Total Parenteral Nutrition_2003.ppt

Group IV The Youngster Group!!!

Total Parenteral Nutrition  PARENTERAL – infusion of nutrient solutions into the

bloodstream.  ENTERAL – feeding via the gut: normal eating, infusion of formulas via a tube inserted into the upper GIT.  TPN - Is the practice of feeding a person intravenously, 

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bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins. Is provided when the GIT is nonfunctional Interruption in its continuity Absorptive capacity is impaired

ENTERAL VERSUS TPN ENTERAL  Maintains the digestive and

absorptive functions of the GIT  Sustains immnunologic barrier which the gut provides, preventing enteric organisms from invading the body.

PARENTERAL  Indicated to prevent the

adverse effects of malnutrition in patients who are unable to obtain adequate nutrients by oral and enteral routes.

ENTERAL VERSUS TPN ENTERAL  The nutrient and

immunologic functions of the gut are supported by luminal nutrients and by the normal gastrointestinal hormones, blood flow, and neural stimulation, all of which are activated by enteral feeding.

PARENTERAL  Other indications:

Short gut syndrome, prolonged ileus,or bowel obstruction  More costly  More hazardous

COMPLICATIONS: Infection ( bacterial, fungal) – indwelling central venous catheter Pneumothorax Accidental arterial puncture

ENTERAL VERSUS TPN ENTERAL  Oral intake  Anorexia, impairmant of

swallowing, distal bowel disease ( tube enteral feeding)

PARENTERAL Liver failure – related to fatty liver ( glucose excess in TPN solutions) Venous thrombosis and priapism (Fat infusion) Acute cholecystitis – complete unusage of GIT resulting in bile stasis in the gallbladder

ENTERAL VERSUS TPN ENTERAL

PARENTERAL  METABOLIC

Hypokalemia Hypophosphatemia Hypomagnesemia Hypoglycemia – abrupt cessation of TPN Hyperglycemia – start of therapy (insulin added to TPN); related to infection

Question 1: Is the disease process likely to cause nutritional impairment? YES Question 2: Is the patient malnourished or strongly at risk for malnutrition? YES Question 3: Would preventing or treating the malnutrition with SNS improve the prognosis and quality of life?

YES Question 4: What are the fluid energy, protein, and micronutrient requirements, and can these be provided enterally? YES Question 5: Can the requirement be met through oral foods and liquid supplements?

NO Question 5: Does the Patient require total parenteral nutrition?

YES Request central venous line (CVL)

NO Risks and discomfort of SNS outweight potential benefits. Explain issue to patient or legal surrogate. Support patient with general comfort measures including oral food and liquid supplements if desired.

NO Request permission to begin supplemental enteral feeding with parenteral nutrition via a peripheral vein, if tolerated of a CVL.

YES Request central venous line (CVL)

NO Request permission to begin supplemental enteral feeding with parenteral nutrition via a peripheral vein, if tolerated of a CVL.

Question 6: What type of CVL?

Likely duration several weeks

Subclavian catheter or PICC

Likely duration several months or years

Buried externalized CVL or subcutaneous infusion part

TPN INDICATIONS  Indicated for patients whose GIT is not functional.  Anticipation of undernutrition (<50% of

metabolic needs met) for > 7 days.  Given before and after treatment to severely

undernourished patient who cannot ingest large volumes of oral feedings and are being prepared for surgery, radiation therapy, or chemotherapy.

TPN INDICATIONS  Reduces morbidity and mortality after major surgery,

severe burns and head trauma, especially in patients with sepsis.  Disorders requiring complete bowel rest ( some stages

of Crohn’s disease, ulcerative colitis, severe pancreatitis), pediatric GI disorders ( congenital anomalies, prolonged diarrhea).

TPN INDICATIONS  Short – term TPN – used if a person’s digestive system

has shut down (peritonitis), and is at a low enough weight to cause concerns about nutrition during an extended hospital stay.  Long-term TPN – to treat people suffering the extended consequences of an accident or surgery or digestive disorder.

TPN NUTRITIONAL CONTENT FLUID REQUIREMENT- estimated by adding the normal daily requirement to any abnormal loss. - 30-40mL/kg/day (adult) - 120mL/kg/day(children) ENERGY REQUIREMENT - Unstressed patient – 25kcal/kg/day - Mildly stressed – 30kcal/kg/day - Moderately stressed – 35kcal/kg/day - Severely stressed – 40kcal/kg/day

TPN NUTRITIONAL CONTENT  PROTEIN REQUIREMENTS

1-2 g/kg/day(adult) 2.5-3.5g/kg/day(children) ESSENTIAL FATTY ACIDS VITAMINS MINERALS Parenteral requirement of some vitamins and minerals may be higher than enteral requirements

TPN NUTRITIONAL CONTENT  Micronutrients are delivered into the systemic rather

than the portal circulation, bypassing the liver and rapidly excreted into the urine.  Many patients who require parenteral support have enteric losses that can result in sodium, potassium, chloride, and bicarbonate wasting and in loss of divalent cations and vitamins that normally have an enterohepatic circulation.  Tubing and delivery bags and exposure to oxygen and light can also destry vitamins (vit. A)

SITES OF VENOUS ACCESS  A. Distal tip of catheter best placed in midpotion of

superior vena cava  B. Enters venous system via: 1. Percutaneous stick into the subclavian, external or internal jugular or antecubital vein. 2. Cutdown site on external jugular (via common facial vein) femoral, axillary, or intercostal vein. C. All catheters can be tunneled subcutaneously to a distal site, which 1. May provide a barrier to skin organisms infcting the line 2. Places exit site at convenient place for self-care in patients at home.

SOLUTIONS  Basic TPN solutions are prepared using sterile

techniques.  Patients with renal insufficiency and are not receiving dialysis or who have liver failure – reduced protein content and a high percentage of essential AA.  Patients with heart or kidney failure – volume intake must be limited.  Patients with respiratory failure – lipid emulsion must provide most of non protein calories.  Neonates – lower dextrose concentrations ( 17 to 18%).

 AMINOGLEBAN – AA (hepatic encephalopathy)  AMINOSTERIL – AA ( children and PT)

 INTRAPID – Pre op. Post-op., cachexia, burns  KABIVEN – AA, glucose, electrolytes  MORIAMIN S2 – AA (protein – calorie malnutrition)

 VITRIMIX - vitamins, glucose, lipids  VAMIN – vitamins, glucose, AA, electrolytes

DELIVERY  Chronic TPN is performed through central venous

catheter.  In infants, umbilical vein is sometimes used.

DELIVERY  The preferred method of delivering TPN is with a

medical infusion pump.  A sterile bag of nutrient solution, between 500mL and 4 L is provided.  The pump infuses a small amount ( 0.1 to 10mL/hr) continuously to keep vein open.  FEEDING SCHEDULE – varies but common regimen ramps up the nutrition over one hour

DELIVERY  Then levels off the rate for a few hours and then ramps

it down over a final hour in order to stimulate a normal metabolic response resembling meal time. This is done over 12 to 14 hours rather than intermittently during the day.

CARE OF CATHETER -Sterile techniques must be used during insertion and maintenance -TPN line should not be used for any other purpose. -External tubing should be changed q24 h with the first bag of the day. - Dressings should be kept sterile and are usually changed q48h using strict sterile techniques - TPN given outside the hospital, patients nust be taught to recognize symptoms of infection, and qualified home nursing must be arranged.

MONITORING  Progress should be followed on a flowchart.  Interdisciplinary nutrition team, if feasible, should    

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monitor the patient. Weight, CBC, electrolytes, BUN monitored daily. Blood glucose q6h till stable. I&O Liver function tests, serum albumin, prothrombin time, urine osmolality; Ca, Mg and phosphate 2xa week. Full nutritional assessment

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