PARENTERAL NUTRITION

Seminar II - Intensive Care

Lesson Plan
Background: Parenteral Nutrition Date: 11/07/2005 Duration: 50 min
Objectives
Acquire theoretical knowledge related to parenteral nutrition, allowing the acqu
isition of knowledge in providing nursing care to a patient subjected to parente
ral nutrition.
Methodology
Methods Media Strategies PowerPoint Computer Data show
Expository
Parenteral Nutrition
Parenteral Nutrition (PN) had its beginnings in the fourteenth century. The firs
t glucose solutions and hydrosaline appeared in the early seventeenth century, b
ut only in the twentieth century, there was the systematization of Parenteral Nu
trition. The proposed Dudrick the University of Pennsylvania, proved the effecti
veness and applicability of the safe use of the method.
"Parenteral Nutrition is a method of delivering a highly concentrated solution i
ntravenously, to maintain the nutritional balance of the patient. When oral or e
nteral nutrition is not possible. "
Phipps, Sands and Mavek (2003, p. 1554)
"Parenteral Nutrition, is the most sophisticated and complex that artificial nut
rition is the administration of almost all nutrients intravenously.
Camilo (2001, p. 102)
The NP should be exclusively used in patients whose needs can not be achieved me
tabólicasnutricionais oral or enteral. It can be administered as a supplement or
as a unique form of nutrition.
The NP is used when there is gastrointestinal dysfunction, when it needs to be a
voided or when it becomes dangerous. The NP is never an emergency therapy. One m
ust not impose NP in patients who have no therapeutic hypothesis.
Parenteral nutrition is usually administered through a central venous access, bu
t can also be administered by peripheral vein. The NP is not the equivalent of f
luid that is the administration of intravenous serum maintenance.
The objectives of Parenteral Nutrition are:
Preventing refeeding syndrome; Maintain or restore the lean body mass, preventin
g or correcting malnutrition and its consequences; Determine the needs adequate
calories, proteins, vitamins, minerals and fluids to the patient; Maintain asept
ic procedures in all techniques for the safety of nutritional support;
Escott-Stump (1999)
Prevent or correct all the side effects of parenteral nutrition; Return to enter
al or oral intake when and if possible; Regular losses and net losses strange as
needed. Avoid superhydration; prevent deficiency of essential fatty acids and p
revent overuse of linoleic acid; Adapt PN solutions according to the patient's c
ondition.
There are two types of solutions for parenteral nutrition:
isotonic solutions administered through peripheral vein (PPN), usually as an a
djunct to nutritional therapy; hypertonic solutions administered by central ve
in (NPC), which frequently provides complete nutritional support.
Routes of Administration
PARENTERAL NUTRITION
Peripheral route
Via Central
The decision to use NPC or NPP is based: On energy needs; The time period in whi
ch the NP is required; the status of peripheral veins; If patients need nutritio
nal rehabilitation.
Peripheral Parenteral Nutrition
When nutritional support is necessary in the short term, this can be provided pe
ripherally; glucose solution 50-10%, an amino acid solution from 3.5 to 5% and a
lipid emulsion of 10-20%. The load of total fat should not exceed 2.5 g / kg /
day. Vitamins, minerals and electrolytes are added, if necessary;
The osmolality of the solution of NPP is the limiting factor and should generall
y stay below 600 mOsm / L. This means that large quantities of solution are need
ed to meet the nutritional requirements, is suitable only for a short term suppo
rt (5-7 days) for a mildly malnourished patient.
In order to accomplish NPP is necessary: there is a reasonable or good upper lim
b venous system, otherwise, you have to use the NP Central. If peripheral venous
access is not possible or sufficient, and if you keep the digestive failure and
need for nutritional therapy, we use the NPC should be considered as a last opt
ion.
Central Parenteral Nutrition
"The Central Parenteral Nutrition is a method of providing complete nutritional
support in the gastrointestinal tract is spared, introducing nutrients assimilab
le into a central vein, usually the superior vena cava.
Mahan and Arlin (1995, p.546)
Basically, their principles are no different from the NPP, but the requirement o
f a central vein catheter significantly increases the risk of complications,€als
o increased by the fact that power supply more nutrient input with possible meta
bolic overload. Thus require nursing care more differentiated and in greater qua
ntity.
NPC solutions generally consist of 25-35% dextrose, 3-5% amino acids, electrolyt
es, minerals and vitamins. Lipids may also be having between 10 and 20%. The cen
tral catheter should be used only for the nutrient solution and not for blood pr
oducts or medication. Unlike the NPP, which provides maximum 1800Kcal/dia, the N
PC can remove enough energy for anabolism, by 4000 kcal / day.
Nominations for the NPC can be grouped according to frequently occurring situati
ons, which are: Diseases in which the NPC is the adjuvant therapy with demonst
rated efficacy; Diseases in which the NPC is controversial adjuvant therapy;
NPC ambulatory.
CALCULATION OF ENERGY NEEDS
"Today's formula is the Harris Benedict equation to predict the most used, based
on indirect calorimetry and determines the basal energy expenditure (ie the ene
rgy required to meet the needs of the body at rest)."
Davis et al (2003)
GEB (Man) = 66.42 + (13.75 x weight kg) + (5 x height cm) + (6.77 x Age years) G
EB (Women) = 655.1 + (9.65 x weight kg) + (1.7 x height cm) + (4.68 x Age years)
"General rule, it is accepted as valid for adult, an average caloric intake of 2
0-25 kcal / kg / day." Davis et al (2003, p.51)
FACTORS THAT INCREASE
the basal metabolic rate and therefore energy needs:
- Activity - specify the dynamic action of feeding; - pain, anxiety and fear - c
atabolism
(Induced by surgery, trauma, sepsis, burns);
- Hyperthyroidism - pheochromocytoma - hyperthermia.
FACTORS Slow down
basal metabolic energy requirements and therefore:
Home, (in prolonged rest, the basal energy expenditure is reduced by about 10-15
%), mechanical ventilation; Drugs: barbiturates, muscle relaxants and curarizant
es pancuronium, beta blockers (propranolol), hypothyroidism, hypothermia; Coma i
nduced by barbiturates.
SOURCES OF ENERGY
Carbohydrates, Proteins, Lipids, Vitamins, Electrolytes, Trace Elements
• Carbohydrates are one of the pillars of energy artificial nutrition; solutions
are stable, easy to obtain and are suitable for intravenous administration Gluc
ose is usually this carbohydrate is ready and fully applied, with no toxic effec
ts to the body. Have low caloric density (4 kcal / g), its concentration in the
NP contributes significantly to the determination of osmolality nutrient mixture
.
Camilo (2001)
NP, glucose typically provides 50-55% of total calories Glucose is not metaboliz
ed cause hyperglycemia, glycosuria, osmotic diuresis and dehydration possibly hy
per-osmolar (this may lead to coma) According to "large loads of glucose can inc
rease minute ventilation, the production of carbon dioxide, respiratory quotient
and oxygen consumption. "
Mahan and Arlin (1995, p.548)
Lipids
In NP, the lipids are administered in the form of emulsions "(...) are rich sour
ces of essential fatty acids, have high caloric density, both on a 10% to 20%, p
roviding 1.1 or 2.0 kcal / ml, respectively, are isotonic by the addition of gly
cerol, which allows the formulation of the lipid system, in order to meet all nu
tritional needs from peripheral veins, and have a toxicity significantly small.
"
Riella (1993, p.88)
"The advantage should point to the high caloric density (9 kcal / g fat), low os
molarity and low respiratory quotient (low CO2 production)."
Camilo (2001)
"Lipids may not be the sole source of energy supplied, for some tissues (brain,
leukocytes, etc.). Require glucose for their metabolism. As a rule, the maximum
percentage of calories supplied by fat shall not exceed 50% of total caloric val
ue, as a routine should be 30% of the total caloric content. "
Camilo (2001, p.126)
the daily quantity to be supplied, if no contraindication, should lie between
0.8 and 1.5 g / kg actual weight / day.
Daily administration of lipid emulsions is absolutely contraindicated in dyslipi
demias and severe hypertriglyceridemia (greater than 250 mg / dL), even reaction
ary. Their use should be cautious (0.8 g / kg / day) in sepsis syndrome, adult r
espiratory distress and severe liver failure.
(Camilo, 2001)
Protein
The protein contained in mixtures for NP is the source of nitrogen needed for pr
otein synthesis. It comes in the form of crystalline Laminoácidos and can used i
n any case as the alternative source of nitrogen di-and tripeptides.
Vitamins
Consider two major groups of vitamins, called soluble, formed by the whole group
B, including folic acid, vitamin C and biotin, and the fat soluble, which consi
st of vitamins A, D, E and K.
(Davis et al, 2003)
Are marketed mixtures of fat-soluble vitamins, in general for administration wit
hin the lipid emulsions. As for the water soluble, must be used a multivitamin t
hat covers recommended needs. Added to the solution of glucose.
Electrolyte
"Sodium, chlorine, potassium, calcium, magnesium and phosphate minerals are need
ed in quantities above 200 mg / day. These micronutrients are essential for main
taining the water balance, heart function, the mineralization of the skeleton, n
ervous system function, and muscle enzyme.
Richardson cited by Riella (1993, p.90)
Phosphorus and potassium are essential for protein synthesis. Without proper
match, we can develop a hypophosphataemia dangerous in presence of rich food in
to energy. Calcium is needed to balance the infusion of phosphate
excessive amounts of sodium may provide important water retention, with conseq
uent edema and / or dilution hyponatremia. The amount of chlorine should be appr
oximated to that of sodium, to prevent acid-base imbalance Some solutes of ami
no acids and some shopping bags, have electrolytes in their composition, they sh
ould be counted towards the daily amount to administer.
Trace elements
"Trace elements are inorganic metals that have daily needs less than 100 mg in t
he body and whose reserves are less than 4g. Currently nine trace elements are c
onsidered essential to the human body: iron, iodine, zinc, copper, chromium, man
ganese, selenium, molybdenum and cobalt.
Richardson cited by Riella (1993, p.91)
When not supplied in sufficient quantities, lead to the emergence of a charact
eristic syndrome of disability of each element.
Zinc is essential for the synthesis of numerous metalloenzymes, interference w
ith protein synthesis and wound healing.
There solutes marketed with several trace elements in different concentrations
. One ampoule daily, added to the solution of amino acids or the stock market, p
rovides a proper basic maintenance needs.
"In the administration of trace elements intravenously is necessary to take spec
ial care to avoid complications and to consider the toxic quantities of the elem
ents that are already present in the solutions of NPC, as a contaminant."
Mahan and Arlin (1995, p.550)
COMPLICATIONS OF NP
"The NP has been used routinely since 1968 (...) despite its widespread use, bas
ed on principles defined, fully established, the NP was not devoid of risks."
Riella (1993, p.120)
COMPLICATIONS OF NP
For Camilo (2001), divided into: Mechanical Metabolic Septic
Mechanical complications
• • • • • • • • Pneumothorax Hemothorax Hematoma local hemomediastinum Hidromedi
astino Subcutaneous emphysema venous thrombosis embolism gas embolism • Incorrec
t placement of the catheter • Arrhythmias • • • Obstruction of the catheter Hydr
othorax
Most occur in an attempt to placing the catheter in the subclavian artery, are r
are in the puncture of internal jugular.
Mechanical complications
Venous air embolism can occur during catheter placement at the time of the unf
itness of the syringe needle; catheter embolism - during placement of the cath
eter when there is difficulty in passing the needle bevel, especially with very
sharp; arrhythmias are rare except embolism in the catheter during its placeme
nt or when the tip is positioned in the right atrium.
Mechanical complications
Venous thrombosis is frequent in NP long-term catheters and of poor quality. S
ometimes, in the subclavian puncture, the catheter does not progress to the cava
, but follows a route up to the distal end of the internal jugular; obstructio
n of the catheter is always due to poor nursing care: angled catheter during the
performance of the dressing insufficient monitoring of the rate of infusion.
Metabolic complications
The main complications are linked to metabolism: Glucose; Lipids; amino ac
ids; Electrolyte, vitamins and trace elements. Other: Bleeding; Anemia;
psychotic reactions.
Most schemes do not result from adequate for the patient concerned.
Sepsis
The catheter sepsis is the most common complication and potentially more sever
e NPC; The frequency of sepsis varies between 2 and 33%; It is defined by:
- Septic episode, not explained by another infectious focus;€- Resolved with the
removal of the catheter - requires confirmation from the agent, isolated in cul
ture from the tip of the catheter and blood cultures.
Causative agents of Sepsis Stafilococus epidermidis; Stafilococus aureus;
Klebsiella pneumoniae; Candida albicans.
Sepsis is a major cause of discontinuation of nutritional therapy.
Davis [et al.] (2003)
The risks of contamination of the solutions and the catheter are enhanced by:
physical situation presented by the patient; a hospital; presence of prote
in-calorie malnutrition.
The NURSE is responsible for: Maintenance of blood flow reduction of contami
nation risks during administration of the nutrient solution
NURSING CARE
The PARENTERAL NUTRITIONAL SUPPORT IN PATIENTS
"The role of nurses and nursing in parenteral nutrition support can be developed
according to nursing systems proposed in order: educational support system: ori
entation, preparation and emotional support of patients and families about the p
rocedure, actions concerning the insertion of the catheter; actions concerning t
he administration of the solution, catheter maintenance and monitoring of the pa
tient. "
Riella (1993, p.406)
EDUCATIONAL SUPPORT SYSTEM
According Riella (1993), the nursing care at this stage aims at:
- Reduce stress and anxiety of the patient and family - Seek the participation o
f both the parenteral nutritional support, thus ensuring that media can promote
the success of therapy.
To minimize the anxiety and get the patient and family participation in nutritio
nal support, it must be flushed:
- Check the level of understanding and motivation of the patient and family - wa
rn patients and families about the benefits and risks, highlighting the importan
ce of participation during the process - Explain the route of administration of
the solution - Provide contacts with other patients on parenteral nutrition supp
ort and visits from friends and relatives;
-Explain the likely complications that may arise;-Explain why the trichotomy (th
e hemifase, side of the neck of the hemithorax) and degreasing of the areas ment
ioned; To prepare the unit and equipment required for the insertion of the cathe
ter;-To concurrent with disinfection solution recommended by the Ministry of Hea
lth
PARENTERAL NUTRITION into a peripheral vein
Objectives: - To keep the weight stable or with slight initial reduction;
- Making a less negative nitrogen balance.
Avoid: - Sepsis - Dehydration or water retention; - Electrolyte imbalance - scle
rosis of the veins or thrombophlebitis.
Procedures
1-Explain the technique to the patient, 2-Wash hands thoroughly with soap or ant
iseptic solution, 3-Place the material in order in the sterile field, 4-The nurs
e chooses the puncture site after the evaluation of the venous system. Use mediu
m-size vein in the upper limbs. Starting at the distal veins but do not use hand
veins, 5-The nurse put the mask, disinfect the puncture site; 6-Place sterile g
loves;
7 - Put "minicatéter or catheter, 8 - Adapts protractor / bottle system already
put in 100-500 cc of saline, 9 - Make sure that there is a good flow without int
ravenous extravasation or pain; 10 - Put solutes or Pocket NP; 11 - Do I think e
specially with transparent or bandages and adhesive. And the protractor fixed to
the arm; 12 - If required, put "nitradisk 5 mg" (think of transdermal nitroglyc
erin), approximately 5 cm above the puncture site.
Administration Regulations
1 - Prepare the solutions / purse as prescribed (the bag must be removed from th
e refrigerator 30 minutes before the start of infusion), 2 - Verify integrity of
bottles / bags, turbidity, color, particles in the solution if present returned
 to the pharmacy; 3 - Check the validity of the solution (if bottle) or time of
administration and patient name on the label of the bag, and 4 - Wash hands thor
oughly. Disinfect the stoppers of vials with iodine solution;
5 - Add additives as required, immediately before administration. Properly label
the bottles, wear gloves. This step is not necessary to the use of grants, 6 -
Use sterile IV infusion. Place new sterile gloves, 7 - Adopt the system bottle /
bag, 8 - Fill the system - expel air pockets; 9 - Adapting to the catheter syst
em / extender;
10 - The simultaneous infusion of two solute system requires a Y or three-way st
opcock, when the scheme includes concurrent lipids, they must first be put in ha
nd. The bag must be prescribed with composition for peripheral vein, as indicate
d in the prescription sheet and the label; 11 - Adjusting the infusion rate as p
rescribed, constant for the indicated time. Ever accelerating pace,€unless presc
ribed by a doctor; 12 - The duration of the infusion solution / bag may not exce
ed 24 hours. Change the system every 24 hours; 13 - The NPP can be interrupted f
or the administration of other medication. Should be discontinued if there are l
ipids in progress; 14 - For analysis, collect blood from the arm controlateral;
15 - Register at every turn (if required): Glycosuria (notify your doctor if ≥ 2
+ BMtest> 180 mg%) and water balance; 16 - If the temperature exceeds 38 ° C, n
ot explained by another cause: - Replace systems and bottles / bags NP - Raise t
hink, if necessary, to search for phlebitis;-If phlebitis occurs immediately cha
nge the puncture site to the arm controlateral. 18 - Changing the site of venipu
ncture every three days, or whenever the patient mentions pain or phlebitis; 19
- Track changes observed in the patient: tremors, pallor, impaired consciousness
, respiratory rate.
PARENTERAL NUTRITION IN CENTRAL VEIA
Objectives: - The weight may remain stable, decrease or increase slightly - Tryi
ng to balance or positive nitrogen balance. Avoid: - Sepsis - Dehydration or wat
er retention; - Air embolism - Hypoglycemia or hyperglycemia - Electrolyte imbal
ance - Liver changes - Deficiency of fatty acid deficiency - vitamins and trace
elements.
Procedures
1 - Explain the technique to the patient, 2 - Wash hands with soap / antiseptic,
3 - Place the material in order; 4 - Place the patient in Trendlenburg, with ro
ll over the shoulders (for subclavian puncture), 5 - Make shaving a wide area ne
ar the puncture site; 6 - The nurse involved in the placement of the catheter;
7 - Put this, the protractor and the perfusion system, previously adapted to ser
um bottle (and after the expulsion of air) are connected to the catheter, 8-Begi
n infusion of isotonic serum and verify flow; 9-Secure the catheter to the skin
with silk. Record the overall length of the catheter; 10 - Disinfect the area ar
ound the catheter with iodine solution, always in radial motion of the insertion
point to the periphery; 11-Check for proper adjustment of the catheter / extend
er / system;
12-Put a sterile dressing, leaving the catheter connection / protractor to avoid
angulations; 13-Adhesive Write on the date of release, the external length of c
atheter and initials of who placed it. Register in the process of the patient; 1
4 - Make Rx chest and, after verifying the correct positioning in the superior v
ena cava near the entrance to the right ear, start with the NP prescribed rhythm
and composition, 15 - Pay attention to screening for complications during place
ment catheter.
I think the catheter
Detailed rules 1 - Explain the technique to the patient, 2 - Place it in the sup
ine position without pillow, 3 - Wash hands with antiseptic soap. The following
maneuvers are performed with a protective sterile gloves, and 4 - to adapt the s
ystem to the bottle or bag and fill that with solute and expel air bubbles, 5 -
Adapting the system to the protractor and fill this with the solute; 6 - Change
the protractor with the patient in apnea, 7 - Check security of all adjustments.
Standards Administration
1-Prepare solutions or choose from the bag, according to the prescription; two-V
erify integrity of bottles / bags: turbidity, color, particles in the solution i
f present return to the pharmacy, 3-Check validity of solution (if bottle ) or t
ime of administration and patient name on the label of the bag, 4-Wash hands tho
roughly. Disinfected with iodine solution corks from bottles, 5 Add-additives (e
lectrolytes, vitamins, trace elements, insulin) as prescribed, immediately befor
e administration. Conveniently label them weak. Use 6-sterile IV infusion set, 7
-adapt the system to the bottle / bag, 8-Fill the system to expel the air bags;
9-Fit system to the catheter / protractor with a protective pad solute iodine or
sterile gloves - risk of contamination, 10-connections system / catheter must b
e made with patient supine if possible after deep expiration: 11-Regulating infu
sion rate prescribed constant for the time period indicated. 12-No bottle / bag
must have an infusion period exceeding 24 hours. Changing the infusion every 24
hours, 13 a continuous infusion of two solute system requires a Y or three-way s
topcock, 13-The NPC should not be interrupted for the administration of other me
dications, however there are some exceptions, 14 - Never assess central venous p
ressure through the catheter. Avoid its use to administer another medication;
15-Register at every turn - or BMtest Glycosuria - Temperature, pulse and blood
pressure (from 4 / 4 hours in the first 48 hours);€- Water balance in unstable p
atient or when required; 16-If fever above 38 º C, not explained by another caus
e: Replace-systems and bottles / bags NP is prescribed;-Cultures: blood, sputum,
urine. Find-inflammation / infection at the catheter entry point, temperature-R
egister on April 4 hours. 17-Do I think the catheter 2-3 times a week, whenever
it is dirty or as the service protocol; 18 - Track changes observed in the patie
nt, tremor, pallor, impaired consciousness or respiratory rate.
Related to patient care
Participate in the support group's nutritional assessment of the patient's res
ponse to PN; Psychological support; Assist in the early diagnosis of complic
ations, hearing the complaints and expectations; Detect signs of glucose intol
erance; Observe the signs of hyperglycemia; Observe signs of osmotic diuresi
s; Observe electrolyte abnormalities and acid-base; Observe signs of lack of
fat and trace elements; Observe signs of intolerance to lipid emulsions; de
tect signs of infection and sepsis; Check temperature every four hours; Stri
ct control the intake and excretion; Look for signs of infiltration of liquid;
ingurgitation Observe the veins of the neck, arms and hands - Reduce the risk
of infection.
Catheter-related care
Maintaining the patency of the catheter; Avoid the proliferation of microorg
anisnos catheter; Preventing complications of mechanical thrombectomy and disp
lacement of air for wide circulation through the catheter; Avoid pulled forwar
d, disconnecting the catheter or equipment; In the presence of secretion at th
e catheter insertion site, to gather material culture; Change the equipment ev
ery 24 hours, protecting the glass from direct sunlight.
Care related to solution
Request the bottles to the pharmacy NP two hours before administration; Obse
rve the appearance of the solution (cloudiness, precipitation and the presence o
f particles); Observe the vial labels (name of patient, type of solution, date
of preparation); Calculate drip and record label in the beginning and end of
the solution; Wash your hands when you install the solution bottle, which shou
ld be administered at room temperature; Control drip every hour; Detect leak
ing of nutrient solution; Advise the patient the risks arising from the increa
se or reduction of drip; Avoid sunlight on the solution; The management of e
ach bottle of nutrient solution should not exceed 24 hours and the lipid emulsio
n, 12 hours; dripping from lipid emulsion should be slow at first and graduall
y increased.
Monitoring NP
"The monitoring is mandatory and most severe cases require greater vigilance in
order to prevent complications, improve and evaluate effectiveness."
Camilo (2001, p.91)
"The administration of nutrient mixtures may be associated with mechanical compl
ications, metabolic and infectious diseases."
Freitas (2003, p.161)
Objectives of Monitoring:
Detect and prevent complications; Determine whether the nutritional contribu
tions are being made properly, Document the positive clinical benefits.
Frequency of monitoring depends on several factors: - State and evolution of the
patient - System of nutrition;-Term;-type complications.
EVALUATION OF RESPONSE TO NUTRITIONAL SUPPORT
The assessment of patient response to nutritional support is a progressive proce
ss, consisting of anthropometric measurements, physical examination and biochemi
cal evaluation. (Davie et al, 1996) • • • • • • Weight, physical examination, mu
scle function, visceral proteins, cellular immunity, balance nitrogen.
Healing ensured adequate food ...!
Work done by:
Ana Claudia Andreia Pereira Bruno Ramos Carla Patricia Gaspar Marta Afonso Perei
ra
Thanks for listening!