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Parenteral Nutrition

Dr. Mehroze Zamir Resident Surgical 4, CHK

Nutritional Support: Yes or no?

Nutritional Support: Yes

Between 30-50% of hospitalized patients are malnourished.

60% of those whom hospital stay is prolonged because of post-op complications.

Negative Effects of Malnutrition on Clinical Outcome

Greater susceptibility to infectious complications Reduced immune competence Poor skin integrity Delayed wound healing Higher incidence of surgical complications Prolonged need for mechanical ventilation Increased mortality Extended length of hospital stay Higher health care costs

Nutritional Support: No

Misuse of Nutritional support can adversely affect patient recovery. Costly The only patient populations that have been identified as clearly benefiting from perioperative nutrition support are severely malnourished patients (J Parenter Enteral Nutr 2002;26:1SA)

Nutritional Support: Who need it?

Nutritional Assessment

Body weight BMI Anthropometric measurements Laboratory tests

Body Weight

Body weight 20% over or under the ideal level places a patient at nutritional risk Hamwi formula:

Men: 106 lb for 5 ft of height plus 6 lb for every inch of height over 5 ft Women: 100 lb for 5 ft plus 5 lb for every inch of height over 5 ft Both: 10% based on frame size

Body Mass Index (BMI)

Eliminates the influence of frame size

BMI
<18.5 18.6-24.9 25-29.9

Interpretation
Underweight Normal Overweight

BMI = Weight (kg) Height (m)

30-34.9
35-39.9 >40

Obesity (class1)
Obesity (class2) Obesity (class3)

Anthropometric Measurements

Mid arm circumference: general health condition Triceps skin fold thickness: body fat percentage Grip strength: easy and readily repeatable; interprets lean muscle index

Laboratory tests
Serum

Albumin:

Determine

chronic nutritional status T = 14-20 days Serum levels of less than 3.5gm/dl is indicative of malnourishment.
Serum
T

Transferrin:

= 8-10 days Serum levels of less than 200mg/dl indicates nutritional deprivation.

Laboratory tests (contd.)


Serum

Prealbumin:

Useful

indicator in acute setting Half life in 2-3 days 10-17 mg/dl mild nutritional depletion 5-10 mg/dl moderate depletion < 5 mg/dl severe depletion

Laboratory tests (contd.)


Immune

function: Frequently altered by malnutrition:


Delayed

type hypersensitivity: anergy to common skin antigens Total Lymphocyte count:


TLC = % lymphos x WBC 100 1500-1800/mm mild depletion 900-1500/mm moderate depletion <900/mm severe depletion

Other methods of Nutritional assessment

Bioelectrical impedance analysis (BIA): Assessment of fluid volume and lean body mass by measurement of resistance to electrical current; used in sports; not fully validated in clinical use. Dual-energy x-ray absorptiometry (DEXA): Measurement of bone density; may help determine fat and lean body compartments; no clear role in predicting outcome. Neutron activation analysis: Use of shielded counters to measure gamma ray decay of naturally occurring isotopes; estimate of total body potassium, an indicator body cell mass; safe in pregnant women and children; used primarily in research.

Nutritional Support: How much to give?

Estimation of Caloric requirement


Total

energy requirement of a stable patient with normal or moderately increased need is approx. 20-30 kcal/kg/day. Not suitable for every patient. Does not take into account the fat percentage of body.

Basal Energy Expenditure


Harris
BEE

Benedict equation:
in Kcal per day for men:

66.4 + [13.7 x wt(kg)] + [5 x ht(cm)] [6.8 x age(yrs)]


BEE

in Kcal per day for women:

655 + [9.6 x wt(kg)] + [1.7 x ht(cm)] [4.7 x age(yrs)]

Actual Caloric requirement calculation using BEE

Obtained by multiplying BEE by specific stress factors. Accurate in 80% of patients. Most stressed patients require 25-35 Kcal/kg/day. Overestimates the caloric needs in obese patients.

Clinical condition

Stress factor

Starvation
Elective operation Peritonitis or other infections ARDS or sepsis Bone marrow transplant Cardiopulmonary disease (non complicated) Cardiopulmonary disease with dialysis or sepsis

0.8-1.00
1.00-1.10 1.05-1.25 1.30-1.35 1.20-1.30 0.80-1.00 1.20-1.30

Cardiopulmonary disease with major surgery


Acute renal failure Liver failure Liver transplant Pancreatitis

1.30-1.55
1.30 1.30-1.55 1.20-1.50 1.30-1.80

Adjusted body weight (ABW)


When a patients BMI falls into an obese category, many clinicians use ABW to determine energy needs. The formula for ABW takes into account that not all of a persons excess weight is adipose tissue, and that the excess tissue, whether fat or not is also metabolically active.

ABW =[(Actual body weight Ideal body weight) 0.25] + Ideal body weight

Nutritional Support: What to give?

Carbohydrates

Main source of energy for cells. Glucose is essential for wound repair. 30-50% of normal calorie intake should be from carbohydrates. Each gram of enteral carbohydrate provides 4 Kcal of energy. Parenteral carbohydrate (e.g. dextrose) provides 3.4 Kcal/gm. Excessive amounts can have adverse effects, including hepatic steatosis and neutrophil dysfunction.

Proteins

The Building blocks. Generally 6.25 gm of protein intake is equal to 1 gm Nitrogen 1 gram of Protein intake yields 4 Kcal of energy Amino acids should constitute 15-20% of Normal energy expenditure

Clinical status No stress factors Acute illness

Protein required 0.8 gm/kg per day 1.2 gm/kg per day

Severely stressed pt. in ICU

2.5 gm/kg per day

Lipids
Lipids

comprise the remaining 25-45% of calories in typical diet. Each gram of lipid provides 9 Kcal of energy. Stress causes dramatic lipolysis Steroids, catecholamines and glucagon also stimulate lipolysis

What else?
Fluids Electrolytes Vitamins

Minerals

and trace elements

Parenteral Nutrition
Indicated

in patients who require nutritional support but cannot meet their needs through oral intake and for whom enteral feeding is contraindicated or not tolerated. Total Parenteral Nutrition (TPN) provides complete nutritional support (Surgery 1968;64:134)

Indications of PN

Primary Therapy

Efficacy shown[*]

Gastrointestinal cutaneous fistulas Renal failure (acute tubular necrosis) Short-bowel syndrome Acute burns Hepatic failure (acute decompensation superimposed on cirrhosis)
Crohn's disease Anorexia nervosa

Efficacy not shown


Supportive Therapy

Efficacy shown[*]

Acute radiation enteritis Acute chemotherapy toxicity Prolonged ileus Weight loss preliminary to major surgery Before cardiac surgery Prolonged respiratory support Large wound losses Patients with cancer Patients with sepsis

Efficacy not shown


Areas Under Intensive Study


* Randomized, prospective trials or similar investigations have suggested that such nutritional intervention results in changed (improved) outcome.

Central versus Peripheral venous access


Central Access

Peripheral Access

High osmolarity fluids Fluid restriction Elevated requirement due to hypermetabolism Long term PN support (> 2 weeks)

Low osmolarity fluids High fluid volume administration Temporary support (< 2 weeks) Partial support

What is the osmolarity tolerated through a peripheral vein?


1000

mosm/L 900 mosm/L <850 mosm/L Geriatric patients Fine bore IV line

Osmolarities and Caloric value of different solutions available in our clinical setup.
Solution 5% D/W Osmolarity Calories mosm/L Kcal/L 278 200 / 170?

10% D/W
Liposcin 20% Aminovil 5%

555
380 590

400 / 340?
1908 200

Further osmolarities?

mOsM = wt of substance (g/L) x no. of ions x 1000 molecular wt (g)

Electrolytes
Electrolyte
Sodium

Form
Sodium chloride Sodium acetate Sodium phosphate

Daily requirement
1-2 mEq/kg

Potassium

Potassium chloride Potassium acetate Potassium phosphate


Sodium chloride Potassium chloride

1-2 mEq/kg

Chloride

As needed for acid base balance

Acetate
Phosphate Magnesium Calcium

Sodium acetate Potassium acetate


Sodium phosphate Potassium phosphate Magnesium sulfate Calcium gluconate

As needed for acid base balance


20-40 mmol 8-20 mEq 10-15 mEq

Vitamins and trace elements

Required daily 1 mg copper 12 mcg chromium 0.3 mcg manganese 60 mcg selenium 5 mg zinc Multivitamins (10ml) Vitamin A and C Vitamin K 10 mg once a week Iron as a separate infusion if required

Insulin

Regular insulin should initially be administered subcutaneously according to a sliding scale, based on a determination of the blood glucose level. After a stable insulin requirement has been established, insulin can be administered in the TPN solution, generally at two thirds of the daily subcutaneous insulin dose.

Beginning PN

Do not start PN until a patient has stable fluid and electrolyte profile. Baseline recordings:

Blood CP Electrolytes (Ca, Mg, P) Glucose Prealbumin Triglycerides Creatinine BUN LFTs

Beginning PN

Gradual introduction. 1000 Kcal on 1st day, and then achievement of desired goal in 2-3 days when normoglycemia is established. Some institutions allow patients to receive the target level of protein and lipid emulsion initially and increase dextrose to goal over 2 days. Delivered mostly as a continuous infusion over 24 hours.

Managing and monitoring PN

Orders, written daily, should reflect the patient's dynamic nutritional status and biochemical profile.

Frequency 6 hourly Daily

Monitoring Vital signs Sreum glucose Weight Intake Output Serum electrolytes BUN Triglycerides CBC PT LFTs

Weekly

Complications of PN

Related to Nutrient defeciency Hypoglycaemia/hypocalcaemia/ hypophosphataemia/hypomagnesaemia (refeeding syndrome) Chronic defeciency syndromes (essential fatty acids, zinc, minerals and trace elements) Related to Overfeeding Excess glucose: hyperglycaemia, hyperosmolar dehydration, hepatic steatosis, hypercapnia, increased sympathetic activity, fluid retention, electrolyte abnormalities Excess fat: hypercholesterolaemia and formation of lipoprotein-X, hypertrigylceridaemia, hypersensitivity reactions Excess amino acids: hyperchloraemic metabolic acidosis, hypercalcaemia, aminacidaemia, uraemia Related to sepsis Catheter related sepsis Possible increased predisposition to systemic sepsis Related to line On insertion: pneumothorax, damage to adjacent artery, air embolism, thoracic duct damage, cardiac perforation or tamponade, pleural effusion, hydromediastinum Long-term use: occlusion, venous thrombosis

Hyperglycaemia

Most common metabolic complication of parenteral nutrition Causes osmotic diuresis that depletes fluids and electrolytes (K, Na & P) Hyperglycaemic hyperpsmolar nonketotic (HHNK) syndrome Hepatic steatosis and neutrophil dysfunction Strict maintenance of serum glucose level below 110mg/dl improves mortality and reduces infectious complications in surgical ICU patients (New Engl J Med 2001;345:1359)

Managing hyperglycaemia

Maintain blood glucose level no higher than 120mg/dl for critically ill patients and no higher than 150mg/dl for stable patients receiving PN. Dextrose infusion rates of 4mg/kg/min or less decreases the incidence of hyperglycaemia Patients with DM and those who are critically ill require insulin to control blood glucose.

0.05-0.1 units of insulin for each gram of dextrose in PN and further subcutaneous insulin coverage as per blood glucose levels.
May use separate insulin infusions for those with an unstable blood glucose profile.

Hepatobiliary complications
of bilirubin Sepsis? Raised liver enzymes
Elevation
Provide

a fat free PN Infusing PN over 12-16 hours thus giving a time off to mimic a post absorptive state to give rest to liver.

Acalculous type cholecystectomy or cholecystostomy Cholestasis GB contraction can be stimulated with CCK (0.02mcg/kg/d iv)
Cholecystitis

Pulmonary complications

The CO2 produced by carbohydrate metabolism can place added stress on patients with CO2 retention and those who are being weaned from mechanical ventilation

To avoid problems related to CO2 production, the formula must meet, not exceed, the patients requirements
In addition to avoiding overfeeding, reducing the carbohydrate dose and increasing the proportion of calories provided as fat can help prevent adverse pulmonary effects of PN.

Refeeding syndrome

Occurs when TPN is administered to severely malnourished patient, resulting in anabolism and a dramatic shift of extracellular ions into intracellular compartment and rapid depletion of ATP stores Mostly presents insidiously as respiratory failure Altered myocardial function, arrhythmias, liver dysfunction, seizures, confusion, coma, tetany and death Hypophosphataemia, hypocalcaemia and hypomagnesaemia Prevention: Avoid overfeeding Gradual increase in caloric provision Frequent monitoring and additional supplementation of potassium, manganese, magnesium and phosphate are required in severely malnourished patients.

Thank you

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