TPN
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การดแู ลผ้ ปู ่ วยทีไ่ ด้ รับสารอาหาร ทางหลอดเลือดดาแบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ.พระมงกุฎเกล้า กทม. Contents 1 Adults TPN 2 Pediatric and neonatal TPN 3 Complications of TPN 4 TPN in special population การดูแลผู้ป่วยทีไ่ ด้ รับสารอาหารทางหลอดเลือดดาแบบสมบูรณ์ 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 การดูแลผู้ป่วยทีไ่ ด้ รับสารอาหารทางหลอดเลือดดาแบบสมบูรณ์ 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 การดูแลผู้ป่วยทีไ่ ด้ รับสารอาหารทางหลอดเลือดดาแบบสมบูรณ์ 3.Complications of TPN - Metabolic - Infectious - Mechanical/technical 4.TPN in special population Definition of nutritional support When normal diets fail to meet the daily requirements. or When assessment documents deficiencies Nutrition planning becomes a part of medical therapeutics 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) 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_____months _____Type:_____sub-optimal solid diet _____full liquid diet _____hypocaloric diet _____starvation 3.Gastrointestinal symptomps(that persisted > 2 wks) _____None _____Nausea _____Vomiting _____Diarrhea _____Anorexia Subjective global assessment (SGA) A.History (cont.) 4.Functional capacity _____No dysfunction (full capacity) _____Dysfunction: duration____wks_____months _____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 Subjective global assessment (SGA) B.Physical (for each specify 0=normal, 1+=mild, 2+=moderate, 3+=severe) _____Loss of subcutaneous fat (triceps, chest) _____Muscle wasting (quadriceps, deltoids) _____Ankle edema _____Sacral edema _____Ascites C.Subjective global assessment rating (select one) _____A=Well nourished _____B=Moderate (or suspected) malnourished _____C=Severely malnourished Nutrition Risk Screening (NRS 2002) Step 1 :Initial screening 1. Is BMI < 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 rescreened 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 Nutrition Risk Screening (NRS 2002) Step 2 :Final screening Impaired nutrition status Severity of disease (=increase in requirements) Normal nutritional Absent requirement Score=0 Absent Score=0 Normal nutritional status Mild Score=1 Wt. loss > 5% in 3 mon. or Food intake below 50-75% of normal requirement in preceding week Mild Score=1 Hip fracture, chronic patients, in particular acute complications: cirrhosis, COPD, chronic hemodialysis, DM, Oncology Moderate Score=2 Wt loss > 5% in 2 mon. or BMI 18.5-20.5 +Impaired general condition or Food intake 25-50% of normal requirement in preceding week Moderate Score=2 Major abdominal surgery, stroke, severe pneumonia,Hematologic malignancy Severe Score 3 Wt loss > 5% in 1 mon. (> 15% in 3 mon.) or Severe Score 3 BMI < 18.5 + Impaired general condition or Food intake 0-25% of normal requirement in preceding week Score: + Score: Head injury, Bone marrow transplantation, Intensive care patients (APACHE > 10) =Tol.score Age: If ≥ 70 yrs; add 1 to total score above Score ≥ 3: the patient is nutritionally at risk and a nutritional care plan is initiated Score < 3: weekly rescreening of the patient.If the patient, e.g., is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status 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 < 18.5 kg /m2 * SGA grade C or NRS ≥ 3 * Serum albumin < 3 g/dl (with no evidence of hepatic or renal dysfunction) Classification of Protein Energy Malnutrition Severity Mild Course Acute Main deficit 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 Protein deficiency Serum albumin < 3.5 g/dl Absolute lymphocyte < 1,500 cell/mm3 Serum transferrin < 150 mg/dl Loss of reactivity to common skin test antigens Lab. test for visceral protein Protein Albumin Transferrin Pre-albumin Half-life 21 days 7 days 2 days Normal value 3.5-5.5 g/dl 270-400 mg/dl 18-40 mg/dl Pre-albumin (mg/dl) Albumin (g/dl) Transferrin (mg/dl) Mild 3.0-3.5 150-200 11-18 Moderate 2.1-3.0 100-150 5-10.9 Severe < 2.1 < 100 <5 Severity Serum albumin (g/dl) Total lymphocytes Status of visceral (cell/mm3) protein 3.0-3.5 1,500-1,800 2.5-3.0 900-1,500 < 2.5 < 900 Mildly depleted Moderately Severely Creatinine-height index (CHI) CHI=Actual 24 hr creatinine excretion x 100% Ideal 24 hr creatinine excretion CHI < 80% =mild 60-80% =moderate < 60% = severe Nitrogen balance = Protein-[24hr UUN(g) + 4] 6.25 Indication for TPN therapy Length of expected NPO status <3d Premorbid BMI > 18.5 and < 10% Wt. loss Dextrose containing IV >3d Premorbid BMI < 18.5 and > 10% Wt. loss Perform complete Nutrition assessment - EN/PN NPO > 3 d or change in clinical status Disease diagnosis GI tract function No Yes Enteral feeding NPO < 7 d PPN NPO > 7 d TPN Indication of PN Adults 1. pt.มีปัญหาการทางานและการดูดซึมสารอาหารของ GI tract * Massive small bowel resection * GI fistula (high output; >500 ml) * Inflammatory bowel diseases * Bowel obstruction * Persistent GI bleeding, GI ischemia * Hyperemesis gravidarum * Diarrheaอย่างรุนแรงและคาดว่าไม่สามารถรับอาหารทาง EN หรืออาการไม่ดขี น้ึ ภายใน 5- 7 วัน 2. pt.CA ทีม่ ภ ี าวะmalnutritionอย่างรุนแรง และGIผิดปกติ จนไม่สามารถกินทางOral/รับทางENได้ เกินกว่า 1 wk Indication of PN Adults (ต่อ) 3. Severe acute pancreatitis ไม่สามารถรับทางENได้เกินกว่า 1 wk e.g.ในpt.ปวดท้องอย่างรุนแรง, มี ascites,fistula output 4. Critical illness คาดว่า GI ทางานไม่ได้ 5-7 วัน e.g. major surgery, trauma, sepsis 5. Catabolic state ระดับปานกลาง-รุนแรง e.g. pt. ตับ ไต ทางเดิน หายใจล้มเหลว + malnutrition when GI tract is not usable 5-7 days 6. Preoperative in severe malnourished without functional GI tract Indication of PN Adults (ต่อ) 7. Anorexia nervosa ไม่สามารถทนรับทาง ENได้ดว้ ยเหตุผลทาง กายภาพ/ทางอารมณ์ Indication of PN Pediatric and neonatal 1. pt.มีปัญหาการทางานและการดูดซึมสารอาหารของ GI tract * Massive small bowel resection * GI fistula e.g. esophageal, tracheosophageal * Inflammatory bowel diseases e.g. necrotizing enterocolitis(NEC), ulcerative colitis * มีความผิดปกติของผนังหน้าท้องตัง้ แต่แรกคลอดและรับทางENไม่ได้ เช่น omphalocele, gastroschisis * อาเจียนรุนแรง และคาดว่าไม่สามารถรับทางENได้มากกว่า 3 วัน Indication of PN Pediatric and neonatal (ต่อ) *Diarrhea อย่างรุนแรง เช่นทารกอายุ < 3 เดือน ท้องเสีย > 2 wk เมือ่ เพาะเชือ้ จากอุจจาระก็ไม่พบเชือ้ ก่อโรค และรับอาหารทางENแล้ว อาการไม่ดขี น้ึ * Bowel obstruction e.g. intestinal atresia, imperforated anus, Hirschsprung’s disease 2.Very low birth weight <1,000 g ทีค่ าดว่า NPO/รับทาง EN ไม่ได้ e.g. respiratory distress syndrome (RDS) 3.pt. CA (เช่นเดียวกับผูใ้ หญ่) 4.Severe acute pancreatitis (เช่นเดียวกับผูใ้ หญ่) 5.Critical illness (เช่นเดียวกับผูใ้ หญ่) Indication of PN Pediatric and neonatal (ต่อ) 6.Catabolic state ระดับปานกลาง-รุนแรง (เช่นเดียวกับผูใ้ หญ่) 7.Preoperative in severe malnourished without functional GI tract (เช่นเดียวกับผูใ้ หญ่) 8.Anorexia nervosa (เช่นเดียวกับผูใ้ หญ่) 9.Inborn error metabolism Contraindication of PN Hemodynamic instability Severe fluid and electrolyte imbalance Renal failure without dialysis (Almost) complete functions of GI tract Patient’s refusal Terminal and hopeless illness Parenteral Nutrition planning Energy requirement Macronutrients Complication Micronutrients Monitoring Energy requirement in adults Total energy expenditure (TEE) TEE=BEE x AF x SF kcal/day 1.Basal energy expenditure (BEE) จากสูตร Harris-Benedict equation Men = 66+(13.7xW)+(5xH)-(6.8xA) Women = 665+(9.6xW)+(1.8xH)-(4.7xA) *W=kg. (actual or usual wt.), H=cm.,A=yr. *ไม่ใช้ในเด็กอายุ < 6 yr *Obesity >120% IBW *Marasmic/underweight use adjust BW actual BW 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 Fever Mild infection Moderate infection Minor operation Moderate operation Skeletal trauma Major sepsis e.g. 1+0.13/1 c Peritonitis 1.05-1.25 Cancer 1.0-1.25 1.0-1.2 Soft tissue trauma 1.0-1.3 1.2-1.4 Weight gain 1.1 1.2 Burns ; 10-30% BSA 1.5 1.2-1.4 ; 30-50% BSA 1.75 1.35 ; > 50% BSA 2.0 1.4-1.6 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 VCO2=CO2 production Energy requirement in Pediatric and neonatal TEE=BMR (in 24 hr) x AF x SF 1.Basal metabolic rate (BMR) -ดูจากตาราง /BEE/REE 2.Activity Factor (AF) - นอนอยูแ่ ต่บนเตียง = 1.1 - จากัดการทากิจกรรม = 1.3 - มีกจิ กรรมปานกลาง = 1.5 - มีกจิ กรรมมาก = 1.75 kcal/hr 3.Stress Factor (SF) (เช่นเดียวกับผูใ้ หญ่) Holliday-Segar 10 kg แรก = 100 kcal/kg/day 10 kg ต่อมา = 50 kcal/kg/day น้าหนักทีเ่ หลือ = 20 kcal/kg/day (water 1 ml/calorie 1 kcal) * ในกรณีทเ่ี ป็ นผูป้ ่ วยหนัก อาจไม่สามารถให้พลังงานได้ครบตามทีก่ าหนด ในกรณีน้ใี นช่วงแรกควรได้รบั พลังงานอย่างน้อย 60% ของพลังงานที่ คานวณได้เพือ่ รักษาน้าหนักตัวให้คงที่ Age (y) kcal/kg 0-1 90-120 1-7 7-12 12-18 > 18 75-90 60-75 30-60 25-30 It’s 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 Carbohydrate (CHO) Lipid Protein Macro nutrients 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 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) Carbohydrate Dextrose = Glucose *adult ; oxidize glucose = 4-7 mg/kg/min * load > 7 mg/kg/min; - glycogen, lipid syn.,metabolic complications (hyperglycemia, excess CO2, lipogenesis, LFT สูง fatty liver) * แนะนา ≤ 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 Carbohydrate *ในเด็กค่อยๆ ให้ทลี ะน้อย hyperglycemia, hyperosmolarity *เริม่ 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 * อาจต้อง add insulin *Provide 50-60% of total energy in adults *Provide 40-50% of total energy in infants and children Carbohydrate Age (year) Energy (kcal/kg/d) Glucose (mg/kg/min) Preterm Term 1-3 4-6 7-10 11-18 80-120 90-120 75-90 65-75 55-75 40-55 10-18 11-18 9-14 8-11 7-11 7-8.5 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 Lipids Lipids Classification-chain length 1. Short chain FA (C1-5);not used in PN 2. Medium chain FA (C6-11);water soluble, good energy source 3. Long chain FA (C12-22);energy, membrane structure, most of the biologic activity Lipids Lipids Classification-number and position of double bonds 1. Saturated fatty acids 2. Monounsaturated fatty acids (MUFA) 3. Polyunsaturated fatty acids (PUFA) Lipids C/= FA C8:0 C10:0 C12:0 C14:0 C16:0 C18:0 C18:1 C18:2 C18;3 Caprylic acid Capric acid Lauric acid Myristic acid Palmitic acid Stearic acid Oleic acid Linoleic acid Alpha-Lionlenic acid ω-3 Intralipid Data expressed in weight percent 0.1 11.0 4.3 22.5 53.8 6.9 LCT/MCT 29.6 19.1 0.3 0.1 6.5 2.0 1.3 35.0 5.8 ClinOleic 0.1 13.5 2.9 59.5 18.5 2.0 Lipids 1st 2nd Soy bean + safflower oil, very rich in ω 6 PUFA(LCT) e.g. Intralipid® • 50% Soy bean+50% Coconut(MCT)oil e.g. Lipofundin MCT/LCT® • 80% Olive oil +20% Soy bean oil e.g. ClinOleic® Mixture soy bean LCT+MCT+Olive oil+Fish oil e.g. SMOFlipid® 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(ω-6), linolenic acid(ω-3) PUFA (LCT) เด็ก start 0.5 g/kg/day hypertriglyceridemia max. 3-3.5 g/kg/day, 50% of total energy Lipids เด็กทีม่ ปี ั ญหารุนแรงของระบบหายใจ/sepsis lipid intolerance ระบบทาลายเชือ้ ของร่างกายลดลง add heparin 0.5-1.0 unit/ml of TPN เพือ่ ช่วยกระตุน้ endothelial lipoprotein lipase ป้ องกันการอุดตันในสาย catheter The first days ;infused as slowly as possible < 0.1 g/kg/h with LCT < 0.15 g/kg/h with LCT+MCT Provide 30-40% of total energy in adults max. = 60% ketosis Lipids Recommendations for Fat emulsion 1. Prevent EFA deficiency - 10% fat emulsion 500 ml x 3 times/wk - 20% fat emulsion 500 ml weekly 2. Acceptable Triglyceride - serum TG < 250 mg/dl 4hr after lipid infusion - serum TG < 400 mg/dl for continues infusion 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 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 Amino acids 1. 2. 3. 4. 5. 6. 7. 8. Essential Isoleucine Leucine Lysine Methionine Phenylalanine Threonine Trytophan Valine • Conditionally essential 1. Arginine 2. Cysteine 3. Glutamine 4. Histidine 5. Taurine 6. Tyrosine • Non- essential 1. Alanine 6. Ornithine 2. Asparagine 7. Proline 3. Aspartic acid 8. Serine 4. Glutamic acid 5. Glycine Amino acids Specialized amino acid solutions 1. Branch chain amino acids; Isoleucine, Leucine, Valine Increased metabolic stress Hepatic failure with encephalopathy 2. Higher concentrations of essential amino acids; Renal failure not receiving dialysis Benefit have not been proven in controlled trials Amino acids 3. Conditionally essential amino acids in infants Histidine for neonates and infants up to 6 mon. CHO+AA+Lipid Suggested pediatric parenteral substrate provision Nutrition Initiation CHO AA Lipid Advancement CHO AA Lipid Usual upper limit CHO -Peripheral -Central AA Amount 10% D (6-8 mg/kg/min) 50-100% of goal 0.5-1.0 g/kg/d 5% D/day (2-4 mg/kg/min) 100% of goal 0.5-1.0 g/kg/d 8-18 mg/kg/min 12.5% D 25-35% D 3.0g/kg/d Non-protein calories : Nitrogen (NPC:N) NPC:N = calories from glucose+calories from fat emulsion x 6.25 amino acid (g) Status NPC:N Adult Pediatric Minor catabolic Moderate stress Severe catabolic state Renal failure 50-250:1 150-200:1 125-180:1 150:1 80-100:1 250-400:1 Electrolytes Trace elements Vitamins Micro nutrients Sodium Chloride, Acetate Magnesium Potassium Electrolytes Calcium Phosphate Electrolytes Suggested electrolytes in adults (per L) Na 60-150 mEq K 40-120 mEq Cl 60-120 mEq PO4 10-30 mM Conditions that require alteration of amount provided -Renal function, Fluid status, GI loss, Traumatic brain injury -Renal function, GI loss, Metabolic acidosis, Refeeding -Renal function, GI loss, Acidbase status -Renal function, Refeeding, Bone disease, Hypercalcemia, Rapid healing,Hepatic function Electrolytes Suggested electrolytes in adults (per L) Acetate 10-40 mEq Ca 4.5-9.2 mEq Mg 8.1-24.3 mEq Conditions that require alteration of amount provided -Renal function, GI loss, Acidbase status, Hepatic function -Hyperparathyroidism, Malignancy, Bone disease, Immobilization, Acute pancreatitis -Renal function, Refeeding, Hypokalemia Electrolytes in Pediatrics Electrolytes Na (mEq/kg/d) K (mEq/kg/d) Cl Ca P (mEq/kg/d) (mg/kg/d) (mg/kg/d) Mg (mg/kg/d) Preterm Term > 1 year 3 2 5 80-100 43-62 3-6 3 2 5 60-90 48-68 6-10.5 3 2 5 24-60 18-45 2.4-6.0 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 longterm PN administration Requirement of Trace element in PN Trace elements Trace elements Requirement/day (adult) Zn (mg) Cr (μg) Cu (mg) Mn (μg) Fe (mg) I (μg/kg) Mo (μg) Se (μg) 2.5-4.0 10-15 0.3-0.5 60-100 1.0-2.0 1.0-2.0 20-130 20-40 Trace Elements Trace Elements Zn Cu Cr Mn Mo Comments -Increase dose with catabolic state, intestinal loss 12.2 mg/L small bowel fluid loss 17.1 mg/kg stool/ileostomy -Reduce or hold dose with biliary disease -Increase to 20 μg with intestinal losses, reduce in renal disease -Reduce dose with biliary disease -Reduce dose with biliary disease 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 μg of vitamin K) Vitamins in PN Vitamin Amount Thiamine B1 Riboflavin B2 Pyridoxine B6 Cyanocobalamin B12 Niacin Folic acid Pantothenic acid Biotin Ascorbic acid Vit. A Vit. D Vit. E Vit. K 6 mg (3) 3.6 mg 6 mg (4) 5 μg 40 mg 600 μg (400) 15 mg 60 μg 200 mg (100) 3300 IU 5 μg 10 IU 150 μg 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 > 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) 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 Monitoring Efficacy of therapy Complication detection and prevention Clinical condition evaluation Clinical outcome determination Growth Metabolic Clinical observations Monitoring Growth Weight Height/Length Head circumference Metabolic E’lytes, BUN, Cr, Ca, PO4, Mg, acid-base Albumin, pre-albumin CBC, glucose, triglycerides, LFTs, PT/PTT Urine markers; specific gravity, glucose, ketones, UUN Monitoring Clinical observations Vital signs Intake and output Catheter site/dressing Administration system Growth and development 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 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 Follow up : parenteral feeding Parameter Initial Follow up Electrolytes BUN/Cr Ca, P, Mg Acid-base Albumin/pre-albumin Glucose Triglyceride LFTs CBC Platelets,PT/PTT Daily to weekly Weekly Twice weekly Until stable Weekly Daily to weekly Daily Weekly Weekly Weekly Weekly to Monthly Weekly to Weekly to Weekly to Weekly to Weekly to Weekly to monthly monthly monthly monthly monthly monthly monthly Weekly to monthly As indicated Monitoring for Adult Patients on PN Baseline Critically ill pateints Stable patients Chemistry screen (Ca, P, Mg, LFTs) Yes 2-3x/week Weekly Electrolytes, BUN, Cr Yes Daily 1-2x/week Serum triglyceride Yes Weekly Weekly CBC with differential Yes Weekly Weekly PT,PTT Yes Weekly Weekly Parameter Capillary glucose 3x/day 3x/day (until consistently <200 mg/dl) 3x/day (until consistently <200 mg/dl) If possible Daily 2-3x/weekly Daily Daily Daily unless fluid status is assessed by physical exam Nitrogen balance As needed As needed As needed Indirect calorimetry As needed As needed As needed Weight Intake& output Patient education 1. อธิบายให้ผรู้ บั บริการเข้าใจถึงความจาเป็ น และวิธปี ฏิบตั ใิ นการแทงเข็ม สอดสายเข้าหลอดเลือดดาส่วนกลาง เพือ่ ผูร้ บั บริการให้การยอมรับและ ร่วมมือ 2. อธิบายความจาเป็ นในการให้สารอาหารทางหลอดเลือดดา 3. ประโยชน์ของการให้สารอาหาร 4. ความจาเป็ นในการตรวจวัดสัญญาณชีพ การตรวจประเมินเป็ นระยะๆ รวมทัง้ การตรวจเลือด 5. ความเสีย่ ง/ภาวะแทรกซ้อน PN Complications Metabolic Infectious Mechanical 1. 2. 3. Metabolic complications Substrate intolerance Fluids & Electrolytes imbalance Acid-Base abnormalities Substrate intolerance Hyperglycemia Traditional > 220 mg/dl Cardiac surgery pts., BS > 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 Substrate intolerance Hyperosmolar hyperglycemic nonketotic dehydration ได้รับ glucose osmotic diuresis (from glucosuria), dehydrate/fluid deficit, coma TX - Isotonic/hypotonic saline Substrate intolerance Excess CO2 production CHO Pt. respiratory distress คัง่ CO2 Tx -Dextrose ≤ 5 mg/kg/min Substrate intolerance Refeeding syndrome Refers to the metabolic and physiological shifts of fluid, E’lytes 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 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 E’lytes 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 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 Substrate intolerance Preventation; start low and go slow Gradual provision of calories over 3 to 5 days Thaimine replacement E’lytes replacement: K, Mg, P 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 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 Substrate intolerance TX -Initiation of a 10% dextrose infusion -Administer 50% dextrose -Stopping any source of insulin administration Substrate intolerance Hypertriglyceridemia Serum triglyceride > 220 mg/dL Risk;neonate , very low birth wt, sepsis Tx - Heparin 0.5-1 unit/1ml of PN solution กระตุน้ enzyme phospholipase Substrate intolerance Hypercholesterolemia Phospholipid/triglycerides ratio 10% fat emulsion = 0.12 20% fat emulsion = 0.06 Pts ;very low birth wt Substrate intolerance Essential fatty acid deficiency (EFAD) Biochemical evidence of EFAD Triene:tetraene ratio > 0.4 Linoleic acid (EFA) M arachidonic acid (tetraene) Oleic acid M eicosatrienoic acid(triene) Risk; immature ถ้าไม่ได้รบั fat 1-2wks Scaly dermatitis, alopecia, anemia, fatty liver, hepatomegaly, thrombocytopenia 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 Substrate intolerance Azotemia Excessive protein intake Increased BUN Pts. With hepatic or renal disease are prone to developing azotemia Osmotic diuresis, dehydration, coma Substrate intolerance Hyperammonemia Hepatic immaturity in low birth weight infants Pts . Renal failure ได้รับเฉพาะ EAA ขาด arginine Tx- ลด protein in PN 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 Substrate intolerance Steatosis-Hepatic Fat Dose related Dextrose infusion rates > max. oxidation rate = steatosis, excessive glycogen deposition in liver Elevated liver function tests Can progress to severe dysfunction 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 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 long–term PN Cholestasis is a serious complication - it may progress to cirrhosis and liver failure Substrate intolerance Cholestasis Elevation of; - Alkaline phosphatase (ALP) - Gamma-glutamyl transpeptidase(GGT) - Conjugated (direct) bilirubin conc.>2 mg/dL - With or without jaundice 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 > PN infusion The lack of oral intake results in decreased cholecystokinin (CCK) release - impaired bile flow and gallbladder contractility 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 Fluids & Electrolytes imbalance Fluid overload พบ fluid overload > fluid deficit Pts. e.g. Critically ill Intake/output Weight gain Osmolarity, Na, Hematocrit effect dilution Fluids & Electrolytes imbalance Fluid deficit or Dehydration พบร่ วมกับ Hyperosmolar hyperglycemic nonketotic dehydration Fluids & Electrolytes imbalance Hyponatremia/ Hypernatremia Hypokalemia/ Hyperkalemia Hypophosphatemia/ Hyperphosphatemia Hypocalcemia/ Hypercalcemia Hypomagnesemia/ Hypermagnesemia Acid-Base abnormalities Metabolic acidosis Hyperchloremic metabolic acidosis Metabolic acidosis anion gap Metabolic alkalosis Others Vitamins Trace elements Metabolic bone disease Routine Monitoring Parameters Base line; E’lytes, Glucose, Ca, Mg, P, Albumin, TG, LFTs, PT, CBC, BUN, Cr Daily; E’lytes, Glucose q6h 2-3 times/week; Ca, Mg ,P Weekly; Prealbumin, LFTs, PT, CBC Infectious complications Sepsis is a serious complication in PN Cause; Catheters ; PVC > Silicone rubber, multilumen compounding PN-Rx Pts. care-Nurse Staphylococcus epidermis, Staphylococcus aureus, Candida albicans, Bacteria gram negative 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. inbetween 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 Infectious complications Diagnostic criteria; Fever >38.5 c or rise in temp. of >1 c White blood count สูง พบเชือ้ ในเลือดและ catheter tip Infectious complications 1.ซักประวัตแิ ละตรวจร่างกายเพือ่ หาตาแหน่งและ source 2.การอักเสบของแผล ถ้ามีหนองให้ทา gram stain, C/S 3.CBC, UA, Hemoculture, PN solution culture 4.เปลี่ยนขวดสารละลาย และ IV line 5.Fat emulsion-off 6.Tx-IV antibiotics Infectious complications Indication to remove the catheters 1. Pts.-Septic shock 2. Persistent pyrexia with positive blood cultures after 48 hrs. of appropriate antibiotics 3. fungemia Mechanical/technical complications e.g. catheter occlusion, pneumothorax, subcutaneous emphysema, thrombosis, arterial injury, air embolism, catheter tear or break TPN in special population 1. 2. 3. 4. 5. 6. Critical illness Renal failure Hepatic disease Pancreatitis Pulmonary disease Heart failure 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 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
