Assessment 2 - Part I

Transitioning TPN

(1) Once gut function returns... -Enteral: Once EN is providing 33-50% or needs, taper PN; After EN providing 75% of needs, discontinue PN -Oral: Diet progression as tolerated (2) PPN does not need to be tapered

upper esophageal, lower esophageal, pyloric, oddi, ileocecal, internal anal, external anal

List the sphincter (name only) in order --- from TOP to BOTTOM (7 total)

•Air embolism •Venous thrombosis •Catheter occlusion •Intra/extravascular malposition •Pneumothorax •Line sepsis •Phlebitis

Mechanical complications of PN

•Overfeeding •Refeeding syndrome •Pre renal azotemia •Hyperglycemia •Hypertriglyceridemia •Electrolyte abnormalities

Metabolic complications of PN

2-in-1

More traditional formulation of dextrose and amino acids in one solution. Lipids are administered in a separate bag.

•Refeeding syndrome •Hyperglycemia •Acid-base disorders •Hypertriglyceridemia •Hepatobiliary complications (fatty liver, cholestasis) •Metabolic bone disease

Other Complications of PN

-Edema -Hypophosphatemia -Hypokalemia -Hypomagnesemia -Cardiac involvement

Refeeding Syndrome - characterized by?

-Anorexia nervosa -Alcoholism -Mental health disorders -Starvation in protest, famine, migration -Cancer -Malabsorptive conditions -Critically ill, unfed -Military recruits, athletes

Refeeding Syndrome - populations at risk?

TPN and PPN

Total parenteral nutrition Peripheral parenteral nutrition

Cyclic infusion PN

Type of PN Administration used for 8-12 hours @ higher rate & should not be used in pts w/ glucose intolerance or fluid intolerance.

Simple CHO, Fats, Amino acids, Vitamins, Minerals, Water

What is absorbed in the Duodenum/Jejunum? Study note: S,F,A,V,M,W

cancer

implanted port - are used for ____ pts; provides constant access to a central line

enterocytes

intestinal cells

liver

makes bile salts, detergent-like substances to help digest FATS

pancreas

makes enzymes to digest energy-yielding nutrients (CHO,FAT,PRO) & bicarbonate to neutralize acid chyme that enters the small intestine; produces insulin & glucagon.

Organs of the gastrointestinal tract

oral cavity, pharynx, esophagus, stomach, small intestine, large intestine

PPN

peripheral vein used; concentration of soln cannot be high; normal PRO with LOW dextrose.

Nutrition Support Team

physician, registered nurse, registered dietitian, pharmacist

epiglottis

protects airway when swallowing

large intestine/colon

reabsorbs WATER & MINERALS; passes waste (fiber + water) to rectum

accessory organs of the digestive system

salivary glands, liver, gallbladder, pancreas

salivary glands

secrete saliva (provides moisture & contains starch digesting enzymes)

small intestine

secretes enzymes that digest energy-yielding nutrients to smaller nutrient particles; cells absorb nutrients into blood & lymph

Monitoring for EN/PN in Acute Care

slide 1

Monitoring for EN/PN in Acute Care

slide 2

gallbladder

stores BILE

rectum

stores waste prior to elimination

exacerbation

to flare up

TPN

uses central line - vena cava, jugular, fed right into the heart -can occupy alot of volume -do not confuse w/ a pick line

kcal, no protein

what do clear liquids provide?

Central access PN

•2 Types: -Short Term Access •One lumen and cannot be used for anything other than feeding -Long Term Access •Can be single or multiple lumen (home therapy) •Should be tunneled •Peripherally Inserted Central Catheter is inserted through a vein in the arm and threaded to the subclavian - non-surgical

Monitoring TPN

•ALWAYS check e-lytes after initiating PN support to pt •Check GI tolerance -N, V, D, distention, pain •Monitor hydration •Check for when pt ready for transition to po or enteral nutrition -Must taper TPN over 1-2 hours

Contraindications PN

•An accessible and functional GI tract •NO venous access available •Expected to last less than 7 days •Prognosis that does not warrant aggressive support or if risks outweigh the benefits (pt is dying)

Lipids in PN

•As an energy source, reduces the need for energy from dextrose •Lowers the risk of hyperglycemia in glucose-intolerant patients •Excessive linoleic content - may aggravate inflammation ie ARDS, sepsis

Types of access PN

•Central: -Subclavian -Internal jugular -Femoral -Cephalic •Peripheral: -any vein

Amino Acids in PN

•Crystalline amino acids •3.5 - 15% •4 kcalories per gram •A 10% amino acid solution = 10 grams amino acids per 100 mL •Disease specific solutions - for patients with liver disease, kidney failure and metabolic stress •Check NPC:N2 ratio

CHO in PN

•Dextrose monohydrate •2.5 - 70% •3.4 kcalories per gram •25% dextrose solution = 25g dextrose per 100 ml solution •Concentrations > 10% - administered through central lines •D20 •Max 5-7 mg/kg/min

intractable vomiting, diarrhea; GI fistula; crohn exacerbation, paralytic ileus

Example of pt who is on TPN?

GLP-1

GI hormone PROLONGS gastric emptying INHIBITS glucagon release STIMULATES insulin release

GLP-2

GI hormone STIMULATES intestinal growth, nutrient digestion & absorption

Somatostatin

GI hormone; decreases motility of stomach & intestine; INHIBITS release of several GI hormones.

secretin

GI hormone; increases output of WATER & BICARBONATE; increases enzyme secretion from PANCREAS & insulin release. study note - pancreas releases insulin & glucagon.

Motilin

GI hormone; promotes gastric emptying & GI motility

GIP (gastric inhibitory peptide)

GI hormone; reduces intestinal motility

gastrin

GI hormone; stimulates secretion of HCl & pepsinogen

CCK (cholecystokinin)

GI hormone; stimulates secretion of pancreatic enzymes; delays gastric emptying-stomach; increase motility-colon

Mechanical Gastrointestinal Metabolic

Complications of PN - list 3.

-Ingestion -Digestion -Utilization

Considerations for Assessment of Digestive System

Types of Administration PN

Continuous infusion Cyclic infusion

4; gallstones

Gallbladder disease •Sludge often builds up in gallbladder if parenteral nutrition > ____weeks •May eventually lead to ____ •May be given cholecystokinin injections or have gallbladder removed surgically

•Bacterial translocation •Gut atrophy •Hepatic (-Fatty liver, -Cholestasis)

Gastrointestinal complications of PN

...

Intro to GI

gastrin, secretin, cck, GIP, Motilin, somatostsatin

List 6 GI hormones.

chyme

Digestion in the stomach Food becomes semiliquid ____.

Hydrochloric acid, pepsin, gastric lipase, mucus, intrinsic factor, gastrin

Digestion in the stomach Gastric secretions contain ___. List 6.

2-3

Digestion in the stomach Solid meal empties in ___ to ___ hrs.

acid

Digestion in the stomach ____ reduces number of microorganisms.

3-in-1

- AKA TNA system, all in one. All components (dextrose, aa's, lipids) admixed in one bag.

Small intestine

-90-97 % of the diet absorbed here -Key role in digestion & absorption (villi, microvilli/brush border) -200-300m long -Duodenum, Jejunum, Ileum

jejunum

-Brush Border enzymes Maltase Isomaltase Lactase Peptidase Sucrase Intestinal lipase

Total Parenteral Nutrition (TPN)

-Entire energy/nutrient needs delivered via "central access" (thru the big veins)

Ileum

-Last portion of small bowel/intestine -Absorbs --> B12, Bile salts, WATER, Salt, Fat-soluble vitamins -Ileocecal valve --> prevents reflux of colonic material back into ileum

peripheral parenteral nutrition (PPN)

-Lower concentration --> nutrients delivered by peripheral vein (baby veins) -Hyperosmolar solution --> NOT tolerated for long period of time -Should require at least 5 but not more than 14 days of PN

Hyperglycemia

-Metabolic complication of PN -Occurs in in patients who have DM, stress, critically ill, overfeeding, excess dextrose, or meds -Prevented by providing insulin -Limiting dextrose content of solutions

duodenum

-Primary site for digestion -Acidic chyme from the stomach enters -Mixed with secretions from the pancreas, gallbladder, and duodenal epithelium -Sodium bicarbonate neutralizes the acidic chyme & allows the digestive enzymes to work more effectively at this location

...

Anatomy of Digestive Tract - Part I

...

Anatomy of Digestive Tract - Part II

stomach

adds ACID, ENZYMES, & FLUID; churns, mixes, grinds food to a liquid mass

Trachea

allows air to pass TO AND FROM lungs

lower esophageal sphincter

allows passage from esophagus to stomach & prevents backflow from stomach

upper esophageal sphincter

allows passage from mouth to esophagus & prevents backflow from esophagus

ileocecal valve/sphincter

allows passage from small to large intestine; prevents backflow from large intestine & controls transit through intestine

pyloric sphincter

allows passage from stomach to small intestine; prevents backflow from small intestine

TPN

bowel rest, then pt must be on ___

pick line

catheter is inserted peripherally! that goes to heart all accesses are PERMANENT

Exocrine cells

cell that secrete various enzymes/juices into lumen of GI tract

Endocrine cells

cells that secrete various hormones into the blood

TPN

central line =

mouth

chews & mixes food w/ saliva

bile duct

directs BILE - from LIVER to SMALL INTESTINE

phraynx

directs food from mouth to esophagus

Esophagus

directs food to stomach

pancreatic duct

directs pancreatic juice from pancreas to small intestine

Functions of GI Tract

•Extracts macronutrients (protein, carbohydrates, lipids, water, and ethanol) from ingested foods and beverages •Absorbs necessary micronutrients and trace elements •Serves as a physical and immunologic barrier •Regulatory and biochemical signaling to the nervous system known as gut-brain axis •Most metabolically active tissue •High turnover rate •More susceptible to nutrient deficiencies, toxins, food allergy reactions, blood flow abnormalities

ASPEN Consensus Statement RS, NCP 2020

•Initiation of Calories -100-150 g of dextrose or 10-20 kcal/kg -Advanced 33% of goal every 1-2 days •E-lytes -Check P, K, Mg before initiation of nutrition -Replete; if unable to correct, DECREASE dextrose by 50% and adv slowly as above •Thiamin and Multivitamins -Supplement 100mg before feeding -100mg/d 5-7 days in severe starvation, ETOH -MVI added daily •Fluid, Na, Pro are unrestricted Note: guidelines are for both EN and PN

Peripheral vs. Central

•Lower concentration of nutrients •Requires lg volume •Not recommended if fluid restricted •Can be used for 2 weeks •Difficult to meet all nutritional needs •Higher concentration of nutrients •Requires less volume •Can be used with fluid restriction •Can be used for years •Can meet all nutritional needs •Higher risk of infection

Hypertriglyceridemia

•Metabolic complication of PN •May occur in critically ill patients •May result from excessive carbohydrate feedings or severe infection •If blood triglyceride levels exceed 350 to 400 mg/dL - lipid infusion is reduced or stopped

Refeeding Syndrome

•Metabolic complication of PN •Metabolic and physiologic consequences that occur during repletion of malnourished pts causing compartmental shifts involving P, Mg, K •Once feeding is initiated, anabolism begins as glucose becomes the predominant source of fuel instead fat •P shifts into intracellular compartments to accommodate for completion of ATP

Hypoglycemia

•Metabolic complication of PN •Too much insulin added to formula •Occurs when feedings are interrupted or discontinued •Those at risk for rebound hypoglycemia benefit from 1-2 hour taper

Digestive System

•Mouth •Esophagus •Stomach •Small intestine •Liver/gallbladder •Pancreas •Large intestine

kcals delivered PN

•PRO 4 kcal/g •Dex 3.4 kcal/g •LIPIDS 9 kcal/g (3 in 1) •Lipids Emulsions (for 2-in-1 system) -10% 1.1 kcal/mL -20% 2 kcal/mL -30% 3 kcal/mL

Likely Candidates PN

•Peritonitis •Intestinal hemorrhage •Intestinal obstruction •Intractable N/V/D or abd distention •SBS •Tx toxicity in Ca patients -Bone marrow recipients •Severe pancreatitis •High output fistula

permissive underfeeding

•Rational: overfdg= hyperglycemia, azotemia, immunesuppression, inflammatory cytokine release -Applicable to critically ill pt -Intake should be 80% of needs -Protein should remain consistent -Length of time should be 7 days, enough for inflammation to subside -Malnourished pt are excluded

NPC:N Ratio

•Rationale: protein should go to healing and stress response and not to BEE •80:1 the most severely stressed patients •100:1 severely stressed patients •150:1 unstressed patients

pre-mixed solutions

•Sold with all components already mixed into solution •For a peripheral line, usually contain: -5 - 10% dextrose -2.75%, 3.5% or 4.25% amino acids •For a central line, usually contain: -20 - 25% dextrose -3.5%, 4.25% or 5% amino acids TPN form Tutorial - Https://www.csun.edu/~cjh78264/parenteral/index.html

Electrolytes

•Standard electrolyte additives are usually -Sodium -Potassium -Calcium -Magnesium -Phosphate •Acetate and chloride may be added based on acid-base balance

Abnormalities in Liver Function PN

•Steatosis often results due to overfeeding •Monitor serum levels of liver enzymes •Usually readily reversed when parenteral feedings discontinued •May become chronic - irreversible liver disease when parenteral nutrition is continued long-term - lead to liver failure

PN: Indications for Use

•Trials of EN have failed or there is not adequate access to GI tract •EN is contraindicated or intestinal tract has severely diminished function -Paralytic ileus -Mesenteric ischemia -SBO -GI fistula except when enteral access can be placed distal to fistula •Post op where healing would be delayed if PN not started within 5-10 days for pt unable to tolerate po or EN •Consider.... -GI tract •N, V, D -Malnutrition •>10% wt loss, prealb < 10, 75% IBW, Hx inadequate po intake -Clinical status

Lipids in PN

•Triglycerides from soybean oil and safflower oil, phospholipids •Lipid emulsions available in 10, 20, 30% solutions •Provided daily •May provide 20-30% of total kcalories •Propofol = 1.1kcal/kg •Max 2 grams/kg/d or < 1g/kg/d in stress or hyperlipidemia

Vitamins & Minerals PN

•Usually a multivitamin product that contains a mix of fat soluble and water soluble vitamins. For adults: -A,D, E, C, Thiamin, Riboflavin, Niacin, Folic Acid, B6, Pantothenic Acid, Biotin, B12 •Vit K added separately