Parenteral NS

• Fluid and electrolyte requirements.

• Calculate enteral and parenteral formulations.

PNS Routes

• Peripheral access

• Short-term central access

• Long-term central access

Peripheral Access

• Veins in limbs

• Cannot exceed 800-900 mOsm/kg

• PICC - enter at peripheral but end of tube at subclavian vein

Central Access

• Figure 20-3 here

• Cephalic vein

• Subclavian vein

• Internal jugular vein

• Superior vena cava

Fig. 20-3. Central access

Central Access

• Short-term– percutaneous technique

• Long-term– implanted vascular devices

PNS

• Time frame for use of PNS– 5 days or less is short-term

• Total nutrients needed

• Capacity of pt to handle fluid

PNS

• Condition of peripheral veins

• If can take adequate oral intake in 5 day - DO NOT do central line

PNS Components

• Protein– crystalline amino acids– 3% to 15% solutions– 10% = 100g protein/L– 4 kcal/g protein– NPC non-protein calories

PNS Components

• Carbohydrate– dextrose monohydrate– 5% to 70% solutions– D50W = 50% solution– 10% solution = 100g/L– 3.4 kcal/g dextrose

PNS Components

• Lipid– soybean or safflower oil– 10%, 20% & 30% solutions– 10% = 1.1 kcal/ml– 20% = 2.0 kcal/ml– 30% = 3.0 kcal/ml

PNS Components

• Lipid– 10% kcal/day every day will provide 4%

of kcal need to prevent EFA deficiency– if have long chain fatty acids

PNS Components

• Electrolytes, vitamins, minerals

PNS

• PPN– less than 8.5% AA– 5-10% dextrose– lipid not more than 1g/kg/day

PNS

• PPN– Rule of thumb for PPN– D5W or D10W with 8.5% AA– D20W with 5% AA and lipid at 125 ml/hr

PNS

• Compounding methods–mix the dextrose and AA– ‘piggy’ back the lipid and filter before

mix with dextrose and AA

PNS

• Initiating TPN– start less than 50 ml/hr and 1 L/day– advance 12 - 24 hr intervals

PNS

• Monitoring– amount receiving– Na– K– BUN– prealbumin

PNS

• Monitoring– cholesterol – TG– I & O– body wt– blood glucose

McClaren 165. Essential fatty acid deficiency.

McClaren 166. Same pt. 165 after EFA supplementation.

Complications TPN

• Catheter in wrong place

• Sepsis

• Deficiencies– EFA def– trace minerals - added routinely

Complications TPN

• Metabolic complications– overloading– imbalances

Complications TPN

• Overloading– solute or fluid - meas. Serum osmolality– CHO, fat, amino acids

Complications TPN

• Imbalances– glucose intolerance– hypokalemia– reactive hypoglycemia– hypophosphatemia– hypo or hypermagnesemia

Refeeding Syndrome

• Too aggressive administration after ‘starving’

• Hypokalemia

• Hypophosphotemia

Transition Feeding

• Parenteral to enteral– start enteral slow– keep TPN going & decrease as increase

enteral– receive 75% from enteral before stop

TPN

Transition Feeding

• Parenteral to oral– start oral and slowly decrease TPN– be careful of hyperosmolality of

common clear liquids– receive 75% of needs before stop TPN

Transition Feeding

• Enteral to oral– ??–mOsm/kg for different clear liquids be

careful not too high

TPN END

• Questions?

• Now for calculations