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Total parenteral nutrition 2

TPN and different conditions

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Total parenteral nutrition 2

  1. 1. Total parenteral nutrition and specific diseases By dr. Venkatesh kolla
  2. 2. Preoperative parenteral nutrition in severe malnourished patients reduces the rate of post operative complications and improves the outcome and also reduces non infectious complications(pulmonary emboli & delayed wound healing. In this condition it requires 7 to 14 days for restoration in malnourished patients . But in mild malnutrition patients parenteral nutrition leads to more infectious complications like pneumonia and wound infection.
  3. 3. Post operative PN 1.Patients unlikely to resume oral feed with in 10days.most commonly used because of paralytic ileus post operative or concern about disrupting a new bowel anastomosis. 2. As a continuation of preoperative PN support for malnutrition. 3.In previously sever malnourished patients undergoing emergency surgery. 4.Major burns and trauma.
  4. 4. Cancer A. Parenteral nutrition should not be used routinely in patients undergoing major cancer operations or along with CT & RT. B. PN is provided only in clinical improvement with quality survival is expected. C. PN is indicated if CT or RT is likely to cause GI toxicity which will prevent oral/enteral intake for more than one week. Immediate morbidity is reduced if glutamine supplement is added to PN solution. D. PN unlikely to benefit patients with rapidly progressive malignancy and in terminal stages of malignancy .
  5. 5. Cardiac disease  In cardiac surgery patients , EN should be deferred until the patient is hemodynamically stable.  Patients requiring PN after cardiac surgery increases the risk of volume overload, hyponatremia , metabolic acidosis & uremia.  To avoid fluid overload in CHF , use maximally concentrated PN solutions.  Cardiac patients with anasarca and HTN need flid and salt restriction.  In patients receiving diuretics, requirement of potassium , magnesium and zinc increases.
  6. 6. Pulmonary disease “Death from starvation is death from pneumonia” Malnutrition inadequate calorie intakeskeletal muscle protein utilized as a source of calories muscle wasting aggravate respiratory failure(decreased respiratory drive and decreased response to hypoxia). It also adversely effect weaning from mechanical ventilators. Impaired immune function reduces pulmonary defense mechanism and increases susceptibility to infection.
  7. 7. Effect of pulmonary disease on nutritional status: advanced disease leads to malnutrition and weight loss, due to increased work of breathing and poor food intake. Nutritional repletion improves diminished respiratory function.ventilation drives returns to normal with refeeding and weaning from ventilator improves.
  8. 8. Requirements  In COPD recommended energy intake is 1.7times their resting energy expenditure.  avoid excess calories from dextrose so as to prevent excessive Co2 production and increased work of breathing.  Lipid is preferential as it provides more energy with less Co2. however excess or to rapid infusion will alter the pulmonary gas exchange.  Dextrose and lipids 70:30 ratio is safe  50:50 ratio is beneficial in weaning of patients from ventilator.(low carbohydrate formula)  Amino acid requirement is 1gm/kg/day. Amino acids also increase the drive and sensitivity of respiratory centers for Co2.  In ARDS patients, administer fluid restricted nutrient formulation, if hemodynamic necessitates.
  9. 9. Avoid hypophosphatemia,hypocalcemia and hypomagnesemia which can reduce respiratory muscle strength.
  10. 10. BURNS Important causes of malnutrition in burn patients: 1. Large loss of protein and micronutrients through damaged skin. 2. Large loss of heat through exposed surface causes increased energy expenditure. 3. post burn hypermetabolism and hypercatabolism.
  11. 11. Requirements current practice is to provide 20-30-% extra calories or 35 to 35kcal/kg/day for most of patients with major burns. Protein -1.3to1.5gm/kg/day. Atleast 15% of calories should be supplied by fat but should not exceed 30-35%. Currerie formula-25kcal/kg bodyweight+40kcal/%of burn.
  12. 12. PANCREATITIS Enteral nutrition can be given into jejunum, distal to ligament of treitz or parenteral nutrition is to provide adequate nutrition without stimulating the pancreatic enzymes secretion and to prevent further damage to pancreas. INDICATIONS: a)Who develop paralytic ileus , pseudocyst, fistulae, pancreatic abscess or pancreatic ascites. b)If enteral feeding leads to exacerbation of abdominal pain.
  13. 13. When to start PN? Patients with acute severe necrotising pancreatitis are highly catabolic and if not provided adequate and timely nutrition, are predisposed to malnutrition. Nutritional support with in 48-72hours of hospitalization is beneficial.when PN was delayed beyond 72hours in these patients, complications and mortality rates were three times higher compared to similar patients treated earlier
  14. 14. Requirements: Energy: 25-35kcal/kg/day Protein:1.2-1.5gm/kg/day Carbohydrate: 4-6gm/day Lipid: up to 2gm/kg/day
  15. 15. Gastrointestinal Fistulae Role of parenteral nutrition is supportive and should be provided to patients with GI fistula with anticipated inadequate oral or EN beyond 7-14days. In patients with GI fistula, bowel rest and PN have contributed significantly to the improvement in clinical outcome(lower mortality rate, higher spontaneous fistula closer and higher surgical closer rates.)
  16. 16. Liver disease • Liver is work horse for metabolic activity. It consumes approximately 20% of resting energy requirements. • It is a major site for metabolism of protein, carbohydrates, nitrogen. • Nutritional requirements in patients with liver diseases vary depending upon preexisting malnutrition, type of disease and severity of illness and its complications.
  17. 17. Energy requirements: Compensated cirrhosis of liver,non-protein energy requirement is 25-35kcal/kg/day. In cirrhotic patients with complications(post operative period,sepsis, GI bleed and hepatic failure) the energy requirement is considerably high (35-45kcal/kg/day). Protein Requirements: a)Compensated cirrhosis not>1gm/kg/day if patient is malnourished and repletion is desired,protein supplementation can be increased by 20%. b)Cirrhosis with encephalopathy  restricted to 0.5gm/kg/day. Administration of branched chain amino acids is helpful because they promote better nitrogen balance and prevent formation of aromatic amino acids.