Date post: | 07-Apr-2018 |
Category: |
Documents |
Upload: | elsayed-ahmed |
View: | 224 times |
Download: | 0 times |
of 28
8/3/2019 Intravenous Nutrient Solutions
1/28
INTRAVENOUS
NUTRIENT SOLUTIONS
Sayed nour
8/3/2019 Intravenous Nutrient Solutions
2/28
Parenteral nutrition is the continuousinfusion of a hyperosmolar solution
containing carbohydrates, proteins, fat,and other necessary nutrients through anintravenous route
Parenteral nutrition is used when theenteral route is unable to provide orsustain sufficient caloric intake.
8/3/2019 Intravenous Nutrient Solutions
3/28
Goals of Nutrition Support
To minimize protein breakdown,
To preserve lean body mass, To promote protein synthesis,
and
To optimize immune responses
8/3/2019 Intravenous Nutrient Solutions
4/28
PN Summary Guidelines
1. Determine if PN is truly indicated
2. Assess the patient (medical history,
medication profile, anthropometricdata & lab values)
3. Determine need for long-term vs.short term
8/3/2019 Intravenous Nutrient Solutions
5/28
4. Confirm or establish adequate IV access
Peripheral or central?
5. Determine estimated kcal, protein andlipid needs
2030 kcal/kg
Protein 0.81.5 gm/kg Higher levels may be needed in severe
catabolic states
Lipid to provide 30% ofkcals
8/3/2019 Intravenous Nutrient Solutions
6/28
6. Determine initial electrolyte,vitamin and trace element
requirements; consider ongoinglosses
7. Consider any additional additives to
PN formulation including insulinand H2-receptor antagonists
8/3/2019 Intravenous Nutrient Solutions
7/28
8. Monitor for: Risk of refeeding syndrome
Glucose intolerance
Start low & advance slowly if labs stableover 24-48 hours
Fluid, electrolyte, metabolic, macro- andmicro-nutrient changes
Complications sepsis, thrombosis, abuse9. Initiate trophic feedings or convert
patient to PO or enteral feeding whenfeasible
8/3/2019 Intravenous Nutrient Solutions
8/28
Dextrose Solutions
the standard nutritional support regimen usescarbohydrates to supply approximately 70%of the daily (nonprotein) calorierequirements.
These are provided by dextrose (glucose)solutions, which are available in variousstrengths.
As dextrose is not a potent metabolic fuel,the solutions must be concentrated toprovide enough calories to satisfy dailyrequirements.
As a result, the dextrose solutions used forTPN are hyperosmolar and should be infusedthrough large central veins
8/3/2019 Intravenous Nutrient Solutions
9/28
Intravenous Dextrose Solutions
8/3/2019 Intravenous Nutrient Solutions
10/28
Amino acid solutions
Amino acid solutions are mixed together withthe dextrose solutions to provide the dailyprotein requirements.
A variety of amino acid solutions are availablefor specific clinical settings.
The standard amino acid solutions containapproximately 50% essential amino acids and50% nonessential + semiessential amino acids
8/3/2019 Intravenous Nutrient Solutions
11/28
Amino acid cont
The nitrogen in essential amino acids ispartially recycled for the production ofnonessential amino acids
So metabolism of essential amino acidsproduces less of a rise in the blood ureanitrogen concentration than metabolism ofnonessential amino acids
amino acid solutions designed for use in renalfailure are rich in essential amino acids
8/3/2019 Intravenous Nutrient Solutions
12/28
Standard and Specialty Amino
Acid Solutions
8/3/2019 Intravenous Nutrient Solutions
13/28
Glutamine
Glutamine is the principle metabolic fuel forintestinal epithelial cells,
Glutamine-supplemented TPN has an
important role in maintaining the functionalintegrity of the bowel mucosa and preventingbacterial translocation.
Glutamine is formed when glutamic acid
combines with ammonia in the presence ofthe enzyme glutamine synthetase. Glutamic acid is given as exogenous source of
glutamine.
8/3/2019 Intravenous Nutrient Solutions
14/28
Amino Acid Solutions with
Glutamic Acid
8/3/2019 Intravenous Nutrient Solutions
15/28
Lipid Emulsions
Intravenous lipid emulsions consist ofsubmicron droplets (=0.45 mm) of cholesteroland phospholipids surrounding a core of long-chain triglycerides
The triglycerides are derived from vegetableoils (safflower or soybean oils) and are rich inlinoleic acid, an essential polyunsaturatedfatty acid
lipid emulsions are available in 10% and 20%strengths (the percentage refers to grams oftriglyceride per 100 mL of solution).
The 10% emulsionsprovide approximately 1kcal/mL, and the 20% emulsions provide 2kcal/mL
8/3/2019 Intravenous Nutrient Solutions
16/28
Unlike the hypertonic dextrose solutions, lipidemulsions are roughly isotonic to plasma
Can be infused through peripheral veins. Thelipid emulsions are available in unit volumesof 50 to 500 mL
They can be infused separately (at amaximum rate of 50 mL/hour) or added to thedextroseamino acid mixtures.
The triglycerides introduced into thebloodstream are not cleared for 8 to 10 hours,and lipid infusions often produce a transient,lipemic-appearing (whitish) plasma.
8/3/2019 Intravenous Nutrient Solutions
17/28
Intravenous Lipid Emulsions
8/3/2019 Intravenous Nutrient Solutions
18/28
Lipid Restriction
Lipids are used to provide up to 30% of thedaily (nonprotein) calorie requirements.
Dietary lipids are oxidation-prone and can
promote oxidant-induced cell injury Use of lipids in critically ill patients (who often
have high oxidation rates) should berestricted.
Minimal amounts (4% of calorie) of lipidinfusion is necessary to prevent essentialfatty acid deficiency (cardiomyopathy,skeletal muscle myopathy)
8/3/2019 Intravenous Nutrient Solutions
19/28
Additives
Electrolytes
Most electrolyte mixtures contain sodium,chloride, potassium, and magnesium; they also
may contain calcium and phosphorous.
The daily requirement for specific electrolyte canbe specified in the TPN orders.
If no electrolyte requirements are specified, theelectrolytes are added to replace normal dailyelectrolyte losses.
8/3/2019 Intravenous Nutrient Solutions
20/28
Normal Serum ElectrolytesParenteral & Enteral Intake Ranges
8/3/2019 Intravenous Nutrient Solutions
21/28
Vitamins
Aqueous multivitamin preparations are added to thedextroseamino acid mixtures.
One unit vial of a standard multivitamin preparation willprovide the normal daily requirements for most vitamins
Enhanced vitamin requirements in hypermetabolic patientsin the ICU may not be satisfied.
Some vitamins are degraded before they are delivered.Some examples are riboflavin and pyridoxine (which aredegraded by light) and thiamine (which is degraded bysulfites used as preservatives for amino acid solutions)
8/3/2019 Intravenous Nutrient Solutions
22/28
Vitamins
Vitamin RDI (FDA/AMA/NAG) Thiamine (B1) 6 mg Riboflavin (B2) 3.6 mg Pyridoxine (B6) 6 mg
Cyanocobalamin (B12) 5 mcg Niacin 40 mg Folic acid 600 mcg Pantothenic acid 15 mg Biotin 60 mcg
Ascorbic acid (C) 200 mg Vitamin A 3300 IU Vitamin D 5 mg Vitamin E 10 IU Vitamin K 150 mcg
8/3/2019 Intravenous Nutrient Solutions
23/28
Trace Elements
A variety of trace element additives are available
Most trace element mixtures contain chromium,copper, manganese, and zinc, but they do notcontain iron and iodine.
Some mixtures contain selenium, which has a role
in proctection against oxidation injury Routine administration of iron is not
recommended in critically ill patients because ofthe pro-oxidant actions of iron
8/3/2019 Intravenous Nutrient Solutions
24/28
Trace Element Preparations
and Daily Requirements
8/3/2019 Intravenous Nutrient Solutions
25/28
Monitoring PN Patients
Clinical Status Vital signs
Intake/output
Urine, Stool, Other (eg fistula output) Weight
Fluid requirements
Patient complaints Physical exam
Overall clinical status
8/3/2019 Intravenous Nutrient Solutions
26/28
Monitoring PN Patients
Metabolic and Biochemical Aspe
Blood studies Renal function: Lytes, Mg, Ca, Phos, BUN, Cr
Hematologic: CBC (Hgb, WBC, Plt), INR
Liver function: Alk Phos, AST/ALT, Bilirubin
Glucose/lipid tolerance: Glucose, Triglycerides
Iron status: Iron, TIBC, Ferritin
Serum proteins: Albumin
Insulin coverage
DEXA
8/3/2019 Intravenous Nutrient Solutions
27/28
thank you
8/3/2019 Intravenous Nutrient Solutions
28/28
Thank you