47.parenteral nutrition
TRANSCRIPT
Parenteral Nutrition
Dr Mohd Nikman AhmadAnaesthesia & Intensive Care
USM
If the gut is functioning,
use it!
Parenteral Nutrition
1. Indications & contraindication2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
Parenteral Nutrition1. Indications2. Routes of
administration3. Nutritional
requirements4. Different disease
state5. Monitoring6. Complications
1. WAIT !! Well Nourished
after 7-10 days, EN not feasible / target
goal calories not met
2. ASAP !! (EN is not feasible)
- Malnourished +major upper
abdominal surgery(5-7 day preoperatively)
- Protein calorie malnutriotion
(after adequate resus)
EN = enteral nutrition
ASAP = as soon as possible
Parenteral Nutrition1. Indications2. Routes of
administration3. Nutritional
requirements4. Different disease
state5. Monitoring6. Complications
1Inadequate intake
2Impossible to eat
3Undesirable to eat
Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat
Poor absorption
-severe nausea & vomiting
-diarrhoea-malabsorption
-short bowel syndrome
- Inflammatory bowel disease
Refusal to eat
-Anorexia nervosa
-Pain-Depression
-Fear
Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat Bowel obstruction
-CA of the GIT-Acute intestinal
obstruction -Adhesion
Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat
Others
-severe burn-severe trauma
-hypercatabolic state-Impaired motor
function
To rest the bowel
-peritonitis-pancreatitis-post surgery
-enterocutaneous fistula
Contraindications:
1. Unstable patients2. Shock3. Serum lactate > 3 mmol/L4. PaO2 < 50 mmHg5. PaCO2 > 75 mmHg
Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
Routes of administration
Central route
- Short term < 2 weeks- Caloric < 2000 kcal/day- 800-900 mosmol/L- Dextrose < 10%- Amino acid < 7% thrombophlebitis
Peripheral routeLarge bore
peripheral line
Routes of administrationPeripheral route
- Suitable for hypertonic & hyperosmolar solution- Long term therapy - high caloric (>2000 kcal/day) Catheter sepsis
Central routeCVP
Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
Total Calorie Need = BEE X Activity Factor X Injury Factor
1.2 confined to bed1.3 out of bed 1.3 non stressed
1.4 minimally stressed: IBD,Ca, elective surgery, moderate skeletal trauma1.5 moderately stressed: ortho surgery, sepsis, burn, major skeletal trauma1.6 severely stressed: multiple trauma, sepsis, multisystem surgery1.7 extremely stressed: severe head injury, ARDS, burn, sepsis2.1 Major burn
Harris Benedict Equation♂ BEE = 66 + (13.7 x W) + (5 x H)) – (6.8 x A)♀ BEE = 655 + (9.6 x W) + (1.8 x H) – (4.7 x A)
W = weight in Kg, H = height in cm, A = age in yearsBEE increases by 13% per 1oC in temperature
Main Ingredient Critically Ill patients Stable patient
Energy (total calories) 25-30 kcl/kg/day 30-40 kcl/kg/day
Fluid Minimum needed to deliver adequate macronutrient
40-40 ml/kg/day
Carbohydrate e.g Dextrose
< 4 g/kg/min1g = 4 kcl @ 16 kJ
< 7 g/kg/min
Fate.g Intralipid, Lipofundin
1 g/kg/day1g = 9 kcal @ 37.6 kJ
1 g/kg/day
Proteine.g Vamin, Aminoplasma
1.2-1.5 g/kg/day1g = 4 kcl @ 16 kJ
1g nitrogen = 6.25g protein
0.8-1.0 g/kg/day
Nutritional Requirements
Energy
CH2OFat
Amino Acid
30-40% 60-70%
NPC (Kcal) : N (g) ratio(CH2O&Fat) : N
80-200 : 1
70 x 25 Kcal/Kg/day = 1750 Kcal
70 x 1 g/Kg/day = 70 g x 4 kcal = 280 Kcal70g/6.25 = 11.2g Nitrogen
1470 Kcal
40% of 1470 = 580 KcalIn g, 580/9 = 64.5g
± 1g/Kg/day
60% of 1470 = 882 KcalIn g, 882/4 = 220.5g
± 3 g/Kg/day
NPC (Kcal) : N (g) 1470:11.2 = 131:1 ratio
70 kg
Carbohydrate
Glucose Fructose
•CH20 of choice•Physiological substrate of all tissue esp: brain•Prerequisite for protein anabolism
•Insulin independent•less irritant•rapidly metabolised•better nitrogen sparing effect•Causes lactic acidosis esp in paediatric
COMPLICATIONS
•Causes hyper/hypo glycaemia
• Increases CO2 production
Fat & ProteinFat Protein
•cell wall integrity, prostaglandin synthesis & function of lipid soluble vitamin•Deficiency leads to dermatitis, fatty liver & reduced immune function
•Essential:Is Leu Met Pheny, Try His Threo Val Ly•Non Essential: GAGAP AS CT•Respiration & transport, enzymes, hormones & antibodies, support & movement
GAGAP AS CTGlycine Alanine Glutamate Proline Aspartate Serine Cystine Tyrosine
Is Leu Met Pheny, Try His Threo Val Ly
Isoleucine Leucine Methionine Phenylalanine Tyrptophan Histidine
Valine Lysine
Nutritional requirements
Energy
CH2OFat
VitaminsElectrolyte
Amino AcidTrac
e Elem
ents
Fluid
Electrolyte Electrolyte mmol/kg/day
Chloride 1.3-2.0
Sodium 1-2
Potassium 0.7-1.5
Phosphate 0.5-0.7
Calcium 0.1-0.15
Magnesium 0.05-0.15
•Calcium & phosphate may precipitate
•Hypophosphataemia occurs in malnourished and trauma patient leading to serious cardiorespiratory
squeal
•Diuresis causes hypomagnesaemia
Vitamins• Essential in the metabolism of carbohydrate, protein & fat• Decompose by light & heat• Short shelf life (within 24 Hrs)
Water soluble vitaminsB1,B2,B6,B12,C, Biotin,
folic acid,glycine
Fat soluble vitaminsADEK
e.g Soluvit NTM, ParentrovitTM
•Deficiencies leads to pancytopeneia (↓folic acid), encephalopaty (↓thiamine),
e.g. VitralipidTM
•Deficiencies leads to coagulopathy (↓Vit K),•Excess Vit A & D leads to exfoliative dermatitis & hypercalcaemia
Trace Elements• Needed only when starved for > 2 weeks• Short term PN therapy vary unlikely to
cause deficiency• Zinc is important if patient has significant
GIT fistula loses• e.g. PeditraceTM AddamelTM
Trace ElementsElement Deficiency State
Zinc •Skin lesions•Anorexia•Impaired immune function•Diarrhoea•Depressed mental function•Poor wound healing
Copper •Neutropenia•Normocytic, hypochromic anaemia
Chromium •Glucose intolerance•Weight loss•Peripheral neuropathy
Manganese •Hypercholesterolaemia•Weight loss
Selenium •Muscle pain & weakness•Cardiomayopathy
Ferum •Anaemia
Immuno modulation
Contains enrich “functional” substrate
• Glutamine• Omega 3 fatty acid• Arginine• Anti-oxidant; Vit E &
ascorbic acid
Benefit in• Major elective surgery• Trauma• Burns• Head& neck Ca• Ventilated critically ill
patients
Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
1.Renal failure2.Liver failure3.Pancreatitis 4.Obesity
Renal Failure - Maximum concentration of nutrient in minimum
volume- Caution with potassium, magnesium & phosphate
administration - Normal daily protein intake & increased to 2.5
g/kg/day in patient on CVVHD- 7.5-10% amino acid solution, higher proportion of
essential AA, tyrosine
Liver failure• Difficult to assess nutritional status because of
ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia
• Should not restrict protein• 5-8% amino acid solution• Higher portion of branched chain amino acid, low
concentration of aromatic amino acid• Branched chain amino acid formulations (BCAA)
should be reserved for the rare encephalopathic patient together with antibiotic & lactulose
Pancreatitis• Enteral feeding is not contraindicated• Change intact protein to small peptides• Change long-chain fatty acids to medium-chain
triglycerides or a nearly fat-free elemental formulation
Obesity
BMI Energy Protein< 30 •60-70%
•11-14 Kcal/kg/Actual BW•22-25 Kcal/kg/Ideal BW
1.2-2.0g/kg/Actual BW
30-40 Same as above 2.0-2.5g/kg/Actual BW
>40 Same as above 2.5g/kg/Actual BW
BW = body weight
Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
Monitoring AIMS 1.Assessment of input vs output
2.Maitenance of metabolic balance3.Detection of deficiency state4.Detaction of toxic accumulation
1. Blood glucose Frequently if unstableDaily once stable
2. BUSE, FBC, Temperature & input output balance
Daily
3. LFT, Ca2+ , PO4-, Mg2+ & Body weight
Weekly
4. ABG & serum lipid As indicated
Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications
Complications
1. Catheter related2. Metabolic complications
1.Catheter related sepsis (3-5%)2.Catheter leaks or clots3.Insertion problems4.Air embolism
Complications
1. Catheter related2. Metabolic complications
1.Glucose imbalance2.Electrolyte imbalance3.Essential Fatty Acid deficiency syndrome4.Fluid Overload5.Refeeding syndrome6.Allergic reaction
Refeeding syndrome• Common in alcoholism,anorexia
nervosa, marasmus, rapid refeeding & excessive dextrose infusion
• Signs: haemolytic anaemia, respiratory distress, paresthesia, tetany, cardiac arrhytmias, low phosphate, mg & K