Parenteral NutritionDr Mohd Nikman AhmadAnaesthesia & Intensive CareUSM

Nutrition

If the gut is functioning, use it!

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications 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 malnutrition(after adequate resus)EN = enteral nutritionASAP = as soon as possible

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications 1Inadequate intake2Impossible to eat3Undesirable to eat

IndicationsInadequate intakeImpossible to eatUndesirable to eatPoor absorption

-severe nausea & vomiting-diarrhoea-malabsorption-short bowel syndrome- Inflammatory bowel diseaseRefusal to eat

-Anorexia nervosa-Pain-Depression-Fear

IndicationsInadequate intakeImpossible to eatUndesirable to eatBowel obstruction

Ca of the GITAcute intestinal obstruction Adhesion

IndicationsInadequate intakeImpossible to eatUndesirable to eatOthers

-severe burn-severe trauma-hypercatabolic state-Impaired motor functionTo rest the bowel

-peritonitis-pancreatitis-post surgery-enterocutaneous fistula

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications

Routes of administrationCentral route Short term < 2 weeks Caloric < 2000 kcal/day Dextrose < 10% Amino acid < 7% thrombophlebitisPeripheral routeLarge bore peripheral line

Routes of administrationPeripheral route Suitable for hypertonic & hyperosmolar solution Long term therapy high caloric (>2000 kcal/day) Catheter sepsisCentral routeCVP

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications

Total Calorie Need = BEE X Activity Factor X Injury Factor 1.2 confined to bed1.3 out of bed1.3 non stressed1.4 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 thermal injuryHarris 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 patientsStable patientEnergy (total calories)25-30 kcl/kg/day30-40 kcl/kg/dayFluidMinimum needed to deliver adequate macronutrient 40-40 ml/kg/dayCarbohydrate e.g Dextrose2 g/kg/day1g = 4 kcl @ 16 kJ3 g/kg/dayFate.g Intralipid, Lipofundin1 g/kg/day1g = 9 kcal @ 37.6 kJ1 g/kg/dayProteine.g Vamin, Aminoplasma1.2-1.5 g/kg/day1g = 4 kcl @ 16 kJ1g nitrogen = 6.25 protein0.8-1.0 g/kg/day

Nutritional RequirementsEnergy CH2OFat Amino Acid30-40%60-70%NPC (Kcal) : N (g) ratio(CH2O&Fat) : N = 80-200 : 170 x 25 Kcal/Kg/day = 1750 Kcal70 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/day60% of 1470 = 882 KcalIn g, 882/4 = 220.5g 3 g/Kg/dayNPC (Kcal) : N (g)1470:11.2 = 131:1 ratio70 kg

CarbohydrateCOMPLICATIONSCauses hyper/hypo glycaemia Increases CO2 production

GlucoseFructoseCH20 of choicePhysiological substrate of all tissue esp: brainPrerequisite for protein anabolismInsulin independentless irritantrapidly metabolisedbetter nitrogen sparing effectCauses lactic acidosis esp in paediatric

Fat & ProteinAS GAGAP CTAspartate Serine Glycine Alanine Glutamate Proline Cystine Tyrosine Is Leu Met Pheny, Try His Threo Val LyIsoleucine Leucine Methionine Phenylalanine Tyrptophan Histidine Valine Lysine

FatProteincell wall integrity, prostaglandin synthesis & function of lipid soluble vitaminDeficiency leads to dermatitis, fatty liver & reduced immune functionEssential:Is Leu Met Pheny, Try His Threo Val LyNon Essential: AS GAGAP CTRespiration & transport, enzymes, hormones & antibodies, support & movement

Nutritional requirements

Electrolyte Calcium & phosphate may precipitateHypophosphataemia occurs in malnourished and trauma patient leading to serious cardiorespiratory squeal Diuresis causes hypomagnesaemia

Electrolytemmol/kg/dayChloride1.3-2.0Sodium1-2Potassium0.7-1.5Phosphate0.5-0.7Calcium0.1-0.15Magnesium0.05-0.15

VitaminsEssential in the metabolism of carbohydrate, protein & fatDecompose by light & heatShort shelf life (within 24 Hrs)

Water soluble vitaminsB1,B2,B6,B12,C, Biotin,folic acid,glycineFat soluble vitaminsADEK e.g Soluvit NTM, ParentrovitTMDeficiencies leads to pancytopeneia (folic acid), encephalopaty (thiamine), e.g. VitralipidTMDeficiencies leads to coagulopathy (Vit K),Excess Vit A & D leads to exfoliative dermatitis & hypercalcaemia

Trace ElementsNeeded only when starved for > 2 weeksShort term PN therapy vary unlikely to cause deficiencyZinc is important if patient has significant GIT fistula losese.g. PeditraceTM AddamelTM

Trace Elements

ElementDeficiency StateZincSkin lesionsAnorexiaImpaired immune functionDiarrhoeaDepressed mental functionPoor wound healingCopperNeutropeniaNormocytic, hypochromic anaemiaChromiumGlucose intoleranceWeight lossPeripheral neuropathyManganeseHypercholesterolaemiaWeight lossSelenium Muscle pain & weaknessCardiomayopathy Ferum Anaemia

Immuno modulation

Contains enrich functional substrateGlutamineOmega 3 fatty acidArginineAnti-oxidant; Vit E & ascorbic acid

Benefit inMajor elective surgeryTraumaBurnsHead& neck CaVentilated critically ill patients

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications 1.Renal failure2.Liver failure3.Pancreatitis 4.Obesity

Renal Failure Maximum concentration of nutrient in minimum volumeCaution with potassium, magnesium & phosphate administration Normal daily protein intake & increased to 2.5 g/kg/day in patient on CVVHD (loss 10-15 d/day during CVVHD)

Liver failureDifficult to assess nutritional status because of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemiaShould not restrict proteinBranched chain amino acid formulations (BCAA) should be reserved for the rare encephalopathic patient together with antibiotic & lactulose

PancreatitisEnteral feeding is not contraindicatedChange intact protein to small peptidesChange long-chain fatty acids to medium-chain triglycerides or a nearly fat-free elemental formulation

Obesity BW = body weight

BMIEnergyProtein< 3060-70%11-14 Kcal/kg/Actual BW22-25 Kcal/kg/Ideal BW1.2-2.0g/kg/Actual BW30-40Same as above2.0-2.5g/kg/Actual BW>40Same as above2.5g/kg/Actual BW

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications

Monitoring

AIMS1.Assessment of input vs output2.Maitenance of metabolic balance3.Detection of deficiency state4.Detaction of toxic accumulation

1. Blood glucoseFrequently if unstableDaily once stable2. BUSE, FBC, Temperature & input output balanceDaily3. LFT, Ca2+ , PO4-, Mg2+ & Body weightWeekly 4. ABG & serum lipidAs indicated

Parenteral NutritionIndicationsRoutes of administrationNutritional requirementsDifferent disease stateMonitoringComplications

ComplicationsCatheter relatedMetabolic complications

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

ComplicationsCatheter relatedMetabolic complications

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