Parenteral Nutrition

Dr Mohd Nikman Ahmad

Anaesthesia & Intensive Care USM

Nutrition

If the gut is functioning, use it!

Parenteral Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state Monitoring Complications

Parenteral Nutrition
1. Indications 2. Routes of 1. Wait Well Nourished administration after 7-10 days, EN 3. Nutritional not feasible / target requirements goal calories not met 4. Different disease state 5. Monitoring 6. Complications
2. ASAP (EN is not feasible) - Malnourished + major upper abdominal surgery
(5-7 day preoperatively)

- Protein calorie malnutrition

(after adequate resus)

EN = enteral nutrition ASAP = as soon as possible

Parenteral Nutrition
1. Indications 2. Routes of administration 3. Nutritional requirements 4. Different disease state 5. Monitoring 6. Complications 1 Inadequate intake 2 Impossible to eat 3 Undesirable to eat

Indications
1. Inadequate intake 2. Impossible to eat 3. Undesirable to eat
Refusal to eat
-Anorexia nervosa -Pain -Depression -Fear Poor absorption -severe nausea & vomiting -diarrhoea -malabsorption -short bowel syndrome - Inflammatory bowel disease

Indications
1. Inadequate intake 2. Impossible to eat 3. Undesirable to eat
Bowel obstruction -Ca of the GIT -Acute intestinal obstruction -Adhesion

Indications
1. Inadequate intake 2. Impossible to eat 3. Undesirable to eat
Others To rest the bowel -peritonitis -pancreatitis -post surgery -enterocutaneous fistula -severe burn -severe trauma -hypercatabolic state -Impaired motor function

Parenteral Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state Monitoring Complications

Routes of administration
Large bore peripheral line
- Short term < 2 weeks - Caloric < 2000 kcal/day - Dextrose < 10% - Amino acid < 7% thrombophlebitis

Routes of administration

CVP

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

Parenteral Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state Monitoring Complications

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 years BEE increases by 13% per 1oC in temperature

Total Calorie Need = BEE X Activity Factor X Injury Factor

1.2 confined to bed 1.3 out of bed

1.3 non stressed 1.4 minimally stressed: IBD,Ca, elective surgery, moderate skeletal trauma 1.5 moderately stressed: ortho surgery, sepsis, burn, major skeletal trauma 1.6 severely stressed: multiple trauma, sepsis, multisystem surgery 1.7 extremely stressed: severe head injury, ARDS, burn, sepsis 2.1 Major thermal injury

Main Ingredient
Critically Ill patients Energy (total calories) Fluid 25-30 kcl/kg/day Minimum needed to deliver adequate macronutrient 2 g/kg/day 1g = 4 kcl @ 16 kJ 1 g/kg/day 1g = 9 kcal @ 37.6 kJ 1.2-1.5 g/kg/day 1g = 4 kcl @ 16 kJ 1g nitrogen = 6.25 protein Stable patient 30-40 kcl/kg/day 40-40 ml/kg/day

Carbohydrate e.g Dextrose Fat e.g Intralipid, Lipofundin Protein e.g Vamin, Aminoplasma

3 g/kg/day

1 g/kg/day

0.8-1.0 g/kg/day

Nutritional Requirements
Fat Energy 70 kg
NPC (Kcal) : N (g) ratio (CH2O&Fat) : N = 80-200 : 1

CH2O

Amino Acid
70 x 25 Kcal/Kg/day = 1750 Kcal

1470 Kcal

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

40% of 1470 = 580 Kcal In g, 580/9 = 64.5g 1g/Kg/day

60% of 1470 = 882 Kcal In g, 882/4 = 220.5g 3 g/Kg/day

NPC (Kcal) : N (g)

1470:11.2 = 131:1 ratio

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

Fructose
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 & Protein

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

Protein
Essential:Is Leu Met Pheny, Try His Threo Val Ly Non Essential: AS GAGAP CT Respiration & transport, enzymes, hormones & antibodies, support & movement
Is Leu Met Pheny, Try His Threo Val Ly
Isoleucine Leucine Methionine Phenylalanine Tyrptophan Histidine Valine Lysine

AS GAGAP CT
Aspartate Serine Glycine Alanine Glutamate Proline Cystine Tyrosine

Nutritional requirements
Fat
CH2O

Energy

Fluid

Electrolyte
Electrolyte Chloride Sodium Potassium Phosphate Calcium Magnesium mmol/kg/day 1.3-2.0 1-2 0.7-1.5 0.5-0.7 0.1-0.15 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 vitamins
B1,B2,B6,B12,C, Biotin, folic acid,glycine

Fat soluble vitamins ADEK e.g. VitralipidTM Deficiencies leads to coagulopathy (Vit K), Excess Vit A & D leads to exfoliative dermatitis & hypercalcaemia

e.g Soluvit NTM, ParentrovitTM Deficiencies leads to pancytopeneia (folic acid), encephalopaty (thiamine),

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 Elements
Element Zinc Deficiency State Skin lesions Anorexia Impaired immune function Diarrhoea Depressed mental function Poor wound healing Neutropenia Normocytic, hypochromic anaemia Glucose intolerance Weight loss Peripheral neuropathy Hypercholesterolaemia Weight loss

Copper Chromium

Manganese

Selenium
Ferum

Muscle pain & weakness Cardiomayopathy

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 Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state 1.Renal failure Monitoring 2.Liver failure Complications 3.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 (loss 10-15 d/day during CVVHD)

Liver failure
Difficult to assess nutritional status because of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia Should not restrict protein 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
< 30

Energy
60-70% 11-14 Kcal/kg/Actual BW 22-25 Kcal/kg/Ideal BW Same as above Same as above

Protein
1.2-2.0g/kg/Actual BW

30-40 >40

2.0-2.5g/kg/Actual BW 2.5g/kg/Actual BW
BW = body weight

Parenteral Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state Monitoring Complications

Monitoring
AIMS 1.Assessment of input vs output 2.Maitenance of metabolic balance 3.Detection of deficiency state 4.Detaction of toxic accumulation Frequently if unstable Daily once stable Daily Weekly

1. Blood glucose 2. BUSE, FBC, Temperature & input output balance 3. LFT, Ca2+ , PO4-, Mg2+ & Body weight

4. ABG & serum lipid

As indicated

Parenteral Nutrition
1. 2. 3. 4. 5. 6. Indications Routes of administration Nutritional requirements Different disease state Monitoring Complications

Complications
1. Catheter related 2. Metabolic complications
1.Catheter related sepsis (3-5%) 2.Catheter leaks or clots 3.Insertion problems 4.Air embolism

Complications
1. Catheter related 2. Metabolic complications
1.Glucose imbalance 2.Electrolyte imbalance 3.Essential Fatty Acid deficiency syndrome 4.Fluid Overload 5.Refeeding syndrome 6.Allergic reaction