This action might not be possible to undo. Are you sure you want to continue?
Presenter:Dr Sachin Anand Mod: Dr Sanjeev Aneja
Parenteral Nutrition (Definition)
Components are in elemental or “predigested” form Protein as amino acids CHO as dextrose Fat as lipid emulsion Electrolytes, vitamins and minerals
Parenteral Nutrition (PN) Definition
Delivery of nutrients intravenously, e.g. via the bloodstream. Central Parenteral Nutrition: often called Total Parenteral Nutrition (TPN); delivered into a central vein Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral vein
(B) When SNS is indicated. EN should generally be used in preference to PN. PN should be used when the gastrointestinal tract is not functional or cannot be accessed and in patients who cannot be adequately nourished by oral diets or EN. (B) The anticipated duration of PN should be >7 days .Indications for PN When Specialized Nutrition Support (SNS) is indicated.
Common Indications for PN Patient has failed EN with appropriate tube placement Severe acute pancreatitis Severe short bowel syndrome Mesenteric ischemia Paralytic ileus Small bowel obstruction GI fistula unless enteral access can be placed distal to the fistula or where volume of output warrants trial of EN . .
osmolarity. and volume . and subclavian vein catheters in the hospital setting Peripherally inserted central catheters (PICC) are inserted via the cephalic and basilic veins Central access required for infusions that are toxic to small veins due to medication pH. internal jugular lines.PN Central Access May be delivered via femoral lines.
Venous Sites for Access to the Superior Vena Cava .
PICC Lines (peripherally inserted central catheter) PICC lines may be used in ambulatory settings or for long term therapy Used for delivery of medication as well as PN Inserted in the cephalic. or median cephalic veins and threaded into the superior vena cava Can remain in place for up to 1 year with proper maintenance and without complications . median basilic. basilic.
PN: Peripheral Access PN may be administered via peripheral access when Therapy is expected to be short term (10-14 days) Energy and protein needs are moderate Formulation osmolarity is <600-900 mOsm/L Fluid restriction is not necessary .
Parenteral Nutrition Macronutrients & Micronutrients .
Macronutrients: Carbohydrate Source: Properties: Monohydrous dextrose Nitrogen sparing Energy source 3.4 Kcal/g Hyperosmolar Recommended intake: 2 – 5 mg/kg/min 50-65% of total calories .
Macronutrients: Carbohydrate Potential Adverse Effects: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems Hyperglycemia .
0 Kcal/g EAA 40–50% NEAA 5060% Glutamine / Cysteine Recommended intake: 0.8-2.0 g/kg/day 15-20% of total calories Source: .Macronutrients: Amino Acids Crystalline amino acids— standard or specialty Properties: 4.
Macronutrients: Amino Acids Potential Adverse Effects: Increased renal solute load Azotemia .
5 g/kg/day (not >2 g/kg) 12 – 24 hour infusion rate .Macronutrients: Lipid Source: Properties: Safflower and/or soybean oil Long chain triglycerides Isotonic or hypotonic Stabilized emulsions 10 Kcals/g Prevents essential fatty acid deficiency Recommended intake: 0.5 – 1.
or 2% to 4% kcals given as linoleic acid Generally 500 mL of 10% fat emulsion given two times weekly or 500 mL of 20% lipids given once weekly will prevent EFAD Usual range 25% to 35% of total kcals Max.Macronutrients: Lipids Requirements 4% to 10% kcals given as lipid meets EFA requirements. 60% of kcal or 2 g fat/kg .
Macronutrients: Lipids Potential Adverse Effects: Egg allergy Hypertriglyceridemia Decreased cell-mediated immunity (limit to <1 g/kg/day in critically ill immunosuppressed patients) Abnormal LFTs .
Parenteral Base Solutions Carbohydrate Carbohydrate Amino acids Amino acids Available in concentrations from 5% to 70% Available in concentrations from 5% to 70% D30.5% and 10% generally used for manual mixing 8.1 kcal/ml 20% emulsions = 2 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA. 5.5. 7. 3. 20% solutions Available in 3. 20% solutions 8. 30% emulsions = 3 kcal/ml (used only in mixing TNA.5.5. D50 and D70 used for manual mixing D30. 8. 15. 5. 8. 15.5% and 10% generally used for manual mixing 10% emulsions = 1. D50 and D70 used for manual mixing Available in 3. 7.5.1 kcal/ml 10% emulsions = 1. not for direct venous delivery) not for direct venous delivery) Fat Fat . 10. 3. 10.
Other Requirements Fluid—30 to 50 ml/kg (1.5 to 3 L/day) L/day) Sterile water is added to PN admixture Sterile water is added to PN admixture to meet fluid requirements to meet fluid requirements Use acetate or chloride forms to Use acetate or chloride forms to manage metabolic acidosis or alkalosis manage metabolic acidosis or alkalosis Electrolytes Electrolytes Vitamins: multivitamin formulations Vitamins: multivitamin formulations Trace elements Trace elements .5 to 3 Fluid—30 to 50 ml/kg (1.
recommendations are lower than DRIs Salt forms of electrolytes can affect acidbase balance .Electrolytes/Vitamins/Trace Elements Because parenterally-administered vitamins and trace elements do not go through digestion/absorption.
vitamin C.Adult Parenteral Multivitamins New FDA requirements published in 2000 replacing NAG-AMA guidelines Increased B1. added Vitamin K MVI Adult (Mayne Pharma) and Infuvite (MVI-13) from Baxter contain Vitamin K and are consistent with the new FDA guidelines MVI-12 (Mayne Pharma) does not contain Vitamin K . folic acid. B6.
Parenteral Nutrition Vitamin Guidelines Vitamin A IU D IU E IU K mcg C mg Folate mcg Niacin mg FDA Guidelines* 3300 IU 200 IU 10 IU 150 mcg 200 600 40 B2 mg B1 mg B6 mg B12 mg Biotin mcg B5 dexpanthenol mg Vitamin FDA Guidelines* 3.6 6 6 5.0 60 15 .
5 mg 60-100 mcg 2.3-0.Daily Trace Element Supplementation for Adult PN TRACE ELEMENT Chromium Copper Manganese Zinc INTAKE 10-15 mcg 0.5-5.0 mg .
Daily Electrolyte Requirements Adult PN Electrolyte Calcium Phosphate Sodium Potassium Acetate Chloride PN Equiv Standard Intake RDA 10 mEq 30 mmol N/A N/A N/A N/A 10-15 mEq 8-20 mEq 20-40 mmol 1-2 mEq/kg + replacement 1-2 mEq/kg As needed for acid-base As needed for acid-base Magnesium 10 mEq .
PN Contaminants Components of PN formulations have been found to be contaminated with trace elements Most common contaminants are aluminum and manganese Aluminum toxicity a problem in pts with renal compromise on long-term PN and in infants and neonates Can cause osteopenia in long term adult PN patients .
PN Contaminants FDA requires disclosure of aluminum content of PN components Safe intake of aluminum in PN is set at 5 mcg/kg/day .
PN Contaminants Manganese toxicity has been reported in long term home PN patients May lead to neurological symptoms Manganese concentrations of 8 to 22 mcg/daily volume have been reported in formulations with no added manganese May need to switch to single-unit trace elements that don’t include manganese .
vitamins. Harris-Benedict) Jones 1992.Calculating Nutrient Needs Provide adequate calories so protein is Provide adequate calories so protein is not used as an energy source not used as an energy source Avoid excess kcal (>35 kcal/kg) Avoid excess kcal (>35 kcal/kg) Determine energy and protein needs Determine energy and protein needs using usual methods (kcals/kg. Harris-Benedict) Use specific PN dosing guides for Use specific PN dosing guides for electrolytes. Iretonusing usual methods (kcals/kg. IretonJones 1992. vitamins. and minerals . and minerals electrolytes.
Caloric requirements Based on Total Energy Expenditure Can be estimated using predictive equations TEE = REE + Stress Factor + Activity Factor Can be measured using metabolic chart .
30% + 15% + 15% + 20% + 13% •Moderate infection + 20% •Severe infection •<20% BSA Burns •>40% BSA Burns + 40% + 50% •20-40% BSA Burns + 80% + 100% .Caloric requirements Stress Factor •Malnutrition •peritonitis •soft tissue trauma •fracture •fever (per oC rise) .
Increase WHO REE by stress factors Fever Cardiac Failure Traumatic Injury Increase 13% per degree C 15-25% 20-30% Severe respiratory distress 25-30% or broncho-pulmonary dysplasia Severe sepsis 45-50 .
Caloric requirements Activity Factor Bed-bound Ambulant Active + 20% + 30% + 50% .
6.7W) + (5H) .8A Females: REE= 655 + (9.8H .7A Schofield Equation 25 to 30 kcal/kg/day .4.Caloric requirements REE Predictive equations Harris-Benedict Equation Males: REE = 66 + (13.6W) + 1.
5 g protein/kg IBW mild or moderate stress Up to 2.2 to 1.Protein Requirements 1.5 g protein/kg IBW burns or severe trauma .
How much protein to give? Based on calorie : nitrogen ratio Based on degree of stress & body weight Based on Nitrogen Balance .
Calorie : Nitrogen Ratio Normal ratio is 150 cal : 1g Nitrogen Critically ill patients 85 to 100 cal : 1 g Nitrogen in .
3 to 1.2 g / kg / day 1.0 to 1.Based on Stress & BW Non-stress patients 0.75 g / kg / day 2 to 2.5 g / kg / day .8 g / kg / day Mild stress Moderate stress Severe stress 1.
5 to 2g / kg / day .Based on Nitrogen Balance Aim for positive balance of 1.
Peripheral Parenteral Nutrition Hyperosmolar solutions cause thrombophlebitis in peripheral veins Limited to 800 to 900 mOsm/kg (MHS uses 1150 mOsm/kg w/ lipid in the solution) Dextrose limited to 5-10% final concentration and amino acids 3% final concentration Electrolytes may also be limited Use lipid to protect veins and increase calories .
requires large fluid volumes to deliver adequate nutrition support (2.5-3L) May be appropriate in mild to moderate malnutrition (<2000 kcal required or <14 days) More commonly used in infants and children Controversial .Peripheral Parenteral Nutrition New catheters allow longer support via this method In adults.
Contraindications to Peripheral Parenteral Nutrition Significant malnutrition Severe metabolic stress Large nutrition or electrolyte needs (potassium is a strong vascular irritant) Fluid restriction Need for prolonged PN (>2 weeks) Renal or liver compromise .
Compounding Methods Total nutrient admixture (TNA) or 3-in-1 Dextrose. additives are mixed together in one container Lipid is provided as part of the PN mixture on a daily basis and becomes an important energy substrate 2-in-1 solution of dextrose. additives Typically compounded in 1-liter bags Lipid is delivered as piggyback daily or intermittently as a source of EFA . amino acids. amino acids. lipid.
continuous infusion of fat Physiological balance of macronutrients .Advantages of TNA Decreased nursing time Decreased risk of touch contamination Decreased pharmacy prep time Cost savings Easier administration in home PN Better fat utilization in slow.
reduced ability to detect precipitates .Disadvantages of TNA Diminished stability and compatibility IVFE (IV fat emulsions) limits the amount of nutrients that can be compounded Limited visual inspection of TNA.
Initiation of PN Adults should be hemodynamically stable. 2 L 2nd day) . and have central venous access If central access is not available. PPN should be considered (more commonly used in neonatal and peds population) Start slowly (1 L 1st day. able to tolerate the fluid volume necessary to deliver significant support.
Initiation of PN: formulation As protein associated with few metabolic side effects. up to 60-70 grams/liter Maximum CHO given first day 150-200 g/day or a 15-20% final dextrose concentration In pts with glucose intolerance. 100-150 g dextrose or 10-15% glucose concentration may be given initially . maximum amount of protein can be given on the first day.
time to reach full support relates inversely to age. may be 3-5 days .Initiation of PN: Formulation Generally energy and protein needs can be met in adults by day 2 or 3 In neonates and peds.
Initiation of PN: Formulation Dextrose content of PN can be increased if capillary blood glucose levels are consistently <180 mg/dL IVFE in PN can be increased if triglycerides are <400 mg/dL .
Parenteral Nutrition Formula Calculations and Monitoring Protocols .
1 (kcal/cc) = 491 cc/24 hr = 20 cc/hr 10% lipid (round to 480 ml) Remaining fluid needs: 2000cc .Example Calculation Nutrient Needs: Kcals: 1800. Some use 10 kcal/gm for lipid emulsions. Fluid: 2000 cc 1800 kcal x 30% = 540 kcal from lipid Lipid (10%): 540 kcal/1.480cc = 1520cc *|Lipid emulsions contain glycerol. . so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Protein: 88 g.
x 4 kcal/gm =352 kcals from protein Remaining kcal needs: 1800 – (528 + 352) = 920 kcal .8% amino acid solution 88 g.Protein Calculations Protein: 88 g / 1520 cc x 100 = 5.
@ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr .a.4 kcal/g = 270 g dextrose 270 g / 1520 cc x 100 = 17.7% dextrose solution Rate of Amino Acid / Dextrose: 1520 cc / 24hr = 63 cc/hr TPN recommendation: Suggest two-in-one PN 17.8% a. 5.Dextrose Concentration 920 kcal/3.7% dextrose.
some clinicians restrict lipid to 30% of nonprotein kcals .Sample Calculation 3-in-1 Nutrient Needs: Kcals: 1800 Protein: 88 g Fluid: 2000 cc Lipid : 1800 kcal x 30% = 540 kcal 540 kcal / 10 kcal per gram = 54 g 54 g / 2000 cc x 100 = 2.4% amino acids 88 g x 4 = 352 kcals from protein In critically ill patients.7% lipid Protein: 88 g / 2000 cc x 100 = 4.
2. protein. 4.7% lipids at 83 cc/hour provides 88 g.4% dextrose.4% amino acids. 1800 kcals. 2000 ml.352) 908/3. fluid .4 kcal/g = 267 g dextrose 267 g / 2000 cc x 100 = 13.4% dextrose solution Rate of Amino Acid / Dextrose/Lipid: 2000 cc / 24hr = 83 cc/hr TPN prescription: Suggest TNA 13.Sample Calculation 3-in-1(cont) Dextrose: 908 kcal (1800 – 540 .
Example: 40 g lipid x 1. 1. Multiply the grams of dextrose per liter by 5. 1.5 = 60.Calculating the Osmolarity of a Parenteral Nutrition Solution 1. Example: 100 g of dextrose x 5 = 500 mOsm/L Multiply the grams of protein per liter by 10. 2.5. 3. Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2 Example: 80 X 2 = 160 Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L . Example: 30 g of protein x 10 = 300 mOsm/L Multiply the grams of lipid per liter by 1.
PN Administration:Transition to Enteral Feedings in Adults Controversial In adults receiving oral or enteral nutrition sufficient to maintain blood glucose. no need to taper PN Reduce rate by half every 1 to 2 hrs or switch to 10% dextrose IV) may prevent rebound hypoglycemia (not necessary in PPN) Monitor blood glucose levels 30-60 minutes after cessation .
PN Administration:Transition to Enteral Feedings in Pediatrics Generally tapered more slowly than in adults as oral or enteral feedings are introduced and advanced Generally PN is continued until 75-80% of energy needs are met enterally .
Medications That May Be Added to Total Nutrient Admixture (TNA) Phytonadione Selenium Zinc chloride Levocarnitine Insulin Metoclopromide Ranitidine Sodium iodide Heparin Octreotide .
Parenteral Nutrition Infusion Schedules .
Infusion Schedules Continuous PN Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous access .
Continuous PN Advantages Well tolerated by most patients Requires less manipulation decreased nursing time decreased potential for “touch” contamination .
Continuous PN Disadvantages Persistent anabolic state altered insulin : glucagon ratios increased lipid storage by the liver Reduces mobility in ambulatory patients .
usually over a period of 12 – 18 hours Patients on continuous therapy may be converted to cyclic PN over 24-48 hours .Infusion Schedules Cyclic PN The intermittent administration of PN via a central or peripheral venous access.
Cyclic PN Advantages Approximates normal physiology of intermittent feeding Maintains: Nitrogen balance Visceral proteins Ideal for ambulatory patients Allows normal activity Improves quality of life .
Disadvantages Incorporation of N into muscle stores 2 may be suboptimal Nutrients administered when patient is less active Not tolerated by critically ill patients Requires more nursing manipulation Increased potential for touch contamination Increased nursing time
Common Indications for PN in Peds
Surgical GI disorders Intractable diarrhea of infancy Short bowel syndrome Inflammatory bowel disease Intractable chylothorax Intensive cancer treatment
Pediatric Energy Needs in PN
No consensus exists as to how to determine energy needs of hospitalized children RDAs are intended for healthy children but can use for healthy/acutely ill children and monitor response Can estimate REE using WHO equation and add stress factors, monitor clinical course Indirect calorimetry recommended in difficult cases REE(KCAL/min=3.94*DVo2+1.11DVCO2)
2 1.0 0.0 0.5 1-3 4-6 7-10 11-14 15-18 11-14 15-18 Energy (kcal/kg/d) Protein (g/kg/d) Females Males 108 102 90 70 47 40 44 45 2.1 1.8 1.9 .0-0.2 1.RDAs for Energy and Protein Category Infants Children Age (yr) 0.0 1.
WHO Equations to predict REE from body weight
Sex/Age Range (years) Males 0-3 Males 3-10 Males 10-18 Females 0-3 Females 3-10 Females 10-18 Equation to Derive REE (kcal/d) (60.0 x wt) – 54 (22.7 x wt) + 495 (17.5 x wt) + 651 (6.1 x wt) – 51 (22.5 x wt) + 499 (12.2 x wt) + 746
Trauma/Critically Ill Peds
Age in years 0-1 1-6 7-12 13-18 Kcals/kg 90-120 75-90 50-75 30-60 G/pro/kg 2.0-3.5 1.8-3.0 1.5-2.5 1.0-2.0
etc. . stress.Pediatric PN: Fluids Standard calculation: 100 kcal/kg for infant 3-10 kg 1000 kcal + 50 kcal/kg for every kg over 10 kg for a child 10-20 kg 1500 kcal + 20 kcal/kg for every kg over 20 kg for a child over 20 kg 1 mL fluid/kcal/d + adjustments for fever. diarrhea.
CHO delivery in PN should begin at 6-8 mg/kg/minute of dextrose and advanced to 10-14 mg/kg/minute.Pediatric PN: Carbohydrate Carbohydrate should comprise 45-50% of caloric intake in infants and children (C) For neonates. (B) .
5 g/kg/day until the maximum or desired dose is reached.5g/kg for 24 months and older . need 0.5 g/kg/day and increase by .5 to 1 g/kg/day for EFA needs Maximum is 3 g/kg for <24 months old and 2.Pediatric PN: Lipid Preterm: start at .5g/kg q day Infants: Start at 1 g/kg and increase by .
Daily Electrolyte and Mineral Requirements for Peds Pts Electrolyte Sodium Chloride Potassium Calcium Phosphorus Magnesium Infants/Children Adolescents 2-6 mEq/kg 2-5 mEq/kg 2-3 mEq/kg 1-2.5-1 mmol/kg 0.5 mEq/kg Individualized Individualized Individualized 10-20 mEq 10-40 mmol 10-30 mEq .5 mEq/kg 0.3-0.
and corrective actions Patient education . drip. complications.Document in Chart Type of feeding formula and tube Method (bolus. pump) Rate and water flush Intake energy and protein Tolerance.
Parenteral Nutrition Monitoring .
upon any change in insulin dose. (B) In patients with diabetes or risk factors for glucose intolerance. potassium. SNS should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. and glucose levels monitored closely at initiation of SNS. (C) Blood glucose should be monitored frequently upon initiation of SNS.Monitoring for Complications Malnourished patients at risk for refeeding syndrome should have serum phosphorus. and until measurements are stable. (B) . magnesium.
potassium.Monitoring for Complications Serum electrolytes (sodium. (C) Liver function tests should be monitored periodically in patients receiving PN. and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are stable. (A) . (B) Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. chloride.
Mg.Acute Inpatient PN Monitoring Parameter Glucose Electrolytes Phos. LFTs √ √ Initially √ Daily Initially Initially Frequency 3x/week √ √ Initially Weekly √ √ . Bili. BUN. Ca TG Fluid/Is & Os Temperature T. Cr.
Inpatient Monitoring PN Parameter Body Weight Nitrogen Balance HGB. HCT Catheter Site Lymphocyte Count Clinical Status √ √ √ Daily Initially Frequency Weekly √ Initially √ PRN √ .
respiration (daily) WBC and differential (as needed) Cultures (as needed) . temperature.Monitor—cont’d Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly) Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity.
Monitoring: Nutrition Serum Hepatic Proteins Parameter Albumin Transferrin Prealbumin Retinol Binding Protein t½ 19 days 9 days 2 – 3 days ~12 hours .
cholestasis) Metabolic bone disease Vascular access sepsis .Complications of PN Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver.
particularly marasmic patients Can occur with enteral or parenteral nutrition Results from intracellular electrolyte shift. .Refeeding Syndrome Patients at risk are malnourished. M C due to hypophosphatemia and Hypoglycemia .
potassium.Refeeding Syndrome Symptoms Reduced serum levels of magnesium. and phosphorus Hyperglycemia and hyperinsulinemia Interstitial fluid retention Cardiac decompensation and arrest .
Refeeding Syndrome Prevention/Treatment Monitor and supplement electrolytes.5 g protein/kg/day Limit fluid to 800 ml + insensible losses (adjust per patient fluid tolerance and status) .2-1. vitamins and minerals prior to and during infusion of PN until levels remain stable Initiate feedings with 15-20 kcal/kg or 1000 kcals/day and 1.
Glycemic Control in Critical Care Until recently. BG<200 mg/dl was tolerated in critically ill patients. Now greater attention is given to glycemic control due to evidence that glucose is associated with morbidity/mortality and risk of infection New recommendation is to keep BG<150 mg/dl or as close to normal as possible .
monitor BG q 4-6 hours and use sliding scale or insulin drip as needed Add a portion of the previous day’s insulin to TPN to maintain blood glucose levels Glycemic Control in PN .For Patients Not Previously on Insulin Monitor blood glucose levels prior to initiating PN When therapy is initiated.
For Patients Previously on Insulin Determine amount of insulin needed prior to illness Determine amount of feedings to be given Provide a portion of daily insulin needs in first PN along with sliding scale or insulin drip to maintain glucose levels (generally insulin needs will increase while on PN) Glycemic Control in PN .
38 kcal/ml.Fluid Excess Critically ill pts and those with cardiac. renal. hepatic failure may require fluid restriction May need to restrict total calories to reduce total volume Use most concentrated source of PN components (70% dextrose = 2. 20% lipid = 2 kcal/ml) PPN may be contraindicated due to fluid volume of 2-4 liters .
metabolic acidosis. or hyperglycemia . potassium administration. metabolic alkalosis. and refeeding Hyperkalemia may be due to renal failure.Electrolytes Electrolytes in PN should be given at a stable dose with intermittent requirements for supplementation given outside the PN Sodium levels often reflect fluid distribution versus sodium status Hypokalemia may be due to excessive GI losses.
Acid-Base Balance Balance chloride and acetate to maintain/achieve equilibrium The standard acetate/chloride ratio is 1:1 Increase proportion of chloride with metabolic alkalosis. increase proportion of acetate with metabolic acidosis Consider chloride and acetate content of amino acids .
Special populations Diabetics Careful monitoring of therapy to avoid hyperglycemia Insulin may be added to the parenteral admixture and combined with sliding-scale insulin administration Reasonable glucose control should ensure a blood glucose level greater than 100 mg/dL and less than 220 mg/dL .
and other source. Branched-chain amino acids (BCAAs. isoleucine.1.. . e. and hypermagnesemia Protein is provided at approximately 1.2 g/kg/day Dialysis is used as indicated to control uremia. hyperphosphatemia. Assessed carefully for signs of fluid overload and Electrolyte abnormalities. hypermetabolic. leucine. particularly hyperkalemia. Frequently afflicted by coexisting multiple-system organ failure. valine) may be combined with other amino acids to improve protein use.Acute renal failure Patients with acute renal failure are hypercatabolic.Careful assessment of nitrogen losses in urine. dialysate.g.
Pulmonary disease Overfeeding may increase CO2 production. complicate respiratory function.5 g/kg/day. An acceptable strategy is to increase the proportion of calories supplied by fat. Restrict the administration of carbohydrate to 4 mg/kg/min. Provide adequate carbohydrate calories to meet energy needs and (with fat) promote protein sparing. and impede weaning from ventilator support. Protein needs should be estimated at 1. .
. carbohydrate. May have fluid overload that may require restriction of TPN volume. protein. Glucose intolerance and insulin resistance. and decreased removal of free fatty acids.Hepatic disease Lipid. increased triglyceridemia. with decreased lipolytic activity. and vitamin metabolism is sharply altered in patients with hepatic failure Lipid clearance is defective. Intolerance to protein presents the greatest challenge to nutritional management.
5 g/kg/day Protein needs in patients with significant encephalopathy are reduced to 1.Hepatic disease (cont) Protein needs in patients with liver failure and mild or no encephalopathy should be calculated at 1.0 g/kg/day. Patients with pronounced encephalopathy should be given a modified amino acid formula containing a high percentage of BCAAs(Do not require hepatic metabolism) .
. The total volume of TPN solution is generally restricted to 1000 to 1500 mL/day in patients with severe congestive heart failure secondary to valvular dysfunction. coronary artery disease. patients with longstanding cardiac disease are vulnerable to a typical wasting (cardiac cachexia).Cardiac disease Prolonged malnutrition. or cardiomyopathy.