Supplementary Nutritional Support - SNS / TPN

Supplementary Nutritional Support - Total Parenteral Nutrition - TPN SNS

1. SUPPLEMENTARY NUTRITIONAL SUPPORT Dr Chandrashekar K Associate Professor, Dept of Medicine, KIMS, Hubballi

2. HISTORY Early 1960 s, the use of intravenous nutrition was restricted to high concentrations of dextrose and electrolytes. 1962 , Wretlind and colleagues developed lipid infusions as the principle source of calories for parenteral feeding.

3. 1966 , Dudrick and Rhoads developed parenteral nutrition (PN) for patients who had lost their small bowel. 1976 , Solassol and Joyeux developed the three-in- one mixture by putting sugars, lipids and amino acids in a single bag. 1978 , Shils and colleagues and Jeejeebhoy and colleagues developed ‘home based’ PN to reduce costs.

4.  Human nutrition is the provision to obtain the essential nutrients necessary to support life and health  Nutrients are the substances that are not synthesized in sufficient quantity in the body and therefore must be supplied from diet

5. Protein (Amino acids) Fat Carbohydrate Dietary fiber Water and electrolytes Vitamins M inerals Trace elements

6. P atients should be assessed for PEM as well as specific nutrient deficiencies Evidence of malabsorption Symptoms of specific nutrient deficiencies Look for factors which may increase metabolic stress ( infection, inflammation, malignancy ) Functional status (bed ridden, suboptimally active, fully active)

7.  Look for tissue depletion (loss of body fat and skeletal muscle wasting )  Assess muscle function (strength testing of individual muscle groups )  Fluid status : dehydration or fluid overload  Look for sources of protein or nutrient losses : large wounds, burns, nephrotic syndrome, chronic diseases, GI losses of nutrients, surgical drains .  Lab parameters : plasma albumin, electrolytes, vitamins and minerals

8. ENERGY PARAMETERS 1 Cal (1 kcal) = 4.128 KJ Carbohydrates : 4 kcal/g Fats : 9 kcal/g Proteins : 4 kcal/g Alcohol : 7 kcal /g

9. UTILIZATION OF ENERGY IN MAN Basal metabolic rate Specific dynamic action Physical activity.

10. BMR BMR is defined as the minimum amount of energy required by the body to maintain life at complete physical and mental rest in the post absorptive state (12 hr after last meal) Normal values of BMR : For an adult man : 35–38 kcal/ sq.m /hr ; 1600kcal/day For an adult woman : 32-35 kcal/ sq.m /hr. 1400kcal/day

11. ESTIMATING ENERGY REQUIREMENTS Harris-Benedict equations : Men: BEE = 66.47 + 13.75W + 5.00H − 6.76A Women: BEE = 65.10 + 9.56W + 1.85H − 4.68A Where , W is weight in kilograms, H is height in centimeters, A is age in years . BEE is Basal Energy Expenditure

12. T E E = B E E + Stress Factor + Activity Factor 1.1 = without evidence of significant physiologic stress 1.4 = marked stress such as sepsis or trauma Other factors :  Pregnancy : Add 300 kcal/day  Lactation : Add 500 kcal/day  Obese or Super obese Add 15-20 kcal/kg ESTIMATING ENERGY REQUIREMENTS

13. Factors affecting BMR Surface area : directly proportional Sex : males 5% more than females Age : infants highest Physical activity : directly proportional Hormones : thyroid Climate and temperature : inversely proportional Starvation : reduces in starvation Fever : increases Diseases : increases Race : eskimos have high BMR

14. Significance of BMR C alculate the calorie requirement of an individual Planning of diets

15. RDA Nutrient Male Female Water ( litre /day) 3.7 2.7 Carbohydrate (g/day) 130 130 Fibre (g/day) 38 25 Protein (g/d) 56 46 Calcium (mg/d) 1000 1000 Iodine (μ g/d) 150 150 Iron (mg/d) 8 18 Magnesium (mg/d) 400-420 310-320 Phosphorus (mg/d) 700 700 Zinc (mg/d) 11 8 Sodium (g/d) 1.5 1.5 Potassium (g/d) 4.7 4.7 Chloride (g/d) 2.3 2.3 Harrisons Principles of Internal medicine , 19 th E , chapter nutrition

16. RDA Nutrient Male Female Vitamin A (μ g/d) 900 700 Vitamin C (mg/d) 90 75 Vitamin D (μ g/d) 15 15 Vitamin E (mg/d) 15 15 Vitamin K ( μ g/d) 120 90 Thiamin (mg/d) 1.2 1.1 Riboflavin (mg/d) 1.3 1.1 Niacin (mg/d) 16 14 Vitamin B6 (mg/d) 1.3 1.3 Folate (μ g/d) 400 400 Vitamin B12 (μ g/d) 2.4 2.4 Pantothenic Acid (mg/d) 5 5 Biotin (μ g/d) 30 30 Harrisons Principles of Internal medicine , 19 th E , chapter nutrition

17. Supplementary Nutritional Support Enteral SNS is the provision of liquid formula meals through a tube placed into the gut Parenteral SNS is the direct infusion of complete mixtures of crystalline amino acids, dextrose, triglyceride emulsions, and micronutrients into the bloodstream through a central venous catheter or via a peripheral vein

18. INDICATIONS FOR SPECIALIZED NUTRITIONAL SUPPORT PEM is already present at the time of hospital admission and remains unimproved or worsens during the ensuing hospital stay INANITION (exhaustion caused by lack of nourishment) INFLAMMATION INACTIVITY

19. Common reasons for PEM worsening Refusal of food because of anorexia, nausea, pain, or delirium, Communication barriers, An unmet need for hand-feeding of patients with physical or sensory impairment, Disordered or ineffective chewing or swallowing, Prolonged periods of physician-ordered fasting

20. Metabolic states Hypometabolic state : relatively less stressed but mildly catabolic and chronically starved individual who, with time, will develop cachexia / marasmus . Hypermetabolic state : stressed from injury or infection is catabolic (experiencing rapid breakdown of body mass) and is at high risk for developing acute malnutrition/ kwashiorkor if nutritional needs are not met and/or the illness does not resolve quickly

21. Nitrogen Balance = N input - N output N input N output = (protein in g / 6.25) = 24h urinary urea nitrogen + non-urinary N losses + 4 to + 6 : Net anabolism +1 to - 1 : Homeostasis - 2 to - 1 : Net catabolism

22. ENTERAL NUTRITION PARENTERAL NUTRITION

23. Does the patient has PEM ? Or is at the risk of PEM ?

24. Enteral Nutrition (Definition) Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum) —Tube feedings —Must have functioning GI tract — IF THE GUT WORKS, USE IT ! —Exhaust all oral diet methods first.

25. GOLDEN RULE THE GUT SHOULD ALWAYS BE THE PREFERRED ROUTE FOR NUTRIENT ADMINISTRATION Enteral feeding also supports gut function by : Stimulating splanchnic blood flow, Neuronal activity, IgA antibody release, and Secretion of gastrointestinal hormones that stimulate gut trophic activity. These factors support the gut as an immunologic barrier against enteric pathogens.

26.  Enteral nutrition is associated with fewer complications than parenteral nutrition and is less expensive to administer  However, the use of enteral nutrition alone often does not achieve caloric targets .  In addition, underfeeding is associated with weakness, infection, increased duration of mechanical ventilation, increased duration of hospital stay and death .  Combining parenteral nutrition with enteral nutrition constitutes a strategy to prevent nutritional deficit but may risk overfeeding which has been associated with liver dysfunction, infection, and prolonged ventilatory support.

27. Parenteral Nutrition

28. Parenteral Nutrition (Definition) Components are in elemental or “pre-digested” form PROTEIN as AMINO ACIDS CARBOHYDRATES as DEXTROSE FAT as LIPID EMULSION ELECTROLYTES, VITAMINS AND MINERALS

29. Parenteral nutrition should be considered if energy intake has been inadequate for more than 7-10 days and enteral feeding is not feasible It involves the continuous infusion of a hyperosmolar solution containing carbohydrates, proteins, fat and other necessary electrolytes through an indwelling catheter

30. Macronutrients: Carbohydrate Source: Properties: Monohydrous D extrose Nitrogen sparing Energy source 3. 4 Kcal/g Hy p er o smolar Recommended intake: 2 – 5 mg/kg/min 50-65% of total calories

31. Macronutrients: Amino Acids Sourc e : Prop e rties: Crystalline amino acids— standard or specialty 4.0 Kcal/g EAA 40–50 %, NEAA 50-60% Recommended intake: 0.8 g/kg/day 15-20% of total calories Potential Adverse Effects: Increased renal solute load Azotemia

32. Additional protein intake : burn injuries, open wounds , protein losing Enteropathy / Nephropathy . A lower protein intake : chronic renal insufficiency who are not treated by dialysis hepatic encephalopathy Each gram of nitrogen lost or gained represents : 30 g of lean tissue.

33. Requirement 3 g/kg/day 30-40 percent of nutrition Liver can synthesize most fatty acids, but cant produce omega-3 and omega-6 fatty acid series. Linoleic acid least 2% and Linolenic acid at least 0.5% of daily caloric intake to prevent essential fatty acid deficiency

34. Parenteral Fats Parenteral fat : 20 % and 30% emulsions A ll-in-one mixture Max. 60% of kcal or 2 g fat/kg 500 mL of 20% lipids given once weekly will prevent EFAD

35. By caloric intake : 1ml/calorie Example: 1800 calorie diet = 1800 calories x 1ml= 1800ml By body weight and age : average requirement is 30 ml/kg/d 16-55 years 35 ml/kg/d 56-65 years 30 ml/kg/d > 65 years 25 ml/kg/d

36. Parenteral Nutrition (Types) 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

37. 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

38. Contraindications Functional and accessible GI tract Patient is taking oral diet Patient expected to meet needs within 14 days

39. Peripheral Parenteral Nutrition Generally intended as supplement to oral feeding And is not optimal for critically ill pts New catheters allow longer support via this method M ore commonly used in infants and childre n Temporary nutritional supplementation with PPN may be useful

40. 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 Contraindications to PPN

41. TOTAL PARENTERAL NUTRITION (TPN) Provides complete nutritional support via a central catheter The solution, volume of administration, and additives are individualized based on an assessment of the nutritional requirements. Nutrition delivered by PICC or CVC (tunneled or non tunneled)

42. ADVANTAGES DISADVANTAGES  Bed side technique  Avoids complications of central venous catheter  Avoid multiple venous C annulations  Hypertonic solutions can be given  Trained personnel is N eeded  Line blockage  Mal position  Phlebitis  Line sepsis  Th rombosis

43. NON TUNNELLED V/S TUNNELLED CENTRAL VENOUS CATHETERS

44. INFUSION TECHNIQUE AND PATIENT MONITORING Solutions with an osmolarity >900-1000 mOsm /L (e.g., those which contain >3% amino acids and 5% glucose [290 kcal/L]) are poorly tolerated peripherally. Peripheral PN may be enhanced by small amounts of heparin (1000 U/L) and co-infusion with parenteral fat to reduce osmolarity

45. FORMULATIONS FOR TPN Emulsions, or admixtures of nutrients that are administered in an elemental form. 2-in-1 or 3-in-1 formulations available with carbohydrate + amino acids +/- lipid emulsions Additives like : insulin, H2 blockers, vitamins can be added

46. Calculations Water = 25 to 35 ml / kg /day = 30x70 = 2100 ml / day Calculating the requirement of TPN formulation for a 70 year old patient :

47. For 2 in 1 formula ( without lipid )

48. Compounding Methods Total nutrient admixture (TNA) or 3-in-1 Dextrose, amino acids, lipid, additives are mixed together in one container 2-in-1 solution of dextrose, amino acids, additives Lipid is delivered as piggyback daily or intermittently as a source of EFA

49. Advantages of TNA ( Total nutrient admixture) Decreased nursing time Decreased pharmacy prep time Cost savings Easier administration in home PN Physiological balance of macronutrients

50. Disadvantages of TNA Diminished stability and compatibility

51. PN Compounding Machines :

52. Initiation of PN Adults should be hemodynamically stable, able to tolerate the fluid volume necessary to deliver significant support, 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; 2 L 2nd day )

53. Initiation of PN: formulation As protein associated with few metabolic side effects, maximum amount of protein can be given on the first day, 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

54. Intensive Insulin and Glycemic Control Hyperglycemia increases inflammation and has deleterious effects on the immune, respiratory, renal, and nervous systems NICE-SUGAR trial established that a slightly more moderate approach (i.e., maintaining blood glucose levels<180 mg/ dL ) yielded much of the benefits of tighter protocols, without decreased morbidity and mortality from hypoglycemia

55. Infusion Schedules Continuous PN Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous access Well tolerated by most patients Requires less manipulation

56. Infusion Schedules Cyclic PN The intermittent administration over a period of 12 – 18 hours Patients on continuous therapy may be converted to cyclic PN over 24-48 hours

57. Home TPN Patient selection Reasonable life expectancy Demonstrates motivation, competence, compliance Home environment conducive to sterile technique

58. Complications Of TPN Mechanical metabolic i n fectio us

59. Air embolism Pneumothorax Hemothorax Cardiac tamponade Injuries to arteries and veins Injury to thoracic duct Brachial plexus injury

60. Infections : Catheter related sepsis is most common life threatening complication Causes: Staph epidermidis and staph aureus , Enterococcus , Candida, E coli, psuedomonas , Klebsiella

61. PN Administration:Transition to Enteral Feedings in Adults In adults receiving oral or enteral nutrition sufficient to maintain blood glucose, need to taper PN When the patient can satisfy 75% of his or her caloric needs with oral intake 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

62. Strict asepsis 24-hr TPN prepared at a time Changing infusion sets daily New amino acid, lipid bottles daily Separate IV access for other drugs Serum Na, K on alt. days; renal parameters biweekly; LFT, triglycerides weekly

63. Clinimix : dextrose + AA Clinimix E : dextrose + AA + Electrolytes Kabiven : 3 in 1 formulation Vitrimix : Dextrose + AA Intralipid : 20% lipid Celepid : 20 % lipid Celemin : AA 10 %

64. References : Harrison’s : Textbook of Internal Medicine Bailey and love : Text book of Surgery Sabiston : Text book of Surgery Maingot’s : Text book of Surgery

65. THANK YOU