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‫بسم هللا الرحمن الرحيم‬
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Parenteral nutrition in ICU patients
Dr Mohammad Safarian
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Who need nutritional support?

Malnourished: one or more of the following:
–BMI < 18.5 kg/m²
– weight loss > 10% within the last 3-6 months
–BMI of < 20 kg/m² and weight loss > 5% within
the last 3-6 months
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Who need nutritional support?
At
risk of malnutrition: one or more of the
following:
– NPO for > 5 days and/or likely to be NPO for
the next 5 days or longer.
– poor absorptive capacity, are catabolic and/or
have high nutrient losses and/or have increased
nutritional needs
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Consider oral nutrition support
if patient malnourished/at risk of malnutrition
and
can swallow safely and gastrointestinal tract is working
stop when the patient is established on adequate
oral intake from normal food
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Consider enteral tube feeding
if patient malnourished/at risk of malnutrition
despite the use of oral interventions
and
has a functional and accessible gastrointestinal
tract
use the most appropriate route of access and mode
of delivery
stop when the patient is established on adequate
oral intake from normal food
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Consider parenteral nutrition
if patient malnourished/at risk of malnutrition
a non-functional,
inaccessible or perforated
gastrointestinal tract
and has either
inadequate or unsafe oral
or enteral nutritional intake
introduce progressively and
monitor closely
use the most appropriate route of access and mode of delivery
stop when the patient is established on adequate
oral intake from normal food or enteral tube feeding
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Do not consider EN
GI obstruction with no access to GI after
obstruction.
 Ileus
 High-output enteric fistula (>500ml/d)
 Sever vomiting or diarrhea
 Acute pancreatitis.
 Refusal of patient or legal guardian.

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Parenteral Nutrition: Indications

Severe malnutrition and prolonged NPO status (>5 days).

Significant catabolism and prolonged NPO status

Bowel obstruction/ileus

Chronic vomiting/diarrhea

Use of GI tract contraindicated

Malabsorption

Bowel rest (severe pancreatitis)

Initially in short bowel syndrome
Parenteral Nutrition: Contraindications

Functioning GI tract

No safe venous access

Hemodynamically unstable

Patient not desiring aggressive support
Total Parenteral Nutrition
Goal In TPN Formulation
“Provide all a patient’s required nutrients
in a fluid volume that is well tolerated.”
Total Parenteral Nutrition
Normal Diet
Protein………………..
Carbohydrates………..
Fat……………………
Vitamins……………...
Minerals……………...
TPN
Amino Acids
Dextrose
Lipid Emulsion
Multivitamin Infusion
Electrolytes and Trace
Elements
Solutions: CHO = Dextrose

Supplied as dextrose: 10% to 35%
– 10%= 100 gm/L, 25% = 250 gm/L

Dextrose provides 3.4 Kcal/gm
– 1 liter of 10% soln = (100gm x 3.4Kcal/gm)
= 340 Kcal

PPN – Peripheral Parenteral Nutrition is put into
peripheral vein. So, more than D10 cannot be
used.
Solutions: Protein

Supplied as Amino acids – essential &
nonessential:

Choices:
– 5, 10% solutions
– 5% = 50 gm/L

Protein provides 4 Kcal/gm.
Parenteral Nutrition Solutions: Lipids

Supplied as aqueous suspension of soybean or safflower oil
with egg yolk phospholipids as the emulsifier.


Glycerol is added to suspension.
2 levels of emulsions:
 10% solution: 1.1 kcal/mL
 20% solution: 2.0 kcal/mL

Lipid emulsion , when given alone, should be completely
infused within 12 hours of hanging of emulsion.
Parenteral Nutrition Solutions

Guidelines for amounts of each to provide:
CHO: 50-65% of kcal
Lipids: ~30% of kcal
Protein: 15 - 20% of kcal
Fluid: 1.5 - 2.5 liters
Kcal: N ration: 125 kcal:1 gm N
Parenteral Nutrition Solutions

Prepared aseptically & delivered in 2 ways:
 “3 in 1” solution: protein, fat and CHO in one bag
and 1 pump is used to infuse solution.
 “3 in 2” solutions: 2 bag method: protein & CHO in 1
bag & lipid solution in glass bottle; each is hooked
up to pump; solutions enter vein together.
Given continuously or cyclically (8-12 hrs/day).
 Insulin may be added to solution.

Rate of infusion



Glucose:
 Start slowly to a target rate of 5mg/kg/min: check
blood sugar every 6 hrs. adjust the rate to keep blood
sugar below 150mg/dl, or add insulin infusion.
Amino acids:
 Start at a lower dose and rate and increase gradually
to desired goal.
Lipids:
 Start slowly to a target rate of 0.05g/kg/hr.Do not
exceed the max. rate of 0.11g/kg/hr. adjust the dose
and rate by checking plasma triglyceride levels.
Care of catheter





The catheter should be inserted under all aseptic
precautions.
Always obtain a chest X-ray to confirm the
position of the catheter before starting PN.
The catheter should be inspected daily and clean
with alcohol based solution.
Avoid drawing blood from TPN line.
Avoid infusing medications through TPN line.
Monitoring
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
Which type of complications?

Who may be at risk?

Early detection and treatment?
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Monitoring of PN therapy
The main objectives:
 To ensure about safety, and early detection
and treatment of complications
 To assess the extent to which nutritional
objectives have been reached.
 To alter the type or components of the
regimen, to improve its effectiveness and to
prevent complications.

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General considerations








Basic clinical observations (temperature, pulse,
oedema)
Observations of feeding technique and its possible
complications
Measures of nutritional intake.
Weight changes
Fluid balance charts (in hospital)
Laboratory data
Outcome factors (complications, improvements)
Change in socio-psychological state which might
influence nutritional therapy
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Monitoring in PN therapy
Variable to be monitored
Initial
Later period
Clinical status
Daily
Daily
Catetheter site
Daily
Daily
Temperature
Daily
Daily
Intake &Output
Daily
Daily
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Monitoring in PN therapy
Variable to be monitored
Initial
Later period
Weight
serum glucose
Daily
Daily
Weekly
3/wk
Electrolytes (Na+, K+, Cl-)
Daily
1-2//wk
BUN
Ca+, P,mg
Liver function Enzymes
Serum triglycerides
CBC
3/wk
3/wk
3/wk
Weekly
Weekly
Weekly
weekly
weekly
weekly
weekly
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Problems
1.
Catheter sepsis
2.
Placement problems
3.
Metabolic complications
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Complications


Dehydration
Possible cause:
–Inadequate fluid support;
–Unaccounted fluid loss (e.g. diarrhea, fistulae, persistent
high fever).

Management:
–Start second infusion of appropriate fluid, such as D5W,
1/2NS, NS.
–Estimate fluid requirement and adjust PN accordingly.
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Complications


Overhydration
Possible cause:
–Excess fluid administration;
–Compromised renal or cardiac function.

Management:
–Consider 20% lipid as calorie source
–Initiate diuretics.
–Limit volume.
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Complications


Alkalosis
Possible cause:
–Inadequate K to compensate for cellular uptake during
glucose transport
–Excessive GI or renal K losses.
–Inadequate Cl- in patients undergoing gastric
decompression.

Management:
–KCl to PN.
–Assure adequate hydration.
–Discontinue acetate.
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Complications


Acidosis
Possible cause:
–Excessive renal or GI losses of base
–Excessive Cl- in PN.

Management:
–Rule out DKA and sepsis.
–Add acetate to PN.
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Complications


Hypercarbia
Possible cause:
–Excessive calorie or carbohydrate load.

Management:
–Decrease total calories or
–CHO load.
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Complications


Hypocalcemia
Possible cause:
–Excessive PO4 salts
–Low serum albumin.
–Inadequate Ca in PN.

Management:
–Slowly increase calcium in PN prescription.
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Complications


Hypercalcemia
Possible cause:
–Excessive Ca in PN
–Administration of vitamin A in patients with renal failure.
–Can lead to pancreatitis.

Management:
–Decrease calcium in PN.
–Ensure adequate hydration.
–Limit vitamin supplements in patients with renal failure to
vitamin C and B vitamins.
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Complications

Hyperglycemia

Possible cause:
–Stress response. Occurs approximately 25% of
cases.
Management:
–Rule out infection.
–Decrease carbohydrate in PN.
–Provide adequate insulin.
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Complications

Hypoglycemia

Possible cause:
–Sudden withdrawal of concentrated glucose.
–More common in children.

Management:
–Taper PN. Start D10.
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Complications

Cholestasis

Possible cause:
–Lack of GI stimulation.
–Sludge present in 50% of patients on PN for 4-6 weeks;
–resolves with resumption of enteral feeding.

Management:
–Promote enteral feeding.
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Complications


Hepatic tissue damage and fat infiltration
Possible cause:
–Unclear etiology.
–May be related to excessive glucose or energy
administration;
–L-carnitine deficiency.

Management:
–Rule out all other causes of liver failure.
–Increase fat intake relative to CHO.
–Enteral feeding.
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Transition from PN to EN
Schedule
PN ml/hr
EN ml/hr
Day1
100%
Day 2
Decrease by 10-20
20-30
Day3
Decrease by 10-20
30-40
Day 4
Decrease by 10-20
40-50
Day5
Stop PN
Increase
10ml/hr
every 24 hr
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Thank you
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