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Prof. Dr. RS Mehta, BPKIHS 1
Nutrition for Critically ill Patients
(TPN)
Prof. Dr. RS Mehta, BPKIHS 2
Nutrition
• Nutrition allows the body to be provided with all basic nutrients substrates and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.
Prof. Dr. RS Mehta, BPKIHS 3
Clinical Manifestations: Malnutrition
• Weight loss• Reduced basal metabolism• Depletion skeletal muscle and
adipose (fat) stores• Decrease tissue turgor• Bradycardia• Hypothermia
Prof. Dr. RS Mehta, BPKIHS 4
Prof. Dr. RS Mehta, BPKIHS 5
Prof. Dr. RS Mehta, BPKIHS 6
Total Parentral Nutrition
Prof. Dr. RS Mehta, BPKIHS 7
Total Parenteral Nutrition Indication • When normal oral feeding is not
possible.e.g.: Chron’s disease, gastric & esophageal carcinoma, paralytic ileus, generalized peronitis, GI. obstruction, intractable vomiting.
• When food is incompletely absorbed.e.g.: Major burns, multiple injuries, radiation therapy, ulcerative colitis, chemotherapy treatment, short bowel syndrome.
• When food intake is undesirable, in case it is prudent to rest the bowel.e.g.: Post GIT surgery, chronic inflammatory diseases, intractable diarrhea.
Prof. Dr. RS Mehta, BPKIHS 8
Total Parenteral Nutrition Indication
• In patients who are able to ingest food, but refuse to do so.e.g.: Geriatric post-operative patients, adolescents with anorexia nervosa, some psychiatric patients with prolonged depression.
• In patients who, as a consequence of their illness are going to be, or have been NPO for 5 – 7 days.
Prof. Dr. RS Mehta, BPKIHS 9
Indications for TPN Short-term use• Bowel injury, surgery, major trauma or burns• Bowel disease (e.g. obstructions, fistulas)• Severe malnutrition• Nutritional preparation prior to surgery. • Malabsorption - bowel cancer• Severe pancreatitis• Malnourished patients who have high risk of
aspiration Long-term use (HOME PN)• Prolonged Intestinal Failure• Crohn’s Disease• Bowel resection
Prof. Dr. RS Mehta, BPKIHS 10
Parenteral NutritionCentral Nutrition
• Subclavian line• Long period• Hyperosmolar
solution• Full
requirement• Minimum
volume• Expensive• More side effect
Peripheral nutrition• Peripheral line• Short period <
14days• Low osmolality < 900 mOsm/L• Min. requirement• Large volume• Thrombophlebitis
Prof. Dr. RS Mehta, BPKIHS 11
Routes of TPNCentral TPN
(usual osmolarity = 2000 mosmol/L)Advantages: Can provide full nutritional support (No
limits in concentration of dextrose and amino acids)
No risk of thrombophlebitis, No pain.Disadvantages: Requires surgery More risk of sepsis than peripheral TPN High risk of mechanical complications
Prof. Dr. RS Mehta, BPKIHS 12
Routes of TPNPeripheral TPN
maximum osmolarity;neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L
Advantages: Does not require surgery Less risk of sepsis than central TPN No risk of mechanical complications
Disadvantages: High risk of thrombophlebitis Painful Does not provide full nutrition support. Needs more fluids to provide more nutrition. (maximum
dextrose = 7.5% and AA = 2.5%).
Prof. Dr. RS Mehta, BPKIHS 13
Note
PPN can infuse through central line but
central TPN can NOT infuse through
the peripheral line
14Prof. Dr. RS Mehta, BPKIHS
Calculating the Osmolarity of a Parenteral Nutrition Solution
Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/LMultiply the grams of protein per liter by
10. Example: 30 g of protein x 10 = 300 mOsm/LMultiply the (mEq per L sodium +
potassium + calcium + magnesium) X 2Example: 80 X 2 = 160
Total osmolarity = 500 + 300 + 160 = 960 mOsm/L
Parenteral Nutrition• Peripheral Parenteral
Nutrition (15 lit D5W/day for a 70 kg !!!)
• Central Parenteral Nutrition (TPN)– Needs CV-line to administer
hyperosmolar solutions
15Prof. Dr. RS Mehta, BPKIHS
Prof. Dr. RS Mehta, BPKIHS 16
Estimation of energy expenditure
Harris-Benedict equations:• BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A• BEE (women) (kcal/day): 655.1+9.56W+1.85H-4.68A• TEE (kcal/day): BEE × Stress factor × Activity factor• Stress factors: Surgery, Infection: 1.2 Trauma: 1.5
Sepsis: 1.6 Burns: 1.6-2• Activity factors: sedentary: 1.2 , normal activity: 1.3,
active: 1.4 , very active: 1.5
Prof. Dr. RS Mehta, BPKIHS 17
Stress level• Normal/mild stress level: 20-25 kcal/kg/day• Moderate stress level: 25-30 kcal/kg/day• Severe stress level: 30-40 kcal/kg/day Pregnant women in second or third trimester:
Add an additional 300 kcal/day
Prof. Dr. RS Mehta, BPKIHS 19
Fluid: mL/day
• 30-40 mL/kg
Prof. Dr. RS Mehta, BPKIHS 20
Protein (amino acids)• Maintenance: 0.8-1 g/kg/day• Normal/mild stress level: 1-1.2 g/kg/day• Moderate stress level: 1.2-1.5 g/kg/day• Severe stress level: 1.5-2 g/kg/day• Burn patients (severe): Increase protein until
significant wound healing achieved• Solid organ transplant: Perioperative: 1.5-2
g/kg/day
Prof. Dr. RS Mehta, BPKIHS 21
Protein need in Renal failure• Acute (severely malnourished or
hypercatabolic): 1.5-1.8 g/kg/day• Chronic, with dialysis: 1.2-1.3 g/kg/day• Chronic, without dialysis: 0.6-0.8 g/kg/day• Continuous hemofiltration: ≥ 1 g/kg/day
Prof. Dr. RS Mehta, BPKIHS 22
Protein need in Hepatic failure• Acute management when other treatments
have failed:– With encephalopathy: 0.6-1 g/kg/day– Without encephalopathy: 1-1.5 g/kg/day
• Chronic encephalopathy– Use branch chain amino acid enriched diets only if
unresponsive to pharmacotherapy• Pregnant women in second or third trimester– Add an additional 10-14 g/day
Prof. Dr. RS Mehta, BPKIHS 23
Fat
• Initial: 20% to 40 % of total calories (maximum: 60% of total calories or 2.5 g/kg/day)– Note: Monitor triglycerides while receiving
intralipids.• Safe for use in pregnancy• I.V. lipids are safe in adults with pancreatitis if
triglyceride levels <400 mg/dL
Prof. Dr. RS Mehta, BPKIHS 24
Components of TPN Formulations
Macro: Calorie: Dextrose 20%, 50% Intralipid 10%, 20% Protein: Aminofusion 5%, 10%
Micro: Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
Prof. Dr. RS Mehta, BPKIHS 25
Dextrose
• 20%, 50% ( from CV-line)• 3.4 kcal/g• 60-70% of calorie requirements should
be provided with dextrose
Prof. Dr. RS Mehta, BPKIHS 26
Dextrose: Contraindications
• Hypersensitivity to corn or corn products• Hypertonic solutions in patients with
intracranial or intra-spinal hemorrhage
Prof. Dr. RS Mehta, BPKIHS 27
Abrupt withdrawal
• Infuse 10% dextrose at same rate and monitor blood glucose for hypoglycemia
Prof. Dr. RS Mehta, BPKIHS 28
Monitoring
29Prof. Dr. RS Mehta, BPKIHS
Monitoring
• Avoid overfeeding• Avoid respiratory problem• Promote nitrogen retention• Triglyceride clearance• Fluid and electrolyte • Weight • Liver function
Prof. Dr. RS Mehta, BPKIHS 30
Complications of TPN
31Prof. Dr. RS Mehta, BPKIHS
Complication• Mechanical: occlusion, catheter
removal, improper rate, thromboses, pneumothorax.• Infection: catheter related • Metabolic: re-feeding syndrome,
hyperglycemia, fluid & electrolyte disturbance • Organic system: hepatobiliary
complication, respiratory, cardiovascular, renal
Prof. Dr. RS Mehta, BPKIHS 32
33Prof. Dr. RS Mehta, BPKIHS
Transitional Feeding• Maintain full PN support until pt is tolerating
1/3 of needs via enteral route
• Decrease TPN by 50% and continue to taper as the enteral feeding is advanced to total
• TPN can reduce appetite if >25% of calorie needs are met via PN
• TPN can be tapered when pt is consuming greater than 500 calories/d and d-c’d when meeting 60% of goal
• TPN can be rapidly decreased if pt is receiving enteral feeding in amount great enough to maintain blood glucose levels
Prof. Dr. RS Mehta, BPKIHS 34
TPN• Doctors decide patient needs it• Dietitian sees patient• Decides best regime• Orders bag from pharmacy• Made up aseptically to requirements• Start low and build up• Monitor bloods
Prof. Dr. RS Mehta, BPKIHS 35
Access for PN• Usually central line in ICU – keep a clean port
if PN may be needed. 5 lumen• Short term PN – can have PIC (need a different
formula) or PICC• Long-term TPN – tunnelled subclavian
catheter (Hickman) or subcutaneous port is usually inserted – OBSERVE STRICT ASEPSIS if handling these lines.
Prof. Dr. RS Mehta, BPKIHS 36
Prof. Dr. RS Mehta, BPKIHS 37
Overfeeding• Lactic acidosis• Hyperglycaemia• Increased infections• Liver impairment (Alk phos, ALT, GGT,
acalculous cholecystitis)• Persistent pyrexia
Prof. Dr. RS Mehta, BPKIHS 38
Complex nutrition: Monitoring
• Urea, Electrolytes, phosphate, calcium, magnesium
• Glucose• LFTs• Fluid balance• Haematology• Weight• Trace elements if long-term
Prof. Dr. RS Mehta, BPKIHS 39
Conclusion• Do not forget about feeding• Keep an eye on whether nutritional
targets are being met• Speak to the surgeons and dietician • Do not be reluctant to start PN in a
supplemental capacity• Avoid hyperglycaemia• Nutrition is often neglected
Prof. Dr. RS Mehta, BPKIHS 40
Thank you
Prof. Dr. RS Mehta, BPKIHS 41