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Nutrition ParenteralNutrition Parenteral
Conquering the ComplexitiesConquering the Complexities
Dr sumer yadavDr sumer yad...
DEFINITIONDEFINITION
Intravenous administration of calories,Intravenous administration of calories,
nitrogen and other nut...
HISTORYHISTORY
 Willium harvey’sWillium harvey’s elucidation of the humanelucidation of the human
circulationcirculation
...
INTRODUCTIONINTRODUCTION
 PNPN uses the vascular system to provide vitaluses the vascular system to provide vital
nutriti...
When PN is required?When PN is required?
PPN is used to prevent or reduce theN is used to prevent or reduce the
adverse ef...
INDICATIONS FOR PNINDICATIONS FOR PN
 Extreme short bowel syndromeExtreme short bowel syndrome
 Structural – resectionSt...
INDICATIONS OF PN CONTD….INDICATIONS OF PN CONTD….
 PPreoperatively only in patients with severereoperatively only in pat...
CONTRADICATIONS FOR PNCONTRADICATIONS FOR PN
 CContradications for central lineontradications for central line (coagulopa...
MERITS OF PNMERITS OF PN
 Turns the catabolic state of patient intoTurns the catabolic state of patient into AnabolicAnab...
Assesment for MalnutritionAssesment for Malnutrition
 BY HISTORYBY HISTORY
 Weight lossWeight loss >10% of body weight>1...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
 BY PHYSICAL FINDINGSBY PHYSICAL FINDINGS
 WeightWeig...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
 BY LABORATORYBY LABORATORY
 SSerum Albumin <30g/Leru...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
 BY SPECIAL PROCEDURESBY SPECIAL PROCEDURES
1. Bioelec...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
 BY SPECIAL PROCEDUREBY SPECIAL PROCEDURE
2. Indirect ...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
STRESS FACTORSTRESS FACTOR
 PeritonitisPeritonitis +15...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
ACTIVITY FACTORACTIVITY FACTOR
 Bed BoundBed Bound - +...
Assesment for Malnutrition contd…Assesment for Malnutrition contd…
SPECIAL PROCEDURE….SPECIAL PROCEDURE….
2.2. Nitrogen ba...
BEFORE STARTING PNBEFORE STARTING PN
 CBCCBC
 LFTLFT
 RFTRFT
 Serum Electrolytes (Na, K, Cl, Ca, Mg)Serum Electrolytes...
BEFORE STARTING PN contd…BEFORE STARTING PN contd…
 CALCULATION OF REQUIREMENTCALCULATION OF REQUIREMENT
A.A. Fluid Requi...
BEFORE STARTING PN contd…BEFORE STARTING PN contd…
 CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
...
BEFORE STARTING PN contd…BEFORE STARTING PN contd…
 CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
...
Contd….Contd….
 CARBOHYDRATESCARBOHYDRATES
Commercial Dextrose – 5%, 25%, and 70% Conc.Commercial Dextrose – 5%, 25%, and...
Shortcut for assessment ofShortcut for assessment of
ENERGY REQIREMENTENERGY REQIREMENT
VariantsVariants
NoNo
StressStress...
BEFORE GIVING PNBEFORE GIVING PN
 VENOUS ACCESSVENOUS ACCESS
1.1. Central VeinCentral Vein – Large Bore, High Flow– Large...
CATHETERSCATHETERS
 FORFOR
 Central Vein CannulationCentral Vein Cannulation – Single Lumen– Single Lumen
- Double Lumen...
CATHETERSCATHETERS
 FORFOR
 Peripheral Vein CannulationPeripheral Vein Cannulation – Simple– Simple
Cannula of 23 GaugeC...
INFUSION OF PNINFUSION OF PN
 BY TWO WAYSBY TWO WAYS
 ContinuousContinuous – For Short Term– For Short Term
- When Rapid...
MONITERING OF PNMONITERING OF PN
 PHYSICAL COMPONENTS – DIALYPHYSICAL COMPONENTS – DIALY
WEIGHTWEIGHT
INPUT / OUTPUT CH...
MONITERING contd..MONITERING contd..
 METABOLIC MONITERINGMETABOLIC MONITERING
 11stst
dayday – CBC/RFT/B.S./LFT/Electro...
METABOLIC MONITERINGMETABOLIC MONITERING
contd….contd….
 Thrice/weekThrice/week – B.S./RFT/Electrolytes/Phosphorus– B.S./...
Adverse Events To Be WatchedAdverse Events To Be Watched
 2+ Glucose in Urine2+ Glucose in Urine
 Mod. Ketones in UrineM...
Side Effects of LipidsSide Effects of Lipids
 Back & Chest PainBack & Chest Pain
 DiaphoresisDiaphoresis
 Fever/Flushin...
Care Of CVAD LineCare Of CVAD Line
 EExamine the site for signs of infectionxamine the site for signs of infection
 AAlt...
Piggybacking of PNPiggybacking of PN
 Should be freshly prepared.Should be freshly prepared.
 Start slowly atStart slowl...
Tapering of PNTapering of PN
 Taper the infusion rate to half for 20 min.Taper the infusion rate to half for 20 min.
& ag...
COMPLICATIONS OF PNCOMPLICATIONS OF PN
 CATHETER RELATEDCATHETER RELATED
 PneumothoraxPneumothorax
 Air EmbolismAir Emb...
COMPLICATIONS contd…COMPLICATIONS contd…
 METABOLICMETABOLIC
 Hyper/Hypo VolumiaHyper/Hypo Volumia
 Hyper/Hypo Glycemia...
COMPLICATIONS contd…COMPLICATIONS contd…
 GASTRO-INTESTINALGASTRO-INTESTINAL
 FATTY LIVERFATTY LIVER
 CHOLESTASISCHOLES...
HOME PNHOME PN
 Required in those who needs PN for long termRequired in those who needs PN for long term
 IndicationsInd...
TPN in Various illnessTPN in Various illness
 ACUTE RENAL FAILUREACUTE RENAL FAILURE
 Avoid- High Protein DietAvoid- Hig...
TPN in Various illness contd..TPN in Various illness contd..
 BURNSBURNS
 Resuscitation Phase (1Resuscitation Phase (1st...
TPN in Various illness contd…TPN in Various illness contd…
 HEPATIC DISEASEHEPATIC DISEASE
 High Caloric IntakeHigh Calo...
TPN in Various illness contd…TPN in Various illness contd…
 RESPIRATORY FAILURERESPIRATORY FAILURE
 Calories 20 – 30 Kca...
IMMUNONUTRITIONIMMUNONUTRITION
 GLUTAMINEGLUTAMINE
–– Semi essential AASemi essential AA
- Improve Immune Functions- Impr...
Newer AgentsNewer Agents
 Anabolic Androgen TherapyAnabolic Androgen Therapy
 Increase the Muscle MassIncrease the Muscl...
Enteral Vs ParentralEnteral Vs Parentral
 CheaperCheaper
 Maintain IntestinalMaintain Intestinal
MucosaMucosa
 Easy to ...
CONCLUSIONCONCLUSION
 TPNTPN is life-saving tool &is life-saving tool &
should be given whenshould be given when
indicate...
Dr. invented new way for PN
infusion
Nurse preparing the PN bag for
infusion
Health
is
Wealth
THANKSTHANKS
parenteral nutrition
parenteral nutrition
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parenteral nutrition

  1. 1. Nutrition ParenteralNutrition Parenteral Conquering the ComplexitiesConquering the Complexities Dr sumer yadavDr sumer yadav
  2. 2. DEFINITIONDEFINITION Intravenous administration of calories,Intravenous administration of calories, nitrogen and other nutrients in sufficientnitrogen and other nutrients in sufficient quantities to achieve tissue synthesis andquantities to achieve tissue synthesis and anabolism is calledanabolism is called Parenteral NutritionParenteral Nutrition..
  3. 3. HISTORYHISTORY  Willium harvey’sWillium harvey’s elucidation of the humanelucidation of the human circulationcirculation  Arvid Wretlind & collegueArvid Wretlind & collegue (1961) – prepared fat(1961) – prepared fat emulsionemulsion  Stanley Dudrick & Jonathan RhoadsStanley Dudrick & Jonathan Rhoads (1968) –(1968) – develop TPNdevelop TPN  Solassol & JoyeuxSolassol & Joyeux (1976) – developed 3-in-1Bag(1976) – developed 3-in-1Bag PN solutionPN solution  Shills & JeejeebhoyShills & Jeejeebhoy (1978) – developed HOME(1978) – developed HOME PNPN
  4. 4. INTRODUCTIONINTRODUCTION  PNPN uses the vascular system to provide vitaluses the vascular system to provide vital nutritional support to malnourished patients & itnutritional support to malnourished patients & it supplies the nutrients in their elemental formssupplies the nutrients in their elemental forms (carbohydrate, lipids, aminoacids, trace(carbohydrate, lipids, aminoacids, trace elements & vitamins)elements & vitamins)  Two TypesTwo Types 1.1. TPNTPN – Total Parentral Nutrition– Total Parentral Nutrition 2.2. PPNPPN – Partial Parentral Nutrition– Partial Parentral Nutrition  Can be administered by two routesCan be administered by two routes 1.1. Large central veinLarge central vein (Central PN)(Central PN) 2.2. Peripheral veinPeripheral vein (Peripheral PN)(Peripheral PN)
  5. 5. When PN is required?When PN is required? PPN is used to prevent or reduce theN is used to prevent or reduce the adverse effects of malnutrition.adverse effects of malnutrition. AAnd is used when entral nutrition (EN) isnd is used when entral nutrition (EN) is unsafe or ineffective and this condition isunsafe or ineffective and this condition is anticipated to last for 7 – 10 days.anticipated to last for 7 – 10 days.
  6. 6. INDICATIONS FOR PNINDICATIONS FOR PN  Extreme short bowel syndromeExtreme short bowel syndrome  Structural – resectionStructural – resection  Functional – Severe inflammationFunctional – Severe inflammation  Bowel RestBowel Rest -- Enterocutaneous fistula (Enterocutaneous fistula (high outputhigh output)) - Anastomotic leak- Anastomotic leak  Paralytic ileusParalytic ileus –– Major abdominal surgeryMajor abdominal surgery -- Major abdominal traumaMajor abdominal trauma  Intestinal ObstructionIntestinal Obstruction –– Cancer, AdhesionsCancer, Adhesions
  7. 7. INDICATIONS OF PN CONTD….INDICATIONS OF PN CONTD….  PPreoperatively only in patients with severereoperatively only in patients with severe malnutritionmalnutrition  MMulti-organ failure with sepsisulti-organ failure with sepsis  OOthersthers  Severe mucositis/oesophagitis/radiation entritisSevere mucositis/oesophagitis/radiation entritis  Inflammatory bowel disease with severeInflammatory bowel disease with severe malnutritionmalnutrition  Intestinal Atresia /Motility disordersIntestinal Atresia /Motility disorders  Intractable vomitingIntractable vomiting (CT, Hyperemesis G.)(CT, Hyperemesis G.)
  8. 8. CONTRADICATIONS FOR PNCONTRADICATIONS FOR PN  CContradications for central lineontradications for central line (coagulopathies)(coagulopathies)  HHemodynamically unstable patientemodynamically unstable patient  PPulmonary edema/Fluid overloadulmonary edema/Fluid overload  AAnuria without dialysisnuria without dialysis  SSevere metabolic/electrolyte disturbencesevere metabolic/electrolyte disturbences  AAdvance cancer or terminal illnessdvance cancer or terminal illness
  9. 9. MERITS OF PNMERITS OF PN  Turns the catabolic state of patient intoTurns the catabolic state of patient into AnabolicAnabolic statestate  ProvidesProvides rest to bowelrest to bowel ( in anastomosis / leaks)( in anastomosis / leaks)  PreventsPrevents wasting of muscleswasting of muscles  ImproveImprove healing of woundshealing of wounds
  10. 10. Assesment for MalnutritionAssesment for Malnutrition  BY HISTORYBY HISTORY  Weight lossWeight loss >10% of body weight>10% of body weight  Decresed food intakeDecresed food intake  G.I. SymptomsG.I. Symptoms - Anorexia- Anorexia - Dysphagia- Dysphagia - Nasuea /Vomiting- Nasuea /Vomiting - Chronic Diarrhoea- Chronic Diarrhoea - Abdominal Pain- Abdominal Pain
  11. 11. Assesment for Malnutrition contd…Assesment for Malnutrition contd…  BY PHYSICAL FINDINGSBY PHYSICAL FINDINGS  WeightWeight <90% of ideal wt.<90% of ideal wt.  AnthropometryAnthropometry (mid-arm circumference in cm.)(mid-arm circumference in cm.)  Loss of subcutaneous fatLoss of subcutaneous fat (skinfold thickness)(skinfold thickness)  Skin rashes/ occular changesSkin rashes/ occular changes  Mucus membrane changesMucus membrane changes for deficiency offor deficiency of  Neurological changesNeurological changes particular nutrientparticular nutrient
  12. 12. Assesment for Malnutrition contd…Assesment for Malnutrition contd…  BY LABORATORYBY LABORATORY  SSerum Albumin <30g/Lerum Albumin <30g/L  TTotal lymphocyte Count <1800/cu mmotal lymphocyte Count <1800/cu mm  SSkin Test Reactivity (to asses immunekin Test Reactivity (to asses immune system)system)  S.S. levels of vitamin A, D, Elevels of vitamin A, D, E  P.P. levels of iron/folic acidlevels of iron/folic acid  S.S. levels of Zn, Mg, Phosphoruslevels of Zn, Mg, Phosphorus
  13. 13. Assesment for Malnutrition contd…Assesment for Malnutrition contd…  BY SPECIAL PROCEDURESBY SPECIAL PROCEDURES 1. Bioelectric Impedence Analysis (BIA)1. Bioelectric Impedence Analysis (BIA) for measurement of – Body Fatfor measurement of – Body Fat - FFM (Fat Free Mass)- FFM (Fat Free Mass) - Total Body Water- Total Body Water Lean Body MassLean Body Mass = Body wt. – Fat Mass= Body wt. – Fat Mass = Total Body Water / 0.73= Total Body Water / 0.73
  14. 14. Assesment for Malnutrition contd…Assesment for Malnutrition contd…  BY SPECIAL PROCEDUREBY SPECIAL PROCEDURE 2. Indirect Calorimetry2. Indirect Calorimetry – To measure REE– To measure REE Harris & Benedicts FormulaHarris & Benedicts Formula REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) -REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) - 6.7(Age in Yr) K cal / day6.7(Age in Yr) K cal / day REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm) - 4.7 (Age in Yrs) K cal / day- 4.7 (Age in Yrs) K cal / day TEE = REE + Stress Factor + Activity FactorTEE = REE + Stress Factor + Activity Factor REE is 60% of TEEREE is 60% of TEE Schofield equationSchofield equation – 25 to 30 K cal / Kg / day– 25 to 30 K cal / Kg / day
  15. 15. Assesment for Malnutrition contd…Assesment for Malnutrition contd… STRESS FACTORSTRESS FACTOR  PeritonitisPeritonitis +15%+15%  Soft tissue traumaSoft tissue trauma +15%+15%  FractureFracture +20%+20%  BurnsBurns <20%BSA +50%<20%BSA +50% 20% - 40%BSA +80%20% - 40%BSA +80% >40%BSA +100%>40%BSA +100%  MalnutritionMalnutrition +30%+30%  InfectionInfection moderate +20%moderate +20% severe +40%severe +40%  FeverFever (per(per oo C rise) +13%C rise) +13%
  16. 16. Assesment for Malnutrition contd…Assesment for Malnutrition contd… ACTIVITY FACTORACTIVITY FACTOR  Bed BoundBed Bound - + 20 %- + 20 %  AmbulantAmbulant - + 30 %- + 30 %  ActiveActive - + 50 %- + 50 %
  17. 17. Assesment for Malnutrition contd…Assesment for Malnutrition contd… SPECIAL PROCEDURE….SPECIAL PROCEDURE…. 2.2. Nitrogen balanceNitrogen balance = N input – N output= N input – N output 1 Gm N = 6.25 Gm Protien1 Gm N = 6.25 Gm Protien N input = Protien in Gm x 6.25N input = Protien in Gm x 6.25 N output = 24 hr. Urinary Urea Nitrogen +N output = 24 hr. Urinary Urea Nitrogen + Non-urinary N lossesNon-urinary N losses (estimated non-urinary N losses ~ 3 - 4 Gm/day)(estimated non-urinary N losses ~ 3 - 4 Gm/day) Aim of Positive N balance =Aim of Positive N balance = 1.5 – 2 G/Kg/day1.5 – 2 G/Kg/day
  18. 18. BEFORE STARTING PNBEFORE STARTING PN  CBCCBC  LFTLFT  RFTRFT  Serum Electrolytes (Na, K, Cl, Ca, Mg)Serum Electrolytes (Na, K, Cl, Ca, Mg)  PT & PTTPT & PTT  Lipid ProfileLipid Profile
  19. 19. BEFORE STARTING PN contd…BEFORE STARTING PN contd…  CALCULATION OF REQUIREMENTCALCULATION OF REQUIREMENT A.A. Fluid RequirementFluid Requirement Basic Need = 1500 + 20 ml/Kg body wt.Basic Need = 1500 + 20 ml/Kg body wt. ((If Wt. is >20 Kg)If Wt. is >20 Kg) Total Need = Basic Need + LossesTotal Need = Basic Need + Losses Losses like – Nasogastric aspirationLosses like – Nasogastric aspiration - Vomit volume- Vomit volume - Drain output- Drain output - Fistula output- Fistula output
  20. 20. BEFORE STARTING PN contd…BEFORE STARTING PN contd…  CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd.. B.B. Protien RequirementProtien Requirement Normal = 1.0 – 1.2 Gm / Kg / dayNormal = 1.0 – 1.2 Gm / Kg / day In catabolic state = 2 Gm / Kg / dayIn catabolic state = 2 Gm / Kg / day Catabolic states – PolytraumaCatabolic states – Polytrauma - Severe Burns- Severe Burns - Pt. taking Renal Replacement- Pt. taking Renal Replacement therapytherapy TPN contains Aminoacids in 3 – 15% concentrationTPN contains Aminoacids in 3 – 15% concentration
  21. 21. BEFORE STARTING PN contd…BEFORE STARTING PN contd…  CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd.. C.C. Energy RequirementEnergy Requirement Normal = 25 – 30 K cal / Kg / dayNormal = 25 – 30 K cal / Kg / day ((Should be provided by non-protein calories i.e.Should be provided by non-protein calories i.e. calculate it from carbohydrate & lipids only, tocalculate it from carbohydrate & lipids only, to minimize nitrogen consumption)minimize nitrogen consumption) Carbohydrate & lipid Ratio ~Carbohydrate & lipid Ratio ~ 70 : 3070 : 30
  22. 22. Contd….Contd….  CARBOHYDRATESCARBOHYDRATES Commercial Dextrose – 5%, 25%, and 70% Conc.Commercial Dextrose – 5%, 25%, and 70% Conc. TPN Dextrose - 50% to 70% Conc.TPN Dextrose - 50% to 70% Conc. 1 Gm Dextrose = 3.4 K cal.1 Gm Dextrose = 3.4 K cal. Rate of infusion ~ < 5 – 7 mg / Kg / min.Rate of infusion ~ < 5 – 7 mg / Kg / min.  LIPIDSLIPIDS In 10% - 20% ConcentrationIn 10% - 20% Concentration Infusion rate < 0.7 K cal / Kg / hr.Infusion rate < 0.7 K cal / Kg / hr. 10 – 15 ml / min for 20% sol.10 – 15 ml / min for 20% sol.  MULTIVITAMINMULTIVITAMIN – Given 1 amp / day i.v.– Given 1 amp / day i.v. Vit. K 1 amp / day i.m.Vit. K 1 amp / day i.m.  ELECTROLYTEELECTROLYTE – Acc. to their serum levels– Acc. to their serum levels
  23. 23. Shortcut for assessment ofShortcut for assessment of ENERGY REQIREMENTENERGY REQIREMENT VariantsVariants NoNo StressStress MildMild StressStress Mod.Mod. StressStress Sev.Sev. StressStress ENERGYENERGY Kcal/Kg/DKcal/Kg/D 2525 3030 3535 4040 Carbo. (Dex.)Carbo. (Dex.) Gm/Kg/DGm/Kg/D 55 66 77 88 LIPIDSLIPIDS Gm/kg/DGm/kg/D 0.80.8 1.01.0 1.21.2 1.41.4 PROTEINSPROTEINS Gm/Kg/DGm/Kg/D 11 1.21.2 1.51.5 2.02.0
  24. 24. BEFORE GIVING PNBEFORE GIVING PN  VENOUS ACCESSVENOUS ACCESS 1.1. Central VeinCentral Vein – Large Bore, High Flow– Large Bore, High Flow - Preferred for TPN- Preferred for TPN - For long term use- For long term use (e.g. Subclavian /Int. jugular /Basilic /femoral)(e.g. Subclavian /Int. jugular /Basilic /femoral) 2.2. Peripheral VeinPeripheral Vein – For short term use– For short term use - When central vein- When central vein contraindicatedcontraindicated Verify the tip of cannula by X ray before PNVerify the tip of cannula by X ray before PN
  25. 25. CATHETERSCATHETERS  FORFOR  Central Vein CannulationCentral Vein Cannulation – Single Lumen– Single Lumen - Double Lumen- Double Lumen - Multiple Lumen- Multiple Lumen In Poly- Lumen CathetersIn Poly- Lumen Catheters Medial/Proximal Lumen – PN infusionMedial/Proximal Lumen – PN infusion Lateral/Distal Lumen - Other UsesLateral/Distal Lumen - Other Uses
  26. 26. CATHETERSCATHETERS  FORFOR  Peripheral Vein CannulationPeripheral Vein Cannulation – Simple– Simple Cannula of 23 GaugeCannula of 23 Gauge
  27. 27. INFUSION OF PNINFUSION OF PN  BY TWO WAYSBY TWO WAYS  ContinuousContinuous – For Short Term– For Short Term - When Rapid Infusion Intolerable- When Rapid Infusion Intolerable  CyclicallyCyclically – When Used For Long Term– When Used For Long Term - When Rapid Infusion Tolerable- When Rapid Infusion Tolerable - Continuous administration for 8 – 12- Continuous administration for 8 – 12 hrs and then rest for next 12 hrshrs and then rest for next 12 hrs - Freedom during day- Freedom during day Use 3-in-1 TPN or 2-in1 PN with DextroseUse 3-in-1 TPN or 2-in1 PN with Dextrose or AA/Lipid/Dextrose seperatelyor AA/Lipid/Dextrose seperately
  28. 28. MONITERING OF PNMONITERING OF PN  PHYSICAL COMPONENTS – DIALYPHYSICAL COMPONENTS – DIALY WEIGHTWEIGHT INPUT / OUTPUT CHARTINPUT / OUTPUT CHART VITAL SIGNSVITAL SIGNS
  29. 29. MONITERING contd..MONITERING contd..  METABOLIC MONITERINGMETABOLIC MONITERING  11stst dayday – CBC/RFT/B.S./LFT/Electrolytes/Mg– CBC/RFT/B.S./LFT/Electrolytes/Mg Lipid & Coagulation ProfileLipid & Coagulation Profile  22ndnd dayday – Electrolytes/B.S./RFT/Phosphorus– Electrolytes/B.S./RFT/Phosphorus  33rdrd dayday - Electrolytes/B.S./RFT- Electrolytes/B.S./RFT  44thth dayday - Electrolytes/B.S./RFT/Phosphorus/Mg- Electrolytes/B.S./RFT/Phosphorus/Mg
  30. 30. METABOLIC MONITERINGMETABOLIC MONITERING contd….contd….  Thrice/weekThrice/week – B.S./RFT/Electrolytes/Phosphorus– B.S./RFT/Electrolytes/Phosphorus  Twice/weekTwice/week – LFT /– LFT / MMgg  Once/weekOnce/week - Lipid &Coagulation Profile- Lipid &Coagulation Profile
  31. 31. Adverse Events To Be WatchedAdverse Events To Be Watched  2+ Glucose in Urine2+ Glucose in Urine  Mod. Ketones in UrineMod. Ketones in Urine  Persistent thirst/Excessive U.O.Persistent thirst/Excessive U.O.  Level of ConsciousnessLevel of Consciousness  HypoglycemiaHypoglycemia  Chills/Rigor/FeverChills/Rigor/Fever  Signs of PhlebitisSigns of Phlebitis  Skin rashesSkin rashes  Hyperventilation / HypotensionHyperventilation / Hypotension
  32. 32. Side Effects of LipidsSide Effects of Lipids  Back & Chest PainBack & Chest Pain  DiaphoresisDiaphoresis  Fever/Flushing/Chills/RigorFever/Flushing/Chills/Rigor  Nausea/VomitingNausea/Vomiting  UrticariaUrticaria  Shortness of BreathShortness of Breath
  33. 33. Care Of CVAD LineCare Of CVAD Line  EExamine the site for signs of infectionxamine the site for signs of infection  AAlt. day change the catheter dressinglt. day change the catheter dressing  PPeriodically check line for blockageeriodically check line for blockage  TTubes should be changed dailyubes should be changed daily  DDedicate one lumen for PN onlyedicate one lumen for PN only  AAvoid accidents like – Pullingvoid accidents like – Pulling  AAllow only one trained person to handlellow only one trained person to handle
  34. 34. Piggybacking of PNPiggybacking of PN  Should be freshly prepared.Should be freshly prepared.  Start slowly atStart slowly at 50ml/hr50ml/hr on day 1on day 1stst ..  Volume must not exceedVolume must not exceed 1000ml1000ml on day 1on day 1stst ..  From 2From 2ndnd day volume should be increased byday volume should be increased by 1 lit./day1 lit./day until goal reached.until goal reached.  Rate of infusion most not exceedRate of infusion most not exceed 125ml/hr125ml/hr..
  35. 35. Tapering of PNTapering of PN  Taper the infusion rate to half for 20 min.Taper the infusion rate to half for 20 min. & again half the rate for other 20 min.& again half the rate for other 20 min.  Flush the line with 10-15 ml NS.Flush the line with 10-15 ml NS.  Flush the line withFlush the line with heparin lockheparin lock..  Clamp the line.Clamp the line.  Infuse 10% Dextrose at the same rate forInfuse 10% Dextrose at the same rate for 1 hr. through other line.1 hr. through other line.  Restart PN next day with aseptic tech…Restart PN next day with aseptic tech…
  36. 36. COMPLICATIONS OF PNCOMPLICATIONS OF PN  CATHETER RELATEDCATHETER RELATED  PneumothoraxPneumothorax  Air EmbolismAir Embolism  Venous ThrombosisVenous Thrombosis  Catheter OcclusionCatheter Occlusion  Catheter SepsisCatheter Sepsis  Catheter EmbolismCatheter Embolism
  37. 37. COMPLICATIONS contd…COMPLICATIONS contd…  METABOLICMETABOLIC  Hyper/Hypo VolumiaHyper/Hypo Volumia  Hyper/Hypo GlycemiaHyper/Hypo Glycemia  HyperosmolarityHyperosmolarity  HypertriglyceridaemiaHypertriglyceridaemia  HyperketoacidosesHyperketoacidoses  Electrolyte ImbalanceElectrolyte Imbalance
  38. 38. COMPLICATIONS contd…COMPLICATIONS contd…  GASTRO-INTESTINALGASTRO-INTESTINAL  FATTY LIVERFATTY LIVER  CHOLESTASISCHOLESTASIS  INTESTINAL MUCOSAL ATROPHYINTESTINAL MUCOSAL ATROPHY To Avoid – Early use of GITTo Avoid – Early use of GIT
  39. 39. HOME PNHOME PN  Required in those who needs PN for long termRequired in those who needs PN for long term  IndicationsIndications – Short Bowel syndrome– Short Bowel syndrome - Bowel Rest- Bowel Rest - Severe Malnutrition- Severe Malnutrition  Patient SelectionPatient Selection  Clinically & Psychologically soundClinically & Psychologically sound  Family SupportFamily Support  Adequate FinanceAdequate Finance
  40. 40. TPN in Various illnessTPN in Various illness  ACUTE RENAL FAILUREACUTE RENAL FAILURE  Avoid- High Protein DietAvoid- High Protein Diet  Avoid NS / RLAvoid NS / RL  Restrict FluidRestrict Fluid  Protein RequirementProtein Requirement  Predialysis – LowPredialysis – Low (0.6-0.8 Gm/kg/day)(0.6-0.8 Gm/kg/day)  Dialysis - StandardDialysis - Standard (1- 1.2 Gm/Kg/day)(1- 1.2 Gm/Kg/day)
  41. 41. TPN in Various illness contd..TPN in Various illness contd..  BURNSBURNS  Resuscitation Phase (1Resuscitation Phase (1stst 24 – 48 hr.)24 – 48 hr.) - Fluids with Crystalloids- Fluids with Crystalloids  Energy RequirementEnergy Requirement - 25 Kcal/Kg/day + 20Kcal/ % of BSA- 25 Kcal/Kg/day + 20Kcal/ % of BSA - Proteins – 2 Gm/Kg/day- Proteins – 2 Gm/Kg/day
  42. 42. TPN in Various illness contd…TPN in Various illness contd…  HEPATIC DISEASEHEPATIC DISEASE  High Caloric IntakeHigh Caloric Intake – 35 Kcal / Kg / day– 35 Kcal / Kg / day  Encephalopathy PresentEncephalopathy Present – Proteins 0.6 Gm/Kg/day– Proteins 0.6 Gm/Kg/day Avoid Aromatic AAAvoid Aromatic AA Use Branched Chain AAUse Branched Chain AA  Encephalopathy AbsentEncephalopathy Absent - Proteins 1- 1.2 Gm/Kg/day- Proteins 1- 1.2 Gm/Kg/day  Edema / Asicitis PresentEdema / Asicitis Present – Restrict Na– Restrict Na
  43. 43. TPN in Various illness contd…TPN in Various illness contd…  RESPIRATORY FAILURERESPIRATORY FAILURE  Calories 20 – 30 Kcal / Kg / dayCalories 20 – 30 Kcal / Kg / day  Give 30 to 35 % calorie as FATGive 30 to 35 % calorie as FAT  Avoid CARBOHYDRATESAvoid CARBOHYDRATES  Proteins 1 – 2 Gm / Kg / dayProteins 1 – 2 Gm / Kg / day
  44. 44. IMMUNONUTRITIONIMMUNONUTRITION  GLUTAMINEGLUTAMINE –– Semi essential AASemi essential AA - Improve Immune Functions- Improve Immune Functions - Restore Protein Stores- Restore Protein Stores  ENTERAL GLUTAMINEENTERAL GLUTAMINE - Increase Intestinal Mucosal Height- Increase Intestinal Mucosal Height - Increase Enterocyte Protein Contents- Increase Enterocyte Protein Contents
  45. 45. Newer AgentsNewer Agents  Anabolic Androgen TherapyAnabolic Androgen Therapy  Increase the Muscle MassIncrease the Muscle Mass  Megestral AcetateMegestral Acetate – Appetite Stimulant– Appetite Stimulant  Growth HormonesGrowth Hormones  Increase the Muscle MassIncrease the Muscle Mass  Increase Visceral Protein StatusIncrease Visceral Protein Status
  46. 46. Enteral Vs ParentralEnteral Vs Parentral  CheaperCheaper  Maintain IntestinalMaintain Intestinal MucosaMucosa  Easy to AdministerEasy to Administer  Less ComplicationsLess Complications  CostlyCostly  Causes IntestinalCauses Intestinal AtrophyAtrophy  Require ProfessionalRequire Professional  More ComplicationsMore Complications
  47. 47. CONCLUSIONCONCLUSION  TPNTPN is life-saving tool &is life-saving tool & should be given whenshould be given when indicated. If conditionsindicated. If conditions allow, switch the patientallow, switch the patient over theover the Enteral NutritionEnteral Nutrition as early as possible.as early as possible.
  48. 48. Dr. invented new way for PN infusion
  49. 49. Nurse preparing the PN bag for infusion
  50. 50. Health is Wealth THANKSTHANKS

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