Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 42 Nutrition PPT-Powerpoint Presentations and lecture notes
NUTRITION
Objectives
1. To understand the decision-making process for
initiating, maintaining, and terminating
Specialized Nutritional Support (SNS) in surgical
patients.
2. To understand the decision-making process for
calculating nutritional requirements, gaining
access for SNS, and monitoring for complications
during SNS.
Case 1
A 67-year-old man with obstructing esophageal cancer
presents for consideration of surgical therapy. He has lost
25 pounds (15% of normal body weight) over the past 4
months, is unable to swallow anything except liquids, and
has near-complete loss of appetite. He has no other past
history of significance and takes medications only for
hypertension. His appearance is gaunt with obvious loss of
body fat and muscle wasting. There is mild peripheral
edema. The remainder of the physical exam is
unremarkable. Workup suggests that he is a candidate for
esophageal resection. His albumin is 2.7g/L and his
hemoglobin is 9g/L with microcytic indices. All other
determinations are normal.
Case 2
A previously healthy 27-year-old woman is the
restrained driver in a head-on collision. She is
diagnosed with intraabdominal injuries and
undergoes emergency laparotomy. At operation, a
crush injury to the pancreas and duodenum is
repaired as is a mesenteric tear and grade II liver
laceration. Appropriate external drainage of the injury
sites is undertaken. She has lost approximately
1000mL of blood and hasreceived 4000mL of
crystalloid solutions intraoperatively. She will be
transferred to the intensive care unit (ICU) for initial
postoperative care. No other major injuries are noted.
What?
Carbohydrate
Lipid
Protein
Trace elements
Vitamins
Who?
Malnourished (>10% lean body mass)
Incapable of eating (>10 days)
Why?
Risks of malnutrition including infection, poor healing
and higher mortality
Malnutrition is exacerbated by physiological stress
When?
Preoperative?
Early?
Late?
---after initial resuscitation following injury or surgery
How?
Parenteral
Enteral
Total
Partial
Issues
Metabolic response to injury
Cytokines, inflammation, hormones
Biology of substrates
Enteral vs. Parenteral
"Ashen faces, a thready pulse
and cold clammy
extremities..."The Ebb Phase
Cuthbertson, Quart. J. Med.25:233,1932
The Ebb Phase
Hypometabolic
Hypercortisolism
Hypothermic
Hyperglucagonemia
Hypoinsulinemic
Hyperglycemia
Hypoperfusion
Hypercatecholemia
"The patient warms
up,cardiac output increases
and the surgical team
relaxes..." The Flow Phase
Cuthbertson. Lancet 1:233, 1942
The Flow Phase
Hypermetabolic
Hyperinsulinism
Hyperthermic
Hypercortisolism
Catabolic
Hyperglucagonemia
High cardiac output
Nutritional Assessment
Body weight
Body mass index
creatinine height index
Serum proteins:albumin, prealbumin, transferrin
Immune competence: lymphocytes, DH
Nitrogen balance
NUTRITIONAL
REQUIREMENTS
PROTEIN
Most important macronutrient.
Normal requirement is 1gm\kg\day
Doubled in stress, burns, trauma or sepsis
19-20% of protien intake should be EAA, which should
be doubled in stress states.
Carbohydrates
1 gm of glucose gives 4 kcal.
Liver and skeletal muscle store it as glycogen.
But glycogen stores are exhausted within 24 hrs of
fasting.
Then?
Gluconeogenesis starts.
Substrates for gluconeogenesis?
Fats
9kcal\gm.
Body depends on fat for energy in depleted states.
Hydrolysis of fats depends on hormone sensitive
lipase.
Which hormones increase lipase activity?
NITROGEN
1 gm = 6.25 gm of proteins.
Obligate nitrogen losses are 56-57mg\kg\day
How?
37mg\kg- urine
12mg\kg ? stools
5mg\kg ? skin
2-3mg\kg ? evaporation
Nitrogen balance= N intake- N losses
N loss = 24hr urinary nitrogen+ 4gm\day
+VE N balance= anabolic state
-VE N balance= ?
BEE
HARRIS- BENEDICT Equation=
Males= 66.47+13.75(W)+5.0(H)- 6.76(A) KCAL\Day
Females= 65.51+ 9.56(W)+1.85(H)- 4.68(A)
REE is the estimation of the pts true energy
requirements after taking into account activity factor
and injury factor.
How do we calculate REE?
REE = BEE *activity factor* injury factor
ACTIVITY FACTOR:
Bed rest = 1.2
Ambulatory = 1.3
INJURY FACTOR =
Minor surgery = 1.2
Trauma = 1.35
Sepsis = 1.6
Burns = 2.1
30 Kcal\kg\d adequately meets the requirement in
postsurgical cases.
During catabolic phase calorie requirement is 1.2- 2.0
times greater than BEE.
Calorie to nitrogen ratio should be between 100 and
150 to 1 in normal states and in sepsis 100:1.
Causes of Inadequate Nutrition
Poor oral intake
Catabolic states
Malabsorption
Increased losses
Drug and alcoholabuse
Depression
Isolation
Poverty
NUTRITIONAL ASSESMENT
Components of Nutrition Assessment
Medical and social history
Diet history and intake
Clinical examination
Anthropometrics
Biochemical data
Medical and Social History
Gathered from chart review and patient interview
Medical history: diagnosis, past medical and surgical
history, pertinent medications, alcohol and drug use,
bowel habits
Psychosocial data: economic status, occupation,
education level, living and cooking arrangements,
mental status
Other: age, sex, level of physical activity, daily living
activities
Dietary History and Intake
Appetite and intake: taste changes, dentition,
dysphagia, feeding independence, vitamin/mineral
supplements
Eating patterns: daily and weekend, diet restrictions,
ethnicity, eating away from home, fad diets
Estimation of typical calorie and nutrient intake: RDAs,
Food Guide Pyramid
Obtain diet intake from 24-hour recall, food frequency
questionnaire, food diary, observation of food intake
Diet Assessment
Evaluate what and how much person is eating, as well
as habits, beliefs and social conditions that may put
person at risk
Usual intake
24 hr recall: retrospective, easy
Food logs: prospective, requires motivation
Food frequency questionnaire: general idea of how
often foods are consumed
Compare to estimation of needs
Nutritional Questions for
the Review of Systems
General
Usual adult weight
Current weight
Maximum, minimum weights
Weight change 1 and 5 years prior
Recent changes in weight and time period
Recent changes in appetite or food tolerance
Presence of weakness, fatigue, fever, chills, night sweats
Recent changes in sleep habits, daytime sleepiness
Edema and/or abnormal swelling
Nutritional Questions for
the Review of Systems
Alimentary
Abdominal pain, nausea, vomiting
Changes in bowel pattern (normal or baseline)
Diarrhea (consistency, frequency, volume, color, presence of
cramps, food particles, fat drops)
Difficulty swallowing (solids vs. liquids, intermittent vs.
continuous)
Early satiety
Indigestion or heartburn
Food intolerance or preferences
Mouth sores (ulcers, tooth decay)
Pain in swallowing
Sore tongue or gums
Nutritional Questions for
the Review of Systems
Neurologic
Confusion or memory loss
Difficulty with night vision
Gait disturbance
Loss of position sense
Numbness and/or weakness
Skin
Appearance of a diagnostic rash
Breaking of nails
Dry skin
Hair loss, recent change in texture
Clinical Examination
Identifies the physical signs of malnutrition
Signs do not appear unless severe deficiencies exist
Most signs/symptoms indicate two or more
deficiencies
Examples:
Head and Neck: hair loss, bitemporal wasting, conjunctival
pallor, xerosis, glossitis, bleeding/sore gums, angular
cheliosis, stomatitis, poor dentition, thyromegaly
Extremities: edema, muscle wasting, loss of s/c fat
Neurologic: evidence of peripheral neuropathy, reflexes,
tetany, decreased mental status
Skin: ecchymosis, petechie, pallor, pressure ulcers, wound
problems/infection
Characteristics of Nutritional
Status
Good
Poor
Alert expression
Apathy
Shiny hair
Dull, lifeless hair
Clear complexion
Greasy, blemished
complexion
Good color
Poor color
39
Characteristics of Nutritional
Status
Good
Poor
Bright, clear eyes
Dull, red-rimmed eyes
Pink, firm gums and
Red, puffy, receding
well-developed teeth
gums, and missing or
cavity-prone teeth
Firm abdomen
Swollen abdomen
Firm, well-developed Underdeveloped, flabby
muscles
muscles
40
Characteristics of Nutritional
Status
Good
Poor
Well-developed bone
Bowed legs, "pigeon
structure
breast"
Normal weight for
Over- or underweight
height
Erect posture
Slumped posture
Emotional stability
Easily irritated,
depressed, poor
attention span
41
Characteristics of Nutritional
Status
Good
Poor
Good stamina
Easily fatigued
Seldom ill
Frequently ill
Healthy appetite
Excessive or poor
appetite
Healthy, normal sleep Insomnia at night,
habits
fatigued during the day
Normal elimination
Constipation or diarrhea
42
Stop and Share
Identify at least 5
signs of
malnutrition
present in this
child.
43
Anthropometrics
Inexpensive, noninvasive, easy to obtain, valuable
with other parameters
Height, weight and weight changes
Segmental lengths, fat folds and various body
circumferences and areas
Repeated periodically to note changes
Individuals serve as own standard
Anthropometric Measurements
Height
Weight
45
Anthropometric Measurements
Head
Triceps skinfold
circumference
Disadvantages of Anthropometrics
Intra and interobserver error
Changes in composition of patient's tissues
Inaccurate application of raw data
Measurements are evaluated by comparing them with
predetermined reference limits that allow for
classification into risk categories
Anthropometrics
Ideal body weight
Males: 106 lbs + 6 lbs per inch over 5 ft
Females: 100 lbs + 5 lbs per inch over 5 ft
Add 10% for large-framed and subtract 10% for small-
framed
%IBW = (current wt/IBW) X 100
80-90% mild malnutrition
70-79% moderate malnutrition
60-69% severe malnutrition
<60% non-survival
Anthropometrics
%UBW: usual body weight
= (current wt/UBW) X 100
85-95% mild malnutrition
75-84% moderate malnutrition
0-74% severe malnutrition
% weight change = usual weight ? present
weight/usual weight X 100
Significant weight loss
>5% in 1 month
>10% in 6 months
Body Mass Index = BMI
Evaluation of body weight independent of height
BMI = weight (kg)/height2 (m)
>40
obesity III
30-40
obesity II
25-30
overweight
18.5-25
normal
17-18.4
PEM I
16-16.9
PEM II
<16
PEM III
Frame Size
Determined using wrist circumference and elbow
breadth
Determines the optimal weight for height to be
adjusted to a more accurate estimate
Wrist circumference: measures the smallest part
of the wrist distal to the styloid process of the ulna
and radius
Elbow breadth: measures the distance between
the two prominent bones on either side of the
elbow
Skinfold Thickness
Estimates subcutaneous fat stores to estimate total
body fat
Triceps, biceps, subscapular, and suprailiac using
calipers are most commonly used
Disadvantages: total body fluid overload, caliper
calibration, inter-individual variability
Body Circumferences and Areas
Estimates skeletal muscle mass (somatic protein stores and
body fat stores
Midarm or upper arm circumference (MAC): on the upper arm
at the midpoint between the tip of the acromial process of the
scapula and the olecranon process of the ulna
Midarm muscle or arm muscle circumference (MAMC):
determined from the MAC and triceps skinfold (TSF)
MAMC = MAC ? (3.14 X TSF)
Total upper arm area: determines upper arm fat stores
Upper arm muscle mass provides a good indication of lean body
mass, used in the calculation of upper arm fat area
Upper arm fat area: calculation may be a better indicator of
changes in fat stores than TSF
Bioelectrical Impedance Analysis (BIA)
Measures electrical conductivity through water in
difference body compartments
Uses regression equations to determine fat and LBM
Serial measures can track changes in body
composition
Obesity treatments
DEXA: dual-energy X-ray absorptiometry
Whole body scan with 2 x-rays of different intensity
Computer programs estimate
Bone mineral density
Lean body mass
Fat mass
"Best estimate" for body composition of clinically
available methods
Biochemical Data
Used to assess body stores
Altered by lack of nutrients, medications, metabolic
changes during illness or stress
Interpret results carefully
Fluid status distorts results
"Stressed" states (infection, surgery) effects results
Use reference values established by individual lab
Visceral Proteins
Produced by the liver
Affected by protein deficiency, but also renal and
hepatic disease, wounds and burns, infections, zinc
and energy deficiency, cancer, inflammation,
hydration status, and stress
Albumin
Half life 14-21 days
Normal value 3.5-5.0 g/DL
Most widely used indicator of nutritional status
Acute phase response: levels decrease in response to
stress (infection, injury)
Affected by volume
Increases with dehydration, decreases with edema and
overhydration
Prealbumin
Better measure of nutritional status due to shorter
half-life, ~2 days
Normal value: 18-40 mg/DL
Responds within days to nutritional repletion
Levels affected by trauma, acute infections, liver and
kidney disease; highly sensitive to minor stress and
inflammation
Creatinine Height Index
Estimates LBM
= actual creat excretion (24 hour urine collection)
expected creat excretion
Males: IBW X 23 mg/kg
Females: IBW X 18 mg/kg
>80% normal
60-80% moderately depleted
<60% severely depleted
Accurate 24-hr urine collection is difficult to
obtain in acute-care setting
Hematological Indices
Determine nutritional anemias
Transferrin: Fe transport protein
TIBC: total Fe binding capacity
Indicates number of free binding cites on transferrin
Fe deficiency: increased transferrin levels, decreased
saturation
Ferritin: Fe storage protein, increases during
inflammation
Depressed hemoglobin is an indicator of Fe deficiency
anemia
Indirect calorimetry/Metabolic Cart
Measures CO2 produced and O2 consumed in critically
ill patients on ventilators
Calculates resting metabolic rate based on gas
exchange
Respiratory quotient calculated
Corresponds to oxidation of nutrients
CHO: 1:1 ratio of CO2 produced/O2 consumed
Lipid: 0.7:1 ratio
Protein: 0.82:1 ratio
Mixed diet: 0.85:1 ratio
Overfeeding/lipogenesis: >1.0
Case 1
55yo male with Crohn's disease has failed Remicade
and needs an ileocolic resection.
What are the surgical nutritional issues?
Nutritional Support
Fundamental goal of nutritional support:
1.
To meet the energy requirement for metabolic
processes
2. To maintain a normal core body temperature
3. For tissue repair
Conditions That Require
Specialized
Nutrition Support
Enteral
--Impaired ingestion
--Inability to consume adequate nutrition orally
--Impaired digestion, absorption, metabolism
--Severe wasting or depressed growth
Parenteral
--Gastrointestinal incompetency
--Hypermetabolic state with poor enteral
tolerance or accessibility
ENTERAL NUTRITION
Enteral Nutrition
Nutrition delivered via the gut
Includes oral feedings and tube feedings
Enteral Tube Feeding
Nutritional support via tube
placement through the nose,
esophagus, stomach, or intestines
(duodenum or jejunum)
--Must have functioning GI tract
--IF THE GUT WORKS, USE IT!
--Exhaust all oral diet methods first.
Oral Supplements
Between meals
Added to foods
Added into liquids for medication pass
by nursing
Enhances otherwise poor intake
May be needed by children or teens to support
growth
Diagram of enteral tube placement.
Copyright ? 2000 by W. B. Saunders Company. Al rights reserved.
Fig. 22-2. p. 468.
Indications for Enteral
Nutrition
Malnourished patient expected to be unable to
eat >5-7 days
Normally nourished patient expected to be
unable to eat >7-9 days
Adaptive phase of short bowel syndrome
Increased needs that cannot be met through
oral intake (burns, trauma)
Inadequate oral intake resulting in
deterioration of nutritional status or delayed
recovery from illness
ASPEN. The science and practice of nutrition
support. A case-Based Core curriculum. 2001; 143
Contraindications for EN
Severe acute pancreatitis
High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001;
143
Contraindications for EN
Inadequate resuscitation or
hypotension; hemodynamic instability
Ileus
Intestinal obstruction
Severe G.I. Bleed
Expected need less than 5-7 days if
malnourished or 7-9 days if normally
nourished
Severe diarrhea
Protracted Vomiting Are Not
Contraindications
Intestinal dysmotility
Do Not Feed a Necrotic Bowel !!
INSTEAD FEED EARLY TO
PREVENT A NECROTIC
BOWEL
Advantages - Enteral vs PN
Preserves gut integrity
Possibly decreases bacterial translocation
Preserves immunological function of gut
Reduces costs
Fewer infectious complications in critically
ill patients
Safer and more cost effective in many
settings
ASPEN. The science and practice of nutrition support. A case-based core curriculum.
2001; 147
ADA EAL, Critical Illness, accessed 8-07
Advantages--Enteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not possible or
adequate
Supplies readily available
Reduces risks associated with
disease state
Disadvantages--Enteral
Nutrition
GI, metabolic, and mechanical
complications--tube migration; increased
risk of bacterial contamination; tube
obstruction; pneumothorax
Costs more than oral diets (not necessarily)
Less "palatable/normal": patient/family
resistance
Labor-intensive assessment,
administration, tube patency and site care,
monitoring
Enteral Formulas
Liquid diets intended for oral use or for tube
feeding
Ready-to-use or powdered form
Designed to meet variety of medical and
nutrition needs
Can be used alone or given with foods
Enteral Formulas
Determine best choice by medical and
nutrition assessment
Meet specific nutrition needs
Enteral Formula Categories
Polymeric
Monomeric
Fiber-containing
Disease-specific
Rehydration
Modular
Route For Feeding Access
Short Term access (for 4-6wk)---
Use Nasal Access :naso-gastric/jejunal tubes
Nasogastric tubes:
?Allow use of hypertonic feeds
higher feeding rates
bolus/Intermittent feeding
?Fine bore 8-10 F NG tubes
Access Techniques.....cont
Nasojejunal NJ tubes
Indicated--gastric reflux
--delayed gastric emptying
--unconcious patient
Fine bore 6-10 F
Insertion same as NG, but once reached stomach,
patient is turned onto the right side advance tube
10cm
To assist postpyloric placement of NJ tube :
10mg Metoclopramide iv 10 min
200mg
Erythromycin iv 30min prior placement
Access Techniques.....cont
Long Term access > 4-6wk----Feeding Ostomies
(Enterostomies)
Percutaneous Endoscopic Enterostomy
Surgical Enterostomy
Percutaneous Endoscopic
Enterostomy
1- Percutaneous Endoscopic Gastrostomy
PEG: Method of choice
Considered in pat. with normal gastric emptying
Percutaneous Endoscopic Gastrostomy
Contraindications:
Gastric cancer
Gastric ulcer
Ascitis
Coagulation disorders
(Source: Kudsk KA, Jacobs DO. Nutrition. In: Surgery: Basic Science and Clinical Medicine.
Norton JA, et al., eds. New York: Springer-Verlag, 2001(2) Part 7, Section 91:136)
Feeding Ostomies (Enterostomies)
Percutaneous Endoscopic Jejunostomy
2- PEJ
New--
Technically difficult
Indicated if postpyloric feeding is needed
Allows concomittent jejunal feeding and gastric
decompression
Administration of EN
Bolus
Continuous
Intermittent
Cyclic
Bo
Ad lu
mi s
n iF
stee
er di
20n
0 gs
-400 ml of
enteral formula into the
stomach over 5 to 20
minutes, usually by gravity
with a large-bore syringe
Indications:
-Recommended for gastric
feedings
-Requires intact gag reflex
-Normal gastric function
Continuous Feedings
Administration into the GIT via pump or gravity,
usually over 8 to 24 hours per day
Indications:
Promote tolerance
Compromised gastric function
Feeding into small bowel
Intolerance to other feeding techniques
Intermittent Feedings
Administration of 200-300 ml over 30-60 minutes q 4-
6 hours
Indications:
Intolerance to bolus administration
Initiation of support without pump
Open vs Closed System
Open System
Product is decanted
into a feeding bag
Allows modulars such
as protein and fiber to
be added to feeding
formulas
Less waste in unstable
patients (maybe)
Shortens hang time
Increases nursing time
Increased risk of
contamination
Closed System or Ready to
Hang
Containers sterile until
spiked for hanging
Can be used for
continuous or bolus
delivery
No flexibility in
formula additives
Less nursing time
Increases safe hang
time
Less risk of
contamination
More expensive than
canned formula
Closed vs Open System
Open System
Closed System
Hang time 8 hours
for decanted formula; Hang time 24-48
4 hours for formula
hours based on mfr
mixtures
recommendations
Feeding bag and
Y port can be used to
tubing should be
rinsed each time
deliver additional
formula replenished
fluid and modulars
Contaminated
May result in less
feedings are
formula waste as
associated with pt
morbidity
open system formula
should be discarded
p 8 hours
Closed vs Open System
In a survey of nurses at MetroHealth, only
28% were aware of the 8 hour hang time for
open system formulas written into nursing
policy
55% recommended adding new formula to
old, in violation of existing nursing protocol
66% could state the 24 hang time for closed
system formulas
The cost of wasted formula is minimal
compared to the cost of nursing time and
risk of illness in patients
Luther H, Barco K, Chima CS, Yowler CJ. Comparative study of two systems of
delivering supplemental protein with standardized tube feedings. J Burn Care
Rehabil 2003;24:167-172.
What are the major problems
associated with tube feeding?
1- Aspiration----Most Important
Prevalence range from 2% - 95%
Several issues should be considered:
1-Tube Size and Position
Large bore vs small bore
Gastric vs Jejunal
2-Body Position Supine vs Semi recumbent
3-Underlying Disease Gastroparesis/ Atony
4-Feeding Regimen
Intermittent or Continuous vs Bolus
To Limit the Risk of Aspiration
1- Raise head of bed 30-400 during feeding and 1 hr
after
2-Use intermittent / continuous feeding regimens
rather than------ bolus method
3-Check gastric residual regularly
4-Consider jejunal access--------
-recurrent tube feeding aspiration
-high risk of gastric motility dysfunction
2-Diarrhea----Most Common
Incidence 2.3% - 68%
Critically ill are more prone
Multiple aetiologies:
1-Medications:
Antibiotics-----overgrowth of C.difficile / Candida
Sorbitol base liquids---Theophylline
Meds containing Magnesium
2-Altered bacterial flora
H2-blockers/ PPI---permit bacterial overgrowth
Bacteria colonize---Gastric pH exceeds 4
2-Diarrhea----Most Common
3-Formula Composition
?Osmolality & Rate
incidence of diarrhea in critically ill
mechanically vent patients----receiving hyperosmolar feeds
at high infusion rates
2-Diarrhea----Most Common
4-Hypoalbuminemia
---Reduces osmotic pr & causes intestinal mucosal
oedema
Critically ill with s.Alb < 2.6g/dl diarrhea with
standard EN
5-Formula Contamination
Altered Drug absorption & Metabolism
Phenytoin
Binds to NG tubing at pH of enteral
formulation----less drug delivery
Warfarin
Resistance 2ndry to Vit K in Enteral feedings
Stop enteral feeding 2 hrs before and 2
hrs after
Metabolic Complications
Less frequent compared to TPN
Hyperglycemia: 2ndry to High CHO load in specific
formula esp critically ill / elderly--------insulin
resistance
Electrolyte imbalance:
Use of high osmolar formulation esp: Pat on fluid
restriction/ renal concentrating difficulties are at risk of
-----Dehydration & Hypernatremia
Mechanical
Feeding tube obstruction
Feeding tube dislodged
Nasal irritation
Skin irritation/excoriation at ostomy site
Refeeding Syndrome
At risk: when refeeding those with marginal body
nutrient stores, stressed, depleted patients, those who
have been unfed for 7-10 days, persons with anorexia
nervosa, chronic alcoholism, weight loss
Symptoms: Hypokalemia, hypophosphatemia and
hypomagnesemia; cardiac arrhythmias, heart failure;
acute respiratory failure
Refeeding Syndrome
Correct electrolyte abnormalities (via oral, enteral,
parenteral route) before initiating nutrition support
Administer volume and energy slowly
Monitor pulse rate, intake and output, and electrolyte
levels
Provide appropriate vitamin supplementation
Avoid overfeeding
Monitoring of Patients on EN
Electrolytes
BUN/Cr
Albumin/prealbumin
Ca++, PO4, Mg++
Weight
Input/output
Vital signs
Stool frequency/consistency
Abdominal examination
Routes of Parenteral Nutrition
Central access
--TPN both long- and short-term placement
Peripheral or PPN
--New catheters allow longer support via
this method limited to 800 to 900 mOsm/kg
due to thrombophlebitis
<2000 kcal required or <10 days
Advantages--Parenteral Nutrition
Provides nutrients when less than
2 to 3 feet of small intestine remains
Allows nutrition support when GI intolerance
prevents oral or enteral support
Indications for Total
Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food
Contraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)
Administration
Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs
or switch to dextrose IV)
Cyclic give 12 to 18 hours per day
Monitor
Weight
(daily)
Blood
Daily
Electrolytes (Na+, K+, Cl-)
Glucose
Acid-base status
3 times/week
BUN
Ca+, P
Plasma transaminases
Monitor--cont'd
Blood
Twice/week
Ammonia
Mg
Plasma transaminases
Weekly
Hgb
Prothrombin time
Zn
Cu
Triglycerides
Monitor--cont'd
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration (daily)
WBC and differential (as needed)
Cultures (as needed)
Problems
PPN
Site irritation
TPN
1. Catheter sepsis
2. Placement problems
3. Metabolic
Q. A young man weighting 65 kg was admitted to the
hospital with severe burns in a severe catabolic state.
An individual in this state requires 40 kcal per kg
body weight per day and 2 gms of protein/kg body
weight/day. This young man was given a solution
containing 20% glucose and 4.25% protein. If 3000 ml
of solution is infused per day -
The patient would not be getting sufficient protein
The calories supplied would be inadequate
Both protein and calories would be adequate
Too much protein is being infused
Q. One is not the indication of total parenteral
nutrition -
Acute pancreatitis
Enterocolic fistula
Chronic liver disease
Faecal fistula
Q. TPN is indicated in all except -
Short bowel syndrome
Burn
Sepsis
Enterocutaneous fistula
Q. A patient on total parenteral nutrition for 20 days
presents with weakness, vertigo and convulsions.
Diagnosis is :
Hypomagnesemia
Hyperammonemia
Hypercalcemia
Hyperkalemia
Q. Ramesh met and accident with a car and has been
in `deep coma' for the last 15 days. The most suitable
route for the administration of protein and calories is
by :
Jejunostomy tube feeding
Gagstrostomy tube feeding
Nasogastric tube feeding
Central venous hyperalimetation
Q. A patient undergoes a prolonged and complicated
pancreatic surgery for chronic pancreatitis. Most
preferred route for supplementary nutrition in this
patient would be :
Total Parentral Nutrition
Feeding Gastrostomy
Feeding Jejunostomy
Oral feeding
This post was last modified on 08 April 2022