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Something About Nutrition And Parenteral Nutrition.
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Parenteral Nutrition
By Dr Kaleem Ullah Bhatti House Surgeon
What is Nutrition?
The taking in and metabolism of nutrients so that life is maintained and growth can take place.
Malnutrition
Definition A disorder of nutrition it may be due
to unbalanced or insufficient diet or to defective assimilation or utilization of foods.
Types Of Nutrition
Following are the types of nutrition Enteral Nutrition Parenteral Nutrition
Parenteral Nutrition
Definition It is administration of nutrition
exclusively through intravenous route bypassing gastrointestinal tract
Indications for parenteral nutrition
Either who are malnourished
Have the potential for developing malnutrition
Are not candidates for enteral support
Indications for Parenteral Nutrition
Parenteral nutrition is usually indicated in the following situations:
Documented inability to absorb adequate nutrients via the gastrointestinal tract; this may be due to:
Massive small-bowel resection / Short bowel syndrome (at least initially)
Radiation enteritis Severe diarrhea ,Steatorrhea Complete bowel obstruction, or
intestinal pseudo-obstruction Severe catabolism with or without
malnutrition when gastrointestinal tract is not usable within 5-7 days
Inability to provide sufficient nutrients/fluids enterally
Persistent GI hemorrhage Acute abdomen/ileus Lengthy GI work-
up requiring NPO status for several days in a malnourished patient
High output enterocutaneous fistula and EN access cannot be obtained distal
to the site.
Parenteral nutrition maybe indicated in the following situations:
Inflammatory bowel disease unresponsive to medical therapy
Hyperemesis gravidarum when nausea and vomiting persist longer than 5 -7
days and enteral nutrition is not possible
Partial small bowel obstruction Intensive chemotherapy / severe
mucositis Major surgery/stress when enteral
nutrition not expected to resume within 7-10 days
Intractable vomiting and jejunal access is not possible
Chylous ascites or chylothorax when EN(with a very low fat formula) does
not adequately decrease output
Assessment Of Nutrition
History Physical ExaminationAnthropometric MeasurementsLaboratory Investigations
Dietary History
It should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems Significant weight loss within last 6 months▪ > 15% loss of body weight▪ compare with ideal weight▪ Beware the patient with ascites/
oedema/amputations
Physical Examination
We will proceed step by step General Appereance Skin and appendages Eyes,Mouth Neurological
Anthropomeric Measures
• Weight for Height comparison• Body Mass Index (<19, or >10%
decrease)• Triceps-skinfold • Mid arm muscle circumference• Bioelectric impedance• Hand grip dynamometry• Urinary creatinine / height index
Biochemical Parameters
Serum Albumins can provide useful information
Low Level Serum Albumin+ raised C-reactive protein
Low level of Serum Albumins+ normal C-reactive
proteins
Rising serum albumins levels
BODY REQUIREMENTS
Caloric Requirement
TEE = REE + Stress Factor + Activity Factor
Rest Energy Expenditure Adults (18-65) 20-30 kcal/kg Elderly (65+) 25 kcal/kg For burns Patients 30-35kcal/kgOther factors: Pregnancy: Add 300 kcal/day Lactation: Add 500 kcal/day Obese or Super obese 15-20 kcal/kg
Stress factor
peritonitis + 15%
• soft tissue trauma + 15%
• fracture + 20%
• fever (per oC rise) + 13%
• Moderate infection + 20%
• Severe infection + 40%
• <20% BSA Burns + 50%
• 20-40% BSA Burns + 80%
• >40% BSA Burns + 100%
Activity Factor
Fluid Requirments
ESTIMATING ADULT FLUID REQUIREMENTS
1. By caloric intake : 1ml/calorie Ex: 1800 calorie diet = 1800 calories x
1ml= 1800ml 2. By body weight and age : Age Fluid requirements 16-55 years 35 ml/kg/day 56-65 years 30 ml/kg/day > 65 years 25 ml/kg/day
COMPONENTS OF PARENTERAL NUTRITION
Macronutrients Micronutrients
Carbohydrate Requirement
Requirement 2g/kg/day 1grams=5kcal/g 40-50 percent of total nutrition
Fat Requirements
Requirement 3 g/kg/day 1 gram= 9kcal/g 30-40 percent of nutrition
Carbohydrate and fat,usually in lipid:carbohydrate ratio of 60:40 or vice versa
Protein/Nitrogen Requirements
Requirement 0.2-0.5g/kg/day 1 gram= 4kcal/g 15-20 percent of nutrition Mild stress 1.0 -1.2 g/kg Moderate stress (most ICU patients)
1.5-2.0 g/kg Severe Obesity 1.5 g – 2.0 g/kg IBW Severe stress, catabolic, burns 2.0
–2.5 g/kg
Nitrogen Balance
Nitrogen Balance = N input - N output
6.25 g protein provides 1 g of nitrogen,as 100grams contains 16 g nitrogen
N input = (protein in g / 6.25) N output = 24h urinary urea nitrogen + non-
urinary N losses
+4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to – 1: Net catabolism
Electrolyte Daily Requirements
Sodium 70 – 100 mEq/day Chloride 70 – 100 mEq/day Potassium 70 – 100 mEq/day Calcium 10 – 20 mEq/day Magnesium 15 – 20 mEq/day Phosphorus 40-60 mEq/day Acetate 0 – 60 mEq/day
Daily Parenteral Vitamins Supplementation
Vitamin A 3300 IU Vitamin D 200 IU Vitamin E 10 IU Vitamin K - 150 mcg Ascorbic acid 100 mg Folic Acid 0.4 mg Niacin 40 mg Riboflavin (B2) 3.6 mg Thiamin (B1) 3 mg Pyridoxine (B6) 4 mg Cyanocobalamin (B12) 5 mcg Pantothenic acid 15 mg Biotin 60 mcg
Daily Parenteral Trace Element Supplementation
Zinc 2.5-4 mg Copper 0.5-1.5mg Chromium 10-15 mcg Selenium 20-60 mcg Manganese 150-800 mcg
Central Venous Access
It can be achieved either by peripheral line indirectly or central line directly
Every route have its own advantages and disadvantages
Decide either for short time or long time
Short term PN may be provided centrally via the subclavian or internal jugular vein.
Long term access can be achieved by
Peripheral Peripherally Inserted Central CatheterLine (PICC line), which is passed via the antecubital vein
Non Cannulated catheters(Hickman and Groshong line)
PICC line
ADVANTAGES
Bed side technique Avoids complications
of central venous catheter
Avoid multiple venous cannulations
Hyperonic solutions can be given
DISADVANTAGES
Trained personnel is needed
Line blockage Mal position Phlebitis Line sepsis thrombosis
Central Catheter(Non Tunneled)
ADVANTAGES
Central access needed
Multiple lumina can be used in acute emergency
Hypertonic solutions can be given
Can be placed for than 6 weeks
DISADVANTAGES
Inserted in theatre Increase infection rate Multiple complications
Central catheter (Tunneled)
ADVANTAGES
Convenient exit site Long lasting than non
tunnels Hypertonic solutions
can be given
DISADVANTAGES
Removal needs surgical dissection
Catheter related sepsis
Other complications
Once the route is decided then we will calculate daily requirements and proceed
Determine Total Fluid Volume
Determine Non- Caloric needs
Determine Protein requirements
Determine Electrolyte and Trace element requirements
Determine need for additives
Lab Investigations
Full Blood Count Renal Function
Test Ca++, Mg++, PO4
2- Liver Function
Test Iron Panel Lipid Panel Nitrogen Balance
weekly, unless indicated daily until stable, then
2x/wk
daily until stable, then
2x/wk weekly weekly 1-2x/wk
weekly
Complications Of TPN
Mechanical
metabolic
infectious
Mechanical Complications
Related to vascular Access• Pneumothorax• Air embolism• Bleeding• Brachial plexus injury• Catheter malplacement• Catheter embolism• Thoracic duct injury
Related to catheter in situ• Venous thrombosis• catheter occlusion
Metabolic Complications
Electrolyte imbalance
•Hypo/hyperglycemia•Hyponatremia,hypokalemia etc
Hepatic •Hepatic steatosis•Acalculous cholecystitis
Acid Base Disorders
Infectious Complications
Insertion site Contamination
Catheter Contamination
•improper insertion technique•use of catheter for non-feeding purposes•contaminated TPN solution •contaminated tubing
Secondary Contamination
•septicemia
References
Adult Enteral and Parenteral Nutrition Handbook, 5th Ed
Oxford Handbook Of Critical Care Internet