surgical infection and nutrition
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Infection and Nutritionin the Surgical Patients
Nyra E. MonteraSenior Clerk
Oct. 2011
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INFECTION
Invasion of the body by pathogenic
microorganisms and reaction of thehost to organisms and their toxins
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SURGICAL INFECTIONS
• A surgical infection is an
infection which requires surgical
treatment and has developedbefore, or as a complication ofsurgical treatment.
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Clinical features
• Local- pain, heat, redness, swelling, loss of function
(apparent in superficial infections)
• Systemic- fever, tachycardia, chills
• Investigations:
Leukocytosis
Exudates- Gram stain, culture
Blood culture ( chills & fever )
Special investigations ( radiology, biopsy )
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Factors contributing to infections
• Adequate dose of microorganisms
• Virulence of microorganisms
• Suitable environment ( closed space )
• Susceptible host
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Principles of Surgical Treatment
• Debridement- necrotic, injured tissue
• Drainage- abscess, infected fluid
•
Removal- infection source, foreign body• Supportive measures:
• immobilization
• elevation• antibiotics
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Pathogenesis of Infection
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Host Defenses
• Entry of microbes into the host isprecluded by the presence of anumber of barriers that possess either
an epithelial (integument) or mucosal(respiratory, gut, and urogenital)surface.
• Host barrier cells may secretesubstances that limit microbialproliferation or prevent invasion.
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• outcomes of microbial invasion and
the interaction of microbes withresident and recruited host defenses:
•
(a) eradication• (b) containment
• (c) locoregional infection
• (d) systemic infection
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• Infection — defined by identification ofmicroorganisms in host tissue or thebloodstream, plus an inflammatory
response to their presence.
– At the site of infection, the classic findings
of rubor, calor, and dolor in areas such as
the skin or subcutaneous tissue arecommon.
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• SIRS — characterized by a
sequence of host phenotypic andmetabolic responses to systemic
inflammation that includes
changes in heart rate, respiratoryrate, blood pressure, temperature
regulation, and immune cell
activation.
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Microbiology of Infectious
Agents
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Bacteria• Bacteria are responsible for the majority
of surgical infections.• Gram-positive bacteria:
– SSI-aerobic skin commensals(Staphylococcus aureus and epidermidis andStreptococcus pyogenes) and entericorganisms such as E. faecalis and faecium.
– enterococci can cause nosocomialinfections (UTIs and bacteremia) inimmunocompromised or chronically illpatients
• gram-negative organisms – Enterobacteriaceae spp, and Pseudomonas
spp
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STREPTOCOCCI
• Gram positive
• Flora of the mouth and pharynx, (bowel)
• Streptococcus pyogenes – ( β hemolytic) 90% of
infections e.g.,lymphangitis, cellulitis, rheumaticfever
• Strep. viridens- endocarditis, urinary infection
• Strep. fecalis – urinary infection, pyogenic
infection
• Strep. pneumoniae – pneumonia, meningitis
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Fungi
•
Fungi of relevance to surgeons: – cause nosocomial infections in surgical patients as
part of polymicrobial infections or fungemia (e.g.,C. albicans )
–
causes of aggressive soft tissue infections (e.g., Mucor , Rhizopus, and Absidia spp.)
– opportunistic pathogens that cause infection inthe immunocompromised host (e.g., Aspergillusfumigatus, niger , terreus, and other spp.,Blastomyces dermatitidis, Coccidioides immitis,and Cryptococcus neoformans)
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Prevention and Treatment of
Surgical Infections
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• Prophylaxis — are maneuvers todiminish the presence of exogenous(surgeon and operating room
environment) and endogenous(patient)
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• Empiric therapy comprises the useof an antimicrobial agent or
agents when the risk of a surgicalinfection is high.
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Infections of Significance in
Surgical Patients
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Surgical Site Infections
• infections of thetissues, organs, or spaces exposed bysurgeons during
performance of aninvasiveprocedure.
• classified into: – Incisional
• superficial
• deep
– organ/spaceinfections
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SURGICAL SITE INFECTION
DEFINITION
• Deep Incisional /Organ / Space Infection• Any infection occuring within postoperative 30 days or
within postoperative one year if any implant is left•
described as;• Presence of any purulant discharge (through drains)• Any positive culture findings from intraabdominalsamples• Spontaneous wound dehiscence
• Presence of abscess • Infection diagnosis determined by the surgeon
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Factors Related to Developmentof SSIs
1. the degree of microbialcontamination of the wound duringsurgery
2. the duration of the procedure
3. host factors
• diabetes, malnutrition, obesity, immune
suppression, and a number of other underlying disease states.
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Diagnosis
• • Redness
• • Swelling
• •
Hyperthermia • • Fluctuation
• • Purulent or turbid aspirate
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Classification of Surgical Wounds
• Clean wounds (class I)
• Clean/contaminated wounds (class II)
• Contaminated wounds (class III)
• Dirty wounds (class IV)
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a. CLEAN WOUND (I):
Elective cases, primarily closed andundrained
Nontraumatic, uninfected, noinflammation
Respiratory, alimentary,
genitourinary or oropharyngealtracts not entered
Hernia repair, breast biopsy
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B. CLEAN – CONTAMINATED WOUND:
Alimentary, respiratory, genito-urinary
tract entered under controlled
conditions and w/o unusual
contamination Minor break in technique
Mechanical drainage
Appendectomy, biliary tract
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C. CONTAMINATED WOUND
Open, fresh traumatic wound
Gross spillage from gastrointestinal tract
Entrance of genitourinary or biliary tracts
in presence of infected urine and bile
Major break in technique
Penetrating abdominal trauma, large
tissue injury, enterotomy during bowelobstruction
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D. DIRTY AND INFECTED WOUND
Traumatic wound with retaineddevitalized tissue, foreign bodies,fecal contamination or delayed
treatment Perforated viscus encountered
Acute bacterial inflammation with pus
encountered during operation
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Surgical management of the wound
In healthy individuals, class I and II woundsmay be closed primarily, while skin closure ofclass III and IV wounds is associated with high
rates of incisional SSIs (25 to 50%).
Class III and IV wounds should be packed
open and allowed to heal by secondary
intention, although selective use of delayedprimary closure has been associated with a
reduction in incisional SSI rates.
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Intra-Abdominal Infections
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• Peritonitis or intra-abdominal
infection — microbial contamination ofthe peritoneal cavity
• Primary microbial peritonitis — when
microbes invade the normally sterileconfines of the peritoneal cavity viahematogenous dissemination from adistant source of infection or directinoculation
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Secondary microbial peritonitis occurssubsequent to contamination of the
peritoneal cavity due to perforation or severe inflammation and infection ofan intra-abdominal organ.
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• postoperative peritonitis, or tertiary(persistent) peritonitis – seen in patientsin whom standard therapy fails, thus
an intra-abdominal abscess develop,and leakage from a GI anastomosisoccurs
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Infections of the Skin and Soft
Tissue
E i l
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Erysipelas
• Superficial spreading
cellulitis & lymphangitis• Area of redness,
sharply definedirregular border
• Follows minor skininjuries
• Streptococcuspyogenes
• Common site: aroundnose extending to bothcheeks
• Penicillin, Erythromycin
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Cellulitis
• Inflammation of skin& subcutaneoustissue
• Non-suppurative
•
Strep. Pyogenes• Common sites- limbs
• Affected area is red,hot & indurated
• Treatment : – Rest, elevation of affected
limb..
Penicillin,Erythromycin,
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This patientpresented with
spreadingcellulites and
pain on motionof his right hip 2
weeks after totalcolectomy.
Cellulitis on right
anterior thigh isoutlined
NECROTIZING FASCIITIS
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NECROTIZING FASCIITIS
• Necrosis of superficial
fascia, overlying skin
• Polymicrobial
strep, staph, enterococci,
bacteroides, enterobacteriaceae
• Sites- abd.wall ( Meleny’s ) ,
perineum (Fournier’s) ,
limbs,
• Usually follows abdominal surgery or trauma
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• More in diabetic patient
• Starts as cellulitis, edema, systemic toxicity
• Appears less extensive than actual
necrosis• Treatment:
Debridement , repeated dressings, skingrafting
Broad spectrum antibiotics ampicillin, clindamycin, aminoglycosides
severe late necrotizing fasciitis and
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severe late necrotizing fasciitis andmyositis due to beta-hemolytic
streptococcal infection
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STAPHYLCOCCAL INFECTIONS•
Abscess- : Localized accumulation ofpurulent
material situated in the dermis or subcutaneous
tissue. Treatment- drainage, antibiotics
• Furuncle- infection of hair follicle / sweatglands
• Carbuncle- extension of furuncle into subcutaneous tissue
common in diabetics
common sites- back, back of neck
Treatment: drainage, antibiotics,
control diabetes
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P t ti N i l
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Postoperative Nosocomial
Infection•
SSI
• UTI -dx: > 104 CFU/ml of microbes by
culture in symptomatic patients or >105 CFU/ml in asymptomatic pxs
• Pneumonia -prolonged mechanicalventilation
• Intravascular catheter infections
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Sepsis
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• Sepsis- is a potentially life threateningcomplications of an infection, occurswhen chemicals released into the
bloodstream to fight the infectiontrigger inflammation throughout thebody.
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Nutrition in the Surgical
Patient
Estimation of Energy
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Estimation of Energy
Requirements
• Basal energy expenditure (BEE) mayalso be estimated using the Harris-Benedict equations:
• where W = weight in kilograms; H = height incentimeters; and A = age in years.
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M k f M l t iti
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Markers of Malnutrition
Unintentional weight loss= ↑ complications
– % weight loss= (usual wt – present wt) x 100
usual wt
<10% - mild malnutrition, over 1 month
10-20%- moderate malnutrition, over 1
month
>20% - severe, in 6 months• >30% - pre-morbid
• >50% - pre-mortality
C l l ti f C l i d
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Calculation of Caloric Needs
Condition Kcal/kg/day Protein/kg/day NPC : N ratio
Normal tomoderate
malnutrition
25 - 30 1 150 : 1
Moderatestress
25 - 30 1.5 120 : 1
Hypermetabolic, stressed
30 - 35 1.5 – 2.0 90-120 : 1
Burns 35 - 40 2.0 – 2.5 90-120 : 1
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Indications
Patients who are nutritionally depleted
Patients who are unable to take nutrients byGI Tract
Those who should not take nutrients by the GItract because of an inherent risk or complicate
management of their current surgical disease
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Indications for Nutritional Support
Short gut syndrome – <0.5 m jejunum/ileum
if with colon
– <1.0 m of small bowel
if without colon
Severely
malnourished
* All other indications are less clear
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Indications for Nutritional Support
Patient not expected to feed in 7 days
– Prolonged ileus or intestinalobstruction
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Indications for Nutritional Support
Patient not expected to feed in 7 days – Entero-cutaneous fistulas
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Indications for Nutritional Support
ESOPHAGECTOMY COLON REPLACEMENT
CAUSTIC INGESTION, ESOPHAGEAL STRICTURE
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Indications for Nutritional Support
Duodenal Leak Gastro-duodeno-pancreatectomy
Ro te of Administration:
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Route of Administration:
1. ENTERAL ROUTE
2. PARENTERAL ROUTE (TPN)
3. COMBINATION
ENTERAL
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ENTERAL
Advantages:1. more physiological (liver not
bypassed)
2. lesser cardiac work
3. safer and more efficient
4. better tolerated by the patient
5. more economical
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ENTERAL NUTRITION
• Enteral access
– NGT
– Gastrostomy
–
Jejunostomy – PEG (percutaneous
endoscopicgastrostomy)
–
Trans-gastric jejunostomy
ENTERAL
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ENTERALRoute:
1. Naso-enteric tube feeding (blended food – Casseinates and whole protein formulas)
Naso-esophageal or NGT / NJT.
2. Gastrostomy tube (blended food)
Stamm (sero-lined) – temporary
Glassman (mucous-lined) – permanent
Percutaneous endoscopic gastrostomy
3. Jejunostomy tube (elemental diet) Roue-en-y - permanent
Witzel - permanent
Endoscopic
ENTERAL
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ENTERAL
Hyperosmolar solution are better tolerated by the stomach:
– Gastric feeding – increase osmolality firstthen the volume
–
Small bowel – volume first is increase thenosmolality
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Rationale for Enteral Nutrition
• Enteral nutrition generally is preferredover parenteral nutrition, based on thelower cost of enteral feeding and the
associated risks of the intravenousroute, including vascular access
complications.
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• The presence of bowel sounds and the
passage of flatus or stool are notabsolute prerequisites for initiation ofenteral nutrition.
•
Gastric residuals of 200 mL or more in a4- to 6-hour period or abdominaldistention requires cessation of feedingand adjustment of the infusion rate.
Decision Making
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GIT functional?
YES NO
ENTERAL ROUTE PARENTERAL ROUTE
Short term Long term Short term Long term
NGT Gastrostomy,
Jejunostomy
Peripheral PN Central PN
Decision Making
Enteral versus Parenteral
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Enteral versus Parenteral
• Blunt and penetratingabdominal trauma
early enteral feeding (Moore
1986 & 1989, Kudsk 1992, 1996) severity = complications if
feed enterally
• Severe head injury
– No benefit (Rapp 1983, Hadley 1986,Young 1987, Borzotta 1984)
– Beneficial (Grahm 1989)
Enteral vs Parenteral
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Enteral vs. Parenteral
• General Surgery – Laparotomy
• Enteral better than parenteral) – Ulcerative Colitis and CD after resection
• Enteral better than parenteral –
Liver transplantation• Enteral = Parenteral (Wicks 1994 Level I evidence)
– Acute pancreatitis• Gastric and duodenal feeding- ↑
complication (Ragins 1973)
• TPN, jejunal feeding (Stabile 1984, Bodoky 1991)
• Jejunal feeding = TPN (McClave 1997 Level I evidence)
• Jejunal feeding better than TPN (Windsor 1998 Level Ievidence)
ENTERAL NUTRITION
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ENTERAL NUTRITION
Nutritional Support Needed?
Parenteral Nutrition
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As Supportive Therapy:
Nutritional support can be achieved but alterationin the disease process have not beenestablished.
New born GIT anomalies ( gastrochisis,omphalocele)
Alimentary tract obstruction (achalasia, stricture,carcinoma, pyloric obstruction)
Prolonged ileus
Prolonged respiratory support
Large wound losses
Parenteral Nutrition
PARENTERAL NUTRITION
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PARENTERAL NUTRITION
Proven efficacyRadiation & Chemoenteritis,
Hyperemesis gravidarum
Efficacy not yet establishedPre-op, cardiac cachexia, pancreatitis,
Ventilatory support, prolonged ileus
Under investigation
– Cancer, sepsis
Parenteral Nutrition
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Indications:Principal indication is found in seriously
ill patients suffering from Malnutrition,Sepsis, severe surgical or accidental
trauma when the use of theGastrointestinal tract for feeding is not possible.
Can be supplemental in patients withinadequate oral intake
Parenteral Nutrition
PARENTERAL NUTRITION
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PARENTERAL NUTRITION
• Primary Therapy – Proven efficacy
• GI fistulas
• Short bowel syndrome
• ATN, Hepaticinsufficiency
– Efficacy not established
• IBD, Anorexia nervosa
Parenteral Nutrition
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Parenteral NutritionContraindication of TPN:
1. Lack of specific goal for severe metabolicmanagement (inevitable dying).
2. Cardiovascular instability / severe
metabolic derangement.3. Feasible GIT feeding
4. Patient with good nutritional status
5. Infants with less than 3cm of small bowel6. Irreversible decerebrate (dehumanized)
PARENTERAL NUTRITION
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PARENTERAL NUTRITION
• Peripheral TPN
– 3% AA in 10% dextrose + 10% lipid
– Used when central line is
contraindicated – Short-term
• Central TPN
– 15-25% dextrose = standard formula – 47% dextrose = special formula
V A
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Venous Access
S b l i A
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Subclavian Access
Venous Access
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Venous Access
PARENTERAL NUTRITION
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PARENTERAL NUTRITION
Peripheral Central
Dextrose content < 5% > 10
Calorie delivery Less More
Volume delivery More Less
Calorie source* Mostly fats Mostly CHO
Calorie distribution CHO 30% CHON20% Fats 50%
CHO 55-60% CHON15-20% Fats 25%
Parenteral Nutrition
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As Primary Therapy:
– TPN influence the disease process:1. GIT fistula
2. Renal failure (ATN)
3. Short Bowel Syndrome
4. Acute Burn (severe trauma)
5. Hepatic failure
6. With normal bowel length but with
malabsorption syndrome due to SPRUE,enzymatic or pancreatic insufficiency,Ulcerative colitis, regional enteritis
7. Anorexia nervosa
Parenteral Nutrition
Parenteral Nutrition
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Parenteral NutritionRoute of TPN:
Central
hyperalimentation
– Subclavian vein
–
Internal jugular vein – Femoral vein
Gauge 16, 8-12
inches radio-opaque
catheter end at SVCCheck position w/
x-ray
Parenteral Nutrition
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Parenteral Nutrition
Complications of TPN:
I. Technical complications:
A. Early: - related to catheter insertion
1. Pneumothorax
2. Arterial laceration
3. Hemothorax
4. Mediastinal hematoma
5. Nerve injury to the brachial plexus
6. Hydrothorax
7. Air embolism
8. Catheter embolism
Parenteral Nutrition
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Complications of TPN:
I. Technical complications:A. Late: Erosion of the catheter to the bronchus or right
atrium
Thrombosis: Upper arm swelling and pain at the base of the
neck
Streptokinase / heparin ---> coumadin
Septic thrombosis: Antibiotic therapy
Fogarty catheter embolectomy
Excision of the subclavian vein and superior
venacava
Parenteral Nutrition
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Complications of TPN:
I. Technical complications:A. Late:
Erosion of the catheter to the bronchus or right atrium
Thrombosis:
Upper arm swelling and pain at the base of theneck
Streptokinase / heparin ---> coumadin
Septic thrombosis:
Antibiotic therapy Fogarty catheter embolectomy
Excision of the subclavian vein and superior
venacava
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Complications of TPN:
II. Metabolic complications:
A. Inadequate administration of certain
nutrient
1. Trace metal deficiency:a) Zinc deficiency:
perioral pustular rash
darkening of the skin creases
neuritis
b) Copper deficiency:
microcytic anemia
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Complications of TPN:
II. Metabolic complications:
A. Inadequate cont’d
2. Essential Fatty Acid deficiency:
Dry flaky skin w/ small reddish papules andalopecia
B. Disorder of Glucose metabolism:
1. Hypoglycemia – unexpected slowing of theglucose infusion / excessive insulinadministration
Parenteral Nutrition
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Complications of TPN:
II. Metabolic complications:B. Disorder of Glucose metabolism:
2. Hyperglycemia – most dangerous metabolismcomplication in TPN
Due to rapid infusion (60 ml/hr the increaseof 20ml/hr every 24-48 hrs)
DM ( Hyperosmolar nonketotic coma) dueto osmotic diuresis ---> dehydration, fever,obtundation and coma ---> death.
Tx: insulin 200 units/day and administrationof large dextrose free hypo=osmolar solution (0.45% NSS w/ K+).
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Parenteral Nutrition
Complications of TPN:
II. Metabolic complications:
C. Liver function derangement:
Abnormalities in SGOT / SGPT / Alk.
PO4 Fatty infiltrate of liver ----> fat
emulsion
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Complications of TPN:
III. Septic complications:A. Catheter infection: most lethal complication of TPN Bacterial / fungal (candida) Site of entry of the organism ---> site of
catheter Symptom: - sudden spike of fever Management:
− Change TPN bottle, tubes and filter –
culture / investigate for presence ofpneumonia, UTI, wound infection, etc.− If fever persist after 8 hrs. ---> removed
catheter and culture the tip of the tube.
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Thank You!
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