การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอดเลือดดำแบบสมบูรณ์ (TPN Patient Care Workshop) 1-3 กรกฎาคม 2552 รพ.พระมงกุฎเกล้า กทม.

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

การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอดเลือดดำแบบสมบูรณ์ 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

การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอดเลือดดำแบบสมบูรณ์ 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

การดูแลผู้ป่วยที่ได้รับสารอาหารทางหลอดเลือดดำแบบสมบูรณ์ 3.Complications of TPN - Metabolic - Infectious - Mechanical/technical 4.TPN in special population

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

Nutrition Risk Screening (NRS 2002) Step 2 :Final screening Impaired nutrition status Severity of disease (=increase in requirements) Absent Score=0 Normal nutritional status Normal nutritional requirement Mild Score=1 Wt. loss > 5% in 3 mon. or Food intake below 50-75% of normal requirement in preceding week 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 Major abdominal surgery, stroke, severe pneumonia,Hematologic malignancy

Severe Score 3 Wt loss > 5% in 1 mon. (> 15% in 3 mon.) or BMI < 18.5 + Impaired general condition or Food intake 0-25% of normal requirement in preceding week 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

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 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

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 Half-life Normal value Albumin Transferrin Pre-albumin 21 days 7 days 2 days 3.5-5.5 g/dl 270-400 mg/dl 18-40 mg/dl

Severity Pre-albumin (mg/dl) Albumin (g/dl) Transferrin (mg/dl) Mild Moderate Severe 3.0-3.5 2.1-3.0 < 2.1 150-200 100-150 < 100 11-18 5-10.9 < 5

Serum albumin (g/dl) Total lymphocytes (cell/mm3) Status of visceral protein 3.0-3.5 2.5-3.0 < 2.5 1,500-1,800 900-1,500 < 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 < 3 d > 3 d Perform complete Nutrition assessment - EN/PN Premorbid BMI > 18.5 and < 10% Wt. loss Premorbid BMI < 18.5 and > 10% Wt. loss Dextrose containing IV NPO > 3 d or change in clinical status

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

1. pt.มีปัญหาการทำงานและการดูดซึมสารอาหารของ GI tract 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 * Diarrheaอย่างรุนแรงและคาดว่าไม่สามารถรับอาหารทาง EN หรืออาการไม่ดีขึ้นภายใน 5- 7 วัน 2. pt.CA ที่มีภาวะmalnutritionอย่างรุนแรง และGIผิดปกติ จนไม่สามารถกินทางOral/รับทางENได้ เกินกว่า 1 wk

หายใจล้มเหลว + malnutrition when GI tract is not 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 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

Indication of PN Adults (ต่อ) 7. Anorexia nervosa ไม่สามารถทนรับทาง ENได้ด้วยเหตุผลทางกายภาพ/ทางอารมณ์

Pediatric and neonatal * Massive small bowel resection 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 * มีความผิดปกติของผนังหน้าท้องตั้งแต่แรกคลอดและรับทางENไม่ได้เช่น omphalocele, gastroschisis * อาเจียนรุนแรง และคาดว่าไม่สามารถรับทางENได้มากกว่า 3 วัน

Pediatric and neonatal (ต่อ) Indication of PN Pediatric and neonatal (ต่อ) *Diarrhea อย่างรุนแรง เช่นทารกอายุ < 3 เดือน ท้องเสีย > 2 wk เมื่อเพาะเชื้อจากอุจจาระก็ไม่พบเชื้อก่อโรค และรับอาหารทางENแล้วอาการไม่ดีขึ้น * 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 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

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 Complication Energy requirement Macronutrients Monitoring Micronutrients

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

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 e.g. Fever 1+0.13/1 c Mild infection 1.0-1.2 Moderate infection 1.2-1.4 Minor operation 1.2 Moderate operation 1.2-1.4 Skeletal trauma 1.35 Major sepsis 1.4-1.6 Peritonitis 1.05-1.25 Cancer 1.0-1.25 Soft tissue trauma 1.0-1.3 Weight gain 1.1 Burns ; 10-30% BSA 1.5 ; 30-50% BSA 1.75 ; > 50% BSA 2.0

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) kcal/hr -ดูจากตาราง /BEE/REE 2.Activity Factor (AF) - นอนอยู่แต่บนเตียง = 1.1 - จำกัดการทำกิจกรรม = 1.3 - มีกิจกรรมปานกลาง = 1.5 - มีกิจกรรมมาก = 1.75 3.Stress Factor (SF) (เช่นเดียวกับผู้ใหญ่)

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 อาจไม่สามารถให้พลังงานได้ครบตามที่กำหนด ในกรณีนี้ในช่วงแรกควรได้รับพลังงานอย่างน้อย 60% ของพลังงานที่ คำนวณได้เพื่อรักษาน้ำหนักตัวให้คงที่

Age (y) kcal/kg 0-1 90-120 1-7 75-90 7-12 60-75 12-18 30-60 > 18 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) Macro nutrients Lipid Protein

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)

*adult ; oxidize glucose = 4-7 mg/kg/min 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) * 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. 12-15 mg/kg/min *infant & child max. 15-20 mg/kg/min

*ในเด็กค่อยๆ ให้ทีละน้อย hyperglycemia, hyperosmolarity 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

Carbohydrate Age (year) Energy (kcal/kg/d) Glucose (mg/kg/min) Preterm 1-3 4-6 7-10 11-18 80-120 90-120 75-90 65-75 55-75 40-55 10-18 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 Short chain FA (C1-5);not used in PN Medium chain FA (C6-11);water soluble, good energy source Long chain FA (C12-22);energy, membrane structure, most of the biologic activity

Lipids Lipids Classification-number and position of double bonds Saturated fatty acids Monounsaturated fatty acids (MUFA) Polyunsaturated fatty acids (PUFA)

Lipids FA Intralipid LCT/MCT ClinOleic C/= C8:0 C10:0 C12:0 C14:0 Caprylic acid Capric acid Lauric acid Myristic acid Palmitic acid Stearic acid Oleic acid Linoleic acid Alpha-Lionlenic acid - 0.1 11.0 4.3 22.5 53.8 6.9 29.6 19.1 0.3 6.5 2.0 1.3 35.0 5.8 13.5 2.9 59.5 18.5 Data expressed in weight percent

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

เด็ก start 0.5 g/kg/day hypertriglyceridemia 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

เด็กที่มีปัญหารุนแรงของระบบหายใจ/sepsis ระบบทำลายเชื้อของร่างกายลดลง Lipids เด็กที่มีปัญหารุนแรงของระบบหายใจ/sepsis lipid intolerance ระบบทำลายเชื้อของร่างกายลดลง add heparin 0.5-1.0 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

Lipids Recommendations for Fat emulsion Prevent EFA deficiency - 10% fat emulsion 500 ml x 3 times/wk - 20% fat emulsion 500 ml weekly 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 Essential Isoleucine Leucine Lysine Methionine Phenylalanine Threonine Trytophan Valine Conditionally essential Arginine Cysteine Glutamine Histidine Taurine Tyrosine Non- essential Alanine 6. Ornithine Asparagine 7. Proline Aspartic acid 8. Serine Glutamic acid Glycine

Specialized amino acid solutions Branch chain amino acids; Isoleucine, Leucine, Valine Increased metabolic stress Hepatic failure with encephalopathy 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 Amount Initiation Advancement Usual upper limit CHO AA Lipid -Peripheral -Central 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 8-18 mg/kg/min 12.5% D 25-35% D 3.0g/kg/d

Non-protein calories : Nitrogen (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 Micro nutrients Trace elements Vitamins

Potassium Sodium Calcium Phosphate Chloride, Acetate Magnesium Electrolytes

Electrolytes Suggested electrolytes in adults (per L) Conditions that require alteration of amount provided Na 60-150 mEq K 40-120 mEq Cl 60-120 mEq PO4 10-30 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

Electrolytes Suggested electrolytes in adults (per L) Conditions that require alteration of amount provided Acetate 10-40 mEq Ca 4.5-9.2 mEq Mg 8.1-24.3 mEq -Renal function, GI loss, Acid- base status, Hepatic function -Hyperparathyroidism, Malignancy, Bone disease, Immobilization, Acute pancreatitis -Renal function, Refeeding, Hypokalemia

Electrolytes in Pediatrics Preterm Term > 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) 3 2 5 80-100 43-62 3-6 60-90 48-68 6-10.5 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 long-term PN administration

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) 2.5-4.0 10-15 0.3-0.5 60-100 1.0-2.0 20-130 20-40

Trace Elements 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

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 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

Clinical observations 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 Daily Weekly to monthly Monthly As indicated

Monitoring for Adult Patients on PN Parameter Baseline Critically ill pateints Stable patients Chemistry screen (Ca, P, Mg, LFTs) Yes 2-3x/week Weekly Electrolytes, BUN, Cr Daily 1-2x/week Serum triglyceride CBC with differential PT,PTT Capillary glucose 3x/day (until consistently <200 mg/dl) (until consistently <200 mg/dl) Weight If possible 2-3x/weekly Intake& output Daily unless fluid status is assessed by physical exam Nitrogen balance As needed Indirect calorimetry

Patient education อธิบายให้ผู้รับบริการเข้าใจถึงความจำเป็น และวิธีปฏิบัติในการแทงเข็มสอดสายเข้าหลอดเลือดดำส่วนกลาง เพื่อผู้รับบริการให้การยอมรับและร่วมมือ อธิบายความจำเป็นในการให้สารอาหารทางหลอดเลือดดำ ประโยชน์ของการให้สารอาหาร ความจำเป็นในการตรวจวัดสัญญาณชีพ การตรวจประเมินเป็นระยะๆ รวมทั้งการตรวจเลือด ความเสี่ยง/ภาวะแทรกซ้อน

PN Complications 1. 2. 3. Metabolic Infectious Mechanical

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 คั่ง 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 กระตุ้น 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 ถ้าไม่ได้รับ 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 dilution effect

Fluids & Electrolytes imbalance Fluid deficit or Dehydration พบร่วมกับ 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. 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

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

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.Fat emulsion-off 6.Tx-IV antibiotics

Infectious complications Indication to remove the catheters Pts.-Septic shock Persistent pyrexia with positive blood cultures after 48 hrs. of appropriate antibiotics fungemia

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

TPN in special population 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

Preceptor and teaching 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

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