بسم اللهِ الرَّحْمَنِ الرَّحِيمِ

ح�من� الله�الله�بسم بسم ح�من�الر� الر�

� ح�يم �الر� ح�يم الر�

ب�ي ”” ر �ي �من عل م�م�ا �ما �ك ب�ي ذل ر �ي �من عل م�م�ا �ما �ك ذل

�ه� �الل ب �ون �ؤ�م�ن ي ال قو�م �ة م�ل �ت� ك ر ت �ي �ن �ه� إ �الل ب �ون �ؤ�م�ن ي ال قو�م �ة م�ل �ت� ك ر ت �ي �ن ““إ

Faculty of MedicineFaculty of Medicine

Department of Anesthesiology, ICU, and Pain Department of Anesthesiology, ICU, and Pain managementmanagement

CME Program – ICU courseCME Program – ICU course

Ain-Shams Ain-Shams universityuniversity

Parenteral Parenteral NutritionNutrition

ByBy

Ahmed El-Shaer, MDAhmed El-Shaer, MD

Def.Def. :a method of feeding patients by :a method of feeding patients by infusing a mixture of all necessary infusing a mixture of all necessary nutrients into the circulatory system, nutrients into the circulatory system, thus bypassing the GIT.thus bypassing the GIT.

Also referred to as:Also referred to as:

intravenous nutrition,intravenous nutrition,

parenteral alimentation, andparenteral alimentation, and

artificial nutrition.artificial nutrition.

The gut should always be the preferred The gut should always be the preferred route for nutrient administration.route for nutrient administration.

Therefore, parenteral nutrition is indicated Therefore, parenteral nutrition is indicated generally when there is generally when there is severe gastro-severe gastro-intestinal dysfunctionintestinal dysfunction ( (patients whopatients who cannot cannot take sufficient food or feeding formulas by take sufficient food or feeding formulas by the enteral route) .the enteral route) .

Categories of PNCategories of PN

If enteral feeding isIf enteral feeding is completely stoppedcompletely stopped or or ineffective,ineffective, Total Parenteral NutritionTotal Parenteral Nutrition is is used (TPN).used (TPN).

If enteral feeding is justIf enteral feeding is just “not enough”“not enough” , , supplementation withsupplementation with Partial Parenteral Partial Parenteral NutritionNutrition (PPN) is indicated(PPN) is indicated..

INDICATIONSINDICATIONS

In well-nourished adults,In well-nourished adults, 7 - 10 days7 - 10 days of of starvation with conventional intravenous starvation with conventional intravenous support (using 5% dextrose solutions) is support (using 5% dextrose solutions) is generally accepted. generally accepted.

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

Indications for TPNIndications for TPN Short-term useShort-term use

Bowel injury, surgery, Bowel injury, surgery, major trauma or burnsmajor trauma or burnsBowel disease (e.g. Bowel disease (e.g. obstructions, fistulas)obstructions, fistulas)Severe malnutritionSevere malnutritionNutritional preparation prior to surgery. Nutritional preparation prior to surgery. Malabsorption - bowel cancerMalabsorption - bowel cancerSevere pancreatitisSevere pancreatitis

Malnourished patients who have high risk Malnourished patients who have high risk of aspirationof aspiration

Long-term use (HOME PN)Long-term use (HOME PN)Prolonged Intestinal FailureProlonged Intestinal FailureCrohn’s DiseaseCrohn’s DiseaseBowel resectionBowel resection

Partial Parenteral Nutrition:Partial Parenteral Nutrition:

PPN can be used to supplement Ordinary or PPN can be used to supplement Ordinary or Tube feeding esp. in malnourished patients.Tube feeding esp. in malnourished patients.

Indications:Indications:

Short bowel syndromeShort bowel syndrome

Malabsorption disordersMalabsorption disorders

Critical illness or wasting disordersCritical illness or wasting disorders

Enteral versus parenteral Enteral versus parenteral nutritionnutrition

As far asAs far as gastrointestinal failuregastrointestinal failure is concerned, is concerned, long termlong term parenteral nutritionparenteral nutrition is a life-saving is a life-saving procedure.procedure.

Enteral nutritionEnteral nutrition has the advantage over has the advantage over parenteral nutrition ofparenteral nutrition of lower % of infectious lower % of infectious complications.complications.

Parenteral nutritionParenteral nutrition has been shown to lead tohas been shown to lead to changes in intestinal morphologychanges in intestinal morphology andand function function and an increase in permeabilityand an increase in permeability (with higher % (with higher % of bacterial translocation)of bacterial translocation)

Nutritional RequirementsNutritional Requirements

Energy: GlucoseEnergy: Glucose

LipidLipid

Amino acids (Nitrogen)Amino acids (Nitrogen)

Water and electrolytesWater and electrolytes

VitaminsVitamins

Trace elementsTrace elements

Requirements:Requirements:

EnergyEnergyBasal energy requirementsBasal energy requirements are a function of are a function of

the individual's the individual's weightweight, , ageage, , gendergender, , activity activity levellevel and the and the disease processdisease process. .

The estimation of energy requirements for The estimation of energy requirements for parenteral nutrition relies on predictive parenteral nutrition relies on predictive equations. equations.

Hospitalized adults require approximately Hospitalized adults require approximately 25-30 25-30 kcal/ kgBW/day.kcal/ kgBW/day.

However, these requirements may be However, these requirements may be greatergreater in in patients with patients with injuryinjury or or infection.infection.

Energy RequirementsEnergy Requirements

Patient conditionPatient condition Basal Basal metabolic metabolic

raterate

Approximate energyApproximate energy

RequirementRequirement

(kcal/kg/day) (kcal/kg/day)

No postoperativeNo postoperative

complications, GITcomplications, GIT

fistula without infectionfistula without infection

NormalNormal 25-3025-30

Mild peritonitis, long-bone Mild peritonitis, long-bone fracture, mild to moderate fracture, mild to moderate injury, malnourishedinjury, malnourished

25% above 25% above normalnormal

30-3530-35

Severe injury or infectionSevere injury or infection 50% above 50% above normalnormal

35-4535-45

Burn 40-100% of total body Burn 40-100% of total body surfacesurface

Up to 100% Up to 100% above normalabove normal

45-8045-80

Requirements:Requirements:Energy Sources: Energy Sources: GlucoseGlucose

The most common source of parenteral energy supply The most common source of parenteral energy supply is is glucoseglucose, being:, being: Readily metabolized in most patients,Readily metabolized in most patients, provides the obligatory needs of the substrate , thus provides the obligatory needs of the substrate , thus

reducing gluconeogenesis and sparing endogenous reducing gluconeogenesis and sparing endogenous protein.protein.

1 gm of glucose gives 4 Kcals.1 gm of glucose gives 4 Kcals.

Most stable patients tolerate rates of Most stable patients tolerate rates of 4-5 mg.kg4-5 mg.kg-1-1.Min.Min-1-1, , but insulin resistance in critically ill patients may lead but insulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin to hyperglycemia even at these rates, so insulin should be incorporated acc. to blood sugar levels.should be incorporated acc. to blood sugar levels.


Energy Sources: Energy Sources: GlucoseGlucose

RouteRoute

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

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

Requirements:Requirements:Energy SourcesEnergy Sources: Lipid: Lipid

Fat mobilization is a major response to stress and Fat mobilization is a major response to stress and infection.infection.

Triacylglycerols are an important fuel source in Triacylglycerols are an important fuel source in those conditions, even when glucose availability is those conditions, even when glucose availability is adequate.adequate.

Need to be restricted in patients withNeed to be restricted in patients with hypertriglyceridemia.hypertriglyceridemia.

Requirements:Requirements:Energy Sources: Energy Sources: LipidLipid

Lipids are also a source for the Lipids are also a source for the essential fatty essential fatty acidsacids which are the building blocks for many of the which are the building blocks for many of the hormones involved in the inflammatory process as hormones involved in the inflammatory process as well as the hormones regulating other body well as the hormones regulating other body functions.functions.

Ideally, energy from fat should not exceed Ideally, energy from fat should not exceed 40%40% of of the total the total (usually 20-30%).(usually 20-30%).

Requirements:Requirements:Energy Sources: Energy Sources: LipidLipid

Fat emulsions can be safely administered via Fat emulsions can be safely administered via peripheral veinsperipheral veins, provide , provide essential fatty acidsessential fatty acids, and , and are concentrated are concentrated energy sourcesenergy sources for fluid-restricted for fluid-restricted patients.patients.

They are available in They are available in 10, 20 and 10, 20 and 30%30% preparations. preparations.

Though lipids have a calorific value of 9Kcal/g, the Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is value in lipid emulsions is 10Kcal/g10Kcal/g due to the due to the contents of glycerol and phospholipidscontents of glycerol and phospholipids..

Requirements:Requirements:NitrogenNitrogen

Protein (Protein (or amino acids, the building blocks of or amino acids, the building blocks of proteinsproteins) is the functional and structural ) is the functional and structural component of the body, so fulfilling patient’s component of the body, so fulfilling patient’s caloric needs with non-protein calories (fat and caloric needs with non-protein calories (fat and glucose) is essential.glucose) is essential.

Protein requirementsProtein requirements for most healthy for most healthy individuals are individuals are 0.8 g/kg/day0.8 g/kg/day..


With disease, poor food intake, and inactivity, body With disease, poor food intake, and inactivity, body protein is lost with the resultant weakness and protein is lost with the resultant weakness and muscle mass wasting.muscle mass wasting.

Critically ill patientsCritically ill patients may need as high as may need as high as 1.5-2.5 g 1.5-2.5 g protein/kg/dayprotein/kg/day depending on the disease process: depending on the disease process:

((major trauma or burn > infection or after surgery > standardmajor trauma or burn > infection or after surgery > standard))

The amount should be reduced in patients with The amount should be reduced in patients with kidney or liver disease.kidney or liver disease.


Daily Protein requirementsDaily Protein requirements

ConditionCondition ExampleExample requirementrequirement

Basic requirementsBasic requirements Normal personNormal person 0.5-1g/Kg0.5-1g/Kg

Slightly increased Slightly increased requirementsrequirements

Post-operative, cancer, Post-operative, cancer, inflammatoryinflammatory

1.5g/Kg1.5g/Kg

Moderately increased Moderately increased requirementsrequirements

Sepsis, polytraumaSepsis, polytrauma 2g/Kg2g/Kg

Highly increased Highly increased requirementsrequirements

Peritonitis, burns, Peritonitis, burns, 2.5g/Kg2.5g/Kg

Reduced requirementsReduced requirements Renal failure, hepatic Renal failure, hepatic encephalopathyencephalopathy

0.6g/Kg0.6g/Kg


Nitrogen Balance =Nitrogen Balance =

Protein intake in grams Protein intake in grams ÷ 6.25 – UUN (in grams) + 3÷ 6.25 – UUN (in grams) + 3

The nitrogen lost in urine derives primarily from amino The nitrogen lost in urine derives primarily from amino acids released by protein breakdown in response to acids released by protein breakdown in response to catabolic mediators that include stress hormones catabolic mediators that include stress hormones (corticosteroids, catecholamines)(corticosteroids, catecholamines) and cytokines. and cytokines.

It is a way to assess the sufficiency of protein intake It is a way to assess the sufficiency of protein intake for the patient.for the patient.


Parenteral amino acid solutions provide all known Parenteral amino acid solutions provide all known essential amino acids.essential amino acids.

Available a.a. preparations are Available a.a. preparations are 3.5 - 15 %3.5 - 15 % (ie (ie contains 3.5-15 gms of protein or a.a.s/100 mL contains 3.5-15 gms of protein or a.a.s/100 mL solution).solution).

1gm of protein = 1gm of protein = 0.16 gm0.16 gm of N of N2.2.


Special a.a. solutions are also available containing Special a.a. solutions are also available containing higher levels of certain a.a.s, most commonly the higher levels of certain a.a.s, most commonly the branched-chain ones (valine, leucine and branched-chain ones (valine, leucine and isoleucine), aimed at the management of liver isoleucine), aimed at the management of liver diseases, sepsis and other stress conditions. diseases, sepsis and other stress conditions.

Conversely, solutions containing fewer a.a.s Conversely, solutions containing fewer a.a.s (primarily the essential ones) are available for (primarily the essential ones) are available for

patients with renal failure.patients with renal failure.


Arginine was added to enteral formulae Arginine was added to enteral formulae claiming positive effects on claiming positive effects on immune functionimmune function and length of hospital stay.and length of hospital stay.

In some clinical trials, In some clinical trials, glutamineglutamine-enriched -enriched solutions improved nitrogen balance and solutions improved nitrogen balance and gut gut morphology. morphology.


Fluids and electrolytesFluids and electrolytes

20–40 mL/kg - daily – young adults20–40 mL/kg - daily – young adults

30 mL/kg – daily – older adults30 mL/kg – daily – older adults

Sodium, potassium, chloride, calcium, Sodium, potassium, chloride, calcium, magnesium, and phosphorus ( as per the table)magnesium, and phosphorus ( as per the table)

Daily lab tests to monitor electrolyte statusDaily lab tests to monitor electrolyte status

Requirements:Requirements:Fluids and electrolytesFluids and electrolytes

NutrientNutrient Requirements (Requirements (/Kg/day)/Kg/day)

WaterWater 20-40 mL20-40 mL

SodiumSodium 0.5-1.0 mmol0.5-1.0 mmol

PotassiumPotassium 0.5-1.0 mmol0.5-1.0 mmol

MagnesiumMagnesium 0.1-0.2 mmol0.1-0.2 mmol

CalciumCalcium 0.05-0.15mmol0.05-0.15mmol

PhosphatePhosphate 0.2-0.5mmol0.2-0.5mmol

Chloride/AcetateChloride/Acetate So a to maintain acid-base balance So a to maintain acid-base balance (normally 0.5 mmol for Cl(normally 0.5 mmol for Cl-- , & 0.1mEq for Acetate) , & 0.1mEq for Acetate)

Requirements:Requirements:Fluids and electrolytesFluids and electrolytes

Normalization of acid-base balance is a priorityNormalization of acid-base balance is a priority and and constant concern in the management of critically ill constant concern in the management of critically ill patients. patients.

Most electrolytes can be safely added to the Most electrolytes can be safely added to the parenteral amino acid/dextrose solution.parenteral amino acid/dextrose solution.

Sodium bicarbonate in high concentrations will tend to Sodium bicarbonate in high concentrations will tend to generate carbon dioxide at the acidic pH of the amino generate carbon dioxide at the acidic pH of the amino acid/glucose mix.acid/glucose mix.

Requirements:Requirements:VitaminsVitamins

These requirements are usually met when These requirements are usually met when standard volumes of a nutrient mix are provided.standard volumes of a nutrient mix are provided.

Increased amounts of vits are usually provided to Increased amounts of vits are usually provided to severely ill patients.severely ill patients.

Vitamins are either fat soluble (A,D,E,K) or water Vitamins are either fat soluble (A,D,E,K) or water soluble (B,C). Separate multivitamin commercial soluble (B,C). Separate multivitamin commercial preparations are now available for both.preparations are now available for both.

Requirements:Requirements:VitaminsVitamins

Multivitamin formulations for parenteral use for Multivitamin formulations for parenteral use for adult patients usually contain 12 vitamins at levels adult patients usually contain 12 vitamins at levels estimated to provide daily requirements.estimated to provide daily requirements.

Additional amounts can be provided separately Additional amounts can be provided separately when indicated. when indicated.

Most adult vitamin formulae do not contain vitamin Most adult vitamin formulae do not contain vitamin K, which is added according to the patient’s K, which is added according to the patient’s coagulation status.coagulation status.


Trace mineralsTrace minerals

These are These are essential component of the parenteral essential component of the parenteral nutrition regimen.nutrition regimen.

A multi-element solution is available commercially, A multi-element solution is available commercially, and can be supplemented with individual minerals. and can be supplemented with individual minerals.

may be may be toxic at high dosestoxic at high doses..

Iron is excludedIron is excluded, as it alters stability of other , as it alters stability of other ingredients. So it is given by separate injection (iv ingredients. So it is given by separate injection (iv or im).or im).

Requirements:Requirements:Trace mineralsTrace minerals

minerals excreted via the liver, such as copper and minerals excreted via the liver, such as copper and manganese, should be used with caution in patients manganese, should be used with caution in patients with liver disease or impaired biliary function. with liver disease or impaired biliary function.

Mineral Mineral Recommended dietary Recommended dietary allowance (RDA) for daily allowance (RDA) for daily

oral intake (mg) oral intake (mg)

Suggested daily Suggested daily intravenous intake intravenous intake

(mg) (mg)

Zinc Zinc 15 15 2.5-5 2.5-5

Copper Copper 2-3 2-3 0.5-1.5 0.5-1.5

Manganese Manganese 2.5-5 2.5-5 0.15-0.8 0.15-0.8

Chromium Chromium 0.05-0.2 0.05-0.2 0.01-0.015 0.01-0.015

Iron Iron 10 (males)-18 (females) 10 (males)-18 (females) 3 3

Osmolarity:Osmolarity:

PPN: Maximum of PPN: Maximum of 900 900 milliosmoles / litermilliosmoles / liter

TPN: as nutrient dense as necessary TPN: as nutrient dense as necessary (>900(>900 m.osmol and up as high as m.osmol and up as high as 30003000).).

Amino acids (10 m.osmol/gm), dextrose (5 Amino acids (10 m.osmol/gm), dextrose (5 m.osmol/gm) and electrolytes (2 m.osmol m.osmol/gm) and electrolytes (2 m.osmol /mEq) contribute most to the osmolarity, while /mEq) contribute most to the osmolarity, while lipids give 1.5 m.osmol/gm.lipids give 1.5 m.osmol/gm.

Application:Application:

The SolutionThe Solution

Manually mixed in hospital pharmacy or Manually mixed in hospital pharmacy or nutrition-mixing service,nutrition-mixing service,

premixed solutions,premixed solutions,

Separate administration for every element Separate administration for every element alone in a separate line.alone in a separate line.

Application:Application:Venous accessVenous access

PPNPPN: (<900 m.osmol/L): a : (<900 m.osmol/L): a peripheral lineperipheral line can be can be enough.enough.TPNTPN: : Central venous access is fundamentalCentral venous access is fundamental,,

Ideally, the venous line should he usedIdeally, the venous line should he used exclusively for parenteral nutrition.exclusively for parenteral nutrition. Catheter can be placed via the Catheter can be placed via the subclaviansubclavian vein, the vein, the

jugularjugular vein (less desirable because of the high rate vein (less desirable because of the high rate of associated infection), or a of associated infection), or a long catheter placed in long catheter placed in an arm veinan arm vein and threaded into the central venous and threaded into the central venous system (a peripherally inserted central catheter line) system (a peripherally inserted central catheter line)

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

Application:Application:

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

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

AdministrationAdministration To ensure that the solution is administered at a To ensure that the solution is administered at a

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

MonitoringMonitoring

Policy: to monitor:Policy: to monitor:

1-1- EffecacyEffecacy: electrolytes (S. Na, K, Ca, Mg, Cl, : electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar, body weight, Hb.Ph), acid-base, Bl. Sugar, body weight, Hb.

2- 2- ComplicationsComplications: ALT, AST, Bil, BUN, total : ALT, AST, Bil, BUN, total proteins and fractions.proteins and fractions.

3- 3- General:General: Input- Output chart. Input- Output chart.

4- 4- Detection of infection:Detection of infection:

Clinical (activity, temp, symptoms)Clinical (activity, temp, symptoms)

WBC count (total & differential)WBC count (total & differential)

CulturesCultures

MonitoringMonitoring

MonitorinMonitoringg

Complications of TPNComplications of TPN

SepsisSepsis

PneumothoraxPneumothorax

Air embolismAir embolism

Clotted catheter lineClotted catheter line

Catheter displacementCatheter displacement

Fluid overloadFluid overload

HyperglycemiaHyperglycemia

Rebound HypoglycemiaRebound Hypoglycemia

Complications of TPNComplications of TPNCatheter-related complicationsCatheter-related complicationso Catheter sepsis:Catheter sepsis: which can be localized or systemic which can be localized or systemic

(skin portal, malnutrion, poor immunity).(skin portal, malnutrion, poor immunity).

ccc byccc by: fever, chills, : fever, chills, ±±drainage around the catheter drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & entrance site, Leukocytosis, +ve cultures (blood & catheter tip).catheter tip).

tttttt:1- exclusion of other causes of fever:1- exclusion of other causes of fever

2- short course of anti-bacterial and antifungal2- short course of anti-bacterial and antifungal

therapy (acc. to C&S)therapy (acc. to C&S)

3- Catheter removal may be required3- Catheter removal may be required

Complications of TPNComplications of TPNCatheter sepsis (Cont.):Catheter sepsis (Cont.):Prevention:Prevention: a rigorous program of catheter care: a rigorous program of catheter care: Only i.v. nutrition solutions are administered through Only i.v. nutrition solutions are administered through

the catheter, no blood may be withdrawn from the the catheter, no blood may be withdrawn from the catheter. catheter.

Catheter disinfection and redressing 2 to 3 times Catheter disinfection and redressing 2 to 3 times weekly. weekly.

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

Other catheter-related complications:Other catheter-related complications: Thromboembolism, pneumothorax, vein or artery Thromboembolism, pneumothorax, vein or artery

perforation, and superior vena cava thrombosisperforation, and superior vena cava thrombosis


Metabolic ComplicationsMetabolic Complications o HyperglycemiaHyperglycemia (an elevated blood sugar): (an elevated blood sugar):

Associated with the infusion of excess glucose in the Associated with the infusion of excess glucose in the feeding solution or the diabetic-like state in the feeding solution or the diabetic-like state in the patient associated with many critical illnesses.patient associated with many critical illnesses.

It can result in an osmotic diuresis (abnormal loss It can result in an osmotic diuresis (abnormal loss of fluid via the kidney), dehydration, and of fluid via the kidney), dehydration, and hyperosmolar coma. hyperosmolar coma.

ttt: decrease the amount of infused glucose (to<4 ttt: decrease the amount of infused glucose (to<4 mg/kg/min) OR insulin can be administered (either mg/kg/min) OR insulin can be administered (either S.C. inj. or incorporation in the infusion bag). S.C. inj. or incorporation in the infusion bag).

Complications of TPNComplications of TPNMetabolic ComplicationsMetabolic Complications o HypertriglyceridemiaHypertriglyceridemia (High S. Triglycerides) (High S. Triglycerides) Associated with excess infusion of fat emulsion.Associated with excess infusion of fat emulsion.

N.B.N.B. Infusion of both glucose and fat emulsion in Infusion of both glucose and fat emulsion in excess may result in pulmonary insufficiency. excess may result in pulmonary insufficiency.

Excess glucose infusion –> excess carbon Excess glucose infusion –> excess carbon dioxide (CO2) production a result of glucose dioxide (CO2) production a result of glucose metabolism.metabolism.

Excess lipid infusion --> the lipid particles may Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce the accumulate in the lungs and reduce the diffusion capacity of respiratory gases.diffusion capacity of respiratory gases.

Complications of TPNComplications of TPNMetabolic ComplicationsMetabolic Complications

o liver toxicityliver toxicity (also know as parenteral nutrition (also know as parenteral nutrition cholestasis): It causes severe cholestatic jaundice, cholestasis): It causes severe cholestatic jaundice, elevation of transaminases, and may lead to elevation of transaminases, and may lead to irreversible liver damage and cirrhosis. irreversible liver damage and cirrhosis.

Multiple Multiple causescauses have been proposed, including have been proposed, including high high infusion rates of aromatic amino acidsinfusion rates of aromatic amino acids, , high proportion high proportion of energy intake from glucoseof energy intake from glucose, e.t.c.., e.t.c..

There is There is no specific treatmentno specific treatment, other than , other than anticholestaticanticholestatic therapy. therapy.


Metabolic ComplicationsMetabolic Complications

o Intestinal bacterial translocation:Intestinal bacterial translocation: The The lack of direct provision of nutrientslack of direct provision of nutrients to the to the intestinal intestinal

epitheliaepithelia during total parenteral nutrition during total parenteral nutrition TrophismTrophism and and altered permeability of the GI mucosa, thus compromising altered permeability of the GI mucosa, thus compromising any potential recovery of the patient’s ability for enteral any potential recovery of the patient’s ability for enteral feeding, and allowing bacterial entery to blood stream feeding, and allowing bacterial entery to blood stream sepsis sepsis

PreventionPrevention is to provide a minimal enteral nutrition supply to is to provide a minimal enteral nutrition supply to

avoid or minimize this risk.avoid or minimize this risk.

Complications of TPNComplications of TPNMetabolic ComplicationsMetabolic Complicationso Other metabolic complications:Other metabolic complications:

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


Mechanical ComplicationsMechanical Complications Catheters and tubing may become clotted or twist and Catheters and tubing may become clotted or twist and

obstruct. obstruct.

Pumps may also fail or operate improperlyPumps may also fail or operate improperly..

HOME PARENTERAL NUTRITIONHOME PARENTERAL NUTRITION

Patients who are unable to eat and absorb adequate Patients who are unable to eat and absorb adequate nutrients for maintenance over the long term may be nutrients for maintenance over the long term may be candidates for home parenteral nutrition e.g. extensive candidates for home parenteral nutrition e.g. extensive Crohn's disease, mesenteric infarction, or severe Crohn's disease, mesenteric infarction, or severe abdominal trauma. abdominal trauma.

patients must be able to master the techniques patients must be able to master the techniques associated with this support system, be motivated, associated with this support system, be motivated, and have adequate social support at home.and have adequate social support at home.

HOME PARENTERAL NUTRITIONHOME PARENTERAL NUTRITIONA patient who is judged to be a candidate for A patient who is judged to be a candidate for home parenteral nutrition requires an indwelling home parenteral nutrition requires an indwelling Silastic catheter designed for long-term Silastic catheter designed for long-term permanent use.permanent use.

The nutrient solutions are prepared weekly and The nutrient solutions are prepared weekly and delivered to the patient's home. delivered to the patient's home.

The patient sets up the infusion system and The patient sets up the infusion system and attaches the catheter to the delivery tubing in attaches the catheter to the delivery tubing in the evening for infusion over the next 12-16 h. the evening for infusion over the next 12-16 h. The intravenous nutrition is terminated by the The intravenous nutrition is terminated by the patient the next morning.patient the next morning.

ب�ي ““ ر� د�ي�ن�ي ي�ه نأ� ى ع�س� ب�ي و�ق�ل ر� د�ي�ن�ي ي�ه نأ� ى ع�س� و�ق�ل

� دا ش� ر� ذ�ا ه� م�ن ب� ر� ق� أل� دا ش� ر� ذ�ا ه� م�ن ب� ر� ق””أل�

Among the indications for parentral nutritionAmong the indications for parentral nutrition

Short bowl syndrome, TShort bowl syndrome, T

Surgical GIT resection followed by more than 5 Surgical GIT resection followed by more than 5 days fasting in a cachectic patient, Tdays fasting in a cachectic patient, T

Polytrauma, FPolytrauma, F

Intractable malabsorption, TIntractable malabsorption, T

Prolonged mechanical ventilation FProlonged mechanical ventilation F

For energy requirementsFor energy requirements

hospitalized adults require approximately 25-30 hospitalized adults require approximately 25-30 kcal/kg/day Tkcal/kg/day T

A single measurement of energy expenditure A single measurement of energy expenditure by indirect calorimetry will provide a reliable by indirect calorimetry will provide a reliable estimate of average requirements. Festimate of average requirements. F

The most common source of parenteral energy The most common source of parenteral energy supply is glucose. Tsupply is glucose. T

Glucose in 5% solution can be safely Glucose in 5% solution can be safely administered via a peripheral vein, Tadministered via a peripheral vein, T

With severe infection or injury, basal metabolic With severe infection or injury, basal metabolic rate rises about 25% above normal Frate rises about 25% above normal F

Regarding Nitrogen balanceRegarding Nitrogen balance

A 70 Kgs normal adult male requires about 60 A 70 Kgs normal adult male requires about 60 gms of protein daily Tgms of protein daily T

Stress induces catabolic state and hence, a Stress induces catabolic state and hence, a positive Nitrogen balance Fpositive Nitrogen balance F

Special amino acid solutions containing higher Special amino acid solutions containing higher levels of branched-chain amino acids (valine, levels of branched-chain amino acids (valine, leucine and isoleucine) are useful in the leucine and isoleucine) are useful in the management of liver diseases. Tmanagement of liver diseases. T

With renal failure, reduction of the amino acid With renal failure, reduction of the amino acid load is recommended. Tload is recommended. T

Glutamine is essential for gut function. FGlutamine is essential for gut function. F

During Monitoring of TPNDuring Monitoring of TPN

Hyperglycemia can be tolerated so long as there is Hyperglycemia can be tolerated so long as there is no ketosis Fno ketosis F

New-onset glucose intolerance in patients receiving New-onset glucose intolerance in patients receiving TPN may represent an early sign of sepsis. TTPN may represent an early sign of sepsis. T

Serum levels of electrolytes including magnesium Serum levels of electrolytes including magnesium and phosphorus should be checked daily until and phosphorus should be checked daily until stabilized, then two times daily. Fstabilized, then two times daily. F

Overfeeding the patients markedly increases Overfeeding the patients markedly increases metabolic and respiratory complications. Tmetabolic and respiratory complications. T

Indirect calorimetry is very useful in mechanically Indirect calorimetry is very useful in mechanically ventilated patients with an FiOventilated patients with an FiO22 greater than 50%. greater than 50%.

FF

Complications of parentral nutritionComplications of parentral nutritionThe most frequent catheter-related complication is The most frequent catheter-related complication is SVC thrombosis FSVC thrombosis FCatheter sepsis is characterized by the classic signs Catheter sepsis is characterized by the classic signs of infection: chills, fever, and white blood cell count of infection: chills, fever, and white blood cell count is usually elevated Tis usually elevated THyperglycemia is a very serious, relatively common, Hyperglycemia is a very serious, relatively common, problem Tproblem TExcessive infusion of aromatic amino acids, glucose, Excessive infusion of aromatic amino acids, glucose, and lipids may lead to the development of liver and lipids may lead to the development of liver toxicity (cholestasis). Ttoxicity (cholestasis). TExcess glucose infusion leads to excess O2 Excess glucose infusion leads to excess O2 consumption, while with lipid infusion, the lipid consumption, while with lipid infusion, the lipid particles may accumulate in the lungs and reduce particles may accumulate in the lungs and reduce the diffusion capacity of respiratory gases. Fthe diffusion capacity of respiratory gases. F

بسم اللهِ الرَّحْمَنِ الرَّحِيمِ

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