งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

การดูแลผู้ป่วยที่ ได้รับสารอาหาร ทางหลอดเลือดดำ แบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ. พระมงกุฎเกล้า กทม.

งานนำเสนอที่คล้ายกัน


งานนำเสนอเรื่อง: "การดูแลผู้ป่วยที่ ได้รับสารอาหาร ทางหลอดเลือดดำ แบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ. พระมงกุฎเกล้า กทม."— ใบสำเนางานนำเสนอ:

1 การดูแลผู้ป่วยที่ ได้รับสารอาหาร ทางหลอดเลือดดำ แบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ. พระมงกุฎเกล้า กทม.

2 Contents Adults TPN 1 Pediatric and neonatal TPN 2 Complications of TPN 3 TPN in special population 4

3 การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอด เลือดดำแบบสมบูรณ์  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

4 การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอด เลือดดำแบบสมบูรณ์  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

5 การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอด เลือดดำแบบสมบูรณ์  3.Complications of TPN - Metabolic - Infectious - Mechanical/technical  4.TPN in special population

6 When normal diets fail to meet the daily requirements. Definition of nutritional support When assessment documents deficiencies or Nutrition planning becomes a part of medical therapeutics

7  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) Nutrition screening tools

8 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

9 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

10 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

11 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 re- screened 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

12 Nutrition Risk Screening (NRS 2002)  Step 2 :Final screening Impaired nutrition status Severity of disease (=increase in requirements) Absent Score=0 Normal nutritional statusAbsent Score=0 Normal nutritional requirement 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 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

13 Severe Score 3 Wt loss > 5% in 1 mon. (> 15% in 3 mon.) or BMI < Impaired general condition or Food intake 0-25% of normal requirement in preceding week Severe Score 3 Head injury, Bone marrow transplantation, Intensive care patients (APACHE > 10) Score: + Score: =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

14 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 /m 2 * SGA grade C or NRS ≥ 3 * Serum albumin < 3 g/dl (with no evidence of hepatic or renal dysfunction)

15 Classification of Protein Energy Malnutrition Severity Course Main deficit Mild Acute 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

16 Protein deficiency  Serum albumin < 3.5 g/dl  Absolute lymphocyte < 1,500 cell/mm 3  Serum transferrin < 150 mg/dl  Loss of reactivity to common skin test antigens

17 ProteinHalf-lifeNormal value Albumin Transferrin Pre-albumin 21 days 7 days 2 days g/dl mg/dl mg/dl Lab. test for visceral protein

18 Severity Albumin (g/dl) Transferrin (mg/dl) Pre-albumin (mg/dl) Mild Moderate Severe < < < 5

19 Serum albumin (g/dl) Total lymphocytes (cell/mm 3 ) Status of visceral protein < 2.5 1,500-1, ,500 < 900 Mildly depleted Moderately Severely

20  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

21 Indication for TPN therapy Length of expected NPO status < 3 d > 3 d Premorbid BMI > 18.5 and < 10% Wt. loss Premorbid BMI < 18.5 and > 10% Wt. loss Perform complete Nutrition assessment - EN/PN Dextrose containing IV NPO > 3 d or change in clinical status

22 Disease diagnosis GI tract function Yes No Enteral feeding NPO < 7 dNPO > 7 d PPN TPN

23 Indication of PN  Adults 1. pt. มีปัญหาการทำงานและการดูดซึมสารอาหารของ GI tract * Massive small bowel resection * GI fistula (high output; >500 ml) * Inflammatory bowel diseases * Bowel obstruction * Persistent GI bleeding, GI ischemia * Hyperemesis gravidarum * Diarrhea อย่างรุนแรงและคาดว่าไม่สามารถรับอาหาร ทาง EN หรืออาการไม่ดีขึ้นภายใน 5- 7 วัน 2. pt.CA ที่มีภาวะ malnutrition อย่างรุนแรง และ GI ผิดปกติ จนไม่สามารถกินทาง Oral/ รับทาง EN ได้ เกินกว่า 1 wk

24 Indication of PN  Adults ( ต่อ ) 3. Severe acute pancreatitis ไม่สามารถรับทาง EN ได้ เกินกว่า 1 wk e.g. ใน pt. ปวดท้องอย่างรุนแรง, มี ascites,fistula output 4. Critical illness คาดว่า GI ทำงานไม่ได้ 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

25 Indication of PN  Adults ( ต่อ ) 7. Anorexia nervosa ไม่สามารถทนรับทาง EN ได้ ด้วยเหตุผลทางกายภาพ / ทางอารมณ์

26 Indication of PN  Pediatric and neonatal 1. pt. มีปัญหาการทำงานและการดูดซึมสารอาหารของ GI tract * Massive small bowel resection * GI fistula e.g. esophageal, tracheosophageal * Inflammatory bowel diseases e.g. necrotizing enterocolitis(NEC), ulcerative colitis * มีความผิดปกติของผนังหน้าท้องตั้งแต่แรกคลอด และรับทาง EN ไม่ได้เช่น omphalocele, gastroschisis * อาเจียนรุนแรง และคาดว่าไม่สามารถรับทาง EN ได้มากกว่า 3 วัน

27 *Diarrhea อย่างรุนแรง เช่นทารกอายุ 2 wk เมื่อเพาะเชื้อจากอุจจาระก็ไม่พบเชื้อก่อโรค และรับ อาหารทาง EN แล้วอาการไม่ดีขึ้น * Bowel obstruction e.g. intestinal atresia, imperforated anus, Hirschsprung’s disease 2.Very low birth weight <1,000 g ที่คาดว่า NPO / รับทาง EN ไม่ได้ e.g. respiratory distress syndrome (RDS) 3.pt. CA ( เช่นเดียวกับผู้ใหญ่ ) 4.Severe acute pancreatitis ( เช่นเดียวกับผู้ใหญ่ ) 5.Critical illness ( เช่นเดียวกับผู้ใหญ่ )  Pediatric and neonatal ( ต่อ ) Indication of PN

28  Pediatric and neonatal ( ต่อ ) 6.Catabolic state ระดับปานกลาง - รุนแรง ( เช่นเดียวกับผู้ใหญ่ ) 7.Preoperative in severe malnourished without functional GI tract ( เช่นเดียวกับผู้ใหญ่ ) 8.Anorexia nervosa ( เช่นเดียวกับผู้ใหญ่ ) 9.Inborn error metabolism Indication of PN

29 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

30 Parenteral Nutrition planning Complication Energy requirement Macronutrients Monitoring Micronutrients

31 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 use adjust BW *Marasmic/underweight actual BW

32 2.Activity Factor (AF) - with respirator = bed rest = ambulatory = Stress Factor (SF)= Metabolic Factor e.g. Fever /1 c Mild infection Moderate infection Minor operation 1.2 Moderate operation Skeletal trauma 1.35 Major sepsis Peritonitis Cancer Soft tissue trauma Weight gain 1.1 Burns ; 10-30% BSA 1.5 ; 30-50% BSA 1.75 ; > 50% BSA 2.0 Energy requirement in adults

33  BEE x 1.4 ( will cover the majority of pt.)  kcal/kg/day  Indirect calorimetry -Resting energy expenditure (REE) REE = [3.9(VO 2 )+1.1(VCO 2 )] x 1.44 VO 2 =O 2 consumption VCO 2 = CO 2 production

34 Energy requirement in Pediatric and neonatal  TEE=BMR (in 24 hr) x AF x SF 1.Basal metabolic rate (BMR) kcal/hr - ดูจากตาราง /BEE/REE 2.Activity Factor (AF) - นอนอยู่แต่บนเตียง = จำกัดการทำกิจกรรม = มีกิจกรรมปานกลาง = มีกิจกรรมมาก = Stress Factor (SF) ( เช่นเดียวกับผู้ใหญ่ )

35  Holliday-Segar 10 kg แรก = 100 kcal/kg/day 10 kg ต่อมา = 50 kcal/kg/day น้ำหนักที่เหลือ = 20 kcal/kg/day (water 1 ml/calorie 1 kcal) * ในกรณีที่เป็นผู้ป่วยหนัก อาจไม่สามารถให้ พลังงานได้ครบตามที่กำหนด ในกรณีนี้ในช่วงแรกควรได้รับพลังงานอย่างน้อย 60% ของพลังงานที่ คำนวณได้เพื่อรักษาน้ำหนักตัวให้คงที่

36  Age (y) kcal/kg >

37 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

38 Carbohydrate (CHO) Lipid Protein Macronutrients

39 Estimation of calories from PN Nutrient Kcal/g  CHO Dextrose.H 2 O 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

40 Carbohydrate  Primary source of energy for normal healthy person  Principle energy substrate for brain, which utilizes 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)

41 Carbohydrate  Dextrose = Glucose *adult ; oxidize glucose = 4-7 mg/kg/min * load > 7 mg/kg/min; - glycogen, lipid syn.,metabolic complications (hyperglycemia, excess CO 2, lipogenesis, LFT สูง fatty liver) * แนะนำ ≤ 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 mg/kg/min *infant & child max mg/kg/min

42 Carbohydrate * ในเด็กค่อยๆ ให้ทีละน้อย hyperglycemia, hyperosmolarity * เริ่ม 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

43 Carbohydrate Age (year) Energy (kcal/kg/d) Glucose (mg/kg/min) Preterm Term

44 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

45 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

46 Lipids  Lipids Classification-number and position of double bonds 1.Saturated fatty acids 2.Monounsaturated fatty acids (MUFA) 3.Polyunsaturated fatty acids (PUFA)

47 Lipids C/= FAIntralipidLCT/MCTClinOleic C8:0 C10:0 C12:0 C14:0 C16:0 C18:0 C18:1 C18:2 C18;3 ω-3 Caprylic acid Capric acid Lauric acid Myristic acid Palmitic acid Stearic acid Oleic acid Linoleic acid Alpha-Lionlenic acid Data expressed in weight percent

48 Lipids 1 st Soy bean + safflower oil, very rich in ω - 6 PUFA(LCT) e.g. Intralipid ® Mixture soy bean LCT+MCT+Olive oil+Fish oil e.g. SMOFlipid ® 2 nd 50% Soy bean+50% Coconut(MCT)oil e.g. Lipofundin MCT/LCT ® 80% Olive oil +20% Soy bean oil e.g. ClinOleic ® 3 rd

49 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 g/kg/day, 50% of total energy

50 Lipids  เด็กที่มีปัญหารุนแรงของระบบหายใจ /sepsis lipid intolerance ระบบทำลายเชื้อของร่างกายลดลง  add heparin unit/ml of TPN เพื่อ ช่วยกระตุ้น endothelial lipoprotein lipase ป้องกันการอุดตันในสาย 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

51 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

52 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

53 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  g/kg/day  Tritration - clinical symptoms and signs - Biochemistry

54 Amino acids  Essential 1.Isoleucine 2.Leucine 3.Lysine 4.Methionine 5.Phenylalanine 6.Threonine 7.Trytophan 8.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

55 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

56 Amino acids 3. Conditionally essential amino acids in infants  Histidine for neonates and infants up to 6 mon.

57 CHO+AA+Lipid  Suggested pediatric parenteral substrate provision NutritionAmount Initiation Advancement Usual upper limit CHO AA Lipid CHO AA Lipid CHO -Peripheral -Central AA 10% D (6-8 mg/kg/min) % of goal g/kg/d 5% D/day (2-4 mg/kg/min) 100% of goal g/kg/d 8-18 mg/kg/min 12.5% D 25-35% D 3.0g/kg/d

58 Non-protein calories : Nitrogen (NPC:N)  NPC:N = calories from glucose+calories from fat emulsion x 6.25 amino acid (g) StatusNPC:N Adult Pediatric Minor catabolic Moderate stress Severe catabolic state Renal failure : : :1 150: : :1

59 Electrolytes Trace elements Vitamins Micronutrients

60 PotassiumSodium Calcium Phosphate Chloride, Acetate Magnesium Electrolytes

61 Suggested electrolytes in adults (per L) Conditions that require alteration of amount provided Na mEq K mEq Cl mEq PO mM -Renal function, Fluid status, GI loss, Traumatic brain injury -Renal function, GI loss, Metabolic acidosis, Refeeding -Renal function, GI loss, Acid- base status -Renal function, Refeeding, Bone disease, Hypercalcemia, Rapid healing,Hepatic function

62 Electrolytes Suggested electrolytes in adults (per L) Conditions that require alteration of amount provided Acetate mEq Ca mEq Mg mEq -Renal function, GI loss, Acid- base status, Hepatic function -Hyperparathyroidism, Malignancy, Bone disease, Immobilization, Acute pancreatitis -Renal function, Refeeding, Hypokalemia

63 Electrolytes in Pediatrics ElectrolytesPretermTerm> 1 year Na (mEq/kg/d) K (mEq/kg/d) Cl (mEq/kg/d) Ca (mg/kg/d) P (mg/kg/d) Mg (mg/kg/d)

64 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 long- term PN administration

65 Requirement of Trace element in PN Trace elements Requirement/day (adult) Zn (mg) Cr (μg) Cu (mg) Mn (μg) Fe (mg) I (μg/kg) Mo (μg) Se (μg)

66 Trace Elements Comments Zn Cu Cr Mn Mo -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

67 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)

68 Vitamins in PN VitaminAmount 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

69 Fluid requirement  Adults * ml/kg * 1 ml/1 kcal * 100 ml/kg for first 10 kg of wt. plus 50 ml/kg of wt. from 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/m 2 of BSA * 1 ml/1 kcal  Fluid need should be calculated with fluid loss (diarrhea, fistula)

70 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

71 Monitoring  Efficacy of therapy  Complication detection and prevention  Clinical condition evaluation  Clinical outcome determination  Growth  Metabolic  Clinical observations

72 Monitoring  Growth  Weight  Height/Length  Head circumference  Metabolic  E’lytes, BUN, Cr, Ca, PO 4, Mg, acid-base  Albumin, pre-albumin  CBC, glucose, triglycerides, LFTs, PT/PTT  Urine markers; specific gravity, glucose, ketones, UUN

73 Monitoring  Clinical observations  Vital signs  Intake and output  Catheter site/dressing  Administration system  Growth and development

74 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,HCO 3 ) should be monitored frequently upon initiation of SNS until measurements are stable

75 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

76 Follow up : parenteral feeding ParameterInitialFollow 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 to monthly Monthly Weekly to monthly As indicated

77 Monitoring for Adult Patients on PN ParameterBaselineCritically ill pateintsStable patients Chemistry screen (Ca, P, Mg, LFTs) Yes2-3x/weekWeekly Electrolytes, BUN, CrYesDaily1-2x/week Serum triglycerideYesWeekly CBC with differentialYesWeekly PT,PTTYesWeekly Capillary glucose3x/day (until consistently <200 mg/dl) 3x/day (until consistently <200 mg/dl) WeightIf possibleDaily2-3x/weekly Intake& outputDaily Daily unless fluid status is assessed by physical exam Nitrogen balanceAs needed Indirect calorimetryAs needed

78 Patient education 1. อธิบายให้ผู้รับบริการเข้าใจถึงความจำเป็น และวิธี ปฏิบัติในการแทงเข็มสอดสายเข้าหลอดเลือดดำ ส่วนกลาง เพื่อผู้รับบริการให้การยอมรับและ ร่วมมือ 2. อธิบายความจำเป็นในการให้สารอาหารทางหลอด เลือดดำ 3. ประโยชน์ของการให้สารอาหาร 4. ความจำเป็นในการตรวจวัดสัญญาณชีพ การตรวจ ประเมินเป็นระยะๆ รวมทั้งการตรวจเลือด 5. ความเสี่ยง / ภาวะแทรกซ้อน

79 PN Complications MetabolicInfectiousMechanical

80 Metabolic complications  S ubstrate intolerance  F luids & E lectrolytes imbalance  A cid- B ase abnormalities

81 Substrate intolerance  Hyperglycemia  Traditional > 220 mg/dl  Cardiac surgery pts., BS > 150 mg/dl  Surgical critical care pts., maintaining BS mg/dl  Pt. sepsis, trauma, burn, CA, Cr deficiency  Tx - add Insulin ;aware in neonate hypoglycemia  Blood and urine glucose monitored closely

82 Substrate intolerance  Hyperosmolar hyperglycemic nonketotic dehydration  ได้รับ glucose osmotic diuresis (from glucosuria), dehydrate/fluid deficit, coma  TX - Isotonic/hypotonic saline

83 Substrate intolerance  Excess CO2 production  CHO  Pt. respiratory distress คั่ง CO2  Tx -Dextrose ≤ 5 mg/kg/min

84 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

85 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

86 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

87 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

88 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

89 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

90 Substrate intolerance  TX -Initiation of a 10% dextrose infusion -Administer 50% dextrose -Stopping any source of insulin administration

91 Substrate intolerance  Hypertriglyceridemia  Serum triglyceride > 220 mg/dL  Risk;neonate, very low birth wt, sepsis  Tx - Heparin unit/1ml of PN solution กระตุ้น enzyme phospholipase

92 Substrate intolerance  Hypercholesterolemia  Phospholipid/triglycerides ratio  10% fat emulsion = 0.12  20% fat emulsion = 0.06  Pts ;very low birth wt

93 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 ถ้าไม่ได้รับ fat 1-2wks  Scaly dermatitis, alopecia, anemia, fatty liver, hepatomegaly, thrombocytopenia

94 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 ml of 10% fat emulsion ml of 20% fat emulsion  Alternately; 500 ml of a 20% fat emulsion once a week

95 Substrate intolerance  Azotemia  Excessive protein intake  Increased BUN  Pts. With hepatic or renal disease are prone to developing azotemia  Osmotic diuresis, dehydration, coma

96 Substrate intolerance  Hyperammonemia  Hepatic immaturity in low birth weight infants  Pts. Renal failure ได้รับเฉพาะ EAA ขาด arginine  Tx- ลด protein in PN

97 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

98 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

99 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

100 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

101 Substrate intolerance  Cholestasis  Elevation of; - Alkaline phosphatase (ALP) - Gamma-glutamyl transpeptidase(GGT) - Conjugated (direct) bilirubin conc.>2 mg/dL - With or without jaundice

102 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

103 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

104 Fluids & Electrolytes imbalance  Fluid overload  พบ fluid overload > fluid deficit  Pts. e.g. Critically ill  Intake/output  Weight gain  Osmolarity, Na, Hematocrit dilution effect

105 Fluids & Electrolytes imbalance  Fluid deficit or Dehydration  พบร่วมกับ Hyperosmolar hyperglycemic nonketotic dehydration

106 Fluids & Electrolytes imbalance  Hyponatremia/ Hypernatremia  Hypokalemia/ Hyperkalemia  Hypophosphatemia/ Hyperphosphatemia  Hypocalcemia/ Hypercalcemia  Hypomagnesemia/ Hypermagnesemia

107 Acid-Base abnormalities  Metabolic acidosis  Hyperchloremic metabolic acidosis  Metabolic acidosis anion gap  Metabolic alkalosis

108 Others  Vitamins  Trace elements  Metabolic bone disease

109 R outine M onitoring P arameters  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

110 Infectious complications  S epsis 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

111 Infectious complications  Prevention;  Aseptic techniques; QC in PN, catheters access, dressing  Amino acid/glucose infusion giving sets and extensions can be left hrs. in- between 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

112 Infectious complications  Diagnostic criteria;  Fever >38.5 c or rise in temp. of >1 c  White blood count สูง  พบเชื้อในเลือดและ catheter tip

113 Infectious complications  1. ซักประวัติและตรวจร่างกายเพื่อหาตำแหน่งและ source  2. การอักเสบของแผล ถ้ามีหนองให้ทำ gram stain, C/S  3. CBC, UA, Hemoculture, PN solution culture  4. เปลี่ยนขวดสารละลาย และ IV line  5.F at emulsion-off  6.Tx-IV antibiotics

114 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

115 Mechanical/technical complications  e.g. catheter occlusion, pneumothorax, subcutaneous emphysema, thrombosis, arterial injury, air embolism, catheter tear or break

116 TPN in special population 1.Critical illness 2.Renal failure 3.Hepatic disease 4.Pancreatitis 5.Pulmonary disease 6.Heart failure

117 PHARMACY PRACTICE Experience in the U.S.  Clinical Pharmacist C hart review D rug information M edication group P harmacy to dose orders D rug utilization review F ormulary review P atient care conference

118  Clinical Pharmacist (cont.) C E and presentation R esponse to code blue D rug monitor P receptor and teaching A DR A ctivity report PHARMACY PRACTICE Experience in the U.S.

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ดาวน์โหลด ppt การดูแลผู้ป่วยที่ ได้รับสารอาหาร ทางหลอดเลือดดำ แบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ. พระมงกุฎเกล้า กทม.

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