Parenteral NS

1
Parenteral NS

• Fluid and electrolyte requirements.
• Calculate enteral and parenteral formulations.

2
PNS Routes

• Peripheral access
• Short-term central access
• Long-term central access

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Peripheral Access

• Veins in limbs
• Cannot exceed 800-900 mOsm/kg
• PICC - enter at peripheral but end of tube at
  subclavian vein

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Central Access

• Figure 20-3 here
• Cephalic vein
• Subclavian vein
• Internal jugular vein
• Superior vena cava

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Fig. 20-3. Central access
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Central Access

• Short-term
• percutaneous technique
• Long-term
• implanted vascular devices

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PNS

• Time frame for use of PNS
• 5 days or less is short-term
• Total nutrients needed
• Capacity of pt to handle fluid

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PNS

• Condition of peripheral veins
• If can take adequate oral intake in 5 day - DO
  NOT do central line

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PNS Components

• Protein
• crystalline amino acids
• 3 to 15 solutions
• 10 100g protein/L
• 4 kcal/g protein
• NPC non-protein calories

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PNS Components

• Carbohydrate
• dextrose monohydrate
• 5 to 70 solutions
• D50W 50 solution
• 10 solution 100g/L
• 3.4 kcal/g dextrose

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PNS Components

• Lipid
• soybean or safflower oil
• 10, 20 30 solutions
• 10 1.1 kcal/ml
• 20 2.0 kcal/ml
• 30 3.0 kcal/ml

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PNS Components

• Lipid
• 10 kcal/day every day will provide 4 of kcal
  need to prevent EFA deficiency
• if have long chain fatty acids

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PNS Components

• Electrolytes, vitamins, minerals

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PNS

• PPN
• less than 8.5 AA
• 5-10 dextrose
• lipid not more than 1g/kg/day

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PNS

• PPN
• Rule of thumb for PPN
• D5W or D10W with 8.5 AA
• D20W with 5 AA and lipid at 125 ml/hr

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PNS

• Compounding methods
• mix the dextrose and AA
• piggy back the lipid and filter before mix with
  dextrose and AA

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PNS

• Initiating TPN
• start less than 50 ml/hr and 1 L/day
• advance 12 - 24 hr intervals

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PNS

• Monitoring
• amount receiving
• Na
• K
• BUN
• prealbumin

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PNS

• Monitoring
• cholesterol
• TG
• I O
• body wt
• blood glucose

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McClaren 165. Essential fatty acid deficiency.
21
McClaren 166. Same pt. 165 after EFA
supplementation.
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Complications TPN

• Catheter in wrong place
• Sepsis
• Deficiencies
• EFA def
• trace minerals - added routinely

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Complications TPN

• Metabolic complications
• overloading
• imbalances

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Complications TPN

• Overloading
• solute or fluid - meas. Serum osmolality
• CHO, fat, amino acids

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Complications TPN

• Imbalances
• glucose intolerance
• hypokalemia
• reactive hypoglycemia
• hypophosphatemia
• hypo or hypermagnesemia

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Refeeding Syndrome

• Too aggressive administration after starving
• Hypokalemia
• Hypophosphotemia

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Transition Feeding

• Parenteral to enteral
• start enteral slow
• keep TPN going decrease as increase enteral
• receive 75 from enteral before stop TPN

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Transition Feeding

• Parenteral to oral
• start oral and slowly decrease TPN
• be careful of hyperosmolality of common clear
  liquids
• receive 75 of needs before stop TPN

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Transition Feeding

• Enteral to oral
• ??
• mOsm/kg for different clear liquids be careful
  not too high

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TPN END

• Questions?
• Now for calculations