Parenteral Nutrition powerpoint

7/25/2019 Parenteral Nutrition powerpoint

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Parenteral Nutrition

Graphic source: http://www.rxkinetics.com/tpntutorial/1_4.html


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Parenteral Nutrition (Definition)

omponents are in elemental or !pre"

#i$este#% form

&Protein as amino aci#s

&' as #extrose

&at as lipi# emulsion

&*lectrol+tes, -itamins an# minerals


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Parenteral Nutrition (PN) Definition

Deli-er+ of nutrients intra-enousl+, e.$. -iathe loo#stream.

&entral Parenteral Nutrition: often calle# otal

Parenteral Nutrition (PN)0 #eli-ere# into a

central -ein

&Peripheral Parenteral Nutrition (PPN):

#eli-ere# into a smaller or peripheral -ein

.2.P.*.N. Nutrition 2upport Practice 3anual, n# e#ition,

556, p. 78


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9n#ications for PN (2P*N)

hen 2peciali;e# Nutrition 2upport (2N2)is in#icate#, *N shoul# $enerall+ e use# inpreference to PN. (


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*N -s PN in ritical are (*B)

C.1. 9f the criticall+ ill 9 patient ishemo#+namicall+ stale with a functional

G9 tract, then *N is recommen#e# o-er PN.

Patients who recei-e# *N experience# lessseptic mori#it+ an# fewer infectious

complications than patients who recei-e#

PN.2tron$, on#itional

D *-i#ence nal+sis Birar+, accesse# A/58


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*N -s PN in ritical are (*B)

9n the criticall+ ill patient, *N is associate#

with si$nificant cost sa-in$s when

compare# to PN. here is insufficient

e-i#ence to #raw conclusions aout the

impact of *N or PN on B2 an# mortalit+.

2tron$, on#itional

D *-i#ence nal+sis Birar+, accesse# A/58


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ommon 9n#ications for PN

Patient has faile# *N with appropriate tueplacement

2e-ere acute pancreatitis

2e-ere short owel s+n#rome 3esenteric ischemia

Paral+tic ileus

2mall owel ostruction

G9 fistula unless enteral access can e place# #istalto the fistula or where -olume of output warrantstrial of *N

#apte# from 3irtallo in 2P*N, he 2cience an# Practice of Nutrition 2upport: ase"


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ontrain#ications

unctional an# accessile G9 tract

Patient is takin$ oral #iet

Pro$nosis #oes not warrant a$$ressi-enutrition support (terminall+ ill)

Cisk excee#s enefit

Patient expecte# to meet nee#s within 14#a+s


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PN entral ccess

3a+ e #eli-ere# -ia femoral lines, internalEu$ular lines, an# sucla-ian -ein cathetersin the hospital settin$

Peripherall+ inserte# central catheters(P9) are inserte# -ia the cephalic an#asilic -eins

entral access re=uire# for infusions thatare toxic to small -eins #ue to me#icationp', osmolarit+, an# -olume


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Fenous 2ites for ccess to the

2uperior Fena a-a


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P9 Bines (peripherall+ inserte#

central catheter)P9 lines ma+ e use# in amulator+

settin$s or for lon$ term therap+

se# for #eli-er+ of me#ication as well as

PN

9nserte# in the cephalic, asilic, me#ianasilic, or me#ian cephalic -eins an#

threa#e# into the superior -ena ca-aan remain in place for up to 1 +ear with

proper maintenance an# withoutcomplications


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PN: Peripheral ccess

PN ma+ e a#ministere# -ia peripheral access

when

herap+ is expecte# to e short term (15"14

#a+s)

*ner$+ an# protein nee#s are mo#erate

ormulation osmolarit+ is @55"755msm/B

lui# restriction is not necessar+

.2.P.*.N. Nutrition 2upport Practice 3anual, 5560 p.74


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3acronutrients H

3icronutrients


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3acronutrients: aroh+#rate

2ource: 3onoh+#rous #extrose

Properties: Nitro$en sparin$*ner$+ source

I.4 Jcal/$

'+perosmolar

Cecommen#e# intake:

& 6 m$/k$/min

65"@6K of total calories


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3acronutrients: aroh+#rate

Potential Adverse Effects:

9ncrease# minute -entilation

9ncrease# pro#uction 9ncrease# CL

9ncrease# consumption

Bipo$enesis an# li-er prolems'+per$l+cemia


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3acronutrients: mino ci#s

2ource: r+stalline amino aci#sMstan#ar# or specialt+

Properties: 4.5 Jcal/$

* 45&65K N* 65" @5K

Glutamine / +steine

Cecommen#e# intake:

5.A".5 $/k$/#a+

16"5K of total calories


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Potential Adverse

Effects:

9ncrease# renal solute

loa#

;otemia


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2peciali;e# mino ci# 2olutions


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3acronutrients: Bipi# 2ource: 2afflower an#/or so+ean oil

Properties: Bon$ chain tri$l+ceri#es

9sotonic or h+potonic

2taili;e# emulsions

15 Jcals/$

Pre-ents essential fatt+ aci#

#eficienc+

Cecommen#e# intake:5.6 & 1.6 $/k$/#a+ (not > $/k$)

1 & 4 hour infusion rate


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3acronutrients: Bipi#s

Ce=uirements

4K to 15K kcals $i-en as lipi# meets *

re=uirements0 or K to 4K kcals $i-en as linoleic

aci#

Generall+ 655 mB of 15K fat emulsion $i-en two

times weekl+ or 655 mB of 5K lipi#s $i-en once

weekl+ will pre-ent *D sual ran$e 6K to I6K of total kcals

3ax. @5K of kcal or $ fat/k$


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3acronutrients: Bipi#s

Potential Adverse Effects:

*$$ aller$+

'+pertri$l+ceri#emiaDecrease# cell"me#iate# immunit+ (limit to

1 $/k$/#a+ in criticall+ ill

immunosuppresse# patients)normal Bs


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Parenteral


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ther Ce=uirements

lui#MI5 to 65 ml/k$ (1.6 to IB/#a+)

& 2terile water is a##e# to PN a#mixtureto meet flui# re=uirements

*lectrol+tes

& se acetate or chlori#e forms to

mana$e metaolic aci#osis or alkalosis Fitamins: multi-itamin formulations

race elements


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*lectrol+tes/Fitamins/race

*lements


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#ult Parenteral 3ulti-itamins

New D re=uirements pulishe# in 555replacin$ NG"3 $ui#elines

9ncrease#


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Parenteral Nutrition Fitamin

Gui#elinesFitamin DGui#elinesO

9 II55 9

D 9 55 9

* 9 15 9

Jmc$ 165 mc$

m$ 55

olate mc$ @55

Niacin m$ 45

Fitamin DGui#elinesO


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Dail+ race *lement

2upplementation for #ult PN

C* *B*3*N 9NJ*

hromium 15"16 mc$

opper 5.I"5.6 m$

3an$anese @5"155 mc$

inc .6"6.5 m$

2P*N: 2afe practices for parenteral nutrition formulations. ?P*N () 47, 177A


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Dail+ *lectrol+te Ce=uirements

#ult PN*lectrol+te PN *=ui-

CD2tan#ar# 9ntake

alcium 15 m*= 15"16 m*=

3a$nesium 15 m*= A"5 m*=

Phosphate I5 mmol 5"45 mmol

2o#ium N/ 1" m*=/k$ Q replacement

Potassium N/ 1" m*=/k$

cetate N/ s nee#e# for aci#"ase

hlori#e N/ s nee#e# for aci#"ase


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PN ontaminants

omponents of PN formulations ha-e eenfoun# to e contaminate# with traceelements

3ost common contaminants are aluminuman# man$anese

luminum toxicit+ a prolem in pts with

renal compromise on lon$"term PN an# ininfants an# neonates

an cause osteopenia in lon$ term a#ult PNpatients

2P*N Nutrition 2upport Practice 3anual 5560 p. 157


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PN ontaminants

D re=uires #isclosure of aluminum

content of PN components

2afe intake of aluminum in PN is set at 6

mc$/k$/#a+


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PN ontaminants

3an$anese toxicit+ has een reporte# inlon$ term home PN patients

3a+ lea# to neurolo$ical s+mptoms

3an$anese concentrations of A to mc$/#ail+ -olume ha-e een reporte# in

formulations with no a##e# man$anese

3a+ nee# to switch to sin$le"unit traceelements that #onRt inclu#e man$anese

2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"

77


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alculatin$ Nutrient Nee#s

Pro-i#e a#e=uate calories so protein is

not use# as an ener$+ source

-oi# excess kcal (>I6 kcal/k$)

Determine ener$+ an# protein nee#s

usin$ usual metho#s (kcals/k$, 9reton"

?ones 177, 'arris"


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Protein Ce=uirements

1. to 1.6 $ protein/k$

9


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Peripheral Parenteral Nutrition

'+perosmolar solutions causethromophleitis in peripheral -eins

Bimite# to A55 to 755 msm/k$ (3'2uses 1165 msm/k$ w/ lipi# in thesolution)

Dextrose limite# to 6"15K finalconcentration an# amino aci#s IK final

concentration *lectrol+tes ma+ also e limite#

se lipi# to protect -eins an# increase

calories


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Peripheral Parenteral Nutrition

New catheters allow lon$er support -ia

this metho#

9n a#ults, re=uires lar$e flui# -olumes to #eli-er

a#e=uate nutrition support (.6"IB) 3a+ e appropriate in mil# to mo#erate

malnutrition (555 kcal re=uire# or 14 #a+s)

3ore commonl+ use# in infants an# chil#ren ontro-ersial


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ontrain#ications to Peripheral

Parenteral Nutrition2i$nificant malnutrition2e-ere metaolic stress

Bar$e nutrition or electrol+te nee#s(potassium is a stron$ -ascular irritant)

lui# restriction

Nee# for prolon$e# PN (> weeks)Cenal or li-er compromise

rom 3irtallo. 9n 2P*N, he 2cience an# Practice of Nutrition 2upport: ase"


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ompoun#in$ 3etho#s

otal nutrient a#mixture (N) or I"in"1&Dextrose, amino aci#s, lipi#, a##iti-es are

mixe# to$ether in one container

&Bipi# is pro-i#e# as part of the PN mixture on a#ail+ asis an# ecomes an important ener$+sustrate

"in"1 solution of #extrose, amino aci#s,

a##iti-es&+picall+ compoun#e# in 1"liter a$s

&Bipi# is #eli-ere# as pi$$+ack #ail+ or

intermittentl+ as a source of *


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#-anta$es of N

Decrease# nursin$ time

Decrease# risk of touch contamination

Decrease# pharmac+ prep time

ost sa-in$s

*asier a#ministration in home PN


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Disa#-anta$es of N

Diminishe# stailit+ an# compatiilit+

9F* (9F fat emulsions) limits the amount

of nutrients that can e compoun#e#

Bimite# -isual inspection of N0 re#uce#

ailit+ to #etect precipitates

2P*N Nutrition 2upport Practice 3anual 5560 p.

7A"77


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wo"in"ne PN


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PN ompoun#in$ 3achines:

utomix


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PN ompoun#in$ 3achines:

3icromix


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PN 2olution omponentsa

entral Peripheral

"""2olutions""" 2olutions

Bipi#" Dextrose"

ase# ase#

Dextrose 14.6K I6.5K 15.5K

mino ci#s 6.6K 6.5K 4.6K

at 6.5K 65 ml/ I.5 " A.5K 5K fat =

3,haK inal oncentration ourtes+ of 3arian, 3?.


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9nitiation of PN

#ults shoul# e hemo#+namicall+ stale,ale to tolerate the flui# -olume necessar+to #eli-er si$nificant support, an# ha-e

central -enous access 9f central access is not a-ailale, PPN

shoul# e consi#ere# (more commonl+ use#in neonatal an# pe#s population)

2tart slowl+(1 B 1st #a+0 B n# #a+)

2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"77


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9nitiation of PN: formulation

s protein associate# with few metaolicsi#e effects, maximum amount of proteincan e $i-en on the first #a+, up to @5"85$rams/liter

3aximum ' $i-en first #a+ 165"55$/#a+ or a 16"5K final #extroseconcentration

9n pts with $lucose intolerance, 155"165 $#extrose or 15"16K $lucose concentrationma+ e $i-en initiall+

2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"77


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9nitiation of PN: ormulation

Generall+ ener$+ an# protein nee#s can e

met in a#ults + #a+ or I

9n neonates an# pe#s, time to reach full

support relates in-ersel+ to a$e, ma+ e I"6

#a+s


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9nitiation of PN: ormulation

Dextrose content of PN can e increase# if

capillar+ loo# $lucose le-els are

consistentl+ 1A5 m$/#B

9F* in PN can e increase# if tri$l+ceri#es

are 455 m$/#B



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PN #ministration:ransition to

*nteral ee#in$s in #ultsontro-ersial

9n a#ults recei-in$ oral or enteral nutrition

sufficient to maintain loo# $lucose, no

nee# to taper PN

Ce#uce rate + half e-er+ 1 to hrs

or switch to 15K #extrose 9F) ma+ pre-ent

reoun# h+po$l+cemia (not necessar+ inPPN)

3onitor loo# $lucose le-els I5"@5 minutes

after cessation


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PN #ministration:ransition to

*nteral ee#in$s in Pe#iatricsGenerall+ tapere# more slowl+ than in

a#ults as oral or enteral fee#in$s are

intro#uce# an# a#-ance#

Generall+ PN is continue# until 86"A5K of

ener$+ nee#s are met enterall+



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3e#ications hat 3a+


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9nfusion 2che#ules


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9nfusion 2che#ules

ontinuous PN

Non"interrupte# infusion of a PN solution o-er 4

hours -ia a central or peripheral -enous access


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ontinuous PN

#-anta$es

ell tolerate# + most patients

Ce=uires less manipulationecrease# nursin$ time

ecrease# potential for !touch% contamination


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ontinuous PN

Disa#-anta$es

Persistent anaolic state

&altere# insulin : $luca$on ratios

&increase# lipi# stora$e + the li-er

Ce#uces moilit+ in amulator+ patients


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9nfusion 2che#ules

+clic PN&he intermittent a#ministration of PN -ia a

central or peripheral -enous access, usuall+

o-er a perio# of 1 & 1A hours

&Patients on continuous therap+ ma+ e

con-erte# to c+clic PN o-er 4"4A hours


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+clic PN

#-anta$es

&pproximates normal ph+siolo$+ of

intermittent fee#in$

&3aintains:S Nitro$en alance

S Fisceral proteins

&9#eal for amulator+ patientsS llows normal acti-it+

S 9mpro-es =ualit+ of life


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+clic PN

Disa#-anta$es

&9ncorporation of N4into muscle stores ma+ e

suoptimal

S Nutrients a#ministere# when patient is less acti-e

&Not tolerate# + criticall+ ill patients

&Ce=uires more nursin$ manipulation

S 9ncrease# potential for touch contaminationS 9ncrease# nursin$ time


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'ome PN


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'ome PN

2afet+ an# efficac+

depend on:

&Proper selection of patients

e=uate #ischar$e plannin$/e#ucation

&'ome monitorin$ protocols


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'ome PN

Patient selection

&Ceasonale life expectanc+

&Demonstrates moti-ation, competence,

compliance

&'ome en-ironment con#uci-e to sterile

techni=ue


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'ome PN: Dischar$e Plannin$

Determination whether patient meets pa+er

criteria for PN0 completion of 3N forms

9#entification of home care pro-i#er an#

D3* supplier

9#entification of monitorin$ team for home

on-ersion of 4"hour infusion sche#ule to

c+clic infusion with monitorin$ of patient

response


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'ome PN

ost effecti-e

&Luicker #ischar$e from hospital

&9mpro-e# rehailitation in the home&Ce#uce# hospital rea#missions

9 #i i f PN i


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ommon 9n#ications for PN in

Pe#s2ur$ical G9 #isor#ers

9ntractale #iarrhea of infanc+

2hort owel s+n#rome

9nflammator+ owel #isease

9ntractale ch+lothorax

9ntensi-e cancer treatment


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Pe#iatric *ner$+ Nee#s in PN

No consensus exists as to how to #etermineener$+ nee#s of hospitali;e# chil#ren

CDs are inten#e# for health+ chil#ren ut

can use for health+/acutel+ ill chil#ren an#monitor response

an estimate C** usin$ ' e=uation an#

a## stress factors, monitor clinical course 9n#irect calorimetr+ recommen#e# in

#ifficult cases

CDs for *ner$+ an# Protein


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CDs for *ner$+ an# Protein

ate$or+ $e (+r) *ner$+

(kcal/k$/#)

Protein

($/k$/#)

9nfants 5.5"5.6 15A .

hil#ren 1"I 15 1.

4"@ 75 1.18"15 85 1.5

emales 11"14 48 1.5

16"1A 45 5.A3ales 11"14 44 1.5

16"1A 46 5.7

Cecommen#e# Dietar+ llowances, 15

th

e#. 17A7. National ca#em+ Press,ashin$ton, D

' * ti t #i t C**


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' *=uations to pre#ict C**

from o#+ wei$ht

2ex/$e Can$e (+ears) *=uation to Deri-e C**(kcal/#)

3ales 5"I (@5.5 x wt) & 643ales I"15 (.8 x wt) Q 476

3ales 15"1A (18.6 x wt) Q @61

emales 5"I (@.1 x wt) & 61

emales I"15 (.6 x wt) Q 477

emales 15"1A (1. x wt) Q 84@

9 ' C** t


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9ncrease ' C** + stress

factorse-er 9ncrease 1IK per #e$ree

ar#iac ailure 16"6K

raumatic 9nEur+ 5"I5K

2e-ere respirator+#istress or roncho"

pulmonar+ #+splasia

6"I5K

2e-ere sepsis 46"65

lson, D. Pe#iatric Parenteral Nutrition. 9n 2harpenin$ +our skills as a nutrition support

#ietitian. DN2, 55I.


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rauma/riticall+ 9ll Pe#s

$e in +ears Jcals/k$ G/pro/k$

5"1 75"15 .5"I.6

1"@ 86"75 1.A"I.5

8"1 65"86 1.6".6

1I"1A I5"@5 1.5".5


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Pe#iatric PN: lui#s

2tan#ar# calculation:

&155 kcal/k$ for infant I"15 k$

&1555 kcal Q 65 kcal/k$ for e-er+ k$ o-er 15 k$

for a chil# 15"5 k$

&1655 kcal Q 5 kcal/k$ for e-er+ k$ o-er 5 k$

for a chil# o-er 5 k$

&1 mB flui#/kcal/# Q a#Eustments for fe-er,#iarrhea, stress, etc.

2P*N


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Pe#iatric PN: aroh+#rate

aroh+#rate shoul# comprise 46"65K of

caloric intake in infants an# chil#ren ()

or neonates, ' #eli-er+ in PN shoul#

e$in at @"A m$/k$/minute of #extrose an#

a#-ance# to 15"14 m$/k$/minute. (


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Pe#iatric PN: Bipi#

Preterm: start at .6 $/k$/#a+ an# increase + .6$/k$= #a+

9nfants: 2tart at 1 $/k$ an# increase + .6 $/k$/#a+

until the maximum or #esire# #ose is reache#0nee# 5.6 to 1 $/k$/#a+ for * nee#s

3aximum is I $/k$ for 4 months ol# an#.6$/k$ for 4 months an# ol#er

Dail+ *lectrol+te an# 3ineral


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Dail+ *lectrol+te an# 3ineral

Ce=uirements for Pe#s PtsElectrolyte Infants/Children Adolescents

2o#ium "@ m*=/k$ 9n#i-i#uali;e#

hlori#e "6 m*=/k$ 9n#i-i#uali;e#

Potassium "I m*=/k$ 9n#i-i#uali;e#

alcium 1".6 m*=/k$ 15"5 m*=

Phosphorus 5.6"1 mmol/k$ 15"45 mmol

3a$nesium 5.I"5.6 m*=/k$ 15"I5 m*=

National #-isor+ Group. 2afe practices for parenteral nutrition formulations ?P*N 177A0:47"@@


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Document in hart

+pe of fee#in$ formula an# tue

3etho# (olus, #rip, pump)

Cate an# water flush 9ntake ener$+ an# protein

olerance, complications, an#

correcti-e actionsPatient e#ucation

Parenteral Nutrition powerpoint

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