Download - TNT Session 6 Revisi
7/24/2019 TNT Session 6 Revisi
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Central VenousCentral Venous
Catheters andCatheters andComplications ofComplications of
Parenteral NutritionParenteral Nutrition
7/24/2019 TNT Session 6 Revisi
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Objectives
• To identify the appropriate methods of central venous
access for parenteral nutrition
• To describe catheter-related, metabolic, and GI
complications of parenteral nutrition
• To explain how to prevent catheter-related, metabolic
and GI complications of parenteral nutrition
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Dierent type of Central Venous
Catheter
Hickman Catheters
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Catheters for Central Venous
Access
• Choosing CVC, the insertion site, placementtechniue based on condition of patient and duration
of !"#• Temporary $% & wee's( or permanent $) & wee's(
• Various lengths, gauges, and number of ports $singlelumen more preferable than * or + lumens, to avoid
increase ris' of infection(
• Catheters treated with antibacterials
• Infusion via a dedicated catheter lumen
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Temporary Subclavian Catheterduration of PN ! " #ee$s%
cCarthy C, et al# JPEN ./012*3.-*4*
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Peripheral Central VenousCatheterP&CC ' Peripherally(&nserted(Central(
catheter
Garanows'i 5# J Intraven Nurs ..+14240-.&
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Central Venous Access
In2 6rey 78, urray 95, eds# Dynamics of Nutritional Support # "orwal', CT2 :ppleton-Century-Crofts1p# +/*#
Vena subclavia
Vena cefálica
Catéter venosocentral
Vena cavasuperior
Yugular interna
Yugular externa
Vena axilar
Vena braquial
Vena basílica
Subclavian Vein
Cephalic Vein
Central Venous
Catheter
Superior
Vena Cava
Internal ugular
!xternal ugular
"xillar# Vein
$rachial Vein
$asilic Vein
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Central Venous Access
• ;irst choice 2 subclavian vein
• 7econd choice 2 internal vein <ugular and external
=ugular vein#
• Third choice 2 cephalic and basilic vein
• 5ast choice 2 femoral vein
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Permanent Central VenousAccess
• Tunneled subclavian catheter or Implantable infusion
port, reuires surgical procedure# >xit point located far
from airway# 9ecommended when !" ) & wee's
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Subclavian Catheter Dressin)
?ressing should be changed using strict, aseptic
techniue every &/-0* hours
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Conclusion in choosin) CVC
•Single lumen more preferable.
•First choice via subclavian vein.
•Dressing : 48-72 hours
•Very rarely permanent V
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Parenteral Nutrition*
Complications
• Catheter-related
• etabolic• Gastrointestinal
9yan <:# Complications of total parenteral nutrition# In2 ;ischer <>, ed# Total Parenteral
Nutrition. 5ittle, @rown and Company1 .04
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Parenteral Nutrition*
ComplicationsCatheter-related
• Insertion
A pneumothoraxA chylothorax
A hemothorax
A air embolus
A arterial punctureA nerve in=ury
?empsey ?T# Complications of total parenteral nutrition# In2 Torosian 9, ed#Nutrition for the Hospitalized Patient. "ew Bor'2 arcel ?e''er, ..3
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Parenteral Nutrition*
ComplicationsCatheter-related
• echanical complications
A poor catheter placement $malpositioned catheter,
3,3-33(
A phlebitis
A thrombosis
A catheter occlusionA rupture
A embolus
9yan <:# Complications of total parenteral nutrition. In2 ;ischer <>, ed# Total Parenteral
Nutrition. 5ittle, @rown and Company1 .04# :7!>" @oard of ?irectors# JPEN *DD*1*4 7uppl2+07:
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Parenteral Nutrition*
ComplicationsCatheter-related
• Infection
A catheter insertion siteA subcutaneous tunnel
A coloniEation
A bacteremia
A sepsis
6emp 5, et al# JPEN ..&1/20-0&
9eed C9# Intensive Care ed ..31*200-/+
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+ospital(dependent ,is$ factors
Physician experienced
Duration catheterization
Number of lumens
Insertion sites
Use of maximum barrier protectionA surgical hand scrubbingA sterile clotting-long sleeved gown, cap, mas'(
A sterile gloves A wide sterile field
6emp 5, et al# JPEN ..&1/20-0&
9eed C9# Intensive Care ed ..31*200-/+
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Parenteral Nutrition*
ComplicationsMetabolic
• 8yperglycemia $max rate dextrose infusion no greater than &-3mgF'gFminute(, hypercapnia
• 8ypoglycemia• Complication from lipid used $hypertriglyceridemia,
immunosuppression, lipid overload syndrome(
• >lectrolyte imbalance
• !rerenal aEotemia• :bnormal acid-base balance
• 9efeeding syndrome A measure !, g, 6, and glucose
?empsey ?T# Complications of total parenteral nutrition# In2 Torosian 9, ed# Nutrition for the
Hospitalized Patient # "B2 arcel ?e''er, Inc#1 ..31 7olomon 7# JPEN ..D1&2.D-.0
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Parenteral Nutrition*
ComplicationsGastrointestinal
• 5iver function disorder, GI atrophy, gastritis and ulcer#
•GI atrophy associated with absence of2 luminalnutrient,mechanical stimulation of the gut, insufficientsupplies of primary enterocyte fuel source#
• GI atrophy begins to develop within &/ h of enteral fastingand maybe permissive for the bacterial translocation#
• Complication can be decreased by providing smallamounts of food enterally when possible and transitioningto tube or oral feeding as soon as possible#
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Parenteral Nutrition*
ComplicationsOerfeedin!
:dministering more than +3 'calF'g results in2A hepatic steatosisA hyperglycemiaA prerenal aEotemiaA hypertriglyceridemia
A increased C*
productionA respiratory distress syndrome
?empsey ?T# In2 Torosian 8, ed# Nutrition for the Hospitalized Patient # "ew Bor'2 arcel
?e''er Inc#1 ..3
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Summary* Appropriate Therapy
%arenteral nutrition is in&icate& 'hen(
• >nteral nutrition is contraindicated
• >nteral nutrition cannot be established or maintained
• ral or enteral nutrition does not satisfy all nutritional
reuirements
:spen @oard of ?irectors2 JPEN *DD*1*4 7uppl 2/7:-.7:
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Summary* Access Devices forParenteral Nutrition
Parenteral nutrition catheters are selected based on"
• >xpected duration of therapy
• "umber of lumens needed
• Huality of peripheral vein access
Garanows'i 5# J Intraven Nurs ..+14240-.&
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Summary* -onitorin)
Parenteral nutrition must be carefully monitored to"
• aintain electrolyte and acid-base balance
• >nsure that nutritional goals are met
• :void mechanical, metabolic, and GI complications
9yan <:# Complications of Total !arenteral "utrition# In2 ;ischer <>, ed# Total Parenteral
Nutrition. 5ittle, @rown and Company1 .04