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TOTAL PARENTRAL NUTRITION

ENTERAL NUTRITION

Enteral nutrition is also called "tube feeding,“

Enteral nutrition is a mixture of all the needed nutrients.  

It is thicker than parenteral nutrition and sometimes it looks like a milk shake.

 It is given through a tube into the stomach or small intestine. 

PARENTERAL NUTRITION

Parenteral nutrition (PN) is an appropriate route of

nutrition support when patients with identified

malnutrition or significant risk of malnutrition cannot

meet their nutritional requirements through the

Gastrointestinal (GI) tract.

THE GOLDEN RULE OF NUTRITION

The gut should always be the preferred route for nutrient

administration.

Therefore, parenteral nutrition is indicated generally when there is severe gastro-intestinal dysfunction

INDICATION FOR PARENTERAL NUTRITION

In well-nourished adults, 7 - 10 days of starvation with conventional intravenous support (using 5% dextrose solutions) is generally accepted.

If the period of starvation is to extend beyond this time, or the patient is not well-nourished, Total Parenteral Nutrition (TPN) is necessary to prevent the potential complications of malnutrition.

IDENTIFYING THE MALNOURISHED PATIENT

HISTORY: Eaten little or nothing for more than 5 days

and/or are likely to eat little or nothing for 5 days or longer.

A poor absorptive capacity. High nutrient losses. Increased nutritional needs from causes such as catabolism Unintentional weight loss

EXAMINATION:

NO FAT BETWEEN FOLDS OF SKIN

SKIN HANGING

ROUGH HAIR

MOUTH SORES

CALCULATE BMI <2O kg/m²

ROUTES OF PARENTERAL NUTRITION

ADMINISTRATION OF PARENTERAL NUTRITION

PERIPHERAL ROUTE: Peripheral administration should be

considered first line for parenteral feeding No requirements for a chest x-ray to confirm

placement A mid-line should be considered as a

peripheral line as it doesnot reach the central circulation

sometimes complicated or delayed by phlebitis

CENTRAL ROUTE

The central venous route is indicated when longer term feeding is anticipated high tonocity formulations peripheral route is inaccessible A range of single, double, triple & quadruple lumen central lines are

available. These lines require skillful insertion,

usually into the jugular or subclavin vein, confirm their positions by X-ray

Tunnelling of the line to an appropriate exit site facilitates line care and may reduce the incidence of significant line sepsis

PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCs)

PICCs are typically inserted into a peripheral vein, usually into cephalic or basilic in the upper arm, with exit tip in the superior vena cava just above the right atrium

They are used for the central administration of infusions

Insertion is less invasive then for conventional central lines

CATEGORIES OF PARENTERAL NUTRITION

PARTIAL PARENTERAL NUTRITION

TOTAL PARENTERAL NUTRITION

PPN

If enteral feeding is just “not enough” , supplementation with Partial Parenteral

Nutrition (PPN) is indicatedIndications: Short bowel syndrome Malabsorption disorders Critical illness or wasting disorders

TPN

If enteral feeding is completely stopped or ineffective, Total Parenteral Nutrition is used

(TPN).

TPN

WELL NOURISHE

D

7-10 DAYS

MILD OR MODERATE MALNUTRIT

ION

5-7 DAYS

SEVERE MALNUTRIT

ION

3-5 DAYS

TPN INDICATIONS FOR CHILDREN

Congenital or acquired anomalies if the G.I. tract: gastroschisis, bowel fistulas, intestinal obstruction, atresias, short gut syndrome.

Chronic or recurrent diarrhea: malabsorption syndrome, inflammatory bowel disease.

Preterm infants Malnutrition (cystic fibrosis, cancer, anorexia

nervosa, hypermetabolic states, e.g., burns). Patient who are Nill Per OS (or who will be NPO)

for sufficient periods of time to cause a significant decrease in caloric intake (e.g., post-operative patients).

TPN INDICATIONS FOR ADULTS

SHORT-TERM USE Bowel injury, surgery, major trauma or burns Bowel disease (e.g. obstructions, fistulas) Severe malnutrition Nutritional preparation prior to surgery. Malabsorption - bowel cancer Severe pancreatitis Malnourished patients who have high risk of

aspirationLONG-TERM USE (HOME PN) Prolonged Intestinal Failure Crohn’s Disease Bowel resection

COMPONENTS OF PARENTERAL NUTRITION

COMPONENTS OF PARENTERAL NUTRITION

MACRO NUTRIE

NTSMICRO NUTRIENTS

MACRO NUTRIENTS

ENERGY AMINOACIDS WATER

MICRO NUTRIENTS

VITAMINS

ELECTROLYTES

TRACE ELEMENTS

ENERGY

DAILY ENERGY REQUIREMENTS IN

ADULTS

Gender Energy (Kcal)

MALE 2900 Kcal

FEMALE 2200 Kcal

DAILY ENERGY REQUIREMENTS IN

INFANTSAge ( Months) Energy (Kcal/kg)

0-3 116

3-6 99

6-9 95

9-12 101

ENERGY Hospitalized adults require

approximately 25-30 kcal/ kg /day.

However, these requirements may be greater in patients with injury or infection.

ENERGY REQUIREMENTS IN DISEASE CONDITIONSPatient condition Approximate energy

Requirement(kcal/kg/day)

No postoperativecomplications, GIT

fistula without infection

25-30

Mild peritonitis, malnourished 30-35

Severe injury or infection 35-45

Burn 40-100% of total body surface

45-80

DUAL ENERGY

Energy should be sourced from a combination of lipid and glucose.

Dual energy minimizes the risk of complications.

GLUCOS

E

LIPIDS

DUAL ENERGY

GLUCOSE

GLUCOSE

Most common source of parenteral energy supply.

1 gm of glucose gives 4 Kcals.

• Most stable patients tolerate rates of 4-5 mg.kg-1.Min-1, but insulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin should be incorporated according to blood sugar levels.

•Do not advance dextrose doses until Potassium and Phosphate levels are corrected.

More Potassium , Phosphates and Magnesium are required during insulin therapy.

Minimum dextrose dose per day is 100- 120g/day.

Glucose in 5% solution can be safely administered via a peripheral vein, but higher concentrations require a central venous line.

20, 25, or even 50 % solutions are needed to administer meaningful amounts of energy to most patients for proper volume administration.

LIPIDS Used as a source of energy and for the

provision of the essential fatty acids, linoleic acid and α- linolenic acid .

FA which are the building blocks for many of the hormones involved in the inflammatory process as well as the hormones regulating other body functions.

Provide 10 Kcal energy per gram of oil.

They are energy rich and can be infused directly into the peripheral veins.

Patients receive upto 2.5 g lipid/Kg/day.

20% lipid emulsions are used in paediatrics as they contain less phospholipids than the 10% emulsions.

Lipid clearance monitoring is important in patients who are hyperlipidaemic, clearance impaired,diabetic and have impaired renal or hepatic function.

AMINO ACIDS (PROTEINS)

PROTEINS Protein (or amino acids, the building

blocks of proteins) is the functional and structural component of the body.

Special amino acid solutions are also available including valine, leucine and isoleucine.

Other amino acids are essential for neonates, infants and children including histidine, proline, tyrosine, taurine.

COMMERCIAL SOLUTIONS OF AMINO

ACIDS Commercially available licensed

solutions of amino acids are available:

Aminoplex Intrafusin Synthamin Vamin

DAILY REQUIREMENTS OF PROTEINS

With disease, poor food intake, body protein is lost with the resultant

weakness and muscle mass wasting.

PROTEIN REQUIREMENTS IN DISEASE CONDITIONS

PATIENT CONDITIONS PROTEIN REQUIREMENTS

g/Kg/dayHealthy, nonstressed 0.8

Bone marrow transplant 1.4- 1.5

Pregnancy 1.3- 1.5

Renal failure 0.6- 1.0

Liver disease 1.0- 1.5

DOSE OF AMINO ACID IN PN

Day : 1 0.5g /Kg/d

Day :2 1 g / Kg/d

Day : 3 1.2- 1.7 g/Kg/d

Amino acid solutions are hypertonic to blood and should not be administered alone into the peripheral circulation.

WATER

WATER Water is the principal component of the

body and accounts for approximately 60% and 55% of total body weight in men and women.

Homeostasis maintains appropriate fluid levels and electrolyte balance.

An adult patient will require 20- 40 ml/Kg/day fluid.

FACTORS AFFECTING WATER REQUIREMENTS:

Abnormal GI loss (vomiting, dehydration).

High environmental temperature.

Acute anabolic state.

Burns or open wounds.

MICRO-NUTRIENTS

Micronutrients are nutrients required by humans and other organisms throughout life in small quantities to orchestrate a range of physiological functions

MICRONUTRIENTS INCLUDES

1. Vitamins

2. Minerals

a. Macromineralsb. microminerals

FACTORS AFFECTING MICRONUTRIENTS REQUIREMENTS

Increased loss Increased requirements Organ dysfunction

Importance of micronutrients

Affect of micronutrients deficiencies

VITAMINS

WATER SOLUBLE VITAMINS

It includes Vitamin B-complex group and vitamin CThiamin (vitamin B1), Riboflavin (vitamin B2), Niacin (vitamin B3), Pantothenic acid (vitamin B5) , Pyridoxine (vitamin B6), Biotin (vitamin B7), Folic acid (vitamin B9), Cobalamin (vitamin B12).water-soluble vitamins dissolve in water and are not stored by the body. with the exception of B12 and folate i-e B9, which are stored in the liver. a continuous daily supply in our diet is required.

FAT SOLUBLE VITAMINS

It includes Vitamin A, D, E and KDissolve in fat before they are absorbed in the bloodstream to carry out their functions. Excesses of these vitamins are stored in the liver, and are not needed every day in the dietIt generally posses a greater risk for toxicity when consumed in excess than water-soluble vitamins.

ELECTROLYTES

Electrolytes are minerals in your blood and other body fluids that carry an electric charge.

Electrolytes affect the amount of water in your body, the acidity of your blood (pH), your muscle function, and other important processes. You lose electrolytes when you sweat. You must replace them by drinking fluids.

TRACE ELEMENTS

A chemical element required in minute quantities by an organism to maintain proper

physical functioning. REQUIREMENT: Less than 100mg

Application:

The Solution Manually mixed in

hospital pharmacy or nutrition-mixing service,

premixed solutions, Separate administration

for every element alone in a separate line.

Osmolality, compatibility, stability, sterility, ease of preparation, and completeness of formula

The easy-to-use PINNACLE TPN Manager Software automates calculations and streamlines the process from order entry to infusion, from physician to pharmacist to patient.

THE AMERICAN HOSPIAL,UAE 2009

Venous access

PPN: (<900 m.osmol/L): a peripheral line can be enough. TPN: Central venous access is fundamental, Ideally, the venous line should he used exclusively for parenteral nutrition. Cyclic infusion; Consider cyclic PN infusion in: • Stable inpatients • Patients involved in daytime acute care therapy or transferring to rehabilitative services/facilities • Otherwise ambulatory patients whose mobility is hindered by infusion equipment • Patients anticipated to receive PN long term at home – Some may prefer daytime infusion due to frequent nocturnal urination – Portable pumps can help increase mobility for patients receiving dayyime infusion or longer infusion duration..

Catheter

Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure.

Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of the high rate of associated infection), or a long catheter placed in an arm vein and threaded into the central venous system (a peripherally inserted central catheter line)

Once the correct position of the catheter has been established (usually by X ray), the infusion can begin

CATHETER CONNECTOR

NEDDLES: 18,19,20,22G

CANOLLA SIZE: TUBE: POLYETHYLENE

PREPERATION: Silicon & plastic

PRECAUTIONS

PARTS OF CATHETER:

Initiation of Therapy TPN infusion is usually initiated at a rate of 25 to 50

mL/h. This rate is then increased by 25 mL/h until the predetermined final rate is achieved.

Administration To ensure that the solution is administered at a

continuous rate, an infusion pump is utilized to administer the solution. In hospitalized patients, infusion usually occurs over 22-24 h/day. In ambulatory home patients, administration usually occurs overnight (12-16 h).

AutoComp6-XP High Speed TPN Compounder.

for accurate, high speed compounding from a reliable

cost-effective. lightweight system with safety and

simplicity you can trust.

HEALTHMARK CANCER HOSPITAL, in Northwest Florida,2011

TPN COMPOUNDING

TPN CALCULATING SOFTWERE

Berlin,1992

Monitoring

1- Efficacy: Electrolytes (S. Na, K, Ca, Mg,

Cl, Ph), acid-base, Bl. Sugar, body weight, Hb.

2- Complications: ALT, AST, Bil, BUN, total

proteins and fractions.3- General: Input- Output chart.4- Detection of infection: Clinical (activity, temp,

symptoms) WBC count (total &

differential) CulturesPolicy: to monitor:

Sapphire Parenteral Nutrition Pump Use With All Liquid Solutions. Ambulatory Treatment.

Monitoring

Monitoring

GUIDELINES FOR TOTAL PARENTERAL NUTRITION (TPN)

• TPN Indications• How much calories with TPN • Fluid Considerations • TPN, Lipid, and IV Drugs Compatibility • Tapering and Discontinuation When the primary reason for starting TPN is resolving (i.e. mucositis, diarrhea, vomiting…etc), taper TPN by reducing the rate into half for one hour then DC TPN. Discontinuation of TPN will stimulate the appetite further.

Team Responsibilities

Physician:

• Orders: Start TPN, taper TPN, DC TPN, total fluid intake in ml/hour, designates desired IV maintenance with TPN. (Note that new start TPN orders are accepted daily excluding weekends. Any TPN order written after 1600 will be processed next day).

• Consults with TPN Pharmacist on medical circumstances requiring special consideration in TPN nutrients.

• Enters ordered laboratory orders (by TPN pharmacist) into Integrated Clinical Information System (ICIS).

• Orders all TPN related medications: Spironolactone, Triamterene, Ranitidine, Insulin, electrolytes boluses, if required before next TPN bag arrives.

TPN Pharmacist: • Nutritional assessment of the patient, in conjunction with the dietitian.

• TPN formula design to meet nutritional needs.

• Daily writing of TPN orders to include lab evaluation, fluid needs, caloric and protein needs.

• Daily calculation of calories and protein (to include all sources of glucose from IVPB, IV fluids, etc.)

• Daily order of necessary laboratory orders.

• Monitor drug-nutrient and lab-nutrient interactions.

• 24-hour on call

Nursing staff:

• Draws blood (turn off for one full minute before drawing all labs and avoid contamination of the drawn blood with TPN).

• Determines adequacy of oral intake.

• TPN monitoring: Daily weights, intake and output, TPN infusion rates and times.

• Ensure safe drug administration in regard to compatibility of drugs with TPN and lipids.

Infectious complicationMechanical complicationsMetabolic Complications

COMPLICATIONS OF TOTAL PARENTERAL NUTRITION

Parenteral nutrition imposes a chronic breech in the body's barrier system.

The infusion apparatus from container to catheter tip may prove a source for the introduction of bacterial or fungal organisms.

INFECTIOUS COMPLICATION: Parenteral nutrition solutions can easily

become contaminated during the preparation process

Infection is one of the two most common problems that arise after central venous access is established

SEPSIS

The most common organisms to cause sepsis in TPN patients are Staphylococcus epidermidis and Staph aureus. Other common bacteria include: Streptococcus, gram-negative organisms and Candida. Catheter site infections also occur.

FUNGEMIA

The most common type, also known as Candidemia, caused by Candida species, but infections by other fungi, including Saccharomyces, Aspergillus and Cryptococcus, are also called fungemia.

TPN is strongly associated with with fungemia , sometime unusal fungi such as Malassezia furfur associated with use of intravenous lipid infusion due to growth requirement of this organism for fatty acid

MECHANICAL COMPLICATION

Catheter related

complication

Site relate

d

Pneumothorax

Line occulusi

on

CATHETER RELATED COMPLICATION

1. Catheter related infection 2. Venous thrombosis3. Pneumothorax, vessel damage,

thrombosis, occlusion, catheter breakage, infection.

CATHETER RELATED INFECTION

Infection can occur at the exit site, and in the subcutaneous tissue through which the catheter is placed.

The two most common routes for transmission of micro-organisms in CR infection are

Contamination from the skin at the catheter exit site,

Contamination of the hub connections on the catheter or catheter tubing

VENOUS THROMBOSIS

Central venous thrombosis (CVT) potentially fatal complications in children receiving prolonged PN

CVT tends to develop after several weeks of PN.

It may result in facial swelling, prominent superficial veins or pain on commencing PN

CVT are associated with recurrent CVC infection, proximal location of the CVC tip in the superior vena cava, frequent blood sampling, concentrated glucose solutions, chemotherapeutic agents or may be idiopathic.

Carers should look for any distress of the child, breathlessness, redness or swelling in the neck or limbs, leakage from the exit site or stiffness of the CVC on flushing and for any increase in pressure of the infusion pumps.

LINE OCCLUSION

Line occulusion may be caused by number of factors

1. Fibrin sheath forming arround the line

2. Thrombosis blocking the tip

3. Internal blockage of lipid

4. Salt or drug precipitate

PNEUMOTHORAX

A pneumothorax is air that is trapped between a lung and the chest wall.

Pneumothorax is the most frequent complication associated with subclavin vein catheter placement

REASON: close proximity of the

lung apex to the subclavain vessels

METABOLIC COMPLICATION

Hyperglycemia orhypoglycemia

Cholestasis

Hyperlipidemia

Hepatic complication

Refeeding

syndrome

HYPERGLYCEMIA

Hyperglycemia is a higher than normal level of sugar in the blood.

Causes It can occur when the TPN

is infused too fast or if the body cannot tolerate the sugar.

HYPOGLYCEMIA

Hypoglycemia is a lower than normal level of sugar in the blood

Causes It can be caused by stopping the TPN infusion

abruptly without a “taper down,” or too much insulin in the TPN bag.

When the body is receiving a large amount of sugar, it produces more insulin. When the TPN infusion stops suddenly, the insulin takes longer to stop being produced. The result is a drop in the blood sugar below normal.

HYPERLIPIDEMIA

Hyperlipidemia in patients receiving PN usually manifests as increased serum triglyceride levels

Hypertriglyceridemia associated with PN is mainly the result of

excessive fat synthesis from dextrose overfeeding,

excessive lipid infusion, or impaired lipid clearance In patients receiving PN, several factors cause

reduction in lipid emulsion clearance, including sepsis, , obesity, diabetes , liver disease , and medications that alter fat metabolism

REFEEDING SYNDROME

Hepatic complications

Include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any age but are most common among infants, particularly premature ones (whose liver is immature).

Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatase; it commonly occurs when TPN is started.

Delayed or persistent elevations may result from excess amino acids.

Pathogenesis is unknown but cholestasis and inflammation may

contribute.

CHOLESTASIS

PN-associated cholelithiasis is the result of decreased gallbladder contractility during fasting.

In the absence of oral intake or enteral stimulation, there is decreased secretion of cholecystokinin (CCK), a peptide hormone secreted by the duodenum in response to meals to induce gallbladder contractility .

Fasting PN patients have been observed to have a distended gallbladder and absence of gallbladder contractions, a finding not observed in enterally fed patients.

As a result of bile stasis, bile accumulation in the biliary tract facilitates cholesterol gallstone formation and calcium bilirubinate precipitation in the form of sludge.

Metabolic Complications

o Other metabolic complications: Electrolyte imbalance, mineral

imbalance, acid-base imbalance, toxicity of contaminants of the parenteral solution.

Fluid and electrolyte complications

Electrolyte management is one of the most difficult aspects of PN therapy. Often electrolytes are outside of the normal range based on an underlying cause rather than directly related to the PN solution

HYPERNATREMIA

Dehydration Excess sodium intake

HYPONATREMIA Excess Fluid

TREATMENT OF

INFECTION AND SEPSIS

Local infections

Require removal of the catheter Local antiseptic treatment of the exit site And in some cases antibiotics

Tincture of iodine

SYSTEMIC INFECTION

DIAGNOSIS Blood cultures from paired peripheral vein blood

samples and from inside the central catheter Another procedure includes rubbing thecatheter tip in bloody agar.

TREATMENT

Catheter removal may be required If removal is not consider in patients on

long-term TPN, then the antibiotics were administered through the contaminated catheter

Short course of anti-bacterial and antifungal

therapy (acc. to C&S)

PREVENTIVE MEASURES

Changing the dressing routinely (every 48-72 hours) or when it becomes soiled, wet or loose.

PREVENTIVE MEASURES

The care-giver should wear a mask and gloves while changing the dressing

Other Preventive Measures Include:

Extending the application of antimicrobial solution at least 1 inch beyond the final dressing.

Placing a sterile sponge over the catheter, then placing an occlusive dressing.

Inspecting the site for tenderness, erythema, edema, or drainage.

Changing the TPN intravenous tubing every 48 hours.

Only i.v. nutrition solutions are administered through the catheter, no blood may be withdrawn from the catheter.

Catheter disinfection and redressing 2 to 3 times weekly.

The entrance site is inspected for signs of infection and if present, culture is taken or the catheter is removed.

FUNGEMIA TREATMENT

Diagnosis is difficult, as routine blood cultures  have poor sensitivity.

Treatment involves use of antifungals such as

Amphocetrin and  Fluconazole

1. Amphotericin B

Amphotericin B is a polyene antifungal drug, often used intravenously for systemic fungal infections. It was originally extracted from Streptomyces nodosus

Dose: 0.25 mg/kg per day IV

AMPHOTERICIN B MECHANISM OF ACTION

Adverse effects Of AMPHOTERICIN B

Fever and chills

Adverse effects Of AMPHOTERICIN B

Renal impairement

Hypotension

2. Fluconazole

Triazoles group Available both Orally and parentrally Treatment and prophylaxis of infections Highly effective in treatment of

Cryptococcus infection Cryptococcus neoformans

Dose:150–300 mg once weekly

MECHANISM OF ACTION

Inhibit an enzyme, reulting in cell membrane leaking

Lead to altered cell membrane Result fungal death The drug is excreted via the kidney, and

doses must be reduced in patients with comprised renal function

MECHANISM OF ACTION

VENOUS THROMBOSISDIAGNOSIS

Ultrasound

VENOGRAPHY

ANTICOAGULANT TREATMENT

Removal or replacement of the Central vein catheter

Patients under long-term TPN will typically receive a periodic HEPARIN flush to dissolve such clots before they become dangerous.  

(Maintenance doses of heparin are considered to be 10 - 25 units/kg per hour)

Pulmonary embolism

DIAGNOSIS Ultrasound Venography TREATMENT Anticoagulant Therapy Fogarty catheter may occasionally be

successful

LINE OCCLUISON TREATMENT Thrombolytic therapy with low dose

Tissue plasminogen activator or Urokinase

After 2-h treatment with 2 mg per 2 mL recombinant tissue plasminogen activator (Alteplase), function was restored to 74% in the alteplase After another dose (2 mg per 2 mL), function was restored in 90% of patients.

PNEUMOTHORAX

DIAGNOSIS: Chest x-ray TREATMENT

Metabolic Complications

o HYPERGLYCEMIA TREATMENTo Decrease the amount of infused glucose

(to<4 mg/kg/min)o Insulin can be administered, was suggested for serum glucose concentrationsexceeding 200 mg/dL

Hypoglycemia Treatment

In general,patients who are undergoing surgery while receiving TPN should have the rate of infusion reduced to 50 ml/h.

Sudden discontinuation of TPN being administered at a high rate should be countered by administering a 10% dextrose solution in the interim.

Hypertriglyceridemia Treatment  NiacinOmega3 Fatty acidStatins

   

Hepatic and biliary dysfunction

TPN-associated cholestasis occurs more frequently in infants.

TREATMENT Cycling of TPN Avoidance of over-feeding (435 kcal/kg

BW/day), Avoidance of high glucose infusion (45

g/kg BW/day),

CHOLECYSTECTOMY

There is no specific treatment For most patients diagnosed with acute

cholecystitis, the definitive treatment is surgical removal of the gallbladder, cholecystectomy 

Oral administration of ursodeoxycholic (Actigall) may improve cholestasis

Treatment Of Fluid And Electrolyte Abnormalities

Minimized by careful monitoring. At least 50 mEq of sodium, 40mEq of potassium, 90±100 mEq of phosphorus, and 28±32 mEq of magnesium and

calcium should be administered daily to all

patients receiving parenteral nutrition

HYPERNATREMIA

TREATMENT Replace fluid deficit Check for excess sodium intake

HYPONATREMIA

TREATMENT Decrease fluid intake Check for causes of fluid retention Check for causes of sodium loss Administer sodium if patient at risk for

seizures

REFEEDING SYNDROM

TREATMENT Correct electrolyte abnormalities Administer volume and energy slowly Monitor pulse, electrolytes closely Provide appropriate vitamin

supplementation Avoid overfeeding Parentral phosphate administration( eg

18mmol\dl) MILK

REFEEDING SYNDROM

On average, patients should receive 2-4 mmol/kg/day potassium, 0.3-0.6 mmol/kg/day phosphate, and 0.2 mmol/kg/day intravenous or 0.4 mmol/kg/day oral magnesium

For Gastrointestinal disturbance during refeeding, domperidone or metoclopramide

As well as acid suppressants such as omeprazole 

CASE HISTORY

CASE

A 64- year- old women Recovering slowly from major abdominal

surgery Fed by total parenteral nutrition (TPN) Ten days into her course of TPN she

develops a high fever and rigors Antibiotics are commenced But after 48 hours there is no response Blood cultures have remained negative

CASE (cont.)

Fungal infection is suspected Fluconazole is commenced Likely fungal cause would be candida

albicans or a related species And because amphotericin was not felt

to be suitable for a frail patient with compromised renal function

The temperature coming down a little She continue to feel unwell

CASE (cont.)

The cannula is then removed The patient’s fever returns to normal

within 24 hours She feels much better. What might have happened????

ANSWER

Colonized cannula Blood culture negative, cannula tip grew

nothing Because there is the possibility that this

was an infection with flucazole-resistant strain of candida

Malassezia furfur didnot grow on conventional culture media; it has growth requirement for fatty acids which are not present in routine lab media

Detection Of Malassezia furfur

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