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Total Parenteral Nutrition

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Total Parenteral Nutrition:

Total Parenteral Nutrition

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What is parenteral nutrition support? Parenteral nutrition support refers to the infusion of an intravenous nutrition formula into the bloodstream . Total Parenteral Nutrition, or TPN, means that the infusion is providing a patient’s complete nutritional requirements. Parenteral nutrition can be delivered either centrally , into the superior vena cava, or peripherally, that is into other veins

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When is parenteral nutrition used? Parenteral nutrition should be considered only when it is not possible to meet an individual’s nutritional requirements by the enteral or oral route. In such cases it may be necessary to bypass the gut and deliver nutrients directly into the bloodstream. Gut failure, intestinal obstruction , or a complete inability to gain enteral access, are examples of situations in which parenteral nutrition is necessary to meet a patient’s nutritional needs . This may occur where there is malabsorption (such as in short bowel syndrome or inflammatory bowel diseases) or where nutritional needs are high (such as in burns).

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Adequate nutrition support is important for the following reasons: Malnutrition has been found to affect around 40% of patients in major hospitals Patients with chronic or debilitating disease processes are often already malnourished on admission to hospital/health care facilities Without appropriate nutrition support, malnourished patients continue to deteriorate in their nutritional status during their hospitalization . I f not addressed, malnutrition may result in a prolonged and complicated recovery from illness or surgery, due to impaired wound healing and increased risk of infection, and persisting functional deficits . This, in turn, leads to a longer hospital stay with an associated increase in cost1,2 and a negative impact on quality of life.

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What is the role of a TPN team ? DIETITIAN performs nutritional assessment and monitoring of the patient, estimates requirements , chooses appropriate formulation/nutrition prescription and infusion rate in consultation with other team members DOCTOR oversees/consults on medical management of the patient, may insert vascular access device, may be responsible for signing off all nutrition prescriptions NURSE oversees care of the vascular access site, physical management of the parenteral nutrition infusion and related equipment, training for home parenteral nutrition. May be responsible for insertion of some vascular access devices and/or loading of additives PHARMACIST oversees/consults on the choice of formulation and additives, may be involved with nutrition prescription and compounding of solutions and/or loading of parenteral additives.

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Indications for parenteral nutrition The main indication for parenteral nutrition is when the gut is not functional or accessible. Examples of inadequate gut function might include: bowel obstruction or suspected gut ischemia some types/locations of gastrointestinal fistula short bowel syndrome persistent severe diarrhoea or significant malabsorption persistent signs of significant gut dysmotility (a distended and/or painful IBD Organ failures- liver, renal

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The gut is not accessible when oral intake is not possible, or an enteral feeding tube cannot be inserted , due to: facial injuries/surgery or malformation upper gastrointestinal tract obstruction or malformation risk of upper gastrointestinal tract bleeding PARENTERAL NUTRITION FORMULATIONS Many different parenteral formulations are available, through several different companies. The dietitian selects an appropriate solution based on an individual nutrition assessment of the patient. Standard parenteral solutions are available in ready-to-hang bags.

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Protein Protein in parenteral nutrition is delivered in the form of free amino acids. The concentration of amino acids in a parenteral solution is often expressed in terms of the nitrogen content. For example , a solution that is called something like ‘Protein 24’ will contain 24 g/L nitrogen. The ratio of nitrogen to total molecular weight varies between amino acids, but an average calculation is [nitrogen x 6.25 = total weight of protein]. This means that our ‘Protein 24’ solution will contain about 24 x 6.25 = about 150g amino acids per litre . Standard parenteral nutrition solutions are relatively low in protein as this has stability advantages. In general, most patients will receive protein at around 1.0 – 1.2 g/kg body weight if their energy needs are fully met with a standard parenteral nutrition solution.

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Glucose Glucose ( D-glucose, also called dextrose) provides the carbohydrate content of parenteral nutrition , up to 75% of the total energy of the solution. Glucose is the body’s main source of energy , and a daily minimum of about 2g/kg body weight is required to meet the needs of those cells ( eg brain, kidney, erythrocytes) that cannot readily use other fuels . There is also a maximum rate of glucose oxidation and utilization, about 4-7 mg/minute/kg body weight (5-10 g/kg per day )

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Fat This is the primary source of Essential fatty acid (linoleic acid) in TPN. Linoleic acid is useful as precursors of prostaglandin and in the synthesis of other fatty acids which are essential for cell membrane integrity Fat is obtained from lipid emulsions. Lipid emulsion has a low osmolality, so adding it to a parenteral nutrition formulation will lower the osmolality of the resulting solution; this is important when the solution is to be given peripherally. Parenteral lipid consists of oil stabilised in an emulsion with eggyolk lecithin. The first successful parenteral lipid emulsion was based on soybean oil and this is still the most widely-available type worldwide . Alternative lipid emulsions are now available, including olive-soybean oil mixture ( in a ratio 80:20)

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Water soluble vitamins Vitamin C 100 mg Niacin 40 mg Riboflavin 3.6 mg Pantothenic acid 7.5 mg Pyridoxine 4 mg Vitamin B 12.5 μ g Folic Acid 400 μ g Biotin 60 μ g Lipid-soluble vitamins Vitamin A 1000 μ g Vitamin D 5 μ g Vitamin E 10 mg Vitamin K no recommendation made

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Trace Elements Chromium 0.2-0.4 μ mol (10-20 μ g) Copper 5-20 μmol (0.3-1.2 mg) Iodide 1.0 μ mol (0.13 mg) Iron 20 μmol (1 mg) Manganese 5 μ mol (275 μ g) Molybdenum 0.4 umol (38 μg) Selenium 0.4-1.5 μ mol (31.6-118 μ g) Zinc 50-100 μmol (3.3-6.6 mg) Fluoride no recommendation made

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Electrolytes Standard parenteral nutrition solutions usually contain electrolytes. Normal electrolyte requirements have been estimated for maintenance nutritional support (assuming normal organ function without abnormal losses ). Recommended amounts per day: Sodium 40-100 mmol or 1-2 mmol /kg Potassium 60-150 mmol or 1-2 mmol /kg Calcium 2.5-5 mmol Magnesium 4-12 mmol Phosphorus 10-30 mmol Chloride As needed to maintain acid-base balance with acetate

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