parenteral nutrition

Nutrition Parenteral Nutrition Parenteral Conquering the ComplexitiesConquering the Complexities

Dr sumer yadavDr sumer yadav

DEFINITIONDEFINITION

Intravenous administration of calories, Intravenous administration of calories,

nitrogen and other nutrients in sufficient nitrogen and other nutrients in sufficient

quantities to achieve tissue synthesis and quantities to achieve tissue synthesis and

anabolism is called anabolism is called Parenteral NutritionParenteral Nutrition..

HISTORYHISTORY Willium harvey’sWillium harvey’s elucidation of the human elucidation of the human

circulationcirculation Arvid Wretlind & collegueArvid Wretlind & collegue (1961) – prepared fat (1961) – prepared fat

emulsionemulsion Stanley Dudrick & Jonathan RhoadsStanley Dudrick & Jonathan Rhoads (1968) – (1968) –

develop TPNdevelop TPN Solassol & JoyeuxSolassol & Joyeux (1976) – developed 3-in-1Bag (1976) – developed 3-in-1Bag

PN solutionPN solution Shills & JeejeebhoyShills & Jeejeebhoy (1978) – developed HOME (1978) – developed HOME

PNPN

INTRODUCTION INTRODUCTION PNPN uses the vascular system to provide vital uses the vascular system to provide vital

nutritional support to malnourished patients & it nutritional support to malnourished patients & it supplies the nutrients in their elemental forms supplies the nutrients in their elemental forms (carbohydrate, lipids, aminoacids, trace (carbohydrate, lipids, aminoacids, trace elements & vitamins)elements & vitamins)

Two TypesTwo Types1.1. TPNTPN – Total Parentral Nutrition – Total Parentral Nutrition2.2. PPNPPN – Partial Parentral Nutrition – Partial Parentral Nutrition

Can be administered by two routesCan be administered by two routes1.1. Large central veinLarge central vein (Central PN) (Central PN)2.2. Peripheral veinPeripheral vein (Peripheral PN) (Peripheral PN)

When PN is required?When PN is required?

PPN is used to prevent or reduce the N is used to prevent or reduce the adverse effects of malnutrition.adverse effects of malnutrition.

AAnd is used when entral nutrition (EN) is nd is used when entral nutrition (EN) is unsafe or ineffective and this condition is unsafe or ineffective and this condition is anticipated to last for 7 – 10 days.anticipated to last for 7 – 10 days.

INDICATIONS FOR PNINDICATIONS FOR PN

Extreme short bowel syndromeExtreme short bowel syndrome Structural – resectionStructural – resection Functional – Severe inflammationFunctional – Severe inflammation

Bowel RestBowel Rest - - Enterocutaneous fistula (Enterocutaneous fistula (high outputhigh output))

- Anastomotic leak- Anastomotic leak Paralytic ileusParalytic ileus – – Major abdominal surgeryMajor abdominal surgery

- - Major abdominal traumaMajor abdominal trauma Intestinal ObstructionIntestinal Obstruction – – Cancer, AdhesionsCancer, Adhesions

INDICATIONS OF PN CONTD….INDICATIONS OF PN CONTD….

PPreoperatively only in patients with severe reoperatively only in patients with severe malnutritionmalnutrition

MMulti-organ failure with sepsisulti-organ failure with sepsis OOthers thers

Severe mucositis/oesophagitis/radiation entritisSevere mucositis/oesophagitis/radiation entritis Inflammatory bowel disease with severe Inflammatory bowel disease with severe

malnutritionmalnutrition Intestinal Atresia /Motility disordersIntestinal Atresia /Motility disorders Intractable vomiting Intractable vomiting (CT, Hyperemesis G.)(CT, Hyperemesis G.)

CONTRADICATIONS FOR PNCONTRADICATIONS FOR PN

CContradications for central line ontradications for central line (coagulopathies)(coagulopathies) HHemodynamically unstable patientemodynamically unstable patient PPulmonary edema/Fluid overloadulmonary edema/Fluid overload AAnuria without dialysisnuria without dialysis SSevere metabolic/electrolyte disturbencesevere metabolic/electrolyte disturbences AAdvance cancer or terminal illnessdvance cancer or terminal illness

MERITS OF PNMERITS OF PN

Turns the catabolic state of patient into Turns the catabolic state of patient into Anabolic Anabolic statestate

Provides Provides rest to bowelrest to bowel ( in anastomosis / leaks) ( in anastomosis / leaks)

Prevents Prevents wasting of muscleswasting of muscles

Improve Improve healing of woundshealing of wounds

Assesment for MalnutritionAssesment for Malnutrition

BY HISTORYBY HISTORY Weight lossWeight loss >10% of body weight >10% of body weight Decresed food intakeDecresed food intake G.I. SymptomsG.I. Symptoms - Anorexia- Anorexia - Dysphagia- Dysphagia - Nasuea /Vomiting- Nasuea /Vomiting - Chronic Diarrhoea- Chronic Diarrhoea - Abdominal Pain- Abdominal Pain

Assesment for Malnutrition contd…Assesment for Malnutrition contd…

BY PHYSICAL FINDINGSBY PHYSICAL FINDINGS WeightWeight <90% of ideal wt. <90% of ideal wt. AnthropometryAnthropometry (mid-arm circumference in cm.) (mid-arm circumference in cm.) Loss of subcutaneous fatLoss of subcutaneous fat (skinfold thickness) (skinfold thickness) Skin rashes/ occular changesSkin rashes/ occular changes Mucus membrane changesMucus membrane changes for deficiency offor deficiency of

Neurological changesNeurological changes particular nutrientparticular nutrient


BY LABORATORYBY LABORATORY SSerum Albumin <30g/Lerum Albumin <30g/L TTotal lymphocyte Count <1800/cu mmotal lymphocyte Count <1800/cu mm SSkin Test Reactivity (to asses immune kin Test Reactivity (to asses immune

system)system) S.S. levels of vitamin A, D, E levels of vitamin A, D, E P.P. levels of iron/folic acid levels of iron/folic acid S.S. levels of Zn, Mg, Phosphorus levels of Zn, Mg, Phosphorus


BY SPECIAL PROCEDURESBY SPECIAL PROCEDURES

1. Bioelectric Impedence Analysis (BIA)1. Bioelectric Impedence Analysis (BIA) for measurement of – Body Fatfor measurement of – Body Fat

- FFM (Fat Free Mass)- FFM (Fat Free Mass)

- Total Body Water- Total Body Water

Lean Body MassLean Body Mass = Body wt. – Fat Mass = Body wt. – Fat Mass

= Total Body Water / 0.73= Total Body Water / 0.73


BY SPECIAL PROCEDUREBY SPECIAL PROCEDURE

2. Indirect Calorimetry2. Indirect Calorimetry – To measure REE – To measure REE

Harris & Benedicts FormulaHarris & Benedicts FormulaREE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) - REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) -

6.7(Age in Yr) K cal / day 6.7(Age in Yr) K cal / day

REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)

- 4.7 (Age in Yrs) K cal / day- 4.7 (Age in Yrs) K cal / day

TEE = REE + Stress Factor + Activity FactorTEE = REE + Stress Factor + Activity Factor

REE is 60% of TEEREE is 60% of TEE

Schofield equationSchofield equation – 25 to 30 K cal / Kg / day – 25 to 30 K cal / Kg / day

Assesment for Malnutrition contd… Assesment for Malnutrition contd… STRESS FACTOR STRESS FACTOR

PeritonitisPeritonitis +15% +15% Soft tissue traumaSoft tissue trauma +15% +15% FractureFracture +20% +20% BurnsBurns

<20%BSA +50%<20%BSA +50%

20% - 40%BSA +80%20% - 40%BSA +80%

>40%BSA +100%>40%BSA +100%

MalnutritionMalnutrition +30% +30% InfectionInfection moderate +20% moderate +20%

severe +40%severe +40% FeverFever (per (per ooC rise) +13%C rise) +13%

Assesment for Malnutrition contd…Assesment for Malnutrition contd…ACTIVITY FACTORACTIVITY FACTOR

Bed BoundBed Bound - + 20 % - + 20 %

AmbulantAmbulant - + 30 % - + 30 %

Active Active - + 50 % - + 50 %


SPECIAL PROCEDURE….SPECIAL PROCEDURE….

2. 2. Nitrogen balanceNitrogen balance = N input – N output = N input – N output

1 Gm N = 6.25 Gm Protien1 Gm N = 6.25 Gm Protien

N input = Protien in Gm x 6.25N input = Protien in Gm x 6.25

N output = 24 hr. Urinary Urea Nitrogen +N output = 24 hr. Urinary Urea Nitrogen +

Non-urinary N lossesNon-urinary N losses

(estimated non-urinary N losses ~ 3 - 4 Gm/day)(estimated non-urinary N losses ~ 3 - 4 Gm/day)

Aim of Positive N balance = Aim of Positive N balance = 1.5 – 2 G/Kg/day1.5 – 2 G/Kg/day

BEFORE STARTING PNBEFORE STARTING PN

CBCCBC LFTLFT RFTRFT Serum Electrolytes (Na, K, Cl, Ca, Mg)Serum Electrolytes (Na, K, Cl, Ca, Mg) PT & PTTPT & PTT Lipid ProfileLipid Profile

BEFORE STARTING PN contd…BEFORE STARTING PN contd… CALCULATION OF REQUIREMENTCALCULATION OF REQUIREMENT

A. A. Fluid RequirementFluid Requirement Basic Need = 1500 + 20 ml/Kg body wt.Basic Need = 1500 + 20 ml/Kg body wt. ((If Wt. is >20 Kg)If Wt. is >20 Kg) Total Need = Basic Need + LossesTotal Need = Basic Need + Losses Losses like – Nasogastric aspirationLosses like – Nasogastric aspiration - Vomit volume- Vomit volume - Drain output- Drain output - Fistula output- Fistula output

BEFORE STARTING PN contd…BEFORE STARTING PN contd… CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..

B.B. Protien RequirementProtien Requirement Normal = 1.0 – 1.2 Gm / Kg / dayNormal = 1.0 – 1.2 Gm / Kg / day

In catabolic state = 2 Gm / Kg / dayIn catabolic state = 2 Gm / Kg / day

Catabolic states – PolytraumaCatabolic states – Polytrauma

- Severe Burns- Severe Burns

- Pt. taking Renal Replacement- Pt. taking Renal Replacement

therapytherapy

TPN contains Aminoacids in 3 – 15% concentrationTPN contains Aminoacids in 3 – 15% concentration

BEFORE STARTING PN contd…BEFORE STARTING PN contd… CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..

C. C. Energy RequirementEnergy Requirement Normal = 25 – 30 K cal / Kg / dayNormal = 25 – 30 K cal / Kg / day

((Should be provided by non-protein calories i.e. Should be provided by non-protein calories i.e.

calculate it from carbohydrate & lipids only, to calculate it from carbohydrate & lipids only, to

minimize nitrogen consumption)minimize nitrogen consumption)

Carbohydrate & lipid Ratio ~ Carbohydrate & lipid Ratio ~ 70 : 3070 : 30

Contd….Contd…. CARBOHYDRATESCARBOHYDRATES

Commercial Dextrose – 5%, 25%, and 70% Conc.Commercial Dextrose – 5%, 25%, and 70% Conc.

TPN Dextrose - 50% to 70% Conc. TPN Dextrose - 50% to 70% Conc.

1 Gm Dextrose = 3.4 K cal.1 Gm Dextrose = 3.4 K cal.

Rate of infusion ~ < 5 – 7 mg / Kg / min.Rate of infusion ~ < 5 – 7 mg / Kg / min. LIPIDSLIPIDS In 10% - 20% Concentration In 10% - 20% Concentration

Infusion rate < 0.7 K cal / Kg / hr.Infusion rate < 0.7 K cal / Kg / hr.

10 – 15 ml / min for 20% sol.10 – 15 ml / min for 20% sol. MULTIVITAMINMULTIVITAMIN – Given 1 amp / day i.v. – Given 1 amp / day i.v.

Vit. K 1 amp / day i.m.Vit. K 1 amp / day i.m. ELECTROLYTEELECTROLYTE – Acc. to their serum levels – Acc. to their serum levels

Shortcut for assessment ofShortcut for assessment ofENERGY REQIREMENTENERGY REQIREMENT

VariantsVariantsNo No

StressStressMild Mild StressStress

Mod. Mod. Stress Stress

Sev.Sev.

StressStressENERGYENERGY

Kcal/Kg/DKcal/Kg/D

2525 3030 3535 4040

Carbo. (Dex.) Carbo. (Dex.)

Gm/Kg/DGm/Kg/D

55 66 77 88

LIPIDSLIPIDS

Gm/kg/DGm/kg/D

0.80.8 1.01.0 1.21.2 1.41.4

PROTEINSPROTEINS

Gm/Kg/DGm/Kg/D

11 1.21.2 1.51.5 2.02.0

BEFORE GIVING PNBEFORE GIVING PN VENOUS ACCESSVENOUS ACCESS

1. 1. Central VeinCentral Vein – Large Bore, High Flow – Large Bore, High Flow - Preferred for TPN- Preferred for TPN

- For long term use- For long term use

(e.g. Subclavian /Int. jugular /Basilic /femoral)(e.g. Subclavian /Int. jugular /Basilic /femoral)

2. 2. Peripheral VeinPeripheral Vein – For short term use – For short term use

- When central vein - When central vein

contraindicatedcontraindicated

Verify the tip of cannula by X ray before PNVerify the tip of cannula by X ray before PN

CATHETERSCATHETERS

FORFOR Central Vein CannulationCentral Vein Cannulation – Single Lumen – Single Lumen

- Double Lumen- Double Lumen

- Multiple Lumen- Multiple Lumen

In Poly- Lumen Catheters In Poly- Lumen Catheters

Medial/Proximal Lumen – PN infusionMedial/Proximal Lumen – PN infusion

Lateral/Distal Lumen - Other UsesLateral/Distal Lumen - Other Uses

CATHETERSCATHETERS

FORFOR Peripheral Vein CannulationPeripheral Vein Cannulation – Simple – Simple

Cannula of 23 GaugeCannula of 23 Gauge

INFUSION OF PNINFUSION OF PN BY TWO WAYSBY TWO WAYS

ContinuousContinuous – For Short Term – For Short Term

- When Rapid Infusion Intolerable - When Rapid Infusion Intolerable CyclicallyCyclically – When Used For Long Term – When Used For Long Term

- When Rapid Infusion Tolerable- When Rapid Infusion Tolerable

- Continuous administration for 8 – 12- Continuous administration for 8 – 12

hrs and then rest for next 12 hrshrs and then rest for next 12 hrs

- Freedom during day - Freedom during day Use 3-in-1 TPN or 2-in1 PN with Dextrose Use 3-in-1 TPN or 2-in1 PN with Dextrose

or AA/Lipid/Dextrose seperately or AA/Lipid/Dextrose seperately

MONITERING OF PNMONITERING OF PN

PHYSICAL COMPONENTS – DIALYPHYSICAL COMPONENTS – DIALYWEIGHTWEIGHT

INPUT / OUTPUT CHARTINPUT / OUTPUT CHART

VITAL SIGNSVITAL SIGNS

MONITERING contd..MONITERING contd..

METABOLIC MONITERINGMETABOLIC MONITERING

11stst day day – CBC/RFT/B.S./LFT/Electrolytes/Mg – CBC/RFT/B.S./LFT/Electrolytes/Mg

Lipid & Coagulation ProfileLipid & Coagulation Profile 22ndnd day day – Electrolytes/B.S./RFT/Phosphorus – Electrolytes/B.S./RFT/Phosphorus 33rdrd day day - Electrolytes/B.S./RFT - Electrolytes/B.S./RFT 44thth day day - Electrolytes/B.S./RFT/Phosphorus/Mg - Electrolytes/B.S./RFT/Phosphorus/Mg

METABOLIC MONITERINGMETABOLIC MONITERINGcontd….contd….

Thrice/weekThrice/week – B.S./RFT/Electrolytes/Phosphorus – B.S./RFT/Electrolytes/Phosphorus

Twice/weekTwice/week – LFT / – LFT / MMgg

Once/weekOnce/week - Lipid &Coagulation Profile - Lipid &Coagulation Profile

Adverse Events To Be WatchedAdverse Events To Be Watched

2+ Glucose in Urine2+ Glucose in Urine Mod. Ketones in UrineMod. Ketones in Urine Persistent thirst/Excessive U.O.Persistent thirst/Excessive U.O. Level of ConsciousnessLevel of Consciousness HypoglycemiaHypoglycemia Chills/Rigor/FeverChills/Rigor/Fever Signs of PhlebitisSigns of Phlebitis Skin rashesSkin rashes Hyperventilation / HypotensionHyperventilation / Hypotension

Side Effects of LipidsSide Effects of Lipids

Back & Chest PainBack & Chest Pain DiaphoresisDiaphoresis Fever/Flushing/Chills/RigorFever/Flushing/Chills/Rigor Nausea/VomitingNausea/Vomiting UrticariaUrticaria Shortness of BreathShortness of Breath

Care Of CVAD LineCare Of CVAD Line

EExamine the site for signs of infectionxamine the site for signs of infection AAlt. day change the catheter dressinglt. day change the catheter dressing PPeriodically check line for blockageeriodically check line for blockage TTubes should be changed dailyubes should be changed daily DDedicate one lumen for PN onlyedicate one lumen for PN only AAvoid accidents like – Pullingvoid accidents like – Pulling AAllow only one trained person to handlellow only one trained person to handle

Piggybacking of PNPiggybacking of PN

Should be freshly prepared.Should be freshly prepared. Start slowly at Start slowly at 50ml/hr50ml/hr on day 1 on day 1stst.. Volume must not exceed Volume must not exceed 1000ml 1000ml on day 1on day 1stst.. From 2From 2ndnd day volume should be increased by day volume should be increased by

1 lit./day1 lit./day

until goal reached.until goal reached. Rate of infusion most not exceed Rate of infusion most not exceed 125ml/hr125ml/hr..

Tapering of PNTapering of PN Taper the infusion rate to half for 20 min. Taper the infusion rate to half for 20 min.

& again half the rate for other 20 min.& again half the rate for other 20 min. Flush the line with 10-15 ml NS.Flush the line with 10-15 ml NS. Flush the line with Flush the line with heparin lockheparin lock.. Clamp the line.Clamp the line. Infuse 10% Dextrose at the same rate for Infuse 10% Dextrose at the same rate for

1 hr. through other line.1 hr. through other line. Restart PN next day with aseptic tech…Restart PN next day with aseptic tech…

COMPLICATIONS OF PNCOMPLICATIONS OF PN

CATHETER RELATEDCATHETER RELATED PneumothoraxPneumothorax Air EmbolismAir Embolism Venous ThrombosisVenous Thrombosis Catheter OcclusionCatheter Occlusion Catheter SepsisCatheter Sepsis Catheter EmbolismCatheter Embolism

COMPLICATIONS contd…COMPLICATIONS contd…

METABOLICMETABOLIC Hyper/Hypo VolumiaHyper/Hypo Volumia Hyper/Hypo GlycemiaHyper/Hypo Glycemia HyperosmolarityHyperosmolarity HypertriglyceridaemiaHypertriglyceridaemia HyperketoacidosesHyperketoacidoses Electrolyte ImbalanceElectrolyte Imbalance

COMPLICATIONS contd…COMPLICATIONS contd…

GASTRO-INTESTINALGASTRO-INTESTINAL FATTY LIVERFATTY LIVER CHOLESTASISCHOLESTASIS INTESTINAL MUCOSAL ATROPHYINTESTINAL MUCOSAL ATROPHY

To Avoid – Early use of GITTo Avoid – Early use of GIT

HOME PNHOME PN

Required in those who needs PN for long termRequired in those who needs PN for long term Indications Indications – Short Bowel syndrome– Short Bowel syndrome - Bowel Rest- Bowel Rest - Severe Malnutrition- Severe Malnutrition Patient SelectionPatient Selection

Clinically & Psychologically soundClinically & Psychologically sound Family SupportFamily Support Adequate FinanceAdequate Finance

TPN in Various illnessTPN in Various illness

ACUTE RENAL FAILUREACUTE RENAL FAILURE

Avoid- High Protein Diet Avoid- High Protein Diet Avoid NS / RLAvoid NS / RL Restrict FluidRestrict Fluid Protein RequirementProtein Requirement

Predialysis – Low Predialysis – Low (0.6-0.8 Gm/kg/day)(0.6-0.8 Gm/kg/day) Dialysis - Standard Dialysis - Standard (1- 1.2 Gm/Kg/day)(1- 1.2 Gm/Kg/day)

TPN in Various illness contd..TPN in Various illness contd.. BURNSBURNS

Resuscitation Phase (1Resuscitation Phase (1stst 24 – 48 hr.) 24 – 48 hr.)

- Fluids with Crystalloids- Fluids with Crystalloids Energy RequirementEnergy Requirement

- 25 Kcal/Kg/day + 20Kcal/ % of BSA- 25 Kcal/Kg/day + 20Kcal/ % of BSA

- Proteins – 2 Gm/Kg/day- Proteins – 2 Gm/Kg/day

TPN in Various illness contd…TPN in Various illness contd… HEPATIC DISEASEHEPATIC DISEASE

High Caloric Intake High Caloric Intake – 35 Kcal / Kg / day – 35 Kcal / Kg / day

Encephalopathy PresentEncephalopathy Present – Proteins 0.6 Gm/Kg/day – Proteins 0.6 Gm/Kg/day Avoid Aromatic AAAvoid Aromatic AA Use Branched Chain AAUse Branched Chain AA

Encephalopathy AbsentEncephalopathy Absent - Proteins 1- 1.2 Gm/Kg/day - Proteins 1- 1.2 Gm/Kg/day

Edema / Asicitis Present Edema / Asicitis Present – Restrict Na – Restrict Na

TPN in Various illness contd…TPN in Various illness contd…

RESPIRATORY FAILURERESPIRATORY FAILURE

Calories 20 – 30 Kcal / Kg / dayCalories 20 – 30 Kcal / Kg / day Give 30 to 35 % calorie as FATGive 30 to 35 % calorie as FAT Avoid CARBOHYDRATESAvoid CARBOHYDRATES Proteins 1 – 2 Gm / Kg / dayProteins 1 – 2 Gm / Kg / day

IMMUNONUTRITIONIMMUNONUTRITION

GLUTAMINEGLUTAMINE

– – Semi essential AASemi essential AA - Improve Immune Functions- Improve Immune Functions - Restore Protein Stores- Restore Protein Stores

ENTERAL GLUTAMINEENTERAL GLUTAMINE

- Increase Intestinal Mucosal Height- Increase Intestinal Mucosal Height - Increase Enterocyte Protein Contents- Increase Enterocyte Protein Contents

Newer AgentsNewer Agents Anabolic Androgen TherapyAnabolic Androgen Therapy

Increase the Muscle MassIncrease the Muscle Mass

Megestral AcetateMegestral Acetate – Appetite Stimulant – Appetite Stimulant

Growth HormonesGrowth Hormones Increase the Muscle MassIncrease the Muscle Mass Increase Visceral Protein StatusIncrease Visceral Protein Status

Enteral Vs ParentralEnteral Vs Parentral

CheaperCheaper

Maintain Intestinal Maintain Intestinal MucosaMucosa

Easy to AdministerEasy to Administer

Less ComplicationsLess Complications

CostlyCostly

Causes Intestinal Causes Intestinal AtrophyAtrophy

Require ProfessionalRequire Professional

More ComplicationsMore Complications

CONCLUSIONCONCLUSION

TPNTPN is life-saving tool & is life-saving tool & should be given when should be given when indicated. If conditions indicated. If conditions allow, switch the patient allow, switch the patient over the over the Enteral NutritionEnteral Nutrition as early as possible. as early as possible.

Dr. invented new way for PN

infusion

Nurse preparing the PN bag for

infusion

Health is Wealth

THANKSTHANKS

parenteral nutrition

Health & Medicine