Parenteral Nutrition

Present Wafaa O. Cafege by

BS, BCPS

IV/PN Supervisor Children's Pharmacy KFMC

OBJECTIVES Introduction  Situation in which PN is commonly used  Initiation of PN  Administration of PN  Monitoring and management of PN  Complications of PN 

Introduction PN refers to combination of nutrients –crystalline amino acids  Dextrose  fat emulsions  Electrolytes  Vitamins and minerals 

PN admixture are two types:  Mixture of dextrose, amino acids, vitamins, minerals are referred to as 2-in-1 I.V fat infused separately  Total nutrition admixture (TNAs),  3-in-1 contain IVFE in the same container.  PN administered via a peripheral line PPN or central line PN. 

Situation in which PN is commonly used 

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GI tract is not functioning or can’t be accessed Nutrition needs cannot be met with oral diet or enteral tube feeding The anticipated duration of PN is at least 7 days

Initiation of PN Due to nutrition’s direct impact on health and disease nutritional goals should be set clearly: 1. Prevention of nutrient deficiency 2. Prevention of chronic disease 3. Nutrition support for therapeutic aim.

Initiation of PN 

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Patient who are hemodynamically stable, able to tolerate the fluid volume necessary to provide macronutrients. Who have central vascular access PPN is commonly used in neonatal and pediatrics

Nutrition Screening 

Hospitalized patients are at risk (up to 65%) of developing malnutrition

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Malnutrition and malabsorption of macro and/or micronutrients contribute to many disease outcomes 

malnutrition: cancer, acute and chronic infections

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Malabsorption: gastrointestinal disease

A.S.P.I.N ‘05

Pediatric nutritional goals Maintain the rate of growth and reverse weight loss  Maintain positive nitrogen balance  Children can lose as much as one third of there body mass in 3-5 days after caloric stores are depleted 

Pediatric PN Age

Kcal/Kg

Protein g/Kg

< 6 mos

85 – 105

3–4

6 – 12 mos

80 – 100

2–3

> 1 – 7 yrs

75 – 90

1–2

> 12 – 18

30 – 50

0.8 – 1.5

Carbohydrates in PN   

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Carbohydrate is provided as dextrose With 3.4 Kcal/Kg Dextrose is the major contributor to the osmolarity of the PN formulation Glucose without fat increases water retention, worsen existing respiratory compromise Glucose alone may exacerbate fatty infiltration of the liver

Lipids in PN    

Lipids are provided as IV fat emulsions 10 Kcal/g Dose 1 -3 g/Kg/day Serum triglycerides should be monitored (DC lipids only when triglyceride > 4.5 mmol/L)

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20 % IVF promote optimal metabolic tolerance

Monitoring and management  PPN  Central

PN  Osmolarity

PPN  

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The maximum osmolatrity for PPN is 900 mOsn/L (1100 in Neonatal) Infusion of PPN needs careful monitoring of the venous access site phlebitis and/or infiltration A 0.22-micron filter should be used for 2– in-1 formulations The indication of PPN is short term need of PN

CENTRAL PN 

Proper CVC tip placement must be confirmed prior to initial PN administration

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Because its hypertonic, central PN is administrated via a CVC with distal tip placed in the superior vena cava adjacent to the right atrium

Administration PN 

PN is to administered via an infusion pump having adequate protection from “free flow” and reliable audible alarms

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PN infusion should be completed within 24 hrs of initiation

Monitoring and management 

monitoring fluid electrolyte and acid/base balance (acetate as NA, K to correct metabolic acidosis)

All patients receiving PN should be monitored for proper glucose control  Adjustments of the PN formula may be necessary as oral intake begins or improves 

Complications of PPN  

The centers of disease control CDC recommended the following: Replace the venous catheter at least every 72 hrs in adult however in pediatrics the risk of phlebitis is not increased. So it should be left alone until the complete of the I.V therapy .

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The peripheral venous access catheter should be removed as soon as thrombophlebitis develops or an infiltration is noted

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Use a transparent, semi-permeable polyurethane dressing or a gauze dressing to cover the peripheral access site Hydrocortisone and heparin may be added to PN to decrease phlebitis

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JCAHO. 2005 National Patient Safety Goals FAQs. www.jcaho.org/ accredited+organizations/patient+safety/05_npsg.html Accessed December 8, 2004

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Catheter occlusion: the inability to infuse a solution and/or aspirate a blood sample 

Subclavian vein thrombosis: can occlude a catheter and manifest clinical symptoms of vascular obstruction 

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Treatment: catheter removal; elevation of the affected arm, catheter-directed thrombolytic agent infusion

Thrombotic occlusion : intraluminal clotting as a result of inadequate flushing or blood reflux 

Treat by instilling a Thrombolytic agent directly into catheter

JCAHO. 2005 National Patient Safety Goals FAQs. www.jcaho.org/ accredited+organizations/patient+safety/05_npsg.html Accessed December 8, 2004

Infectious complications 

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75% catheter related infections occur in pediatric receiving Proper hand hygiene must be observed Aseptic technique must be observed for the insertion and care of the intravascular catheter All catheter injection ports should be cleansed with 70% alcohol before the system is accessed Antibiotic lock solutions should not be routinely used

JCAHO. 2005 National Patient Safety Goals FAQs. www.jcaho.org/ accredited+organizations/patient+safety/05_npsg.html Accessed December 8, 2004

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Thank you Patient care comes !! first