implication of parenteral nutrition

7/25/2019 Implication of Parenteral Nutrition

1/78

PRANITHI HONGSPRABHAS MD.

IMPLICATION OFPARENTERAL NUTRITION


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History of Parenteral Ntrition

Year!"#$ %illia& Har'ey Dis(o'ery of (ir(lation

!""# Lo)er Bloo* transfsion of s+ee, to yon- &an

!"" C+risto,+er %ren Infsion of )ine/ ale/ o,iates in *o-s0sa&e ine1riatin- e2e(t as oral for&3

!4!# %illia& Corten Infse* oli'e oil in *o-s50Se'ere res,iratory *istress fro& fat e&1oli3

!$!$ Bln*ell S--est ,ossi1ility of 1loo* transfsion in ,t )it+1lee*inin ICU

!$6!76# Latta Saline infsion in (+olera ,atients0Ra,i* i&,ro'e&ent3

!$46 E*)ar* Ho**er Infse fat in for& of &il8 in 6 (+olera ,ts0# re(o'ere* (o&,letely/ ! *ie*3

!$"9 Men:el an* Per(o Gi'e fat s1(taneosly to *o-s0feasi1le3

!9;< Pal Frie*ri(+ S1(taneos a*&inistration of ntrients

0Painfl3=innars E. History of ,arenteral ntrition. >PEN #;;6?#45 ##76.


3/78

St*ies )it+ Gl(ose

=innars E. History of ,arenteral ntrition. >PEN #;;6?#45 ##76.

!$9 Cla*e Bernar* Le &ilie interior@ i&,ortan(e of -l(ose for&eta1olis&

!$9" Bei*l an* rats First infse -l(ose in +&an 0#;;76;; &l of !;-l(ose soltion3Fe1rile rea(tion5 -l(ose fe'er

!9! %oo*att Constant infsion of -l(ose 1y ,&,/ 'arie* infsionrate to esta1lis+ *ose res,onse relations+i, of rinary-l(ose e(retion

!9#< Matas Continos -l(ose *ri,

!9


4/78

Use Of Plas&a As Protein Sor(es

!96; %+i,,le/ Hol&an/Ma**en

Protein reire&ent of *o- (ol* 1e,ro'i*e* 1y infsin- ,las&a ,rotein 1y'ein *rin- free ,rotein *iet

Al1ri-+t Meta1oli( fate of infse* ,las&a,rotein in +&ans an* *e&onstrate N 1alan(e*

ilie Infse* la1ele* ,las&a ,rotein in*o-s an* fon* -ra*al tisse

ra*ioa(ti'ity an* fall of!PEN #;;6?#45 ##76.


5/78

Protien Hy*rolysates an* CrystallineA&ino A(i*s

!9!6 Henries an*An*erson

Infse* 1eef +y*rolysate into -oat an*a(+ie'e* N 1alan(e

=ansly8e an* Meyer Meta1olis& of aa o1tain* fro& +y*rolysis of(asein or 1eef ,rotein infse* into *o-s

!96; Rose Deter&ine EAA in +&ans an* ,ro,ose* i*eal&itre of aa t+at (ol* 1e s,,ort ,roteinsyntlesis in +ealt+y a*lts

!964 El&anFather of IV nutrition

Infse aa in for& of 1rino-en +y*rolysate in&an

!9PEN #;;6?#45 ##76.


6/78

Protien Hy*rolysates an* CrystallineA&ino A(i*s

!9"< Bansi Intro*(e* (rystalline aa. 01ase onRoseJs )or85 AA rerre&ent of &an3

Late!9"9

%ritlin* More (o&,lete (rystalline aa soltion=a&inKMore e2e(ti'e in ,osto, N 1alan(e

!94; Protein +y*rolysate *isa,,ear

It )as *i(lt to in(l*e Tyr/ Cys/ (ystine/ Gln in aa. Soltion 0te(+ni(alreason3

!9$; Frst Glta&in *i,e,ti*e 0Gln7Tyr3



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Positi'e N Balan(e In Can(er PatientsRe(ei'in- A**ition Of Ca(ein Hy*rolysate To

An Infsion Of Gl(ose


8/78

De'elo,&ent Of Safe Fat E&lsions


!9#;7!9"; USA an* >a,an De'elo,e* an* teste* fat e&lsion

U,o+n Co USA Li,o&l eas ,o*(e*A*'erse e2e(ts5 0(+ill/ fe'er/ +y,oia an*+y,otension3)it+*ra)n

!9"! %retlin* an* S(+1ert+

=itr& Co

Fat e&lsion ,re,are* fro& soy1ean oil an* e2 yol8

,+os,+oli,i*5 safely infse*Co&&er(iali:ation Intrali,i*J

!9"# Sweden First sy&,osi& of ,arenteral ntritionAr'i* %retlin*5 fat+er of (o&,lete ,arenteral ntritionJ

!9"$ D*ri(8 First report of long term growth and survival in puppies

with puppies with IV feeding using CVCD*ri(8

S)e*is+

Hi-+ *ose of -l(ose )it+ot fat/ aa/ ot+er ntrientGl(ose syste& of (alories as li,i*/ an* t+e re&ain*er as -l(oseFat syste&

R+oa*s De,lete* or +y,er&eta1oli( ,ts s+ol* re(ei'e &ore

t+an reire&ents +y,erali&entationJ


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Landmarks of The Development ofTPN

!964 E&an S((essfl I= ,rotein +y*rolysate in &an

!96 Sel*in-er Des(ri1e (at+eter o'er )ire te(+nie

!9"! S(+1ert+

%retlin*

De'elo,&ent of a safe I= fat e&lsion

!9"$ D*ri(8 First re,ort of lon- ter& -ro)t+ an* sr'i'al in,,,ies )it+ ,,,ies )it+ I= fee*in- sin- C=C

!94< Solassol De&onstrates t+at fat e&lsions (an 1e safely&ie* )it+ (rystalline aa an* *etrose soltions

!94" Many at+ers (onr& t+at fat e&lsions +a'e ei'alent Ns,arin- e2e(t as -l(ose

R+oa*s De,lete* or +y,er&eta1oli( ,ts s+ol* re(ei'e&ore t+an reire&ents +y,erali&entationJ

!9$< Many at+ers Conr& t+at fe) sr-i(al ,atients )ill reire&ore t+an #;;; 8(al@*


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Parenteral Nutrition Components

Energy

gluose

! intravenous lipid emulsion

Nitrogen" aa# of peptides

$ater

%ineral

Vitamins

Trae elements


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Con(e,ts an* Consi*erations5 CHOMeta1olis&

Nitrogen sparing eect

s,,ress en*o-enos -l(ose ,ro*(tion5 rst fe) +rs

*ire(t infse* -l(ose oi*ation5 se'eral +rs/ nee* inslin

e2e(t of inslin 0&ini&al3When load: RQ >1 lipogenesis fro! "#$

fatty li'er

in(rease* &eta1oli( rate5 in(rease* =O#/ =CO#/ )ater,ro*(tion

In cata%olic stress inslin resistan(e5 -l(ose oi*ation in inslin *e,en*ent tisse an*

,refer FA for oi*ati'e ,ro(ess

GH resistan(e5 attenate ,rotein synt+esis

Gl(ose is &aor CHO se* in PN



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C&' %eta(olism")luose Infusion *ate

Gl(ose infsion &-@8-@&in

Basal #

O,ti&& . Juppl ;"..J,.:Chan J# et al: Chest ;


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Con(e,ts an* Consi*erations5 ProteinMeta1olis&

Nor!al

,rotein synt+esis 6;; -@*

'ery sensiti'e an* +i-+ly re-late* 1alan(e 1et)eensynt+esis an* 1rea8*o)n

In se'ere stress

&s(le ,rotein synt+esis

,rotein 1rea8*o)n

-o !ini!i.ed protein %rea/down

1y anal-esia/ se*ati'es/ te&, (ontrol/ 71lo(8a*e-o sti!ulate protein s,nthesis

tra*itional PN not eno-+

s,e(iali:e* aa5 Gln



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Protein %eta(olism" Liver ProteinJynthesis

Positive

C*P

Fi(rinogen Prothrom(in

,ntihemophili

Plasminogen

Complement &aptoglo(ulin

Ceruloplasmin

Negative

,L8

P,8TFN

*8P

,:J:P:E:N: Nutrition Jupport Pratie %anual .nd Ed: 2=:


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E+ogenous Protein ,dministration

,im to attenuate (reakdown of endogenousprotein

N2 (alane remains Ave into the

onvalesent stage *eommended ;:.2.:? g/kg/d

&igher amount do not promote further Nretention

Inrease intake in e+ternal loss of protein"(urn# CVV&D

$eissman C: Nutrition in the intensive are unit: Critial Care ;


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Denition5 Total Parenteral Ntrition0TPN3

T+e a*&inistration of(o&,lete an* 1alan(e*ntrition 1y I= infsionin or*er to s,,ort

ana1olis&/ 1o*y )ei-+t&aintenan(e or -ain/an* nitro-en 1alan(e/)+enoral or enteralntrition are not feasi1leor are ina*eate


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Total Parenteral Ntrition

No&en(latre

TPN5 Total Parenteral Ntrition

I=H5 Intra'enos Hy,erali&entation

TNA5 Total Ntrient A*&itreTPN5 Total Parenteral Ntrition

67In7! A*&itre

All7In7One A*&itre

PPN5 Peri,+eral Parneteral Ntrition or PartialParenteral Ntrition


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In*i(ations For TPN

Intestinal o1str(tion

Se'ere &ala1sor,tion syn*ro&es5 SBS0V!;; (&s&all 1o)el re&ains3

Proi&al intestinal stla Ina&&atory 1o)el *isease

Se'ere ,aralyti( iles

Se'ere ,an(reatitis )it+ ina*eate EN

Pra(ti(ally all ,atients reirin- ntrition s,,ort1t (anJt tolerate enteral fee*s/ or C@I to enteralfee*in-


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In*i(ations for TPN

Con*itions reirin- (o&,lete 1o)el rest for,rolon-e* ,erio*s

Pre an* ,ost7o,erati'e s,,ort in ,atients )it+

,re7eistin- &alntrition/ in )+o& GI fn(tion isi&,aire*

Mali-nan(y n*er-oin- treat&ent/ sr-ery/ra*iation/ (+e&o )+o are na1le to o1taina*eate ntrition 1y an enteral rote


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Criti(ally Ill Patients5 %+en To Use PN

0na%le -o eet (nerg, Re2uire!ents0na%le -o eet (nerg, Re2uire!ents 0Tar-etGoal Calories3

ASPEN5 not a(+ie'e tar-et after 47!; *ays 1y ENalone/ (onsi*er initiatin- s,,le&ental PN 0E3

Initiatin- PN ,rior 47!; *5 not i&,ro'e ot(o&e an* &ay 1e*etri&ental to t+e ,atient

In PCM5 Initiate PN as soon as ,ossi1le follo)in- a*&issionan* a*eate ress(itation 0C3

ESPEN5 not a(+ie'e tar-et after # *ays/ (onsi*ere*

s,,le&ental PNNot e)pected to %e on nor!al nutritionNot e)pected to %e on nor!al nutritionin 6*ays/

(onsi*er PN )it+in#


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Parenteral Nutrition 0PN3

PPN 's. TPN

"entral 3eripheral

=eins S1(la'ian/-lar

Basili(@(e,+alli(

Os&olarity W$; &os&@L V$; &os&@L

Perio* Lon- ti&e 0W#)ee8s3

S+ort ter& 0V#)ee8s3


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TPN for&lation

Normal Diet TPN

Car1o+y*ratesXXX..........Detrose

ProteinXXXXXX...........A&ino A(i*s

FatXXXXXXXXXXXXX.Li,i* E&lsion

=ita&insXXXXXX.........Mlti'ita&in Infsion

MineralsXXXXXXXXEle(trolytes an* Tra(eele&ents


51/78

Car1o+y*rate

Detrose5 7;/ ,ro'i*e 6.< 8(al@-

Can 1e t+e only sor(e of ener-y

Closely relate* to soltion os&olality

Detrose infsion rate s+ol* not e(ee* &-@8-@&in

%i$$ G&' et a$. Br J Surg19(4;71:1


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Li,i*s

Pre'ent EFADs5 0


53/78

Intra'enos Li,i* E&lsion

ero -en5 (otton see* oil5 li,o&l

First -en5 Soy 1ase5 intrali,i*/ li,o'enos

Se(on* -en5 Mie* MCT@LCT/ str(tre li,i* 0&ie* MCT@LCT3

T+ir* -eneration Fis+ oil5 o&e-a'en

Mie*5 SMOF/ li,i*e& 0soy/ MCT/ s+ oil3 Con(entration5 !; !.!8(al@&l

#; # 8(al@&l


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Intra'enos Li,i* E&lsion In Criti(allyIll Patients

I=LE5 ,ro'i*e ener-y an* ensre essential fatty a(i*

ESPEN5 I=LE 0LCT/ MCT or &ie*35 ;.47!. -@8-@*o'er !#7#< +r 0B3

Mie* MCT@LCT5 )ell tolerate

Oli'e oil 1ase5 )ell tolerate 0B3

Fis+ oil enri(+e* li,i* e&lsion5 e2e(ts on (ell &e&1ranean* ina&&ation 0B3

ASPEN5

In t+e rst )ee8 /PN )it+ot soy 1ase* li,i*s 0D3

&S3(N +uideline4 53(N!!"# $$# %%& (S3(N +uideline4 "lin Nutr677896:;


55/78

A&ino A(i*

Stan*ar* Gen I5 a&inosol

Gen II5 a&i,aren/ a&inosteril/ a&ino,las&a7l

Disease s,e(i( Ne,+ro for&la

He,ati( for&la

Glta&ine Y*i,e,ti*e

Con(entration

6/ 6./ / 4/ $./!;/ ! (on(entration Pro'i*e


56/78

Glta&ine 0Gln3

Con*itionallyin*is,ensi1le a&inoa(i*

Me(+anis& Syste&i( antioi*ant

e2e(t

Maintenan(e of -tinte-rity

In*(e +eat s+o(8,roteins

Fel sor(e for ra,i*re,li(atin- (ell

ESPEN CPG #;;"5 Gln s+ol* 1e a**e*

in STD EN in Tra&aan* Brn 0A3

Ins(ient *ata forsr-i(al or+etero-eneosly(riti(ally ill

ASPEN CPG #;;9 S+ol* 1e (onsi*ere*

in 1rn/ tra&a/ an*&ie* ICU ,atients 0B3


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Ot+er Reire&ents

Fli*5 6; to


58/78

TPN5 Co&,on*in- Met+o*s

#7in7! soltion of *etrose/ a&inoa(i*s/ a**iti'es Ty,i(ally (o&,on*e* in !7liter 1a-s

Li,i* is *eli'ere* as ,i--y1a(8 *aily or

inter&ittentlyTotal ntrient a*&itre 0TNA3 or 67

in7! Detrose/ a&ino a(i*s/ li,i*/ a**iti'es

are &ie* to-et+er in one (ontainer

Li,i* is ,ro'i*e* as ,art of t+e *ailyPN&itre I&,ortant ener-y s1strate


59/78

&d'antage *isad'antage

nrsin- ti&e

ris8 of to(+(onta&ination

,+ar&a(y ,re, ti&e Cost sa'in-s

Easier a*&inistration in

HPN Better fat tili:ation

P+ysiolo-i(al 1alan(e of&a(rontrients

sta1ility an*(o&,ati1ility

I=FE 0I= fat e&lsions3li&its t+e a&ont ofntrients t+at (an 1e(o&,on*e*

Li&ite* 'isal ins,e(tionof TNA? re*(e* a1ilityto *ete(t ,re(i,itates

TNA

ASPEN Ntrition S,,ort Pra(ti(e Manal #;;? ,. 9$799


60/78

Ty,e of Infsion5 Continos PN

A*'anta-es %ell tolerate*

Reires less

&ani,lationnrsin- ti&e,otential for

Zto(+K(onta&ination

Disa*'anta-esPersistent

ana1oli( state

altere* inslin5-l(a-on ratios

li,i* stora-e 1yt+e li'er

&o1ility ina&1latory,atients


61/78

Ty,e of Infsion5 Continos PN

&d'antages

%ell tolerate*

Reires less&ani,lation

nrsin- ti&e ,otential for

Zto(+K(onta&ination

*isad'antages

Persistent ana1oli(state

altere* inslin5-l(a-on ratios

li,i* stora-e 1y

t+e li'er &o1ility ina&1latory ,atients


62/78

Ty,e of Infsion5 Cy(li( PN

T+e inter&ittent

a*&inistration ofPN/ sally o'era ,erio* of !# Y!$ +rs

A*'anta-es A,,roi&ates

nor&al ,+ysiolo-yof inter&ittentfee*in-

Maintains5 Nitro-en 1alan(e =is(eral ,roteins

I*eal for a&1latory,atients Allo)s nor&al a(ti'ity I&,ro'es ality of

life


63/78

Compliation of PN

Line sepsis" C*I

%eta(oli derangement/ re2feeding syndrome

Fluid/ eletrolyte/ aid2(ase im(alane

'verfeeding syndrome Li'er (o&,li(ation

Infetious Compliation


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Infetious CompliationSCatheter related infetion 0CRI3

Tunnel site infetion &u( ontamination

Infusate ontamination

Jeeding of other site of infetion

e for prevention of intravasular devie2related infetion:Infetious ontrol and hospital epidemiology ;


65/78

Refee*in- Syn*ro&e 0Ntrition Re(o'ery Syn*ro&e3

Metabolic complication occurs whennutritional support given to severelymalnourished

Ele(trolyte a1nor&alities Hy,o / M-#/ PO


66/78

Ris8 For Refee*in- Syn*ro&e

? 1BMI V!"

Unintentional )ei-+t loss W! in 67" &ont+s

[ !; *ays )it+ little or no ntritional inta8e

Lo) M-#/ / or PO


67/78

Ho) To Pre'ent an* Mana-e&ent ofRefee*in- Syn*ro&e

In high risk patientsStart !; 8(al@8-@*/ -ra*ally )it+in a )ee8Before@*rin- of !st!; * of fee*in-oral t+ia&in #;;76;; &-@*ay

!7# 'ita&in B (o stron- ta1lets 6 ti&es@* or I= 'ita&in B

1alan(e* &lti'ita&in an* &ineral s,,le&ent ea(+ *ay

&onitor an* s,,le&ent oral/ enteral/ orintra'enos / PO


68/78

Meta1oli( Co&,li(ation to O'erfee*in-

Hy,er-ly(e&ia

Hy,ertri-ly(eri*e&ia Hy,er(a,nia

Fatty li'er

Hy,o,+os,+ate&ia/+y,o&a-nese&ia/ +y,o8ale&ia

Barton RG. Nutr Clin Pract 1994;9:127-139


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Gly(e&i( Control In Criti(ally Ill

=an *en Ber-e#;;! Sr-i(al ICU

=an *en Ber-e #;;"Me*i(al ICUMore +y,o-ly(e&ia

Brn8+orst #;;$More

+y,o-ly(e&ia

Intensi'e Insulin -herap,


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0.8

5.1

0

5

10

15

20

25

30

an !en Ber"#e,

2001

an !en Ber"#e

200$

S&P, 2008 N'&(S)+,

2009

'on-enional

nen/i-e

3.1

18.7


71/78

NICE7SUGAR st*y NE>M #;;9 =ol&e 6";5!#$67!#94

T+e NICE SUGAR St*y In'esti-ators#;;9


72/78

ASPEN Gi*eline Re(o&&en*ations in A*ltHos,itali:e* Patients %it+ Hy,er-ly(e&ia

Reco!!endation +rade

Desire* 1loo*-l(ose -oal ran-ein ,atients re(ei'in-

ntrition s,,ort

Tar-et 1loo* -l(ose!


73/78

Monitorin-

PN toleran(e

=ital si-n as nee*e*7*aily

B% *aily7 )ee8ly

Fli*5 I@O *aily

Ele(trolyte5 *aily in rst 67 * t+en #@)8

CBC/ LFT !7#@)ee8s

M it i P ti t P t l


74/78

Monitorin- Patient on ParenteralNtrition

Metabolic

Gl(ose

Fli* an*

ele(trolyte 1alan(e

Renal an* +e,ati(fn(tion

Tri-ly(eri*es an*(+olesterol

Assessment

Bo*y )ei-+t

Nitro-en 1alan(e

Plas&a ,rotein

Creatinine@+ei-+tin*e

,a*#+e$$ S' Boers D/. Parentera$ N"trition. 0n: Handbook of Clinical Dietetics. a$e niersit Press' 1992


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He,ato1iliary Co&,li(ation

A*ltsSteatosis

Steatohepatitis

CholestasisBiliary sludge

Cholelithiasis

A(al(los (+ole(ystitis

Fi1rosis

Mi(rono*lar (irr+osis


76/78

Mana-e&ent

A*'an(e&ent to fll EN an* *is(ontine PN is t+e 1esttreat&ent for PNALD

PN (y(lin- Dr- R )it+ rso*eoy(+oli( a(i*/ (+ole(ysto8inin/ oral

anti1ioti(s

Ntrient restri(tion5 soy1ean71ase* I=FE an* ,ro'i*in-(onser'ati'e ,rotein an* *etrose (alories to ,re'ento'erfee*in-

)luose infusion rate 3)I*4 7mg/kg/min Lipid infusion " M; g/kg/d of onventional LCT

'ther lipid Com(ined mi+ture of %CT/LCT# or %RF, ontaining lipid emultionas opposed to the traditional LCTs

'mega2fatty aids anti2in0ammatory properties

,ssoiated with fewer hepati ompliations

(ects $f Nutrition $n Intestinal


77/78

(ects $f Nutrition $n Intestinalucosa

A5 TPNB5 ENC5 IMN

D5 Control

Ulsoy H/ et al. >ornal of Clini(al Neros(ien(e #;;6?!;035 9"Y";!


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implication of parenteral nutrition

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