TOTAL PARENTERAL NUTRITION

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TOTAL PARENTERAL NUTRITION : 

TOTAL PARENTERAL NUTRITION BY : DR. KALPESH R FALDU GUIDE TO TOPIC : DR.V.J.ANAND

DEFINITION : 

DEFINITION TOTAL PARENTERAL NUTRITION IS DEFINED AS THE INTRAVENOUS PROVISION OF ALL NUTRITIONAL REQUIREMENTS, WITHOUT THE USE OF THE GASTROINTESTINAL TRACT.

Parenteral Nutrition : 

Parenteral Nutrition Graphic source: http://www.rxkinetics.com/tpntutorial/1_4.html

General Conditions Suggesting Initiation of Nutrition Support : 

General Conditions Suggesting Initiation of Nutrition Support ▪    Poor nutritional status (oral intake <50% of energy needs)    ▪    Catabolic disease (burn, sepsis, pancreatitis)    ▪    Significant weight loss (>10%)    ▪    Anticipated duration of artificial nutrition longer than 7 days    ▪    More than 7 days' inanition    ▪    Nonfunctioning gastrointestinal tract    ▪    Serum albumin <3 g/dL in the absence of an inflammatory state

INDICATIONS FOR TPN : 

INDICATIONS FOR TPN Proximal intestinal fistula Inflammatory bowel disease Massive intestinal resection(<100 cm small bowel remains) Paralytic ileus/obstruction Severe pancreatitis Practically all patients requiring nutrition support but can’t tolerate enteral feeds, or C/I to enteral feeding.

Total Parenteral Nutrition : 

Total Parenteral Nutrition GENERAL INDICATIONS Patient who can’t eat Patient who won’t eat Patient who shouldn’t eat Patient who can’t eat enough “If the gut works, use it.”

Total Parenteral Nutrition : 

Total Parenteral Nutrition A.S.P.E.N Guidelines *(Indication for nutritional support) Severe stress or malnutrition NPO > 4-5 days Moderate stress or malnutrition NPO > 7-10 days Non-stressed / normal nourished NPO > 10 days No indication for TPN < 4 days

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

Total Parenteral Nutrition : 

Total Parenteral Nutrition NOMENCLATURE TPN: Total Parenteral Nutrition IVH: Intravenous Hyperalimentation TNA: Total Nutrient Admixture 3-In-1 Admixture All-In-One Admixture PPN: Peripheral Parneteral Admxtiure

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

Nutritional Indices : 

Nutritional Indices Body mass index (BMI)BMI = weight (kg)/[height (m)]2 = 703 × weight (lb)/[height (in.)]2BMI: normal 18.5–24.9, overweight 25–29.9, obese 30–40, morbid obesity >40Prognostic nutritional index (PNI)PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)DH: >5 mm induration = 2; 1–5 mm induration = 1; anergy = 0PNI: >50% = high risk for complications; 40%–49% = intermediate risk; <40% = low riskNutrition risk indexNRI = 15.19 (Alb) + 41.7 [weight (kg)/ideal weight (kg)]NRI: <100 = malnourishedCatabolic index (CI)CI = UUN - [0.5 (dietary nitrogen intake in g)]CI: 0 = no significant stress; 0–5 = mild stress; >5 = moderate to severe stress

Anthropomorphic Measurements : 

Anthropomorphic Measurements Creatinine-height index, Triceps skinfold thickness Midarm muscle circumference calculation of Ideal body weight (IBW) (when usual body weight, or weight of the patient before the onset of illness, is unknown) •    For males: 106 lb for the first 5 ft and 6 lb for each inch thereafter.    •    For females: 100 lb for the first 5 ft and 5 lb for each inch thereafter.

Biochemical Measurements : 

Biochemical Measurements Serum albumin of less than 3.5 g/dL (35 g/L) in a stable, hydrated patient; half-life is 14 to 20 days. Serum prealbumin may be a more useful indicator of acute changes: 10 to 17 mg/dL corresponds to mild depletion, 5 to 10 mg/dL to moderate depletion, and less than 5 mg/dL to severe depletion; half-life is 2 to 3 days. Serum transferrin of less than 200 mg/dL; half-life is 8 to 10 days.

Parenteral Nutrition (PN) Definition : 

Parenteral Nutrition (PN) Definition Delivery of nutrients intravenously, e.g. via the bloodstream. Central Parenteral Nutrition: often called Total Parenteral Nutrition (TPN); delivered into a central vein Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral vein A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p. 97

PN Central Access : 

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

Venous Sites for Access to the Superior Vena Cava : 

Venous Sites for Access to the Superior Vena Cava

PICC Lines (peripherally inserted central catheter) : 

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

PN: Peripheral Access : 

PN: Peripheral Access PN may be administered via peripheral access when Therapy is expected to be short term (10-14 days) Energy and protein needs are moderate Formulation osmolarity is <600-900 mOsm/L Fluid restriction is not necessary A.S.P.E.N. Nutrition Support Practice Manual, 2005; p. 94

Macronutrients: Carbohydrate : 

Macronutrients: Carbohydrate Source: Monohydrous dextrose Properties: Nitrogen sparing Energy source 3.4 Kcal/g Hyperosmolar Recommended intake: 2 – 5 mg/kg/min 50-65% of total calories

Total Parenteral Nutrition : 

Total Parenteral Nutrition Carbohydrate Max rate of glucose oxidation: 5 – 7 mg/kg/min Max dextrose rate stable patients: Not >7 mg/kg/min Max dextrose rate critical care patient: Not > 4 mg/kg/min

Macronutrients: Carbohydrate : 

Macronutrients: Carbohydrate Potential Adverse Effects: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems Hyperglycemia

Macronutrients: Amino Acids : 

Macronutrients: Amino Acids Source: Crystalline amino acids— standard or specialty Properties: 4.0 Kcal/g EAA 40–50% NEAA 50- 60% Glutamine / Cysteine Recommended intake: 0.8-2.0 g/kg/day 15-20% of total calories

Macronutrients: Amino Acids : 

Macronutrients: Amino Acids Potential Adverse Effects: Increased renal solute load Azotemia

Macronutrients: Amino Acids : 

Macronutrients: Amino Acids Specialized Amino Acid Solutions Branched chain amino acids (BCAA) Essential amino acids (EAA) Not shown to improve patient outcome More expensive than standard solutions

Macronutrients: Lipid : 

Macronutrients: Lipid Source: Safflower and/or soybean oil Properties: Long chain triglycerides Isotonic or hypotonic Stabilized emulsions 9 Kcals/g Prevents essential fatty acid deficiency Recommended intake: 0.5 – 1.5 g/kg/day (not >2 g/kg) 12 – 24 hour infusion rate

Macronutrients: Lipids : 

Macronutrients: Lipids Requirements 4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as linoleic acid Generally 500 mL of 10% fat emulsion given two times weekly or 500 mL of 20% lipids given once weekly will prevent EFAD Usual range 25% to 35% of total kcals Max. 60% of kcal or 2 g fat/kg

Macronutrients: Lipids : 

Macronutrients: Lipids Potential Adverse Effects: Egg allergy Hypertriglyceridemia Decreased cell-mediated immunity (limit to <1 g/kg/day in critically ill immunosuppressed patients) Abnormal LFTs

Parenteral Base Solutions : 

Parenteral Base Solutions Carbohydrate Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixing Amino acids Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions 8.5% and 10% generally used for manual mixing Fat 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA, not for direct venous delivery) The A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p. 97; Barber et al. In ASPEN, The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001.

Other Requirements : 

Other Requirements Fluid—30 to 50 ml/kg (1.5 to 3 L/day) Sterile water is added to PN admixture to meet fluid requirements Electrolytes Use acetate or chloride forms to manage metabolic acidosis or alkalosis(in patients with normal electrolytes acetate : chloride 1:2) Vitamins: multivitamin formulations Trace elements

Electrolytes/Vitamins/Trace Elements : 

Electrolytes/Vitamins/Trace Elements Because parenterally-administered vitamins and trace elements do not go through digestion/absorption, recommendations are lower than DRIs Salt forms of electrolytes can affect acid-base balance

Adult Parenteral Multivitamins : 

Adult Parenteral Multivitamins New FDA requirements published in 2000 replacing NAG-AMA guidelines Increased B1, B6, vitamin C, folic acid, added Vitamin K MVI Adult (Mayne Pharma) and Infuvite (MVI-13) from Baxter contain Vitamin K and are consistent with the new FDA guidelines MVI-12 (Mayne Pharma) does not contain Vitamin K (added separately 10 mg once a week)

Total Parenteral NutritionTrace Elements : 

Total Parenteral NutritionTrace Elements Recommendations per NAG Zinc Poor wound healing Copper Anemia Chromium Glucose Intolerance Manganese ?? Selenium Keshan’s Disease

Parenteral Nutrition Vitamin Guidelines : 

Parenteral Nutrition Vitamin Guidelines *Federal Register 66(77): April 20, 2000

Daily Trace Element Supplementation for Adult PN : 

Daily Trace Element Supplementation for Adult PN ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49, 1998

Daily Electrolyte Requirements Adult PN : 

Daily Electrolyte Requirements Adult PN ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49, 1998

PN Contaminants : 

PN Contaminants Components of PN formulations have been found to be contaminated with trace elements Most common contaminants are aluminum and manganese Aluminum toxicity a problem in pts with renal compromise on long-term PN and in infants and neonates Can cause osteopenia in long term adult PN patients ASPEN Nutrition Support Practice Manual 2005; p. 109

PN Contaminants : 

PN Contaminants FDA requires disclosure of aluminum content of PN components Safe intake of aluminum in PN is set at 5 mcg/kg/day

PN Contaminants : 

PN Contaminants Manganese toxicity has been reported in long term home PN patients May lead to neurological symptoms Manganese concentrations of 8 to 22 mcg/daily volume have been reported in formulations with no added manganese May need to switch to single-unit trace elements that don’t include manganese ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Peripheral Parenteral Nutrition : 

Peripheral Parenteral Nutrition Hyperosmolar solutions cause thrombophlebitis in peripheral veins Limited to 800 to 900 mOsm/kg (MHS uses 1150 mOsm/kg w/ lipid in the solution) Dextrose limited to 5-10% final concentration and amino acids 3% final concentration Electrolytes may also be limited Use lipid to protect veins and increase calories

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. In ASPEN, The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001, 222.

EQUATIONS : 

EQUATIONS HARRIS-BENEDICT EQUATION : BEE in kilocalories per day for men equals 66.4 + [13.7 × weight (kg)] + [5 × height (cm)] – [6.8 × age (years)]. BEE in kilocalories per day for women equals 65.5 + [9.6 × weight (kg)] + [1.7 × height (cm)] – [4.7 × age (years)]. NORMAL ADULT : 20-25 KCAL/KG/DAY

Stress Factors Used in Calculation of Total Energy Expenditure : 

Stress Factors Used in Calculation of Total Energy Expenditure Clinical condition Stress factor Starvation 0.80–1.00 Elective operation 1.00–1.10 Peritonitis or other infections 1.05–1.25 Adult respiratory distress syndrome sepsis 1.30–1.35 Pancreatitis 1.30–1.80

Estimates of protein requirements : 

Estimates of protein requirements The appropriate calorie:nitrogen ratio is approximately 150:1 (calorie:protein ratio of 24:1) 1.5 g protein per kilogram body weight should be provided daily Twenty-four–hour nitrogen balance is calculated by subtracting nitrogen loss from nitrogen intake. Nitrogen intake is the sum of nitrogen delivered from enteral and parenteral feedings. Nitrogen is lost through urine, fistula drainage, diarrhea, and so on. The usual approach is to measure the urine urea nitrogen (UUN) concentration of a 24-hour urine collection and multiply by urine volume to estimate 24-hour urinary loss. Nitrogen loss equals 1.2 × [24-hour UUN (g per day)] + 2 g per day as a correction factor to account for nitrogen losses in stool and skin exfoliation.

Estimated Protein Requirements in Various Disease States : 

Estimated Protein Requirements in Various Disease States Clinical condition Protein requirements (g/kg ideal body weight/day) Healthy, nonstressed 0.80 Simplified estimates   Mild metabolic stress (elective hospitalization) 1.00–1.10 Moderate metabolic stress (complicated postoperative care, infection) 1.20–1.40 Severe metabolic stress (major trauma, pancreatitis, sepsis) 1.50–2.50

Compounding Methods : 

Compounding Methods Total nutrient admixture (TNA) or 3-in-1 Dextrose, amino acids, lipid, additives are mixed together in one container Lipid is provided as part of the PN mixture on a daily basis and becomes an important energy substrate 2-in-1 solution of dextrose, amino acids, additives Typically compounded in 1-liter bags Lipid is delivered as piggyback daily or intermittently as a source of EFA

Advantages of TNA : 

Advantages of TNA Decreased nursing time Decreased risk of touch contamination Decreased pharmacy prep time Cost savings Easier administration in home PN Better fat utilization in slow, continuous infusion of fat Physiological balance of macronutrients

Disadvantages of TNA : 

Disadvantages of TNA Diminished stability and compatibility IVFE (IV fat emulsions) limits the amount of nutrients that can be compounded Limited visual inspection of TNA; reduced ability to detect precipitates ASPEN Nutrition Support Practice Manual 2005; p. 98-99

3 IN 1 ADMIXTURE : 

3 IN 1 ADMIXTURE PROTEIN (AMINO ACIDS) (10%; 4 kcal/g) CARBOHYDRATE (DEXTROSE) (70%; 3.4 kcal/g) FAT (LIPID EMULSION OF SOYBEAN/SAFFLOWEROIL) (20%; 9 kcal/g)

Suggested Sequence for the Initiation of Parenteral Nutrition Therapy : 

Suggested Sequence for the Initiation of Parenteral Nutrition Therapy PARAMETER DAY 1 DAY 2 DAY 3 Volume (mL/24 hr) 1000 1000-1500 1500-2000 Calories (% of goal) 50% 75%, may add fat 100% Dextrose (g/24 hr) 100-150 150-200 200-350 Amino acids (% of total) 50%-100% 100% 100%, check BUN Fat No Perhaps Often (3%-5%, 30-50 g/24 hr) Insulin Give separately Add 50% to TPN Add 50% to TPN

Initiation of PN : 

Initiation of PN Adults should be hemodynamically stable, able to tolerate the fluid volume necessary to deliver significant support, and have central venous access If central access is not available, PPN should be considered (more commonly used in neonatal and peds population) Start slowly(1 L 1st day; 2 L 2nd day) ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: formulation : 

Initiation of PN: formulation As protein associated with few metabolic side effects, maximum amount of protein can be given on the first day, up to 60-70 grams/liter Maximum CHO given first day 150-200 g/day or a 15-20% final dextrose concentration In pts with glucose intolerance, 100-150 g dextrose or 10-15% glucose concentration may be given initially ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: Formulation : 

Initiation of PN: Formulation Generally energy and protein needs can be met in adults by day 2 or 3 In neonates and peds, time to reach full support relates inversely to age, may be 3-5 days

Initiation of PN: Formulation : 

Initiation of PN: Formulation Dextrose content of PN can be increased if capillary blood glucose levels are consistently <180 mg/dL IVFE in PN can be increased if triglycerides are <400 mg/dL ASPEN Nutrition Support Practice Manual 2005; p. 109

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 ASPEN Nutrition Support Practice Manual 2005; p. 109

Medications That May Be Added to Total Nutrient Admixture (TNA) : 

Medications That May Be Added to Total Nutrient Admixture (TNA) Phytonadione Selenium Zinc chloride Levocarnitine Insulin Metoclopromide Ranitidine Sodium iodide Heparin Octreotide

Infusion Schedules : 

Infusion Schedules Continuous PN Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous access

Continuous PN : 

Continuous PN Advantages Well tolerated by most patients Requires less manipulation decreased nursing time decreased potential for “touch” contamination

Continuous PN : 

Continuous PN Disadvantages Persistent anabolic state altered insulin : glucagon ratios increased lipid storage by the liver Reduces mobility in ambulatory patients

Infusion Schedules : 

Infusion Schedules Cyclic PN The intermittent administration of PN via a central or peripheral venous access, usually over a period of 12 – 18 hours Patients on continuous therapy may be converted to cyclic PN over 24-48 hours

Cyclic PN : 

Cyclic PN Advantages Approximates normal physiology of intermittent feeding Maintains: Nitrogen balance Visceral proteins Ideal for ambulatory patients Allows normal activity Improves quality of life

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

Home TPN : 

Home TPN Safety and efficacy depend on: Proper selection of patients Adequate discharge planning/education Home monitoring protocols

Home TPN : 

Home TPN Patient selection Reasonable life expectancy Demonstrates motivation, competence, compliance Home environment conducive to sterile technique

Home TPN : 

Home TPN Cost effective Quicker discharge from hospital Improved rehabilitation in the home Reduced hospital readmissions

Common Indications for PN in Peds : 

Common Indications for PN in Peds Surgical GI disorders Intractable diarrhea of infancy Short bowel syndrome Inflammatory bowel disease Intractable chylothorax Intensive cancer treatment

Pediatric Energy Needs in PN : 

Pediatric Energy Needs in PN No consensus exists as to how to determine energy needs of hospitalized children RDAs are intended for healthy children but can use for healthy/acutely ill children and monitor response Can estimate REE using WHO equation and add stress factors, monitor clinical course Indirect calorimetry recommended in difficult cases

RDAs for Energy and Protein : 

RDAs for Energy and Protein Recommended Dietary Allowances, 10th ed. 1989. National Academy Press, Washington, DC

WHO Equations to predict REE from body weight : 

WHO Equations to predict REE from body weight

Increase WHO REE by stress factors : 

Increase WHO REE by stress factors Olson, D. Pediatric Parenteral Nutrition. In Sharpening your skills as a nutrition support dietitian. DNS, 2003.

Trauma/Critically Ill Peds : 

Trauma/Critically Ill Peds

Pediatric PN: Fluids : 

Pediatric PN: Fluids Standard calculation: 100 kcal/kg for infant 3-10 kg 1000 kcal + 50 kcal/kg for every kg over 10 kg for a child 10-20 kg 1500 kcal + 20 kcal/kg for every kg over 20 kg for a child over 20 kg 1 mL fluid/kcal/d + adjustments for fever, diarrhea, stress, etc. ASPEN BOD Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26;26SA, 2001

Pediatric PN: Carbohydrate : 

Pediatric PN: Carbohydrate Carbohydrate should comprise 45-50% of caloric intake in infants and children (C) For neonates, CHO delivery in PN should begin at 6-8 mg/kg/minute of dextrose and advanced to 10-14 mg/kg/minute. (B) ASPEN BOD Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26;28-29SA, 2001

Daily Electrolyte and Mineral Requirements for Peds Pts : 

Daily Electrolyte and Mineral Requirements for Peds Pts National Advisory Group. Safe practices for parenteral nutrition formulations JPEN 1998;22:49-66

Total Parenteral NutritionCompatibility : 

Total Parenteral NutritionCompatibility Insulin Reports of up to 50% of insulin is lost to adsorption to TPN bag, tubing and filter Insulin loss due to adsorption to EVA systems probably only 5-15%. However: Addition of insulin to TPN is considered physically compatible and therapeutically appropriate Tomato theory (dose is titrated)

Total Parenteral NutritionCompatibility : 

Total Parenteral NutritionCompatibility Insulin Practical Guidelines Minimum dose = 10 U / bag Dose in 10 U increments Avoid putting too much in TPN Suppliment with sliding scale Add ½ of previous day’s SS to TPN

Total Parenteral NutritionCompatibility : 

Total Parenteral NutritionCompatibility

TPN Complications : 

TPN Complications MECHANICAL Pneumothorax – air Hemothorax - blood Hydrothorax - solution (TPN) Intravascular Misplacement - often IJ Catheter Embolism - sheared tip Air Embolism Venous Thrombosis

TPN ComplicationsGlucose Metabolism : 

TPN ComplicationsGlucose Metabolism Hyperglycemia HHCN: Hyperglycemic, hyperosmolar, nonketotic coma Renal threshold for glucose = 180 mg/dl One episode of hyperglycemia may affect the outcome in critical care patient

TPN ComplicationsGlucose Metabolism : 

TPN ComplicationsGlucose Metabolism Hyperglycemia: Prevention and Treatment Start TPN at 50 ml/hr or with 10% dextrose Advance rate at 25 ml/hr each day Do not overfeed (<5-7mg/kg/min) Check BS at least daily Do not advance if BS > 200 mg/dl If > 200 give insulin to control BS then advance May decrease the % of total calories from dextrose

TPN ComplicationsGlucose Metabolism : 

TPN ComplicationsGlucose Metabolism Rebound Hypoglycemia May occur if TPN interrupted for > 30 min Endogenous and exogenous insulin Prevention Taper TPN before stopping (1/2 rate x 1-2 hours) Hang D10%

TPN ComplicationsGlucose Metabolism : 

TPN ComplicationsGlucose Metabolism CO2 Retention Occurs in pts with resp. dz. (ie. COPD) Occurs with overfeeding Especially if primary source of calories dextrose Prevention Feed per nutritional assessment Provide mixed substrate

TPN ComplicationsProtein Metabolism : 

TPN ComplicationsProtein Metabolism Azotemia Occurs in pts with renal failure Prevention: restrict protein ARF: 0.5-0.8gm/kg/d CRF: 0.8-1 gm/kg/d Dialysis Specialized AA formulations??

TPN ComplicationsProtein Metabolism : 

TPN ComplicationsProtein Metabolism Hyperammonemia and Hepatic Encephalopathy (HE) Occurs in pts with liver failure Restrict protein as necessary ie. 0.5 gm/kg/d Treat HE with lactulose or antibiotic enemas For HE consider Hepatamine

TPN ComplicationsFat Metabolism : 

TPN ComplicationsFat Metabolism Essential Fatty Acid Deficiency EFA = linoleic acid Cause: TPN without fat Prevention: Give IV fat emulsion Hyperlipidemia If trig too high (>400 mg/dL) give IV fat emulsion for EFA only

TPN ComplicationsAbnormalities of LFT’s : 

TPN ComplicationsAbnormalities of LFT’s Elevated liver function tests AST (SGOT) also from heart ALT (SGPT) more specific LDH and Bilibrubin Possible cause: fatty infiltrates of liver (hepatic steatois) Exceed rate of glucose metabolism 5-7 mg/kg/min Less risk with cyclic infusion (ie. 12hr on 12 hr off) Prevention Keep rate < 5mg/kg/min Provide mixed substrates (Lipids) Provide calories per nutritional assessment Possible cause: Cholestatis

TPN ComplicationsFluid and Electrolyte Disorders : 

TPN ComplicationsFluid and Electrolyte Disorders Fluid and virtually any electrolyte Refeeding Syndrome Low serum levels of intracellular electrolytes Hpokalemia Hypomagnesemia Hypophosphatemia Setting: Malnourished patients Serum lytes may be normal but TBS are low Prevention: Daily lytes when starting TPN Make electrolyte adjustments

TPN ComplicationsSeptic Complications : 

TPN ComplicationsSeptic Complications Usually catheter related Not commonly from contaminated TPN Most common bacteria: Staph sp. Most common fungi: Candida sp. Prevention: Monitor for S&S of infection Proper catheter care

celemin : 

celemin

celemin : 

celemin

HERMIN-T : 

HERMIN-T CompositionI NJ - EACH 100 ML - L-ISOLEUCINE 560 MG+L-LEUCINE 1250 MG+ LYSINE 1100 MG+L-METHIONINE 350 MG+L-THREONINE 650 MG+ L-PHENYLALANINE 935 MG+L-TRYPTOPHAN 130 MG+L-VALINE 450 MG+ L-ARGININEHCL 955 MG+L-ASPARTIC ACID 380 MG+L-CYSTEINE 1 MG+L-GLUTAMIC ACID 650 MG+L-PROLINE 330 MG+L-SERINE 220 MG+ L-TYROSINE 35 MG+L-ALANINE 620 MG+GLYCINE 1070 MG+ XYLITOL 5000 MG

KABIVEN® G19% : 

KABIVEN® G19%

kabiven : 

kabiven

Slide 98: 

infusion rate: The maximum infusion rate for glucose is 0.25 g/kg/h. Amino acid dosage should not exceed 0.1 g/kg/h. Fat dosage should not provide more than 0.15 g/kg/h. The infusion rate should not exceed 2.6 mL/kg b.w./hour (corresponding to 0.25 g glucose, 0.09 g amino acid and 0.1 g fat/kg b.w.). The recommended infusion period is 12-24 hours. Maximum daily dose 40 mL/kg b.w./day. This is equal to one bag (largest size) to a 64 kg-patient and will provide 1.3 g amino acids/kg b.w./day (0.21 g N/kg b.w./day), 31 kcal/kg b.w./day non-protein energy (3.9 g glucose/kg b.w./day and 1.6 g fat/kg b.w./day). The maximum daily dose varies with the clinical condition of the patient and may even change from day to day.

Slide 99: 

Contraindications Hypersensitivity to egg-, soya- or peanut protein or to any of the ingredients Severe hyperlipaemia Severe liver insufficiency Severe blood coagulation disorders Inborn errors of amino acid metabolism Severe renal insufficiency without access to haemofiltration or dialysis Acute shock Hyperglycaemia, which requires more than 6 units insulin/h Pathologically elevated serum levels of any of the included electrolytes General contraindications to infusion therapy: acute pulmonary oedema, hyperhydration, decompensated cardiac insufficiency and hypotonic dehydration Haemophagocytotic syndrome Unstable conditions (e.g. severe post-traumatic conditions, uncompensated diabetes, acute myocardial infarction, metabolic acidosis, severe sepsis and hyperosmolar coma) Due to composition, Kabiven G19% is not suitable for use in new-borns or infants under 2 years of age.

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