Parenteral Nutrition Notes PDF

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Dr Rickeard...

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Friday, March 23, 2018

Parenteral Nutrition

- Parenteral nutrition ! • Refers to the admin of nutrients by a route other than the GI tract (bloodstream) ! • Used when a patient is not a candidate for enteral nutrition ! • The goal is to meet the patients nutritional needs ! - Peripheral parenteral nutrition (PPN)! • A client is receiving a portion of the estimated nutrition needs or a component (carbs and protein, but no lipids) via the vein !

• can be given through a peripheral vein ! - Total parenteral nutrition (TPN/CPN) ! • A client is receiving a 100% of his/her nutritional requirements via a vein ! • Includes carbs, protein, fat, vitamins, minerals and often fluid ! • Administered through a central venous line (central parenteral nutrition CPN) ! - Common indications for PN ! • Chronic severe diarrhea and vomiting ! • Complicated surgery or trauma ! • GI obstruction ! • GI tract anomalies and fistulas ! • Intractable diarrhea ! • Severe anorexia nervosa ! • Severe malabsorption ! • Short bowel syndrome ! - Composition of parenteral nutrition ! • Commercially prepared PN solutions containing dextrose and protein in the form of amino acids are avilable !

• The pharmacy adds the prescribed electrolytes, vitamins, and trace elements according to patients needs !

• A 3 in 1 mixture available, contains dextrose, amino acids and an IV fat emulsion ! 1

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• Calories ! - Primarily from carbs in the form of dextrose and fat in the form of fat emulsion ! - Dextrose comes in various concentrations ! - Need adequate non-protein calories to allow metabolism of amino acids for wound healing (not for energy) !

- IV fat administration delivers a high number of calories in a relatively small amount of fluid !

- Quick infusion of lipids can cause nausea, vomiting and fever ! • Protein! - Higher needs for patients under stress (surgical stress and burns) ! • Electrolytes ! • Monitor electrolytes daily at the beginning of therapy and then several times per week !

- Vitamins ! • Single and mixtures of both fat and water soluble vitamins ! - Trace elements ! • zinc, coppers, chromium ! - Methods of administration ! • Central parenteral nutrition ! - Indicated with long term support and high protein/caloric requirements ! - Can be given through a central venous catheter that originates from the subclavian or jugular vein or through a peripherally inserted central catheters (PICCs) placed into the basilic or cephalic vein !

- Tip of catheter lies in superior vena cava ! - Solutions are hypertonic and contain high glucose concentrations (20-50%) ! - Must be given into a large central vein to allow rapid dilution ! - Would cause irritation and thrombophlebitis in a smaller vein ! • Peripheral parenteral nutrition ! - Preferred when the risk of a central venous catheter is too great, or PB is used to supplement inadequate oral intake!

- Administered into large peripheral vein ! 2

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- Less hypertonic than CPN, typically using 10% glucose concentration ! - There is risk of phlebitis and fluid overload as nutrients need to be infused in larger volumes as compared to CPN !

- Catheter placement ! • A central venous catheter placement is performed under sterile conditions by a physician or advanced practice nurse (APN) !

• Most commonly used vein is the subclavian ! • Isotonic IV solution infused until placement confirmed by x-ray ! • Exit site covered with sterile dressing and labelled with the date ! • Complications of placements include hemorrhage, hydrothorax, pneumothorax, hemothorax, air embolism, venous thrombosis !

- Parenteral nutrition ! • Catheter used for PN should not be used for other purposes due to compatibility issues and infection risk !

• No blood administrations ! • No blood draws ! • No meds ! • No CVP monitoring ! - Administration of solution ! • PN solutions are prepared by pharmacy under strict aseptic technique ! • Nothing can be added to solutions after they are prepared ! • Risk of incompatibilities and contamination is high ! • PN solutions ordered daily to adjust for patients changing needs ! • Solutions ordered daily to adjust for patients changing needs ! • Solutions are stable for 24hrs and must be refrigerated until 30 mins before use ! • PN solution is always administered via infusion pump ! - Complications of parenteral nutrition ! • Complications of PN can be divided into three categories ! - Infectious ! - Metabolic !

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- Mechanical ! - Infectious complications of PN ! • High risk of infection d/t high glucose content ! • Need to administered with special filter ! • Change IV tubing and filter ! - Q24h for PN with lipids ! - Q72h for PN with amino acids and dextrose ! • Label the tubing and filter with date ad time ! • Use strict aseptic technique during dressing changes (mask for nurse and patient) ! • Change dressing covering catheter site according to institutional policy ! • Catheter-related sepsis is most common life threatening complication ! • Assess for local (at insertion site) and systemic evidence of infection ! • If an infection is suspected, culture blood/tubing cultures and notify MRP ! • Assess PN solution for signs of contamination, such as cloudy appearance ! - Metabolic complications ! • hyperglycemia, hypoglycemia, azotemia, hyperlipidemia, fatty acid deficiency, electrolyte and vitamin imbalances !

• Hyperglycemia may occur in patients receiving PN with or without diabetes ! - High glucose load can lead to hyperglycemic hyperosmolar syndrome —> osmotic diuresis —> coma and possible death !

- To prevent: gradually increase rate of PN in the first 24hrs, check glucose levels Q4-6hrs, treat with insulin !

• Re-feeding syndrome ! - Can develop any time a malnourished patient is started on aggressive nutritional patients !

- More likely in chronically malnourished patients ! - Characterized with fluid retention, hyperglycemia, and electrolyte imbalances (decreased PO4, decreased K and Mg) !

- hypophosphatemia—> dysrhythmias, respiratory arrest, neurological disturbances (paresthesias) !

- Mechanical complications of PN ! 4

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• Insertion ! • Air embolus ! • Pneumothorax, hemothorax, hydrothorax! • Hemorrhage! • Dislodgement ! • Thrombosis of great vein ! • Phlebitis ! - Nursing management ! • VS Q4-8 hr; I&O, daily weights! • Blood glucose Q4-6 hr (insulin prn)! • Routine BUN, electrolytes, CBC, and hepatic enzyme studies minimum of three times/week until stable, then weekly!

• Check solution label and ingredients against orders! • Inspect solution for leaks, colour changes, clarity, presence of sediment ! do not use!

• Replace solution Q24 hr even if bag not fully infused! prevention of microorganism growth!

• Always administer via infusion pump • Never increase or decrease infusion rate by more than 10% to prevent glucose fluctuations!

• Never abruptly stop PN infusion unless replaced by another glucose source (to prevent hypoglycemia)!

• Weaning is gradual ! • 60% of caloric needs should be met orally before discontinuation of EN or PN! • Daily dressings when central venous catheter discontinued until site healed! - Signs of hyperglycemia !

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• Thirst

• Polyurea

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• Confusion

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• Elevated blood glucose • Blurred vision 5

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• Dizziness

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• N&V

• Dehydration! - Signs of hypoglycemia ! • Diaphoresis • Hunger

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• Weakness • Tremors • Tachy•

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cardia

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