PARENTERAL NUTRITION Seminar II - Intensive Care Lesson Plan Background: Parenteral Nutrition Date: 11/07/2005 Duration: 50 min Objectives

Acquire theoretical knowledge related to parenteral nutrition, allowing the acqu isition of knowledge in providing nursing care to a patient subjected to parente ral nutrition. Methodology Methods Media Strategies PowerPoint Computer Data show Expository Parenteral Nutrition Parenteral Nutrition (PN) had its beginnings in t glucose solutions and hydrosaline appeared in ut only in the twentieth century, there was the trition. The proposed Dudrick the University of veness and applicability of the safe use of the the fourteenth century. The firs the early seventeenth century, b systematization of Parenteral Nu Pennsylvania, proved the effecti method.

"Parenteral Nutrition is a method of delivering a highly concentrated solution i ntravenously, to maintain the nutritional balance of the patient. When oral or e nteral nutrition is not possible. " Phipps, Sands and Mavek (2003, p. 1554) "Parenteral Nutrition, is the most sophisticated and complex that artificial nut rition is the administration of almost all nutrients intravenously. Camilo (2001, p. 102) The NP should be exclusively used in patients whose needs can not be achieved me tabólicasnutricionais oral or enteral. It can be administered as a supplement or as a unique form of nutrition. The NP is used when there is gastrointestinal dysfunction, when it needs to be a voided or when it becomes dangerous. The NP is never an emergency therapy. One m ust not impose NP in patients who have no therapeutic hypothesis. Parenteral nutrition is usually administered through a central venous access, bu t can also be administered by peripheral vein. The NP is not the equivalent of f luid that is the administration of intravenous serum maintenance. The objectives of Parenteral Nutrition are: Preventing refeeding syndrome; Maintain or restore the lean body mass, preventin g or correcting malnutrition and its consequences; Determine the needs adequate calories, proteins, vitamins, minerals and fluids to the patient; Maintain asept ic procedures in all techniques for the safety of nutritional support; Escott-Stump (1999) Prevent or correct all the side effects of parenteral nutrition; Return to enter al or oral intake when and if possible; Regular losses and net losses strange as needed. Avoid superhydration; prevent deficiency of essential fatty acids and p revent overuse of linoleic acid; Adapt PN solutions according to the patient's c ondition. There are two types of solutions for parenteral nutrition: isotonic solutions administered through peripheral vein (PPN), usually as an a

djunct to nutritional therapy; hypertonic solutions administered by central ve in (NPC), which frequently provides complete nutritional support. Routes of Administration PARENTERAL NUTRITION Peripheral route Via Central The decision to use NPC or NPP is based: On energy needs; The time period in whi ch the NP is required; the status of peripheral veins; If patients need nutritio nal rehabilitation. Peripheral Parenteral Nutrition When nutritional support is necessary in the short term, this can be provided pe ripherally; glucose solution 50-10%, an amino acid solution from 3.5 to 5% and a lipid emulsion of 10-20%. The load of total fat should not exceed 2.5 g / kg / day. Vitamins, minerals and electrolytes are added, if necessary; The osmolality of the solution of NPP is the limiting factor and should generall y stay below 600 mOsm / L. This means that large quantities of solution are need ed to meet the nutritional requirements, is suitable only for a short term suppo rt (5-7 days) for a mildly malnourished patient. In order to accomplish NPP is necessary: there is a reasonable or good upper lim b venous system, otherwise, you have to use the NP Central. If peripheral venous access is not possible or sufficient, and if you keep the digestive failure and need for nutritional therapy, we use the NPC should be considered as a last opt ion. Central Parenteral Nutrition "The Central Parenteral Nutrition is a method of providing complete nutritional support in the gastrointestinal tract is spared, introducing nutrients assimilab le into a central vein, usually the superior vena cava. Mahan and Arlin (1995, p.546) Basically, their principles are no different from the NPP, but the requirement o f a central vein catheter significantly increases the risk of complications,€als o increased by the fact that power supply more nutrient input with possible meta bolic overload. Thus require nursing care more differentiated and in greater qua ntity. NPC solutions generally consist of 25-35% dextrose, 3-5% amino acids, electrolyt es, minerals and vitamins. Lipids may also be having between 10 and 20%. The cen tral catheter should be used only for the nutrient solution and not for blood pr oducts or medication. Unlike the NPP, which provides maximum 1800Kcal/dia, the N PC can remove enough energy for anabolism, by 4000 kcal / day. Nominations for the NPC can be grouped according to frequently occurring situati ons, which are: Diseases in which the NPC is the adjuvant therapy with demonst rated efficacy; Diseases in which the NPC is controversial adjuvant therapy; NPC ambulatory. CALCULATION OF ENERGY NEEDS "Today's formula is the Harris Benedict equation to predict the most used, based on indirect calorimetry and determines the basal energy expenditure (ie the ene rgy required to meet the needs of the body at rest)." Davis et al (2003)

GEB (Man) = 66.42 + (13.75 x weight kg) + (5 x height cm) + (6.77 x Age years) G EB (Women) = 655.1 + (9.65 x weight kg) + (1.7 x height cm) + (4.68 x Age years) "General rule, it is accepted as valid for adult, an average caloric intake of 2 0-25 kcal / kg / day." Davis et al (2003, p.51) FACTORS THAT INCREASE the basal metabolic rate and therefore energy needs: - Activity - specify the dynamic action of feeding; - pain, anxiety and fear - c atabolism (Induced by surgery, trauma, sepsis, burns); - Hyperthyroidism - pheochromocytoma - hyperthermia. FACTORS Slow down basal metabolic energy requirements and therefore: Home, (in prolonged rest, the basal energy expenditure is reduced by about 10-15 %), mechanical ventilation; Drugs: barbiturates, muscle relaxants and curarizant es pancuronium, beta blockers (propranolol), hypothyroidism, hypothermia; Coma i nduced by barbiturates. SOURCES OF ENERGY Carbohydrates, Proteins, Lipids, Vitamins, Electrolytes, Trace Elements • Carbohydrates are one of the pillars of energy artificial nutrition; solutions are stable, easy to obtain and are suitable for intravenous administration Gluc ose is usually this carbohydrate is ready and fully applied, with no toxic effec ts to the body. Have low caloric density (4 kcal / g), its concentration in the NP contributes significantly to the determination of osmolality nutrient mixture . Camilo (2001) NP, glucose typically provides 50-55% of total calories Glucose is not metaboliz ed cause hyperglycemia, glycosuria, osmotic diuresis and dehydration possibly hy per-osmolar (this may lead to coma) According to "large loads of glucose can inc rease minute ventilation, the production of carbon dioxide, respiratory quotient and oxygen consumption. " Mahan and Arlin (1995, p.548) Lipids In NP, the lipids are administered in the form of emulsions "(...) are rich sour ces of essential fatty acids, have high caloric density, both on a 10% to 20%, p roviding 1.1 or 2.0 kcal / ml, respectively, are isotonic by the addition of gly cerol, which allows the formulation of the lipid system, in order to meet all nu tritional needs from peripheral veins, and have a toxicity significantly small. " Riella (1993, p.88) "The advantage should point to the high caloric density (9 kcal / g fat), low os molarity and low respiratory quotient (low CO2 production)." Camilo (2001) "Lipids may not be the sole source of energy supplied, for some tissues (brain, leukocytes, etc.). Require glucose for their metabolism. As a rule, the maximum percentage of calories supplied by fat shall not exceed 50% of total caloric val ue, as a routine should be 30% of the total caloric content. "

Camilo (2001, p.126) the daily quantity to be supplied, if no contraindication, should lie between 0.8 and 1.5 g / kg actual weight / day. Daily administration of lipid emulsions is absolutely contraindicated in dyslipi demias and severe hypertriglyceridemia (greater than 250 mg / dL), even reaction ary. Their use should be cautious (0.8 g / kg / day) in sepsis syndrome, adult r espiratory distress and severe liver failure. (Camilo, 2001) Protein The protein contained in mixtures for NP is the source of nitrogen needed for pr otein synthesis. It comes in the form of crystalline Laminoácidos and can used i n any case as the alternative source of nitrogen di-and tripeptides. Vitamins Consider two major groups of vitamins, called soluble, formed by the whole group B, including folic acid, vitamin C and biotin, and the fat soluble, which consi st of vitamins A, D, E and K. (Davis et al, 2003) Are marketed mixtures of fat-soluble vitamins, in general for administration wit hin the lipid emulsions. As for the water soluble, must be used a multivitamin t hat covers recommended needs. Added to the solution of glucose. Electrolyte "Sodium, chlorine, potassium, calcium, magnesium and phosphate minerals are need ed in quantities above 200 mg / day. These micronutrients are essential for main taining the water balance, heart function, the mineralization of the skeleton, n ervous system function, and muscle enzyme. Richardson cited by Riella (1993, p.90) Phosphorus and potassium are essential for protein synthesis. Without proper match, we can develop a hypophosphataemia dangerous in presence of rich food in to energy. Calcium is needed to balance the infusion of phosphate excessive amounts of sodium may provide important water retention, with conseq uent edema and / or dilution hyponatremia. The amount of chlorine should be appr oximated to that of sodium, to prevent acid-base imbalance Some solutes of ami no acids and some shopping bags, have electrolytes in their composition, they sh ould be counted towards the daily amount to administer. Trace elements "Trace elements are inorganic metals that have daily needs less than 100 mg in t he body and whose reserves are less than 4g. Currently nine trace elements are c onsidered essential to the human body: iron, iodine, zinc, copper, chromium, man ganese, selenium, molybdenum and cobalt. Richardson cited by Riella (1993, p.91) When not supplied in sufficient quantities, lead to the emergence of a charact eristic syndrome of disability of each element. Zinc is essential for the synthesis of numerous metalloenzymes, interference w ith protein synthesis and wound healing. There solutes marketed with several trace elements in different concentrations . One ampoule daily, added to the solution of amino acids or the stock market, p rovides a proper basic maintenance needs.

"In the administration of trace elements intravenously is necessary to take spec ial care to avoid complications and to consider the toxic quantities of the elem ents that are already present in the solutions of NPC, as a contaminant." Mahan and Arlin (1995, p.550) COMPLICATIONS OF NP "The NP has been used routinely since 1968 (...) despite its widespread use, bas ed on principles defined, fully established, the NP was not devoid of risks." Riella (1993, p.120) COMPLICATIONS OF NP For Camilo (2001), divided into: Mechanical Metabolic Septic

Mechanical complications • • • • • • • • Pneumothorax Hemothorax Hematoma local hemomediastinum Hidromedi astino Subcutaneous emphysema venous thrombosis embolism gas embolism • Incorrec t placement of the catheter • Arrhythmias • • • Obstruction of the catheter Hydr othorax Most occur in an attempt to placing the catheter in the subclavian artery, are r are in the puncture of internal jugular. Mechanical complications Venous air embolism can occur during catheter placement at the time of the unf itness of the syringe needle; catheter embolism - during placement of the cath eter when there is difficulty in passing the needle bevel, especially with very sharp; arrhythmias are rare except embolism in the catheter during its placeme nt or when the tip is positioned in the right atrium. Mechanical complications Venous thrombosis is frequent in NP long-term catheters and of poor quality. S ometimes, in the subclavian puncture, the catheter does not progress to the cava , but follows a route up to the distal end of the internal jugular; obstructio n of the catheter is always due to poor nursing care: angled catheter during the performance of the dressing insufficient monitoring of the rate of infusion. Metabolic complications The main complications are linked to metabolism: Glucose; Lipids; amino ac ids; Electrolyte, vitamins and trace elements. Other: Bleeding; Anemia; psychotic reactions. Most schemes do not result from adequate for the patient concerned. Sepsis The catheter sepsis is the most common complication e NPC; The frequency of sepsis varies between 2 and - Septic episode, not explained by another infectious removal of the catheter - requires confirmation from ture from the tip of the catheter and blood cultures. and potentially more sever 33%; It is defined by: focus;€- Resolved with the the agent, isolated in cul

Causative agents of Sepsis Stafilococus epidermidis; Stafilococus aureus; Klebsiella pneumoniae; Candida albicans. Sepsis is a major cause of discontinuation of nutritional therapy. Davis [et al.] (2003) The risks of contamination of the solutions and the catheter are enhanced by: physical situation presented by the patient; a hospital; presence of prote in-calorie malnutrition. The NURSE is responsible for: Maintenance of blood flow reduction of contami

nation risks during administration of the nutrient solution NURSING CARE The PARENTERAL NUTRITIONAL SUPPORT IN PATIENTS "The role of nurses and nursing in parenteral nutrition support can be developed according to nursing systems proposed in order: educational support system: ori entation, preparation and emotional support of patients and families about the p rocedure, actions concerning the insertion of the catheter; actions concerning t he administration of the solution, catheter maintenance and monitoring of the pa tient. " Riella (1993, p.406) EDUCATIONAL SUPPORT SYSTEM According Riella (1993), the nursing care at this stage aims at: - Reduce stress and anxiety of the patient and family - Seek the participation o f both the parenteral nutritional support, thus ensuring that media can promote the success of therapy. To minimize the anxiety and get the patient and family participation in nutritio nal support, it must be flushed: - Check the level of understanding and motivation of the patient and family - wa rn patients and families about the benefits and risks, highlighting the importan ce of participation during the process - Explain the route of administration of the solution - Provide contacts with other patients on parenteral nutrition supp ort and visits from friends and relatives; -Explain the likely complications that may arise;-Explain why the trichotomy (th e hemifase, side of the neck of the hemithorax) and degreasing of the areas ment ioned; To prepare the unit and equipment required for the insertion of the cathe ter;-To concurrent with disinfection solution recommended by the Ministry of Hea lth PARENTERAL NUTRITION into a peripheral vein Objectives: - To keep the weight stable or with slight initial reduction; - Making a less negative nitrogen balance. Avoid: - Sepsis - Dehydration or water retention; - Electrolyte imbalance - scle rosis of the veins or thrombophlebitis. Procedures 1-Explain the technique to the patient, 2-Wash hands thoroughly with soap or ant iseptic solution, 3-Place the material in order in the sterile field, 4-The nurs e chooses the puncture site after the evaluation of the venous system. Use mediu m-size vein in the upper limbs. Starting at the distal veins but do not use hand veins, 5-The nurse put the mask, disinfect the puncture site; 6-Place sterile g loves; 7 - Put "minicatéter or catheter, 8 - Adapts protractor / bottle system already put in 100-500 cc of saline, 9 - Make sure that there is a good flow without int ravenous extravasation or pain; 10 - Put solutes or Pocket NP; 11 - Do I think e specially with transparent or bandages and adhesive. And the protractor fixed to the arm; 12 - If required, put "nitradisk 5 mg" (think of transdermal nitroglyc erin), approximately 5 cm above the puncture site. Administration Regulations 1 - Prepare the solutions / purse as prescribed (the bag must be removed from th e refrigerator 30 minutes before the start of infusion), 2 - Verify integrity of bottles / bags, turbidity, color, particles in the solution if present returned

to the pharmacy; 3 - Check the validity of the solution (if bottle) or time of administration and patient name on the label of the bag, and 4 - Wash hands thor oughly. Disinfect the stoppers of vials with iodine solution; 5 - Add additives as required, immediately before administration. Properly label the bottles, wear gloves. This step is not necessary to the use of grants, 6 Use sterile IV infusion. Place new sterile gloves, 7 - Adopt the system bottle / bag, 8 - Fill the system - expel air pockets; 9 - Adapting to the catheter syst em / extender; 10 - The simultaneous infusion of two solute system requires a Y or three-way st opcock, when the scheme includes concurrent lipids, they must first be put in ha nd. The bag must be prescribed with composition for peripheral vein, as indicate d in the prescription sheet and the label; 11 - Adjusting the infusion rate as p rescribed, constant for the indicated time. Ever accelerating pace,€unless presc ribed by a doctor; 12 - The duration of the infusion solution / bag may not exce ed 24 hours. Change the system every 24 hours; 13 - The NPP can be interrupted f or the administration of other medication. Should be discontinued if there are l ipids in progress; 14 - For analysis, collect blood from the arm controlateral; 15 - Register at every turn (if required): Glycosuria (notify your doctor if ≥ 2 + BMtest> 180 mg%) and water balance; 16 - If the temperature exceeds 38 ° C, n ot explained by another cause: - Replace systems and bottles / bags NP - Raise t hink, if necessary, to search for phlebitis;-If phlebitis occurs immediately cha nge the puncture site to the arm controlateral. 18 - Changing the site of venipu ncture every three days, or whenever the patient mentions pain or phlebitis; 19 - Track changes observed in the patient: tremors, pallor, impaired consciousness , respiratory rate. PARENTERAL NUTRITION IN CENTRAL VEIA Objectives: - The weight may remain stable, decrease or increase slightly - Tryi ng to balance or positive nitrogen balance. Avoid: - Sepsis - Dehydration or wat er retention; - Air embolism - Hypoglycemia or hyperglycemia - Electrolyte imbal ance - Liver changes - Deficiency of fatty acid deficiency - vitamins and trace elements. Procedures 1 - Explain the technique to the patient, 2 - Wash hands with soap / antiseptic, 3 - Place the material in order; 4 - Place the patient in Trendlenburg, with ro ll over the shoulders (for subclavian puncture), 5 - Make shaving a wide area ne ar the puncture site; 6 - The nurse involved in the placement of the catheter; 7 - Put this, the protractor and the perfusion system, previously adapted to ser um bottle (and after the expulsion of air) are connected to the catheter, 8-Begi n infusion of isotonic serum and verify flow; 9-Secure the catheter to the skin with silk. Record the overall length of the catheter; 10 - Disinfect the area ar ound the catheter with iodine solution, always in radial motion of the insertion point to the periphery; 11-Check for proper adjustment of the catheter / extend er / system; 12-Put a sterile dressing, leaving the catheter connection / protractor to avoid angulations; 13-Adhesive Write on the date of release, the external length of c atheter and initials of who placed it. Register in the process of the patient; 1 4 - Make Rx chest and, after verifying the correct positioning in the superior v ena cava near the entrance to the right ear, start with the NP prescribed rhythm and composition, 15 - Pay attention to screening for complications during place ment catheter. I think the catheter Detailed rules 1 - Explain the technique to the patient, 2 - Place it in the sup

ine position without pillow, 3 - Wash hands with antiseptic soap. The following maneuvers are performed with a protective sterile gloves, and 4 - to adapt the s ystem to the bottle or bag and fill that with solute and expel air bubbles, 5 Adapting the system to the protractor and fill this with the solute; 6 - Change the protractor with the patient in apnea, 7 - Check security of all adjustments. Standards Administration 1-Prepare solutions or choose from the bag, according to the prescription; two-V erify integrity of bottles / bags: turbidity, color, particles in the solution i f present return to the pharmacy, 3-Check validity of solution (if bottle ) or t ime of administration and patient name on the label of the bag, 4-Wash hands tho roughly. Disinfected with iodine solution corks from bottles, 5 Add-additives (e lectrolytes, vitamins, trace elements, insulin) as prescribed, immediately befor e administration. Conveniently label them weak. Use 6-sterile IV infusion set, 7 -adapt the system to the bottle / bag, 8-Fill the system to expel the air bags; 9-Fit system to the catheter / protractor with a protective pad solute iodine or sterile gloves - risk of contamination, 10-connections system / catheter must b e made with patient supine if possible after deep expiration: 11-Regulating infu sion rate prescribed constant for the time period indicated. 12-No bottle / bag must have an infusion period exceeding 24 hours. Changing the infusion every 24 hours, 13 a continuous infusion of two solute system requires a Y or three-way s topcock, 13-The NPC should not be interrupted for the administration of other me dications, however there are some exceptions, 14 - Never assess central venous p ressure through the catheter. Avoid its use to administer another medication; 15-Register at every turn - or BMtest Glycosuria - Temperature, pulse and blood pressure (from 4 / 4 hours in the first 48 hours);€- Water balance in unstable p atient or when required; 16-If fever above 38 º C, not explained by another caus e: Replace-systems and bottles / bags NP is prescribed;-Cultures: blood, sputum, urine. Find-inflammation / infection at the catheter entry point, temperature-R egister on April 4 hours. 17-Do I think the catheter 2-3 times a week, whenever it is dirty or as the service protocol; 18 - Track changes observed in the patie nt, tremor, pallor, impaired consciousness or respiratory rate. Related to patient care Participate in the support group's nutritional assessment of the patient's res ponse to PN; Psychological support; Assist in the early diagnosis of complic ations, hearing the complaints and expectations; Detect signs of glucose intol erance; Observe the signs of hyperglycemia; Observe signs of osmotic diuresi s; Observe electrolyte abnormalities and acid-base; Observe signs of lack of fat and trace elements; Observe signs of intolerance to lipid emulsions; de tect signs of infection and sepsis; Check temperature every four hours; Stri ct control the intake and excretion; Look for signs of infiltration of liquid; ingurgitation Observe the veins of the neck, arms and hands - Reduce the risk of infection. Catheter-related care Maintaining the patency of the catheter; Avoid the proliferation of microorg anisnos catheter; Preventing complications of mechanical thrombectomy and disp lacement of air for wide circulation through the catheter; Avoid pulled forwar d, disconnecting the catheter or equipment; In the presence of secretion at th e catheter insertion site, to gather material culture; Change the equipment ev ery 24 hours, protecting the glass from direct sunlight. Care related to solution Request the bottles to the pharmacy NP two hours before administration; Obse rve the appearance of the solution (cloudiness, precipitation and the presence o f particles); Observe the vial labels (name of patient, type of solution, date of preparation); Calculate drip and record label in the beginning and end of

the solution; Wash your hands when you install the solution bottle, which shou ld be administered at room temperature; Control drip every hour; Detect leak ing of nutrient solution; Advise the patient the risks arising from the increa se or reduction of drip; Avoid sunlight on the solution; The management of e ach bottle of nutrient solution should not exceed 24 hours and the lipid emulsio n, 12 hours; dripping from lipid emulsion should be slow at first and graduall y increased. Monitoring NP "The monitoring is mandatory and most severe cases require greater vigilance in order to prevent complications, improve and evaluate effectiveness." Camilo (2001, p.91) "The administration of nutrient mixtures may be associated with mechanical compl ications, metabolic and infectious diseases." Freitas (2003, p.161) Objectives of Monitoring: Detect and prevent complications; Determine whether the nutritional contribu tions are being made properly, Document the positive clinical benefits. Frequency of monitoring depends on several factors: - State and evolution of the patient - System of nutrition;-Term;-type complications. EVALUATION OF RESPONSE TO NUTRITIONAL SUPPORT The assessment of patient response to nutritional support is a progressive proce ss, consisting of anthropometric measurements, physical examination and biochemi cal evaluation. (Davie et al, 1996) • • • • • • Weight, physical examination, mu scle function, visceral proteins, cellular immunity, balance nitrogen. Healing ensured adequate food ...! Work done by: Ana Claudia Andreia Pereira Bruno Ramos Carla Patricia Gaspar Marta Afonso Perei ra Thanks for listening!