Fluid and Parenteral Nutrition PDF Lecture Notes

This Document has been modified with Flexcil app (Android) https://www.fexcil.com Fluid and parenteral nutrition Dr. Mohammad Alameen Qasim F.I.B.M.S ( Clinical pharmacy ) Al Nahrain University / college of pharmacy Flexcil - The Smart Study Toolkit & PDF,...

This Document has been modified with Flexcil app (Android) https://www.fexcil.com Fluid and parenteral nutrition Dr. Mohammad Alameen Qasim F.I.B.M.S ( Clinical pharmacy ) Al Nahrain University / college of pharmacy Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Distribution of total body fluid ( TBF) : 75 % of extracellular fluid is interstitial 60 % of TBF 40 % of TBF is is extracellular intracellular 25% of extracellular fluid is intravascular ( about 5 liter of blood ) Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Infused volume ( Intravascular fluid Equivalent intravascular volume expansion ( ml) ml ) Normal saline ( NS ) 1000 250 Ringer lactate ( RL) 1000 250 Dextrose ( D5W) 1000 100 Albumin 5% 500 500 Albumin 25 % 100 500 Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Sign and symptoms of intravascular volume depletion : Symptoms : 1- Tachycardia ( > 100 beat / minutes ). 2- Hypotension ( SBP< 80 mm Hg ). 3- Reduced volume output ( 10: 1 Sign : 1- Dry mucus membrane. 2- Decreased skin turgor. 3- Dizziness. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Resuscitation : Patients with hemodynamic unstable. To prevent organ hypoperfusion. 500 – 1000 ml bolus – preferable centrally. 0.9% normal saline or ringer lactate. Note : - Unstable mean ( hypotension. Increase heart rate , increase respiratory rate , decrease conscious ). - Bolus mean ( infused over 30 minutes ). - Patient assessment by heart rate and blood pressure ). - Total infused volume ( 4- 6 ) liter. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Maintenance : Patient is hemodynamically stable. Unable to tolerate oral fluids. To maintain fluid and electrolyte balance. Continuous infused peripherally or centrally ( 1500 ml + 20 ml /kg for remaining wight after 20 kg ). Formula ( D5W + 0.45% normal saline + 20 -40 mEq of KCL per liter ). Note : D5W ( Dextrose ) avoided in : 1- elevated intracranial pressure 2- hyperglycemia. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com When we used colloids : 1- if resuscitation with crystalloid ( 4- 6 l ) has failed. 2- after clinically significant edema ( pulmonary edema ) and limits the further administration of crystalloid. 3- Albumin consider in patients with albumin< 2.5 g/dl. 4- Albumin + diuretics for patients with clinically significant edema an albumin concentration less than 2.5 g /dl. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com above 290 mosm/kg 275 -290 mosm/kg below 275 mosm/kg Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Rule in the management of fluid : 1- Correct fluid depletion first. 2- Correct hypomagnesemia before hypokalemia. 3- Correct hypokalemia before hyponatremia. 4- Give electrolyte replacement to asymptomatic hypo except sodium. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Sodium ( Na ) 136 -145 mEq / L Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com - Both chronic hyponatremia and hypernatremia are mostly A symptomatic due to osmotic adaptation. < 125 mEq/L Nausea , malaise 115- 120 mEq/L Confusion < 115 mEq/L Seizure , coma , respiratory arrest Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Management of hyponatremia (< 136 mEq /L ). 1- Asymptomatic : Treatment according to volume status ( no replacement ) : Hypervolemia Euvolemic Hypovolemia Fluid loss , third space , Heart failure , Cirrhosis SIADH , Medication Example renal loss ( diuretics ) , nephrotic syndrome 1- Sodium and water 1- If drug induce remove Fluid resuscitation. Treatment restriction. it. 2- Vasopressin 2- Fluid restriction. receptor antagonist. 3- Demeclocycline. 3- Diuretics. 4- Vasopressin receptor antagonist Flexcil - The Smart. PDF, Annotate, Note Study Toolkit &  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Note : - Medication cause hyponatremia : 1- Due to hypovolemia ( thiazide diuretics ) 2- Due to SIADH { antiepileptic drugs ( carbamazepine , oxcarbazepine ) and antidepressants ( SSRIs ) ( tricyclic antidepressants ) }. - Avoid change in serum sodium either increase or decrease or decrease of more than 10 – 12 mmol/L in 24 hours to avoid irreversible central myelinolysis. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com When we use hypertonic saline in the treatment of hyponatremia : Appropriate use 3% 1- If symptomatic hyponatremia ( confusion , 7.5 % delirium , seizure , coma ) + Na < 120 mEq /L. 23.4 % 2- If traumatic brain injury + Central iv intracranial pressure is access greater than 20 mmHg. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Management of hypernatremia (> 145 mEq /L ). If concurrent Na and If concurrent Na and In general condition H2o loss ( diarrhea , H2o loss ( diarrhea , vomiting ). vomiting ). Free water orally or D5W + 0.225% Nacl. Fluid resuscitation D5W intravenous If severe central insipidus Desmopressin ( a synthetic analog of ADH ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Potassium ( K). 3.5- 5 mEq / L Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hypokalemia ( K concentration less than 3.5 mEq /L ) : Symptoms : 1- Muscle weakness. 2- ECG change ( flat T wave ). 3- Arrythmia ( bradycardia , heart block ) 4- Digoxin toxicity. Causes of hypokalemia : A- Reduce intake. B- Increased shift of K into the cell can occur with the following : 1- Alkalosis. 2- Insulin or carbohydrate load. 3- B2 receptor stimulation caused by stress induced epinephrine release or administration of ( B agonist ). 4- Hypothermia. C- Increased gastrointestinal loss of K. D- Increased urinary losses. E- Hypomagnesemia. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Management of hypokalemia : Oral KCL < 3.5 60- 80 mEq / day Recheck K daily. Oral KCL or IV 10 -20 k < 5 ). 2- Severe muscle weakness 3- ECG change. Cation exchange resin ( eg : patient Take digoxin patient not Take sodium digoxin polystyrene ( No calcium ) JUST (UIR) sulfonate ). ( IR ) 15 g ( 1-4 ) U : Urgent. time daily. I : immediate. R : Remove Flexcil -excess. Toolkit & PDF, Annotate, Note The Smart Study  This Document has been modified with Flexcil app (Android) https://www.fexcil.com 1- Urgent treatment: - By calcium to prevent ( hyperkalemia induced arrythmia ) , even normocalcemic. - Intravenous calcium gluconate ( 10 ml of 10 % 2- 5 minutes ) , give peripheral. - Intravenous calcium chloride ( 500 – 1000 mg ) , give centrally. 2- Immediate treatment : - Include : ( Insulin , sodium bicarbonate , B2 agonist ). A- patient with renal failure : take only insulin. 10 unit IV of regular insulin if patient is hyperglycemia , and 10 unit IV of regular insulin plus 25 - 50 g of glucose as 50 % dextrose intravenous. B- Patient with no renal failure : take B2 adrenergic agonist + insulin , take sodium bicarbonate in patients with metabolic acidosis. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com 3- Remove excess K from the body ( after immediate treatment ) : A- Patients with renal failure ( severe hyperkalemia { > 7 mEq /L } or advance kidney failure ) , treated with dialysis. B- Patients with no renal failure treated with : 1- Diuretics. 2- Cation exchange resin. NOTE : - Renal failure mean eGFR < 60. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Magnesium 1.7- 2.3 mg /dl Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hypomagnesemia : less than 1.7 mg /dl Causes : 1- Impaired intestinal absorption. 2- Ulcerative colitis. 3- Diarrhea. 4- Pancreatitis. 5- Chronic laxative use. 6- Diuretics. 5- Alcoholism. Symptoms : 1- Neuromuscular symptoms : Twitching , Seizures , Tetany. 2- Cardiovascular symptoms : Hypertension , Arrythmia. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hypomagnesemia Asymptomatic Symptomatic Emergency Oral supplement ( limited by the No emergency ( Torsades ) high frequency of diarrhea ) ( No torsades ) Note : 1-4 g 1-2 g - Reduced dose by half in patients with CKD. Slow IV Push - Mg replacement should occur over 3- 5 days. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Calcium 8.5- 10.5 mg /dl Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hypocalcemia : serum Ca < 8.5 mg /dl Hypocalcemia Asymptomatic symptomatic 200 -300 mg of IV Ca Oral Ca +/- Vitamin D - Ca cl ( central line ). - Calcium gluconate ( peripheral ). Ca corrected = serum Ca +[ 0.8 *( 4 – albumin ) ] Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Nutrition Enteral nutrition EN used in hemodynamic stable patients at risk of malnutrition Indication and timing and anticipated that oral feeding will be inadequate for at least 5- 7 days. EN contraindication 1- Complete intestinal obstruction. 2- Gastrointestinal fistula. 3- Severe diarrhea or vomiting. 4- Extreme short bowel. 5- Hemodynamic instability or intestinal ischemia. 6- Paralytic ileus. Routes A- Short term : 1- NG most common. 2- OG preferred in patients with nasal / facial trauma. 3- ND and NJ for gastric ileus ( less aspiration ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com B- Long term : Routes 1- Gastrostomy. 2- Jejunostomy. Benefit 1- Lower risk of infection than parenteral nutrition. 2- Avoid GI mucosal atrophy. Note : - EN superior to PN. - EN ( short term ) superior to long term ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com EN formulation : Normal digestive process Intact or polymetric formula typically contain 1- 1.2 Kcal / ml. Impaired digestive Elemental formula. capacity Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Disease specific EN Renal failure 1- Concentrated ( 2 Kcal / ml to adhere to fluid restriction. 2- Less protein and electrolytes if no dialysis. 3- more protein and moderate electrolyte if dialysis. Respiratory failure More fat less dextrose. and diabetic Highly stressed Enhanced with protein , arginine , glutamine , omega 3 patients fatty acid. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com EN complication : 1- Clog , resolved by flushing. 2- Aspiration pneumonia : A- Keeping head of bed elevation ( 30 -45 degree ). B- Monitoring gastric residual ( 250- 500 ml ) by :* prevent delays in gastric emptying using less fat. * increase gastric motility by metoclopramide , erythromycin. * EN tube post pyloric valve ( using duodenal feeding tube ). * initiation EN at a slow rate. 3- Constipation. 4- Dehydration. 5- Electrolyte abnormality ( avoid refeeding symptoms ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Drug administration using enteral access 1- liquid are preferable and they should diluted with 2- 3 times the medication volume with water. 2- Diarrhea can occur with medication having high osmolarity. 3- Flush with 20 ml of water before and after drug administration. 4- Mix crushed tablets or capsule content with 10 -15 ml of water and administered each drug separately. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Dumping syndrome ( Rapid gastric emptying ) Dumping syndrome is largely avoided by : 1- Eat several meals a day that are low in carbohydrate , high fat and high protein. 2- Fiber delay gastric emptying. 3- Octreotide , proton pump inhibitors. 4- switch to ND or NJ. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Nutrition Parenteral nutrition The administration of intravenous nutrition in patients with a non Uses : functional GI tract in which the duration pf PN is anticipated to be at least 7 days. Indication 1- Severe pancreatitis in patients who not tolerate EN. 2- peritonitis. 3- Severe inflammatory bowel disease. 4- Short bowel syndrome. 5- Complete bowel obstruction. IV infusion - PN is usually administered through a central line. - Peripheral access when osmolarity not exceed 900 mosm/ L. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Nutritional components of PN 1- CHO … dextrose 70 % and contains 3.4 Kcal / gram. 2- Amino acid provide 4 Kcal / gram. 3- Fat : available as 10 % and 20 % and contains about 10 Kcal /g. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com A- < 30 = 0.8 to 2 g /kg /day. BMI B- 30 -40 = 2 g/kg/day. C- > 40 = 2.5 g/kg /day. Without dialysis Amino acid Kidney 1 g/kg /day. requirement dysfunction Dialysis A- intermittent ( 1.2 -1.5 g /kg /day ) B- continuous replacement therapy ( 1.5 -2.5 g /kg /day ) Burn 3 g /kg /day Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Parenteral nutrition complication : 1- Catheter related infection : caused by staphylococcus aureus and candida albican. 2- Acid – base imbalances : usually related to the pateints underlying condition however , excessive chloride salts in the PN can cause a metabolic acidosis. Whereas excessive acetate salts cause a metabolic alkalosis. 3- Hyperglycemia. 4- Gut atrophy. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Parenteral nutrition complication : 5 –Over feeding can cause hepatic steatosis , hypercapnia , hyperglycemia , azotemia , to resolved this problem should decrease the calories. 6- Essential fatty acid deficiency : symptoms include skin desquamation , hair loss , impaired wound healing. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Parenteral nutrition complication : 7- Refeeding syndrome : can occur in acutely ( critically ill patients ) or chronically malnourished patients when EN or PN is initiated. A- Characterized by hypophosphatemia , hypokalemia , hypomagnesemia ) B- Preventing of refeeding syndrome by : 1- Identify patients at risk ( anorexia , alcoholism , cancer , poor nutrition intake. 2- Initially provide less than 50 % of caloric requirements 3- Supplements vitamins before initiation PN as well as K , phosphate Mg. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Parenteral nutrition complication : 8- Hepatobiliary disorder : include steatosis , cholestasis and gallbladder sludge or stones , can occur with long term PN administration. 9- Osteoporosis and osteomalacia. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Monitoring patients who are receiving PN : 1- Prealbumin is very useful in monitoring the effects of of long term nutrition support in patients who are not critically. - Normal range 16- 40 mg/dl. - Moderate malnutrition 11-16 mg /dl. - Severe malnutrition less than 11 mg /dl. *** Goal for malnourished patients is an increase of at least 3-5 mg /dl / week until within normal range. *** Serum albumin is a poor predictor of nutrition status because it has long half-life and concentrations fluctuate during illness. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Monitoring patients who are receiving PN : 2- Hyperglycemia and hypoglycemia : A- A common blood glucose goal is < 150 mg /dl. B- Regular insulin ( initially 0.05 – 0.2 unit of dextrose per gram can added to the PN. 3- Monitor for electrolyte and acid base imbalances : - For metabolic alkalosis , Na and K can be administered as chloride salts. - For metabolic acidosis , Na and K can administered as the acetate salts. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Monitoring patients who are receiving PN : 4- Monitoring triglyceride concentrations : - Withhold lipid in patients with a concentration > 400 mg /dl. - When calculating lipid requirements account for any drugs mixed in a emulsion ( propofol , clevidipine). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Flexcil - The Smart Study Toolkit & PDF, Annotate, Note