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What is the general definition for parenteral nutrition and the two types?
- PN refers to the provision of nutrients by any route that does not involves the intestine tract.
- 1.Total parenteral nutrition (more common)
- 2. Periperal/partial parenteral nutrition
- Delivering nurition thru vein, pass the GI
- Fluid is broken down when go thru vein
What are some things to know about the hanging bags of solution?
- once spiked they can hang for 48 hrs
- the yellow bag contains vitamins, mineral, and lipid and is given its color because if B vitamin (plus may be added seperatly)
- The white bag is typically CHO, protein, and lipid
- Both connect at base forming a "Y" shape
What are indications for PN?
- a not working GI
- npo (nothing by mouth) for more than 7 days
- Fistula in GI
- short bowel syndrme
- Needed GI res-massive bowel ressection
- intractable vomiting/diarrhea-pregnancy
what are contraindications for PN?
- tx anticipated for more than 5 days
- a working GI
- no venous access
- terminal condition-put someone at higher risk
- risks are higher than benefits
What is the definition for tpn?
- all nutrition!
- central access for catheter tip placement in large, high blood flow vein ( superior vena cava, jugular or femoral)
what are two common ways to deliver access thru ppn and tpn?
- PICC line:
- *threated into superior vena cava (in arm)
- *one at bedside by RN's-surgery??
- *in subclavian vein
- *can be used for many things
- *thick and dense
- *not comforatble
- IJ(interal jugular) vein:
- *easiest, go straight to heart
- *high risk because of infection
what are some important things about ppn?
- It is not commonly used
- its peripheral access
- it avoids risk of central route
- has lower osmolality(because of sm vein)
- short term(no more than 5 days)
- can increase fluid (because low conc.= high fluid)
what are the indications for ppn?
- for short term nutrition (5 days-so vein wont burst)
- to avoid risk linked to central route placement
- FOR SUPPLEMENTAL NUTRITION
- intermediate way to wean from tpn (dont switch right away)
what are the macronutrients for pn?
dextrose (cho's), amino acids (protein), fat/essential f.a's (lipids)
What are some important things to know about dextrose?
- = 3.4 kcals/kg
- con. of 5-70%, 5-20% in soltn.
- limit venous access because hypertonicity
- limit to 5mg/kg/min (limit per body per minute, to control blood sugar, keeps vein healthy)
- max 10% for ppn
What are some important things to know about a.a's?
- =4 kcals/kg
- crystalline a.a's ( so small)
- provides all Eaa's and 10-12 non-Eaa's
- max at 4% for ppn
- usually 10-20% kcal
What are some important things to know about fatty acids?
- in 10% or 20% conc.
- 100 ml (kids), 250 ml, or 500 ml
- provide 20-30% kcal
- max at 60% of 2 mg/kg/min
- use egg phospholipid (if allergic to egg then dont use!)
- stablized by glycerol
What patients may benefit from higher fat?
- those who need less fluid (heart failure, not raise bp)
- glucose intolerance( low CHO, so increase fat)
- respiratory compromise( CHO make breath out CO2)
what are the contraindications for using lipid emulsions?
- acute pancreatitis with hypertrygliceridemia
- high amount lipid-contain medicine
- bad egg allergy
what are some important things about electrolytes?
- they vary in need by patient
- they increase amount from GI, skin, and urine loss
- they correct severe imbalances
what are some important things about vitamins?
- 10-12 ml MVI added daily
- larger doses to correct deficinecies
- vitamin K not incuded in addition
- RD/pharmacists determine
what are some important things about trace elements?
- added daily
- withhold cu and mg because liver failure
- xtra zn for GI loss
- fe not really added because burns
what is the mixture of totoal nutrient admixture solutions (3 in 1)?
dextrose, fats, a.a's, vitamins, trace elements, electrolytes
what are pro/con of total nutrient admixture?
- pro: convinience, ensure mixed fuel
- con: not stable, limited info, $$$, higher contamination, not felxible
What do you consider when doing a nutrition Rx?
- dosing weight
- protein needs
- distribute remaining kcal between pro and fat
- electrolyte, vitamins/min needed
- fluid needs
when calcualting fluid needs what is something important to take into consideration?
that it should be 30 ml/kg??
what do you moniter with regards to a nutrition Rx?
- check lytes, BUN, ca/mg/po4 until stable
- check TG and liver function tests every 7-10 days
- change medicine
- actual intake
- signs of GI function
what is the tpn advancing guidelines?
- start at 30 cc/hr
- advance 20-25 cc/hr q every 12 hrs
- (q 12-24 hr in icu)
- start slow!!
what are the advancement guidelines for ppn?
- start at half the goal rate
- advance to goal after 12 hrs
- max dextrose at 10% and AA at 4%
what are complications associated with pn?
- electroltye imbalance
- mechanical issues (power die)
- liver problems
- under/over feed
- refeeding syndrme
- gut bacterial translocator
what is the etiology of hyperglycemia?
- increases CHO
- high steriod doses
- overfeed total kcal
- insulin in tpn bag
what is rebound hyperglicemia?
can happen with abrupt stopping of tpn, need to ween off tpn
what are important things about refeeding syndrome?
- can occur thru pn, enteral, etc
- labs show low PO4, MG, CA, K, high BG
- due to cell uptake of increased CHO
- people can die from low PO4+ MG= cardio death
what patients are at risk for re-feeding syndrome?
- classic kwashiorkor
- chronic malnutrition/underfeed
- chronic alcoholism
- morbid obesity
- unfed 7-10 days
how do you prevent refeeding syndrome?
- be aware of signs within 24 hrs
- recognition of patients with risk
- do lab tests
- re-feed slooww
what are the infectious and mechanical complications?
- line sepsis
- venuos thrombosis
- vein/ line occulusion
- pump problems
what are hepatic complications?
what are some important things about fatty liver?
- happen within 2-3 weeks of TPN- with overfeeding
- labs show increase LFTS
- return to normal after stop tpn, or modify delivery
what are the etiologies/implications of fatty liver?
- too much: kcal, glucose (more than 5mg/kg/min), fat
- EFA and carnitine deficient
what are some important things about cholestasis?
- etioligy unknown
- stones cause blockage in liver
- increase billi, and alk phos in labs
how would you prevent/manage hepatic condidtions?
- limit CHO (5 mg/kg/min)
- dont overfeed
- used mixed fuel source
- carnitine supplement
- find other causes
- use GI
- cycle tpn and lipids
why would you use cyclic/intermittent pn?
- allow motility
- lessens load on organs
- allow adminster blood products
what are benefits of enteral nutrition?
- more physiologic
- maintain gut
- provide glutamine
- avoid complications with pn
- less $$$