introduction to tpn 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師....
Post on 18-Dec-2015
262 views
TRANSCRIPT
![Page 1: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/1.jpg)
Introduction to TPN
新光吳火獅紀念醫院 內科部 胃腸肝膽科
柯威旭 醫師
![Page 2: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/2.jpg)
Nutrition Support Team
• Physicians• Clinical pharmacists• Nurse-Clinicians• Dietitians• Laboratory research technician• Ward nursing staff• In SKH: 主任 ,執行秘書 ,各科醫師 ,藥劑師 ,營養師
![Page 3: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/3.jpg)
Source of Nutrition
• Enteral nutrition
• Parenteral nutrition– Central parenteral nutrition (CPN=TPN)– Peripheral parenteral nutrition (PPN)– Long-term home parenteral nutrition (HPN)
![Page 4: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/4.jpg)
Clinical decision algorithm route of nutrition support
Decision to institute special nutrition support
Oral Feeding
Nutrition Assessment
Functional GI Tract
Enteral Nutrition Parenteral Nutrition
GI function PPN TPN
GI function returnIntactNutrients
DefinedFormula
Adequate InadequatePN
Short-term: NG, ND,NJ
Long-term:Gastrostomy Jejunostomy
YES NO
NOYESAdequate
![Page 5: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/5.jpg)
PPN
• High risk of thrombophlebitis• Osmolarity: less than 800-900 mOsm/kg• Short-term: up to 2 weeks• Not the optimal choice for
– significant malnutrition– severe metabolic stress– large nutrient or electrolyte needs (especially potassium,
a strong vascular irritant)– fluid restriction– the need for prolonged intravenous nutrition support
![Page 6: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/6.jpg)
Indications of TPN
• Impossibility for enteral nutrition
• Inadequacy for enteral nutrition
• Increment of the severity of disease by enteral nutrition
PLUS
• Anticipated to have PN for more than 7 days
![Page 7: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/7.jpg)
TPN in Internal Medicine• Acute pancreatitis• Intestinal disease (IBD, NEC, radiation colitis, ileus, int
ractable diarrhea / vomiting)• Cancer• Hepatic failure• Renal failure• Short bowel syndrome• Enterocutaneous fistula• AIDS• Perioperative support
![Page 8: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/8.jpg)
TPN should not be used in
• Malignancy: poor response to R/T or C/T
• Active stage of IBD
• Relative preserved GI function
• Hypertriglyceridemia (TG > 400 md/dl)
![Page 9: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/9.jpg)
Components of TPN
• Carbohydrate, Amino acid, Fat, Electrolyte, Water, Vitamin, Trace element
• Standard solution– Dextrose, Amino acid– Electrolyte (Na, K, Cl, Mg, Ca, P)– Vitamin (A, B1, B2, Niacin, B6, Panthothenic a
cid, C, D, E, Zn, Cu, Mn, Cr)
• Lipid emulsion
![Page 10: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/10.jpg)
Dextrose-content Solution
• 1 g glucose = 3.4 Kcal
• 1 g glucose = 5 mOsm/L
![Page 11: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/11.jpg)
Amino acid solution
7% A.A.含 essential A.A. 較高 , 適用於腎衰竭病患
8% A.A.含高濃度 branch chain A.A., 低濃度 aromatic A.A., 可使肝衰竭病患之 HE 改善
12% A.A. 成人 Standard Solution 之 A.A. 來源
![Page 12: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/12.jpg)
Lipid emulsions
10% intralipid
20% intralipid
10% lipofundin
Volume 500 ml/B 250 ml/B 100 ml/B
Calorie 550 Kcal/B 500 Kcal/B 110 Kcal/B
![Page 13: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/13.jpg)
TPN formula
• B: standard solution• D: 8% A.A., high BCAA, low AAA; for
hepatic disease• E: 35% Dextrose, 12% A.A.; for HD and
water restriction• F: 29% Dextrose, 12% & 7% A.A.; for
ARF with HD• G: 29% Dextrose, 7% A.A.; for ESRD
![Page 14: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/14.jpg)
TPN Order
![Page 15: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/15.jpg)
Vascular Access for TPN
Care Complication Infection
Subclavian vein Easy High Low
Internal jugular vein Hard Low High
Femoral vein Hard Low Highest
Antecubital vein Easy Low High
![Page 16: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/16.jpg)
Mechanical complication
• Insertion-of-catheter related:– pneumothorax, brachial plexus injury, subclavi
an and carotid artery puncture, hemothorax, thoracic duct injury and chylothorax, cardiac perforation, catheter malposition
• Air embolism
• Catheter fragment embolism
![Page 17: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/17.jpg)
Metabolic complication• Fluid overload / Dehydration from osmotic diuresis• Hypertriglyceridemia• Hypocalcemia• Hypomagnesemia• Hypophosphatemia• Hyperglycemia / Rebound hypoglycemia on sudden
cessation of TPN• Hyperammonemia• Hyperchloremic metabolic acidosis• NKHS
![Page 18: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/18.jpg)
Infectious complication
• Catheter-related sepsis: Staph. epidermidis and aureus; solution contamination
• GNB for immunocompromise• Direct evidence: tip culture or blood culture• Indirect evidence: fever (up to 38C, 2 times,
every 4 hours), chills, abrupt increase of blood sugar, hypotension, tachycardia, leukocytosis
![Page 19: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/19.jpg)
Hepatic complication
• Biochemical: elevated serum aminotransferase and alkaline phosphatase
• Histological: steatosis, steatohepatitis, cholestasis, fibrosis and cirrhosis
• Usually benign and transient, but severe in TPN for > 16 weeks
• Additive use of Choline, Glutamine and Carnitine may be helpful
• If cholestasis is present, Cu and Mg should be deleted to prevent acculumation in liver and BG
![Page 20: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/20.jpg)
Biliary complication
• Acalculous cholecystitis, GB sludge, cholelithiasis in TPN for > 3 weeks
• Decrease of bile salt reabsorption leads to formation of GB stone;
• Encouraging enteral intake to stimulate GB contraction
![Page 21: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/21.jpg)
Intestinal complication
• Villous atrophy: decreases in gut weight and mucosal height
![Page 22: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/22.jpg)
Metabolic bone disease
• Present in TPN for > 3 months
• Bone pain, bone fracture or asymptomatic but demineralization in CxR
• Possible mechanisms– Aluminum toxicity– Vitamin D toxicity– Negative calcium balance
![Page 23: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/23.jpg)
Refeeding syndrome
• The metabolic and physiologic consequences of the depletion, repletion, compartmental shifts and interrelationships of the followings
– Phosphorus (< 1mg/dl, death within hours)– Potassium– Magnesium– Glucose metabolism– Vitamin deficiency– Fluid resuscitation
![Page 24: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/24.jpg)
Case History• 66 y/o female, abdominal pain and anorexia
for 6 weeks
• persistent profuse, yellow, watery diarrhea after construction an ileal conduit for ureteral obstruction lasting for 3 months
• PE: BW 36 kg, 70% of IBW; afebrile, 108, 14, 98/70
anasarca, cachectic with generalized muscle wastage
![Page 25: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/25.jpg)
Hct 38%, WBC 17000, BUN/Cr 22/1.0, K 3.4, P 3.4, HCO3 17, Sugar 48, Alb. 1.59
• Hospital Course TPN was started with 750g dextrose, 120g
AA, 60 mEq Na, 20 mEq K, 15 mmol P in 3L fluid
24 hrs after start of TPN, HR 180, SBP 50, CVP < 3 cmH2O
P 0.7, Na 142, K 1.4, HCO3 19, Mg 1.8, Sugar 1010, BUN/Cr 27/1.3 pH 7.31, O2 59, CO2 24 (O2 2L)
![Page 26: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/26.jpg)
Apnea and respiratory failure developed within one hour
With stopping TPN and fluid replacement, P 6.9, K 3.5 and Sugar 45 were obtained.
In the following hospitalization, bilateral pneumonia and ARDS were complicated.
Died on the 6th day
• Autopsy: ischemic enterocolitis, pneumonia, ARDS and peritonitis and the heart was unremarkable
![Page 27: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/27.jpg)
![Page 28: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/28.jpg)
Sequence of events
P, Sugar, K, Meta. acidosis GI bleeding, Sepsis
Tachycardia, Hypotension
Apnea, MV support
ARDS, Pneumonia
Persistent Cardiopulmonary Instability
Death
Within 48 hrs of starting TPN After correction of hypophosphatemia
![Page 29: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/29.jpg)
Physiology of Starvation
• When BMR = energy output to the limited intake, endogenous fuels must be used
• Major storage fuel is fat in form of TG (60-75 days)
• Carbohydrate, in contrast, is quantitatively insignificant storage fuel (1200 kcal, 1 day’s resting ER)
• Protein, 12kg, 2 weeks’ worth of calories; but is for nonfuel function
![Page 30: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/30.jpg)
Metabolic Response to Refeeding
• A shift from body fat to CHO as major fuel source• Insulin • Glycogenolysis, gluconeogenesis and FA mobiliza
tion from adipose tissue is inhibited• Cellular uptake of glucose, K, P, and Mg is enhanc
ed by insulin• Antinatriuretic effect (Na retention and ECF expan
sion)
![Page 31: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/31.jpg)
Patient of risk for refeeding syndrome
• Chronic alcoholism• Anorexia nervosa• Classic marasmus• Classic kwashiorkor• Chronic undernourishment• Morbid obesity with massive weight loss• Prolonged hypocaloric intravenous hydration• NPO for greater than 7-10 days• Cardiac and cancer cachexia
![Page 32: Introduction to TPN 新光吳火獅紀念醫院 內科部 胃腸肝膽科 柯威旭 醫師. Nutrition Support Team Physicians Clinical pharmacists Nurse-Clinicians Dietitians Laboratory](https://reader030.vdocuments.net/reader030/viewer/2022012318/56649d265503460f949fcb50/html5/thumbnails/32.jpg)
Recommendations to avoid refeeding syndrome
• Be aware of the syndrome• Recognize the patient at risk• Correct electrolyte
imbalance before initiating nutritional support whether by the oral , enteral or parenteral route
• Judiciously restore circulatory volume, monitor HR, and I/O
• Increase caloric delivery slowly
• Administer vitamins routinely
• Closely monitor electrolyte over the 1st week: Serum P, K, Mg, Sugar and urine electrolytes
• A little nutrition support is good, too much is lethal