Total parenteral Nutrition in Critical Care Units

ICU Nurses' Knowledge towards Total Parenteral Nutrition

1. Effectiveness of an Interventional program on Nurses' Knowledge and Practice toward Parenteral Nutrition in Critical Care Units اشراف :- ا.م.د عقيل حبيب أعداد طالبة الدكتوراه: أسماء جمعة

2. TPN solution Bag

3. Feeding tubes Methods

4. Introduction

5. Nutrition and Nutritional Support

6. Cont.

7. Practice Guidelines for Nutrition in Critical Ill Patients   All the critically ill patients should undergo nutrition assessment, on admission Observation of signs of malnutrition (e.g., cachexia, edema, muscle atrophy, BMI <20 kg/m 2 ) is critical EN should be started early, preferably within first 24–48 h In case the nutrition requirement is not met adequately with EN even after 7 days of ICU admission, then usage of parenteral nutrition (PN) may be considered

8. Practice Guidelines for Nutrition in Critical Ill Patients   Nutritional support should to be considered as of therapeutic benefits and not just supportive or adjunctive Electrolytes should be strictly monitored in the patient on nutrition therapy Assessment of drug–nutrient interaction to be done on daily basis Tube feeding to be considered if even 50%–60% of nutrition targets are not met adequately within 72 h of oral nutrition support

9. Benefits of Adequate Nutrition for Patients Wound healing is improved' Reduced the response of catabolic injury Improved function of gastrointestinal Complication reduction, reduced hospitalization and cost. Also, it has been proposed that malnourishment in ventilated patients result in deceased ventilator drive, decreased surfactant synthesis, and difficulty weaning due to muscular exhaustion induced by diaphragmatic and skeletal muscle weakening.

10. Objectives of Nutritional Assessment for the Patient in Critical Cases To document baseline subjective and objective nutritional parameters Determine nutritional risk factors Identify nutritional deficits Establish nutritional needs for patients Identify medical, psychosocial and socioeconomic factors that may influence the administration of nutrition support therapy.

11. Approach to Determine Nutritional Status Medical history and physical examination Nutrition and medication histories Physical assessment Anthropometric measures Laboratory data

12. Assessment of Nutritional Status in Critical Ill Patients Anthropometric Measures : includes Body weight, Height, Skin fold thickness, Mid – upper arm circumference Assessing the body weight and height of critically ill patients in the intensive care unit (ICU) is often essential, but a real challenge for the healthcare professionals concerned. is especially true for physicians, nurses and dieticians, as many forms of clinical management - mechanical ventilation by tidal volume per kilogram per breath, antibiotics, nutritional support, inotropes and the dosage of other drugs - all require the patient’s body weight to inform management procedures. To estimate the patients’ body weight, the usual ICU practice is simply visual estimation, but such methods have been shown to be significantly inaccurate with an error ranged from 11.4% to greater than 20% against measured values

13. Assessment of Nutritional Status in Critical Ill Patients According to Malnutrition universal screening tool of Asian BMI= weight(kg ) \height ( m 2 ) WHO (BMI classification) Underweight: BMI<18.5 kg/m2 Healthy weight: 18.5 - 24.9 kg/m2 Overweight: 25-29.9 kg/m2 Estimated body weight = 20× [ estimated body height (in meter)] 2

14. 2. Biochemical Data 2. Biochemical Data Parameter Purpose Glucose To assess glucose tolerance and identify need for insulin requirements 2. Sodium , Potassium, Magnesium, Phosphate To assess refeeding syndrome risks, toxicity and depletion status 3. Urea , Creatinine   To assess renal function and hydration status, 4. Liver enzymes & Bilirubin To assess overfeeding or hepatobiliary dysfunction 5. C- reactive protein To assess the presence of infection

15. 2. Biochemical Data 6. CBC , MCV, Iron &B12   Indicator of infection, sepsis, anemia or blood loss 7. Cholesterol & TG   Overfeeding 8. Zinc , Copper , Selenium , Thiamine & Folic acid To decrease the risks of trace elements deficiency and toxicity 9. Bone densitometry & Vit. D To diagnose metabolic bone disease 10. Urine To detect ketones 11. Arterial Blood Gases ABG Metabolic state

16. 3. Clinical Examination assessment of metabolic activity (T, HR, BP, RR, level of arousal) hydration status muscle wasting signs of micro-nutrient deficiency (glossitis, angular stomatitis, anemia, bleeding gums, skin/hair/nail condition

17. 4.Dietary intake Nutritional History: Food intake History/duration of poor oral intake or prolonged fasting periods Current intake compared with usual intake Other factors affecting intake e.g. dysphagia, taste changes, poor dentition, abdominal pain and/or depression Consideration of micro and macro nutrient intake is necessary here Unintentional recent weight loss Significant weight loss : • 5% weight loss in one month , 10 % weight loss in six months Severe weight loss : • >5% body weight in one month, 10% in three months7 Risk of re-feeding syndrome

18. 5. Medical and surgical history Severity of illness and duration Conditions such as trauma, major abdominal surgery, chronic illness with acute complications, sepsis, losses (e.g. fistula, wounds, diarrhea) altered mental state and large wounds increase risk of malnutrition and increase patient requirements

19. 6. Medication History Has the patient been on medication which has the potential to affect nutritional status, either through gastrointestinal side effects (e.g. nausea) or neurological side effects (e.g. confusion), or through direct drug-nutrient interaction

20. ESPEN Recommendations Tool for measuring Nutritional Status

21. CONT. ESPEN (European Society for Parenteral and Enteral Nutrition) which is an organization means in publication of clinical researches and established in 1980 and the changed to European Society for Clinical Nutrition and Metabolism

22. Screening Tools Malnutrition Universal Screening Tool ( MUST) Nutritional Risk Screening (NSR-2002) Mini Nutritional Assessment (MNA)

23. Cont. Nutritional Risk Screening (NSR-2002) The purpose of NRS -2002 system is to analyses BMI, weight loss, recent dietary intake and severity of illness to detect the presence, and risk of developing malnutrition in the hospital setting