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PARENTERAL FEEDING

Defenition. Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the intravenous route and without the use of the gastrointestinal tract.. Indications:. Massive intestinal resection (short bowel syndrome) where < 100cm of small bowel remain.Proxi

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PARENTERAL FEEDING

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    1. PARENTERAL FEEDING BY:WAFA DAWAHER

    2. Defenition Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the intravenous route and without the use of the gastrointestinal tract.

    3. Indications: Massive intestinal resection (short bowel syndrome) where < 100cm of small bowel remain. Proximal intestinal fistula IBD Paralytic ileus ,small bowel obstruction Severe pancreatitis Motility disorders such as scleroderma or sclerosing peritonitis Following severe injury or burns where metabolic demands increase greatly Comatozed patients.

    4. Route of delivery TPN can be administered either by a catheter inserted in : 1. central vein 2. peripheral line

    5. peripheral Peripheral feeding is appropriate for short-term feeding of up to 2 weeks. Access can be achieved either : 1. peripherally inserted central venous catheter (PICC) line (catheter inserted into a peripheral vein and manoeuvred into the central venous system.(up to 7 days) 2. by peripheral IV catheter.(short canula)up to 3 days

    7. Complications : 1.Phlebitis: ( inflammation of the vein) Redness ,tenderness,swelling and hotness along the vein on the skin, with hardening of the vein. 2.Thrombosis 3.Thrombophlepitis

    8. These side effects are due to high osmolarity and low PH of the feeding solutions, thus to limit these side effects we use: * small caliber catheter * slow rate of administration * Lipid based solution is used which have lower osmolarity than glucose based solution

    9. Central the catheter can be inserted via the subclavian or internal or external jugular vein until the catheter tip lies in the distal superior vena cava In External or internal jugular vein catheter the exit site is situated inconveniently on the side of the neck,where repeated movements result in disruption of the dressing with the attendant risk of sepsis The infraclavicular subclavian approach is more suitable for feeding as the catheter then lies flat on the chest wall

    11. -We use it for long term nutrition ( more than 2 weeks) - a post-insertion chest radiograph is essential before feeding is commenced to confirm the absence of pneumothorax and that the catheter tip lies in the distal superior vena cava.

    12. How to insert IV central line? Patient in supine. Head down. The skin is cleaned, and local anesthetic. Make a larg insision by larg bore needle (1mm) in the inferior surface of the clavicle, ask the patient to hold his breath. Remove the syringe and Introduce catheter to reach SVC. Fix it by stitch

    13. Components

    14. Estimating Nutritional Requirement 1.Adjust the body Weight Actual body weight (ABW) Ideal body weight (IBW): male = 50+(2.3*num of inches over 5 feet) female =45+2.3*num of inches over 5 feet) _If ABW greater than 125%of IBW, then : Dosing weight= IBW+0.25

    15. 2.Daily protiens and caloric needs

    16. 3.Fluid replacement : 30- 50 ml/kg/day We also have to replace any ongoing losses ex. fever give 2.5 ml/kg/day for each 1 c above 37 4. fat : 1 g /kg/day we give 500 cc 20% fat emulsion 2-3 times a week

    18. Complications: 1.Technical complications: Air embolism Arterial lacerations Arteriovenous fistula Brachial plexus injury Cardiac perforation Catheter embolism Catheter malposition Hemothorax Pneumothorax Subclavian vein thrombosis Thoracic duct injury Thromboembolism Venous laceration

    19. 2.Infectious complications: Catheter based bacteremia Catheter colonization Cellulitis

    20. 3.Metabolic complications: Azotemia Essential fatty acid deficiency Fluid over load /dehydration Hyperchloremic metabolic acidosis Hyper/hypocalcemia Hyperglycemia Hyper/hypokalemia Hyper/hypomagnesemia Hyper/hyopnatremia Hyper/hypophosphatemia Interinsic liver dis. Metabolic bone dis. Trace element deficiency Vitamine deficiency

    21. Re- feeding syndrome During starvation intracellular electrolyte stores, particularly phosphate, are depleted despite normal serum concentrations. Feeding stimulates the cellular uptake of electrolytes and can lead to electrolyte disturbances with profound hypophosphataemia. Clinical features usually develop within 4 days of re-feeding, but are often non-specific. Later manifestations include : - Rhabdomyolysis. - Cardiac failure. - Hypotension. - Arrhythmias. - Respiratory failure. - Seizures and coma. To avoid the development of the refeeding syndrome, nutrition support in patients at risk should be increased slowly while assuring adequate amounts of vitamins and minerals.

    22. monitoring

    23. Thank you

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