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
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Monitoring for EN/PN in Acute Care
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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
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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
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Anatomy of Digestive Tract - Part I
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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
