11 - Parenteral Needs Flashcards
Why is ENTERAL nutrition preferred > Parenteral Nutrition?
Better supports Viscera
Hepatic Protein Synthesis // Regulation of Metabolic Processes
Cost - Effective
Helps maintain:
Functional GUT MUCOSA
EN Administration is MORE CONVIENIENT vs PN
EN is associated with:
LESS severe complications
Indications for Parenteral Nutrition
EN > PN
_*INABILITY* to eat or absorb adequate nutrients via GI tract:_
Massive Small Bowel Resection
Intractable Vomiting / Chronic Malabsorption / Severe Diarrhea
Bowel Rest:
GI Obstruction / Perforated GI tract /Enterocutaneous Fistula
Pancreatitis
Chemo / Radiation / Eating Disorder
TPN vs PPN
Complications:
Needs central line
risk for catheter insertion
higher infxn risk
TPN:
Hyperosmolar, Hypertonic Dextrose <35%
AA <10% and FAT
Complete energy & protein Needs = Higher Concentration
Indicated for :
LONG-TERM Supplementation ( >1-2 weeks)
- *Allows for FLUID RESTRICTION**
- if necessary*
PPN vs TPN
Negatives of PPN:
Needs Peripheral Line
Higher incidense of phlebitis
Frequent IV site changes
less complications with IV insertion vs TPN
Limited by Osmolality: < 900 mOsm/L
Max Dextrose = 10% - 12.5%
no FAT –> need to provide
most calories from fat emulsion
Indicated for SHORT duration ( 7-10 days )
Requires LARGE VOLUMES < 3000mL
to meet caloric & protein needs
- *Continuous vs Cyclic**
- *PN administration**
C_ontinuous = Over 24 Hours_:
Constant fluid admin.
Consistant glucose admin w/ those with glucose intolerance
Used in MOST HOSPITILIZED PATIENTS
- *CYCLIC**
- MINIMIZES HEPATOTOXICITY*
- Poor appetite during infusion* / limited IV access
- *Increase MOBILITY**
- *HOME BASED CARE**
Steps for
DESIGNING PN REGIMEN
- Determine fluid, calorie and protein requirements
- Start with 30% of calories from fat unless contraindication
a. Calculate volume and rate of administration
b. Calculate fluid left for TPN - Calculate kcal from protein
- Calculate grams of glucose based on kcal left
- Calculate % dextrose and % protein
- Add electrolytes, MVI and trace elements
Triglyceride Monitoring
If fat is infused over 12 hours:
get level 4 hours-post infusion = < 300 mg/dL
If fat is continuous infusion:
goal is <400 mg/dL
Fat should be limited to 5% of total kcal
IF ELEVATED LEVEL
Repeat TG Monitoring WEEKLY
Electrolytes / BUN / Creatinine
MONITORING
ELECTROLYTES AT LEAST DAILY
Generally Daily until Stable –> twice weekly
Electrolyte Adjustments
BEFORE making adjustments:
Determine FLUID & Acid-Base STATUS
Requirements are better when:
DOSED PER WEIGHT
Use ABW, unless OBESE
use Adj body weight = IBW +(0.25)(TBW-IBW)
Elevation in LIVER FUNCTION TESTS (LFT)
A Complication of PN
Mild Elevation
<3x upper limit of normal
common during first 2-4 weeks of therapy
SEVERE ELEVATION
>5x Upper Limit
REQUIRES MANAGEMENT
Sequence of Elevations:
AST > ALK Phos > Bilirubin
BABIES IS OPPOSITE DIRECTION
Cause of ELEVATED LFT
&
MANAGEMENT
OVERFEEDING = most likely cause
also causes increased Insulin & dextrose -> fat conversion
Management
Reassess Estimated CALORIC NEEDS
AVOID INSULIN
- *Continuous Glucose Infusion**
- *Management of Liver Complications**
Mechanism
Increased INSULIN LEVELS
Enhanced conversion of DEXTROSE –> FAT
Management
CYCLE over 12-16 hours
Monitor fluid & glycemic response
- *Distribution of Macronutrients**
- *Management of Liver Complications**
Mechanism
Increased INSULIN LEVELS
Enhanced conversion of DEXTROSE –> FAT
Management
Provide 70:30 (Dex:Fat)
Adjust Calorie to Nitrogen Ratio to 100:1
Glucose Intolerance
Complication of PN
OVERFEEDING is the MOST LIKELY cause
in the non-diabetic patient
Reassess caloric needs & adjust
Addition of insulin should be LAST treatment measure
insulin admin may PROMOTE STEATOSIS in overfed patient
Refeeding Syndrome
Seen in pts with:
Decreased oral intake for extended periods of time
Then as GLUCOSE is initiated –>
causing LOW:
Potassium / Phosphorus / Magnesium
