Parenteral NS
• Fluid and electrolyte requirements.
• Calculate enteral and parenteral
formulations.
PNS Routes
• Peripheral access
• Short-term central access
• Long-term central access
Peripheral Access
• Veins in limbs
• Cannot exceed 800-900 mOsm/kg
• PICC - enter at peripheral but end of
tube at subclavian vein
Central Access
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•
•
•
•
Figure 20-3 here
Cephalic vein
Subclavian vein
Internal jugular vein
Superior vena cava
Fig. 20-3. Central access
Central Access
• Short-term
– percutaneous technique
• Long-term
– implanted vascular devices
PNS
• Time frame for use of PNS
– 5 days or less is short-term
• Total nutrients needed
• Capacity of pt to handle fluid
PNS
• Condition of peripheral veins
• If can take adequate oral intake in 5
day - DO NOT do central line
PNS Components
• Protein
– crystalline amino acids
– 3% to 15% solutions
– 10% = 100g protein/L
– 4 kcal/g protein
– NPC non-protein calories
PNS Components
• Carbohydrate
– dextrose monohydrate
– 5% to 70% solutions
– D50W = 50% solution
– 10% solution = 100g/L
– 3.4 kcal/g dextrose
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
PNS Components
• Lipid
– 10% kcal/day every day will provide 4%
of kcal need to prevent EFA deficiency
– if have long chain fatty acids
PNS Components
• Electrolytes, vitamins, minerals
PNS
• PPN
– less than 8.5% AA
– 5-10% dextrose
– lipid not more than 1g/kg/day
PNS
• PPN
– Rule of thumb for PPN
– D5W or D10W with 8.5% AA
– D20W with 5% AA and lipid at 125 ml/hr
PNS
• Compounding methods
– mix the dextrose and AA
– ‘piggy’ back the lipid and filter before
mix with dextrose and AA
PNS
• Initiating TPN
– start less than 50 ml/hr and 1 L/day
– advance 12 - 24 hr intervals
PNS
• Monitoring
– amount receiving
– Na
–K
– BUN
– prealbumin
PNS
• Monitoring
– cholesterol
– TG
–I&O
– body wt
– blood glucose
McClaren 165. Essential fatty acid deficiency.
McClaren 166. Same pt. 165 after EFA supplementation.
Complications TPN
• Catheter in wrong place
• Sepsis
• Deficiencies
– EFA def
– trace minerals - added routinely
Complications TPN
• Metabolic complications
– overloading
– imbalances
Complications TPN
• Overloading
– solute or fluid - meas. Serum osmolality
– CHO, fat, amino acids
Complications TPN
• Imbalances
– glucose intolerance
– hypokalemia
– reactive hypoglycemia
– hypophosphatemia
– hypo or hypermagnesemia
Refeeding Syndrome
• Too aggressive administration after
‘starving’
• Hypokalemia
• Hypophosphotemia
Transition Feeding
• Parenteral to enteral
– start enteral slow
– keep TPN going & decrease as increase
enteral
– receive 75% from enteral before stop
TPN
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
Transition Feeding
• Enteral to oral
– ??
– mOsm/kg for different clear liquids be
careful not too high
TPN END
• Questions?
• Now for calculations