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Tpn by dr. aakif

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Total parentral nutrition
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Tpn by dr. aakif

  1. 1. BY THE NAME OF ALLAH THE MOST BENEFICENT AND THE MOST MERCIFUL
  2. 2. Definition: Total parenteral nutrition ("TPN"), means the administration of complete and balanced nutrition by intravenous infusion in order to support anabolism, body weight maintenance or gain, and nitrogen balance, when oral or enteral nutrition are not feasible or are inadequate. Also referred to as Intravenous nutrition, parenteral alimentation, and artificial nutrition.
  3. 3. Indications for TPN Short-term use • Bowel disease (e.g. obstructions, fistulas > 1500ml/day). • Nutritional preparation prior to surgery. • Severe pancreatitis. • Malnourished Patient—Inadequate intake for > 7 days. • Unintentional weight loss > 10% or weight is > 20% below ideal body weight. • Inability to use GI tract—For greater than 7 days. • Major trauma or burns. • Long-term use (HOME PN) • Prolonged Intestinal Failure(e.g mesenteric infarction) • Crohn’s Disease • Bowel resection(short gut )
  4. 4. Energy: Glucose and Lipids Amino acids (Nitrogen) Water and electrolytes Vitamins Trace elements
  5. 5. Requirements Energy Energy requirement = BEE x activity factor x injury factor .  Basal energy expenditure(BEE) is calculated =25-30 kcal/ kg BW/day.(Harris Benedict formula) ACTIVITY FACTOR: •1.2 Confined to bed •1.3 Ambulatory INJURY FACTOR: •Uncomplicated patient1 •Postoperative state 1.1 •Fractures 1.2 •Sepsis 1.3 •Peritonitis 1.4 •Multiple trauma 1.5 •Multiple trauma and Sepsis 1.6 •Burns 30 - 50% 1.7 •Burns 50 - 70% 1.8 •Burns 79 - 90% 2
  6. 6. Requirements  Glucose(50-60 % of total energy)
  7. 7. Requirements  Glucose • 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 acc. to blood sugar levels. Route • Glucose in 5 – 15 % solution can be administered via a peripheral vein, but higher concentrations require a central venous line.
  8. 8. Requirements  Lipids(30-40 %)
  9. 9. Requirements  Energy Sources: Lipid • Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted patients. • They are available in 10, 20 and 30% preparations. • Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is 10Kcal/g due to the contents of glycerol and phospholipids.
  10. 10. Requirements: Protein : Protein is the functional and structural component of the body, so fulfilling patient’s caloric needs with non- protein calories (fat and glucose) is essential. Protein requirements for most healthy individuals are 0.8 g/kg/day. But it varies in different conditions.
  11. 11. Requirements Protein: Daily Protein requirements Condition Example requirement Basic requirements Normal person 0.5-1g/Kg Slightly increased requirements Post-operative, cancer, 1.5g/Kg inflammatory Moderately increased Sepsis, polytrauma 2g/Kg requirements Highly increased requirements Peritonitis, burns, 2.5g/Kg Reduced requirements Renal failure, hepatic 0.6g/Kg encephalopathy •Parenteral amino acid solutions provide all known essential amino acids. •Available A.A preparations are 3.5 - 15 % (ie contains 3.5-15 gms of protein or A.As/100 mL solution).
  12. 12. Requirements Protein: •Special a.a. solutions are also available containing higher levels of certain a.a.s, most commonly the branched-chain ones (valine, leucine and isoleucine), aimed at the management of liver diseases, sepsis and other stress conditions. •Conversely, solutions containing fewer a.a.s (primarily the essential ones) are available for patients with renal failure.
  13. 13. Requirements Fluids and electrolytes: Nutrient Requirements (/Kg/day) Water 20-40 mL Sodium 0.5-1.0 mmol Potassium 0.5-1.0 mmol Magnesium 0.1-0.2 mmol Calcium 0.05-0.15mmol Phosphate 0.2-0.5mmol Chloride/Acetate So as to maintain acid-base balance (normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)
  14. 14. Requirements Vitamins Vitamins are either fat soluble (A,D,E,K) or water soluble (B,C). Separate multivitamin commercial preparations are now available for both. Most adult vitamin formulae do not contain vitamin K, which is added according to the patient’s coagulation status.
  15. 15. Requirements Trace minerals These are essential component of the parenteral nutrition regimen. A multi-element solution is available commercially, and can be supplemented with individual minerals. May be toxic at high doses. Iron is excluded, as it alters stability of other ingredients. So it is given by separate injection (iv or im).
  16. 16. Requirements Trace minerals Mineral Recommended dietary Suggested daily allowance (RDA) for daily intravenous intake oral intake (mg) (mg) Zinc 15 2.5-5 Copper 2-3 0.5-1.5 Manganese 2.5-5 0.15-0.8 Chromium 0.05-0.2 0.01-0.015 Iron 10 (males)-18 (females) 3
  17. 17. Osmolarity PPN: Maximum of 1000 mosmoles / liter. TPN: as nutrient dense as necessary (1000 - 3000) mosmoles/liter.
  18. 18. • Total calories required = BEE x activity factor x injury factor x weight = 25 x 1.2 x 1.2 x 40 = 1440 kcal/day • Glucose(50-60 %): Out of 100 kcal glucose should give = 60 kcal 1440 ------------------------------- = 60/100x1440 = 864 kcal 1ml 25% glucose = 1kcal 864 ml/day of 25% glucose Lipids(25-40%): out of 100 kcal lipids should give = 40 kcal 1440 kcal --------------------- = 40/100x1440 = 576 1ml 20% lipid sol = 2kcal ml of 20% lipid required = 576/2 = 288 ml Protein: 1.5g per kg per day 1.5x40 = 60 g/day 5g A.A is contained in = 100ml 5% sol. 1g------------------------- = 100/5 60g----------------------- = 100/5x60 = 1200 ml/ day
  19. 19. Application The Solution Single bottle + Systems “All-in-one” mixtures 2- or 3-chamber bags +
  20. 20. Location Subclavian Veins Internal Jugular Veins Femoral Veins Brachial Veins Types Non-tunneled Tunneled Cordis Hickman Swan Ganz Broviac Double Lumen Portacath Triple Lumen PICC
  21. 21. Application 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.
  22. 22. First week Later Energy balance weight Daily Daily Metabolic variables Blood measurements Serum electrolytes Daily 1-2 /week RFTs 3 / week 2/week Glucose Daily (initially 6hrly until stabilized) 3/week Hemoglobin Weekly Weekly LFT’s(including PT, Weekly Weekly APTT) Serum total protein 2/week Weekly Serum triglycerides weekly weekly Serum Ca+2 & PO4 3/week 2/week Serum Magnesium 2/week weekly Selenium, Zinc, Monthly Copper
  23. 23. First week Later Urine measurements Glucose daily Specific gravity and osmolarity Daily Daily General measurements Input & output Daily Daily Prevention and detection of infection Clinical observation (activity, Daily Daily temperature, symptoms ) TLC & DLC As indicated As indicated Cultures As indicated As indicated
  24. 24. Complications of TPN About 5 to 10% of patients have complications related to central venous access. Catheter-related sepsis occurs in about ≥ 50% of patients. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients. *(The Merck Manual)
  25. 25. Catheter related: Problem of insertion Problem of care • Failure to cannulate. . Sepsis • Pneumothorax. . Infective endocarditis • Haemothorax. . Air embolism • Arterial puncture. . Line/cardiac thrombosis • Brachial plexus injury. . Catheter migration/ • Mediastinal hematoma. embolism • Thoracic duct injury. •
  26. 26. Feeding regimen related:
  27. 27. Complications of TPN Catheter sepsis Prevent by : 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. Detect by : Fever, chills, ±drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip). Treat by : 1- exclusion of other causes of fever 2- short course of anti-bacterial and antifungal therapy (acc. to C&S) 3- Catheter removal may be required
  28. 28. Complications of TPN  Metabolic Complications o Hyperglycemia :Associated with the infusion of excess glucose in the feeding solution or the diabetic-like state in the patient associated with many critical illnesses. Management: decrease the amount of infused glucose (to<4 mg/kg/min) OR insulin can be administered (either S.C. inj. or incorporation in the infusion bag).
  29. 29. Complications of TPN Metabolic Complications Hypertriglyceridemia Associated with excess infusion of fat emulsion. • Can cause pulmonary insufficiency.
  30. 30. Complications of TPN  Metabolic Complications o Hepatic complications (also known as parenteral nutrition cholestasis): It causes severe cholestatic jaundice, elevation of transaminases, and may lead to irreversible liver damage and cirrhosis. Multiple causes have been proposed, including high infusion rates of aromatic amino acids, high proportion of energy intake from glucose, e.t.c.. There is no specific treatment, other than anticholestatic therapy.
  31. 31. HOME PARENTERAL NUTRITION Patients who are unable to eat and absorb adequate nutrients for maintenance over the long term may be candidates for home parenteral nutrition e.g. extensive Crohn's disease, mesenteric infarction, or severe abdominal trauma. patients must be able to master the techniques associated with this support system, be motivated, and have adequate social support at home.
  32. 32. ‫” وقل عس ى أن يهادينل ي ربل ي ألقر ادَ من هذا رشادا“‬ ‫ادَ ْلُ ه ْ ادَ ادَ ادَ ه ْ ادَ ه ْ نِ ادَ نِ ادَ يِّ ادَ ه ْ ادَب نِ ه ْ ادَ ادَ ادَ ادَ ”ً‬ ‫‪And say it may be that my Lord guide me to the nearest of the rational‬‬

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