Case study of a 22 year old male patient admitted under medics with an unknown disease process, likely infectious with unknown causative agent. Extensive investigation revealed leptospirosis. Presented at hospital lunchtime medical meeting. These slides have been altered to ensure patient anonymity, and to better display information without a presenter.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
Patient case - Persistent Upper Respiratory Tract Infection *RE-UPLOAD*Robert Ferris
*Re-upload of slides originally posted 16th April 2019.*
Note: Uploading to SlideShare causes disruption to slide layout. Original layout visible on download.
Case presentation of a patient (anonymised) seen in outpatient clinic during course of medical school studies.
NOTE: Slide 7 references the patient never having had a flu vaccination due to their egg allergy. Although trivalent influenza vaccinations are grown in embryonated hens' eggs, other preparations (such as the Influenza A-specific flu vaccine) are grown in mammalian cells and are therefore safe for patients with egg allergy.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
Feasting or fasting in ICU? by Professor Marianne ChapmanSMACC Conference
Despite the publication of a number of studies over recent years looking at energy delivery and outcomes in the critically ill population we remain uncertain how best to determine optimal calorie delivery for our patients. The concept that energy delivery should match energy consumption is plausible and intellectually attractive bu Broadly speaking clinicians can be divided into 3 categories according to their approach on energy delivery to the critically ill. Some believe that optimal clinical outcomes are achieved by closely approximating energy consumption i.e. providing full calorie requirement, usually around 2000kcal/d for the standard sized adult. This position is supported by a number of observational studies, however, patients usually only receive about 60% of what they are prescribed. Some believe that attempting to provide full feeding exposes the patient to the risk of overfeeding and that ‘permissive’ underfeeding is safe and better tolerated in critically ill patients where gastrointestinal function is frequently deranged. Interestingly, recent data suggest that the patient group potentially most at risk of overfeeding are those who are malnourished at presentation. Finally, some believe that the amount of energy delivered during ICU stay has little impact on recovery. Only when the ICU stay becomes unusually prolonged may the amount of energy delivered become important. There is evidence to suggest that some nutrition should be given enterally from early in the ICU stay to provide gastrointestinal mucosal protection and improve subsequent gut function. In recent years there have been several randomised controlled trials addressing energy delivery but they have unfortunately given conflicting results. Furthermore, these studies have had a number of limitations including: being underpowered to show an effect on survival; open to bias because of being open-labelled; most have not delivered full energy requirements so the effect of this on outcomes remains uncertain. It is hoped that many of these issues will be addressed in the currently recruiting TARGET trial which will be completed next year.t, while energy delivery can be measured with indirect calorimetry, this is not a technique that lends itself to routine clinical care. Accurate measurement or calculation of day to day energy expenditure is not currently routinely possible. Delivery of nutrition is an important supportive activity in the ICU. Patients generally receive less than prescribed nutritional needs and there is no robust evidence as yet to suggest that this is deleterious to outcomes.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Case study of a 22 year old male patient admitted under medics with an unknown disease process, likely infectious with unknown causative agent. Extensive investigation revealed leptospirosis. Presented at hospital lunchtime medical meeting. These slides have been altered to ensure patient anonymity, and to better display information without a presenter.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
Patient case - Persistent Upper Respiratory Tract Infection *RE-UPLOAD*Robert Ferris
*Re-upload of slides originally posted 16th April 2019.*
Note: Uploading to SlideShare causes disruption to slide layout. Original layout visible on download.
Case presentation of a patient (anonymised) seen in outpatient clinic during course of medical school studies.
NOTE: Slide 7 references the patient never having had a flu vaccination due to their egg allergy. Although trivalent influenza vaccinations are grown in embryonated hens' eggs, other preparations (such as the Influenza A-specific flu vaccine) are grown in mammalian cells and are therefore safe for patients with egg allergy.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
Feasting or fasting in ICU? by Professor Marianne ChapmanSMACC Conference
Despite the publication of a number of studies over recent years looking at energy delivery and outcomes in the critically ill population we remain uncertain how best to determine optimal calorie delivery for our patients. The concept that energy delivery should match energy consumption is plausible and intellectually attractive bu Broadly speaking clinicians can be divided into 3 categories according to their approach on energy delivery to the critically ill. Some believe that optimal clinical outcomes are achieved by closely approximating energy consumption i.e. providing full calorie requirement, usually around 2000kcal/d for the standard sized adult. This position is supported by a number of observational studies, however, patients usually only receive about 60% of what they are prescribed. Some believe that attempting to provide full feeding exposes the patient to the risk of overfeeding and that ‘permissive’ underfeeding is safe and better tolerated in critically ill patients where gastrointestinal function is frequently deranged. Interestingly, recent data suggest that the patient group potentially most at risk of overfeeding are those who are malnourished at presentation. Finally, some believe that the amount of energy delivered during ICU stay has little impact on recovery. Only when the ICU stay becomes unusually prolonged may the amount of energy delivered become important. There is evidence to suggest that some nutrition should be given enterally from early in the ICU stay to provide gastrointestinal mucosal protection and improve subsequent gut function. In recent years there have been several randomised controlled trials addressing energy delivery but they have unfortunately given conflicting results. Furthermore, these studies have had a number of limitations including: being underpowered to show an effect on survival; open to bias because of being open-labelled; most have not delivered full energy requirements so the effect of this on outcomes remains uncertain. It is hoped that many of these issues will be addressed in the currently recruiting TARGET trial which will be completed next year.t, while energy delivery can be measured with indirect calorimetry, this is not a technique that lends itself to routine clinical care. Accurate measurement or calculation of day to day energy expenditure is not currently routinely possible. Delivery of nutrition is an important supportive activity in the ICU. Patients generally receive less than prescribed nutritional needs and there is no robust evidence as yet to suggest that this is deleterious to outcomes.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
presentation will give a idea about management of thoracoabdominal aortic aneurysm, including detail of investigation and treatment options available today.
Infective Endocarditis- surgical indication & principle of surgeryDhaval Bhimani
this presentation is to give idea about surgical indication for Infective Endocarditis and what are the principle of surgery for infective endocarditis.
Neurocognitive function in on pump vs off pump CABGDhaval Bhimani
CABG(coronary artery bypass grafting) is most common operation done in cardiac surgery, this presentation will give idea about neurocognitive dysfunction in on pump vs off pump CABG.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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.
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
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.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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
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.
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
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
2. DEFINITION
• PARENTERAL NUTRITION (PN) IS PHARMACOLOGICAL THERAPIES WHERE
NUTRIENTS, VITAMINS, ELECTROLYTES AND MEDICATIONS ARE DELIVERED VIA
THE VENOUS ROUTE TO THOSE PATIENTS WHOSE GASTROINTESTINAL TRACT IS
NOT FUNCTIONING AND ARE UNABLE TO TOLERATE ENTERAL NUTRITION.
• PN IS AN EFFECTIVE MEANS OF SUSTAINING LIFE AND PROMOTING RECOVERY IN
CRITICALLY ILL PATIENT INCAPABLE OF INGESTING, ABSORBING, OR
ASSIMILATING NUTRIENTS.
• SIMILARLY PN IS A LIFE SUPPORTING THERAPY EVEN FOR NON-CRITICALLY ILL
PATIENTS WHO HAVE PRE-EXISTING MALNUTRITION AND FOR NON-STRESSED
BUT HOSPITALIZED PATIENTS WHO ARE UNABLE TO TAKE ORAL INTAKE FOR 5
TO 7 OR MORE DAYS.
3. BASIC PRINCIPAL OF NUTRITION
• AVOID MALNUTRITION. THERE IS NO DISEASE PROCESS THAT BENEFITS FROM
STARVATION.
• IF THE BOWEL WORKS, USE IT. WHENEVER FEASIBLE, ENTERAL NUTRITION (EN)IS
PREFERRED OVER PARENTERAL NUTRITION BUT SAFE AND ADEQUATE
ADMINISTRATION OF NUTRITION IS MORE IMPORTANT THAN THE ROUTE OF
ADMINISTRATION.
• AVOID OVERFEEDING: OVERFEEDING THE PATIENT IS ASSOCIATED WITH
SIGNIFICANT COMPLICATIONS INCLUDING HYPERGLYCEMIA, HEPATIC STEATOSIS
(FATTY INFILTRATION OF LIVER) WITH HEPATIC DYSFUNCTION, ELEVATED
BLOOD UREA NITROGEN, AND EXCESSIVE C02 PRODUCTION.
4. • THE ROUTE, TIMING AND TYPE OF NUTRITIONAL FORMULATION ARE MORE·
IMPORTANT THAN THE SPECIFIC AMOUNTS OF NUTRIENTS SUPPLIED.
• DURING ACUTE STRESS, THE BODY MOBILIZES ENDOGENOUS AMINO ACID AND
ENERGY STORES.
• IT IS NOT POSSIBLE TO MAKE CATABOLIC PATIENTS ANABOLIC. THE ROLE OF
NUTRITIONAL SUPPORT IS TO LIMIT PROTEIN WASTING AND TO SUPPLY
ESSENTIAL AND CONDITIONALLY ESSENTIAL NUTRIENTS.
5. WHY IT IS IMPORTANT TO AVOID
MALNUTRITION?
• MALNUTRITION LEADS TO INCREASED SUSCEPTIBILITY TO INFECTION, POOR
WOUND HEALING, FISTULA FORMATIONS, DELAYED CALLUS FORMATIONS,
PULMONARY COMPLICATIONS (IMPAIRMENT OF RESPIRATORY MUSCLES LEADING
TO REDUCTION OF VITAL CAPACITY AND HYPOXIC VENTILATORY RESPONSE)
DECREASED TOLERANCE TO RADIOTHERAPY AND CHEMOTHERAPY, REDUCE
ENZYME SYNTHESIS, AND IMPAIRED OXIDATION OF DRUGS BY THE LIVER.
• A LONGER RECOVERY PERIOD AND INCREASED DURATION OF HOSPITALIZATION
• POOR QUALITY OF LIFE.
6. GOAL OF PARENTERAL THERAPY
• TO MAINTAIN OR IMPROVE THE NUTRITIONAL STATUS BY PROVIDING ALL
NUTRIENTS (PROTEINS, CARBOHYDRATES, LIPIDS, ELECTROLYTES, MINERALS,
TRACE ELEMENTS AND VITAMINS) FOR ONGOING METABOLIC FUNCTIONS.
• TO MINIMIZE THE DELETERIOUS EFFECTS OF CATABOLISM BY MAXIMIZING
PROTEIN SYNTHESIS, LIMITING BODY PROTEIN BREAKDOWN AND REDUCING THE
RATE OF WEIGHT LOSS.
• TO BOOST UP THE IMMUNE FUNCTION AND TO IMPROVE WOUND HEALING.
7. • TO IMPROVE THE CARDIAC AND RESPIRATORY FUNCTION BY RESTORING THE
GLYCOGEN STORAGE IN CARDIAC AND DIAPHRAGMATIC MUSCLES.
• TO MAINTAIN OR CORRECT ACID-BASE AND ELECTROLYTE DISTURBANCES.
• TO ACCELERATE REHABILITATION AND IMPROVE THE QUALITY OF LIFE.
8. INDICATION FOR TPN
• A. GENERAL INDICATIONS
• INADEQUATE ORAL OR ENTERAL NUTRITION FOR AT LEAST 7-1 O DAYS
• PRE EXISTING SEVERE MALNUTRITION WITH INADEQUATE ORAL OR ENTERAL
NUTRITION
• B. ANTICIPATED OR ACTUAL INADEQUATE ORAL OR ENTERAL INTAKE
• GIT INDICATION LIKE SHORT BOWEL SYNDROME, ENTEROCUTANEOUS FISTULA,
ACUTE PANCREATITIS, ISCHEMIC BOWEL, SMALL BOWEL OBSTRUCTION, PERITONITIS
• MOTILITY DISORDER- PARALYTIC ILEUS
• INABILITY TO MAINTAIN INTEGRITY OF INTESTINAL TRACT- MASSIVE GI BLEED.
9. • C. SIGNIFICANT MULTIORGAN SYSTEM DISEASE
• SIGNIFICANT RENAL, HEPATIC, AND PULMONARY DISEASES OR CRITICAL ILLNESS
(MULTI-ORGAN FAILURE, SEVERE HEAD INJURY, BURNS ETC.), WHICH PREVENTS
ADEQUATE ORAL OR ENTERAL NUTRITION.
10. CONTRAINDICATION FOR PN
• A. GENERAL CONTRAINDICATIONS
• IF ENTERAL NUTRITION MEETS OR EXCEEDS THE CALCULATED NUTRITIONAL
REQUIREMENTS.
• PATIENT WITH GOOD NUTRITIONAL STATUS WHO REQUIRES SHORT-TERM SUPPORT.
• SEVERE LIVER FAILURE, CARDIAC FAILURE, SHOCK AND BLOOD DYSCRASIAS.
• FLUID-ELECTROLYTE IMBALANCES
11. • B. DISEASE SPECIFIC CONTRAINDICATIONS
• AVOID EXCESS USE OF CARBOHYDRATES IN PATIENTS WITH COMPROMISED
PULMONARY FUNCTION AND IN PATIENTS WITH VENTILATOR SUPPORT DURING
WEANING PERIOD, AS IT MAY RESULT IN PRODUCTION OF LARGE AMOUNT OF
CARBON DIOXIDE.
• AVOID LIPID ADMINISTRATION, IF THE TRIGLYCERIDE LEVEL IS MORE THAN 350
MG/DL OR IN PATIENTS WITH SEVERE SEPSIS, MODERATE DEGREE OF JAUNDICE, LOW
PLATELET COUNT ( < 50,000 TO 60,000/ MM) AND ARDS OR SEVERE RESPIRATORY
DISEASE.
• IN PATIENTS WITH HEPATIC ENCEPHALOPATHY AND SEVERE RENAL FAILURE
MODIFIED AMINO ACIDS ARE PREFERRED OVER STANDARD AMINO ACIDS.It is important to remember that parenteral nutrition is not to be
undertaken lightly. It is potentially hazardous and can be dangerous
in inexperienced hands.
12. HOW TO PLAN TPN
• SELECTION OF PATIENT
• CALCULATIONS OF NUTRITIONAL REQUIREMENTS.
• SELECT AND ESTABLISH APPROPRIATE ROUTE OF ADMINISTRATION
• ADMINISTRATION, MONITORING AND AVOIDING COMPLICATIONS PARENTERAL
NUTRITION
13. • SELECTION OF PATIENT:
• NUTRITIONAL SUPPORT IS RECOMMENDED ONLY WHEN POTENTIAL BENEFITS
(IMPROVEMENT IN PROGNOSIS AND QUALITY OF-LIFE) EXCEED THE RISKS.
• ENTERAL NUTRITION (EN) IS PREFERRED OVER PARENTERAL NUTRITION (PN)
14. WHY ??
• MAINTAINS MUCOSAL PROTECTION
• EN SUPPLIES GUT-PREFERRED FUELS (GLUTAMINE, GLUTAMATE AND SHORT
CHAIN FATTY ACIDS) UNLIKE STANDARD PN.
• MORE PHYSIOLOGICAL THE LIVER IS NOT BY-PASSED. SO HEPATIC ABILITY TO
TAKEUP, PROCESS AND STORE THE VARIOUS NUTRIENTS FOR LATER RELEASE ON
NEURAL OR HORMONAL COMMAND IS MAINTAINED.
• PREVENTS CHOLELITHIASIS BY STIMULATING GALL BLADDER MOTILITY.
• LESS COSTLY AND EASIER TO MAINTAIN THAN PN.
15. WHEN IS ENTERAL NUTRITION
CONTRAINDICATED?
• GI CAUSES: SEVERE DIARRHOEA, PARALYTIC ILEUS, INTESTINAL OBSTRUCTION,
SEVERE GI BLEEDING, SEVERE ACUTE PANCREATITIS AND HIGH OUTPUT EXTERNAL
FISTULA.
• CARDIAC CAUSES: HAEMODYNAMIC INSTABILITY, LOW CARDIAC OUTPUT,
HYPOTENSIVE PATIENTS ON MODERATE TO LARGE DOSE OF ALPHA AGONISTS OR IN
CIRCULATORY SHOCK. ENTERAL FEEDING IN HAEMODYNAMICALLY UNSTABLE
PATIENTS CARRIES POTENTIAL RISK OF GASTROINTESTINAL ISCHEMIA.
• LACK OF ACCESS: UNOBTAINABLE SAFE ACCESS TO GASTROINTESTINAL TRACT.
• THE PATIENTS WITH COMPLICATIONS OF ENTERAL FEEDING (I.E. PULMONARY
ASPIRATION, SEVERE DIARRHOEA, AND INTESTINAL LSCHEMIA OR INFARCT
PRECIPITATED BY ENTERAL FEEDING IN PATIENTS WITH ISCHEMIC BOWEL SYNDROME)
SHOULD NOT BE FED BY ENTERAL ROUTE.
16. ADVANTAGES OF PARENTERAL NUTRITION
OVER ENTERAL NUTRITION
• ENSURED, DESIRED VOLUME DELIVERY OF NUTRIENTS WITHOUT THE CONCERNS
OF GASTROINTESTINAL INTOLERANCE OR COMPLIANCE WITH TRANSNASAL
FEEDING TUBES.
• IMPROVED METABOLIC, ELECTROLYTE, AND MICRONUTRIENT MANAGEMENT.
• BETTER ACID-BASE MANIPULATION.
• DRUG DELIVERY CAPABILITIES (HISTAMINE H2 BLOCKERS, METOCLOPRAMIDE,
INSULIN, HEPARIN ETC).
• SO, PN NOT ONLY DELIVERS NUTRITION BUT ALSO REGULATES FLUID,
ELECTROLYTE AND ACID-BASE HOMEOSTASIS.
17. CALCULATIONS OF NUTRITIONAL
REQUIREMENTS.
• ENERGY REQUIREMENTS:-
1. SIMPLE BODY WEIGHT BASED CALCULATION:
REE (KCAL/DAY) = 25 X WEIGHT
2. HARRIS-BENEDICT EQUATION:
REE (MAN) = 66 + (13.7 X W) + (5.0 X H) - (6.7 X A)
REE (WOMEN) = 655 + (9.6 X W) + (1.8 X H) - (4.7 X A)
• W = WEIGHT IN KG H = HEIGHT IN CM A = AGE IN YEARS.
18. SO, TEE = REE X AF X DF X TF
• GUIDELINES FOR ADJUSTMENT IN ENERGY REQUIREMENTS
• AF=ACTIVITY FACTOR
• 1.2 - BED REST , 1.3 - OUT OF BED
• DF=DISEASE FACTOR
• 1.25 GENERAL SURGERY
• 1.3 SEPSIS
• 1.6 MULTIORGAN FAILURE
• 1.7- 1.8- 1.9 - 30-50%, 50-70%,70-90% BURNS, RESPECTIVELY
• TF= THERMAL FACTOR.
• 1.1 - 38°C, 1.2 - 39°C , 1.3 – 40 °C , 1.4 - 41 °C
19. HOW TO PROVIDE ENERGY REQUIREMENTS TO
A PATIENT ON PN?
• APPROXIMATE PROPORTION OF DIFFERENT MACRONUTRIENTS (CARBOHYDRATE,
FAT AND PROTEIN) IN PARENTERAL SOLUTION FOR ENERGY SUPPLEMENTATION
IS AS FOLLOWS:
• 50 - 70% CARBOHYDRATE (1 GRAM DEXTROSE = 3.4 KCAL)
• 20 -30% FAT (1 GRAM LIPID = 9 KCAL)
• 15 - 20% PROTEIN (1 GRAM PROTEIN = 4 KCAL)
20. IMPORTANT NOTE
• USUALLY ONLY NON PROTEIN CALORIES ARE UTILIZED FOR ENERGY CONTENT
OF PN, APPLYING THE THEORY THAT PROTEIN WILL BE USED FOR ANABOLIC
PROCESS RATHER THAN AS AN ENERGY SOURCE.
• IN CLINICAL PRACTICE, USUALLY A MIXTURE OF GLUCOSE AND TRIGLYCERIDES
IS GIVEN IN A RATIO OF APPROXIMATELY 60 TO 70% GLUCOSE AND 30-40% OF
FAT.
• THIS MIXED FUEL NUTRIENT IN STRESSED PATIENTS SIGNIFICANTLY REDUCES
C02 PRODUCTION AND THEREFORE, REDUCES THE RESPIRATORY WORK OF
BREATHING.
21. MONITORING OF PN
• RECORD VITAL SIGNS AT LEAST EVERY 4 HOURS. TEMPERATURE ELEVATION IS ONE
OF THE EARLIEST SIGNS OF CATHETER RELATED SEPSIS.
• PATIENTS SHOULD BE WEIGHED DAILY AT THE SAME TIME EACH MORNING AFTER
VOIDING, ON THE SAME SCALE WEIGHT GAIN MAY INDICATE FLUID OVERLOAD.
• PERFORM SITE CARE AND DRESSING CHANGE AT LEAST THREE TIMES A WEEK, OR
WHENEVER THE DRESSING BECOMES WET.
• PATIENTS RECEIVING PN SHOULD BE MONITORED CAREFULLY TO DE.TECT EARLY
SIGNS OF COMPLICATIONS SUCH AS FLUID OVERLOAD, ELECTROLYTES IMBALANCE,
NUTRITIONAL PROBLEMS OR ALLERGIC REACTIONS.
22. • MONITOR SERUM GLUCOSE LEVELS EVERY 6 HOURS INITIALLY, THEN ONCE A
DAY . WATCH FOR THE SYMPTOMS OF HYPERGLYCEMIA SUCH AS THIRST AND
POLYURIA.
• MONITOR ELECTROLYTE AND PROTEIN LEVELS DAILY AT FIRST, AND THEN
TWICE A WEEK. ALBUMIN LEVELS MAY DROP INITIALLY AS TREATMENT RESTORES
HYDRATION.
• ASSESS LIVER FUNCTION WITH LIVER FUNCTION TESTS, BILIRUBIN, SGPT,
TRIGLYCERIDE, AND CHOLESTEROL LEVELS. ABNORMAL VALUES MAY INDICATE
INTOLERANCE.
• MONITORING RESPONSE TO NUTRITIONAL THERAPY. THERE IS NO SINGLE
CRITERION . WHICH CAN RELIABLY INDICATE EFFECTIVENESS OF PN.
IMPROVEMENT IN CLINICAL STATUS AND VISCERAL PROTEIN CONCENTRATIONS
(E.G. ALBUMIN, PREALBUMIN AND TRANSFERRIN) ARE MOST COMMONLY USED
TO MONITOR NUTRITIONAL STATUS.
23. TERMINATION OF PN
• PN IS THE TEMPORARY METHOD OF NUTRITIONAL SUPPLEMENTATION. THE
ULTIMATE GOAL IS TO RESTART ORAL/ENTERAL FOOD INTAKE AS SOON AS·
GASTROINTESTINAL FUNCTION RETURNS.
• THE TRANSITION FROM PN TO ORAL OR ENTERAL NUTRITION SHOULD BE DONE
GRADUALLY TO AVOID THE DETERIORATION IN NUTRITIONAL STATUS WHEN PN IS
DISCONTINUED.
• PN SHOULD NOT BE DISCONTINUED ABRUPTLY. REDUCE INFUSION RATE TO 50% FOR
1 TO 2 HOURS BEFORE DISCONTINUING PN. SUCH REDUCTION WILL MINIMIZE THE
RISK OF REBOUND HYPOGLYCEMIA.
• IF THERE IS A NEED TO DISCONTINUE PN ABRUPTLY, A 10% DEXTROSE SOLUTION
MAY BE ADMINISTERED FOR A FEW HOURS AND THEN DISCONTINUED TO PREVENT
HYPOGLYCEMIA. ONCE PATIENT IS ABLE TO TAKE 60% OF THE TOTAL ENERGY AND
PROTEIN REQUIREMENTS ORALLY OR ENTERA!LY,. PN MAY BE STOPPED.
24. COMPLICATIONS
Mechanical Metabolic/GI Infectious
First 48 hours Malposition,
hemothorax,
pneumothorax, air
embolism, blood
loss, puncture of
subclavian or carotid
artery
Fluid overload
Hyperglycemia
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Refeeding syndrome
------
First 2 weeks Catheter
displacement
Catheter thrombosis
Catheter occlusion
Air embolism
Hyperglycemic coma
Acid base imbalance
Electrolyte imbalance
Catheter induce
sepsis
3 month onwards Fracture or tear of
catheter,
Air embolism
Essential fatty acid
deficiency,
Vitamin deficiency,
PN metabolic bone
and liver disease.
Tunnel infection
Catheter site sepsis.