Total Parenteral Nutrition ICU Nurses' Knowledge

Total Parenteral Nutrition in Critical care units

1. Complications of Parenteral Nutrition اشراف :- ا.م.د عقيل حبيب أعداد طالبة الدكتوراه: أسماء جمعة

2. The Main Complications Associated with Parenteral Nutrition Metabolic imbalance: that causes hyperglycemia, hypertriglyceridemia and electrolyte imbalance Hyperglycemia is found in up to 50% of PN patients. Important predictors are insulin resistance or diabetes mellitus, severity of the underlying illness, concomitant steroid therapy, and the amount of glucose provided. Hyperglycemia adversely affects morbidity and mortality in surgical and medical intensive care patients. Numerous clinical studies have associated hyperglycemia with increased morbidity and mortality in surgical patients with sepsis, patients after bypass surgery, and patients with myocardial infarction or stroke. Patients receiving parenteral nourishment who are critically ill should begin getting intensive glucose management and insulin therapy.

3. Normal Glucose Metabolism

4. Hypertriglyceridemia: Hypertriglyceridemia is found in approximately 25–50% of PN patients. The extent of hypertriglyceridemia depends on the presence of accompanying hyperglycemia, simultaneous renal insufficiency, steroid administration, extent of the illness and the amount of lipids infused. Severe hypertriglyceridemia (>1000 mg/ dL or 11.4 mmol/L and particularly >5000 mg/ dL or 57.0 mmol/L) can induce acute pancreatitis, similar to patients with severe hypertriglyceridemia without PN, and it can affect micro circulation. It is not known whether long-term hypertriglyceridemia in PN patients is associated with increased cardiovascular risk. To manage hypertriglyceridemia, the above-mentioned causative factors should be corrected. Hyperglycemia plays an especially important role. Heparin activates lipoprotein lipase and hence can lower blood triglyceride levels but it increases non-esterified fatty acid concentrations .

5. Electrolyte fluid balance

6. Electrolyte imbalance: That may lead to another complication such as acid-base disturbance, liver dysfunction and renal failure. Liver Dysfunction: Long term complications may lead to liver steatosis, liver cirrhosis and cholestasis and those complications may lead to liver failure Overfeeding: Parenteral nutrition might result in overfeeding because to the elevated glucose and fat concentrations. Sedation patients using propofol should avoid obtaining lipids in their parenteral feeding. Advised that all patients might optimize the benefits of parenteral nutrition while minimizing the dangers by avoiding lipid in the mixture on the first week of admission

7. S &S of Hyponatremia , Hypokalemia , Hypocalcemia

8. S &S of Hypernatremia , Hyperkalemia , Hypercalcemia

9. Hypoglycemia: A rapid decrease in the rate of parenteral nourishment infusion may cause the patients' blood sugar to drop dangerously low. As a result, parenteral nutrition is rarely immediately discontinued and is always given via infusion pump. Catheter associated infection: as a result of use central venous catheter (CVC) and the infection may cause by bacteria, fungi and may leads to sepsis Thrombosis : Parenteral nutrition may cause DVT or pulmonary embolism as a result of use CVC and elevated osmotic pressure of parenteral nutrition  

10. Nursing Interventions and Rationale Monitor vital signs, observe for signs of infection such as, fever, leukocytosis, erythema, chill, tachycardia and positive blood culture Assuring that central lines was placed using proper barrier procedure is the first step in minimizing risk of infection To help avoid –catheter – associated sepsis, Complete barrier precautions should be used during catheter insertion, and the location should be prepared with chlorhexidine Use strict aseptic technique with IV lines, dressing changes and TPN solution change. (infusion set at high risk for developing infection) every 24 hours

11. Eliminating lipid from parenteral feeding also assists in infection prevention, as lipids increase the growth of variety pathogens If it is suspected the catheter site is the source of infection, the catheter is removed and the tip is typically sent for culture and sensitivity testing Because the subclavian vein is the preferred access point, a chest x-ray is required following catheter insertion and before using the IV to checkout pneumothorax and to ensure catheter placement A separate line is required for parenteral feeding infusion. There should be no more IV infusions or boluses administered through the line, and no blood collected from it

12. Monitor blood glucose level observe for the signs of hyperglycemia or hypoglycemia, administer insulin as directed, hypoglycemia as a result of rapid decrease in the rate of parenteral nutrition may cause the patient's blood glucose level to drop dangerously low, so that parenteral nutrition is rarely immediately discontinued and is always given via an infusion pump Monitor for signs of fluid overload (TPN is a hypertonic solution and can create intravascular shifting of extracellular fluid) Monitor renal status (intake and output, daily weight, laboratory studies such as S. creatinine and BUN to assess renal function) Maintain accurate infusion rate with infusion pump, make rate change gradually and never discontinue TPN abruptly to prevent fluctuation in blood glucose level.

13. Methods of Giving Parenteral Nutrition Peripheral Method Peripheral parenteral nutrition (PPN) may be provided to supplement oral consumption. PPN is administered via peripheral vein due to the solution's low hypertonicity than a full- caloric parenteral nutrition solution. Due to low dextrose level in PPN formulation, they are nutritionally inadequate. Simultaneously, lipids are supplied to puffer the PPN and prevent the peripheral vein from irritation. The typical duration of therapy with PPN is 5 to 7 days.

14. Central Method Central parenteral solutions (CPNs) contain five to six times the solute concentration of blood (and have an osmotic pressure of roughly 2000mOsm\L) and are injected into the vascular system via a catheter placed into a large, high flow blood vein (e.g. the subclavian vein). The blood in this artery dilutes concentrated solutions to isotonic levels extremely quickly. Nontunneled or percutaneous central catheters, peripherally inserted central catheters, tunneled catheters, and implanted ports are the four types of central venous access devices (CVADs) available

15. Initiating Therapy: PN solutions are started cautiously and gradually increased at the necessary rate each day, depending on the patient's fluid and dextrose tolerance. The physician monitors the patient's laboratory test results and reaction to PN therapy on a going basis, Standing orders are established for weighing the patient; monitoring intake, output and blood glucose; and monitoring complete blood count, platelet count, and chemical panel, which include serum carbon dioxide, magnesium, phosphorus, and triglycerides, at baseline and on a recurring basis. Nitrogen balance analysis may be performed using a 24-hour urine nitrogen determination. The TPN solution are prescribed on a daily standard PN order from in the majority of hospitals. Each day, the formulation of the PN solution is carefully calculated to ensure that the patient's total nutritional needs are met.

16. http://www.infusionsolutionsinc.com https://youtu.be/WwKtHyfkGm8 How to prepare and administer TPN videos

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