Download Basic Concepts of Total Parenteral Nutrition

Nutrition Support of the
Surgical Patient
Randa Jaroudi, Pharm.D
Clinical Coordinator
TPN Coordinator
KKUH
Nutrition
 Nutrition allows the body to be provided with all
basic nutrients substrates and energy required for
maintaining or restoring all vital body functions
from carbohydrate and fat and for building up
body mass from amino acid.
Malnutrition
 Malnutrition—come from extended inadequate
intake of nutrient or severe illness burden on the
body composition and function—affect all systems
of the body
Type of Malnutrition
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Marasmus
Protein – calorie malnutrition
The patient's oral diet may include an acceptable
protein:calorie ratio but is inadequate in quantity and calories.
(depleted somatic proteins, normal visceral proteins)
Normal Albumin and transferrin
Patients look thin and malnourished.
e.g. Patients with mild to moderate starvation, common severe burns,
injuries, systemic infections, cancer etc or conditions where patient
does not eat like anorexia nervosa
Clinical Manifestations
 Weight loss
 Reduced basal metabolism
 Depletion skeletal muscle and adipose (fat) stores
 Decrease tissue turgor
 Bradycardia
 Hypothermia
Type of Malnutrition
 Kwashiorkor (Kwa-shior-kor)
Protein malnutrition
the diet contains various amounts of nonprotein calories
(inadequate, adequate, or excessive) from carbohydrates and fats,
but is deficient in total protein and essential amino acids.
(normal somatic proteins depleted visceral proteins)
↓ Serum Albumin and transferrin
Patients appear normal or overweight
e.g. Hypercatabolic critical care patients, chronic diarrhea, chronic kidney
disease, trauma , burns, hemorrhage, and liver cirrhosis
Clinical Manifestations
 Marked hypoalbuminemia
 Anemia
 Edema and ascites
 Muscle atrophy
 Delayed wound healing
 Impaired immune function
Diagnosis
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Mixed
Marasmus-Kwashiorkor:
(depleted somatic and visceral proteins)
All above data are reduced
Patients appear cachexic and severely malnourished.
e.g. *Chronic hypercatabolic patients (250 to 500g loss of weight)
*Prolonged starvation
Marasmic-kwashiorkor is a mixed form of any PCM
symptoms.
It frequently occurs when the marasmic patient experiences
the catabolic stress of illness or trauma.
Medical causes (Risk factors for malnutrition)
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Recent surgery or trauma
Sepsis
Chronic illness
Gastrointestinal disorders
Anorexia, other eating disorders
Dysphagia
Recurrent nausea, vomiting, or diarrhea
Pancreatitis
Inflammatory bowel disease
Gastrointestinal fistulas
Cancer
Metabolic Rate
Resting metabolism (% of normal)
Major burn
Sepsis
Trauma
Partial starvation
Total starvation
180
160
140
120
Normal range
100
80
60
0
10
20
30
Days
40
50
Long CL, et al. JPEN 1979;3:452-6
Protein Catabolism
Major burn
Trauma
Sepsis
Partial starvation
Total starvation
Nitrogen excretion (g/day)
30
25
20
15
10
Normal range
5
0
0
10
20
Days
30
40
Long CL. Contemp Surg 1980;16:29-42
The Goals of Preoperative Nutrition
Support
 ↓ surgical mortality
 ↓surgical complications and infection
 Reduce the catabolic state and restore anabolism
 ↓the hospital length of stay
 Speed the healing/recovery process
Indications
Aggressive nutritional support (enteral or
parenteral) should be considered in minimum 3
of:
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Looks clinically malnourished.
Has a low serum albumin <3.5g/dL.
Has a recent loss of 10% or greater within
Has a history of recent poor intake.
Who as a consequence of his illness is going to be or
has been NPO for 5-7 days.
The term “If gut works, use it” remains the golden rule. However, recently this was
changed to: If gut works use it; and if gut works partially, use it partially.
Preoperative Nutrition Assessment-1
1. Medical & Nutritional History
Medical history includes acute or chronic disease, medication,
surgeries, & other therapies (i.e., chemotherapeutics,
immunosuppressive)
Nutrition History includes recent changes in appetite or
weight, activity level, use of diet.
Subject Global Assessment (SGA)
Preoperative Nutrition Assessment-2
2. Physical
examination
Logical assessment from head to toe
3. Anthropometric
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parameters
% of IBW = Actual weight x 100/Ideal body weight
Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores
are depleted.
Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion.
TSF and Mid Arm Circumference are no more recommended as an accurate measurement.
Creatinine Height Index (CHI) to assess somatic protein stores.
Serum Protein Determination to assess the degree of visceral protein depletion, e.g.
Albumin, Transferring, Prealbumin.
Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired
4. Lab assessment
Fat, Anthropometric parameters
Assessment of body fat
Triceps Skinfold Thickness (TSF) for
assessing fat reserve. It is decreased when
fat stores are depleted.
Protein (Somatic Protein)
 Assessment of the fat-free muscle mass (Somatic Protein)
depletion
 Mid-upper-arm circumference (MAC)
TSF and MAC are no more
recommended as an accurate measurement
Creatinine-height index (CHI )
 [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a
given height]
 Ideal Cr = IBW x 23 mg/kg male
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= IBW x 18 mg/kg female
 CHI > 80
mild depletion
 CHI 60 – 80 moderate
 CHI < 60
severe
Average Body Mass Index (BMI) for
Adult
Classification
BMI (kg/m2)
Underweight
<18.5
Normal
18.5-24.9
Overweight
25.0-29.9
Obesity
30.0-34.9
I
Moderate obesity
35.0-39.9
II
Extreme obesity
>40.0
III
Obesity Class
Nutrition Provides
 Energy
 Amino Acid
 Fluid & Electrolyte
 Trace minerals (elements)
 Vitamin
 Certain drugs
Fluid Requirement
Fluid Requirement
Amount of fluid requirement needed depend on age
 Pediatric: 1st 10kg = 100ml/kg
2nd 10kg = 50ml/kg
3rd 10kg & up 20ml/kg
 Adult:
30-35ml/kg
Additional fluid for vomiting, nasogastric tube
output, diarrhea, large open wound, fever,
hyperventilation, fistula drainage.
Fluid Requirements
Special situation for fluid restriction:
Fluid overload,
 Cardiac, Renal, or Liver failure
 Elderly
 Medication
NRC* recommends 1 to 2 ml of water for each
kcal
of energy expenditure
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*NRC= National research council
Energy Requirements
Total Energy Expenditure
 TEE (kcal/day) = BEE x stress/activity factor
 BEE:
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The Harris-Benedict equation is a mathematical
formula used to calculate BEE
Harris-Benedict Equation
 Women =
655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age)
 Men =
66 + (13.7 x wt) + (5 x ht) - (6.8 x age)
 Calories Multiply by stress factor
A correlation factor that estimates the extent
of hyper-metabolism
 1.15 for bedridden patients
 1.10 for patients on ventilator support
 1.25 for normal patients
The stress factors are:
 1.3 for low stress
 1.5 for moderate stress
 2.0 for severe stress
 1.9-2.1 for burn
Calories Requirements
 Obesity: 18-20kcal/kg/day of IBW
 Normal need: 25-30kcal/kg/day
 Elective surgery: 28-30kcal/kg/day
 Severe injury: 30-40kcal/kg/day
 Extensive trauma/burn: 40-45kcal/kg/day
Carbohydrate
 Primary energy substrate
 The amount of carbohydrate is determined by
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patient’s calorie requirement
glucose oxidation rate
optimal balance of carbohydrate and fat
 Maximum oxidized rate 4 - 7mg/kg/min (adult).
Carbohydrate
 Provide from a non nitrogen source
 Energy requirement depends on number of
factors!
 Stress factors, increase calories requirements
 60% - 80% of caloric requirement as glucose
CHO Oxidation Rate
 1gm = 3.4kcal
 Kcl ÷ 3.4 x 1000 ÷ 1440 ÷ wt kg =
not more than 5mg/kg/min
e.g. 1700 ÷ 3.4 x 1000 ÷ 1440 ÷ 70 =
4.9mg/kg/min
or
 5 mg x 3.4 ÷ 1000 x wt x 1440
 5 x 3.4 ÷ 1000 x 70 x 1440 = ~ 1700 kcal
Carbohydrate Source
Starting with:
 200 - 250 gm or 15% dextrose solution started or 2.5
mg/kg/min
 100 - 150 gm or 10% - 15% dextrose solution in
stress & DM
 Increase gradually up to 5 mg/kg/min,
 Max 7 mg/kg/min
How to Calculate Percentage
 Total volume of fluid x 3.4 x %
 e.g. 2000ml x 3.4 x 0.20 = 1360 kcal.
Or
 1400 ÷ 3.4 ÷ 2000ml = 20% as started then
 1700 ÷ 3.4 ÷ 2000ml = 25% full requirement
Protein (Amino Acid)
AAs are the vital components of body protein. The
primary aim of providing AAs to the body is to
prevent:
 Disease related catabolic state.
 The development of manifest protein deficiency with
subsequent impaired wound healing.
 Disturbances of blood clotting.
 The impairment of hepatic and renal function.
 A reduced immuno-competence.
Protein (Amino Acid)
 1g of protein = 4 Kcal
 1g of nitrogen is equivalent to 6.3g of protein
 Non-protein k.cal: nitrogen
 150-200: 1 (normal patient)
Note:
In renal and hepatic failure the ratio is 1:300-400.
Adult dose: Normal patients requirement 0.8-1.0 g/kg
max. 2.5g/kg depend on patient status
Renal failure patient 0.6 g/kg
Protein (Amino Acid)
12% - 16% of calories as protein
Note:
 Products containing only essential Aas have been
formulated for renal failure.
 BCAA (Branched Chain Amino Acids) are used
for Hepatic Encephalopathy or in severely stressed
patients.
Fat Emulsion
 Essential linoleic acid stabilized by egg yolk
phospholipids
 Delivered in the form of an emulsion
 fat emulsion has no isotonicity by itself, glycerol
is added to render emulsion isotonic (300 mosm/l).
 Concentrated source of calories
 Source of essential fatty acids (EFAs)
 Substitute for carbohydrate in diabetic & fluid
restricted patients
Fat Emulsion
 Fat should provide 20-40% of total calories.
 Fat provides a concentrated caloric source. 1g provide 10
Kcal.
 Also fat is an alternative source to dextrose to the patients
with compromised respiration since it does produce little
CO2 in its metabolism. While dextrose, when oxidized, it
produces CO2 which must be eliminated via lungs.
 Start with 0.5g/kg/d  gradually up to1.5g/kg/d.
Fat Emulsion
 The caloric density
 10% FE is 1.1 kcal/ml
 20% FE is 2 kcal/ml
 30% FE is 3 kcal/ml
 There is LCT, and MCT/LCT products
 1gm = 9kcal of fat
 Each 1ml = 2kcal
 Lipid emulsions contain glycerol, so lipid emulsion does not have 9
kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for
lipid emulsions.
 Propofol: Soybean oil in water emulsion, 1ml - 1.112kcal
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Fat Emulsion Contraindications
 Hyperlipdemia
 Acute pancreatitis
 Previous history of fat embolism
 Severe liver disease
 Allergies to egg, soybean oil or safflower oil
Electrolytes
 Na, K, CL, Ca, Mg, PO4, & acetate.
 Electrolytes given to maintain normal serum
concentration or to correct deficit.
 Requirements for specific electrolytes will vary
according to the patients disease state
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Restrict electrolytes
 Severe renal dysfunction.
 Edema & congestive heart failure.
 Patients on corticosteroids.
 Metabolic acidosis, acute pancreatitis fistulas, or
diarrhea.
 Metabolic alkalosis, vomiting.
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Multivitamins
B – Complex: Co-enzyme in absorptive and metabolic processes,
transfer of energy from protein, fat and carbohydrate to the cells and their
storage as ATP.
Ascorbic Acid: Required for collagen synthesis, wound healing. An
additional amount may be required in major burns, traumas, and extensive
surgeries.
Vitamin A: Essential for vision, the production of mucus-secreting
epithelial cells and bone growth.
Vitamin D: For calcium and phosphate hemeostasis and boncalcification.
Vitamin K: For prothrombin generation (Fibrin Fibrinogen).
Vitamin K
 TPN solution does not contain vitamin K and it
can predispose patient to deficiency
 Vitamin K 10 mg should be given weekly IV or
IM if patient is on long-term TPN
Multivitamin and Trace Minerals
 Standard form of multivitamin & trace mineral use.
 Zinc, copper, manganese & chromium.
 Additional of trace mineral required depend on GI
losses.
 Renal failure patients reduce dose
 Biliary stasis disease, avoid copper & manganese
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Additives
 INSULIN: For hyperglycemia when glucose is spilling in urine.
 HEPARIN: To promote blood circulation (especially with peripheral
TPN) and to prevent thrombophlebitis.
 HYDROCORTISONE: To prevent thrombophlebitis in patients
receiving peripheral TPN.
 ACETATE: For acidosis.
 ZINC: Extra amount is needed for patient with severe stress,
diarrhea, and ileostomy.
Status of Organic failure
 Hypermetabolism
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Tachycardia, Tachypnea, Fever, Leucocytosis
 Hypercatabolism
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Hyperglycemia, Uremia, Hypertriglyceridemia, -NB
Renal Failure Considerations
 Present with problems of volume limitation and
poor tolerance of nitrogen wastes.
 Treated with 0.5-0.6g/kg amino acid, higher
glucose and lipid concentration.
 Limit amounts of sodium, potassium, magnesium,
and phosphate.
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Liver Failure Considerations
 Inability to tolerate large fluid volume and difficulty with
nitrogen loads
 Maintain glucose
 Supply moderate protein(1.0-1.3g/kg) and fat intake up to
30% of T.k.calorie
 Restrict fluid and salt intake
 BCAA
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Fluid Restricted Considerations
 As pulmonary, cardiac failure, head injuries, and elderly.
 Special concentrated TPN solution.
 High fat emulsion, low glucose.
 Normal protein requirement.
 Normal electrolyte.
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Respiratory Failure
 Non-protein calories to nitrogen ration is not a major
consideration.
 Major problem total calories, either from CHO or fat
or both
 Protein increases oxygen consumption demands and
that is not indicated to reducing protein
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Going to surgery
 In postoperative surgical patients;
TPN is indicated if the patient is indicated
to stay NPO for 5 – 7 days in malnourished
patients, and 7 – 10 days in well-nourished
patients.
 In preoperative patients;
TPN should be considered in patients who
cannot or should not eat for more than 3 – 5
days.
Practice Guidelines Preoperative
 NS should be administered for 7-14 days to
moderately or severely malnourished patients
undergoing major GI surgery
 PN should NOT be routinely given in the
immediate postoperative period to patients
undergoing major GI procedures
OR Patient
 Hold TPN during OR if it more than 1 1/2 hrs
 2hrs pre-operation:
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↓ TPN rate 50% for 1hr
Hold TPN
Start D10% infusion at same TPN rate
 6hrs post – operation
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Start new TPN bottle at 50% of TPN rate for 1hr
↑ TPN rate as in order
 MONITORING BLOOD SUGAR
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Routes of Nutrition Support
Enteral Nutrition
Enteral Nutrition Indication
 Inability to consume or absorb adequate nutrition
e.g. who do not eat or receive nutrition support for ≥10-14 days after
hospital admission
 Functional or partially functional gut
e.g. who are unable or not allowed to eat, or partial functional gut
Potential benefits of EN over PN
 Nutrients are metabolized and utilized more
effectively via the enteral than parenteral route
 Gut and liver process EN before their release into
systemic circulation
 Gut and liver help maintain the homeostasis of the
AA pool and skeletal muscle tissue
EN (Immunologic)
 Gut integrity is maintained by enteral feeding and
prevent the bacterial translocation from the gut
and minimize risk of gut related sepsis
Enteral nutrition (EN)
Long-term nutrition:
 Gastrostomy
 Jejunostomy
Short-term nutrition:
 Nasogastric feeding
 Nasoduodenal feeding
 Nasojejunal feeding
Benefits of EN
 Physiological/metabolic benefits
The gut can be used for administration of complex nutrients that cannot be
given intravenously e.g. intact protein, peptides, fiber
 Safety benefits
Safer than PN and less side effects
 Cost benefits
Contraindication to EN
 Terminal illness
 Short bowel
 Obstruction
 GI bleeding
 Vomiting and diarrhea
 Fistulas
 GI ischemia
 Illues
 GI inflammation
 A. pancreatitis
Enteral Nutrition Complications
 Mechanical complication
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During placement of feeding tube
 Airway injury, infection, ↑ICP
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Presence of a feeding tube
Tube clogging
Declogging methods
Aspiration
 GI complication
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Gastroesophageal reflux duodenal gastric reflux
Diarrhea
Metabolic complication
Enteral Nutrition Complications
 Metabolic complication
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Hyperglycemia
Electrolyte and mineral deficiences
Refeeding syndrome
Total Parentral Nutrition
Total Parenteral Nutrition Indication
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When normal oral feeding is not possible.
e.g.: Chron’s disease, gastric & esophageal carcinoma, paralytic ileus,
generalized peronitis, GI. obstruction, intractable vomiting.
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When food is incompletely absorbed.
e.g.: Major burns, multiple injuries, radiation therapy, ulcerative colitis,
chemotherapy treatment, short bowel syndrome.
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When food intake is undesirable, in case it is prudent to
rest the bowel.
e.g.: Post GIT surgery, chronic inflammatory diseases, intractable
diarrhea.
Total Parenteral Nutrition Indication
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In patients who are able to ingest food, but refuse to do
so.
e.g.: Geriatric post-operative patients, adolescents with anorexia nervosa,
some psychiatric patients with prolonged depression.
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In patients who, as a consequence of their illness are
going to be, or have been NPO for 5 – 7 days.
Administration
Parenteral Nutrition
Central Nutrition
Peripheral nutrition
 Subclavian line
 Peripheral line
 Long period
 Short period < 14days
 Hyperosmolar solution
 Low osmolality
 Full requirement
< 900 mOsm/L
 Min. requirement
 Large volume
 Thrombophlebitis
 Minimum volume
 Expensive
 More side effect
Routes of TPN
Central TPN
(usual osmolarity = 2000 mosmol/L)
Advantages:
 Can provide full nutritional support (No
 limits in concentration of dextrose and amino acids)
 No risk of thrombophlebitis, No pain.
Disadvantages:
 Requires surgery
 More risk of sepsis than peripheral TPN
 High risk of mechanical complications
Routes of TPN
Peripheral TPN
maximum osmolarity;
neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L
Advantages:
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Does not require surgery
Less risk of sepsis than central TPN
No risk of mechanical complications
Disadvantages:
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High risk of thrombophlebitis
Painful
Does not provide full nutrition support. Needs more
fluids to provide more nutrition. (maximum dextrose
= 7.5% and AA = 2.5%).
Note
PPN can infuse through central line but
central TPN can NOT infuse through
the peripheral line
Calculating the Osmolarity of a
Parenteral Nutrition Solution
Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/L
Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L
Multiply the (mEq per L sodium + potassium + calcium +
magnesium) X 2
Example: 80 X 2 = 160
Total osmolarity = 500 + 300 + 160 = 960 mOsm/L
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Monitoring
Monitoring
 Avoid overfeeding
 Avoid respiratory problem
 Promote nitrogen retention
 Triglyceride clearance
 Fluid and electrolyte
 Weight
 Liver function
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Monitoring for Complications
 Malnourished patients at risk for refeeding syndrome should
have serum phosphorus, magnesium, potassium, and glucose
levels monitored closely
 In patients with diabetes or risk factors for glucose intolerance,
insulin infusion should be initiated with a low dextrose infusion
rate and blood and urine glucose monitored closely.
 Blood glucose should be monitored frequently upon initiation,
any change in insulin dose, and until measurements are stable.
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Monitoring for Complications
 Serum electrolytes (sodium, potassium, chloride, and
bicarbonate) should be monitored frequently until
measurements are stable.
 Patients receiving intravenous fat emulsions should have
serum triglyceride levels monitored until stable and when
changes are made in the amount of fat administered.
 Liver function tests should be monitored periodically in
patients receiving PN.
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Complications of TPN
Complication
 Mechanical: occlusion, catheter removal, improper rate,
thromboses, pneumothorax.
 Infection: catheter related
 Metabolic: re-feeding syndrome, hyperglycemia, fluid &
electrolyte disturbance
(cont..)
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Complication
 Organic system:
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hepatobiliary complication
respiratory
cardiovascular
renal
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Transitional Feeding
 Maintain full PN support until pt is tolerating 1/3 of needs via
enteral route
 Decrease TPN by 50% and continue to taper as the enteral
feeding is advanced to total
 TPN can reduce appetite if >25% of calorie needs are met via
PN
 TPN can be tapered when pt is consuming greater than 500
calories/d and d-c’d when meeting 60% of goal
 TPN can be rapidly d-c’d if pt is receiving enteral feeding in
amount great enough to maintain blood glucose levels
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Defense Against NS Complications
 Select appropriate patients to appropriate nutrition
 Aseptic technique
 Do not overfeed
 Maintain glycemic control <150-170 mg/dl
 Limit lipids to 1 gm/kg and monitor TG levels
 Adjust protein based on metabolic demand and organ
function
 Monitor fluid/electrolyte/mineral status
 Provide standard vitamin and trace element preps
daily
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Thank you