TPN2

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Mohamed Abdel-Ghaffar TOTAL PARENTRAL NUITRITION A SIMPLE AND PRACTICAL APPROACH MOHAMED EMAD EL-DIN ABDEL-GHAFFAR Professor and Chairman Department of Anesthesiology CCM Faculty of Medicine Suez Canal University.

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What is TPN  The administration of all nutrient requirements via central or much less commonly peripheral venous route to patients who are unable to fulfill their daily protein caloric and hydration requirements via normal route ie GIT. Mohamed Abdel-Ghaffar

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Important  It is best to feed most patients through the enteral route whenever possible  TPN provides no advantages and may  morbidity cost compared with enteral feeding in patients with a functioning GIT. Mohamed Abdel-Ghaffar

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Indications:  Patients with requirements unable to be met by enteral feeding are those who benefit from TPN Mohamed Abdel-Ghaffar

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Indications:  Such patients include:  Those with short bowel syndrome  Exacerbation of inflammatory bowel diseases or pancreatitis  large foregut fistulae.  Bone marrow transplant patients with mucositis or diarrhea who need bowel rest.  Malnourished patients with malabsorption syndromes Mohamed Abdel-Ghaffar

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Basic Concepts  To write a proper TPN regimen It is essential to estimate or better measure the daily energy and protein requirements. 1. Energy requirements:  Are measured in critically ill patients using indirect calorimetry metabolic cart this method measures Vo 2 Vco 2 RQ and TEE it is the most accurate method available  TEE Kcal/day 3.9 X Vo 2 + 1.1 X Vco 2 - 61 Mohamed Abdel-Ghaffar

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Energy requirements: Cont.  Predictive equations: 1. BEE Kcal/day BW kg X 25  TEE Kcal/day BW kg X 25 X 1.2 2. Harris-Bendict equations:  Men: BEE 66+ 13.7X BW + 5Xht – 6.7X age  Women: BEE 655 +9.6XBW +1.8Xht – 4.7Xage  TEE BEE X 1.2 Mohamed Abdel-Ghaffar

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 Adjustments in TEE: to allow for enhanced EE in hypermetabolic conditions the following corrections apply:  Fever: BEE X 1.1 for each 1 °C above normal  Mild stress: BEE X 1.2  Moderate stress: BEE X 1.4  Severe stress: BEE X 1.6 Mohamed Abdel-Ghaffar Energy requirements: Cont.

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Basic Concepts cont. 2. rotein requirements:  Accurate method: measure 24 hr urine urea nitrogen UUN Estimated Protein Req. gm/day UUN X 6.25 + 4 Predictive method:  Estimated Protein Req. gm/day BW kg X 1 - 1.4 Mohamed Abdel-Ghaffar

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LAB tests required before and during TPN  Baseline values for Na K Cl HCO 3 PO 4 Mg Ca BUN creatinine FBS albumin LFT and CBC with differential should be drawn.  Lytes and glucose should be checked daily for 3-4 days until stable then every other day  RFT Ca Mg PO 4 should be checked every other day until stable then twice a week  LFT and albumin should be checked every 10- 14 days  More frequent testing may be necessary depending on the clinical situation Mohamed Abdel-Ghaffar

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Creating a TPN Regimen A simple stepwise approach is used: A 60 kg adult patient is used as an example:  Step 1: estimate the daily protein and caloric requirements:  Protein req. BW X 1.4 60 X 1.4 84 gm  Caloric req. BW X25X1.2 60X25X1.2 1800 Kcal Mohamed Abdel-Ghaffar

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Creating a TPN Regimen: cont.  Step 2: make a standard TPN mixture solution of 500 ml amino acid AA 10 + 500 ml D50 the final concentration of the mixture 1 L will be AA 5+ D25 i.e. each 1L contains 50 gm AA + 250 gm Dextrose.  Determine how much volume of this solution in required to supply the patient protein requirements  Volume of A 10 -D 50 84/50 1.68 L 1680 ml  To give the hourly rate divide this volume by 24 1680/24 70 ml/hr Mohamed Abdel-Ghaffar

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Creating a TPN Regimen: cont.  Step 3: determine how much calories this volume will give to the patient using an energy yield of 3.4 kcal/gm of dextrose 1.68 X 250 X 3.4 1428 Kcal As the estimated caloric requirements of this patient was 1800 Kcal So he still needs 1800- 1428 372 Kcal. These remaining calories can be supplied by intralipid or smoflipid. Mohamed Abdel-Ghaffar

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Creating a TPN Regimen: cont.  Step 4: A 10 lipid emulsion yields 1 Kcal/ml so the patient needs 372 ml of 10 lipid to complete his caloric requirements we can approximate it to the nearest 50 to be 400 ml  This volume can be given over 10 hrs at a rate of 40 ml/hr. Mohamed Abdel-Ghaffar

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Creating a TPN Regimen: cont.  Step 5: determine electrolytes vitamins and trace elements requirements  Current recommended ranges for lytes in TPN for adults are:  Na: 1 - 2 mEq/kg/day  K: 1 – 2 mEq/kg/day  Chloride: 1 – 1.5 mEq/kg/day  Acetate: 0.2 – 0.5 mEq/kg/day  Mg: 8 -15 mEq/day  Ca: 5 - 20 mEq/day  2 multivitamin vials should be added daily: one contains B 1 B 2 B 3 B 6 B 12 pantothenic acid biotin folic acid the other contains the fat soluble vitamins A D E and K.  A trace elements vial should be added daily: it contains Zn Co Fe Selenium Mn Cr Cobalt and Iodine Mohamed Abdel-Ghaffar

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How can you administer Na K and Cl in Egypt  K is given as KCl.  Na is given as 1/6 molar Na lactate:  Each liter contains 167 mEq Na.  So this patient needs 90 mEq of Na ie 90/167 539 ml/ day of Na lactate.  KCl can be added to D 50  Fat soluble vitamins can be added to intralipid and water soluble vitamins and trace elements are added to Na lactate. Mohamed Abdel-Ghaffar

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Some special clinical situations  Renal failure: AAs` solutions used in patients suffering from CRF contain more essential AAs 89 compared to 50 in the standard AAs solutions  the N 2 in essential AAs is partially recycled for the production of non-essential AAs thus leading to less production and rise in BUN. Mohamed Abdel-Ghaffar

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Some special clinical situations cont  Hepatic failure: BCAAs isoleucine leucine valine antagonize the uptake of aromatic AAs e.g. tryptophan into the CNS this helps prevent the subsequent breakdown of the aromatic AAs to form false neurotransmitters which have been implicated in the pathogenesis of hepatic encephalopathy  So we prefer to use AAs solutions with higher 46 v 25 content of BCAAs in this patient subset. Mohamed Abdel-Ghaffar

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Peripheral Parentral Nutrition  It is useful for patients who require partial nutritional support for short periods e.g. postop patients who are expected to be NPO for few days.  The goal here is to provide just enough non protein calories to spare the breakdown of muscle proteins to provide energy. Mohamed Abdel-Ghaffar

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Peripheral Parentral Nutrition  Allowed solutions in peripheral veins are those with osmolarity 900 mOsm/L include: D5 D10 AAs 1.5 and intralipid 10  A common admixture is AA 3- D20 a 2.5 L of this mixture give 850 kcal if we add 500 ml intralipid 10 this gives almost 1350 kcal just enough calories to satisfy BEE Mohamed Abdel-Ghaffar

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Potential disadvantages:  Complications of CV access:  Immediate: pneumothorax air embolism vascular nerve injury hemothorax arrhythmias loss of catheter integrity  Delayed: thrombosis AVM pulmonary embolism and infection Mohamed Abdel-Ghaffar

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Potential disadvantages: Cont.  Hyperglycemia:  A full TPN feeding will produce hyperglycemia.  So insulin is usually added directly to the TPN 10 – 20 iu/L.  A separate insulin infusion is sometimes required to assist the body’s own insulin production to achieve euglycemia.  Glucose tolerance improves and insulin requirements usually decrease over time. Mohamed Abdel-Ghaffar

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Potential disadvantages: Cont. Hypophosphatemia:  This effect is due to enhanced uptake of PO 4 into cells associated with glucose entry into cells.  Serum PO 4 level returns to normal values after few weeks of TPN. Cumulative effect of TPN on serum PO4 level 0 0.5 1 1.5 2 2.5 3 3.5 4 0 2 4 6 8 10 Duration of TPN days Serum PO4 mg/dL Mohamed Abdel-Ghaffar

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Potential disadvantages: Cont.  Fatty liver: when glucose calories exceed TEE there is lipogenesis in the liver which may progress to fatty infiltration.  Hypercapnia: although this has been attributed to high RQ associated with carbohydrate metabolism it usually is a reflection of overfeeding in general. Mohamed Abdel-Ghaffar

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Potential disadvantages: Cont.  Cost: TPN costs 2-10 times more and requires more lab tests than enteral feeding. Mohamed Abdel-Ghaffar

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Mohamed Abdel-Ghaffar

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Food for thought  The goal of nutrient intake in the malnourished patient is to correct malnutrition  However malnutrition that accompanies critical illness is different from that which accompanies simple starvation  This difference has important implications for the value of nutrient intake in each situation Mohamed Abdel-Ghaffar

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Food for thought  The malnutrition in the critically ill isn’t only due to inadequate food intake but also due to disease induced abnormal nutrient processing.  Thus nutrient intake will not fully correct this type of malnutrition as long as the underlying disease is active. Mohamed Abdel-Ghaffar

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Food for thought  Thus the important factor in correcting malnutrition is not only the intake of nutrients but also a decrease in the activity of the underlying disease process  TPN must include all nutritional components and be delivered continuously over 24 hrs via a central line. Mohamed Abdel-Ghaffar

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CONCLUSION ♠ TPN is indicated for malnourished patients severely catabolic patients trauma burns sepsis cancer patients and patients with organ failure without a functioning GIT. ♠ Special nutritional support is not indicated for well-nourished surgical patients with uncomplicated surgery who will have a limited period of fasting 2–4 days. Mohamed Abdel-Ghaffar

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CONCLUSION ♠ If nutritional support is indicated it should be initiated as soon as possible. ♠ The benefits and risks should be carefully calculated for each individual patients. ♠ Once the GIT recovers it should be the ideal route for feeding critically ill patients. Mohamed Abdel-Ghaffar

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Mohamed Abdel-Ghaffar

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