1. Parenteral Nutrition (PN)

2. Approach to specialize Nutritional Support
Nutritional Assessment
Maintenance
Repletion
GI Tract Functional
YES NO
Enteral Nutrition
Parenteral Nutrition

3. Definition nutrients directly into bloodstream intravenously.
Parenteral nutrition is provision of
nutrients directly into bloodstream
intravenously.

4. PN Indications

5. Indications Inadequate enteral nutrition > 7-10 d
Unavailable GIT, bowel rest:
Intestinal obstruction
Fistulas
Hyper emesis/intractable vomiting
Ileus
Sepsis
Inflammatory bowel disease
Short bowel syndrome
Hepatic disease
Pancreatitis

6. Indications (cont) Acquired immune deficiency syndrome (AIDS)
Respiratory failure
Eating disorders
severe malnutrition/ preoperative nutrition
rehabilitation

7. PN Contraindications

8. Contraindications Functional GIT Nutrition support < 7 d
Risks PN>benefits

9. Contraindications (cont)
Aggressive nutrition support contraindicated
- not desired by patient
- terminal illness, prognosis poor

10. Type of PN

11. Two main forms of PN Peripheral Parenteral Nutrition (PPN)
Central Parenteral Nutrition (CPN)

12. Another Classification of PN
Partially parenteral nutrition (PPN)
Total parenteral noutrition (TPN)

13. Peripheral Parenteral Nutrition (PPN)

14. PPN
Given through peripheral vein

15. PPN (cont 1) Short term use (14> day) Mildly stressed patients
Low caloric requirements
Needs large amounts of fluid

16. PPN (cont 2) Addition of heparin & hydrocortisone improve
tolerance to PPN
Osmolarity of PPN solution be limited to 900
mosm/l

17. Central Parenteral Nutrition (CPN)

18. CPN Long term use (>14 day) High caloric requirements
Solution with greater osmolarity (>900 mosmol/l)
may be administered via CPN

19. Venous Access for CPN
Need venous access to a “large” central line with fast flow to avoid thrombophlebitis
Long peripheral line
subclavian approach
internal jugular approach
external jugular approach
Superior Vena Cava

20. Type of central venous access in CPN

21. Type of central venous access
Tunneled Catheter (TC):
Placed in operating room
Enter the vein on the upper chest wall & are
tunneled away from the vein to an exit site
With proper care can be left for several years
TC available in single, double or triple lumen

22. TC

23. Type of central venous access (cont 1)
2) Implanted ports (IP)
Similar to TC in that must be placed in
operating room
Suitable for long term access
Unlike TC lie completely under skin
Be accepted well by patient

25. Type of central venous access (cont 2)
They are usually placed just below the
clavicle on the chest wall
Nursing intervention may be required to
change needles used to gain access to these
port

26. Type of central venous access (cont 3)
3) Short Term Access (STA):
Is provided via a central catheter inserted
percutaneously at bedside under local
anesthesia
These catheter available in single or multiple
lumen
Usually change every 5 days

29. Type of central venous access (cont 4)
4) Peripherally Inserted Central Catheter (PICC)
PICC is a thin, flexible tube inserted into a
vein near the bend of the elbow.
The PICC is used to get samples of your blood.
You can also get fluids, medicines and
nutrients through it.

30. PICC

31. PICC (2)

32. Comparison between CPN & PPN

33. Differences between PPN & CPN
Total amount delivered
Osmolarity
Duration
Speed of delivery
The total amount delivered is depend on the
concentration and osmolarity of the fluids infused.

34. Advantage & disadvantages of CPN/PPN
Disadv - central
++ Risk infection
Invasive
+ Nursing care time
More expensive
More complications
Needs more technical
expertise
Adv - central
Hypertonic solution
Meets nutrition
requirements
Long term use

35. Advantage & disadvantages of CPN/PPN (cont)
Adv - peripheral
Non-invasive
Peripheral vein – risk
infection
Disadv – peripheral
High volume of high
mOsm/L to meet need
short term use

36. Steps to ordering TPN

37. Steps to ordering TPN Determine Total Fluid Volume
Determine Non-N Caloric needs
Decide how much fat & carbohydrate to give
Determine Protein requirements
Determine vitamins, Electrolyte and Trace element requirements
Determine need for additives

38. How much volume to give? Cater for maintenance & on going losses
Normal maintenance requirements
By body weight
25-55 year 35 cc/kg
56-65 year 30 cc/kg
Add on going losses based on I/O chart
Consider insensible fluid losses also
add 13% for every oC rise in temperature

39. Based on Total Energy Expenditure
Caloric requirements
Based on Total Energy Expenditure
Can be estimated using predictive equations
TEE = BEE × Stress Factor × Activity Factor

40. Caloric requirements (cont1)
Stress Factor
Malnutrition
peritonitis
soft tissue trauma 1.15
fracture
fever (per oC rise) 1.13
Moderate infection
Severe infection
<20% BSA Burns
20-40% BSA Burns
>40% BSA Burns

41. Caloric requirements (cont2)
Activity Factor
Bedridden 1.2
Ambulant 1.3
Active 1.5

42. Caloric requirements (cont3)
BEE Predictive equation
1) Harris-Benedict Equation:
Males: BEE = (13.75×Wt) + (5×H) – (6.76×A)
Females: BEE = (9.56×Wt) + (1.85×H) – (4.68×A)
2) Schofield Equation:
25 to 30 kcal/kg/day

43. Caloric requirements (cont4)
Activity (Stress)
Weight
Low
Moderate
Severe
Decrease
15 kcal/kg
20 kcal/kg
25 kcal/kg
Maintenance
30 kcal/kg
Increase
35 kcal/kg

44. How much CHO? CHO usually form 50-75 % of calories
Commercial CHO consist anhydrous dextrose
monohydrate in sterile water
These are available in concentration
ranging 5% to 70% & contain 3.4 kcal/g of
dextrose
Not more than 5 mg / kg / min Dextrose
(less than 7 g / kg / day)

45. How much Fat? Fats usually form 25 to 30% of calories
Not more than 40 to 50%
Increase usually in severe stress
Aim for serum TG levels < 350 mg/dl s

46. How much Fat? (cont) Three concentration 10%, 20% & 30% are available
Lipid emulsion 10% have 1.1 kcal/ml, 20%
have 2 kcal/ml & 30% have 3 kcal/ml
Not more than 50 cc/hr Lipid
(less than 1 g / kg / day)

47. How much protein to give?
Based on non pro calorie / nitrogen ratio
Based on degree of stress & body weight (BW)
Based on Nitrogen Balance (NB)

48. Non pro calorie / Nitrogen Ratio
Normal ratio is
kcal : 1g Nitrogen
Critically ill patients
85 to 100 kcal : 1 g Nitrogen

49. Based on Stress & BW Non-stress patients 0.8 to 1 g / kg / day
Mild stress g / kg / day
Moderate stress g / kg / day
Severe stress to 2 g / kg / day

50. Nutritional Balance NB = N input - N output 1 g N= 6.25 g protein
N input = (protein in g / 6.25)
N output = 24h urinary urea nitrogen + non-urinary N losses
(estimated normal non-urinary Nitrogen losses about 3-4 g/d)

51. Electrolyte Requirements
Cater for maintenance + replacement needs
Na to meq/kg/d
K to meq/kg/d
Mg to meq/kg/d
Ca to meq/kg/d
PO to mmol/d

52. Trace Elements Requirements
Zn mg/day
Cr mg/day
Cu 0.3 to 0.5 mg/day
Mn 0.15 to 0.8 mg/day

53. Standard electrolytes solution
Na meq/L
K meq/L
Ca meq/L
Phos mmol/L
Cl meq/L
Acetate meq/L

54. Standard trace elements solution
MTE-6 per cc have:
Zn mg
Cu mg
Mn mg
Cr mcg
Se mcg
I mcg

55. PN Vitamins Give 1 ampoule MultiVit per bag of TPN
MultiVit does not include vit K
Vit K Can give 1 mg/day or mg/wk
most institutes have a standard vitamin/mineral solution but can also order special formulations based on biochemical assessment and special needs

56. Vitamins Requirements
Vitamin A IU
Vitamin D IU
Vitamin E IU
Ascorbic acid mg
Folacin µg
Niacin mg

57. Vitamins Requirements (cont 1)
Riboflavin mg
Thiamine mg
B6 ( pyridoxine) mg
B12( cyanocobalamin) µg
Pantothenic acid mg
Biotin µg

58. Standard vitamins solution
MVI-2 include 2 ampoule
Ampoule 1 per cc have:
Vit A IU
Vit E IU
Vit B mg
Vit B mg
Vit C mg
Vit D IU
Vit B mg

59. Standard vitamins solution (cont)
Vit B mg
Vit B mg
Ampoule 2 per cc have:
Vit B µg
Vit B µg
Vit B µg
Prescribed dose MVI-12: 10 CC/L

60. Medications can added to TPN
Insulin
alternate regimes
0.1 u per g dextrose in TPN
10 u per litre TPN initial dose
Heparin
often added to reduce complication of
catheter occlusion
Be added 1000 unit per lit

61. Medications can added to TPN (cont)
H2-blockers:
Famottidine: mg
Ranitidine hydrochloride
Cimitidine: 5g
Albumin
Aminophylline
Steroids

62. Parenteral Nutrition Solutions

63. Parenteral Nutrition Solutions
Every institute has its own standard
solutions for both peripheral and central
nutrition
amino acids (crystalline and variable amounts)
dextrose solutions (hydrous glucose)
combined amino acid dextrose solutions
lipid emulsions (10 and 20 % )
vitamin/mineral solutions
electrolytes (amount to add in mmol)

64. Parenteral Nutrition Solutions
Guidelines for amounts of each to provide:
Protein: % of kcal
Lipids: ~30% of kcal
CHO: 50-75% of kcal
Electrolytes, vitamins, trace elements: lower than DRI
Fluid: liters total
Kcal: N ration: 125 kcal:1 gm N

65. Parenteral Nutrition Solutions
Prepared aseptically & delivered 2 ways:
“3 in 1” method: pro, fat, CHO in one bag and 1
pump is used to infuse solution
“2 in 1” methodok: pro & CHO in 1 bag & lipid in
glass bottle; solutions enter vein together
Given continuously or cyclic (8-12 hrs/day)

66. Osmolarity of solution
Calculated by adding the osmolarity of
the solutions to be infused
Estimation:
Grams of dextrose × 5 ( per L)
Grams of AA × 10 ( per L)
electrolytes, vitamins, minerals add
mOsm/L
IV fat is isotonic

67. Example solution of 500 ml 50% dextrose and
500 ml 8.5% AA plus electrolytes, min
and vitamins has osmolarity of:
(50 × 5 × 5) + (8.5 × 5 × 10) + (300 to 400)
= 1975 to 2075 mOsm/L

68. Available solution sample

69. Available solution sample
DEXTROSE-SALINE
DEXTROSE
RINGER
AMINO PLASMA
ELECTROLITES

70. DEXTROSE-SALINE

71. DEXTROSE-SALINE (cont1)

72. DEXTROSE

73. DEXTROSE (cont1)

74. AMINO PLASMAL

75. AMINO PLASMAL (cont1)

76. LIPOFUNDIN

77. RINGER

78. RINGER (cont1)

79. ELECTROLITES

80. ELECTROLITES (cont1)

81. ELECTROLITES (cont2)

82. TPN Monitoring

83. TPN Monitoring Baseline Lab Investigations Complete blood count
Coagulation tests
Serums electrolytes
Ca++, Mg++, PO42-
TG, Hg, Hct
Other tests when indicated

84. Adjust TPN order accordingly
TPN Monitoring (cont1)
Clinical Review
Lab investigations
Adjust TPN order accordingly

85. TPN Monitoring (cont2) Clinical Review clinical examination
vital signs
fluid balance
catheter care
sepsis review
blood sugar profile
Body weight

86. TPN Monitoring (cont3) Lab investigations blood glucose, BUN, Cr
urinary glucose
Alb & Pre Alb
electrolytes, k, Na
Body weight
Alkaline phosphates,
Chol, TG, Transferrin, PT
chest x-ray, Ca, Mg
daily ,then 3 times weekly :weekly
daily
Weekly
daily, then 3 times weekly
Daily
weekly

87. TPN Monitoring (cont4) Lab investigations (cont) Weekly once stable
Seum phophorus
Serum selenium, amylase, lipase, bilirubin, serum ammonia, H&H, serum Fe, folacin, B12, AST, ALT, WBC, PCO2, PO2

88. Starting & stopping PN

89. What to do before starting PN
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations

90. Starting PN variable 50 ml/hr day 1(not meet all requirements day 1-2)
patient dependent
volume dependent
50 ml/hr day 1(not meet all requirements day 1-2)
75 ml/hr day 2
125 ml/hr day 3
 delivered in one system or piggy-back using y-joint

91. Stopping TPN Stop TPN when enteral feeding can restart
Wean slowly to avoid hypoglycemia
Give IV Dextrose 10% solution at previous infusion rate for at least 4 to 6h
Alternatively, wean TPN while introducing enteral feeding and stop when enteral intake meets TEE

92. Transitional Feeding Examples:
A process of moving from one type of feeding to another with multiple feeding methods used simultaneously
Examples:
parenteral feeding to enteral feeding
parenteral feeding to oral feeding
enteral feeding to oral feeding

93. Transitional Feeding parenteral to enteral
Introduce enteral feeding – 30 cc/hr while giving parenteral
If tolerated, gradually ↓ parenteral while increasing enteral
Once pt tolerate 75% of needs enterally, d/c parenteral
Process is called a stepwise decrease

94. Transitional Feeding parenteral to oral and enteral to oral
Use step-wise decrease method; wait until pt accepting 75% oral and then decrease parenteral or enteral method
But may need to:
Some children & adults may continue on
oral during the day and enteral at night

95. Complications of PN

96. Complications related to PN
Mechanical Complications
Metabolic Complications
Infectious Complications

97. Mechanical Complications
Related to vascular access technique
Pneumothorax
Air embolism
Arterial injury
Bleeding
Catheter misplacement
Catheter embolism
Thoracic duct injury

98. Mechanical Complications (cont)
Related to catheter
Venous thrombosis
Catheter occlusion

99. Metabolic Complications
Abnormalities related to excessive or
inadequate administration
Hyper / hypoglycemia
Electrolyte abnormalities
Acid-base disorders
Hyperlipidemia

100. Metabolic Complications (cont)
Hepatic complications
Biochemical abnormalities
too much calories (carbohydrate intake)
too much fat
Calculus cholecystis

101. Infectious Complications
Insertion site contamination
Catheter contamination
improper insertion technique
use of catheter for non-feeding purposes
contaminated TPN solution
contaminated tubing
Secondary contamination
septicemia

102. THE END