parenteral nutrition

parenteral nutrition

1. Nutrition Parenteral Nutrition Parenteral
Conquering the ComplexitiesConquering the Complexities
Dr sumer yadavDr sumer yadav

2. DEFINITIONDEFINITION
Intravenous administration of calories, Intravenous administration of calories,
nitrogen and other nutrients in sufficient nitrogen and other nutrients in sufficient
quantities to achieve tissue synthesis and quantities to achieve tissue synthesis and
anabolism is called anabolism is called Parenteral NutritionParenteral Nutrition..

3. HISTORYHISTORY

Willium harvey’sWillium harvey’s elucidation of the human elucidation of the human
circulationcirculation

Arvid Wretlind & collegueArvid Wretlind & collegue (1961) – prepared fat (1961) – prepared fat
emulsionemulsion

Stanley Dudrick & Jonathan RhoadsStanley Dudrick & Jonathan Rhoads (1968) – (1968) –
develop TPNdevelop TPN

Solassol & JoyeuxSolassol & Joyeux (1976) – developed 3-in-1Bag (1976) – developed 3-in-1Bag
PN solutionPN solution

Shills & JeejeebhoyShills & Jeejeebhoy (1978) – developed HOME (1978) – developed HOME
PNPN

4. INTRODUCTION INTRODUCTION

PNPN uses the vascular system to provide vital uses the vascular system to provide vital
nutritional support to malnourished patients & it nutritional support to malnourished patients & it
supplies the nutrients in their elemental forms supplies the nutrients in their elemental forms
(carbohydrate, lipids, aminoacids, trace (carbohydrate, lipids, aminoacids, trace
elements & vitamins)elements & vitamins)

Two TypesTwo Types
1.1.TPNTPN – Total Parentral Nutrition – Total Parentral Nutrition
2.2.PPNPPN – Partial Parentral Nutrition – Partial Parentral Nutrition

Can be administered by two routesCan be administered by two routes
1.1.Large central veinLarge central vein (Central PN) (Central PN)
2.2.Peripheral veinPeripheral vein (Peripheral PN) (Peripheral PN)

5. When PN is required?When PN is required?

PPN is used to prevent or reduce the N is used to prevent or reduce the
adverse effects of malnutrition.adverse effects of malnutrition.
AAnd is used when entral nutrition (EN) is nd is used when entral nutrition (EN) is
unsafe or ineffective and this condition is unsafe or ineffective and this condition is
anticipated to last for 7 – 10 days.anticipated to last for 7 – 10 days.

6. INDICATIONS FOR PNINDICATIONS FOR PN

Extreme short bowel syndromeExtreme short bowel syndrome

Structural – resectionStructural – resection

Functional – Severe inflammationFunctional – Severe inflammation

Bowel RestBowel Rest - - Enterocutaneous fistula (Enterocutaneous fistula (high outputhigh output))
- Anastomotic leak- Anastomotic leak

Paralytic ileusParalytic ileus – – Major abdominal surgeryMajor abdominal surgery
- - Major abdominal traumaMajor abdominal trauma

Intestinal ObstructionIntestinal Obstruction – – Cancer, AdhesionsCancer, Adhesions

7. INDICATIONS OF PN CONTD….INDICATIONS OF PN CONTD….

PPreoperatively only in patients with severe reoperatively only in patients with severe
malnutritionmalnutrition

MMulti-organ failure with sepsisulti-organ failure with sepsis

OOthers thers

Severe mucositis/oesophagitis/radiation entritisSevere mucositis/oesophagitis/radiation entritis

Inflammatory bowel disease with severe Inflammatory bowel disease with severe
malnutritionmalnutrition

Intestinal Atresia /Motility disordersIntestinal Atresia /Motility disorders

Intractable vomiting Intractable vomiting (CT, Hyperemesis G.)(CT, Hyperemesis G.)

8. CONTRADICATIONS FOR PNCONTRADICATIONS FOR PN

CContradications for central line ontradications for central line (coagulopathies)(coagulopathies)

HHemodynamically unstable patientemodynamically unstable patient

PPulmonary edema/Fluid overloadulmonary edema/Fluid overload

AAnuria without dialysisnuria without dialysis

SSevere metabolic/electrolyte disturbencesevere metabolic/electrolyte disturbences

AAdvance cancer or terminal illnessdvance cancer or terminal illness

9. MERITS OF PNMERITS OF PN

Turns the catabolic state of patient into Turns the catabolic state of patient into Anabolic Anabolic
statestate

Provides Provides rest to bowelrest to bowel ( in anastomosis / leaks) ( in anastomosis / leaks)

Prevents Prevents wasting of muscleswasting of muscles

Improve Improve healing of woundshealing of wounds

10. Assesment for MalnutritionAssesment for Malnutrition

BY HISTORYBY HISTORY

Weight lossWeight loss >10% of body weight >10% of body weight

Decresed food intakeDecresed food intake

G.I. SymptomsG.I. Symptoms
- Anorexia- Anorexia
- Dysphagia- Dysphagia
- Nasuea /Vomiting- Nasuea /Vomiting
- Chronic Diarrhoea- Chronic Diarrhoea
- Abdominal Pain- Abdominal Pain

11. Assesment for Malnutrition contd…Assesment for Malnutrition contd…

BY PHYSICAL FINDINGSBY PHYSICAL FINDINGS

WeightWeight <90% of ideal wt. <90% of ideal wt.

AnthropometryAnthropometry (mid-arm circumference in cm.) (mid-arm circumference in cm.)

Loss of subcutaneous fatLoss of subcutaneous fat (skinfold thickness) (skinfold thickness)

Skin rashes/ occular changesSkin rashes/ occular changes

Mucus membrane changesMucus membrane changes for deficiency offor deficiency of

Neurological changesNeurological changes particular nutrientparticular nutrient

12. Assesment for Malnutrition contd…Assesment for Malnutrition contd…

BY LABORATORYBY LABORATORY

SSerum Albumin <30g/Lerum Albumin <30g/L

TTotal lymphocyte Count <1800/cu mmotal lymphocyte Count <1800/cu mm

SSkin Test Reactivity (to asses immune kin Test Reactivity (to asses immune
system)system)

S.S. levels of vitamin A, D, E levels of vitamin A, D, E

P.P. levels of iron/folic acid levels of iron/folic acid

S.S. levels of Zn, Mg, Phosphorus levels of Zn, Mg, Phosphorus

13. Assesment for Malnutrition contd…Assesment for Malnutrition contd…

BY SPECIAL PROCEDURESBY SPECIAL PROCEDURES
1. Bioelectric Impedence Analysis (BIA)1. Bioelectric Impedence Analysis (BIA)
for measurement of – Body Fatfor measurement of – Body Fat
- FFM (Fat Free Mass)- FFM (Fat Free Mass)
- Total Body Water- Total Body Water

Lean Body MassLean Body Mass = Body wt. – Fat Mass = Body wt. – Fat Mass
= Total Body Water / 0.73= Total Body Water / 0.73

14. Assesment for Malnutrition contd…Assesment for Malnutrition contd…

BY SPECIAL PROCEDUREBY SPECIAL PROCEDURE
2. Indirect Calorimetry2. Indirect Calorimetry – To measure REE – To measure REE
Harris & Benedicts FormulaHarris & Benedicts Formula
REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) - REE (Man) = 66.4+13.7 (wt. in Kg) + 5 (Ht. in cm) -
6.7(Age in Yr) K cal / day 6.7(Age in Yr) K cal / day
REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)REE (Women) = 655 + 9.4 (Wt. in Kg) – 1.8 (Ht. in cm)
- 4.7 (Age in Yrs) K cal / day- 4.7 (Age in Yrs) K cal / day
TEE = REE + Stress Factor + Activity FactorTEE = REE + Stress Factor + Activity Factor
REE is 60% of TEEREE is 60% of TEE
Schofield equationSchofield equation – 25 to 30 K cal / Kg / day – 25 to 30 K cal / Kg / day

15. Assesment for Malnutrition contd… Assesment for Malnutrition contd…
STRESS FACTOR STRESS FACTOR

PeritonitisPeritonitis +15% +15%

Soft tissue traumaSoft tissue trauma +15% +15%

FractureFracture +20% +20%

BurnsBurns
<20%BSA +50%<20%BSA +50%
20% - 40%BSA +80%20% - 40%BSA +80%
>40%BSA +100%>40%BSA +100%


MalnutritionMalnutrition +30% +30%

InfectionInfection moderate +20% moderate +20%
severe +40%severe +40%

FeverFever (per (per
oo
C rise) +13%C rise) +13%

16. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
ACTIVITY FACTORACTIVITY FACTOR

Bed BoundBed Bound - + 20 % - + 20 %

AmbulantAmbulant - + 30 % - + 30 %

Active Active - + 50 % - + 50 %

17. Assesment for Malnutrition contd…Assesment for Malnutrition contd…
SPECIAL PROCEDURE….SPECIAL PROCEDURE….
2. 2. Nitrogen balanceNitrogen balance = N input – N output = N input – N output
1 Gm N = 6.25 Gm Protien1 Gm N = 6.25 Gm Protien
N input = Protien in Gm x 6.25N input = Protien in Gm x 6.25
N output = 24 hr. Urinary Urea Nitrogen +N output = 24 hr. Urinary Urea Nitrogen +
Non-urinary N lossesNon-urinary N losses
(estimated non-urinary N losses ~ 3 - 4 Gm/day)(estimated non-urinary N losses ~ 3 - 4 Gm/day)
Aim of Positive N balance = Aim of Positive N balance = 1.5 – 2 G/Kg/day1.5 – 2 G/Kg/day

18. BEFORE STARTING PNBEFORE STARTING PN

CBCCBC

LFTLFT

RFTRFT

Serum Electrolytes (Na, K, Cl, Ca, Mg)Serum Electrolytes (Na, K, Cl, Ca, Mg)

PT & PTTPT & PTT

Lipid ProfileLipid Profile

19. BEFORE STARTING PN contd…BEFORE STARTING PN contd…

CALCULATION OF REQUIREMENTCALCULATION OF REQUIREMENT
A. A. Fluid RequirementFluid Requirement
Basic Need = 1500 + 20 ml/Kg body wt.Basic Need = 1500 + 20 ml/Kg body wt.
((If Wt. is >20 Kg)If Wt. is >20 Kg)
Total Need = Basic Need + LossesTotal Need = Basic Need + Losses

Losses like – Nasogastric aspirationLosses like – Nasogastric aspiration
- Vomit volume- Vomit volume
- Drain output- Drain output
- Fistula output- Fistula output

20. BEFORE STARTING PN contd…BEFORE STARTING PN contd…

CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
B.B.Protien RequirementProtien Requirement
Normal = 1.0 – 1.2 Gm / Kg / dayNormal = 1.0 – 1.2 Gm / Kg / day
In catabolic state = 2 Gm / Kg / dayIn catabolic state = 2 Gm / Kg / day
Catabolic states – PolytraumaCatabolic states – Polytrauma
- Severe Burns- Severe Burns
- Pt. taking Renal Replacement- Pt. taking Renal Replacement
therapytherapy
TPN contains Aminoacids in 3 – 15% concentrationTPN contains Aminoacids in 3 – 15% concentration

21. BEFORE STARTING PN contd…BEFORE STARTING PN contd…

CALCULATION OF REQUIREMENT contd..CALCULATION OF REQUIREMENT contd..
C. C. Energy RequirementEnergy Requirement
Normal = 25 – 30 K cal / Kg / dayNormal = 25 – 30 K cal / Kg / day
((Should be provided by non-protein calories i.e. Should be provided by non-protein calories i.e.
calculate it from carbohydrate & lipids only, to calculate it from carbohydrate & lipids only, to
minimize nitrogen consumption)minimize nitrogen consumption)
Carbohydrate & lipid Ratio ~ Carbohydrate & lipid Ratio ~ 70 : 3070 : 30

22. Contd….Contd….

CARBOHYDRATESCARBOHYDRATES
Commercial Dextrose – 5%, 25%, and 70% Conc.Commercial Dextrose – 5%, 25%, and 70% Conc.
TPN Dextrose - 50% to 70% Conc. TPN Dextrose - 50% to 70% Conc.
1 Gm Dextrose = 3.4 K cal.1 Gm Dextrose = 3.4 K cal.
Rate of infusion ~ < 5 – 7 mg / Kg / min.Rate of infusion ~ < 5 – 7 mg / Kg / min.

LIPIDSLIPIDS In 10% - 20% Concentration In 10% - 20% Concentration
Infusion rate < 0.7 K cal / Kg / hr.Infusion rate < 0.7 K cal / Kg / hr.
10 – 15 ml / min for 20% sol.10 – 15 ml / min for 20% sol.

MULTIVITAMINMULTIVITAMIN – Given 1 amp / day i.v. – Given 1 amp / day i.v.
Vit. K 1 amp / day i.m.Vit. K 1 amp / day i.m.

ELECTROLYTEELECTROLYTE – Acc. to their serum levels – Acc. to their serum levels

23. Shortcut for assessment ofShortcut for assessment of
ENERGY REQIREMENTENERGY REQIREMENT
VariantsVariants
No No
StressStress
Mild Mild
StressStress
Mod. Mod.
Stress Stress
Sev.Sev.
StressStress
ENERGYENERGY
Kcal/Kg/DKcal/Kg/D
2525 3030 3535 4040
Carbo. (Dex.) Carbo. (Dex.)
Gm/Kg/DGm/Kg/D
55 66 77 88
LIPIDSLIPIDS
Gm/kg/DGm/kg/D
0.80.8 1.01.0 1.21.2 1.41.4
PROTEINSPROTEINS
Gm/Kg/DGm/Kg/D
11 1.21.2 1.51.5 2.02.0

24. BEFORE GIVING PNBEFORE GIVING PN

VENOUS ACCESSVENOUS ACCESS
1. 1. Central VeinCentral Vein – Large Bore, High Flow – Large Bore, High Flow
- Preferred for TPN- Preferred for TPN
- For long term use- For long term use
(e.g. Subclavian /Int. jugular /Basilic /femoral)(e.g. Subclavian /Int. jugular /Basilic /femoral)
2. 2. Peripheral VeinPeripheral Vein – For short term use – For short term use
- When central vein - When central vein
contraindicatedcontraindicated
Verify the tip of cannula by X ray before PNVerify the tip of cannula by X ray before PN

25. CATHETERSCATHETERS

FORFOR

Central Vein CannulationCentral Vein Cannulation – Single Lumen – Single Lumen
- Double Lumen- Double Lumen
- Multiple Lumen- Multiple Lumen
In Poly- Lumen Catheters In Poly- Lumen Catheters
Medial/Proximal Lumen – PN infusionMedial/Proximal Lumen – PN infusion
Lateral/Distal Lumen - Other UsesLateral/Distal Lumen - Other Uses

26. CATHETERSCATHETERS

FORFOR

Peripheral Vein CannulationPeripheral Vein Cannulation – Simple – Simple
Cannula of 23 GaugeCannula of 23 Gauge

27. INFUSION OF PNINFUSION OF PN

BY TWO WAYSBY TWO WAYS

ContinuousContinuous – For Short Term – For Short Term
- When Rapid Infusion Intolerable - When Rapid Infusion Intolerable

CyclicallyCyclically – When Used For Long Term – When Used For Long Term
- When Rapid Infusion Tolerable- When Rapid Infusion Tolerable
- Continuous administration for 8 – 12- Continuous administration for 8 – 12
hrs and then rest for next 12 hrshrs and then rest for next 12 hrs
- Freedom during day - Freedom during day
Use 3-in-1 TPN or 2-in1 PN with Dextrose Use 3-in-1 TPN or 2-in1 PN with Dextrose
or AA/Lipid/Dextrose seperately or AA/Lipid/Dextrose seperately

28. MONITERING OF PNMONITERING OF PN

PHYSICAL COMPONENTS – DIALYPHYSICAL COMPONENTS – DIALY

WEIGHTWEIGHT

INPUT / OUTPUT CHARTINPUT / OUTPUT CHART

VITAL SIGNSVITAL SIGNS

29. MONITERING contd..MONITERING contd..

METABOLIC MONITERINGMETABOLIC MONITERING

11
stst
day day – CBC/RFT/B.S./LFT/Electrolytes/Mg – CBC/RFT/B.S./LFT/Electrolytes/Mg
Lipid & Coagulation ProfileLipid & Coagulation Profile

22
ndnd
day day – Electrolytes/B.S./RFT/Phosphorus – Electrolytes/B.S./RFT/Phosphorus

33
rdrd
day day - Electrolytes/B.S./RFT - Electrolytes/B.S./RFT

44
thth
day day - Electrolytes/B.S./RFT/Phosphorus/Mg - Electrolytes/B.S./RFT/Phosphorus/Mg

30. METABOLIC MONITERINGMETABOLIC MONITERING
contd….contd….

Thrice/weekThrice/week – B.S./RFT/Electrolytes/Phosphorus – B.S./RFT/Electrolytes/Phosphorus

Twice/weekTwice/week – LFT / – LFT / MMgg

Once/weekOnce/week - Lipid &Coagulation Profile - Lipid &Coagulation Profile

31. Adverse Events To Be WatchedAdverse Events To Be Watched

2+ Glucose in Urine2+ Glucose in Urine

Mod. Ketones in UrineMod. Ketones in Urine

Persistent thirst/Excessive U.O.Persistent thirst/Excessive U.O.

Level of ConsciousnessLevel of Consciousness

HypoglycemiaHypoglycemia

Chills/Rigor/FeverChills/Rigor/Fever

Signs of PhlebitisSigns of Phlebitis

Skin rashesSkin rashes

Hyperventilation / HypotensionHyperventilation / Hypotension

32. Side Effects of LipidsSide Effects of Lipids

Back & Chest PainBack & Chest Pain

DiaphoresisDiaphoresis

Fever/Flushing/Chills/RigorFever/Flushing/Chills/Rigor

Nausea/VomitingNausea/Vomiting

UrticariaUrticaria

Shortness of BreathShortness of Breath

33. Care Of CVAD LineCare Of CVAD Line

EExamine the site for signs of infectionxamine the site for signs of infection

AAlt. day change the catheter dressinglt. day change the catheter dressing

PPeriodically check line for blockageeriodically check line for blockage

TTubes should be changed dailyubes should be changed daily

DDedicate one lumen for PN onlyedicate one lumen for PN only

AAvoid accidents like – Pullingvoid accidents like – Pulling

AAllow only one trained person to handlellow only one trained person to handle

34. Piggybacking of PNPiggybacking of PN

Should be freshly prepared.Should be freshly prepared.

Start slowly at Start slowly at 50ml/hr50ml/hr on day 1 on day 1
stst
..

Volume must not exceed Volume must not exceed 1000ml 1000ml on day 1on day 1
stst
..

From 2From 2
ndnd
day volume should be increased by day volume should be increased by
1 lit./day1 lit./day
until goal reached.until goal reached.

Rate of infusion most not exceed Rate of infusion most not exceed 125ml/hr125ml/hr..

35. Tapering of PNTapering of PN

Taper the infusion rate to half for 20 min. Taper the infusion rate to half for 20 min.
& again half the rate for other 20 min.& again half the rate for other 20 min.

Flush the line with 10-15 ml NS.Flush the line with 10-15 ml NS.

Flush the line with Flush the line with heparin lockheparin lock..

Clamp the line.Clamp the line.

Infuse 10% Dextrose at the same rate for Infuse 10% Dextrose at the same rate for
1 hr. through other line.1 hr. through other line.

Restart PN next day with aseptic tech…Restart PN next day with aseptic tech…

36. COMPLICATIONS OF PNCOMPLICATIONS OF PN

CATHETER RELATEDCATHETER RELATED

PneumothoraxPneumothorax

Air EmbolismAir Embolism

Venous ThrombosisVenous Thrombosis

Catheter OcclusionCatheter Occlusion

Catheter SepsisCatheter Sepsis

Catheter EmbolismCatheter Embolism

37. COMPLICATIONS contd…COMPLICATIONS contd…

METABOLICMETABOLIC

Hyper/Hypo VolumiaHyper/Hypo Volumia

Hyper/Hypo GlycemiaHyper/Hypo Glycemia

HyperosmolarityHyperosmolarity

HypertriglyceridaemiaHypertriglyceridaemia

HyperketoacidosesHyperketoacidoses

Electrolyte ImbalanceElectrolyte Imbalance

38. COMPLICATIONS contd…COMPLICATIONS contd…

GASTRO-INTESTINALGASTRO-INTESTINAL

FATTY LIVERFATTY LIVER

CHOLESTASISCHOLESTASIS

INTESTINAL MUCOSAL ATROPHYINTESTINAL MUCOSAL ATROPHY
To Avoid – Early use of GITTo Avoid – Early use of GIT

39. HOME PNHOME PN

Required in those who needs PN for long termRequired in those who needs PN for long term

Indications Indications – Short Bowel syndrome– Short Bowel syndrome
- Bowel Rest- Bowel Rest
- Severe Malnutrition- Severe Malnutrition

Patient SelectionPatient Selection

Clinically & Psychologically soundClinically & Psychologically sound

Family SupportFamily Support

Adequate FinanceAdequate Finance

40. TPN in Various illnessTPN in Various illness

ACUTE RENAL FAILUREACUTE RENAL FAILURE

Avoid- High Protein Diet Avoid- High Protein Diet

Avoid NS / RLAvoid NS / RL

Restrict FluidRestrict Fluid

Protein RequirementProtein Requirement

Predialysis – Low Predialysis – Low (0.6-0.8 Gm/kg/day)(0.6-0.8 Gm/kg/day)

Dialysis - Standard Dialysis - Standard (1- 1.2 Gm/Kg/day)(1- 1.2 Gm/Kg/day)

41. TPN in Various illness contd..TPN in Various illness contd..

BURNSBURNS

Resuscitation Phase (1Resuscitation Phase (1
stst
24 – 48 hr.) 24 – 48 hr.)
- Fluids with Crystalloids- Fluids with Crystalloids

Energy RequirementEnergy Requirement
- 25 Kcal/Kg/day + 20Kcal/ % of BSA- 25 Kcal/Kg/day + 20Kcal/ % of BSA
- Proteins – 2 Gm/Kg/day- Proteins – 2 Gm/Kg/day

42. TPN in Various illness contd…TPN in Various illness contd…

HEPATIC DISEASEHEPATIC DISEASE

High Caloric Intake High Caloric Intake – 35 Kcal / Kg / day – 35 Kcal / Kg / day

Encephalopathy PresentEncephalopathy Present – Proteins 0.6 Gm/Kg/day – Proteins 0.6 Gm/Kg/day
Avoid Aromatic AAAvoid Aromatic AA
Use Branched Chain AAUse Branched Chain AA

Encephalopathy AbsentEncephalopathy Absent - Proteins 1- 1.2 Gm/Kg/day - Proteins 1- 1.2 Gm/Kg/day

Edema / Asicitis Present Edema / Asicitis Present – Restrict Na – Restrict Na

43. TPN in Various illness contd…TPN in Various illness contd…

RESPIRATORY FAILURERESPIRATORY FAILURE

Calories 20 – 30 Kcal / Kg / dayCalories 20 – 30 Kcal / Kg / day

Give 30 to 35 % calorie as FATGive 30 to 35 % calorie as FAT

Avoid CARBOHYDRATESAvoid CARBOHYDRATES

Proteins 1 – 2 Gm / Kg / dayProteins 1 – 2 Gm / Kg / day

44. IMMUNONUTRITIONIMMUNONUTRITION

GLUTAMINEGLUTAMINE
– – Semi essential AASemi essential AA
- Improve Immune Functions- Improve Immune Functions
- Restore Protein Stores- Restore Protein Stores

ENTERAL GLUTAMINEENTERAL GLUTAMINE
- Increase Intestinal Mucosal Height- Increase Intestinal Mucosal Height
- Increase Enterocyte Protein Contents- Increase Enterocyte Protein Contents

45. Newer AgentsNewer Agents

Anabolic Androgen TherapyAnabolic Androgen Therapy

Increase the Muscle MassIncrease the Muscle Mass

Megestral AcetateMegestral Acetate – Appetite Stimulant – Appetite Stimulant

Growth HormonesGrowth Hormones

Increase the Muscle MassIncrease the Muscle Mass

Increase Visceral Protein StatusIncrease Visceral Protein Status

46. Enteral Vs ParentralEnteral Vs Parentral

CheaperCheaper

Maintain Intestinal Maintain Intestinal
MucosaMucosa

Easy to AdministerEasy to Administer

Less ComplicationsLess Complications

CostlyCostly

Causes Intestinal Causes Intestinal
AtrophyAtrophy

Require ProfessionalRequire Professional

More ComplicationsMore Complications

47. CONCLUSIONCONCLUSION

TPNTPN is life-saving tool & is life-saving tool &
should be given when should be given when
indicated. If conditions indicated. If conditions
allow, switch the patient allow, switch the patient
over the over the Enteral NutritionEnteral Nutrition
as early as possible. as early as possible.

50. Dr. invented new way for PN
infusion

51. Nurse preparing the PN bag for
infusion

52. Health
is

Wealth

THANKSTHANKS