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بسم الله الرحمن الرحيم

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Parenteral nutrition in ICU patients

Dr Mohammad SafarianDr Mohammad Safarian

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Who need nutritional Who need nutritional support?support?

Malnourished: one or more of the Malnourished: one or more of the following:following:

–BMI < 18.5 kg/mBMI < 18.5 kg/m²²

– weight lossweight loss > 10% within the last 3-6 months > 10% within the last 3-6 months

–BMI of < 20BMI of < 20 kg/m kg/m² ² andand weight lossweight loss > 5% within > 5% within the last 3-6 monthsthe last 3-6 months

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Who need nutritional Who need nutritional support?support?

At risk of malnutrition: one or more of At risk of malnutrition: one or more of the following:the following:

– NPO NPO forfor > > 5 days and/or likely to be NPO for 5 days and/or likely to be NPO for the next 5 days or longer.the next 5 days or longer.

– poor absorptive capacity, are catabolic and/or poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased have high nutrient losses and/or have increased nutritional needsnutritional needs

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Consider oral nutrition supportConsider oral nutrition support

and

stop when the patient is established on adequateoral intake from normal food

if patient malnourished/at risk of malnutrition

can swallow safely and gastrointestinal tract is working

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Consider enteral tube Consider enteral tube feedingfeeding

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use the most appropriate route of access and mode of delivery

stop when the patient is established on adequateoral intake from normal food

has a functional and accessible gastrointestinal tract

if patient malnourished/at risk of malnutritiondespite the use of oral interventions

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Consider parenteral Consider parenteral nutritionnutrition

use the most appropriate route of access and mode of delivery

stop when the patient is established on adequateoral intake from normal food or enteral tube feeding

and has either

introduce progressively and monitor closely

if patient malnourished/at risk of malnutrition

a non-functional, inaccessible or perforated

gastrointestinal tract

inadequate or unsafe oral or enteral nutritional intake

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Do not consider EN Do not consider EN

GI obstruction with no access to GI GI obstruction with no access to GI after obstruction.after obstruction.

Ileus Ileus High-output enteric fistula High-output enteric fistula

(>500ml/d)(>500ml/d) Sever vomiting or diarrheaSever vomiting or diarrhea Acute pancreatitis.Acute pancreatitis. Refusal of patient or legalRefusal of patient or legal guardian. guardian.

Parenteral Nutrition: Indications Parenteral Nutrition: Indications Severe malnutrition and prolonged NPO status (>5 days).Severe malnutrition and prolonged NPO status (>5 days).

Significant catabolism and prolonged NPO statusSignificant catabolism and prolonged NPO status

Bowel obstruction/ileusBowel obstruction/ileus

Chronic vomiting/diarrheaChronic vomiting/diarrhea

Use of GI tract contraindicatedUse of GI tract contraindicated

MalabsorptionMalabsorption

Bowel rest (severe pancreatitis)Bowel rest (severe pancreatitis)

Initially in short bowel syndrome Initially in short bowel syndrome

Parenteral Nutrition: Parenteral Nutrition: ContraindicationsContraindications

Functioning GI tractFunctioning GI tract

No safe venous accessNo safe venous access

Hemodynamically unstableHemodynamically unstable

Patient not desiring aggressive supportPatient not desiring aggressive support

Total Parenteral NutritionTotal Parenteral Nutrition

Goal In TPN FormulationGoal In TPN Formulation

““Provide all a patient’s required Provide all a patient’s required

nutrients in a fluid volume that is nutrients in a fluid volume that is

well tolerated.”well tolerated.”

Total Parenteral NutritionTotal Parenteral Nutrition

Normal Diet TPN

Protein………………..

Amino Acids

Carbohydrates………..

Dextrose

Fat……………………

Lipid Emulsion

Vitamins……………...

Multivitamin Infusion

Minerals……………...

Electrolytes and Trace Elements

Solutions: CHO = DextroseSolutions: CHO = Dextrose Supplied as dextrose: 10% to 35%Supplied as dextrose: 10% to 35%

– 10%= 100 gm/L, 25% = 250 gm/L10%= 100 gm/L, 25% = 250 gm/L

Dextrose provides 3.4 Kcal/gmDextrose provides 3.4 Kcal/gm– 1 liter of 10% soln = (100gm x 3.4Kcal/gm)1 liter of 10% soln = (100gm x 3.4Kcal/gm)

= 340 Kcal= 340 Kcal

PPN – Peripheral Parenteral Nutrition is put PPN – Peripheral Parenteral Nutrition is put into peripheral vein. So, more than D10 into peripheral vein. So, more than D10 cannot be used.cannot be used.

Solutions: ProteinSolutions: Protein

Supplied as Amino acids – essential & Supplied as Amino acids – essential &

nonessential:nonessential:

Choices:Choices:

– 5, 10% solutions5, 10% solutions

– 5% = 50 gm/L5% = 50 gm/L

Protein provides 4 Kcal/gm.Protein provides 4 Kcal/gm.

Parenteral Nutrition Solutions: Parenteral Nutrition Solutions: LipidsLipids

Supplied as aqueous suspension of soybean or safflower Supplied as aqueous suspension of soybean or safflower

oil with egg yolk phospholipids as the emulsifier.oil with egg yolk phospholipids as the emulsifier.

Glycerol is added to suspension.Glycerol is added to suspension.

2 levels of emulsions:2 levels of emulsions:

10% solution: 1.1 kcal/mL10% solution: 1.1 kcal/mL

20% solution: 2.0 kcal/mL20% solution: 2.0 kcal/mL

Lipid emulsion , when given alone, should be completely Lipid emulsion , when given alone, should be completely

infused within 12 hours of hanging of emulsion.infused within 12 hours of hanging of emulsion.

Parenteral Nutrition SolutionsParenteral Nutrition Solutions Guidelines for amounts of each to provide:Guidelines for amounts of each to provide:

CHO: 50-65% of kcalCHO: 50-65% of kcal

Lipids: ~30% of kcal Lipids: ~30% of kcal

Protein: 15 - 20% of kcalProtein: 15 - 20% of kcal

Fluid: 1.5 - 2.5 liters Fluid: 1.5 - 2.5 liters

Kcal: N ration: 125 kcal:1 gm NKcal: N ration: 125 kcal:1 gm N

Parenteral Nutrition SolutionsParenteral Nutrition Solutions Prepared aseptically & delivered in 2 ways:Prepared aseptically & delivered in 2 ways:

““3 in 1” solution: protein, fat and CHO in one bag 3 in 1” solution: protein, fat and CHO in one bag and 1 pump is used to infuse solution.and 1 pump is used to infuse solution.

““3 in 2” solutions: 2 bag method: protein & CHO 3 in 2” solutions: 2 bag method: protein & CHO in 1 bag & lipid solution in glass bottle; each is in 1 bag & lipid solution in glass bottle; each is hooked up to pump; solutions enter vein together.hooked up to pump; solutions enter vein together.

Given continuously or cyclically (8-12 Given continuously or cyclically (8-12 hrs/day).hrs/day).

Insulin may be added to solution.Insulin may be added to solution.

Rate of infusionRate of infusion Glucose:Glucose:

Start slowly to a target rate of 5mg/kg/min: Start slowly to a target rate of 5mg/kg/min: check blood sugar every 6 hrs. adjust the rate to check blood sugar every 6 hrs. adjust the rate to keep blood sugar below 150mg/dl, or add insulin keep blood sugar below 150mg/dl, or add insulin infusion.infusion.

Amino acids:Amino acids: Start at a lower dose and rate and increase Start at a lower dose and rate and increase

gradually to desired goal.gradually to desired goal. Lipids:Lipids:

Start slowly to a target rate of 0.05g/kg/hr.Do Start slowly to a target rate of 0.05g/kg/hr.Do not exceed the max. rate of 0.11g/kg/hr. adjust not exceed the max. rate of 0.11g/kg/hr. adjust the dose and rate by checking plasma the dose and rate by checking plasma triglyceride levels.triglyceride levels.

Care of catheterCare of catheter The catheter should be inserted under all The catheter should be inserted under all

aseptic precautions.aseptic precautions. Always obtain a chest X-ray to confirm the Always obtain a chest X-ray to confirm the

position of the catheter before starting PN.position of the catheter before starting PN. The catheter should be inspected daily The catheter should be inspected daily

and clean with alcohol based solution.and clean with alcohol based solution. Avoid drawing blood from TPN line. Avoid drawing blood from TPN line. Avoid infusing medications through TPN Avoid infusing medications through TPN

line.line.

Monitoring Monitoring

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Which type of complications? Which type of complications?

Who may be at risk?Who may be at risk?

Early detection and treatment?Early detection and treatment?

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Monitoring of PN therapyMonitoring 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 considerationsGeneral 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 therapyMonitoring 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 therapyMonitoring in PN therapyVariable to be monitored Initial Later period

Weight Daily Weekly

serum glucose Daily 3/wk

Electrolytes (Na+, K+, Cl-) Daily 1-2//wk

BUN 3/wk Weekly

Ca+, P,mg 3/wk Weekly

Liver function Enzymes 3/wk Weekly

Serum triglycerides weekly weekly

CBC weekly weekly

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ProblemsProblems1.1. Catheter sepsisCatheter sepsis

2.2. Placement problemsPlacement problems

3.3. Metabolic complicationsMetabolic complications

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Complications Complications

DehydrationDehydration Possible cause:Possible cause:

–Inadequate fluid support;Inadequate fluid support;–Unaccounted fluid loss (e.g. diarrhea, fistulae, Unaccounted fluid loss (e.g. diarrhea, fistulae, persistent high fever).persistent high fever).

Management: Management: –Start second infusion of appropriate fluid, such as Start second infusion of appropriate fluid, such as D5W, 1/2NS, NS. D5W, 1/2NS, NS.

–Estimate fluid requirement and adjust PN Estimate fluid requirement and adjust PN accordingly.accordingly.

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Complications Complications

OverhydrationOverhydration Possible cause:Possible cause:

–Excess fluid administration;Excess fluid administration;–Compromised renal or cardiac function.Compromised renal or cardiac function.

Management: Management: –Consider 20% lipid as calorie sourceConsider 20% lipid as calorie source–Initiate diuretics.Initiate diuretics.–Limit volume.Limit volume.

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Complications Complications

AlkalosisAlkalosis Possible cause:Possible cause:

–Inadequate K to compensate for cellular uptake Inadequate K to compensate for cellular uptake during glucose transportduring glucose transport

–Excessive GI or renal K losses.Excessive GI or renal K losses.–Inadequate Cl- in patients undergoing gastric Inadequate Cl- in patients undergoing gastric decompression.decompression.

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

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Complications Complications

AcidosisAcidosis Possible cause:Possible cause:

–Excessive renal or GI losses of baseExcessive renal or GI losses of base–Excessive ClExcessive Cl-- in PN. in PN.

Management: Management: –Rule out DKA and sepsis.Rule out DKA and sepsis.–Add acetate to PN.Add acetate to PN.

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Complications Complications

HypercarbiaHypercarbia Possible cause:Possible cause:

–Excessive calorie or carbohydrate load.Excessive calorie or carbohydrate load. Management: Management:

–Decrease total calories orDecrease total calories or–CHO load.CHO load.

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Complications Complications

HypocalcemiaHypocalcemia Possible cause:Possible cause:

–Excessive PO4 saltsExcessive PO4 salts–Low serum albumin.Low serum albumin.–Inadequate Ca in PN.Inadequate Ca in PN.

Management: Management: –Slowly increase calcium in PN prescription.Slowly increase calcium in PN prescription.

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Complications Complications

HypercalcemiaHypercalcemia Possible cause:Possible cause:

–Excessive Ca in PNExcessive Ca in PN–Administration of vitamin A in patients with renal Administration of vitamin A in patients with renal failure. failure.

–Can lead to pancreatitis.Can lead to pancreatitis. Management: Management:

–Decrease calcium in PN.Decrease calcium in PN.–Ensure adequate hydration.Ensure adequate hydration.–Limit vitamin supplements in patients with renal Limit vitamin supplements in patients with renal failure to vitamin C and B vitamins.failure to vitamin C and B vitamins.

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Complications Complications

HyperglycemiaHyperglycemia

Possible cause:Possible cause:–Stress response. Occurs approximately Stress response. Occurs approximately 25% of cases.25% of cases.

Management: Management: –Rule out infection. Rule out infection. –Decrease carbohydrate in PN. Decrease carbohydrate in PN. –Provide adequate insulin.Provide adequate insulin.

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Complications Complications

HypoglycemiaHypoglycemia

Possible cause:Possible cause:–Sudden withdrawal of concentrated Sudden withdrawal of concentrated glucose. glucose. –More common in children.More common in children.

Management: Management: –Taper PN. Start D10.Taper PN. Start D10.

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Complications Complications

CholestasisCholestasis

Possible cause:Possible cause:–Lack of GI stimulation.Lack of GI stimulation.–Sludge present in 50% of patients on PN for 4-6 Sludge present in 50% of patients on PN for 4-6 weeks; weeks;

–resolves with resumption of enteral feeding.resolves with resumption of enteral feeding.

Management: Management: –Promote enteral feeding.Promote enteral feeding.

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Complications Complications

Hepatic tissue damage and fat infiltrationHepatic tissue damage and fat infiltration Possible causePossible cause::

–Unclear etiology. Unclear etiology. –May be related to excessive glucose or energy May be related to excessive glucose or energy administration;administration;

–L-carnitine deficiency.L-carnitine deficiency.

Management: Management: –Rule out all other causes of liver failure.Rule out all other causes of liver failure.–Increase fat intake relative to CHO.Increase fat intake relative to CHO.–Enteral feeding.Enteral feeding.

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Transition from PN to ENTransition from PN to EN

Schedule Schedule PN ml/hrPN ml/hr EN ml/hrEN ml/hr

Day1Day1 100%100%

Day 2Day 2 Decrease by 10-20Decrease by 10-20 20-3020-30

Day3Day3 Decrease by 10-20Decrease by 10-20 30-4030-40

Day 4Day 4 Decrease by 10-20Decrease by 10-20 40-5040-50

Day5Day5 Stop PN Stop PN Increase Increase 10ml/hr 10ml/hr every 24 hr every 24 hr

44Thank you