Parenteral nutrition in ICU patients Dr Mohammad Safarian

Parenteral nutrition in ICU patients Dr Mohammad Safarian 2

Who need nutritional support? n 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 3

Who need nutritional support? n. 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 4

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 5

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 6

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 7

Do not consider EN n GI obstruction with no access to GI after obstruction. n Ileus n High-output enteric fistula (>500 ml/d) n Sever vomiting or diarrhea n Acute pancreatitis. n Refusal of patient or legal guardian. 8

Parenteral Nutrition: Indications n Severe malnutrition and prolonged NPO status (>5 days). n Significant catabolism and prolonged NPO status n Bowel obstruction/ileus n Chronic vomiting/diarrhea n Use of GI tract contraindicated n Malabsorption n Bowel rest (severe pancreatitis) n Initially in short bowel syndrome

Parenteral Nutrition: Contraindications n Functioning GI tract n No safe venous access n Hemodynamically unstable n 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 n Supplied as dextrose: 10% to 35% – 10%= 100 gm/L, 25% = 250 gm/L n Dextrose provides 3. 4 Kcal/gm – 1 liter of 10% soln = (100 gm x 3. 4 Kcal/gm) = 340 Kcal n PPN – Peripheral Parenteral Nutrition is put into peripheral vein. So, more than D 10 cannot be used.

Solutions: Protein n Supplied as Amino acids – essential & nonessential: n Choices: – 5, 10% solutions – 5% = 50 gm/L n 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/m. L 20% solution: 2. 0 kcal/m. L Lipid emulsion , when given alone, should be completely infused within 12 hours of hanging of emulsion.

Parenteral Nutrition Solutions n 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 5 mg/kg/min: check blood sugar every 6 hrs. adjust the rate to keep blood sugar below 150 mg/dl, or add insulin infusion. ü Amino acids: § Start at a lower dose and rate and increase gradually to desired goal. ü Lipids: § Start slowly to a target rate of 0. 05 g/kg/hr. Do not exceed the max. rate of 0. 11 g/kg/hr. adjust the dose and rate by checking plasma triglyceride levels. ü

Care of catheter n n n 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 20

n Which type of complications? n Who may be at risk? n Early detection and treatment? 21

Monitoring of PN therapy The main objectives: n To ensure about safety, and early detection and treatment of complications n To assess the extent to which nutritional objectives have been reached. n To alter the type or components of the regimen, to improve its effectiveness and to prevent complications. n 22

General considerations n n n n 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 23

Monitoring in PN therapy Variable to be monitored Initial Later period Clinical status Daily Catetheter site Daily Temperature Daily Intake &Output Daily 25

Monitoring in PN therapy Variable to be monitored Initial Later period Weight serum glucose Daily Weekly 3/wk Electrolytes (Na+, K+, Cl-) Daily 1 -2//wk BUN Ca+, P, mg Liver function Enzymes Serum triglycerides CBC 3/wk Weekly weekly 26

Problems 1. Catheter sepsis 2. Placement problems 3. Metabolic complications 27

Complications n n Dehydration Possible cause: –Inadequate fluid support; –Unaccounted fluid loss (e. g. diarrhea, fistulae, persistent high fever). n Management: –Start second infusion of appropriate fluid, such as D 5 W, 1/2 NS, NS. –Estimate fluid requirement and adjust PN accordingly. 28

Complications n n Overhydration Possible cause: –Excess fluid administration; –Compromised renal or cardiac function. n Management: –Consider 20% lipid as calorie source –Initiate diuretics. –Limit volume. 29

Complications n n 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. n Management: –KCl to PN. –Assure adequate hydration. –Discontinue acetate. 30

Complications n n Acidosis Possible cause: –Excessive renal or GI losses of base –Excessive Cl- in PN. n Management: –Rule out DKA and sepsis. –Add acetate to PN. 31

Complications n n Hypercarbia Possible cause: –Excessive calorie or carbohydrate load. n Management: –Decrease total calories or –CHO load. 32

Complications n n Hypocalcemia Possible cause: –Excessive PO 4 salts –Low serum albumin. –Inadequate Ca in PN. n Management: –Slowly increase calcium in PN prescription. 33

Complications n n Hypercalcemia Possible cause: –Excessive Ca in PN –Administration of vitamin A in patients with renal failure. –Can lead to pancreatitis. n Management: –Decrease calcium in PN. –Ensure adequate hydration. –Limit vitamin supplements in patients with renal failure to vitamin C and B vitamins. 34

Complications n Hyperglycemia n Possible cause: –Stress response. Occurs approximately 25% of cases. Management: –Rule out infection. –Decrease carbohydrate in PN. –Provide adequate insulin. 35

Complications n Hypoglycemia n Possible cause: –Sudden withdrawal of concentrated glucose. –More common in children. n Management: –Taper PN. Start D 10. 36

Complications n Cholestasis n Possible cause: –Lack of GI stimulation. –Sludge present in 50% of patients on PN for 4 -6 weeks; –resolves with resumption of enteral feeding. n Management: –Promote enteral feeding. 37

Complications n n Hepatic tissue damage and fat infiltration Possible cause: –Unclear etiology. –May be related to excessive glucose or energy administration; –L-carnitine deficiency. n Management: –Rule out all other causes of liver failure. –Increase fat intake relative to CHO. –Enteral feeding. 38

Transition from PN to EN Schedule PN ml/hr EN ml/hr Day 1 100% Day 2 Decrease by 10 -20 20 -30 Day 3 Decrease by 10 -20 30 -40 Day 4 Decrease by 10 -20 40 -50 Day 5 Stop PN Increase 10 ml/hr every 24 hr 43

Thank you 44