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بسم اللهِ الرَّحْمَنِ الرَّحِيمِ. ” ذَلِكُمَا مِمَّا عَلَّمَنِي رَبِّي إِنِّي تَرَكْتُ مِلَّةَ قَوْمٍ لا يُؤْمِنُونَ بِاللَّهِ “. Ain-Shams university. Faculty of Medicine Department of Anesthesiology, ICU, and Pain management CME Program – ICU course.
”ذَلِكُمَا مِمَّا عَلَّمَنِي رَبِّي
إِنِّي تَرَكْتُ مِلَّةَ قَوْمٍ لا يُؤْمِنُونَ بِاللَّهِ“
Faculty of Medicine
Department of Anesthesiology, ICU, and Pain management
CME Program – ICU course
Also referred to as:
parenteral alimentation, and
The gut should always be the preferred route for nutrient administration.
Long-term use (HOME PN)
PPN can be used to supplement Ordinary or Tube feeding esp. in malnourished patients.
Short bowel syndrome
Critical illness or wasting disorders
(major trauma or burn > infection or after surgery > standard)
Daily Protein requirements
Nitrogen Balance =
Protein intake in grams ÷ 6.25 – UUN (in grams) + 3
Ideally, the venous line should he used
exclusively for parenteral nutrition.
Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of the high rate of associated infection), or a long catheter placed in an arm vein and threaded into the central venous system (a peripherally inserted central catheter line)
Once the correct position of the catheter has been established (usually by X ray), the infusion can begin.
TPN infusion is usually initiated at a rate of 25 to 50 mL/h. This rate is then increased by 25 mL/h until the predetermined final rate is achieved.
To ensure that the solution is administered at a continuous rate, an infusion pump is utilized to administer the solution. In hospitalized patients, infusion usually occurs over 22-24 h/day. In ambulatory home patients, administration usually occurs overnight (12-16 h).
1-Effecacy: electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar, body weight, Hb.
2- Complications: ALT, AST, Bil, BUN, total proteins and fractions.
3- General: Input- Output chart.
4- Detection of infection:
Clinical (activity, temp, symptoms)
WBC count (total & differential)
ccc by: fever, chills, ±drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip).
ttt:1- exclusion of other causes of fever
2- short course of anti-bacterial and antifungal
therapy (acc. to C&S)
3- Catheter removal may be required
Catheter sepsis (Cont.):
Prevention: a rigorous program of catheter care:
Thromboembolism, pneumothorax, vein or artery perforation, and superior vena cava thrombosis
It can result in an osmotic diuresis (abnormal loss of fluid via the kidney), dehydration, and hyperosmolar coma.
ttt: decrease the amount of infused glucose (to<4 mg/kg/min) OR insulin can be administered (either S.C. inj. or incorporation in the infusion bag).
Associated with excess infusion of fat emulsion.
N.B. Infusion of both glucose and fat emulsion in excess may result in pulmonary insufficiency.
Excess glucose infusion –> excess carbon dioxide (CO2) production a result of glucose metabolism.
Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce the diffusion capacity of respiratory gases.
Multiple causes have been proposed, including high infusion rates of aromatic amino acids, high proportion of energy intake from glucose, e.t.c..
There is no specific treatment, other than anticholestatic therapy.
The lack of direct provision of nutrients to the intestinal epithelia during total parenteral nutrition Trophism and altered permeability of the GI mucosa, thus compromising any potential recovery of the patient’s ability for enteral feeding, and allowing bacterial entery to blood stream sepsis
Prevention is to provide a minimal enteral nutrition supply to avoid or minimize this risk.
Electrolyte imbalance, mineral imbalance, acid-base imbalance, toxicity of contaminants of the parenteral solution.
Catheters and tubing may become clotted or twist and obstruct.
Pumps may also fail or operate improperly.
“وَقُلْ عَسَى أَنْ يَهْدِيَنِي رَبِّي لأَقْرَبَ مِنْ هَذَا رَشَداً”