Introduction of Parenteral Nutrition

By ,

What is Parenteral nutrition (PN)

commonly, via venous access
PPN: peripheral parenteral nutrition, (1000mosm/1, 12dextrose)
TPN: total, or central parenteral nutrition, higher tolerated conc.
Indication of TPN:
, The
common possible causes are described as below; TPN
appendix
1.G-I disease: IBD, short-bowel syndrome, instertinal fistula, pancreatitis
2.preoperative preparation: for malnutrition patients
3.postoperative complication: ileus, fistula, or prologation of sarvation
4.others:severe burn or trauma, anorexia nervosa, some liver or renal disease
** TPN ,
-, PE(muscular atrophy, flabby skin),
-body weight loss15
-Lab finding: serum Alb3g/dl, transferrin200mg/dl, total lymphocyte1200/ul
How is the TPN ordered
Thinking process: Total calorie and fluid - protein -carbohydrate
- C-N ratio(1) is used for rechecking the rationality
Daily requirement
Energy requirement:
Harris-Benedict equation for BEE(basal energy expenditure)
Mal:66+(13.7W)+(5H)-(6.8A)
Female:655+(9.6W)+(1.7H)-(4.7A)
TEE: BEE stress factor (or activity factor)
1:mild stress : 1.0-1.2
moderate stress : 1.2-1.5
severe stress : 1.5-2.5
2: BEE 25kcal/kg/day
Macronutrient daily requirement:
Protein:0.8-2.5g/kg/day, 4kcal/gm
Fat:1-2g/kg/day, 9kcal/gm, (intralipid 10:1.1kcal/ml, 20:2kcal/ml)

Carbohydrate:2-5g/kg/day, 3.4kcal/gm(mohydrate vs ahydrous glucose)

Micronutrient daily requirement:
Electrolyte
Na:60-200mEq/day*(60-80mEq/day)
K:50-150mEq/day*(30-60mEq/day)
Ca:8-32mEq/day*(4.6-9.2mEq/day) e- supply vary from place to place
Mg:8-24mEq*(8.1-20mEq/day)
Phosphate: 15-30mM/day*(12-24mEq/day)
Vitamin:5ml/day (from Lyo-povigen), VitK10-25mg/week(TPN 1-2ml/d)
trace element: 2ml/day(, )
Acetate: 50-120mEq/day (product bicarbonate to correct acidosis)
Additive:
RI: TPN , initial dose:5-1u/l(*2)
Heparin: TPN thrombosis (1000u/liter)
Explaination of the special term:
T15:standard solution, Aminosyn;,(1ml=1.02kcal)
TH: aminopoly-H , rich in branched-chain amino acid
TR: amiyu , rich in essential amino acid,
R/Q: respiratory quotient, CO2 Prduction/02 consumption
3-in-1 admixture: Y-set, .
Calorie-nitrogen ratio: , non-protein calorie nitrogen ,
Nitrogen balance: , NB = (intake protein/6.25) (UUN+4), 4 UUN
,.
PN osmolality: 10xprotein(g) + 6xCHO(g) + 0.3xml(20 intrallpid)/ total
fluid(L), mosm/l, PPN .
Protein sparing: carbohydrate intake , minimal requirement
100gm, that is, 1000ml 10 G/W
Example:
30y/o 160cm, 60kg, stress factor 1.4 ( activity factor)
our thinking process:
1.find the total calories and fluid requirement
BEE=66+(13.7x60)+(5x160)-(6.8x30)=66+822+800-204=1484

( 225kcal/kg/day-60x25=1500kcal/day)
patients TEE=1484x1.4 = 2077.6kcal/day
fluid requirement = 2300 ml (via 100-50-20 rule, or 4-2-1 rule)
2.find the daily protein requirement
1.5g/kg/day patient requirement = 60x1.5 = 90g
energy supply = 90x4 = 360kcal
(,protein , nitrogen balance
,, total calories )
3.find the daily fat requirement
1g/kg/day patient requirement = 60x1 = 60g
intralipid 20 (20g/100ml/bt, 2kcal/ml) ,
energy supply = 300ml 20 intrlipid = 2x300ml = 600kcal
4.find the residual calories provided by carbohydrate
dextrose calories = total amount - protein supply - fat supply
= 2077.6 - 360 - 600 =1117.6kcal
, dextrose = 1117.6/3.4 = 328.7 g
5.check the formula with C/N ratio
non-protein calories = 1117.6 + 600 kcal = 1717.6
protein 90 g = nitrogen 14.4 g
C/N ratio is 1717.6/14.4 = 119.21(acceptable)

, protein and dextrose , TPN

total fluid requirement 2300ml - intralipid 20 300 ml = 2000ml
dextrose 328.7g/2000ml = 16.4
protein 90g/2000ml = 4.5
2300/24=95.8ml/hr (including the fat emulsion)

, ,
Initiating:
a. 1st day 1000ml-2nd day 2000ml -3rd day 3000ml
b. 1st day 1000kcal, increased by 500kcal/day till reached your goal

c. 50ml/hr-75ml/hr-100ml/hr
tapering and discontinuing:
tapered over 48 hours, reduced to 50ml/hr for 30-60 mins, then DC.
Halved for 1 hour, halved for a second hour, then DC.
TPN supply 1000kcal/day, no need to taper the infusion rate.
2-3 days later, Lab survey; check UUN for nitrogen balance
The last dance
Complication:
Catheter-related infection
Metabolic complication (sugar, electrolyte and others..)
Hepatic dysfunction
Acaculous cholecystitis
Venous access:
The catheter entered via subclavian v. and int. jugular v. is much better
Appendix:

(*1) C/N ratio : non-protein calorie / nitrogen (kcal/g), explained subsequently.

(*2)insulin plastic bag or drip set , 5-10u, RI