Total Parenteral Nutrition

1
Total Parenteral Nutrition
Ms.Nikethana R Nair, M.Sc (Nsg), MBA (HA), M.Sc
(Psy), M.Phil (HHSM), NABH Assessor, Nursing
Superintendent, MMHRC - Madurai!
2
Introduction
3
DEFINITION

• A method of feeding patients by infusing a
  mixture of all necessary nutrients into the
  circulatory system, thus bypassing the GIT.

4
Also referred to as

• Intravenous nutrition
• Parenteral alimentation
• Artificial nutrition.

5
THE GOLDEN RULE OF NUTRITION

• The gut should always be the preferred route for
  nutrient administration.
• Therefore, parenteral nutrition is indicated
  generally when there is severe
  gastro-intestinal dysfunction (patients who
  cannot take sufficient food or feeding formulas
  by the enteral route) .

6
Criteria of TPN

• If enteral feeding is completely stopped or
  ineffective, Total Parenteral Nutrition is used
  (TPN).
• If enteral feeding is just not enough ,
  supplementation with Partial Parenteral Nutrition
  (PPN) is indicated.

7
Indications for TPN

• Short-term use
• Bowel injury, surgery, major trauma or burns
• Bowel disease (e.g. obstructions, fistulas)
• Severe malnutrition
• Nutritional preparation prior to surgery.
• Malabsorption - bowel cancer
• Severe pancreatitis
• Malnourished patients who have high risk of
  aspiration
• Long-term use (HOME PN)
• Prolonged Intestinal Failure
• Crohns Disease
• Bowel resection

8
Severe Malnutrition

• In well-nourished adults, 7 - 10 days of
  starvation with conventional intravenous
  support (using 5 dextrose solutions) is
  generally accepted.
• If the period of starvation is to extend beyond
  this time, or the patient is not well-nourished,
  Total Parenteral Nutrition (TPN) is necessary
  to prevent the potential complications of
  malnutrition.

9
Nutritional Requirements

• Energy Glucose
• Lipid
• Amino acids (Nitrogen)
• Water and electrolytes
• Vitamins
• Trace elements

10
Patient's Needs

1. Metabolic needs
2. Clinical history
3. Blood work

11
What Central PN solution?

• 3 in 1 PN - Total Nutrient Admixture
• Consists of dextrose, amino acids, intravenous
  fat emulsion, electrolytes, vitamins, minerals
  trace elements.

12
What Peripheral PN solution?

• Lower concentrations of dextrose amino acids
  may be administered through peripheral veins
• PPN will usually involve a more diluted formula
  with fewer calories and is only recommended

13
Advantage

• Potentially life-saving when GI tract cannot be
  used or when oral/parenteral nutrition cannot
  meet nutrient requirements of patient.

14
Disadvantages

• Costly
• Long term risk of liver dysfunction, kidney and
  bone disease nutrient deficiencies

15
Routes Of Administration

• Provision of nutrients intravenously
• Central
• Peripheral

16
Application - Central Venous Access

• Catheter can be placed via the
• Sub Clavian Vein
• The Jugular Vein Less desirable because of the
  high rate of associated infection, or
• Note Once the correct position of the catheter
  has been established (usually by X ray), the
  infusion can begin.

17
Peripheral Line

• A peripherally inserted central catheter line
  (PICC Line) A long catheter placed in an arm
  vein and threaded into the central venous system.

18
Purpose Central Parenteral Nutrition (CPN)
Central Venous Access

1. Utilization of large central veins for the
   administration of a patients complete nutrient
   needs
2. Preferred Route
3. Can deliver daily requirement for kcals, protein,
   micronutrients in concentrated volumes

19
Benefits of PICC Line

• Access to central vein is not possible
• Can accommodate hypertonic fluids
• Lower risk of phlebitis
• Easier to insert than central line

20
Nurses Role

• Its an stat order
• Check with the pharmacy with the availability of
  the pack as written by the physician
• Counter check with what name it is reflected in
  the HIS then rise it
• Once the feed comes it should be started without
  any delay
• Preparation must be done in an sterile method
  i.e. in the medication preparation area.

21

• Compression on the pack must be like Compression
  on the first compartment by keeping it on a flat
  surface, the pressure merges the 2 compartments
  the contents gets mixed then compress the
  merged compartment, the pressure aids the
  contents to merge with the 3rd compartment. Mix
  it well.

22
Articles Required

• Hand Care
• Alcohol swab
• Poshi flush
• Transparent dressing (to change the dressing of
  the central line or PICC Line)
• Gauze Pack 2
• AHD 1000 (Strictly use only AHD 1000)

23
Application

• Initiation of Therapy
• TPN infusion is usually initiated at a rate of
  25 to 50 mL/h. This rate is then increased by 25
  mL/h until the predetermined final rate is
  achieved.
• Administration
• To ensure that the solution is administered at
  a continuous rate, an infusion pump is utilized
  to administer the solution. In hospitalized
  patients, infusion usually occurs over 22-24
  h/day. In ambulatory home patients,
  administration usually occurs overnight (12-16 h).

24
Initiation of Therapy - Protocol

• Physicians Order
• 40 ml for 2 hours
• After 2 hours 60 ml/hour is the constant rate
  that is been maintained.

25
Calculation (Example)

• A Packet contains 1000 ml
• Initial rate if doctor is advising 40 ml for 2
  hours means 80 ml for 2 hours gets over.
• So therefore 1000 ml 80 ml 920ml
• Formula Total volume in bag
• ml/hour
  
• 920 ml in bag/60 ml/hour 15.3 hours
• So the balance amount in the bag must go within
  15 hours 30 mins

26
Special Consideration

• If in case the TPN is discontinued, then it
  should wrapped in the new pharmacy cover after
  wiping it fully especially with the alcohol
  swab in the line inserted area
• It should be labeled with the patients sticker
• Use hand care when performing the procedure
• Then store it in the refrigerator, do not freeze
  it.

27
Special Consideration

• Validity for the pack is 24 hours. Eg If the
  Pack is opened at 8 am its been discontinued at
  around 3pm, it can be packed well kept in the
  refrigerator until next day 8am. If incase its
  not been used then it should be discarded.
• If the TPN is continued from 7pm onwards then it
  should be as per the rate ordered by the
  physician (60ml/hour) until next day morning 8am
  the remaining amount should be discarded.
• Should keep the feed out for 15 minutes then
  connect it for the patient.
• No catch up feed should be done.

28
Monitoring

• Efficacy Electrolytes (S. Na, K, Ca, Mg, Cl,
  Ph), acid-base, Bl. Sugar, body weight, Hb.
• Complications ALT Alanine Amniotransferase
  (SGPT), AST - Aspartate aminotransferase), Bil,
  BUN, total proteins and fractions.
• General Input- Output chart.
• Detection of infection
• Clinical (activity, temp, symptoms)
• WBC count (total differential)
• Cultures

29
MMHRC Protocol

• Site Central Line - X Ray - 6Hours
• Bag 1000ml 2000ml for central line 1000ml
  for Peripheral Line
• Flow Rate 30ml - 1000ml 100ml - 2000ml
• Investigations
• Everyday - GRBS
• 7th Day - LFT TGS
• 48 hrs - RFT Electrolytes once

30
Complications of TPN

• Sepsis
• Pneumothorax
• Air embolism
• Clotted catheter line
• Catheter displacement
• Fluid overload
• Hyperglycemia
• Rebound Hypoglycemia

31
Complications of TPN

• Catheter-related complications
• Catheter sepsis which can be localized or
  systemic (skin portal, malnutrition, poor
  immunity).
• Symptoms Fever, chills, drainage around the
  catheter entrance site, Leukocytosis, ve
  cultures (blood catheter tip).
• Treatment
• Exclusion of other causes of fever
• Short course of anti-bacterial and antifungal
  therapy (acc. to CS)
• Catheter removal may be required

32

• Catheter sepsis (Cont.)
• Prevention A rigorous program of catheter care
• Only I.V. nutrition solutions are administered
  through the catheter, no blood may be withdrawn
  from the catheter.
• Catheter disinfection and redressing 2 to 3 times
  weekly.
• The entrance site is inspected for signs of
  infection and if present, culture is taken or the
  catheter is removed.
• Other catheter-related complications
• Thromboembolism, pneumothorax, vein or artery
  perforation, and superior vena cava thrombosis

33

• Metabolic Complications
• Hyperglycemia (an elevated blood sugar)
• Associated with the infusion of excess glucose in
  the feeding solution or the diabetic-like state
  in the patient associated with many critical
  illnesses.
• It can result in an osmotic diuresis (abnormal
  loss of fluid via the kidney), dehydration, and
  hyperosmolar coma.
• Treatment Decrease the amount of infused
  glucose (tolt4 mg/kg/min) OR insulin can be
  administered (either S.C. inj. or incorporation
  in the infusion bag).

34

• Metabolic Complications
• Hypertriglyceridemia (High S. Triglycerides)
  Associated with excess infusion of fat emulsion.
• Cause Infusion of both glucose and fat emulsion
  in excess may result in pulmonary insufficiency.
• Excess glucose infusion gt excess carbon
  dioxide (CO2) production a result of glucose
  metabolism.
• Excess lipid infusion --gt the lipid particles
  may accumulate in the lungs and reduce the
  diffusion capacity of respiratory gases.

35

• Metabolic Complications
• Liver toxicity (also know as parenteral nutrition
  cholestasis) It causes severe cholestatic
  jaundice, elevation of transaminases, and may
  lead to irreversible liver damage and cirrhosis.
• Cause Multiple causes have been proposed,
  including high infusion rates of aromatic amino
  acids, high proportion of energy intake from
  glucose, e.t.c.
• Treatment There is no specific treatment,
  other than anticholestatic therapy.

36

• Metabolic Complications
• Intestinal bacterial translocation
• The lack of direct provision of nutrients to
  the intestinal epithelia during total parenteral
  nutrition ?Trophism and altered permeability of
  the GI mucosa, thus compromising any potential
  recovery of the patients ability for enteral
  feeding, and allowing bacterial entery to blood
  stream ? sepsis
• Treatment Prevention is to provide a minimal
  enteral nutrition supply to avoid or minimize
  this risk.

37

• Metabolic Complications
• Other metabolic complications
• Electrolyte imbalance, mineral imbalance,
  acid-base imbalance, toxicity of contaminants of
  the parenteral solution.

38

• Mechanical Complications
• Catheters and tubing may become clotted or
  twist and obstruct.
• Pumps may also fail or operate improperly.

39
(No Transcript)