PPN involves infusion of nutrients into small, peripheral veins, usually in the arm. CPN usually involves infusion into the superior vena cava. Yorel Gorbunov-Posadov Professional. How expensive is TPN? The cost of providing TPN for an average of Carleen Quintus Professional. What is Clinimix used for? Indications and Usage for Clinimix E. Gustavo Straeten Professional. Why would someone need TPN? TPN is ordered for patients who, for whatever reason, cannot obtain adequate nutrition through their digestive tract.
Some patients have absorption issues as well, perhaps due to short bowel syndrome. In short, when the digestive tract is not functional, TPN is necessary for patients to maintain adequate nutrition. Guiying Bejines Explainer. How do you calculate PPN? To calculate solution osmolarity:. Fikret Marialva Explainer. Why can TPN be given peripherally? Historically, total parenteral nutrition TPN has been administered by the central venous route because of the rapid development of thrombophlebitis when TPN solutions are administered into peripheral veins.
By avoiding central venous catheterization, TPN can be made safer. Tariel Galdran Explainer. What are the side effects of TPN? What are the side effects of parenteral nutrition? Jewell Knopfli Pundit. Why does TPN need a filter?
Agency policy may allow amino acids and lipid emulsions to be infused together above the filters. Giada Tiefenbrunner Pundit. What is in a TPN bag? NPO for more than five days; GI fisula; nutrient needs can't be met enterally; inflammatory bowel disease; short bowel syndrome; enteropathy related AIDS; hyperemesis gravidarum; pancreatitis.
PPN involves infusion of nutrients into small, peripheral veins, usually in the arm. CPN usually involves infusion into the superior vena cava. Because the small veins cannot tolerate high osmolarity, high dextrose concentrations cannot be infused into the peripheral veins inflammation and thrombosis could result. A higher osmolarity can be tolerated with CPN because the superior vena cava has a large diameter and the blood quickly dilutes the TPN solution.
VH has high nutritional needs because she is malnourished and has severe stress factors surgery as well as chemotherapy and radiation therapy. She will need to be on TPN for an extended period of time. PPN could not adequately meet her needs and is only appropriate for use of ten days or less. CPN can easily meet allof her needs and can be used for an extended period. There are a variety of ways to calculate kcalorie requirements.
Which of the abnormal lab values could be indicative of malnutrition? Hemoglobin, hematocrit and albumin levels are low, indicating compromised iron and visceral protein status. Before any iron is given, serum transferrin levels should be checked.
Typically, patients receiving PN are given 1 to 2 g of protein per kg of body weight per day. In general, the more highly stressed a patient is, the more protein he or she requires to maintain nitrogen equilibrium i. In patients weighing less than ideal body weight, actual body weight should be used to calculate caloric and protein requirements. In obese patients, adjusted body weight is commonly used to determine protein requirements. A nitrogen balance study can estimate whether SNS is meeting a patient's protein requirements.
A hour urine collection is performed and urinary urea nitrogen UUN or total urea nitrogen TUN is measured by the laboratory. The number 4 in this formula is an estimate of fecal and cutaneous loss of nitrogen 2 g , plus non-urea urinary nitrogen 2 g. To calculate nitrogen intake, the number of grams of protein supplied to the patient is divided by 6. The goal is to have a positive balance; that is, it is preferable that a patient receive more nitrogen than is excreted, which implies a net gain of lean body mass.
However, this is unrealistic for many severely ill patients during the height of disease. In such cases, the goal is to minimize the loss of lean body mass i. However, protein in lower amounts is not optimal because acute renal insufficiency is most frequently seen concomitantly with catabolic illnesses. Such patients require dialysis in order to be adequately fed from both a fluid and protein standpoint.
Dialysis therapy also removes excess nitrogenous waste from protein metabolism. Complications of PN can be divided into three main categories--mechanical, metabolic, and infectious.
Mechanical complications include pneumothorax with catheter placement, thrombosis, and phlebitis. A chest x-ray should always be performed after catheter insertion to ensure that the catheter tip is correctly located before PN administration. Thrombosis can occur at the catheter tip and generally begins with formation of a fibrin sheath on the outside of the catheter. Clearing of a catheter occlusion due to a fibrin sheath or thrombosis can be accomplished by infusion of a thrombolytic agent, such as tissue plasminogen activator, through the catheter.
Phlebitis with PPN can be minimized through frequent rotation of catheter sites and careful choice of catheter size and type. The addition of heparin and hydrocortisone to PPN solutions has not been effectively shown to reduce phlebitis. Significant preexisting abnormalities are preferably corrected prior to PN initiation. Hypokalemia, hypomagnesemia, and hypophosphatemia are common complications of PN.
Adding more of these electrolytes to the PN or as separate infusions should correct these abnormalities. Hyperkalemia, hypermagnesemia, and hyperphosphatemia are most commonly seen with renal insufficiency; restriction should help correct these abnormalities.
Alteration of the acetate-to-chloride ratio may be helpful in correcting metabolic acidosis or metabolic alkalosis that may or may not be related to PN. Specific guidelines for the correction of electrolyte abnormalities in critically ill patients have been published. Some home care companies may monitor serum concentrations of certain micronutrients on a regular basis, perhaps once or twice a year. For example, patients with draining fistulas may be monitored closely for development of zinc deficiency.
Concern about accumulation of copper and manganese in patients with significant hepatic disease is prudent; in such cases, these trace elements may be omitted, and chromium, zinc, and selenium may be added as separate entities. Generally, monitoring for vitamin and trace element abnormalities becomes more critical as a patient remains on PN for a longer amount of time. Overhydration and dehydration are concerns in patients receiving PN.
The pharmacist is frequently called upon to concentrate or dilute PN to better match fluid requirements. The importance of tight glycemic control, especially in critically ill patients, has recently been emphasized.
Many patients will require insulin to keep blood glucose within acceptable limits. Insulin should be added to PN in the pharmacy preparation area; it should not be added after the PN is hung, due to sterility concerns. One recommendation is to start with 0. Since metabolism of carbohydrate results in production of more carbon dioxide than metabolism of lipid, it was sometimes recommended to give relatively more lipid and less dextrose in mechanically ventilated patients.
Liver function test abnormalities have been frequently reported in patients receiving PN. These abnormalities are generally divided into two categories in adult patients--hepatic steatosis and cholestasis. Hepatic steatosis due to PN is not as common as in the past, due to conservative amounts of nutrients now prescribed. However, elevations in ALT and AST--especially in the first seven to 10 days of PN--should cause the clinician to reassess the formulation to ensure the patient is not being overfed.
Most patients on long-term PN develop some cholestasis. In the absence of enteral intake, the gallbladder is not stimulated to empty. Bile becomes thick and sludgy and can eventually cause biliary obstruction. Elevations in total bilirubin and alkaline phosphatase occurring a few weeks or more after initiation of PN may indicate cholestasis.
The best prevention and treatment is the use of enteral feedings even small amounts , if possible. Metabolic bone disease is a complication unique to home PN.
Many patients receiving long-term PN will develop osteoporosis or osteomalacia. The definitive cause is unknown, although several preventative strategies such as careful attention to the amounts of calcium, magnesium, phosphorus, and vitamin D provided in the PN have been suggested.
CRS can also be a complication of patients receiving PN through a temporary access device. With temporary devices, the catheter is typically replaced if infection is suspected. With permanent devices, attempts to salvage the catheter are often made because of difficulty in removing and replacing the device.
The catheter is removed and replaced only if infection fails to clear after an adequate trial of antibiotics. Most clinicians would remove the catheter if fungal CRS is confirmed, as this is exceedingly difficult to clear with the catheter in place. Monitoring should be individualized, and baseline values should be obtained for most of these parameters prior to PN initiation.
In critically ill patients, monitoring is generally performed more frequently than in stable patients. Laboratory monitoring may be done quite infrequently in stable patients on home PN.
Drug Compatibility with PN. Several drugs have been proven stable when admixed with PN solutions and are commonly added. The most common are histamine-2 antagonists and regular insulin. In addition, pharmacists are often queried regarding Y-site compatibility of various drugs with PN solutions. The reader is referred to a standard reference text for information regarding compatibility of drugs with PN solutions. PN, a potentially lifesaving therapy, is sometimes combined with intake via the oral or tube route.
Some physicians still use PN in situations where no SNS is required, such as in previously adequately nourished patients who are expected to resume oral intake within a week. Other physicians underuse EN and instead prescribe PN in patients with a functional gut.
In patients requiring PN, the pharmacist will be called upon for expertise, especially when stability and compatibility issues arise. While the amount of dextrose and lipid supplied in PN has decreased over the years, the value of supplying substantial protein is still recognized.
Since parenteral micronutrient requirements are sometimes difficult to determine, PN requires careful monitoring.
The emerging importance of tight glycemic control in hospitalized patients is another challenge for clinicians managing PN. Dudrick SJ. A year obsession and passionate pursuit of optimal nutrition support: puppies, pediatrics, surgery, geriatrics, home TPN, A. J Parenter Enteral Nutr. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.
Grant JP. Parenteral access. Clinical Nutrition: Parenteral Nutrition. Philadelphia: WB Saunders Company; Orr ME. The peripherally inserted central catheter: what are the current indications for its use? Nutr Clin Pract. Peripheral parenteral nutrition. Lipid emulsions in parenteral nutrition.
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