Parenteral nutrition for Surgical patient.pptx

Parentetal

1. PARENTERAL NUTRITION dr. mayank raj karn Resident 1 st year ( general surgery) 1

2. OVERVIEW Introduction Indications Formulas Routes of administration TPN Complications 2

3. Artificial Nutrition Support Any patient who has sustained 5 days of inadequate intake or who is anticipated to have no or inadequate intake for this period should be considered for nutritional support. 3

4. Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids , amino acids, vitamins, trace elements, electrolytes and water. 4

5. Indications for Parenteral Nutritional Support 5

6. 6 ESPEN Practical Guideline: Clinical Nutrition in Chronic Intestinal Failure. Clin . Nutr . 2021 , 40, 5196–5220.

7. Beginning PN (supplemental or full) in well-nourished patients who are not able to achieve necessary nutritional requirements after 7 days. In patients at risk of malnutrition ,starting PN earlier, within 3–6 days, if they are unlikely to achieve satisfactory oral nutrition or EN. 7

8. The inappropriate use of PN increases the risk of complications, leading to an increase in hospitalization and morbidity, as has been shown in the study. Hospitalized patients should be regularly screened for risk of malnutrition, especially those who might be candidates for PN . PN is not an emergency treatment and should be started electively and revised frequently to check if the enteral route might be available . 8

9. Developing support policies and procedures is also recommended to assist with the decision-making for PN initiation, as well as implementing a quality improvement process to ensure appropriate use of PN. 9

10. Formulas Polymeric formulas Polymeric isotonic formulas are appropriate for most patients. Polymeric balanced; nutrient profiles mimic a healthy diet. It is the most common formula type. 12–20% protein Can have increased concentrations with higher caloric density (e.g ., 1.5 or 2 kcal/mL). These are helpful for patients on fluid restriction or with high caloric needs . Fischer’s Mastery of Surgery, 6th ed . 10

11. Elemental ; hydrolyzed; predigested; chemically defined; elemental or semi elemental formulas Require minimal digestion, and therefore are designed for patients with malabsorption and maldigestion . Proteins are in short-chain peptides and free amino acids; carbohydrates are as glucose oligosaccharides and fats are in long and medium-chain triglycerides. Fischer’s Mastery of Surgery, 6th ed 11

12. Immune modulating formulas Supplemented with arginine eicosapentaenoic acid, docosahexaenoic acid , glutamine and nucleic acid . Renal formulas Generally lower in total protein (and therefore lower nitrogen loads) and have increased amounts of histidine and essential amino acids. Usually, they also have reduced levels of K, Mg, and Phos . Useful in patients with poor renal clearance and those trying to avoid dialysis. Patients with adequate renal replacement therapy can be on standard formulas. Fischer’s Mastery of Surgery, 6th ed 12

13. Hepatic formulas Have increased branch-chain amino acids and reduced aromatic amino acids (AAA’s contribute to hepatic encephalopathy because they can act as a false neurotransmitter) Can be useful in patients with hepatic encephalopathy that are resistant to standard treatments and are malnourished Pulmonary formulas Low in carbs, high in fats to decrease the respiratory quotient May not have as great of an effect on the respiratory quotient as overfeeding Fischer’s Mastery of Surgery, 6th ed 13

14. Vascular Access and Administration 14

15. 15

16. Patients who require short-term PN, majority of hospitalized patients with PN, typically receive PN as a 24 h continuous infusion . H ome PN is often administered on a cyclic ( discontinuous) schedule. Cyclic administration during a portion of the day or night allows the patient freedom from the intravenous tubing and pump apparatus. Cyclic PN administration has also been used as a strategy against liver impairment associated with PN. 16

17. Composition Of PN Admixture PN administration include T wo-in-one system (containing amino acids and glucose). A ll-in-one system ( containing amino acids, fat and carbohydrates ). The two-in-one system includes amino acids and glucose in a single bag along with micronutrients but requires separate administration of the lipid product . In an all-in-one system, also called total PN (TPN) or total parenteral admixture (TNA ), all nutrients are mixed in a single bag and infused simultaneously. 17

18. Total Parenteral Nutrition Composition: 20:30:50 ratio = protein: fat : carbohydrate multivitamins 2000kcal Based of carbohydrate content High osmolar TPN : used in renal failure patient. Low osmolar TPN : used in Patient with Respiratory failure , risk of thrombosis 18

19. Monitoring of patient in TPN For fever / infections Daily weight measurement : >1kg/day is sign of fluid overload Weight gain after TPN usually starts fron day 5-7. Monitoring: Daily weight Vitals LFT/RFT : once a week(initially twice weekly) Serum electrolyte : twice a week(initially daily) 19

20. 20

21. Hypergylcemia : Predictors found to be associated with hyperglycemia during PN therapy include amount of glucose administered, critically ill patients, age > 65 years, underlying diabetes, presence of infection, renal impairment and concomitant use of glucose-elevating drugs (e.g., glucocorticoids, tacrolimus , somatostatin or octreotide ). 21

22. Hypertriglyceridemia Factors found to be associated with hypertriglyceridemia include sepsis , renal failure, hyperglycemia , obesity , alcoholism , pancreatitis , high-output fistula, multiple organ failure pre-existing hyperlipidemia and co-administration of drugs such as corticosteroids cyclosporine , tacrolimus, sirolimus or propofol . 22

23. Use of omega-3 fatty-acid enriched lipids and limiting lipid intake is recommended (< 1 g/kg/day including external sources such as propofol ) to avoid hypertriglyceridemia . To help monitoring, when hypertriglyceridemia is present, blood samples should be properly collected to avoid possible artifactual results. 23

24. REFEEDING SYNDROME Refeeding syndrome is occurrence of severe fluid and electrolyte imbalance in severely malnourished individual while starting the proper feeding enteral or parenteral nutrition. It is more common in TPN . Leads to hypocalcemia , hypophosphatemia, hypomagnesemia, hypokalemia. 24

25. Criteria for stratifying patients as moderate and high risk for refeeding syndrome Low BMI < 18.5 kg/m2; Recent weight loss of 5% in 1 month or 7.5–10% in 3 to 6 months; None or negligible oral intake 5–6 days; Caloric intake < 75% estimated for >5 days during acute illness or injury; Caloric intake < 75% estimated energy for >1 month ; 25

26. Abnormal potassium, phosphorus, or magnesium serum concentrations ; Loss of subcutaneous fat; Loss of muscle mass; Higher-risk comorbidities (diseases and clinical conditions associated with the presence of the prior criteria, such as alcoholism, eating disorders, cancer, malabsorptive states , etc.). 26

27. Pathophysiology 27

28. 28

29. Prevention of refeeding syndrome Gradually increasing the quantity of food. Thiamine supplementation. Strict monitorning of serum electrolyte. 29

30. Hepatobiliary Complications Parenteral nutrition-associated liver disease ( PNALD ) is a spectrum of diseases that can range from mild liver enzyme abnormalities to steatosis to eventual fibrosis or cirrhosis . There are three primary types of PNALD: S teatosis , C holestasis, G allbladder sludge/stones. 30

31. PNALD , is often defined biochemically as 1.5 times the upper limit of normal elevation of two out of the following liver test: G amma- glutamyl transferase or Alkaline phosphatase and/or S erum conjugated bilirubin 2 mg/ dL . Elevation occurs within 1 to 3 weeks of initiating PN. 31

32. 32

33. 33

34. Reference Bailey and love’s short practice of surgery 28 th edition. Sabistion textbook of surgery 21 st edition. ESPEN practical guideline: Clinical nutrition in surgery. ASPEN guidelines , 2020 34

35. THANK YOU.. 35