Template

1
??????????????????????????????????????????????????
????? (TPN Patient Care Workshop)
1-3 ??????? 2552 ??.????????????? ???.
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Contents
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?????

• 1.Adults TPN
• - Physical and nutritional assessment
• - Indication for TPN therapy
• - Requirements of fluid, calorie, protein
• and micronutrient
• - Patient monitoring and formula
• adjustment
• - Patient education

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?????

• 2.Pediatric and neonatal TPN
• - Physical and nutritional assessment
• - Indication for TPN therapy
• - Requirements of fluid, calorie, protein
• and micronutrient
• - Patient monitoring and formula
• adjustment
• - Patient education

5
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?????

• 3.Complications of TPN
• - Metabolic
• - Infectious
• - Mechanical/technical
• 4.TPN in special population

6

or
Nutrition planning becomes a part of medical
therapeutics
7
Nutrition screening tools

• Objective Measurement
• Anthropometry
• Laboratory
• Delayed cutaneous hypersensitivity
• skin test
• Subjective Measurement
• History-diet/medical/surgical/social
• -functional/family/GI
• Nutrition focused physical assessment
• SGA, NRS (2002)

8
Subjective global assessment (SGA)

• A.History
• 1.Weight change
• Overall loss in past 6 mo
  amount___kg, loss _____
• Change in last 2 wk_____Increase
• _____No
  change
• 
  _____Decrease
• 2.Dietary intake change (relative to
  normal)
• ____No change
• _____Change duration____wks_____mont
  hs
• _____Type_____sub-optimal solid diet
• _____full liquid
  diet
• _____hypocaloric
  diet
• _____starvation
• 3.Gastrointestinal symptomps(that
  persisted gt 2 wks)
• _____None _____Nausea
  _____Vomiting
• _____Diarrhea _____Anorexia

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Subjective global assessment (SGA)

• A.History (cont.)
• 4.Functional capacity
• _____No dysfunction (full capacity)
• _____Dysfunction duration____wks_____m
  onths
• _____Type______Working sub-optimally
• ______Ambulatory
• ______Bed ridden
• 5.Disease and its relationship to
  nutritional requirments
• Primary diagnosis (specify)___________
• Metabolic demand(stress) ______No
  stress
• 
  ______Low stress
• 
  ______Moderate stress
• 
  ______High stress

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Subjective global assessment (SGA)

• B.Physical (for each specify 0normal, 1mild,
• 2moderate, 3severe)
• _____Loss of subcutaneous fat
  (triceps, chest)
• _____Muscle wasting (quadriceps,
  deltoids)
• _____Ankle edema
• _____Sacral edema
• _____Ascites
• C.Subjective global assessment rating (select
  one)
• _____AWell nourished
• _____BModerate (or suspected)
  malnourished
• _____CSeverely malnourished

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Nutrition Risk Screening (NRS 2002)

• Step 1 Initial screening
• 1. Is BMI lt 20.5 ?
• 2. Has the patient lost weight within the last 3
  months ?
• 3. Has the patient had a reduced dietary intake
  in the last week ?
• 4. Is the patient severely ill (e.g. in intensive
  therapy) ?
• If the answer is Yes to any question, the
  screening in step 2 is performed.
• If the answer is No to all questions the
  patient is re-screened weekly intervals.
• If the patient e.g. is scheduled for a major
  operation a preventive nutritional care plan is
  considered to avoid the associated risk status

Yes/No Yes/No Yes/No Yes/No
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Nutrition Risk Screening (NRS 2002)

• Step 2 Final screening
• Impaired nutrition status
  Severity of disease (increase in
• 
  requirements)

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Severe Nutritional Risk

• Presence of 1 criteria
• Involuntary increase or decrease in weight
• - 10 usual weight over 6 months or
• - 5 of usual weight over 1 month
• BMI lt 18.5 kg /m2
• SGA grade C or NRS 3
• Serum albumin lt 3 g/dl (with no evidence
• of hepatic or renal dysfunction)

15
Classification of Protein Energy Malnutrition
Mild Acute
Energy Moderate
Chronic Protein Severe
Both Both
Kwashiorkor - predominantly protein
deficiency Marasmus - mainly energy
deficiency Marasmic kwashiorkor - combination of
chronic energy deficiency
and chronic or acute protein
deficit
16
Protein deficiency

• Serum albumin lt 3.5 g/dl
• Absolute lymphocyte lt 1,500 cell/mm3
• Serum transferrin lt 150 mg/dl
• Loss of reactivity to common skin test antigens

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Lab. test for visceral protein
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Pre-albumin (mg/dl)
Albumin (g/dl)
Transferrin (mg/dl)
Severity
150-200 100-150 lt 100
Mild Moderate Severe
3.0-3.5 2.1-3.0 lt 2.1
11-18 5-10.9 lt 5
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• Creatinine-height index (CHI)
• CHIActual 24 hr creatinine excretion x 100
• Ideal 24 hr creatinine excretion
• CHI lt 80 mild
• 60-80 moderate
• lt 60 severe
• Nitrogen balance
• Protein-24hr UUN(g) 4
• 6.25

21
Indication for TPN therapy
Length of expected NPO status
gt 3 d
lt 3 d
Perform complete Nutrition assessment -
EN/PN

Premorbid BMI gt 18.5 and lt 10 Wt. loss
Premorbid BMI lt 18.5 and gt 10 Wt. loss
Dextrose containing IV
NPO gt 3 d or change in clinical status
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Disease diagnosis
GI tract function
Yes
No
Enteral feeding
NPO lt 7 d
NPO gt 7 d
TPN
PPN
23
Indication of PN

• Adults
• 1. pt.?????????????????????????????????????? GI
  tract
• Massive small bowel resection
• GI fistula (high output gt500 ml)
• Inflammatory bowel diseases
• Bowel obstruction
• Persistent GI bleeding, GI ischemia
• Hyperemesis gravidarum
• Diarrhea?????????????????????????????????????
  ??? EN
• ??????????????????????? 5- 7 ???
• 2. pt.CA ?????????malnutrition???????????
  ???GI???????
• ?????????????????Oral/??????EN??? ????????
  1 wk

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Indication of PN

• Adults (???)
• 3. Severe acute pancreatitis ???????????????EN???
  ???????? 1
• wk e.g.??pt.??????????????????, ??
  ascites,fistula output
• 4. Critical illness ?????? GI ??????????? 5-7
  ??? e.g. major
• surgery, trauma, sepsis
• 5. Catabolic state ????????????-?????? e.g. pt.
  ??? ?? ???????
• ???????????? malnutrition when GI tract
  is not
• usable 5-7 days
• 6. Preoperative in severe malnourished without
• functional GI tract

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Indication of PN

• Adults (???)
• 7. Anorexia nervosa ?????????????????
  EN??????????????????????/?????????

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Indication of PN

• Pediatric and neonatal
• 1. pt.?????????????????????????????????????? GI
  tract
• Massive small bowel resection
• GI fistula e.g. esophageal,
  tracheosophageal
• Inflammatory bowel diseases e.g.
• necrotizing enterocolitis(NEC), ulcerative
• colitis
• ?????????????????????????????????????????????
  ??????EN?????????? omphalocele, gastroschisis
• ????????????? ????????????????????????EN?????
  ????? 3 ???

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Indication of PN

• Pediatric and neonatal (???)

• Diarrhea ??????????? ???????????? lt 3 ?????
  ???????? gt 2 wk
• ??????????????????????????????????????????
  ??????????????EN??????????????????
• Bowel obstruction e.g. intestinal atresia,
• imperforated anus, Hirschsprungs disease
• 2.Very low birth weight lt1,000 g ?????????
  NPO/??????
• EN ?????? e.g. respiratory distress syndrome
  (RDS)
• 3.pt. CA (???????????????????)
• 4.Severe acute pancreatitis (???????????????????)
• 5.Critical illness (???????????????????)

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Indication of PN

• Pediatric and neonatal (???)
• 6.Catabolic state ????????????-??????
  (???????????????????)
• 7.Preoperative in severe malnourished without
• functional GI tract (???????????????????)
• 8.Anorexia nervosa (???????????????????)
• 9.Inborn error metabolism

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Contraindication of PN

• Hemodynamic instability
• Severe fluid and electrolyte imbalance
• Renal failure without dialysis
• (Almost) complete functions of GI tract
• Patients refusal
• Terminal and hopeless illness

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Parenteral Nutrition planning
31
Energy requirement in adults

• Total energy expenditure (TEE)
• TEEBEE x AF x SF kcal/day
• 1.Basal energy expenditure (BEE)
• ??????? Harris-Benedict equation
• Men 66(13.7xW)(5xH)-(6.8xA)
• Women 665(9.6xW)(1.8xH)-(4.7xA)
• Wkg. (actual or usual wt.), Hcm.,Ayr.
• ???????????????? lt 6 yr
• Obesity gt120 IBW use adjust BW
• Marasmic/underweight actual BW

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Energy requirement in adults

• 2.Activity Factor (AF)
• - with respirator 0.7-0.9
• - bed rest 1.2
• - ambulatory 1.3
• 3.Stress Factor (SF)Metabolic Factor e.g.

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Energy requirement in adults

• BEE x 1.4 (will cover the majority of pt.)
• 25-30 kcal/kg/day
• Indirect calorimetry
• -Resting energy expenditure (REE)
• REE 3.9(VO2)1.1(VCO2) x 1.44
• VO2 O2 consumption
• VCO2CO2 production

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Energy requirement in Pediatric and neonatal

• TEEBMR (in 24 hr) x AF x SF
• 1.Basal metabolic rate (BMR) kcal/hr
• -?????????? /BEE/REE
• 2.Activity Factor (AF)
• - ????????????????? 1.1
• - ????????????????? 1.3
• - ???????????????? 1.5
• - ???????????? 1.75
• 3.Stress Factor (SF) (???????????????????)

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• Holliday-Segar
• 10 kg ??? 100 kcal/kg/day
• 10 kg ????? 50 kcal/kg/day
• ??????????????? 20 kcal/kg/day
• (water 1 ml/calorie 1 kcal)
• ???????????????????????? ??????????????????????
  ?????????????????
• ???????????????????????????????????????????
  60 ?????????????
• ????????????????????????????????????

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• Age (y) kcal/kg
• 0-1 90-120
• 1-7 75-90
• 7-12 60-75
• 12-18 30-60
• gt 18 25-30

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Its All about Nutrients

• Macronutrients
• ? Energy sources
• ? Substrate sources
• ? Modulating functions
• ? CHO, Proteins, Lipids
• Micronutrients
• ? Non-energy providing nutrients
• ? Regulatory functions
• ? Electrolytes, Trace element, Vitamins
• Water

38
Carbohydrate (CHO)
Macro nutrients
Lipid
Protein
39
Estimation of calories from PN

• Nutrient Kcal/g
• CHO
• Dextrose.H2O 3.4
• Dextrose anhydrous 4.0
• Glycerol 4.3
  
• Fat source
• Long chain fat emulsion 9
• Medium chain fat emulsion 8.3
• Protein
• Amino acids 4

40
Carbohydrate

• Primary source of energy for normal healthy
  person
• Principle energy substrate for brain, which
  utilizes 130-140 g of glucose per day
• All CHO are absorbed in the form of glucose
• Reduce ketone production
• Facilitates storage of TG in fat tissue
• Preserve body protein ( gluconeogenesis)

41
Carbohydrate

• Dextrose Glucose
• adult oxidize glucose 4-7 mg/kg/min
• load gt 7 mg/kg/min
• - glycogen, lipid syn.,metabolic
  complications
• (hyperglycemia, excess CO2,
  lipogenesis,
• LFT ??? fatty liver)
• ????? 5 mg/kg/min
• neonate oxidize glucose 6-8 mg/kg/min
  max.10-14 mg/kg/min
• preterm (very low birth wt.) oxidize glucose
  max. 12-15 mg/kg/min
• infant child max. 15-20 mg/kg/min

42
Carbohydrate

• ??????????? ??????????? hyperglycemia,
  hyperosmolarity
• ????? conc.10, 10 g/kg/day max. 25 g/kg/day
• pt.sepsis/stress hyperglycemia
• closely monitored and adjusted in the
  postoperative period in neonates and children to
  avoid hyperglycemia
• ??????? add insulin
• Provide 50-60 of total energy in adults
• Provide 40-50 of total energy in infants and
• children

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Carbohydrate
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Lipids

• Source of energy
• Carries of fat-soluble vitamins
• Precursors of eicosanoids, modulate immune
  function
• Substrate for fat formation in adipose tissue

High energy content in a low volume 9
kcal/g lipids
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Lipids

• Lipids Classification-chain length
• Short chain FA (C1-5)not used in PN
• Medium chain FA (C6-11)water soluble, good
  energy source
• Long chain FA (C12-22)energy, membrane
  structure, most of the biologic activity

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Lipids

• Lipids Classification-number and position of
  double bonds
• Saturated fatty acids
• Monounsaturated fatty acids (MUFA)
• Polyunsaturated fatty acids (PUFA)

47
Lipids
Data expressed in weight percent
48
Lipids
3rd
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Lipids

• Contents
• - lipid emulsion based on soybean oil
  safflower oil
• - egg phospholipid emulsifier
• - glycerol isotonic
• 10 fat emulsion 1.1 kcal/ml
• 20 fat emulsion 2.0 kcal/ml
• Source of EFA linoleic acid(?-6), linolenic
  acid(?-3) PUFA (LCT)
• ???? start 0.5 g/kg/day hypertriglyceridemia
  
• max. 3-3.5 g/kg/day, 50 of total energy

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Lipids

• ????????????????????????????????/sepsis
• lipid intolerance
• ????????????????????????????
• add heparin 0.5-1.0 unit/ml of TPN ?????
• ??????????? endothelial
  lipoprotein lipase
• ????????????????????? catheter
• The first days infused as slowly as possible
• lt 0.1 g/kg/h with LCT
• lt 0.15 g/kg/h with LCTMCT
• Provide 30-40 of total energy in adults
• max. 60 ketosis

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Lipids

• Recommendations for Fat emulsion
• Prevent EFA deficiency
• - 10 fat emulsion 500 ml x 3 times/wk
• - 20 fat emulsion 500 ml weekly
• Acceptable Triglyceride
• - serum TG lt 250 mg/dl 4hr after lipid
  infusion
• - serum TG lt 400 mg/dl for continues
  infusion

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Proteins

• Tissue synthesis
• Constitutes of hair, skin, nails, tendon,
  bones,ligaments,major organs, muscle
• Precursors of neurotransmitters
• Major part of antibodies, enzymes, transports of
  ions and substrates in blood
• Initiators of muscle contraction

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Amino acids

• First to introduce, last to withdraw
• Protein deficiency VS Energy deficiency
• Amino acids as fuel VS as substrate
• Infusion of glucose along with amino acids
• 0.5-3.0 g/kg/day
• Tritration
• - clinical symptoms and signs
• - Biochemistry

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Amino acids

• Conditionally essential
• Arginine
• Cysteine
• Glutamine
• Histidine
• Taurine
• Tyrosine
• Non- essential
• Alanine 6. Ornithine
• Asparagine 7. Proline
• Aspartic acid 8. Serine
• Glutamic acid
• Glycine

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Amino acids

• Specialized amino acid solutions
• Branch chain amino acids
• Isoleucine, Leucine, Valine
• Increased metabolic stress
• Hepatic failure with encephalopathy
• Higher concentrations of essential amino acids
• Renal failure not receiving dialysis
• Benefit have not been proven in controlled trials

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Amino acids

• 3. Conditionally essential amino acids in
• infants
• Histidine for neonates and infants up to 6 mon.

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CHOAALipid

• Suggested pediatric parenteral substrate
  provision

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Non-protein calories Nitrogen (NPCN)

• NPCN
• calories from glucosecalories from fat emulsion
  x 6.25
• amino acid (g)

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Electrolytes
Micro nutrients
Trace elements
Vitamins
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Electrolytes
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Electrolytes
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Electrolytes in Pediatrics
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Trace Elements

• Prosthetic groups of enzymes
• Routine addition of zinc, copper, selenium,
  chromium, and manganese recommended
• Addition of molybdenum probable
• Vitamin and trace element levels should be
  monitored periodically during long-term PN
  administration

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Requirement of Trace element in PN
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Trace Elements
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Vitamins

• Vitamin requirements
• - Vitamin requirements during PN therapy are
  uncertain because they are not based on balance
  studies.
• - The requirements for an adult TPN
• FDA 2003 (increase in vitamin B1, B6,
• C and folic acid and include 150 ตg of
• vitamin K)

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Vitamins in PN
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Fluid requirement

• Adults
• 30-35 ml/kg
• 1 ml/1 kcal
• 100 ml/kg for first 10 kg of wt. plus
• 50 ml/kg of wt. from 11-20 kg plus
• Age 50 y.20 ml/kg over 20 kg or
• Age gt 50 y.15 ml/kg over 20 kg
• Pediatrics
• Holliday-Segar formula
• 1,500-1,700 ml/m2 of BSA
• 1 ml/1 kcal
• Fluid need should be calculated with fluid loss
• (diarrhea, fistula)

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Fluid and Electrolytes

• Variations depending on clinical status
• PN not meant to correct severe fluid and
  electrolytes imbalance
• Water and electrolyte requirements should be
  adjusted in pediatric patients undergoing
  surgical procedures or who have on-going losses
  from stomas or other sites

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Monitoring

• Efficacy of therapy
• Complication detection and prevention
• Clinical condition evaluation
• Clinical outcome determination
• Growth
• Metabolic
• Clinical observations

72
Monitoring

• Growth
• ? Weight
• ? Height/Length
• ? Head circumference
• Metabolic
• ? Elytes, BUN, Cr, Ca, PO4, Mg, acid-base
• ? Albumin, pre-albumin
• ? CBC, glucose, triglycerides, LFTs, PT/PTT
• ? Urine markers specific gravity, glucose,
• ketones, UUN

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Monitoring

• Clinical observations
• ? Vital signs
• ? Intake and output
• ? Catheter site/dressing
• ? Administration system
• ? Growth and development

74
Monitoring

• Malnourished patients at risk for refeeding
  syndrome should have serum P, Mg, K and glucose
  levels monitored closely at initiation of SNS.
• In pt.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
• Blood glucose should be monitored frequently upon
  initiation of SNS, after any change in insulin
  dose, and until measurements are stable
• Serum electrolytes (Na, K, Cl,HCO3) should be
  monitored frequently upon initiation of SNS until
  measurements are stable

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Monitoring

• Pts. receiving IV fat emulsion should have serum
  triglyceride levels monitored until stable and
  when changes are made in the amount of fat
  administerd
• Liver function tests should be monitored
  periodically in patients receiving PN
• Bone densitometry should be performed upon
  initiation of long-term SNS and periodically
  thereafter
• Postpyloric placement of feeding tubes should be
  considered in pts. At high risk for aspiration
  who are receiving EN

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Follow up parenteral feeding
77
Monitoring for Adult Patients on PN
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Patient education

• ????????????????????????????????????????
  ??????????????????????????????????????????????????
  ????? ???????????????????????????????????????
• ??????????????????????????????????????????????
• ?????????????????????????
• ???????????????????????????????
  ??????????????????????? ???????????????????
• ??????????/????????????

79
PN Complications
80
Metabolic complications

• Substrate intolerance
• Fluids Electrolytes imbalance
• Acid-Base abnormalities

81
Substrate intolerance

• Hyperglycemia
• Traditional gt 220 mg/dl
• Cardiac surgery pts., BS gt 150 mg/dl
• Surgical critical care pts., maintaining BS
  80-110 mg/dl
• Pt. sepsis, trauma, burn, CA, Cr deficiency
• Tx - add Insulin aware in neonate
• hypoglycemia
• Blood and urine glucose monitored closely

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Substrate intolerance

• Hyperosmolar hyperglycemic nonketotic dehydration
• ?????? glucose osmotic diuresis (from
  glucosuria), dehydrate/fluid deficit, coma
• TX - Isotonic/hypotonic saline

83
Substrate intolerance

• Excess CO2 production
• CHO
• Pt. respiratory distress ???? CO2
• Tx -Dextrose 5 mg/kg/min

84
Substrate intolerance

• Refeeding syndrome
• Refers to the metabolic and physiological shifts
  of fluid, Elytes and minerals e.g. P, Mg, K
• Occur in malnourished pts. during rapid
  nutritional replacement
• Risk factor starvation, alcoholism, anorexia,
  morbid obesity with massive wt. loss

85
Substrate intolerance

• Aggressive nutrition support delivery of calories
  in the form of CHO
• CHO delivery stimulates insulin secretion during
  starvation
• CHO stimulates the release of insulin
• Causes an intracellular shift of these Elytes
  and minerals
• Insulin shifts K,P into cells
• Potential for severe hypo P, Mg, K
• Na retention leads to fluid overload, pulmonary
  edema and cardiac decompensation

86
Substrate intolerance

• Symtoms of refeeding syndrome is characterizied
• Generalized fatique, lethargy muscle weakness,
  edema, cardiac arrhythmia, and hemolysis
• Calories should be initialed and advanced slowly
  in pt. who are at risk for refeeding syndrome

87
Substrate intolerance

• Preventation
• start low and go slow
• Gradual provision of calories over 3 to 5 days
• Thaimine replacement
• Elytes replacement K, Mg, P

88
Substrate intolerance

• Hypoglycemia
• Abrupt discontinuation of PN can lead to rebound
  hypoglycemia
• Excessive or erroneous insulin administration
• Pts. requiring large doses of insulin have a
  greater risk for rebound hypoglycemia

89
Substrate intolerance

• Prevention
• 10 dextrose should be infused for 1 or 2 hrs
  following PN discontinuation avoid a possible
  rebound hypoglycemia
• Infusion 1 to 2 hrs taper down in susceptible
  pts.
• Obtaining a capillary blood glucose conc. 30 min.
  to 1 hr after the PN solution is discontinuation
  will help identify rebound hypoglycemia

90
Substrate intolerance

• TX -Initiation of a 10 dextrose
• infusion
• -Administer 50 dextrose
• -Stopping any source of insulin
• administration

91
Substrate intolerance

• Hypertriglyceridemia
• Serum triglyceride gt 220 mg/dL
• Riskneonate , very low birth wt, sepsis
• Tx - Heparin 0.5-1 unit/1ml of PN solution
  ??????? enzyme phospholipase

92
Substrate intolerance

• Hypercholesterolemia
• Phospholipid/triglycerides ratio
• 10 fat emulsion 0.12
• 20 fat emulsion 0.06
• Pts very low birth wt

93
Substrate intolerance

• Essential fatty acid deficiency (EFAD)
• Biochemical evidence of EFAD
• Trienetetraene ratio gt 0.4
• Linoleic acid (EFA) M arachidonic acid
  (tetraene)
• Oleic acid M eicosatrienoic acid(triene)
• Risk immature ???????????? fat 1-2wks
• Scaly dermatitis, alopecia, anemia, fatty liver,
  hepatomegaly, thrombocytopenia

94
Substrate intolerance

• Prevention
• 1-2 of daily energy requirement should be
  derived from linoleic acid
• 0.5 of energy from linolenic acid
• Approximately twice weekly of
• - 500 ml of 10 fat emulsion
• - 250 ml of 20 fat emulsion
• Alternately 500 ml of a 20 fat emulsion once a
  week

95
Substrate intolerance

• Azotemia
• Excessive protein intake
• Increased BUN
• Pts. With hepatic or renal disease are prone to
  developing azotemia
• Osmotic diuresis, dehydration, coma

96
Substrate intolerance

• Hyperammonemia
• Hepatic immaturity in low birth weight infants
• Pts . Renal failure ??????????? EAA ??? arginine
• Tx- ?? protein in PN

97
Substrate intolerance

• Hepatobiliary complications
• Disorders of the liver and biliary system are
  common in pts. receiving PN, long term support
• Types of Hepatobiliary disoders
• - Steatosis
• - Cholestasis
• - Gallbladder sludge/stones
• disorders may coexist

98
Substrate intolerance

• Steatosis-Hepatic Fat
• Dose related
• Dextrose infusion rates gt max. oxidation rate
  steatosis, excessive glycogen deposition in liver
• Elevated liver function tests
• Can progress to severe dysfunction

99
Substrate Intolerance

• Steatosis-Hepatic Fat
• Steatosis is the condition of hepatic fat
  accumulation
• Predominant in adults and is generally benign
• Modest elevations of serum aminotransferase conc.
  (AST,ALT)that occur within 2 wks. of PN therapy
• Most pts. are asymptomic
• Steatosis is a complication of overfeeding

100
Substrate intolerance

• Cholestasis
• Cholestasis is a condition of impaired bile
  secretion or frank biliary obstruction
• - Predominant in children
• - May also occur in adult pts. receiving
• longterm PN
• Cholestasis is a serious complication
• - it may progress to cirrhosis and
  liver
• failure

101
Substrate intolerance

• Cholestasis
• Elevation of
• - Alkaline phosphatase (ALP)
• - Gamma-glutamyl transpeptidase(GGT)
• - Conjugated (direct) bilirubin conc.gt2
• mg/dL
• - With or without jaundice

102
Substrate intolerance

• Gallbladder sludge/stones
• Gallbladder stasis during PN therapy lead to
  gallstones or gallbladder sludge with subsequent
  cholecystitis
• Related more to the lack of enteral stimulation gt
  PN infusion
• The lack of oral intake results in decreased
  cholecystokinin (CCK) release
• - impaired bile flow and gallbladder
• contractility

103
Substrate intolerance

• Gallbladder sludge/stones
• The duration of PN therapy seems to correlate
  with the development of biliary sludge
• Biliary sludge may progress to acute
  cholecystitis in the absence of gallstones
• This condition is also referred to as acalculous
  cholecystitis

104
Fluids Electrolytes imbalance

• Fluid overload
• ?? fluid overload gt fluid deficit
• Pts. e.g. Critically ill
• Intake/output
• Weight gain
• Osmolarity, Na, Hematocrit dilution
  effect

105
Fluids Electrolytes imbalance

• Fluid deficit or Dehydration
• ????????? Hyperosmolar hyperglycemic nonketotic
  dehydration

106
Fluids Electrolytes imbalance

• Hyponatremia/ Hypernatremia
• Hypokalemia/ Hyperkalemia
• Hypophosphatemia/ Hyperphosphatemia
• Hypocalcemia/ Hypercalcemia
• Hypomagnesemia/ Hypermagnesemia

107
Acid-Base abnormalities

• Metabolic acidosis
• Hyperchloremic metabolic acidosis
• Metabolic acidosis anion gap
• Metabolic alkalosis

108
Others

• Vitamins
• Trace elements
• Metabolic bone disease

109

• Routine Monitoring Parameters
• Base line Elytes, Glucose, Ca, Mg, P, Albumin,
  TG, LFTs, PT, CBC, BUN, Cr
• Daily Elytes, Glucose q6h
• 2-3 times/week Ca, Mg ,P
• Weekly Prealbumin, LFTs, PT, CBC

110
Infectious complications

• Sepsis is a serious complication in PN
• Cause
• Catheters PVC gt Silicone rubber, multilumen
• compounding PN-Rx
• Pts. care-Nurse
• Staphylococcus epidermis, Staphylococcus aureus,
  Candida albicans, Bacteria gram negative

111
Infectious complications

• Prevention
• Aseptic techniques QC in PN, catheters access,
  dressing
• Amino acid/glucose infusion giving sets and
  extensions can be left 48-72 hrs. in-between
  changing.
• Lipid sets should be changed every 24 hrs.
• PN solution should be changed every 24 hrs
• Carers should be taught about the signs of
  catheter related sepsis

112
Infectious complications

• Diagnostic criteria
• Fever gt38.5 c or rise in temp. of gt1 c
• White blood count ???
• ????????????????? catheter tip

113
Infectious complications

• 1.?????????????????????????????????????????
  source
• 2.??????????????? ?????????????? gram stain, C/S
• 3.CBC, UA, Hemoculture, PN solution culture
• 4.?????????????????? ??? IV line
• 5.Fat emulsion-off
• 6.Tx-IV antibiotics

114
Infectious complications

• Indication to remove the catheters
• Pts.-Septic shock
• Persistent pyrexia with positive blood cultures
  after 48 hrs. of appropriate antibiotics
• fungemia

115
Mechanical/technical complications

• e.g. catheter occlusion, pneumothorax,
  subcutaneous emphysema, thrombosis, arterial
  injury, air embolism, catheter tear or break

116
TPN in special population

• Critical illness
• Renal failure
• Hepatic disease
• Pancreatitis
• Pulmonary disease
• Heart failure

117
PHARMACY PRACTICE Experience in the U.S.

• Clinical Pharmacist
• Chart review
• Drug information
• Medication group
• Pharmacy to dose orders
• Drug utilization review
• Formulary review
• Patient care conference

118
PHARMACY PRACTICE Experience in the U.S.

• Clinical Pharmacist (cont.)
• CE and presentation
• Response to code blue
• Drug monitor
• Preceptor and teaching
• ADR
• Activity report

119
Thank You !