1. 1 بسم الله الرحمن الرحيم

2. 2 Parenteral nutrition in ICU patients Dr Mohammad Safarian

3. 3 Who need nutritional support? Malnourished: one or more of the following: Malnourished: one or more of the following: –BMI < 18.5 kg/m² – weight loss > 10% within the last 3-6 months –BMI of 5% within the last 3-6 months

4. 4 Who need nutritional support? At risk of malnutrition: one or more of the following: At risk of malnutrition: one or more of the following: – NPO for > 5 days and/or likely to be NPO for the next 5 days or longer. – poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs

5. 5 Consider oral nutrition support and stop when the patient is established on adequate oral intake from normal food if patient malnourished/at risk of malnutrition can swallow safely and gastrointestinal tract is working

6. 6 Consider enteral tube feeding and use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food has a functional and accessible gastrointestinal tract if patient malnourished/at risk of malnutrition despite the use of oral interventions

7. 7 Consider parenteral nutrition use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food or enteral tube feeding and has either introduce progressively and monitor closely if patient malnourished/at risk of malnutrition a non-functional, inaccessible or perforated gastrointestinal tract inadequate or unsafe oral or enteral nutritional intake

8. 8 Do not consider EN GI obstruction with no access to GI after obstruction. GI obstruction with no access to GI after obstruction. Ileus Ileus High-output enteric fistula (>500ml/d) High-output enteric fistula (>500ml/d) Sever vomiting or diarrhea Sever vomiting or diarrhea Acute pancreatitis. Acute pancreatitis. Refusal of patient or legal guardian. Refusal of patient or legal guardian.

9. Parenteral Nutrition: Indications Parenteral Nutrition: Indications Severe malnutrition and prolonged NPO status (>5 days). Severe malnutrition and prolonged NPO status (>5 days). Significant catabolism and prolonged NPO status Significant catabolism and prolonged NPO status Bowel obstruction/ileus Bowel obstruction/ileus Chronic vomiting/diarrhea Chronic vomiting/diarrhea Use of GI tract contraindicated Use of GI tract contraindicated Malabsorption Malabsorption Bowel rest (severe pancreatitis) Bowel rest (severe pancreatitis) Initially in short bowel syndrome Initially in short bowel syndrome

10. Parenteral Nutrition: Contraindications Functioning GI tract Functioning GI tract No safe venous access No safe venous access Hemodynamically unstable Hemodynamically unstable Patient not desiring aggressive support Patient not desiring aggressive support

11. Total Parenteral Nutrition Goal In TPN Formulation “Provide all a patient’s required nutrients in a fluid volume that is well tolerated.”

12. Total Parenteral Nutrition Normal DietTPN Protein………………..Amino Acids Carbohydrates………..Dextrose Fat……………………Lipid Emulsion Vitamins……………...Multivitamin Infusion Minerals……………...Electrolytes and Trace Elements

13. Solutions: CHO = Dextrose Supplied as dextrose: 10% to 35% Supplied as dextrose: 10% to 35% –10%= 100 gm/L, 25% = 250 gm/L Dextrose provides 3.4 Kcal/gm Dextrose provides 3.4 Kcal/gm –1 liter of 10% soln = (100gm x 3.4Kcal/gm) = 340 Kcal = 340 Kcal PPN – Peripheral Parenteral Nutrition is put into peripheral vein. So, more than D10 cannot be used. PPN – Peripheral Parenteral Nutrition is put into peripheral vein. So, more than D10 cannot be used.

14. Solutions: Protein Supplied as Amino acids – essential & nonessential: Supplied as Amino acids – essential & nonessential: Choices: Choices: –5, 10% solutions –5% = 50 gm/L Protein provides 4 Kcal/gm. Protein provides 4 Kcal/gm.

15. Parenteral Nutrition Solutions: Lipids  Supplied as aqueous suspension of soybean or safflower oil with egg yolk phospholipids as the emulsifier.  Glycerol is added to suspension.  2 levels of emulsions:  10% solution: 1.1 kcal/mL  20% solution: 2.0 kcal/mL  Lipid emulsion, when given alone, should be completely infused within 12 hours of hanging of emulsion.

16. Parenteral Nutrition Solutions Guidelines for amounts of each to provide: Guidelines for amounts of each to provide: CHO: 50-65% of kcal CHO: 50-65% of kcal Lipids: ~30% of kcal Lipids: ~30% of kcal Protein: 15 - 20% of kcal Protein: 15 - 20% of kcal Fluid: 1.5 - 2.5 liters Fluid: 1.5 - 2.5 liters Kcal: N ration: 125 kcal:1 gm N Kcal: N ration: 125 kcal:1 gm N

17. Parenteral Nutrition Solutions  Prepared aseptically & delivered in 2 ways:  “3 in 1” solution: protein, fat and CHO in one bag and 1 pump is used to infuse solution.  “3 in 2” solutions: 2 bag method: protein & CHO in 1 bag & lipid solution in glass bottle; each is hooked up to pump; solutions enter vein together.  Given continuously or cyclically (8-12 hrs/day).  Insulin may be added to solution.

18. Rate of infusion Glucose: Glucose:  Start slowly to a target rate of 5mg/kg/min: check blood sugar every 6 hrs. adjust the rate to keep blood sugar below 150mg/dl, or add insulin infusion. Amino acids: Amino acids:  Start at a lower dose and rate and increase gradually to desired goal. Lipids: Lipids:  Start slowly to a target rate of 0.05g/kg/hr.Do not exceed the max. rate of 0.11g/kg/hr. adjust the dose and rate by checking plasma triglyceride levels.

19. Care of catheter The catheter should be inserted under all aseptic precautions. The catheter should be inserted under all aseptic precautions. Always obtain a chest X-ray to confirm the position of the catheter before starting PN. Always obtain a chest X-ray to confirm the position of the catheter before starting PN. The catheter should be inspected daily and clean with alcohol based solution. The catheter should be inspected daily and clean with alcohol based solution. Avoid drawing blood from TPN line. Avoid drawing blood from TPN line. Avoid infusing medications through TPN line. Avoid infusing medications through TPN line.

20. Monitoring 20

21. 21 Which type of complications? Which type of complications? Who may be at risk? Who may be at risk? Early detection and treatment? Early detection and treatment?

22. 22 Monitoring of PN therapy The main objectives: To ensure about safety, and early detection and treatment of complications To assess the extent to which nutritional objectives have been reached. To alter the type or components of the regimen, to improve its effectiveness and to prevent complications.

23. 23 General considerations Basic clinical observations (temperature, pulse, oedema) Observations of feeding technique and its possible complications Measures of nutritional intake. Weight changes Fluid balance charts (in hospital) Laboratory data Outcome factors (complications, improvements) Change in socio-psychological state which might influence nutritional therapy

24. 24 Monitoring in PN therapy Weight (on a daily basis,initialy and ) Weight (on a daily basis,initialy and ) Blood Daily Electrolytes (Na +, K +, Cl - ) Glucose Acid-base status 3 times/week BUN Ca +, P Plasma transaminases Blood Daily Electrolytes (Na +, K +, Cl - ) Glucose Acid-base status 3 times/week BUN Ca +, P Plasma transaminases

25. 25 Monitoring in PN therapy Variable to be monitoredInitialLater period Clinical status Daily Catetheter site Daily Temperature Daily Intake &Output Daily

26. 26 Monitoring in PN therapy Variable to be monitoredInitialLater period WeightDailyWeekly serum glucoseDaily3/wk Electrolytes (Na +, K +, Cl - )Daily1-2//wk BUN3/wkWeekly Ca +, P,mg3/wkWeekly Liver function Enzymes3/wkWeekly Serum triglycerides weekly CBC weekly

27. 27 Problems 1. Catheter sepsis 2. Placement problems 3. Metabolic complications 3. Metabolic complications

28. 28 Complications Dehydration Dehydration Possible cause: Possible cause: –Inadequate fluid support; –Unaccounted fluid loss (e.g. diarrhea, fistulae, persistent high fever). Management: Management: –Start second infusion of appropriate fluid, such as D5W, 1/2NS, NS. –Estimate fluid requirement and adjust PN accordingly.

29. 29 Complications Overhydration Overhydration Possible cause: Possible cause: –Excess fluid administration; –Compromised renal or cardiac function. Management: Management: –Consider 20% lipid as calorie source –Initiate diuretics. –Limit volume.

30. 30 Complications Alkalosis Alkalosis Possible cause: Possible cause: –Inadequate K to compensate for cellular uptake during glucose transport –Excessive GI or renal K losses. –Inadequate Cl- in patients undergoing gastric decompression. Management: Management: –KCl to PN. –Assure adequate hydration. –Discontinue acetate.

31. 31 Complications Acidosis Acidosis Possible cause: Possible cause: –Excessive renal or GI losses of base –Excessive Cl - in PN. Management: Management: –Rule out DKA and sepsis. –Add acetate to PN.

32. 32 Complications Hypercarbia Hypercarbia Possible cause: Possible cause: –Excessive calorie or carbohydrate load. Management: Management: –Decrease total calories or –CHO load.

33. 33 Complications Hypocalcemia Hypocalcemia Possible cause: Possible cause: –Excessive PO4 salts –Low serum albumin. –Inadequate Ca in PN. Management: Management: –Slowly increase calcium in PN prescription.

34. 34 Complications Hypercalcemia Hypercalcemia Possible cause: Possible cause: –Excessive Ca in PN –Administration of vitamin A in patients with renal failure. –Can lead to pancreatitis. Management: Management: –Decrease calcium in PN. –Ensure adequate hydration. –Limit vitamin supplements in patients with renal failure to vitamin C and B vitamins.

35. 35 Complications Hyperglycemia Hyperglycemia Possible cause: Possible cause: –Stress response. Occurs approximately 25% of cases. Management: –Rule out infection. –Decrease carbohydrate in PN. –Provide adequate insulin.

36. 36 Complications Hypoglycemia Hypoglycemia Possible cause: Possible cause: –Sudden withdrawal of concentrated glucose. –More common in children. Management: Management: –Taper PN. Start D10.

37. 37 Complications Cholestasis Cholestasis Possible cause: Possible cause: –Lack of GI stimulation. –Sludge present in 50% of patients on PN for 4-6 weeks; –resolves with resumption of enteral feeding. Management: Management: –Promote enteral feeding.

38. 38 Complications Hepatic tissue damage and fat infiltration Hepatic tissue damage and fat infiltration Possible cause: Possible cause: –Unclear etiology. –May be related to excessive glucose or energy administration; –L-carnitine deficiency. Management: Management: –Rule out all other causes of liver failure. –Increase fat intake relative to CHO. –Enteral feeding.

39. 39 Refeeding Syndrome What is it? What is it? Severe fluid and electrolyte shifts and related metabolic disturbances found in malnourished patients being re-fed. Severe fluid and electrolyte shifts and related metabolic disturbances found in malnourished patients being re-fed.

40. 40 Refeeding Syndrome Who is at risk? Who is at risk? - Chronic alcoholics - Chronic malnutrition - Anorexia nervosa - Patients unfed for 7-10 days with evidence of stress/depletion - Oncology/haematology patients - Morbid obesity (weight loss >10% over the previous 3 months

41. 41 Refeeding Syndrome Consequences Consequences - Hypophosphataemia - Hypokalaemia - Hypomagnesaemia - Altered glucose metabolism - Altered fluid status - Vitamin deficiency

42. 42 High risk of refeeding problems Consider: Consider: Increasing levels slowly Increasing levels slowly Restoring circulatory volume and monitoring fluid balance and clinical status Restoring circulatory volume and monitoring fluid balance and clinical status Providing a multivitamin/trace element supplement Providing a multivitamin/trace element supplement Providing extra potassium, phosphate and magnesium Providing extra potassium, phosphate and magnesium

43. 43 Transition from PN to EN Schedule PN ml/hr EN ml/hr Day1100% Day 2 Decrease by 10-20 20-30 Day3 30-40 Day 4 Decrease by 10-20 40-50 Day5 Stop PN Increase 10ml/hr every 24 hr

44. 44 Thank you