Parenteral nutritional fluids

The authors speculated that the catheter tip had spontaneously migrated because the ulcer on the left shoulder had eroded deeply to form a venocutaneous fistula with the left cephaUc vein. Continuous leakage of parenteral nutrition fluid through the fistula was soaked up by the gauze pads used to cover the ulcer, preventing early recognition of the problem. 

The chnical differentiation of chylothorax from leakage of parenteral nutrition fluid into the pleural space can be difficult. However, in one case the diagnosis of leakage of parenteral nutrition fluid was made by additional tests of electrolytes, showing very high concentrations of potassium (11.3 mmol/1) and glucose (128 mmol/1), mhng out chylothorax (13). 

As stated previously, contaminated products injected directly into the bloodstream or instilled into the eye cause the most serious problems. Intrathecal and epidural injections are potentially hazardous procedures. In practice, epidural injections are frequently given through a bacterial filter. Injectable and ophthalmic solutions are often simple solutions and provide Gram-negative opportunist pathogens with sufficient nutrients to multiply during storage if contaminated, a bioburden of 106 CFU as well as the production of endotoxins should be expected. Total parenteral nutrition fluids, formulated for individual patients ... 

Often the condition leading to the requirement for parenteral nutrition has seriously depleted the trace element stores of the patient concerned and so it is vitally important that adequate amounts of trace elements are present in parenteral nutrition fluids. 

Only one study (Ibrahim et ai, 2003) has reported iodine balances in a cohort of extreme preterm infants who were (initially) parenterally fed. Iodine intakes and urinary iodine outputs were determined for 13 infants over four separate 24h periods at postnatal day 1, 6, 13 and 27. The types and volumes of all enteral and parenteral nutrition fluids used for each infant were accurately recorded. 

Table 40.1 The types and volumes of enteral and parenteral nutrition fluids at balance days (Ibrahim et al., 2003) ...

Enteral and parenteral nutrition fluids are the principal sources of iodine intake in these infants. If the mother has adequate iodine nutrition, breast milk is the best source of iodine for the newborn. 

Also in this situation a separate room is required for preliminary operations, e.g. disinfection of utensils and surfaces of materials. In the preparation room medicines are reconstituted, e.g. filling of syringes, infusion bags, medication cartridges, disposable infusion pumps and irrigations. In addition, parenteral nutrition fluids, antineoplastics, radiopharmaceuticals and eye preparations may be prepared in these premises. Radiopharmaceuticals and other very... 

Impla.nta.ble Ports. The safest method of accessing the vascular system is by means of a vascular access device (VAD) or port. Older VAD designs protmded through the skin. The totally implanted ports are designed for convenience, near absence of infection, and ease of implantation. Ports allow dmgs and fluids to be deUvered directiy into the bloodstream without repeated insertion of needles into a vein. The primary recipients of totally implanted ports are patients receiving chemotherapy, bolus infusions of vesicants, parenteral nutrition, antibiotics, analgesics, and acquired immune disease syndrome (AIDS) medications. 

The composition of body fluids remains relatively constant despite the many demands placed on the body each day. On occasion, these demands cannot be met, and electrolytes and fluids must be given in an attempt to restore equilibrium. The solutions used in the management of body fluids discussed in this chapter include blood plasma, plasma protein fractions, protein substrates, energy substrates, plasma proteins, electrolytes, and miscellaneous replacement fluids. Electrolytes are electrically charged particles (ions) that are essential for normal cell function and are involved in various metabolic activities. This chapter discusses the use of electrolytes to replace one or more electrolytes that may be lost by the body. The last section of this chapter gives a brief overview of total parenteral nutrition (TPN). 

Along with a disturbance in fluid volume (eg, loss of plasma, blood, or water) or a need for providing parenteral nutrition with the previously discussed solutions, an electrolyte imbalance may exist. An electrolyte is an electrically charged substance essential to the normal functioning of all cells. Electrolytes circulate in the blood at specific levels where they are available for use when needed by the cells. An electrolyte imbalance occurs when the concentration of an electrolyte in the blood is either too high or too low. In some instances, an electrolyte imbalance may be present without an appreciable disturbance in fluid balance For example, a patient taking a diuretic is able to maintain fluid balance by an adequate oral intake of water, which... 

When normal enteral feeding in not possible or is inadequate to meet an individual s nutritional needs, intravenous (IV) nutritional therapy or total parenteral nutrition (TPN) is required. Products used to meet the IV nutritional requirements of the patient include protein substrates (amino acids), energy substrates (dextrose and fat emulsions), fluids, electrolytes, and trace minerals (see the Summary Drug Table Electrolytes). 

Concentrate intravenous medications ° Evaluate maintenance fluids ° Concentrate parenteral nutrition 0 Use concentrated enteral nutrition products Avoid and/or discontinue nephrotoxins wherever possible... 

Adjunctive therapy with fluid and electrolyte replacement should be initiated. Nutritional support with enteral or parenteral nutrition may be indicated for patients unable to eat for more than 5 to 7 days.2 Some evidence suggests that enteral nutrition provides anti-inflammatory effects in patients with active CD.40,41... 

D/C all antiretrovirals symptomatic support with fluids some patients require IV bicarbonate, hemodialysis, parenteral nutrition, or mechanical ventilation once syndrome resolves, consider using NRTIs with 4- mitochondrial toxicity (ABC, TDF, 3TC, or FTC) monitor lactate after restarting NRTIs some clinicians use NRTI-sparing regimens. 

O Parenteral nutrition (PN), also called total parenteral nutrition (TPN), is the intravenous administration of fluids, macronutrients, electrolytes, vitamins, and trace elements for the purpose of weight maintenance or gain, to preserve or replete lean body mass and visceral proteins, and to support anabolism and nitrogen balance when the oral/enteral route is not feasible or adequate. 

A chronically iU patient on long-term (home) parenteral nutrition develops metabolic acidosis, a grayish pallor, scaly dermatitis, and alopecia (hair loss). These symptoms subside upon addition of the B vitamin biotin to the alimentation fluid. 

Severe negative nitrogen balance may occasionally have to be corrected by hyperalimentation or total parenteral nutrition (TPN). Intravenous solutions used in TPN contain essential and nonessential amino acids, plus a source of calories in the form of fat and carbohydrate. They "spare" the administered amino acids and allow them to be used for tissue repair. The TPN fluid must also contain all other nutritional factors required for life, including essential fatty acids, vitamins, and minerals. Severe metal and essential fatty acid deficiencies have been observed in situations in which such inclusions had not been made. 

Peripheral PN (PPN) is a relatively safe and simple method of nutritional support. PPN candidates do not have large nutritional requirements, are not fluid restricted, and are expected to begin enteral intake within lOto 14days. Thrombophlebitis is a common complication this risk is greater with solution osmolarities greater than 600 to 900 mOsm/L (Table 60-2). Solutions for PPN have lower final concentrations of amino acid (3% to 5%), dextrose (5% to 10%) and micronutrients as compared to central parenteral nutrition (CPN). 

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