Parenteral Nutrition

Presenter:Dr Sachin Anand Mod: Dr Sanjeev Aneja

Parenteral Nutrition (Definition)

Components are in elemental or predigested form Protein as amino acids CHO as dextrose Fat as lipid emulsion Electrolytes, vitamins and minerals

Parenteral Nutrition (PN) Definition

Delivery of nutrients intravenously, e.g. via the bloodstream. Central Parenteral Nutrition: often called Total Parenteral Nutrition (TPN); delivered into a central vein Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral vein

Indications for PN
When Specialized Nutrition Support (SNS) is indicated, EN should generally be used in preference to PN. (B) When SNS is indicated, PN should be used when the gastrointestinal tract is not functional or cannot be accessed and in patients who cannot be adequately nourished by oral diets or EN. (B) The anticipated duration of PN should be >7 days

Common Indications for PN

Patient has failed EN with appropriate tube placement Severe acute pancreatitis Severe short bowel syndrome Mesenteric ischemia Paralytic ileus Small bowel obstruction GI fistula unless enteral access can be placed distal to the fistula or where volume of output warrants trial of EN

PN Central Access
May be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting Peripherally inserted central catheters (PICC) are inserted via the cephalic and basilic veins Central access required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume

Venous Sites for Access to the Superior Vena Cava

PICC Lines (peripherally inserted central catheter)

PICC lines may be used in ambulatory settings or for long term therapy Used for delivery of medication as well as PN Inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into the superior vena cava Can remain in place for up to 1 year with proper maintenance and without complications

PN: Peripheral Access

PN may be administered via peripheral access when Therapy is expected to be short term (10-14 days) Energy and protein needs are moderate Formulation osmolarity is <600-900 mOsm/L Fluid restriction is not necessary

Parenteral Nutrition
Macronutrients & Micronutrients

Macronutrients: Carbohydrate
Source: Properties:

Monohydrous dextrose Nitrogen sparing Energy source 3.4 Kcal/g Hyperosmolar Recommended intake: 2 5 mg/kg/min 50-65% of total calories

Macronutrients: Carbohydrate
Potential Adverse Effects:

Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems Hyperglycemia

Macronutrients: Amino Acids

Crystalline amino acids standard or specialty Properties: 4.0 Kcal/g EAA 4050% NEAA 5060% Glutamine / Cysteine Recommended intake: 0.8-2.0 g/kg/day 15-20% of total calories

Source:

Macronutrients: Amino Acids

Potential Adverse Effects:

Increased renal solute load Azotemia

Macronutrients: Lipid

Source: Properties:

Safflower and/or soybean oil Long chain triglycerides Isotonic or hypotonic Stabilized emulsions 10 Kcals/g Prevents essential fatty acid deficiency Recommended intake: 0.5 1.5 g/kg/day (not >2 g/kg) 12 24 hour infusion rate

Macronutrients: Lipids
Requirements

4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as linoleic acid Generally 500 mL of 10% fat emulsion given two times weekly or 500 mL of 20% lipids given once weekly will prevent EFAD Usual range 25% to 35% of total kcals Max. 60% of kcal or 2 g fat/kg

Macronutrients: Lipids
Potential Adverse Effects: Egg allergy Hypertriglyceridemia Decreased cell-mediated immunity (limit to <1 g/kg/day in critically ill immunosuppressed patients) Abnormal LFTs

Parenteral Base Solutions

Carbohydrate Carbohydrate

Amino acids Amino acids

Available in concentrations from 5% to 70% Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixing D30, D50 and D70 used for manual mixing Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions 8.5% and 10% generally used for manual mixing 8.5% and 10% generally used for manual mixing 10% emulsions = 1.1 kcal/ml 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA, 30% emulsions = 3 kcal/ml (used only in mixing TNA, not for direct venous delivery) not for direct venous delivery)

Fat Fat

Other Requirements

Fluid30 to 50 ml/kg (1.5 to 3 Fluid30 to 50 ml/kg (1.5 to 3 L/day) L/day)

Sterile water is added to PN admixture Sterile water is added to PN admixture to meet fluid requirements to meet fluid requirements Use acetate or chloride forms to Use acetate or chloride forms to manage metabolic acidosis or alkalosis manage metabolic acidosis or alkalosis

Electrolytes Electrolytes

Vitamins: multivitamin formulations Vitamins: multivitamin formulations Trace elements Trace elements

Electrolytes/Vitamins/Trace Elements
Because parenterally-administered vitamins and trace elements do not go through digestion/absorption, recommendations are lower than DRIs Salt forms of electrolytes can affect acidbase balance

Adult Parenteral Multivitamins

New FDA requirements published in 2000 replacing NAG-AMA guidelines Increased B1, B6, vitamin C, folic acid, added Vitamin K MVI Adult (Mayne Pharma) and Infuvite (MVI-13) from Baxter contain Vitamin K and are consistent with the new FDA guidelines MVI-12 (Mayne Pharma) does not contain Vitamin K

Parenteral Nutrition Vitamin Guidelines

Vitamin A IU D IU E IU K mcg C mg Folate mcg Niacin mg FDA Guidelines* 3300 IU 200 IU 10 IU 150 mcg 200 600 40 B2 mg B1 mg B6 mg B12 mg Biotin mcg
B5 dexpanthenol mg

Vitamin

FDA Guidelines* 3.6 6 6 5.0 60 15

Daily Trace Element Supplementation for Adult PN

TRACE ELEMENT Chromium Copper Manganese Zinc INTAKE 10-15 mcg 0.3-0.5 mg 60-100 mcg 2.5-5.0 mg

Daily Electrolyte Requirements Adult PN

Electrolyte Calcium Phosphate Sodium Potassium Acetate Chloride PN Equiv Standard Intake RDA 10 mEq 30 mmol N/A N/A N/A N/A 10-15 mEq 8-20 mEq 20-40 mmol 1-2 mEq/kg + replacement 1-2 mEq/kg As needed for acid-base As needed for acid-base

Magnesium 10 mEq

PN Contaminants
Components of PN formulations have been found to be contaminated with trace elements Most common contaminants are aluminum and manganese Aluminum toxicity a problem in pts with renal compromise on long-term PN and in infants and neonates Can cause osteopenia in long term adult PN patients

PN Contaminants
FDA requires disclosure of aluminum content of PN components Safe intake of aluminum in PN is set at 5 mcg/kg/day

PN Contaminants

Manganese toxicity has been reported in long term home PN patients May lead to neurological symptoms Manganese concentrations of 8 to 22 mcg/daily volume have been reported in formulations with no added manganese May need to switch to single-unit trace elements that dont include manganese

Calculating Nutrient Needs

Provide adequate calories so protein is Provide adequate calories so protein is

not used as an energy source not used as an energy source Avoid excess kcal (>35 kcal/kg) Avoid excess kcal (>35 kcal/kg) Determine energy and protein needs Determine energy and protein needs using usual methods (kcals/kg, Iretonusing usual methods (kcals/kg, IretonJones 1992, Harris-Benedict) Jones 1992, Harris-Benedict) Use specific PN dosing guides for Use specific PN dosing guides for electrolytes, vitamins, and minerals electrolytes, vitamins, and minerals

Caloric requirements
Based on Total Energy Expenditure

Can be estimated using predictive equations TEE = REE + Stress Factor + Activity Factor Can be measured using metabolic chart

Caloric requirements
Stress Factor
Malnutrition peritonitis soft tissue trauma fracture fever (per oC rise) - 30% + 15% + 15% + 20% + 13% Moderate infection + 20% Severe infection <20% BSA Burns >40% BSA Burns + 40% + 50%

20-40% BSA Burns + 80% + 100%

Increase WHO REE by stress factors

Fever Cardiac Failure Traumatic Injury Increase 13% per degree C 15-25% 20-30%

Severe respiratory distress 25-30% or broncho-pulmonary dysplasia Severe sepsis 45-50

Caloric requirements
Activity Factor
Bed-bound Ambulant Active
+ 20% + 30% + 50%

Caloric requirements
REE Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W) + (5H) - 6.8A Females: REE= 655 + (9.6W) + 1.8H - 4.7A

Schofield Equation 25 to 30 kcal/kg/day

Protein Requirements

1.2 to 1.5 g protein/kg IBW mild or moderate stress Up to 2.5 g protein/kg IBW burns or severe trauma

How much protein to give?

Based on calorie : nitrogen ratio Based on degree of stress & body weight Based on Nitrogen Balance

Calorie : Nitrogen Ratio

Normal ratio is 150 cal : 1g Nitrogen Critically ill patients 85 to 100 cal : 1 g Nitrogen in

Based on Stress & BW

Non-stress patients 0.8 g / kg / day Mild stress Moderate stress Severe stress 1.0 to 1.2 g / kg / day 1.3 to 1.75 g / kg / day 2 to 2.5 g / kg / day

Based on Nitrogen Balance

Aim for positive balance of 1.5 to 2g / kg / day

Peripheral Parenteral Nutrition

Hyperosmolar solutions cause thrombophlebitis in peripheral veins Limited to 800 to 900 mOsm/kg (MHS uses 1150 mOsm/kg w/ lipid in the solution) Dextrose limited to 5-10% final concentration and amino acids 3% final concentration Electrolytes may also be limited Use lipid to protect veins and increase calories

Peripheral Parenteral Nutrition

New catheters allow longer support via this method In adults, requires large fluid volumes to deliver adequate nutrition support (2.5-3L) May be appropriate in mild to moderate malnutrition (<2000 kcal required or <14 days) More commonly used in infants and children Controversial

Contraindications to Peripheral Parenteral Nutrition

Significant malnutrition Severe metabolic stress Large nutrition or electrolyte needs (potassium is a strong vascular irritant) Fluid restriction Need for prolonged PN (>2 weeks) Renal or liver compromise

Compounding Methods
Total nutrient admixture (TNA) or 3-in-1 Dextrose, amino acids, lipid, additives are mixed together in one container Lipid is provided as part of the PN mixture on a daily basis and becomes an important energy substrate 2-in-1 solution of dextrose, amino acids, additives Typically compounded in 1-liter bags Lipid is delivered as piggyback daily or intermittently as a source of EFA

Advantages of TNA
Decreased nursing time Decreased risk of touch contamination Decreased pharmacy prep time Cost savings Easier administration in home PN Better fat utilization in slow, continuous infusion of fat Physiological balance of macronutrients

Disadvantages of TNA
Diminished stability and compatibility IVFE (IV fat emulsions) limits the amount of nutrients that can be compounded Limited visual inspection of TNA; reduced ability to detect precipitates

Initiation of PN
Adults should be hemodynamically stable, able to tolerate the fluid volume necessary to deliver significant support, and have central venous access If central access is not available, PPN should be considered (more commonly used in neonatal and peds population) Start slowly (1 L 1st day; 2 L 2nd day)

Initiation of PN: formulation

As protein associated with few metabolic side effects, maximum amount of protein can be given on the first day, up to 60-70 grams/liter Maximum CHO given first day 150-200 g/day or a 15-20% final dextrose concentration In pts with glucose intolerance, 100-150 g dextrose or 10-15% glucose concentration may be given initially

Initiation of PN: Formulation

Generally energy and protein needs can be met in adults by day 2 or 3 In neonates and peds, time to reach full support relates inversely to age, may be 3-5 days

Initiation of PN: Formulation

Dextrose content of PN can be increased if capillary blood glucose levels are consistently <180 mg/dL IVFE in PN can be increased if triglycerides are <400 mg/dL

Parenteral Nutrition Formula Calculations and Monitoring Protocols

Example Calculation
Nutrient Needs: Kcals: 1800. Protein: 88 g. Fluid: 2000 cc 1800 kcal x 30% = 540 kcal from lipid Lipid (10%): 540 kcal/1.1 (kcal/cc) = 491 cc/24 hr = 20 cc/hr 10% lipid (round to 480 ml) Remaining fluid needs: 2000cc - 480cc = 1520cc

*|Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.

Protein Calculations
Protein: 88 g / 1520 cc x 100 = 5.8% amino acid solution 88 g. x 4 kcal/gm =352 kcals from protein

Remaining kcal needs: 1800 (528 + 352) = 920 kcal

Dextrose Concentration
920 kcal/3.4 kcal/g = 270 g dextrose 270 g / 1520 cc x 100 = 17.7% dextrose

solution Rate of Amino Acid / Dextrose: 1520 cc / 24hr = 63 cc/hr

TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr

Sample Calculation 3-in-1

Nutrient Needs:

Kcals: 1800 Protein: 88 g Fluid: 2000 cc

Lipid : 1800 kcal x 30% = 540 kcal

540 kcal / 10 kcal per gram = 54 g 54 g / 2000 cc x 100 = 2.7% lipid

Protein: 88 g / 2000 cc x 100 = 4.4% amino acids 88 g x 4 = 352 kcals from protein In critically ill patients, some clinicians restrict lipid to 30% of nonprotein kcals

Sample Calculation 3-in-1(cont)

Dextrose: 908 kcal (1800 540 - 352) 908/3.4 kcal/g = 267 g dextrose 267 g / 2000 cc x 100 = 13.4% dextrose solution Rate of Amino Acid / Dextrose/Lipid: 2000 cc / 24hr = 83 cc/hr TPN prescription: Suggest TNA 13.4% dextrose, 4.4% amino acids, 2.7% lipids at 83 cc/hour provides 88 g. protein, 1800 kcals, 2000 ml. fluid

Calculating the Osmolarity of a Parenteral Nutrition Solution

1. 2. 3. 1.

1.

Multiply the grams of dextrose per liter by 5. Example: 100 g of dextrose x 5 = 500 mOsm/L Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L Multiply the grams of lipid per liter by 1.5. Example: 40 g lipid x 1.5 = 60. Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2 Example: 80 X 2 = 160 Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L

PN Administration:Transition to Enteral Feedings in Adults

Controversial In adults receiving oral or enteral nutrition sufficient to maintain blood glucose, no need to taper PN Reduce rate by half every 1 to 2 hrs or switch to 10% dextrose IV) may prevent rebound hypoglycemia (not necessary in PPN) Monitor blood glucose levels 30-60 minutes after cessation

PN Administration:Transition to Enteral Feedings in Pediatrics

Generally tapered more slowly than in adults as oral or enteral feedings are introduced and advanced Generally PN is continued until 75-80% of energy needs are met enterally

Medications That May Be Added to Total Nutrient Admixture (TNA)

Phytonadione Selenium Zinc chloride Levocarnitine Insulin Metoclopromide Ranitidine Sodium iodide Heparin Octreotide

Parenteral Nutrition
Infusion Schedules

Infusion Schedules

Continuous PN
Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous access

Continuous PN
Advantages Well tolerated by most patients Requires less manipulation decreased nursing time decreased potential for touch contamination

Continuous PN
Disadvantages Persistent anabolic state altered insulin : glucagon ratios increased lipid storage by the liver Reduces mobility in ambulatory patients

Infusion Schedules

Cyclic PN The intermittent administration of PN via a central or peripheral venous access, usually over a period of 12 18 hours Patients on continuous therapy may be converted to cyclic PN over 24-48 hours

Cyclic PN

Advantages Approximates normal physiology of intermittent feeding Maintains: Nitrogen balance Visceral proteins Ideal for ambulatory patients Allows normal activity Improves quality of life

Cyclic PN

Disadvantages Incorporation of N into muscle stores 2 may be suboptimal Nutrients administered when patient is less active Not tolerated by critically ill patients Requires more nursing manipulation Increased potential for touch contamination Increased nursing time

Common Indications for PN in Peds

Surgical GI disorders Intractable diarrhea of infancy Short bowel syndrome Inflammatory bowel disease Intractable chylothorax Intensive cancer treatment

Pediatric Energy Needs in PN

No consensus exists as to how to determine energy needs of hospitalized children RDAs are intended for healthy children but can use for healthy/acutely ill children and monitor response Can estimate REE using WHO equation and add stress factors, monitor clinical course Indirect calorimetry recommended in difficult cases REE(KCAL/min=3.94*DVo2+1.11DVCO2)

RDAs for Energy and Protein

Category Infants Children Age (yr) 0.0-0.5 1-3 4-6 7-10 11-14 15-18 11-14 15-18 Energy
(kcal/kg/d)

Protein
(g/kg/d)

Females Males

108 102 90 70 47 40 44 45

2.2 1.2 1.1 1.0 1.0 0.8 1.0 0.9

WHO Equations to predict REE from body weight

Sex/Age Range (years) Males 0-3 Males 3-10 Males 10-18 Females 0-3 Females 3-10 Females 10-18 Equation to Derive REE (kcal/d) (60.0 x wt) 54 (22.7 x wt) + 495 (17.5 x wt) + 651 (6.1 x wt) 51 (22.5 x wt) + 499 (12.2 x wt) + 746

Trauma/Critically Ill Peds

Age in years 0-1 1-6 7-12 13-18 Kcals/kg 90-120 75-90 50-75 30-60 G/pro/kg 2.0-3.5 1.8-3.0 1.5-2.5 1.0-2.0

Pediatric PN: Fluids

Standard calculation: 100 kcal/kg for infant 3-10 kg 1000 kcal + 50 kcal/kg for every kg over 10 kg for a child 10-20 kg 1500 kcal + 20 kcal/kg for every kg over 20 kg for a child over 20 kg 1 mL fluid/kcal/d + adjustments for fever, diarrhea, stress, etc.

Pediatric PN: Carbohydrate

Carbohydrate should comprise 45-50% of caloric intake in infants and children (C) For neonates, CHO delivery in PN should begin at 6-8 mg/kg/minute of dextrose and advanced to 10-14 mg/kg/minute. (B)

Pediatric PN: Lipid

Preterm: start at .5 g/kg/day and increase by .5g/kg q day Infants: Start at 1 g/kg and increase by .5 g/kg/day until the maximum or desired dose is reached; need 0.5 to 1 g/kg/day for EFA needs Maximum is 3 g/kg for <24 months old and 2.5g/kg for 24 months and older

Daily Electrolyte and Mineral Requirements for Peds Pts

Electrolyte Sodium Chloride Potassium Calcium Phosphorus Magnesium Infants/Children Adolescents 2-6 mEq/kg 2-5 mEq/kg 2-3 mEq/kg 1-2.5 mEq/kg 0.5-1 mmol/kg 0.3-0.5 mEq/kg Individualized Individualized Individualized 10-20 mEq 10-40 mmol 10-30 mEq

Document in Chart
Type of feeding formula and tube Method (bolus, drip, pump) Rate and water flush Intake energy and protein Tolerance, complications, and corrective actions Patient education

Parenteral Nutrition
Monitoring

Monitoring for Complications

Malnourished patients at risk for refeeding syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely at initiation of SNS. (B) In patients with diabetes or risk factors for glucose intolerance, SNS should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. (C) Blood glucose should be monitored frequently upon initiation of SNS, upon any change in insulin dose, and until measurements are stable. (B)

Monitoring for Complications

Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are stable. (B) Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. (C) Liver function tests should be monitored periodically in patients receiving PN. (A)

Acute Inpatient PN Monitoring

Parameter
Glucose Electrolytes Phos, Mg, BUN, Cr, Ca TG Fluid/Is & Os Temperature T. Bili, LFTs Initially

Daily
Initially Initially

Frequency 3x/week
Initially

Weekly

Inpatient Monitoring PN
Parameter
Body Weight Nitrogen Balance HGB, HCT Catheter Site Lymphocyte Count Clinical Status

Daily
Initially

Frequency Weekly
Initially

PRN

Monitorcontd

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)

Monitoring: Nutrition
Serum Hepatic Proteins Parameter
Albumin Transferrin Prealbumin Retinol Binding Protein

t
19 days 9 days 2 3 days ~12 hours

Complications of PN
Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver, cholestasis) Metabolic bone disease Vascular access sepsis

Refeeding Syndrome
Patients at risk are malnourished, particularly marasmic patients Can occur with enteral or parenteral nutrition Results from intracellular electrolyte shift. M C due to hypophosphatemia and Hypoglycemia .

Refeeding Syndrome Symptoms

Reduced serum levels of magnesium, potassium, and phosphorus Hyperglycemia and hyperinsulinemia Interstitial fluid retention Cardiac decompensation and arrest

Refeeding Syndrome Prevention/Treatment

Monitor and supplement electrolytes, vitamins and minerals prior to and during infusion of PN until levels remain stable Initiate feedings with 15-20 kcal/kg or 1000 kcals/day and 1.2-1.5 g protein/kg/day Limit fluid to 800 ml + insensible losses (adjust per patient fluid tolerance and status)

Glycemic Control in Critical Care

Until recently, BG<200 mg/dl was tolerated in critically ill patients. Now greater attention is given to glycemic control due to evidence that glucose is associated with morbidity/mortality and risk of infection New recommendation is to keep BG<150 mg/dl or as close to normal as possible

For Patients Not Previously on Insulin

Monitor blood glucose levels prior to initiating PN When therapy is initiated, monitor BG q 4-6 hours and use sliding scale or insulin drip as needed Add a portion of the previous days insulin to TPN to maintain blood glucose levels

Glycemic Control in PN

For Patients Previously on Insulin

Determine amount of insulin needed prior to illness Determine amount of feedings to be given Provide a portion of daily insulin needs in first PN along with sliding scale or insulin drip to maintain glucose levels (generally insulin needs will increase while on PN)

Glycemic Control in PN

Fluid Excess

Critically ill pts and those with cardiac, renal, hepatic failure may require fluid restriction May need to restrict total calories to reduce total volume Use most concentrated source of PN components (70% dextrose = 2.38 kcal/ml; 20% lipid = 2 kcal/ml) PPN may be contraindicated due to fluid volume of 2-4 liters

Electrolytes

Electrolytes in PN should be given at a stable dose with intermittent requirements for supplementation given outside the PN Sodium levels often reflect fluid distribution versus sodium status Hypokalemia may be due to excessive GI losses, metabolic alkalosis, and refeeding Hyperkalemia may be due to renal failure, metabolic acidosis, potassium administration, or hyperglycemia

Acid-Base Balance
Balance chloride and acetate to maintain/achieve equilibrium The standard acetate/chloride ratio is 1:1 Increase proportion of chloride with metabolic alkalosis; increase proportion of acetate with metabolic acidosis Consider chloride and acetate content of amino acids

Special populations
Diabetics Careful monitoring of therapy to avoid hyperglycemia Insulin may be added to the parenteral admixture and combined with sliding-scale insulin administration Reasonable glucose control should ensure a blood glucose level greater than 100 mg/dL and less than 220 mg/dL

Acute renal failure

Patients with acute renal failure are hypercatabolic, hypermetabolic, Frequently afflicted by coexisting multiple-system organ failure. Assessed carefully for signs of fluid overload and Electrolyte abnormalities, particularly hyperkalemia, hyperphosphatemia, and hypermagnesemia Protein is provided at approximately 1- 1.2 g/kg/day Dialysis is used as indicated to control uremia.Careful assessment of nitrogen losses in urine, dialysate, and other source. Branched-chain amino acids (BCAAs; e.g., leucine, isoleucine, valine) may be combined with other amino acids to improve protein use.

Pulmonary disease

Overfeeding may increase CO2 production, complicate respiratory function, and impede weaning from ventilator support. Provide adequate carbohydrate calories to meet energy needs and (with fat) promote protein sparing. An acceptable strategy is to increase the proportion of calories supplied by fat, Restrict the administration of carbohydrate to 4 mg/kg/min. Protein needs should be estimated at 1.5 g/kg/day.

Hepatic disease

Lipid, carbohydrate, protein, and vitamin metabolism is sharply altered in patients with hepatic failure Lipid clearance is defective, with decreased lipolytic activity, increased triglyceridemia, and decreased removal of free fatty acids. Glucose intolerance and insulin resistance. Intolerance to protein presents the greatest challenge to nutritional management. May have fluid overload that may require restriction of TPN volume.

Hepatic disease (cont)

Protein needs in patients with liver failure and mild or no encephalopathy should be calculated at 1.5 g/kg/day Protein needs in patients with significant encephalopathy are reduced to 1.0 g/kg/day. Patients with pronounced encephalopathy should be given a modified amino acid formula containing a high percentage of BCAAs(Do not require hepatic metabolism)

Cardiac disease
Prolonged malnutrition, patients with longstanding cardiac disease are vulnerable to a typical wasting (cardiac cachexia). The total volume of TPN solution is generally restricted to 1000 to 1500 mL/day in patients with severe congestive heart failure secondary to valvular dysfunction, coronary artery disease, or cardiomyopathy.

Thanks