Parenteral Nutrition

Dr. Mehroze Zamir Resident Surgical 4, CHK

Nutritional Support: Yes or no?

Nutritional Support: Yes

Between 30-50% of hospitalized patients are malnourished.

60% of those whom hospital stay is prolonged because of post-op complications.

Negative Effects of Malnutrition on Clinical Outcome

Greater susceptibility to infectious complications  Reduced immune competence  Poor skin integrity  Delayed wound healing  Higher incidence of surgical complications  Prolonged need for mechanical ventilation  Increased mortality  Extended length of hospital stay  Higher health care costs

Costly “The only patient populations that have been identified as clearly benefiting from perioperative nutrition support are severely malnourished patients” (J Parenter Enteral Nutr 2002.Nutritional Support: No  Misuse of Nutritional support can adversely affect patient recovery.26:1SA)   .

Nutritional Support: Who need it? .

Nutritional Assessment     Body weight BMI Anthropometric measurements Laboratory tests .

Body Weight  Body weight 20% over or under the ideal level places a patient at nutritional risk Hamwi formula:     Men: 106 lb for 5 ft of height plus 6 lb for every inch of height over 5 ft Women: 100 lb for 5 ft plus 5 lb for every inch of height over 5 ft Both: ± 10% based on frame size .

9 25-29.5 18.9 35-39.Body Mass Index (BMI)  Eliminates the influence of frame size BMI <18.9 >40 Obesity (class1) Obesity (class2) Obesity (class3) .9 Interpretation Underweight Normal Overweight  BMI = Weight (kg) Height² (m) 30-34.6-24.

Anthropometric Measurements  Mid arm circumference: general health condition Triceps skin fold thickness: body fat percentage Grip strength: easy and readily repeatable. interprets lean muscle index   .

Laboratory tests  Serum Albumin:  Determine chronic nutritional status  T½ = 14-20 days  Serum levels of less than 3. .  Serum  T½ Transferrin: = 8-10 days  Serum levels of less than 200mg/dl indicates nutritional deprivation.5gm/dl is indicative of malnourishment.

)  Serum Prealbumin:  Useful indicator in acute setting  Half life in 2-3 days  10-17 mg/dl  mild nutritional depletion  5-10 mg/dl  moderate depletion  < 5 mg/dl  severe depletion .Laboratory tests (contd.

)  Immune function: Frequently altered by malnutrition:  Delayed type hypersensitivity: anergy to common skin antigens  Total Lymphocyte count: TLC = % lymphos x WBC 100  1500-1800/mm³  mild depletion  900-1500/mm³  moderate depletion  <900/mm³  severe depletion  .Laboratory tests (contd.

safe in pregnant women and children.Other methods of Nutritional assessment    Bioelectrical impedance analysis (BIA): Assessment of fluid volume and lean body mass by measurement of resistance to electrical current. no clear role in predicting outcome. Dual-energy x-ray absorptiometry (DEXA): Measurement of bone density. Neutron activation analysis: Use of shielded counters to measure gamma ray decay of naturally occurring isotopes. may help determine fat and lean body compartments. . an indicator body cell mass. used in sports. estimate of total body potassium. not fully validated in clinical use. used primarily in research.

Nutritional Support: How much to give? .

20-30 kcal/kg/day.  Does not take into account the fat percentage of body.Estimation of Caloric requirement  Total energy requirement of a stable patient with normal or moderately increased need is approx.  Not suitable for every patient. .

7 x wt(kg)] + [5 x ht(cm)] – [6.7 x age(yrs)] .6 x wt(kg)] + [1.Basal Energy Expenditure  Harris  BEE Benedict equation: in Kcal per day for men: 66.8 x age(yrs)]  BEE in Kcal per day for women: 655 + [9.7 x ht(cm)] – [4.4 + [13.

55 1.00 1.80-1.50 1.30-1.  Most stressed patients require 25-35 Kcal/kg/day.  Accurate in 80% of patients.35 1.05-1.30 1.25 1.30-1.00 1.30 Cardiopulmonary disease with major surgery Acute renal failure Liver failure Liver transplant Pancreatitis 1.20-1.80 .20-1.30-1. Clinical condition Stress factor Starvation Elective operation Peritonitis or other infections ARDS or sepsis Bone marrow transplant Cardiopulmonary disease (non complicated) Cardiopulmonary disease with dialysis or sepsis 0.30-1.55 1.30 0.8-1.00-1.20-1.  Overestimates the caloric needs in obese patients.Actual Caloric requirement calculation using BEE  Obtained by multiplying BEE by specific stress factors.10 1.

25] + Ideal body weight . many clinicians use ABW to determine energy needs. and that the excess tissue.Adjusted body weight (ABW) When a patient’s BMI falls into an obese category.  The formula for ABW takes into account that not all of a person’s excess weight is adipose tissue. whether fat or not is also metabolically active.  ABW =[(Actual body weight – Ideal body weight) 0.

Nutritional Support: What to give? .

Carbohydrates  Main source of energy for cells.  30-50% of normal calorie intake should be from carbohydrates. dextrose) provides 3. .4 Kcal/gm.  Glucose is essential for wound repair. including hepatic steatosis and neutrophil dysfunction.  Excessive amounts can have adverse effects.  Parenteral carbohydrate (e.  Each gram of enteral carbohydrate provides 4 Kcal of energy.g.

in ICU 2.Proteins  The Building blocks.8 gm/kg per day 1.  Generally 6.5 gm/kg per day .2 gm/kg per day Severely stressed pt.25 gm of protein intake is equal to 1 gm Nitrogen  1 gram of Protein intake yields 4 Kcal of energy  Amino acids should constitute 15-20% of Normal energy expenditure Clinical status No stress factors Acute illness Protein required 0.

 Each gram of lipid provides 9 Kcal of energy.  Stress causes dramatic lipolysis  Steroids.Lipids  Lipids comprise the remaining 25-45% of calories in typical diet. catecholamines and glucagon also stimulate lipolysis .

What else?  Fluids  Electrolytes  Vitamins  Minerals and trace elements .

Parenteral Nutrition  Indicated in patients who require nutritional support but cannot meet their needs through oral intake and for whom enteral feeding is contraindicated or not tolerated.  Total Parenteral Nutrition (TPN) provides complete nutritional support (Surgery 1968.64:134) .

Indications of PN  Primary Therapy  Efficacy shown[*]      Gastrointestinal cutaneous fistulas Renal failure (acute tubular necrosis) Short-bowel syndrome Acute burns Hepatic failure (acute decompensation superimposed on cirrhosis) Crohn's disease Anorexia nervosa  Efficacy not shown    Supportive Therapy  Efficacy shown[*]     Acute radiation enteritis Acute chemotherapy toxicity Prolonged ileus Weight loss preliminary to major surgery Before cardiac surgery Prolonged respiratory support Large wound losses Patients with cancer Patients with sepsis  Efficacy not shown     Areas Under Intensive Study   * Randomized. . prospective trials or similar investigations have suggested that such nutritional intervention results in changed (improved) outcome.

Central versus Peripheral venous access Central Access  Peripheral Access      High osmolarity fluids Fluid restriction Elevated requirement due to hypermetabolism Long term PN support (> 2 weeks)   Low osmolarity fluids High fluid volume administration Temporary support (< 2 weeks) Partial support .

What is the osmolarity tolerated through a peripheral vein?  1000 mosm/L  900 mosm/L  <850 mosm/L  Geriatric patients  Fine bore IV line .

Osmolarities and Caloric value of different solutions available in our clinical setup. Solution 5% D/W Osmolarity Calories mosm/L Kcal/L 278 200 / 170? 10% D/W Liposcin 20% Aminovil 5% 555 380 590 400 / 340? 1908 200 .

Further osmolarities? mOsM = wt of substance (g/L) x no. of ions x 1000 molecular wt (g) .

Electrolytes Electrolyte Sodium Form Sodium chloride Sodium acetate Sodium phosphate Daily requirement 1-2 mEq/kg Potassium Potassium chloride Potassium acetate Potassium phosphate Sodium chloride Potassium chloride 1-2 mEq/kg Chloride As needed for acid base balance Acetate Phosphate Magnesium Calcium Sodium acetate Potassium acetate Sodium phosphate Potassium phosphate Magnesium sulfate Calcium gluconate As needed for acid base balance 20-40 mmol 8-20 mEq 10-15 mEq .

Vitamins and trace elements  Required daily  1 mg copper  12 mcg chromium  0.3 mcg manganese  60 mcg selenium  5 mg zinc  Multivitamins (10ml)  Vitamin A and C  Vitamin K 10 mg once a week  Iron as a separate infusion if required .

generally at two thirds of the daily subcutaneous insulin dose. based on a determination of the blood glucose level.  After a stable insulin requirement has been established. . insulin can be administered in the TPN solution.Insulin  Regular insulin should initially be administered subcutaneously according to a sliding scale.

P) Glucose Prealbumin Triglycerides Creatinine BUN LFTs .Beginning PN  Do not start PN until a patient has stable fluid and electrolyte profile.  Baseline recordings:         Blood CP Electrolytes (Ca. Mg.

Some institutions allow patients to receive the target level of protein and lipid emulsion initially and increase dextrose to goal over 2 days.Beginning PN   Gradual introduction. and then achievement of desired goal in 2-3 days when normoglycemia is established. Delivered mostly as a continuous infusion over 24 hours. 1000 Kcal on 1st day.   .

Frequency 6 hourly Daily Monitoring Vital signs Sreum glucose Weight Intake Output Serum electrolytes BUN Triglycerides CBC PT LFTs Weekly .Managing and monitoring PN  Orders. should reflect the patient's dynamic nutritional status and biochemical profile. written daily.

cardiac perforation or tamponade. hydromediastinum  Long-term use: occlusion. damage to adjacent artery. thoracic duct damage. hypersensitivity reactions  Excess amino acids: hyperchloraemic metabolic acidosis. hepatic steatosis. aminacidaemia. pleural effusion. zinc.Complications of PN  Related to Nutrient defeciency  Hypoglycaemia/hypocalcaemia/ hypophosphataemia/hypomagnesaemia (refeeding syndrome)  Chronic defeciency syndromes (essential fatty acids. minerals and trace elements) Related to Overfeeding  Excess glucose: hyperglycaemia. uraemia Related to sepsis  Catheter related sepsis  Possible increased predisposition to systemic sepsis Related to line  On insertion: pneumothorax. venous thrombosis    . hypertrigylceridaemia. hyperosmolar dehydration. hypercapnia. electrolyte abnormalities  Excess fat: hypercholesterolaemia and formation of lipoprotein-X. air embolism. fluid retention. increased sympathetic activity. hypercalcaemia.

345:1359) .Hyperglycaemia      Most common metabolic complication of parenteral nutrition Causes osmotic diuresis that depletes fluids and electrolytes (K. Na & P) Hyperglycaemic hyperpsmolar nonketotic (HHNK) syndrome Hepatic steatosis and neutrophil dysfunction Strict maintenance of serum glucose level below 110mg/dl improves mortality and reduces infectious complications in surgical ICU patients (New Engl J Med 2001.

May use separate insulin infusions for those with an unstable blood glucose profile.    0.Managing hyperglycaemia  Maintain blood glucose level no higher than 120mg/dl for critically ill patients and no higher than 150mg/dl for stable patients receiving PN.  .1 units of insulin for each gram of dextrose in PN and further subcutaneous insulin coverage as per blood glucose levels.05-0. Dextrose infusion rates of 4mg/kg/min or less decreases the incidence of hyperglycaemia Patients with DM and those who are critically ill require insulin to control blood glucose.

02mcg/kg/d iv)  Cholecystitis .  Acalculous type  cholecystectomy or cholecystostomy  Cholestasis  GB contraction can be stimulated with CCK (0.Hepatobiliary complications of bilirubin  Sepsis?  Raised liver enzymes  Elevation  Provide a fat free PN  Infusing PN over 12-16 hours thus giving a “time off” to mimic a post absorptive state to give rest to liver.

the formula must meet. the patient’s requirements In addition to avoiding overfeeding.  .Pulmonary complications  The CO2 produced by carbohydrate metabolism can place added stress on patients with CO2 retention and those who are being weaned from mechanical ventilation  To avoid problems related to CO2 production. reducing the carbohydrate dose and increasing the proportion of calories provided as fat can help prevent adverse pulmonary effects of PN. not exceed.

. resulting in anabolism and a dramatic shift of extracellular ions into intracellular compartment and rapid depletion of ATP stores Mostly presents insidiously as respiratory failure Altered myocardial function. seizures.Refeeding syndrome      Occurs when TPN is administered to severely malnourished patient. coma. tetany and death Hypophosphataemia. hypocalcaemia and hypomagnesaemia Prevention:  Avoid overfeeding  Gradual increase in caloric provision  Frequent monitoring and additional supplementation of potassium. liver dysfunction. arrhythmias. manganese. confusion. magnesium and phosphate are required in severely malnourished patients.

Thank you .

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