Total parenteral nutrition

Dr.K.Priyatham

• It goes without saying that without food there can be no life, that food is a basic human right & that it is necessary for every doctor to pay attention to the nutritional needs of their patients.

• Nevertheless , approximately 1/3 rd of the patients admitted to an acute hospital will have evidence of PEM & 2/3 rd will leave the hospital either malnourished or having lost weight.

• Malnutrition has damaging effects on psychological status, activity levels & appearance.

• Paradoxically, in the surgical patient a low body fat content may sometimes viewed as an advantage making technical aspects of surgery easier.

• There is, however clear evidence that patients with severe protein depletion have a significantly greater incidence of postoperative complications & prolonged hospital stay.

• Nutritional disorders in surgical practice have two principal components.

• First – starvation can be initiated by the effects of the disease, by restriction of oral intake, or both.

Simple starvation leads to progressive loss of body’s energy & protein reserves.• Second – there are the metabolic effects of

stress/ inflammation

namely – increased catabolism & reduced anabolism.

• In most surgical patients it results from a combination of reduced food intake & metabolic changes

Nutrient requirements per day

Calories – 25 kcal/kg• Proteins – 0.8-2kgs/day (mild/mod/sev stress

– 1,1.5,2g/kg/day)• Carbohydrates –minimum – 75/100 g/day• Fats – minimum requirement is 500 ml of 20%

lipid emulsion/week to prevent EFA deficiency.

• Water – 30/40 ml/kg/day + extra for any fluid loss + 500 ml/day/degree Celsius rise in temperature.

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

• Electrolytes – Sodium – 60-80 mEq/dayPotassium – 30-60mEq/dayChlorine – 80-100 mEq/dayCalcium – 15-20 mEq/dayMagnesium – 15-25 mEq/dayPhosphate – 12-24 mEq/day• Vitamins & micronutrients (trace elements)

Methods of providing nutritional support

• Enteral nutrition• Parenteral nutrition.

Enteral nutrition

vs

Parenteral nutrition

Enteral Nutrition • The enteral route is generally favored over the

parenteral one because it is the natural portal of entry for exogenous nutrients.

• The enteral route obviates the need for intravascular access with its attendant risk of infections and sepsis.

• The array of nutrients that can be administered via the gastrointestinal tract is greater than what is available for parenteral use, allowing for better tailoring of nutrient intake.

More Advantages—Enteral Nutrition

• Intake easily/accurately monitored• Costs less than parenteral nutrition• Supplies readily available• Reduces risks associated with

disease state• Preserves gut integrity• Decreases likelihood of bacterial translocation• Preserves immunologic function of gut• Increased compliance with intake

Disadvantages—Enteral Nutrition

• GI, metabolic, and mechanical complications—tube migration; contamination; tube obstruction;

• Labor-intensive assessment, administration, tube patency and site care, monitoring

Parenteral nutrition

• Parenteral nutrition is the provision of all nutritional requirements by means of the intravenous route and without the use of gastrointestinal tract.

• Parenteral nutrition is used when the enteral route is unable to provide or sustain sufficient caloric intake.

• About 5% of hospital admissions require TPN

Indications

• INDICATIONS– Patient who can’t eat– Patient who won’t eat– Patient who shouldn’t eat– Patient who can’t eat enough

“If the gut works, use it.”

Indications

• Those who do not eat: anorexia nervosa, • Those who can not eat: esophageal

stenosis, prolonged ileus, • Those who are not allowed to eat:

gastrointestinal fistula, inflammatory bowel disease, radiation enteritis, GI chemo toxicity, pancreatitis, tracheoesophageal fistula, massive intestinal atresia.

Indications

• Those who are not eating enough: short bowel syndrome, burns, sepsis

• Those who cant manage what they eat: hepatic failure

• Others: renal failure, major surgeries.

General Conditions Suggesting Initiation of Nutrition Support

▪ Poor nutritional status (oral intake <50% of energy needs) ▪ Significant weight loss (>10%) ▪ Anticipated duration of artificial nutrition longer than 7 days ▪ More than 7 days' inanition ▪ Serum albumin <3 g/dL in the absence of an inflammatory state

The gut should always be the preferred route for nutrient administration.

If you are going to start TPN, there needs to be a reason why you cant use EN.

Routes for TPN

• Parenteral nutrition is administered through either central or peripheral venous catheters.

• In the early days of parenteral nutrition, the only energy source available was hypertonic glucose which had to be given into a central vein to avoid thrombophlebitis.

• In the second half of the last century, there were a number of important developments which led to usage of isotonic safe, non toxic emulsions for TPN.

Peripheral TPN

• Peripheral veins cannot tolerate an osmolarity of more than 750 mOsm/L (the equivalent of 12.5% dextrose)

• The fluid volume that can be tolerated limits the caloric intake.

• Therefore, this route is used mainly for supplementation or short-term feeding (<2 weeks).

PN: Peripheral Access

• Access can be achieved by means of a:1) Dedicated catheter inserted into a peripheral

vein and maneuvered into central venous system (peripheral inserted central venous catheter PICC line).

2) Conventional short cannula in the wrist veins.

Peripherally inserted central catheters (PICCs)

• Introduced via the basilic vein, • Can be used both in the inpatient setting and also for

longer-term outpatient therapy. • PICC line in the outpatient setting has a lifetime of 4 to 6

weeks – Benefits

• Access to central vein• Can accommodate hypertonic fluids• Lower risk of phlebitis than PPN• Easier to insert than central line

PPN Solution1. Typically delivers 1400-2500 kcals/day2. Carbohydrate: Dextrose (glucose) 3. Protein: AAs4. Lipid: IV lipid emulsion

a. Concentrated source of kcalsb. Isotonicc. Administered every day to protect

vein

Central TPN• Central venous catheters are the main route of TPN

administration. • The catheter should be a single-lumen catheter, used

only for TPN.• Multiple-lumen catheters and multiple-purpose

single-lumen catheters have higher infection rates .

• The preferred entry of location is the subclavian vein, which provides a stable site, good patient acceptability, and lower infection rates than either the internal jugular or femoral routes.

• Most intensive care physicians and anesthetists favor jugular veins as it is technically easier.

Subcutaneously tunneled central catheters (Hickman)

• The catheter of these devices can be inserted into the vein percutaneously (e.g., the subclavian, internal jugular, or femoral) and then tunneled to the final skin exit site

• Subcutaneous tract forms a barrier to bacterial encroachment and colonization

• Tunneled catheters are desirable when frequent access is required

Implanted Venous Access Device (portacath)

• Portacath is completely subcutaneous

• It is accessed by percutaneous insertion of a special low-profile needle (Huber needle)

• Which passes through the self-sealing diaphragm of the device into the chamber.

Parenteral Nutrition planning

Complication

Energy requirement

Macronutrients

Monitoring

Micronutrients

Energy Expenditure and Caloric Requirements

• Basal energy expenditure (BEE)—also called basal metabolic rate (BMR)—the energy expenditure on awakening from a 12-hour fast measured in a thermoneutral environment (25°C).

• Thermogenic effect of food—also called specific dynamic action—the energy expenditure after the ingestion of food. After a meal, energy expenditure may increase 5% to 10%

• Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open. Includes the thermogenic effect of food if performed within a few hours of a meal or during continuous infusions of nutrients such as during continuous TPN administration. About 10% greater than BEE.

• Sleeping energy expenditure (SEE)—the energy expenditure during sleep; it is usually 10% to 15% lower than REE.

• Activity energy expenditure (AEE)—the energy expended during physical activity. During maximum exercise it can be 6- to 10-fold greater than the BEE.

• Environmental temperature—energy expenditure increases to warm patients placed in a cold environment. Warming occurs through shivering and increased metabolism of brown fat (neonates).

• Fever—Fever increases metabolic rate 10% per °C (or 7% per °F).

• Total energy expenditure (TEE)—total energy expended over 24 hours: the sum of energy expended during periods of sleep, resting, and activity.

Energy requirement in adults

• 1.Basal energy expenditure (BEE) • Harris-Benedict equation

• Males: eBEE (kcal/day) = 66 + (13.7 • W) + (5 • H) - (6.8 • A)

• Females: eBEE (kcal/day) = 655 + (9.6 • W) + (1.7 • H) - (4.7 • A)

*W=kg. (actual or usual wt.), H=cm.,A=yr.

• eREE = eBEE • stress factor

• eTEE = eREE • activity factor

• Total energy expenditure (TEE) TEE= BEE x AF x SF kcal/day

• eBEE, estimated basal energy expenditure; W, weight (kg); H, height (cm); A, age (years); eREE, estimated resting energy expenditure; eTEE, estimated total energy expenditure.

2.Activity Factor (AF) - with respiratory supports = 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 1.0-1.2Moderate infection 1.2-1.4 Minor operation 1.2Moderate operation 1.2-1.4Skeletal trauma 1.35Major sepsis 1.4-1.6

Peritonitis 1.05-1.25 Cancer 1.0-1.25 Soft tissue trauma 1.0-1.3Weight gain 1.1Burns ; 10-30% BSA 1.5 ; 30-50% BSA 1.75 ; > 50% BSA 2.0

Energy requirement in adults

Components of TPN

Carbohydrate (CHO)

Lipid

Protein

Macronutrients

Proteins

• Protein (or amino acids, the building blocks of proteins) is the functional and structural component of the body, so fulfilling patient’s caloric needs with non-protein calories (fat and glucose) is essential.

Protein Requirements

• 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

Essential1. Isoleucine 2. Leucine 3. Lysine4. Methionine 5. Phenylalanine6. Threonine7. Trytophan 8. Valine

• Conditionally essential1. Arginine 2. Cysteine 3. Glutamine4. Histidine 5. Taurine6. Tyrosine• Non- essential1. Alanine 6. Ornithine2. Asparagine 7. Proline3. Aspartic acid 8. Serine4. Glutamic acid5. Glycine

Amino acid solutions – • Ex: 10% amino acids solution• Content – 100g/L• Nitrogen content – 15.34g/L• Calorie – 400 kcal/L • Osm – 965 mOsm/L• The concentration of amino acids should be

reduced in patients suffering from hepatic & renal failure.

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• Reduces ketone production• Facilitates storage of TG in fat tissue• Preserve body protein ( gluconeogenesis)•

provides the obligatory needs of the substrate , thus reducing gluconeogenesis and sparing endogenous protein.

1 gm of glucose gives 4 Kcals.• Most stable patients tolerate rates of 4-5 mg.kg-1.Min-

1, but insulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin should be incorporated acc. to blood sugar levels

Route• Glucose in 5% solution can be safely

administered via a peripheral vein, but higher concentrations require a central venous line.

• 20, 25, or even 50 % solutions are needed to administer meaningful amounts of energy to most patients for proper volume administration

Lipids

• Source of energy• Carriers of fat-soluble vitamins• Precursors of eicosanoids, modulate immune

function• Substrate for fat formation in adipose tissue

High energy content ina low volume: 9 kcal/g lipids

Lipids, cont.

e. Helps minimize hyperglycemiaf. Helps prevent respiratory acidosis (in respiratory

failure)g. Need at least 10% of kcals from lipid to prevent EFA,

which are the building blocks for many of the hormones involved in the inflammatory process as well as the hormones regulating other body functions.

h. Excessive lipid administration may suppress immune fx.i. Often hung separatelyj. Admixtures (3:1) becoming more commonk. Potential source of vit. K: potential problem if

anticoagulants used

• Fat mobilization is a major response to stress and infection.

• Triacylglycerol are an important fuel source in those conditions, even when glucose availability is adequate.

• Need to be restricted in patients with hypertriglyceridemia.

• Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted patients.

• Ideally, energy from fat should not exceed 40% of the total (usually 20-30%).

• Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is 10Kcal/g due to the contents of glycerol and phospholipids

Lipids

Lipid emulsions

• Contents - lipid emulsion based on soybean oil/ safflower oil - egg phospholipid = emulsifier - glycerol = isotonic

Solutions• 10% fat emulsion = 1.1 kcal/ml• 20% fat emulsion = 2.0 kcal/ml

• Calories – 1080 kcal/L• Osmolarity – 280 mOsm/L• Start 0.5 g/kg/day max. 3-3.5 g/kg/day, 50% of total energy

• Rate of infusion – 20% solution – 14-16 hours.

Electrolytes

Trace elements

Vitamins

Micronutrients

PotassiumSodium

Calcium

Phosphate

Chloride, Acetate

Magnesium

Electrolytes

Electrolytes

Suggested electrolytes in adults

(per L)

Conditions that require alteration of amount

providedNa 60-150 mEq

K 40-120 mEq

Cl 60-120 mEq

PO4 10-30 mM

-Renal failure, GI loss, Traumatic brain injury-Renal failure, GI loss, Metabolic acidosis, Refeeding-Renal failure, GI loss, Acid- base status-Renal function, Refeeding, Bone disease, Hypercalcemia, Rapid healing,Hepatic failure

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 AmountThiamine B1Riboflavin B2Pyridoxine B6Cyanocobalamin B12NiacinFolic acidPantothenic acidBiotinAscorbic acidVit. AVit. DVit. EVit. K

6 mg (3)3.6 mg6 mg (4)5 μg 40 mg600 μg (400)15 mg60 μg 200 mg (100)3300 IU5 μg10 IU150 μg

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 elementsTrace elements

Requirement/day (adult)

Zn (mg)Cr (μg)Cu (mg)Mn (μg)Fe (mg)I (μg/kg)Mo (μg)Se (μg)

2.5-4.010-15

0.3-0.560-1001.0-2.01.0-2.020-13020-40

Trace Elements

Trace Elements CommentsZn

Cu

Cr

MnMo

-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

TPN Administration

A. Rate1. Start slowly, especially w/dextrose. Allows blood

to adapt to increased glucose/osmolality 2. Infusion pump is used to ensure proper rate.3. Start slowly

(1 L 1st day; 2 L 2nd day)Example: Start at 40ml/hr x 24hr. Then progress to 80ml/hr x 24h (equivalent to increasing TPN by 1 liter per day), etc. until goal rate has been reached or patient intolerance is noted.

a. If rate is increased too quickly, hyperglycemia may result b. Monitor tolerance: electrolytes, blood glucose, triglycerides, ammonia, etc.

4. Introduce lipids gradually to avoid adverse reactions (fever, chills, backache, chest pain, allergic reactions, palpitations, rapid breathing, wheezing, cyanosis, nausea, and unpleasant taste in the mouth)

5. When pt. is taken off TPN, rate must be tapered off gradually to prevent hypoglycemia.

6. PPN doesn’t need to be tapered off (uses more dilute solution w/less dextrose)

B. Cyclic Infusion1. TPN infused at a constant rate for only <24

hours/day (e.g. 12-14hr overnight)2. Allows more freedom/normal daytime activity 3. Can be used to reverse fatty liver resulting from

continuous infusion (Chronically high insulin levels may inhibit fat mobilization

fatty liver)

4. Fewer kcals may be necessary to maintain N balance (body fat better mobilized for energy)

5. Requires higher infusion rate: not all patients can tolerate it.

Why should we do monitoring?

It helps us in -• Detection of Efficacy of therapy• Complication detection and prevention• Clinical condition evaluation• Clinical outcome determination

Indicators of monitoring

• 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 for Adult Patients on PN

Parameter Baseline Critically ill pateints Stable patientsChemistry screen (Ca, P, Mg, LFTs)

Yes 2-3x/week Weekly

Electrolytes, BUN, Cr Yes Daily 1-2x/weekSerum triglyceride Yes Weekly WeeklyCBC with differential Yes Weekly WeeklyPT,PTT Yes Weekly WeeklyCapillary glucose 3x/day 3x/day

(until consistently<200 mg/dl)

3x/day (until consistently <200 mg/dl)

Weight If possible Daily 2-3x/weeklyIntake& output Daily Daily Daily unless fluid status is

assessed by physical exam

Nitrogen balance As needed As needed As neededIndirect calorimetry As needed As needed As needed

• Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)

PN Complications

1. 2. 3.

Metabolic Infectious Mechanical

Metabolic complications

• Substrate intolerance

• Fluids & Electrolytes imbalance

• Acid-Base abnormalities

• Others

Substrate intolerance

1) Hyperglycemia/hypoglycemia2) Refeeding syndrome3) Hyperlipidemia4) E.F.A.D5) Azotemia6) Hyperammonemia7) Hepatobiliary complications

Substrate intolerance

• Hyperglycemia– Traditional > 160 mg/dl– Surgical critical care pts., maintaining BS 80-

110 mg/dl– Cardiac surgery pts., BS > 150 mg/dl– Tx - add Insulin according to sliding scale until

the serum glucose is <140mg/dl – Blood and urine glucose monitored closely

Substrate intolerance

• Hyperosmolar hyperglycemic nonketotic dehydration– glucose osmotic diuresis (from

glucosuria), dehydrate/fluid deficit, coma

– TX - Isotonic/hypotonic saline

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

• TX -Initiation of a 10% dextrose infusion -Administer 50% dextrose -Stopping any source of insulin administration

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

• Refeeding syndrome– Refers to the metabolic and physiological shifts

of fluid, E’lytes and minerals e.g. P, Mg, K– Occurs in malnourished pts. during rapid

nutritional replacement– Risk factor; starvation, alcoholism, anorexia,

morbid obesity with massive wt. loss• Symptoms - Generalized fatique, lethargy

muscle weakness, edema, cardiac arrhythmia, and hemolysis

Substrate intolerance

• Prevention;– start low and go slow– Gradual provision of calories over 3 to 5

days– Thaimine replacement– E’lytes replacement: K, Mg, P

Substrate intolerance• Hyperlipidemia

– Serum triglyceride > 220 mg/dL– Risk;neonate , very low birth wt, sepsis– Tx – Stop or limit the lipid content in TPN

Substrate intolerance

• Essential fatty acid deficiency (EFAD)– Only two fatty acids are known to be essential for humans:

alpha-linolenic acid (an omega-3 fatty acid) and linoleic acid (an omega-6 fatty acid)

– 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 (azot, "nitrogen" + -emia, "blood condition") & Hyperammonemia– Excessive protein intake– Increased BUN– Pts. With hepatic or renal disease are

prone to developing azotemia– Osmotic diuresis, dehydration, coma– Tx- decrease/stop protein in PN

Substrate intolerance

• Hepatobiliary complications– Disorders of the liver and biliary system

are common in pts. receiving, long term PN

– Types of Hepatobiliary disoders - Steatosis - Acalculus cholecystitis *disorders may coexist

Substrate Intolerance

• Steatosis-Hepatic Fat– Steatosis is the condition of hepatic fat

accumulation– Predominant in adults and is generally benign– Most pts. are asymptomic– Steatosis is a complication of overfeeding– Dextrose Dose related– Excessive glycogen deposition in liver which

can progress to severe dysfunction

Acalculous Cholecystitis

• The absence of lipids in the proximal small bowel prevents cholecystokinin-mediated

contraction of the gallbladder.

• Bile stasis

• Acalculous cholecystitis

Fluids & Electrolytes imbalance

• Fluid overload• Fluid deficit or Dehydration• Hyponatremia/ Hypernatremia• Hypokalemia/ Hyperkalemia• Hypophosphatemia/ Hyperphosphatemia• Hypocalcemia/ Hypercalcemia• Hypomagnesemia/ Hypermagnesemia

Acid-Base abnormalities

• Metabolic acidosis• Metabolic alkalosis

Others

• Vitamin deficiencies• Trace elements

Mucosal Atrophy• The absence of bulk nutrients in the

bowel produces atrophy and disruption of the bowel mucosa.

• These changes can predispose to translocation of enteric pathogens across the bowel mucosa and subsequent septicemia.

• Because TPN is usually accompanied by bowel rest, one of the indirect complications of TPN is bacterial translocation and sepsis of bowel origin.

• Glutamine-supplemented TPN may help reduce the risk of this complication.

Metabolic Bone Disease • Patients administered TPN over prolonged periods

have decreased bone mineral density (BMD) • Patients at greatest risk are postmenopausal women,

patients with long-standing malnutrition or malabsorption (e.g., Crohn's disease), those with preexisting liver disease, or patients receiving steroids

• TPN-associated deficiency states, such as calcium, magnesium, copper, boron or silicon, have been suggested to play a role.

• Use of bisphosphonates which prevents osteoclast-mediated bone resorption is being tried

Infectious complications

• Sepsis is a serious complication in PN• Cause;

– Catheter contamination ; PVC > Silicone rubber, exit site infection/cellulitis

– Infections are uncommon during the first 72 hours after insertion but then increase in incidence

– Staphylococcus epidermis, Staphylococcus aureus, Candida albicans, Bacteria gram negative

Infectious complications

• Diagnostic criteria;– Fever >38.5 c or rise in temp. of >1 c – Increased White blood count – catheter site induration, erythema or

purulent discharge– A positive blood culture– Exclusion of other potential sources of

infection.

Infectious complications

• Indication to remove the catheters1. Pts.-Septic shock2. Persistent pyrexia with positive blood

cultures after 48 hrs. of appropriate antibiotics

3. fungemia

Infectious complications

• Prevention;– Aseptic techniques; 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– Nurses should be taught about the signs of

catheter related sepsis

Mechanical/technical complications

• Catheter occlusion, tear or break.• Pneumothorax, hydrothorax,• Subcutaneous emphysema, • Arterial/venous injury, A-V fistula• Air embolism, thromboembolism• Brachial plexus injury

Over feeding

How much feed should we give?

• Overfeeding is– useless - upper limit to amounts of protein and

energy that can be used– dangerous

• hyperglycaemia and increased infection• uraemia• hypercarbia and failure to wean• hyperlipidaemia• hepatic steatosis

HOME PARENTERAL NUTRITION• Patients who are unable to eat and absorb adequate

nutrients for maintenance over the long term may be candidates for home parenteral nutrition e.g. extensive Crohn's disease, mesenteric infarction, or severe abdominal trauma.

• patients must be able to master the techniques associated with this support system, be motivated, and have adequate social support at home.

HOME PARENTERAL NUTRITION• A patient who is judged to be a candidate for home

parenteral nutrition requires an indwelling Silastic catheter designed for long-term permanent use.

• The nutrient solutions are prepared weekly and delivered to the patient's home.

• The patient sets up the infusion system and attaches the catheter to the delivery tubing in the evening for infusion over the next 12-16 h. The intravenous nutrition is terminated by the patient the next morning.