Parenteral Nutrition

Dr Mohd Nikman AhmadAnaesthesia & Intensive Care

USM

Nutrition

If the gut is functioning,

use it!

Parenteral Nutrition

1. Indications & contraindication2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

Parenteral Nutrition1. Indications2. Routes of

administration3. Nutritional

requirements4. Different disease

state5. Monitoring6. Complications

1. WAIT !! Well Nourished

after 7-10 days, EN not feasible / target

goal calories not met

2. ASAP !! (EN is not feasible)

- Malnourished +major upper

abdominal surgery(5-7 day preoperatively)

- Protein calorie malnutriotion

(after adequate resus)

EN = enteral nutrition

ASAP = as soon as possible

Parenteral Nutrition1. Indications2. Routes of

administration3. Nutritional

requirements4. Different disease

state5. Monitoring6. Complications

1Inadequate intake

2Impossible to eat

3Undesirable to eat

Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat

Poor absorption

-severe nausea & vomiting

-diarrhoea-malabsorption

-short bowel syndrome

- Inflammatory bowel disease

Refusal to eat

-Anorexia nervosa

-Pain-Depression

-Fear

Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat Bowel obstruction

-CA of the GIT-Acute intestinal

obstruction -Adhesion

Indications1. Inadequate intake2. Impossible to eat3. Undesirable to eat

Others

-severe burn-severe trauma

-hypercatabolic state-Impaired motor

function

To rest the bowel

-peritonitis-pancreatitis-post surgery

-enterocutaneous fistula

Contraindications:

1. Unstable patients2. Shock3. Serum lactate > 3 mmol/L4. PaO2 < 50 mmHg5. PaCO2 > 75 mmHg

Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

Routes of administration

Central route

- Short term < 2 weeks- Caloric < 2000 kcal/day- 800-900 mosmol/L- Dextrose < 10%- Amino acid < 7% thrombophlebitis

Peripheral routeLarge bore

peripheral line

Routes of administrationPeripheral route

- Suitable for hypertonic & hyperosmolar solution- Long term therapy - high caloric (>2000 kcal/day) Catheter sepsis

Central routeCVP

Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

Total Calorie Need = BEE X Activity Factor X Injury Factor

1.2 confined to bed1.3 out of bed 1.3 non stressed

1.4 minimally stressed: IBD,Ca, elective surgery, moderate skeletal trauma1.5 moderately stressed: ortho surgery, sepsis, burn, major skeletal trauma1.6 severely stressed: multiple trauma, sepsis, multisystem surgery1.7 extremely stressed: severe head injury, ARDS, burn, sepsis2.1 Major burn

Harris Benedict Equation♂ BEE = 66 + (13.7 x W) + (5 x H)) – (6.8 x A)♀ BEE = 655 + (9.6 x W) + (1.8 x H) – (4.7 x A)

W = weight in Kg, H = height in cm, A = age in yearsBEE increases by 13% per 1oC in temperature

Main Ingredient Critically Ill patients Stable patient

Energy (total calories) 25-30 kcl/kg/day 30-40 kcl/kg/day

Fluid Minimum needed to deliver adequate macronutrient

40-40 ml/kg/day

Carbohydrate e.g Dextrose

< 4 g/kg/min1g = 4 kcl @ 16 kJ

< 7 g/kg/min

Fate.g Intralipid, Lipofundin

1 g/kg/day1g = 9 kcal @ 37.6 kJ

1 g/kg/day

Proteine.g Vamin, Aminoplasma

1.2-1.5 g/kg/day1g = 4 kcl @ 16 kJ

1g nitrogen = 6.25g protein

0.8-1.0 g/kg/day

Nutritional Requirements

Energy

CH2OFat

Amino Acid

30-40% 60-70%

NPC (Kcal) : N (g) ratio(CH2O&Fat) : N

80-200 : 1

70 x 25 Kcal/Kg/day = 1750 Kcal

70 x 1 g/Kg/day = 70 g x 4 kcal = 280 Kcal70g/6.25 = 11.2g Nitrogen

1470 Kcal

40% of 1470 = 580 KcalIn g, 580/9 = 64.5g

± 1g/Kg/day

60% of 1470 = 882 KcalIn g, 882/4 = 220.5g

± 3 g/Kg/day

NPC (Kcal) : N (g) 1470:11.2 = 131:1 ratio

70 kg

Carbohydrate

Glucose Fructose

•CH20 of choice•Physiological substrate of all tissue esp: brain•Prerequisite for protein anabolism

•Insulin independent•less irritant•rapidly metabolised•better nitrogen sparing effect•Causes lactic acidosis esp in paediatric

COMPLICATIONS

•Causes hyper/hypo glycaemia

• Increases CO2 production

Fat & ProteinFat Protein

•cell wall integrity, prostaglandin synthesis & function of lipid soluble vitamin•Deficiency leads to dermatitis, fatty liver & reduced immune function

•Essential:Is Leu Met Pheny, Try His Threo Val Ly•Non Essential: GAGAP AS CT•Respiration & transport, enzymes, hormones & antibodies, support & movement

GAGAP AS CTGlycine Alanine Glutamate Proline Aspartate Serine Cystine Tyrosine

Is Leu Met Pheny, Try His Threo Val Ly

Isoleucine Leucine Methionine Phenylalanine Tyrptophan Histidine

Valine Lysine

Nutritional requirements

Energy

CH2OFat

VitaminsElectrolyte

Amino AcidTrac

e Elem

ents

Fluid

Electrolyte Electrolyte mmol/kg/day

Chloride 1.3-2.0

Sodium 1-2

Potassium 0.7-1.5

Phosphate 0.5-0.7

Calcium 0.1-0.15

Magnesium 0.05-0.15

•Calcium & phosphate may precipitate

•Hypophosphataemia occurs in malnourished and trauma patient leading to serious cardiorespiratory

squeal

•Diuresis causes hypomagnesaemia

Vitamins• Essential in the metabolism of carbohydrate, protein & fat• Decompose by light & heat• Short shelf life (within 24 Hrs)

Water soluble vitaminsB1,B2,B6,B12,C, Biotin,

folic acid,glycine

Fat soluble vitaminsADEK

e.g Soluvit NTM, ParentrovitTM

•Deficiencies leads to pancytopeneia (↓folic acid), encephalopaty (↓thiamine),

e.g. VitralipidTM

•Deficiencies leads to coagulopathy (↓Vit K),•Excess Vit A & D leads to exfoliative dermatitis & hypercalcaemia

Trace Elements• Needed only when starved for > 2 weeks• Short term PN therapy vary unlikely to

cause deficiency• Zinc is important if patient has significant

GIT fistula loses• e.g. PeditraceTM AddamelTM

Trace ElementsElement Deficiency State

Zinc •Skin lesions•Anorexia•Impaired immune function•Diarrhoea•Depressed mental function•Poor wound healing

Copper •Neutropenia•Normocytic, hypochromic anaemia

Chromium •Glucose intolerance•Weight loss•Peripheral neuropathy

Manganese •Hypercholesterolaemia•Weight loss

Selenium •Muscle pain & weakness•Cardiomayopathy

Ferum •Anaemia

Immuno modulation

Contains enrich “functional” substrate

• Glutamine• Omega 3 fatty acid• Arginine• Anti-oxidant; Vit E &

ascorbic acid

Benefit in• Major elective surgery• Trauma• Burns• Head& neck Ca• Ventilated critically ill

patients

Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

1.Renal failure2.Liver failure3.Pancreatitis 4.Obesity

Renal Failure - Maximum concentration of nutrient in minimum

volume- Caution with potassium, magnesium & phosphate

administration - Normal daily protein intake & increased to 2.5

g/kg/day in patient on CVVHD- 7.5-10% amino acid solution, higher proportion of

essential AA, tyrosine

Liver failure• Difficult to assess nutritional status because of

ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia

• Should not restrict protein• 5-8% amino acid solution• Higher portion of branched chain amino acid, low

concentration of aromatic amino acid• Branched chain amino acid formulations (BCAA)

should be reserved for the rare encephalopathic patient together with antibiotic & lactulose

Pancreatitis• Enteral feeding is not contraindicated• Change intact protein to small peptides• Change long-chain fatty acids to medium-chain

triglycerides or a nearly fat-free elemental formulation

Obesity

BMI Energy Protein< 30 •60-70%

•11-14 Kcal/kg/Actual BW•22-25 Kcal/kg/Ideal BW

1.2-2.0g/kg/Actual BW

30-40 Same as above 2.0-2.5g/kg/Actual BW

>40 Same as above 2.5g/kg/Actual BW

BW = body weight

Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

Monitoring AIMS 1.Assessment of input vs output

2.Maitenance of metabolic balance3.Detection of deficiency state4.Detaction of toxic accumulation

1. Blood glucose Frequently if unstableDaily once stable

2. BUSE, FBC, Temperature & input output balance

Daily

3. LFT, Ca2+ , PO4-, Mg2+ & Body weight

Weekly

4. ABG & serum lipid As indicated

Parenteral Nutrition1. Indications2. Routes of administration3. Nutritional requirements4. Different disease state5. Monitoring6. Complications

Complications

1. Catheter related2. Metabolic complications

1.Catheter related sepsis (3-5%)2.Catheter leaks or clots3.Insertion problems4.Air embolism

Complications

1. Catheter related2. Metabolic complications

1.Glucose imbalance2.Electrolyte imbalance3.Essential Fatty Acid deficiency syndrome4.Fluid Overload5.Refeeding syndrome6.Allergic reaction

Refeeding syndrome• Common in alcoholism,anorexia

nervosa, marasmus, rapid refeeding & excessive dextrose infusion

• Signs: haemolytic anaemia, respiratory distress, paresthesia, tetany, cardiac arrhytmias, low phosphate, mg & K