TPN NOW2

TOTAL PARENTERAL NUTRITION : 

TOTAL PARENTERAL NUTRITION PHARMACOLOGY RNLC Instructor: Dr. Carlota Cinco

KEY TERMS : 

KEY TERMS TPN – TOTAL PARENTERAL NUTRITION PN – PARENTERAL NUTRITION PICC- PERIPHERALLY INSERTED CENTRAL CATHETERS

DEFINITION (TPN) : 

DEFINITION (TPN) Total parenteral nutrition (TPN) is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein.

PURPOSE 1 : 

PURPOSE 1 TPN is used when individuals cannot or should not get their nutrition through eating. TPN is used when the intestines are obstructed, when the small intestine is not absorbing nutrients properly, or a gastrointestinal abnormal connection is present. TPN is also used for individuals with severe burns, multiple fractures, and in malnourished individuals to prepare them for major surgery, chemotherapy, or radiation treatment

PURPOSE 2 : 

PURPOSE 2 Intestinal  obstruction Inadequate digestive or absorptive capacity Uncontrollable vomiting (this is particularly life threatening to a diabetic animal) High risk of aspiration because the patient is unconscious or has a neurologic problem Need for complete GI tract rest due to digestive disease, healing time needed for GI tract lesions or surgical repairs, acute pancreatitis or hepatitis

PURPOSE 3 : 

PURPOSE 3 Parenteral nutrition should not be used routinely in patients with an intact GI tract. Compared with enteral nutrition, it causes more complications, does not preserve GI tract structure and function as well, and is more expensive.

PARENTERAL NUTRITIONACCESS : 

PARENTERAL NUTRITIONACCESS PN Central Access May be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting Peripherally inserted central catheters (PICC) are inserted via the cephalic and basilic veins Central access required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume

PICC LINES : 

PICC LINES PICC Lines (peripherally inserted central catheter) : PICC lines may be used in ambulatory settings or for long term therapy Used for delivery of medication as well as PN Inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into the superior vena cava Can remain in place for up to 1 year with proper maintenance and without complications

PRECAUTIONS : 

PRECAUTIONS Individuals need to tell their doctor if they have any allergies, what medications they are taking, if they are diabetic, have had liver, kidney, heart, lung, or hormonal disorders, and if they are pregnant. All these factors can affect the type and amount of TPN required

ADMINISTRATION : 

ADMINISTRATION Beginning TPN administration: Because the central venous catheter needs to remain in place for a long time, strict sterile technique must be used during insertion and maintenance. The TPN line should not be used for any other purpose. External tubing should be changed q 24 h with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed q 48 h using strict sterile techniques. If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged.

ADMINISTRATION : 

ADMINISTRATION The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular insulin/L of TPN fluid.

MONITORING 1 : 

MONITORING 1 Monitoring: Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored q 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.

MONITORING 2 : 

MONITORING 2 Liver function tests should be done. Plasma proteins (eg, serum albumin, Lpossibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and Ca, Mg, and phosphate should be measured twice/wk. If possible, blood tests should not be done during glucose infusion. Full nutritional assessment (including BMI calculation and anthropometric measurements

CONTRAINDICATIONS : 

CONTRAINDICATIONS Contraindications :Contraindications Functional and accessible GI tract Patient is taking oral diet Prognosis does not warrant aggressive nutrition support (terminally ill) Risk exceeds benefit Patient expected to meet needs within 14 days Methods of Nutritional Assessment :Methods of Nutritional Assessment ▪    Clinical history    Weighing, subjective assessment       ▪    Indirect calorimetry    Oxygen consumption, determination of respiratory quotient    ▪    Anthropomorphic measurements    Ideal body weight, skinfold thickness    ▪    Biochemical measurements    Albumin, transferrin, prealbumin    ▪    Measurement of nitrogen balance    ▪    Measurements of immunologic function

PPN : 

PPN Peripheral Parenteral Nutrition :Peripheral Parenteral Nutrition New catheters allow longer support via this method In adults, requires large fluid volumes to deliver adequate nutrition support (2.5-3L) May be appropriate in mild to moderate malnutrition (<2000 kcal required or <14 days) More commonly used in infants and children Controversial Contraindications to Peripheral Parenteral Nutrition :Contraindications to Peripheral Parenteral Nutrition Significant malnutrition Severe metabolic stress Large nutrition or electrolyte needs (potassium is a strong vascular irritant) Fluid restriction Need for prolonged PN (>2 weeks) Renal or liver compromise From Mirtallo.

RISKS : 

RISKS TPN requires close monitoring. Two types of complications can develop. Infection, air in the lung cavity (pneumothorax) and blood clot formation (thrombosis) all can develop as a result of inserting the catheter into a vein. Metabolic and fluid imbalances can occur if the contents of the nutritional fluid are not properly balanced and monitored. The most common metabolic imbalance is hypoglycemia, or low blood sugar, caused by abruptly discontinuing a solution high in sugar.

LABS : 

LABS Routine physiologic and laboratory monitoring :Routine physiologic and laboratory monitoring Clinical: Daily fluid balance, body weight, evidence of infection Laboratory:    Baseline: Electrolytes, BUN, creatinine, glucose, calcium, magnesium, inorganic phosphate, liver function (bilirubin, alanine transaminase, aspartate transaminase, alkaline phosphatase), triglyceride, albumin, prothrombin time   Every 6 to 12 hours: Glucose, usually for the initial 3 to 5 days or until stable    Daily until stable: Electrolytes, BUN, creatinine, glucose, calcium, magnesium, PO4    Weekly: Liver function, triglyceride, albumin, prothrombin time

LABS 2 : 

LABS 2 monitor patient’s Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored q 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.

PEDS/ADULTS : 

PEDS/ADULTS PN Administration:Transition to Enteral Feedings in Adults :PN Administration:Transition to Enteral Feedings in Adults Controversial In adults receiving oral or enteral nutrition sufficient to maintain blood glucose, no need to taper PN Reduce rate by half every 1 to 2 hrsor switch to 10% dextrose IV) may prevent rebound hypoglycemia (not necessary in PPN) Monitor blood glucose levels 30-60 minutes after cessation PN Administration:Transition to Enteral Feedings in Pediatrics :PN Administration:Transition to Enteral Feedings in Pediatrics Generally tapered more slowly than in adults as oral or enteral feedings are introduced and advanced Generally PN is continued until 75-80% of energy needs are met enterally

AFTERCARE : 

AFTERCARE During the time the catheter is in place, patients and caregivers must be alert to any signs of infection such as redness, swelling, fever, drainage, or pain.

COMING SOON : 

COMING SOON I.V. FLUIDS ON JOEL

THANK YOU : 

THANK YOU IF IT IS TO BE…. IT IS ALL UP TO ME! MABUHAY!!!!!