Nutritional physiology

Nutrition for adults,parential nutrition and overview

Parential nutrition (PN) is arguably the most complex pharmaceutical practice used in clinical practice. It
is an admixture of over 60 individual chemical entities that must be chemically, physically and
microbiologically sound to be safely infused. Mistake associated with PN can have fatal consequences.

INDICATION (what is is known for)

In recent years a proactive and interventional approach to enteral nutrition has seen an overall decrease
in the use of PN. Particularly in the peri-operative period. In addition the use of enhanced recovery
program has reduced the incidence and duration of post operative ileus. The basic indication for PN is
intestinal failure which can be short, medium or long term.

CAUSES OF INTESTINAL FAILURE INCLUDE:

1. An inaccessible gut e.g a bowel obstruction secondary to adhesion, tumors or stutures.

2. A malabsorptive or high output state such as severe mucositis graft vs host diseases or high
output stoma.
3. A shortened or absent gut
4. A dysmotility syndrome or post operative ileus.
The need to provide PN is dependent on the duration of intestinal failure and nutritional status
of the patient. Any intestinal failure persisting for a more than few days should be considered
for a PN.
PRESCRIPTION
To prescribe an appropriate (PN) Regimen a full assessment is required by a competent
praticioner or variably by a multi dispensary nutritional team. A recent enquiry into care of
hospital patient receiving PN conducted by the national confidential enquiry into patient
outcome and death found that patient where inadequately accessed before starting PN. Ideally
patient nutritional fluid and electrolyte requirement should be reviewed in the light of their
sex,age weight and size,piror nutrition status and intate, current medical condition, past medical
history, fluid balance,drug therapy and venous access. Current requirement are initially
calculated by the nutritional team using predictive formula such as :
1.

Scho field formula and then adjusted according to stress and physical activity. This provides a starting
point of which to adjust the regimen depending on patient response. Weight gain will not be archived
for patients receiving PN if they are catabill in the Sense that patients with ongoing sexes, infection/
inflammation. Therefore weight stabilization is usually the goal of short to medium term parietal
nutrition. Excess calorie provision will result in central adiposity and fatty liver rather functional weight

COMPOSITION OF PN
The prescribe PN should provide a balanced supply of major nutrient (lipid, carbohydrates,amino acid)
with adequate electrolyte, vitamins and trace elements. Carbohydrates is provided as glucose which
provide approximately 4 g/kcal. About 40-60% of all patients total energy is usually provided in this
form. It is important to ensure that the glucose oxidation rate of 4-7 milligram is not exceeded since the
result in hyperglycemia hyper or smaller dehydration or excessive Co2 production lipids are provided as
triglycerides. The first generation lipid emulsion where from soya bean oil and provided long chain
triglycerides which are high in Omega 6- Fatty acid. Newer generation lipid emulsion contains
triglycerides.

Source from olive oil/Omega 9, coconut oil or medium chained triglycerides of fish oil or Omega 3.

Each of the newer emulsion have potential beneficial properties. Lipid provisions should not exceed 1.5
g/kg per day and ideally should be less than these particularly for patients receiving PN long term.

Amino acids content of (PN) should be sufficient to meet patient requirement which will be affected by
factors such as wound healing and fluid losses. The fluid and electrolyte prescribe in PN should be taken
into consideration base line requirement. Any addition loses and concomitant administration of fluid
through electrolyte and medicine different salts can be used to Adjust the Acid - base calculation of PN.

ADMINISTRATION

Appropriate various access should be secured before starting PN. Peripheral cannulate or canola has
been used with some success however, patient should be monitored regularly for signs phlevivities. For
peripheral administration, the osmolarity of PN should be as low of possible. A max of 900 mini moles is
recommended. Peripherally inserted central catheters and midlines are used 3-6 wks.

Osmolarity of the PN shouldn't exceed 1200 mini moles.

Peripherally inserted central catheters can stay in a place for up to a year if they are well taken care of.
Temporarily, central lines needs to be changed frequently but are appropriate for short term PN. Long
term veinous catheters should only be considered when there is little risk of sepsis or infection. PN
should be infused via a dedicated lumen and through an appropriately sized inline filter.

MONITORING

Effective monitoring and review is one of the most important aspect of PN provision. Routine monitoring
should include vital signs, blood glucose , fluid balance, blood and urine for chemistry test. The purpose
for monitoring is to ensure that the prescribe regimen isolerated by the client or patient and than any
complications are detected easily so that action can be taken promptly.

COMPLICATIONS

The most common complications of PN are fluid and electrolyte imbalances which are relatively easy to
correct provided that appropriate steps to do so are taken quickly . This can be done so through
administering additional fluids or electrolyte or through tailoring or adjustment of the PN prescription.
Intravenous line sepsis can be life threatening if not identified and treated quickly. The cause up action
is dependent on the type of veinous access and the condition of the patient with removal of the line is
appropriate.

Prevention of infection is always better than cure.so comprehensive training for nursing staff
administering PN and care protocol are essential.

SUMMARY

- **Nutritional Physiology**

- **Nutrition for adults, parenteral nutrition, and overview**

- Parenteral nutrition (PN) is a complex pharmaceutical practice used in clinical settings.

- It involves an admixture of over 60 chemical entities that must be chemically, physically, and
microbiologically sound for safe infusion.

- Mistakes associated with PN can have fatal consequences.

- **Indications**

- The use of PN has decreased due to a proactive approach to enteral nutrition and enhanced recovery
programs.

- The primary indication for PN is intestinal failure, which can be short, medium, or long-term.

- **Causes of Intestinal Failure**

- Inaccessible gut: bowel obstruction due to adhesions, tumors, or strictures.

- Malabsorptive or high output state: severe mucositis, graft-versus-host disease, or high output
stoma.

- Shortened or absent gut.

- Dysmotility syndrome or postoperative ileus.

- **Prescription**

- A full assessment by a competent practitioner or a multidisciplinary nutritional team is required to

prescribe an appropriate PN regimen.

- Nutritional fluid and electrolyte requirements should be reviewed considering sex, age, weight, size,
prior nutritional status, current medical condition, past medical history, fluid balance, drug therapy, and
venous access.
 - Current requirements are calculated using predictive formulas like the Schofield formula and
adjusted based on stress and physical activity.

- Weight stabilization is usually the goal of short to medium-term parenteral nutrition.

- **Composition of PN**

- The prescribed PN should provide a balanced supply of major nutrients (lipids, carbohydrates, amino
acids), electrolytes, vitamins, and trace elements.

- Carbohydrates are provided as glucose, providing approximately 4 kcal/g.

- Lipids are provided as triglycerides. Newer lipid emulsions contain triglycerides from olive oil/Omega
9, coconut oil, or medium-chained triglycerides of fish oil or Omega 3.

- Amino acid content should meet patient requirements, considering factors like wound healing and
fluid losses.

- **Administration**

- Appropriate vascular access should be secured before starting PN.

- Peripheral cannulation or cannula can be used, but patients should be monitored for signs of
phlebitis.

- Peripherally inserted central catheters and midlines are used for 3-6 weeks.

- Temporarily central lines need to be changed frequently but are appropriate for short-term PN.

- Long-term venous catheters should only be considered when there is a low risk of sepsis or infection

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- **Monitoring**

- Effective monitoring and review are crucial in PN provision.

- Routine monitoring includes vital signs, blood glucose, fluid balance, and blood and urine chemistry
tests.

- The purpose is to ensure the prescribed regimen is tolerated by the patient and detect any
complications promptly.

- **Complications**

- Fluid and electrolyte imbalances are common complications of PN but are relatively easy to correct.
 - Intravenous line sepsis can be life-threatening and requires prompt identification and treatment.

- Prevention of infection is essential through comprehensive training for nursing staff and proper care
protocols.