Parenteral Nutrition. Objectives To define Parenteral Nutrition Therapy To explain parenteral...
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Parenteral NutritionParenteral Nutrition
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Objectives
• To define Parenteral Nutrition Therapy • To explain parenteral nutrition components• To describe monitoring parameters of parenteral
nutrition
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Definition
Parenteral nutrition is partial or total nutrition administered intravenously. A peripheral or central vein is used for access.
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Indications: Parenteral Nutrition
• Non-functional gastrointestinal tract• Inability to use the gastrointestinal tract
– intestinal obstruction– peritonitis– intractable vomiting– severe diarrhea– high-output enterocutaneous fistula– short bowel syndrome
– severe malabsorption. • Need for bowel rest
Palliative use in terminal patients is controversial.
ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA
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Contraindications: Parenteral Nutrition
• Ability to consume and absorb adequate nutrients orally or by enteral tube feeding
• Hemodynamic instability
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Formulas: Parenteral Nutrition
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Central Parenteral Nutrition
Selection depends on caloric requirements, volume to be administered and patient condition, as well as final concentration of components:
•Amino acids > 5%•Dextrose > 20%•Lipids•Includes vitamins, minerals, and trace elements•Osmolality > 700 mOsm/kg H2O
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Formulas: Parenteral Nutrition
Dextrose
• Provides 3.4 kcal/g• Can be the only source of energy• Dextrose infusion rate should not exceed 5 mg/kg/min• Closely related to solution osmolality
Hill GL, et al. Br J Surg 1984;71:1
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Formulas: Parenteral Nutrition
Amino Acids
• Standard concentrations can vary between 5% and 15%• Energy value of amino acids (4 kcal/g)• Nitrogen (g) = protein (g) / 6.25
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Sources of Protein: Parenteral Nutrition
Customize this slide for your situation. Indicate the available parenteral protein solutions for your country; i.e., standard
and specialized solutions
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Formulas: Parenteral Nutrition
Lipids
• Prevent essential fatty acid deficiency• Non-protein source of kcal. Recommended dose
1 g/kg/day• Available in 10%, 20% and 30% concentrations• Included as LCT or a mix of MCT/LCT at 10% and 20%• Added to basic parenteral nutrition solutions or
administered individually
Trimbo SL, et al. Nutr Supp Serv 1986;6:18
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Formulas: Parenteral Nutrition
Lipids
• Less hyperglycemia• Lower concentrations of serum insulin• Less risk of hepatic damage• High doses can interfere with immune functions • High infusion rates can affect respiratory functions• Should be used with care in:
– Hyperlipidemia– Symptomatic atherosclerosis– Acute pancreatitis with hypertriglyceridemia
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Formulas: Parenteral Nutrition
Electrolytes
• Calcium, magnesium, phosphorus, chloride, potassium, sodium, and acetate
• Forms and amounts are titrated based on metabolic status and fluid/electrolyte balance
• Must consider calcium-phosphate solubility
Alpers DH, et al., eds. In: Manual of Nutritional Therapeutics. Little, Brown and Company; 1995
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Formulas: Parenteral Nutrition
Vitamins and Minerals
• In general, amounts below daily recommended intake for healthy people, but nonetheless sufficient to cover requirements, are added to oral or enteral formulas
• Added daily to parenteral nutrition• Acute illness, infection, preexisting malnutrition, and
excessive fluid loss increase vitamin requirements
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Formulas: Parenteral Nutrition
Trace Elements
• Include daily zinc, copper, chromium, and manganese for patients with kidney or liver failure
• Different requirements dictated by patient and pathology• Patients under extended parenteral nutrition require the
addition of iron and selenium
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Peripheral Parenteral Nutrition
Selection of peripheral access depends on clinical situation, requirements, tolerance to volume, and final formula concentration
•Osmolality < 700 mOsm/kg•Total kcal limited by concentration and ratio to
volume being administered•Include ½ of the recommended electrolytes for PN
Torosian MH, ed. In: Nutrition for the Hospitalized Patient. Marcel Dekker Inc.; 1995
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PN: Types of Infusion
• Continuous – Total volume of formula is administered over a 24 hour period
• Cyclic – Volume is administered in one period, with infusion adjustments and a period of rest
• Selection of infusion type depends on patient’s condition• Use a parenteral infusion pump
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Monitoring Patient on Parenteral Nutrition
Metabolic
• Glucose• Fluid and electrolyte balance• Renal and hepatic function• Triglycerides and cholesterol
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992
Assessment
• Body weight• Nitrogen balance• Plasma protein• Creatinine/height
index
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Summary
• Parenteral nutrition supplies partial or total nutrition by venous access
• Total parenteral nutrition components supply all required nutrients
• Metabolic monitoring and changes in solution components are needed to maintain adequate metabolic balance