normally, predisposing patients to serious
nutritional deficits, muscle wasting, weakness,
and delayed recovery, longer stay in hospital
For critically ill pts provision of specialized
nutritional support considered which represent
major advance in medical therapy
Although at least 15-20% of pts in acute care
hospitals have evidence of significant
malnutrition, only a small fraction will benefit
from SNS
9. Nutritional support, via either enteral or
parenteral routes, is used in three main settings:
(1) To provide adequate nutritional intake
during recuperative phase of illness or injury
(2) to support the pts during systemic response
to inflammation, injury or infection during an
extended critical illness
(3) pts with permanent loss of intestinal length
or function
10. Decision to use SNS should be based on the
likelihood that preventing PEM will increase
the likelihood of recovery, reduce infection
rate, improve healing and shorten the stay in
hospital
SNS should be recommended only when
potential benefits exceed risks, and it should
be undertaken with consent of the pt
11.
12. Efficacy studies have shown that
malnourished pts undergoing major
thoracoabdominal surgery benefit from SNS,
critical illness requiring ICU care, including
major burns, major trauma, severe sepsis,
closed head injuries and severe pancreatitis,
all benefit from early nutritional support, as
indicated by reduced mortality and morbidity
13. Refers to feeding via a tube placed into the gut to
deliver liquid formulas containing all essential
nutrients
Preferred route because of benefits derived from
maintaining the digestive, absorptive and
immunological barrier function of GIT
Enteral/tube feeding is useful in pts who have
functional GIT, but who cannot digest or ingest
adequate amount of nutrients
Short term (<6 weeks) tube feeding can be
achieved by nasogastric, nasoduodenal or
nasojejunal tubes
14. Long term feeding (>6 wk) usually requires
gastrostomy or jejunostomy tube that can be
placed percutaneously by endoscopic (PEG) or
radiographic assistance
Enteral feeding is often required in pts with
anorexia, impaired swallowing, or bowel
disease. The bowel and its associated
digestive organs derive 70% of their required
nutrients directly from food in lumen
Enteral formulas: standard (osmolality- 300)
and modified
Complications of enteral feeding include
mainly aspiration pneumonia and diarrhoea
15. Enteral nutrition is associated with fewer complications than
parenteral nutrition and is less expensive to administer.
However, the use of enteral nutrition alone often does not
achieve caloric targets.
In addition, underfeeding is associated with weakness,
infection, increased duration of mechanical ventilation,
increased duration of hospital stay and death.
Combining parenteral nutrition with enteral nutrition
constitutes a strategy to prevent nutritional deficit but may
risk overfeeding which has been associated with liver
dysfunction, infection, and prolonged ventilatory support.
16. The consequences of major surgeries and PEM
can lead to hypermetabolism and subsequent
malnutrition. A strong association exist between
malnutrition and increased post operative
morbidity and mortality.
The administration of TPN can prevent the effects
of starvation in pts with non functional GIT
Parenteral nutrition should be considered if
energy intake has been inadequate for more than
7-10 days and enteral feeding is not feasible.
(based on ICU focused meta- analysis discussed
in 2009 ASPEN)
17. The gut should always be the
preferred route for nutrient
administration.
Therefore, parenteral nutrition is
indicated generally when there is
severe gastro-intestinal dysfunction
(cannot take sufficient food or feeding
formulas by the enteral route) .
18. It involves the continuous infusion of a
hyperosmolar solution containing
carbohydrates, proteins, fat and other
necessary electrolytes through an indwelling
catheter inserted into (usually) SVC to meet
the nutritional needs of the patient.
PN through a peripheral vein is limited by
osmolality and volume constraints
Solutions that contain more than 3%
aminoacid and 5% glucose are poorly
tolerated peripherally
19. Peripheral parenteral nutrition (PPN)
administered through a peripheral intravenous
catheter.
The osmolarity of PPN solutions generally is limited
to 1,000 mOsm (approximately 12% dextrose
solution) to avoid phlebitis.
Thus, large volumes (>2,500 mL) are needed.
Temporary nutritional supplementation with PPN
may be useful
Generally intended as supplement to oral feeding
and is not optimal for critically ill pts
20. Total parenteral nutrition (TPN)
provides complete nutritional support
The solution, volume of administration, and
additives are individualized based on an
assessment of the nutritional requirements.
21. TPN formulation without lipid (2-in-1
solution)
Calories from amino acids- 20 to 25%
Calories from dextrose- 75-80%
TPN formulation with lipid ( 3-in-1 solution)
calories from amino acids- 20 to 25%
calories from lipids- 20%
calories from dextrose- 55 to 60 %
22. Special solutions that contain low,
intermediate, or high nitrogen concentrations
as well as varying amounts of fat and
carbohydrate are available for pts with
diabetes, renal or pulmonary failure, or
hepatic dysfunction.
23. Additives:
Electrolytes (i.e., sodium, potassium, chloride,
acetate, calcium, magnesium, phosphate) should be
adjusted daily.
The number of cations and anions must balance;
this is achieved by altering the concentrations of
chloride and acetate.
If the serum bicarbonate is low, the solution should
contain more acetate.
The calcium:phosphate ratio must be monitored to
prevent salt precipitation.
24. Medications:
Albumin, H2-receptor antagonists, heparin, iron,
dextran, insulin, and metoclopramide can be
administered in TPN solutions. However, not all
medications are compatible with 3-in-1 admixtures.
Regular insulin should initially be administered
subcutaneously according to a sliding scale, based on a
determination of the blood glucose level. After a stable
insulin requirement has been established, insulin can be
administered in the TPN solution, generally at two thirds
of the daily subcutaneous insulin dose.
25. Crystalline amino acid solutions containing 40-
50% essential and 50-60% non essential amino
acids are used to provide protein needs
Some amino acid solutions have been modified:
rich in branched chain amino acids for hepatic
encephalopathy, rich in essential amino acid for
renal insufficiency pts
Glucose in IV solutions is hydrated; each gm of
dextrose monohydrate provides 3.4 kcal. While
there is no absolute requirement of glucose in
most pts, providing >150g glucose/d maximizes
protein balance
26. Lipid emulsions are available as 10%
(1.1kcal/ml) or 20% (2 kcal/ml) solutions and
provide energy as well as source of essential
fatty acids.
Rate of infusion should not exceed 1
kcal/kg/h
28. gastrointestinal cutaneous fistula
Renal failure (ATN)
Short bowel syndrome
Severe burns
Hepatic failure
Crohn’s disease
Anorexia nervosa
Acute radiation enteritis
Acute chemotherapy toxicity
Prolonged ileus
Weight loss preliminary to major surgery
29. Energy
Basal energy requirement is the function of the
individual's weight, age, gender, activity level and
the disease process
The major components of energy output are
resting energy expenditure and physical activity;
minor sources include the energy cost of
metabolizing food and shivering thermogenesis.
Total energy expenditure= resting energy
expenditure (70% of TEE) +thermic effect of food
(10% of TEE) + energy expenditure of physical
activity (20% of TEE)
30. Average energy intake is about 2600 kcal/d for
men and 1900 kcal/d for female, though these
estimates vary with body size and activity level
Formula for estimating REE are useful for
assessing the energy needs of an individual
whose weight is stable
For males, REE=900+10m, and for females,
REE=700+7m, where m is mass in kilograms
Calculated REE is the adjusted for physical
activity level (multiplying by 1.2 for sedentary,
1.4 for moderately active and 1.8 for very active)
31. TEE = REE + Stress Factor + Activity
Factor
Rest Energy Expenditure
Adults (18-65) 20-30 kcal/kg
Elderly (65+) 25 kcal/kg
For burns Patients 30-35kcal/kg
Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
Obese or Super obese 15-20 kcal/kg
33. BMI (kg/m2) Energy requirement (kcal/kg/d)
15 35-40
15-19 30-35
20-24 20-25
25-29 15-20
30 and >30 <15
These values are recommended for critically ill pts and obese pts;
add 20% of total calories in estimating energy requirement in non
critically ill pts
34. Requirement 2g/kg/day
1grams=5kcal/g
40-50 percent of total nutrition
Generally, because glucose is an essential
tissue fuel, glucose and amino acids are
provided parenterally until the level of resting
energy expenditure is reached. Fats are
added thereafter
35. Requirement 3 g/kg/day
1 gram= 9kcal/g
30-40 percent of nutrition
Liver can synthesize most fatty acids, but
humans lack the desaturase enzyme needed
to produce n-3 and n-6 fatty acid series.
Therefore linoleic acid should constitute at
least 2% and linolenic acid at least 0.5% of
daily caloric intake to prevent essential fatty
acid deficiency
36. Clinical condition requirement
normal 0.8
Metabolic stress (illness, injury) 1.0-1.5
Acute renal failure (undialyzed) 0.8-1.0
hemodialysis 1.2-1.4
Peritoneal dialysis 1.3-1.5
Additional protein intake may be needed to compensate for
excess protein loss in specific patient population such as
burn injuries, open wounds, protein losing Enteropathy /
Nephropathy. A lower protein intake may be necessary in
patient with chronic renal insufficiency who are not treated
by dialysis and certain patients with hepatic encephalopathy
37. The standard enteral and parenteral formulas
contain protein of high biological value and
meet the requirements for the eight essential
amino acids
Protein or nitrogen balance provides a
measure of feeding efficacy of PN or EN
Calculated as protein intake/6.25 minus 24h
urine urea nitrogen plus 4g nitrogen, which
reflects the other losses
38. Nitrogen Balance = N input - N output
6.25 g protein provides 1 g of nitrogen as
100grams contains 16 g nitrogen
N 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
39. ESTIMATING ADULT FLUID REQUIREMENTS
By caloric intake : 1ml/calorie
Example: 1800 calorie diet = 1800 calories x
1ml= 1800ml
By body weight and age : average requirement
is 30 ml/kg/d
16-55 years 35 ml/kg/d
56-65 years 30 ml/kg/d
> 65 years 25 ml/kg/d
41. 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
42. Zinc 2.5-4 mg
Copper 0.5-1.5mg
Chromium 10-15 mcg
Selenium 20-60 mcg
Manganese 150-800 mcg
43. Introduction of TPN should be gradual. For
example, approximately 1,000 kcal is provided
the first day. If there is metabolic stability (i.e.,
normoglycemia), this is increased to the caloric
goal over 1 to 2 days.
TPN solutions are delivered most commonly as a
continuous infusion. A new 3-in-1 admixture
bag of TPN is administered daily at a constant
infusion rate over 24 hours. Additional
maintenance intravenous fluids are unnecessary,
and total infused volume should be kept constant
while nutritional content is increased.
44. Cyclic administration of TPN solutions may be useful
for
(1) those who will be discharged from the hospital
and subsequently receive home TPN,
(2) those with limited intravenous access who require
administration of other medications, and
(3) those who are metabolically stable and desire a
period during the day when they can be free of an
infusion pump.
Cyclic TPN is administered for 8 to 16 hours, most
commonly at night. This should not be done until
metabolic stability has been demonstrated for
patients on standard, continuous TPN infusions.
45. Venous access
The infusion of hyperosmoler nutrient solution
requires a large bore, high flow vessel to
minimize vessel irritation and damage.
Percutaneous subclavian vein catheterization
and PICC are the most commonly used
techniques for parenteral nutrition
Catheter can be placed via the subclavian vein,
the jugular vein (less desirable because of the
high rate of associated infection), or a long
catheter placed in an arm vein and threaded
into the central venous system (a peripherally
inserted central catheter line)
Position of catheter is confirmed by radiograph
46.
47. ADVANTAGES DISADVANTAGES
Bed side technique
Avoids complications
of central venous
catheter
Avoid multiple venous
cannulations
Hypertonic solutions
can be given
Trained personnel is
needed
Line blockage
Mal position
Phlebitis
Line sepsis
thrombosis
48.
49. advantages disadvantages
Central access needed
Multiple lumen can be
used in acute
emergency
Hypertonic solutions
can be given
Can be placed for than
6 weeks
Inserted in theatre
Increase infection rate
Multiple complications
50.
51. advantages disadvantages
Convenient exit site
Long lasting than non
tunnels
Hypertonic solutions
can be given
Removal needs surgical
dissection
Catheter related sepsis
Other complications
52.
53.
54. Clinical Data Monitored Daily
General sense of well-being
Strength as evidenced in getting out of bed, walking, resistance exercise as
appropriate
Vital signs including temperature, blood pressure, pulse, and respiratory rate
Fluid balance: weight at least several times weekly, fluid intake (parenteral and
enteral) vs. fluid output (urine, stool, gastric drainage, wound, ostomy)
Parenteral nutrition delivery equipment: tubing, pump, filter, catheter,
dressing
Nutrient solution composition
55. Laboratory Daily
Finger-stick glucose Three times daily until stable
Blood glucose, Na, K, Cl, HCO3, BUN Daily until stable and fully
advanced, then twice weekly
Serum creatinine, albumin, PO4, Ca,
Mg, Hb/Hct, WBC
Baseline, then twice weekly
INR Baseline, then weekly
Micronutrient tests As indicated
56. Discontinuation of TPN should take place
when the patient can satisfy 75% of his or her
caloric and protein needs with oral intake or
enteral feeding.
To discontinue TPN, the infusion rate should
be halved for 1 hour, halved again the next
hour, and then discontinued.
Tapering in this manner prevents rebound
hypoglycemia from hyperinsulinemia.
It is not necessary to taper the rate if the
patient demonstrates glycemic stability.
58. Air embolism
Pneumothorax
Hemothorax (a type of pleural effusion in which
blood accumulates in the pleural cavity).
Cardiac tamponade (compression of the heart by an
accumulation of fluid in the pericardial sac).
Injuries to arteries and veins
Injury to thoracic duct
59. Early or nutrient related
hyperglycemia
hypoglycemia
hyperlipidemia
refeeding syndrome
late or related to long term administration
hepatic dysfunction
Steatosis (accumulation of fat in the liver), steatohepatitis,
Lipidosis (any disorder of lipid metabolism involving
abnormal accumulation of lipids, including GAUCHER'S
DISEASE)
Cholestasis (a decrease in bile flow due to impaired
secretion by hepatocytes),
cirrhosis
biliary complications: cholecystitis (Inflammation of gall
bladder), cholelithiasis (Gallstones in biliary tract).
Metabolic bone disease: osteomalacia, osteopenia
60. Fluid overload
Hypo/hypernatremia
Hypercalcemia
Hypo/hyperkalemia
Infection :
Catheter related sepsis is most common life
threatening complication
Causes: staph epidermidis and staph aureus,
enterococcus, candida, E coli, psuedomonas,
klebsiella etc in immunocompromised pts
61. Severe electrolyte and fluid shifts that may
result from refeeding after severe weight loss
(PEM)
Hypophosphatemia is the hallmark of
refeeding syndrome due to shift from fat to
glucose metabolism.
Hypokalemia and hypomagnesemia
↓K and ↓PO4→ ATP deficiency which can be
life threatening.
62. Store reconstituted PN bags in a refrigerator until
use
Always use aseptic techniques while connecting and
infusing PN
Always use an infusion set with in-built air vent and
0.2 m filter
Never insert a needle for air venting in a PN bag
Never add any medication to the PN bag
Avoid frequent changes in the formulation of the PN
solution
Infuse the prescribed volume and avoid wastage of
PN solution
63. Clinical trials and meta-analysis of parenteral
feeding in the perioperative period have
suggested that preoperative nutritional
support may benefit some surgical patients,
particularly those with extensive malnutrition.
Short-term use of parenteral nutrition in
critically ill patients (duration <7 days) when
enteral nutrition may have been instituted is
associated with higher rates of infectious
complications
64. Parenteral feeding with complete bowel rest
results in augmented stress hormone and
inflammatory mediator response to an
antigenic challenge .
In cancer patients, parenteral nutrition has
not been shown to benefit clinical response,
survival, or toxic effects of chemotherapy,
while infectious complications increased.
Following severe injury, parenteral nutrition is
associated with higher rates of infectious
risks when compared with enteral feeding
65. the early initiation of parenteral nutrition to
supplement insufficient enteral nutrition
during the first week after ICU admission in
severely ill patients at risk for malnutrition
appears to be inferior to the strategy of
withholding parenteral nutrition until day 8
while providing vitamins, trace elements, and
minerals. Late parenteral nutrition was
associated with fewer infections, enhanced
recovery, and lower health care costs
66. Subjects receiving intravenous feedings and
bowel rest had significantly exaggerated
response to injury
67. Strict asepsis
24-hr TPN prepared at a time
Changing infusion sets daily
New amino acid, lipid bottles daily
Separate IV access for other drugs
Serum Na, K on alt. days;
renal parameters biweekly;
LFT, triglycerides weekly