The partial parenteral nutrition covering the daily nutritional needs incomplete and only supplemented oral delivery. Hospital patients receive after this diet method dextrose or amino acid solutions.
Parenteral nutrition is by definition i.v. administered. The partial parenteral nutrition covering the daily nutritional needs incomplete and only supplemented oral delivery. Hospital patients receive after this diet method dextrose or amino acid solutions. The total parenteral nutrition (TPE) provides all the necessary daily nutrients. It is given in hospital or at home. Since TPE solutions are concentrated and can lead to thrombosis in the peripheral veins, a central venous catheter is required for this diet. Parenteral nutrition should not be routinely used in patients with intact gastrointestinal tract. Compared with enteral nutrition it causes more complications, protects the structure and function of the gastrointestinal tract less and is more expensive. Indications The TPE may be the only viable option for patients who do not have a functioning gastrointestinal tract, or suffering from disorders that require a full protection of the intestine, such as the following: Some stages in ulcerative colitis bowel obstruction Certain Pediatric Gastrointestinal disorders ( z. B. congenital gastrointestinal abnormalities, persistent diarrhea are independent of the cause) short bowel syndrome due to surgery nutrient content for the TPE water (30-40 ml / kg / day), energy (30-45 kcal / kg / day, depending on energy consumption ), amino acids (1.0-2.0 g / kg / day, depending on the intensity of the catabolism), essential fatty acids, vitamins and minerals, they ( he table: Daily basic needs for adults with total parenteral nutrition) is required. For children who need to be fed completely parenterally, another fluid requirement, moreover, they need more energy (up to 120 kcal / kg / day) and amino acids (up to 2.5 or 3.5 g / kg / day). Daily basic needs for adults with total parenteral nutrition nutritional amount of water (/ kg bw / day) 30-40 ml Energy * (/ kg bw / day) an internist patient 30 kcal Postoperative patient 30-45 kcal Hyperkatabolischer patient 45 kcal Amino acids (/ kg bw / day) an internist patient 1.0g Postoperative Patient 2.0 g 3.0 g Hyperkatabolischer patient minerals acetate / gluconate 90 mmol calcium 15 mmol chloride 130 mmol chromium 15 mcg Copper 1.5 mg Iodine 120 mcg manganese magnesium 20 mmol 2 mg Phosphorus 300 mg 100 mmol potassium Selenium 100 mcg Sodium 100 mmol zinc vitamins 5 mg ascorbic acid 100 mg Biotin 60 mcg Cobalamin 5 mcg folate (folic acid) 400 mcg Niacin 40 mg pantothenic acid 15 mg Pyridoxine 4 mg riboflavin 3.6 mg thiamine 3 mg Vitamin A 4000 IU Vitamin D 400 IU Vitamin E 15 mg Vitamin K 200 mcg * The energy requirement for fever increases by 12% per 1 ° C increase in temperature. TPE basic solutions are prepared using sterile techniques for infusion, and administered in liter bags according to standardized formulas. Normally, a patient needs from the standard solution 2 liters / day. The solutions can be, depending on the laboratory values, modify existing diseases, hypermetabolism, or other parameters. Most calories are supplied as carbohydrates. Normally, about 4-5 mg / kg / min of dextrose are added. Standard solutions contain up to about 25% dextrose, but the amount and concentration is dependent on other factors such as the metabolic demand and the portion of the caloric requirement, which is administered in the form of lipids. Commercially available lipid emulsions are often added to provide essential fatty acids and triglycerides are available; 20-30% of the total calories are usually administered as lipids. However, the retention of lipids and their calories in obese patients supports the mobilization of endogenous fat stores and increases insulin sensitivity. Solutions are usually used many different solutions. Electrolytes can be added to meet the patient demand. Depending on the presence of other disease and the patient’s age, the following solutions are used: In non-dialysis-dependent renal failure or hepatic insufficiency: reduced protein content and a high proportion of essential amino acids In heart or kidney failure: limited hydration In respiratory failure: fat emulsion of most of non-protein calorie supplies in order to minimize CO2 production by the carbohydrate metabolism for newborns: dextrose in lower concentrations (17-18%) the beginning of the TPE Since the central venous catheter is a long time, need for and find after installing strict sterile techniques application. The TPE hose must not be used for other purposes. The external system should be changed once a day when attaching the first food bag. Filter in the system have not yet proven that they are capable of reducing complications. The Association remains sterile and is usually renewed every 48 hours. If a patient outside the hospital nourished completely parenterally, it must be trained to recognize signs of infection. In addition, a skilled nursing is to organize at home. The TPE solution is slowly at the beginning, administered at 50% of the calculated requirement. In this case, 5% dextrose is used to compensate for the fluid balance. Energy and nitrogen should be supplied simultaneously. The amount of regularly given insulin, which is added to the TPE solution directly depends on the blood sugar value; this is normal and, the administered solution contains the usual 25% dextrose, the starting dose is 5-10 I.U. Short-acting insulin / l. the patient monitoring progress can be observed on a flow chart. If necessary, a multidisciplinary nutritional team monitors the patient. Weight, blood status, electrolytes and urea nitrogen levels of blood should be regularly in the hospital, checked daily. Plasma glucose levels should be checked every 6 h until patients and blood sugar levels are stable. The Flüssigkeitsein- and exports is continuously recognized. the patient’s condition remains stable, blood tests may be performed at longer intervals. Hepatic function should be checked. Plasma proteins (serum albumin, possibly transthyretin or retinol-binding protein), plasma and urine osmolality as well as calcium, magnesium and phosphate should be determined twice a week. Changes in transthyretin and retinol-binding protein rather reflect the overall clinical status resist as the nutritional status alone. If possible blood tests should not be done during glucose infusion. A full assessment of nutritional status, including a calculation of BMI and anthropometric measurements (overview of malnutrition: Physical examination and obesity: Physical Constitution). Is to carry out every 2 weeks. Clinical Calculator: Body Mass Index (Quetelet’s index) complications Approximately 5-10% of patients have complications associated with central venous access. A catheter-associated sepsis is likely to occur at ? 50% of patients. Glucose abnormalities (hyperglycemia or hypoglycemia), or liver problems occur the patients at> 90%. Abnormalities in glucose levels occur frequently. Hyperglycaemic states can be avoided by frequently plasma glucose values ??are removed, adjusted the dose of insulin in the TPE-solution each and insulin is administered subcutaneously as needed. Hypoglycaemia occurs rapidly when the otherwise continuous Dextroseinfusion is suddenly interrupted. Treatment depends on the degree of hypoglycemia. A short-term hypoglycemia can with 50% dextrose i.v. be reversed; longer duration of hypoglycemia requires the infusion of 5% or 10% dextrose for 24 hours before resumption of TPN through a central venous catheter. To liver complications include impaired liver function, a painful enlargement of the liver (hepatomegaly) and hyperammonemia. These complications can appear at any age, but are small children, v. a. preterm infants, most commonly, the liver is not mature. A temporarily impaired liver function manifests itself in increased transaminases, elevated bilirubin and increased alkaline phosphatase; it typically occurs at the beginning of TPN. A delayed or permanent increase in these values ??is due to an excess of amino acids. The pathogenesis is unknown, but cholestasis and inflammation contribute. Sometimes a progressive fibrosis developed. A reduced protein intake has a remedy. A painful liver enlargement is due to an accumulation of fat; carbohydrate intake should be reduced. In infants, a hyperammonemia may develop, leading to lethargy, twitching and generalized seizures. By arginine intake of 0.5 to 1.0 mmol / kg / day can be correct that. If liver complications occur in infants, amino acids should be supplied at a dose of 1.0 g / kg / day. Abnormalities of serum electrolytes and -mineral should be corrected either by an adjustment of the subsequent infusion therapy, or, if a balance is urgently needed, be removed with suitable peripheral venous infusions. Vitamin and mineral deficiencies are rare if the dose regimen is maintained. Increased urea nitrogen levels reflect dehydration, which can be corrected owned by peripheral administration of free liquid as 5% dextrose solution. Fluid overload (one / to go for a weight gain of> 1 kg day) results when patients have a high daily energy requirements and therefore need plenty of hydration. Disturbances of bone metabolism or bone demineralization (osteoporosis or osteomalacia) develop in patients receiving more than> 3 months a TPE. The underlying mechanism is not known. Advanced disease strong periarticular pain and back pain as well as pain in the lower extremities occur. Defensive reactions to lipid emulsions such as dyspnea, allergic skin reactions, nausea, headache, back pain, sweating or dizziness are not common, but can occur when lipids are infused at rates of> 1.0 kcal / kg / h. Out it comes, v. a. in patients with kidney or liver failure, hyperlipidemia; Countermeasures are not usually required. As delayed defense reactions against lipid emulsions hepatomegaly, a slight increase in liver enzymes, splenomegaly, thrombocytopenia, leukopenia and abnormal lung function that occurs particularly in preterm infants with acute respiratory syndrome apply. prevents temporarily or permanently slowed or stopped lipid emulsion or minimize these adverse reactions. As complications of gallbladder apply in this context, cholelithiasis, biliary gravel and cholecystitis. These complications are caused by a longer-term cholestasis or worse. It is advantageous to stimulate the contraction of the gallbladder through the administration of 20 to 30% of calories as fat and interrupting the glucose infusion over several hours a day. The improvement of this state is also oral and enteral food intake. Some patients with cholestasis benefit from treatment with metronidazole, ursodeoxycholic acid, phenobarbital or cholecystokinin. Important points Parenteral nutrition is indicated in patients who have a non-functioning gastrointestinal tract, or suffering from disorders that require a full protection of the intestine. The necessary requirement for water (30-40 ml / kg / day), energy (30-60 kcal / kg / day, depending on energy consumption) (amino acids 1.0-2.0 g / kg / day, depending on the intensity catabolism), essential fatty acids, vitamins and minerals is to be calculated. Depending on the age of the patient and the status of the organ functions, a particular solution is to be selected; for newborns and for patients whose heart, kidney or lung function is impaired, there are several solutions. During and after the installation of the central venous catheter strict sterile techniques must be applied. Because of possible complications, patients should be monitored closely (z. B. central venous catheter, blood sugar levels, electrolyte and mineral content, impairment of liver or gallbladder, volume or lipid emulsions).