Parentral nutrition

an introduction to parentral nutrition

1. Parentral nutrition. An introduction Dr. S. K. MOHAN S3 unit VMMC & SJH, NEW DELHI

2. NUTRITION Nutrition is the provision to obtain essential nutrients necessary to support life & health. Nutrients are the substances that are not synthesised in our body sufficiently and therefore must be supplied.

3. Oral, entral , parenteral

4. Enteral nutrition Indicated for patients who have a functioning GI system but cant accept / ingest orally

5. Parenteral nutrition Includes IV infusion of nutrients in an elemental form, that bypasses the usual process of digestion.

6. Indications of parenteral nutrition. Inadequate – oral/ enteric nutrition for at least 7- 10 days. Partial/ complete GI dysfunction. Pre- existing severe malnutrition. Massive small bowel resections, prolonged ileus, high output fistulas. Severe burns Pre/ post operative buildup .

7. Types of parenteral nutrition 1.Peripheral (partial) parentral nutrition

8. Total parenteral nutrition Provides complete nutritional support. A large amount of nutrients in a hypertonic solution is infusing via a centrally placed venous access. Normally incudes – carbohydrates, proteins, lipids, as major share

9. Contents 1. Carbohydrates Mainly dextrose. Commercially available in diff. concentrations -5% to 70%. Supplies calories – 3.4 Kcal/gm. Prevents catabolism and have N2 sparing effect.

10. 2. Lipids. Iv fat emulsion which provides a dense source of Calories(9Kcal/gm.) Contains long chain triglycerides – combination of soya and sun flower oils Disadv -causes immune suppression, modulate inflammatory responses.

11. 3. proteins. Provide up to 2-3 gm /kg/day proteins in form of amino acids. Normal protein :fat: glucose ratio for PN is 20:30:50. Low protein formula with CRF and hepatic failure.

12. Fluid and electrolytes Normal adult requirements;- Fluid-30-40 ml/kg Na+/ k+ kg.-1-2 mEq /kg Ca +-10-20 meq /kg 8-20 mEq of Mg Trace metals[Zn, Cu, etc ]

13. Types of TPN 1. TPN without lipids ( 2 in 1 solutions) Calories from amino acids -20-25% Calories from dextrose-75- 80 %

14. TPN with lipids( 3 in 1 solution) Amino acids-20-25% Lipids-20% Dextrose-55-60%

15. Systems of PN delivery:- Multiple bottle vs 3 in 1 system Duration of delivery. continuous vs cyclical

16. Initiation of TPN Examine and establish nutritional requirement, indications, route access of patient Should be initiated slowly @ 50% of the goal in first day, 75% in 2nd day and 100% in 3-4 th day. Prevent fluid over load, refeeding syndrome, hyper glycemia , hypertriglyceridemia

17. Refeeding syndrome -severe fluid electrolyte imbalance in severely malnourished pateints under going refeeding Starving patients- less carbohydrates-uses fat- sudden change causes increased insulin secreation - HYPOKALEMIA. Cardiac arrhythmia HYPOPHOSPHATEMIA. Renal, hepatic failure HYPOMAGNESEMIA.

18. Monitoring nutritional support Monitor vital, fluid balance, weight. Local care, change delivery systems. RBS q6h, electrolytes, RFT, LFT, INR, albumin.

19. Termination of TPN Gradual termination with starting of oral / enteral feeding. Decrease infusion rate by 50 % for 2-3 hrs and stop/ add D10 After stopping TPN. OR stop when patient can take 60% of total energy need enteraly .

20. Complications of TPN MECHNICAL Due to improper cvp placement Venous thrombosis.

21. INFECTIVE Intestinal side effects – due to atrophy Catheter related infections

22. METABOLIC Volume over load, hyper-hypo- glycemia , tryglyceridemia , refeeding synd. Hepatic complications- fatty liver, NASH, cholestasis, - lithiasis . Bone demineralisation, essen . Fatty acid deficiency.

23. Thank you … skm25 .