Aryanti R.

Bamahry
Departement of Nutrition
Medical Faculty of Indonesia Moslem University
2014
Parenteral
Nutrition
Resuscitation
Fluid
Therapy
Repair/
correction
Enteral Nutrition
Nutrition
Therapy
Maintenance
3
GOAL OF NUTRITION THERAPY
(medical nutrition therapy)
Minimized loss of protein and energy for patient with in
adequate intake
Through enteral and parenteral nutrition


NUTRITION
NUTRITION
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SUCCESS
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Dikutip dari Presentasi Prof. DR. Dr. Eddy Rahardjo, SpAn KIC.
What influence does the disease exert on nutritional state and
energy and substrate metabolism?
What influence does nutritional state exert on the outcome of
the underlying disease?
What are the goals of PN?
When is PN indicated?
Is PN better than EN?
Does PN have specific contraindications or complications?
?
ICU Nutrition in the 1970s
Organisation of Nutrition Support

3. NICE Guidelines for Nutrition Support in Adults 2006
Screen
Recognise
Treat
Oral Enteral
Monitor &
Review
Parenteral
NICE Guidelines for Nutrition Support in Adults 2006
Treat: Enteral
use the most appropriate route of access and mode of delivery
has a functional and accessible gastrointestinal tract
if patient malnourished/at risk of malnutrition
despite the use of oral interventions and
3. NICE Guidelines for Nutrition Support in Adults 2006
NICE Guidelines for Nutrition Support in Adults 2006
If the gut works, use it.
Treat: PN
and has either
introduce progressively and
monitor closely
if patient malnourished/at risk of malnutrition
a non-functional,
inaccessible or perforated
gastrointestinal tract
inadequate or unsafe oral
or enteral nutritional intake
use the most appropriate route of access and mode of delivery
3. NICE Guidelines for Nutrition Support in Adults 2006
NICE Guidelines for Nutrition Support in Adults 2006
Definition
Parenteral Nutrition
Partial or total parenteral nutrition
A peripheral or central vein is used for access
Nutrients are provided intravenously
Pertkiewics M, Dudrick SJ, Basic in Clinical Nutrition. ESPEN. 2011
- Total Parenteral Nutrition (TPN)
- Supplemental PN
- PN for palliative care

Indications:
Total Parenteral Nutrition
Non-functional gastrointestinal tract
(e.g., perforation, obstruction, ileus or inadequate
absorptive or propulsive capacity)
The gut is not accessible (e.g., for anatomical reasons)
Tube feeding is not safe
(e.g. ischaemic bowel disease) or unlikely to be
effective (e.g. intractable vomiting)
ESPEN LLL Programme 2012
Supplemental PN in Critical ill patients
Results from EPANIC study (2011)
which compare early PN (within 48 h after
admission) to late PN after 7 days admission
found better outcome in late PN
Early PN vs Late PN
ESPEN LLL Programme 2012
Patient who cant eat enough
To prevent
MALNUTRITION
+PN
ESPEN LLL Programme 2012
Containdications:
Parenteral Nutrition
Ability to adequately receive and absorb
necessary foods orally or by gastric or
enteral tube.
Hemodynamic instability
Contraindications
Severe liver insufficiency
Severe renal insufficiency without
access to hemodialysis
Severe hyperlipemia
Severe blood coagulation disorder
Acute shock
Inborn error of amino acid metabolism
Contraindications
Acute pulmonary oedema
Decompensated cardiac insufficiency
Acute myocardial infarct
Metabolic acidosis
Severe sepsis
Initiation of PN

Adults should be hemodynamically stable, able to
tolerate the fluid volume necessary to provide
significant macronutrient intake, and have central
venous access
If central access is not available, PPN should be
considered (more commonly used in neonatal and
peds population)
Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs or switch to
dextrose IV)


ASPEN Parenteral Nutrition Handbook, 2009

18
Initiation of PN

Generally energy and protein needs can be
met in adults by day 2 or 3
In neonates and peds, time to reach full
support relates inversely to age, may be 3-5
days


ASPEN Parenteral Nutrition Handbook, 2009

19
A Hickman line. It is
tunnelled under the
skin to the jugular
vein.


Implanted port


CVC with three
lumen
Formula of PN
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CRITICAL CARE ACUTE CARE
Energy
Obese(BMI 30)
Non Obese (BMI 15-29)
Undernourished (BMI <15)

15-20 kcal/kg/day
20-35 kcal/kg/day
35-40 kcal/kg/day

15-20 kcal/kg/day
20-35 kcal/kg/day
35-40 kcal/kg/day
Protein 1,2-2,0 g/kg/day 0,8-1,0 g/kg/day
Carbohydrate(dextrose) < 4 g/kg/day < 7 g/kg/day
Lipid < 1 g/kg/day < 1-2 g/kg/day
Fluid Minimum needed to
deliver prescribed formula
30-35 mL/kg/day+losses
If refeeding risk starts at 15 kcal/kg
If patient catabolic increases to 1,2 to 2,0 g/kg/day
ENERGY AND SUBSTRATE GUIDELINES FOR ADULTS
PATIENTS ON PARENTERAL NUTRITION
Alpers, et al. Parenteral Nutritional Therapy. In : Manual of Nutritional Therapeutics.
5
th
ed. Lippincott. Williams&Wilkins. 2008.
Central Parenteral Nutrition
Selection depends on caloric requirements, volume
to be administered and patient condition, as well as
final concentration of components:
Amino acids > 5%
Dextrose > 20%
Lipids
Includes vitamins, minerals, and trace elements
Osmolality > 700 mOsm/kg H
2
O
Formulas :
Parenteral Nutrition
Dextrose
Provides 3.4 kcal/g
Can be the only source of energy
Dextrose infusion rate should not exceed 5 mg/kg/min
Closely related to solution osmolality
Formulas :
Parenteral Nutrition
Amino Acids
Standard concentrations can vary between 5%
and 15%
Energy value of amino acids (4 kcal/g)
Nitrogen (g) = protein (g) / 6.25
Formulas :
Parenteral Nutrition
Lipids
Prevent essential fatty acids deficiency
Non-protein source of kcal. Recommended dose 1 g/kg/day
Available 10%, 20%, and 30% concentrations
Included as LCT or a mix of MCT/LCT at 10% and 20%
Added to basic parenteral nutrition solutions or administered
individually
Trimbo SL. et al. Nutr Supp Serv 1986;6:18
Formulas :
Parenteral Nutrition
Lipids
Less hyperglicemia
Lower concentrations of serum insulin
Less risk of hepatic damage
High dose can interfere with immune functions
High infusion rates can affect respiratory functions
Should be used with care in:
- Hyperlipidemia
- Symptomatic atherosclerosis
- Acute pancreatitis with hypertrigliceridemia
Formulas :
Parenteral Nutrition
Electrolytes
Calcium, magnesium, phosphorus, chloride,
potassium, sodium, and acetate
Forms and amounts are titrated based on metabolic
status and fluid/electrolyte balance
Must consider calcium-phosphate solubility
Alpers DH. et al., eds. In: Manual of Nutritional Therapeutics. Little, Brown and
Company; 1995
Formulas :
Parenteral Nutrition
Vitamins and Minerals
In general, amounts below daily recommended intake for
healthy people, but nonetheless sufficient to cover
requirements, are added to oral or enteral formulas
Added daily to parenteral nutrition.
Acute illness, infection, preexisting malnutrition,
and excessive fluid loss increase vitamin
requirements.

Formulas :
Parenteral Nutrition
Trace elements
Include daily zinc, copper, chromium, and manganase for
patients with kidney or liver failure.
Different requirements dictated by patient and pathology
Patients under extended parenteral nutrition require the
addition of iron and selenium.

Peripheral Parenteral Nutrition
Selection of peripheral access depends on clinical
situation, requirements, tolerance to volume, and final
formula concentration.
Osmolality < 700 mOsm/kg
Total kcal limited by concentration and ratio to volume
being administered
Include of the recommended electrolytes for PN
Torosian MH, ed. In: Nutrition for the Hospitalized Patient. Marcel Dekker Inc.;1995
Monitoring Patient on Parenteral
Nutrition
Metabolic
Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholesterol
Assessment
Body weight
Nitrogen balance
Plasma protein
Creatinine/height index
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University
Press. 1992
COMPLICATIONS
35
Complications
Parenteral Nutrition
Metabolic
Hyperglycemia (max rate dextrose infusion no greater
than 4-5 mg/kg/minute), hypercapnia
Hypoglycemia
Complication from lipid used (hypertriglyceridemia,
immunosuppression, lipid overload syndrome)
Electrolyte imbalance
Prerenal azotemia
Abnormal acid-base balance
Refeeding syndrome measure P, Mg, K, and glucose
Dempsey DT. Complications of total parenteral nutrition. In: Torosian MR, ed. Nutrition
for the Hospitalized Patient. NY: Marcel Dekker, Inc.; 1995; Solomon SM. JPEN
1990;14:90-97
37
MACRONUTRIENT
RELATED COMP.
MICRONUTRIENT &
FLUID RELATED
COMP.
HEPATOBILIARY
COMP.
METABOLIC BONE
DISEASE
VASCULAR ACCESS SEPSIS
AZOTEMIA &
HYPERAMMONEMIA
COMP. ASSOCIATED
WITH IVFE
HYPOGLYCEMIA
HYPERGLYCEMIA
REFEEDING SYNDR.
ELECTROLYTE
IMBALANCE
VITAMINS &
MINERALS DEF.
ACIDS BASE
DISORDER
CHOLESTASIS (PNAC) STEATOSIS
GALLBLADDER SLUDGE/STONES
OSTEOPOROSIS
OSTEOMALACIA
ASPEN Parenteral Nutrition Handbook, 2009

Summary
Parenteral nutrition supplies partial or total
nutrition by venous access.
Total parenteral nutrition components supply all
required nutrients.
Metabolic monitoring and changes in solution
components are needed to maintain adequate
metabolic balance.

START SLOW GO SLOW, OBSERVE CAREFULLY,
TREAT IMMEDIATELY.
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SUCCESS
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