nutritional support
DESCRIPTION
nutritional supportTRANSCRIPT
23/4/12 Nutrition in Critical illness 1
Nutritional Support in Critical illness
Tianjin Medical University General Hospital
Emergency Center
Shou songtao
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Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets.
Definition
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‘ A slender and restricted diet is always dangerous in chronic and in acute diseases’
Hippocrates 400 B.C.
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Malnutrition occurs in approx.40% of hospitalized patients
Can lead to increased morbidity and mortality Impairment of skeletal, cardiac, respiratory
muscle function Impairment of immune function Atrophy of GIT Impaired healing
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1970s: TPN - separate CH, AAs and Lipids 2500-3000kcals/day: Lactic acidosis, high glucose
loads, fatty livers, high insulin Single lumen C/Lines, no pumps Urinary urea measured, N calculated
1980s: Scientific studies of metabolism: recognition of overfeeding
1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials
2000s: glucose control, specific nutrients
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ICU Nutrition through the ages
Overfeeding1980s
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4 basic questions to be answered: Who? When? How much? How?
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Organisation of Nutrition Support
3. NICE Guidelines for Nutrition Support in Adults 2006
Screen
Recognise
Treat
Oral Enteral Parenteral
Monitor & Review
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Screen
Various nutritional screening tools• Low risk: routine clinical care• Medium risk: observe• High risk: treat- refer to dietitian/local protocols
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Screening in ICU
Almost all patients require artificial nutrition- cannot ‘observe’
Needs adaptation using NICE Guidelines Adapted MUST for ICU: Uses BMI/weight
loss/food intake + refeeding risk assessment; linked to feeding flowchart
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Nutritional Assessment
History – 10% weight loss or more suggests protein malnutrition
Exam – Weight/Ideal body weight (<85% predicted), temporal muscle wasting, anthropometrics
Nutritional markers-daily weight – more a measure of fluid status than nutritional status-24 hour urine urea nitrogen (cannot be used in renal failure)-albumin (<30mg/dl,t1/221), prealbumin(<12mg/dl, 2), transferrin(<150mmol/L, 7)-albumin influenced by fluid status, acute phase response
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Nutritional Assessment
Immune function – skin testing, anergy,total lymphocyte count<1800/mm3
Anthropometric measures > 10 % loss of ‘well’ body weight Body mass index : weight (kg)/ height 2 (m2)
<18 kg/m2 assoc. With prolonged ICU, increased post-operative complications, higher readmission rates
Mid-arm circumference, skin fold thickness Poor accuracy, specificity, reproducibility
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Nutritional assessment
Serum proteins Albumin
Reflects synthesis, degradation, losses, exchange between intracellular and extracellular compartments
Half life 21 days – limited ability to reflect acute changes
< 3.5 g/dL assoc. increased morbidity
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Nutritional assessment
Serum proteins Transferrin (1/2 life 7 days), Pre-albumin (1/2
life 2 days) More accurately reflect acute changes Limited by erratic responses to stress, sepsis,
cancer
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Nutritional assessment
Nitrogen balance= N intake – N loss
= (dietary protein x 0.16) – (urea nitrogen (urine) + 4 g (stool/skin) )
Positive balance indicates anabolic state Negative balance indicates catabolic state Aim to provide non-protein sources of fuel to
allow protein to be used for anabolic processes
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How much to give in ICU?
Schofield equation/Harris Benedict e.g. for 65 year old woman: BMR = (9.2x weight in
kg) + 687, = requirement in Kcal/24hr Add Activity and Stress factors e.g. 10% for
bedbound + 20-60% for sepsis/burns For 65kg ventilated woman with sepsis: 1670 Kcal
= approx 25 Kcal/kg/d No dietitian? Rough guide: 25 Kcal/kg/day total
energy. Increase to 30 as patient improves
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How much to give?
0.2g/Kg/day of Nitrogen (1.25g/kg/day protein) 30 – 35ml fluid/kg/24 hours baseline Add 2-2.5ml/kg/day of fluid for each degree of
temperature Account for excess fluid losses Adequate electrolytes, micronutrients, vitamins Avoid overfeeding Obesity: feed to BMR, add stress factor only if
severe i.e. burns/trauma
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Types of nutrition support
Routes of nutrition support Enteral nutrition Parenteral nutrition
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Enteral nutrition
In general, the preferred method of choice
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Enteral NutritionEnteral Nutrition
Nutrition delivered via the gut Includes oral feedings and tube feedings
Nutrition delivered via the gut Includes oral feedings and tube feedings
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Indications for Enteral Nutrition
Malnourished patient expected to be unable to eat >5-7 days
Normally nourished patient expected to be unable to eat >7-9 days
Adaptive phase of short bowel syndrome Increased needs that cannot be met
through oral intake (burns, trauma) Inadequate oral intake resulting in
deterioration of nutritional status or delayed recovery from illness
ASPEN. The science and practice of nutrition support. A case-Based Core curriculum. 2001; 143
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Contraindications for EN
Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143
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Contraindications for EN Inadequate resuscitation or
hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if
malnourished or 7-9 days if normally nourished
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Long-term nutrition• Gastrostomy• Jejunostomy
Short-term nutrition• Nasogastric feeding• Nasoduodenal feeding• Nasojejunal feeding
Enteral nutrition
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Diagram of enteral tube placement.
With/without endoscopic
Long time
with endoscopic operation
Gastric tube duodenal tube gastrostomy Gastrostomy Duodenum feeding
Jejunostomyfeeding
Decision of Selecting The Modes of Administration
Enteral Nutrition
Short time
Tube Percutaneous tube
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Enteral Formulas Liquid diets intended for oral use or for
tube feeding Ready-to-use or powdered form Designed to meet variety of medical
and nutrition needs Can be used alone or given with foods
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Formula SelectionThe suitability of a feeding formula should be evaluated based on
Functional status of GI tract
Digestion and absorption capability of patient
Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)
Macronutrient ratios
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte needs or restriction
Cost effectiveness
Functional status of GI tract
Digestion and absorption capability of patient
Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)
Macronutrient ratios
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte needs or restriction
Cost effectiveness
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Enteral Formulas Determine best choice by medical and
nutrition assessment Meet specific nutrition needs
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Enteral Formula Categories Polymeric Monomeric Fiber-containing Disease-specific Rehydration Modular
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Enteral Formula CategoriesPolymeric
Whole protein nitrogen source For use in patients with normal or near
normal GI function Protein isolate formulas
Protein that has been separated from a food (casein from milk, albumin from egg)
Blenderized formulas May contain pureed meat, vegetables, fruits,
milk, starches with v/m added Made at home or purchased commercially
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Enteral Formula CategoriesPolymeric
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Enteral Formula CategoriesMonomeric
Elemental/hydrolyzed Predigested nutrients Free amino acids and/or short peptide
chains Has low fat content or high percentage
of MCT, LCT, structured lipids
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Enteral Formula CategoriesMonomeric
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Enteral Formula CategoriesMonomeric
Use in patients with compromised digestive and/or absorptive capacity
More expensive than standard formulas Tend to be more hyperosmolar
because of small particle size
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Enteral Formula CategoriesFiber-Containing
Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients
Soy polysaccharide is the most common fiber additive in enteral feedings
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
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Enteral Formula CategoriesFiber-Containing
Soluble fiber (guar gum, oat fiber, pectin) may exert trophic effect on colonic mucosa and be useful in normalizing bowel function
Patients with impaired gastric emptying should not be fed fiber-containing formula into the stomach
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
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Enteral Formula CategoriesFiber-Containing
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Enteral Formulas: Calorie Dense May be used in fluid-restricted or
volume-sensitive patients Calorie density ranges from 1.3 to 2
kcals/ml Monitor fluid/hydration status
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Enteral Formulas: Calorie Dense
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Enteral Formula CategoriesDisease Specific
Designed for patients with specific disease states.
Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise.
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Enteral Formula CategoriesDisease Specific
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Disease Specific FormulasDiabetic
Amount and type of CHO modified to reduce blood glucose response
Increased fat content (may have increased monounsaturated fats)
May be worth trying diabetes formulas in patients who have failed to achieve good blood glucose control on standard formulas
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Disease Specific Formulas: Diabetic
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Disease Specific FormulasHepatic
Generally have reduced aromatic amino acids and increased branched chain amino acids
More expensive than standard products Often lower in protein than standard formulas
(may be too low for most liver patients)
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Disease Specific FormulasRenal Typically are calorie dense (2.0 kcal/cc)
products with relatively low protein levels and modified electrolytes
Generally too low in protein for dialyzed patients and acutely ill patients
May be useful for short term use as supplement or calorie source in pre-dialysis chronic renal failure patients
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Disease-Specific Formulas Renal
Novasource Renal
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Disease Specific FormulasImmune-Enhancing
Have added “immune-enhancing” nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides)
Meta-analysis suggests that they might be most beneficial in surgical patients
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Immune-Enhancing Formulas
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Disease-Specific Formula Pulmonary Contain higher percentage of total calories
from fat to reduce respiratory quotient and make it easier to wean from respirator
High fat gastric feedings may cause delayed emptying in critically ill patients
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Disease-Specific Formulas: Pulmonary
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Enteral Formula Nutrient SourcesCarbohydrate CHO content ranges from 40-90% of total
calories Fiber: soy polysaccharide (most common)
guar gum, oat fiber, pectin
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Enteral Formula Nutrient SourcesLipids Fat provides isotonic, concentrated energy
source Corn and soybean oil common May include MCTs; more easily digested and
absorbed Fat content ranges from <10% to >50% of
calories
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148
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Enteral Formulas Nutrient SourcesProtein Whole protein, hydrolyzed protein, free
amino acids Casein, soy protein, lactalbumin, whey, egg
white albumin Small peptides absorbed as efficiently as
free amino acids Free amino acids are more hyperosmolar
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Initiation of Feeds
Approaches Bolus vs continuous feeds Full feeds vs graded regimens
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Assessment of Clinical Response
Anthropometric measurements Feeding tolerance
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Enteral nutrition
Complications Gastrointestinal Mechanical Metabolic Formula related
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GI Complications
Vomiting Diarrhea Constipation Abdominal pain / bloating Gastric irritation Aspiration
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Mechanical Complications
Tube occlusion Nasopharyngeal effects Tube fractures Leakage Obstruction Irritation
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Metabolic Complications
Hypovolemia Hyperkalemia Hypophosphatemia Hypertonic dehydration Fluid overload
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Formula Complications
Incompatibility with medications Hyperosmolality Contamination
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Application Criterion of EN“When the gut works, and can
be used safely, use it ”
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Parenteral Nutrition
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Parenteral NutritionAllows greater caloric intake
BUT Is more expensive Has more complications Needs more technical
expertise
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Who Will Benefit From Parenteral Nutrition?
Patients with/who Abnormal gut function
Cannot consume adequate amounts of nutrients by enteral feeding
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Two Main Forms of Parenteral Nutrition
Peripheral Parenteral Nutrition Central (Total) Parenteral
Nutrition
Both differ in composition of feed primary caloric source potential complications method of administration
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Peripheral Parenteral Nutrition
Given through peripheral vein Short term use Mildly stressed patients Low caloric requirements Contraindications to central
TPN
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What to Do Before Starting TPN
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
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Venous Access for TPN
Need venous access to a “large” central line
with fast flow to avoid thrombophlebitis
SuperiorSuperiorVena CavaVena Cava
• Subclavian approachSubclavian approach
• Internal jugular approachInternal jugular approach
• External jugular approachExternal jugular approach
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Baseline Lab Investigations
Full blood count Coagulation screen Ca++, Mg++, PO4
2-
Lipid Other tests when indicated
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Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Non-N Caloric needsDetermine Non-N Caloric needs
Determine Protein requirementsDetermine Protein requirements
Determine Electrolyte and Trace Determine Electrolyte and Trace element requirementselement requirements
Determine need for additivesDetermine need for additives
Steps to Ordering TPN
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Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Non-N Caloric needsDetermine Non-N Caloric needs
Determine Protein requirementsDetermine Protein requirements
Determine Electrolyte and Trace Determine Electrolyte and Trace element requirementselement requirements
Determine need for additivesDetermine need for additives
Steps to Ordering TPN
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How Much Volume to Give? Cater for maintenance & on going
losses Normal maintenance requirements
By body weight alternatively, 30 to 50 ml/kg/day
Add on going losses based on I/O chart Consider insensible fluid losses also
e.g. add 10% for every oC rise in temperature
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Steps to Ordering TPN
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Caloric needsDetermine Caloric needs
Determine Protein requirementsDetermine Protein requirements
Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Electrolyte and Trace Determine Electrolyte and Trace element requirementselement requirements
Determine need for additivesDetermine need for additives
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Caloric Requirements
Based on Total Energy Expenditure
Can be estimated using predictive equations
TEE = REE + Stress Factor + Activity Factor
Can be measured using metabolic cart
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Stress Factor
Malnutrition - 30%
Peritonitis + 15%
Soft tissue trauma + 15%
Fracture + 20%
Fever (per oc rise) + 13%
Moderate infection + 20%
Severe infection + 40%
<20% BSA burns + 50%
20-40% BSA burns + 80%
>40% BSA burns + 100%
Caloric Requirements
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Activity Factor
Bed-bound + 20%
Ambulant + 30%
Active + 50%
Caloric Requirements
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How Much CHO & Fats?
“Too much of a good thing causes problems”
Not more than 4 mg / kg / min Dextrose(less than 6 g / kg / day)
Not more than 0.7 mg / kg / min Lipid(less than 1 g / kg / day)
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Fats usually form 25 to 30% of calories Not more than 40 to 50%
Increase usually in severe stress
Aim for serum TG levels < 350 mg/dl or 3.95 mmol/L
CHO usually form 70-75 % of calories
How Much CHO & Fats?
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Steps to Ordering TPN
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Caloric needsDetermine Caloric needs
Determine Protein requirementsDetermine Protein requirements
Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Electrolyte and Trace Determine Electrolyte and Trace element requirementselement requirements
Determine need for additivesDetermine need for additives
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How Much Protein to Give?
Based on calorie : nitrogen ratio
Based on degree of stress & body weight
Based on Nitrogen Balance
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Calorie : Nitrogen Ratio
Normal ratio is
150 cal : 1g Nitrogen
Critically ill patients
85 to 100 cal : 1 g Nitrogen in
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Based on Stress & BW
Non-stress patients 0.8 g / kg / day
Mild stress 1.0 to 1.2 g / kg / day
Moderate stress 1.3 to 1.75 g / kg / day
Severe stress 2 to 2.5 g / kg / day
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Based on Nitrogen Balance
Aim for positive balance of
1.5 to 2g / kg / day
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Steps to Ordering TPN
Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Protein requirementsDetermine Protein requirements
Determine Non-N Caloric needsDetermine Non-N Caloric needs
Determine Electrolyte and Determine Electrolyte and Trace element requirementsTrace element requirements
Determine need for additivesDetermine need for additives
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Electrolyte Requirements
Cater for maintenance + replacement needs
Na+ 1 to 2 mmol/kg/d (or 60-120 meq/d)
K+ 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d)
Mg++ 0.35 to 0.45 meq/kg/d (or 10 to 20 meq /d)
Ca++ 0.2 to 0.3 meq/kg/d (or 10 to 15 meq/d)
PO42- 20 to 30 mmol/d
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Trace Elements
Total requirements not well established
Commercial preparations exist to provide RDA
Zn 2-4 mg/day
Cr 10-15 ug/day
Cu 0.3 to 0.5 mg/day
Mn 0.4 to 0.8 mg/day
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Decide how much fat & Decide how much fat & carbohydrate to givecarbohydrate to give
Determine Total Fluid VolumeDetermine Total Fluid Volume
Determine Protein requirementsDetermine Protein requirements
Determine Non-N Caloric needsDetermine Non-N Caloric needs
Determine Electrolyte and Trace Determine Electrolyte and Trace element requirementselement requirements
Determine need for additivesDetermine need for additives
Steps to Ordering TPN
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Other Additives
Vitamins
Give that recommended for oral intake
1 ampoule MultiVit per bag of TPN
MultiVit does not include Vit K can give 1 mg/day or 5-10 mg/wk
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Other Additives
Medications
Insulin 0.1 u per g dextrose in TPN 10 u per litre TPN initial dose
Other medications
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TPN Monitoring
Clinical Review
Lab investigations
Adjust TPN order accordingly
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Clinical Review Clinical examination Vital signs Fluid balance Catheter care Sepsis review Blood sugar profile Body weight
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Lab investigations
Full Blood Count
Renal Panel # 1
Ca++, Mg++, PO42-
Liver Function Test
Iron Panel
Lipid Panel
Nitrogen Balance
Full Blood Count
Renal Panel # 1
Ca++, Mg++, PO42-
Liver Function Test
Iron Panel
Lipid Panel
Nitrogen Balance
weekly, unless indicated
daily until stable, then 2x/wk
daily until stable, then 2x/wk
weekly
weekly
1-2x/wk
weekly
weekly, unless indicated
daily until stable, then 2x/wk
daily until stable, then 2x/wk
weekly
weekly
1-2x/wk
weekly
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Complications Related to TPN
Mechanical Complications
Metabolic Complications
Infectious Complications
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Mechanical ComplicationsRelated to vascular access technique
• pneumothoraxpneumothorax
• air embolismair embolism
• arterial injuryarterial injury
• bleedingbleeding
• brachial plexus injurybrachial plexus injury
• catheter malplacementcatheter malplacement
• catheter embolismcatheter embolism
• thoracic duct injurythoracic duct injury
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Mechanical Complications
Venous thrombosis
Catheter occlusion
Related to catheter in situRelated to catheter in situ
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Metabolic ComplicationsAbnormalities related to excessive or inadequate administration
hyper / hypoglycaemia
electrolyte abnormalities
acid-base disorders
hyperlipidaemia
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Metabolic ComplicationsHepatic complications
Biochemical abnormalities
Cholestatic jaundice too much calories (carbohydrate intake) too much fat
Acalculous cholecystitis
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Infectious Complications
Insertion site contamination Catheter contamination
improper insertion technique use of catheter for non-feeding
purposes contaminated TPN solution contaminated tubing
Secondary contamination septicaemia
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Stopping TPN
Stop TPN when enteral feeding can restart
Wean slowly to avoid hypoglycaemia Monitor during wean
Give IV Dextrose 10% solution at previous infusion rate for at least 4 to 6h
Alternatively, wean TPN while introducing enteral feeding and stop when enteral intake meets TEE
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Approach to Nutritional Support
Nutritional Assessment
Maintenance Repletion
GI Tract Functional
YES NO
Enteral Nutrition
Parenteral Nutrition
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Advantages - Enteral vs PN Preserves gut integrity Possibly decreases bacterial translocation Preserves immunological function of gut Reduces costs Fewer infectious complications in critically ill
patients Safer and more cost effective in many
settings
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 147
ADA EAL, Critical Illness, accessed 8-07
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Single nutrient supplementation
L-glutamine Used in purine, pyrimidine, lymphocyte and macrophage
function, gut integrity and gut barrier function If given, reduces nitrogen loss Reduced length of stay, following colorectal surgery in elective
setting Other studies shown reduced risk of pneumonia, bacteraemia,
sepsis following major trauma ? Role in short gut syndrome – improving GI absorbtion
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Single nutrient supplementation
Essential fatty acids Variety of functions, key role in maintaining membrane
structure and function Alter immune function (n-3 FA suppress immune function) Preliminary studies using n-3 FA in inflammatory bowel
disease showed improvement in histological appearance, reduction in disease activity, decreased steroid requirement
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Importants:
Definition of nutritional support Routs of nutritional support Advantages of EN Common complications of TPN
Nutrition in Critical illnessNutrition in Critical illness 11411423/4/1223/4/12
MaintainsMaintainsStimulates Stimulates
the environmentthe environmentdefencesdefences
FEEDINGFEEDING
Provides Provides energyenergy
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Thank you !!
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Essential Nonessential
Arginine Alanine
Histidine Asparagine
Isoleucine Aspartate
Leucine Cysteine
Lysine Glutamate
Methionine Glutamine
Phenylalanine Glycine
Threonine Proline
Tryptophan Serine
Valine Tyrosine