Author: Dr. Shailaja Shankar Behera
MBBS, MD (IMS BHU), PDCC Crical Care Medicine (IMS BHU), Post Doctoral Fellowship in Neuro Critcal Care (NIMHANS, Bengaluru), DM (Critical Care), AIIMS New Delhi" Apex Super specialty Hospitals, Varanasi.
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Abstract
Malnutrition among critically ill patients is very prevalent. The metabolic response to stress, injury, surgery, or inflammation cannot be accurately predicted and these metabolic alterations may change during the course of illness. Underfeeding and overfeeding both are very common in Intensive Care Unit (ICU), and this resulting in large energy and other nutritional imbalances. Better understanding of human nutrition and metabolic process has led to formulation of scientific parenteral solutions to suit specific situations. This article shows the negative consequences due to lack of nutrition and how Total Parenteral Nutrition can be helpful for the critically ill patients.
Keywords: Parenteral Nutrition, Total Parenteral Nutrition
Introduction
The feeding of nutritional product to a person intravenously, bypassing the usual process of eating and digestion is known as Parenteral nutrition. When no significant nutrition is obtained by other routes then the person will receive a nutritional formula that contain nutrients including glucose, salts, amino acids, lipids and added vitamins and dietary minerals. It is called total parenteral nutrition (TPN). Total parenteral nutrition (TPN) supplies all daily nutritional requirements.
The interruption in the continuity of gastrointestinal tract or the impairment in the absorptive capacity of gastrointestinal tract can be treated by total parenteral nutrition (TPN). TPN is also used to prevent malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral route.
JW Lifesciences is a Korea-based company, primarily engaged in manufacture and distribution of Intravenous(IV) fluid products and infusion solutions. The Company offers product that contents amino acids, lipids, proteins, vitamins, and minerals which is used in special cases. The company is also engaged in manufacture of total parenteral nutrition (TPN) products and others. COMBIKLAS is unique “Three-in-One” formulation, scientifically designed by JW Lifesciences.
Negative Consequences Regarding Lack of Nutrition
According to WHO, Nutrition is the pillar of human life, health and development across the entire life span. The body requires many different vitamins and minerals that are crucial for both body development and preventing disease. Nutrients aren’t produce naturally in the body, so you have to get them from your diet. An unhealthy diet increases the risk of many diet-related diseases. Basic nutrients for all life activities are carbohydrates, fats, and proteins. These constitute the carbon skeleton of numerous useful molecules, and deliver energy through oxidative decomposition. The main aim of nutrition is to prevent and treat nutritional deficiencies.
The critical ill patients are at high risk of malnutrition because of stress catabolism and inadequate or delayed nutrition intake.
Catabolic hormones (such as glucagon, cortisol, and catecholamines) are secreted in the early stage of critical illness to mobilize body nutrition reserves (muscle and adipose tissue) for the generation of endogenous energy substrate (glucose, amino acids, and free-fatty acids) and to prioritize the delivery of these energy substrates to vital organs (such as the brain or the heart). Proinflammatory cytokines such as Interleukin (IL)-1, IL-6 and tumor necrosis factor-α are also secreted at the same time in response to the body’s acute insult and further exaggerate the catabolism process [1]. During such inflammatory states, the provision of nutrition is not able to completely reverse the loss of body cell mass [2]. Such conditions make critically ill patients more prone to develop a risk of malnutrition (loss of body cell mass to a critical level), and the risk of complications is significantly increased if malnutrition develops [3]. At this stage, the priority is to provide nutrition support to support vital organ system functions and preserve appropriate host responses while the underlying disease is treated [4].
Depending on the patient’s history, the patients may already have features of malnutrition with a reduced or restricted food intake long before intensive care unit (ICU) admission the reason behind could be either underlying chronic conditions (such as chronic obstructive pulmonary disease, cancer, or chronic renal failure) or have reduced intake from a hospital stay prior to ICU admission [4,5].
Moreover, in the ICU, the patients may continue to have restricted nutrition intake and thus they may experience prolonged fasting or frequent feeding interruptions due to various ICU procedures [5].
These two factors, preexisting malnutrition and iatrogenic underfeeding, may further complicated the nutrition status and worsen clinical outcomes.
Infection and malnutrition have always been intricately linked. Malnutrition is the primary cause of immunodeficiency worldwide, with infants, children, adolescents, and the elderly most affected. Malnutrition and infection shows a strong relationship, because poor nutrition leaves individual underweight, weakened, and vulnerable to infections, primarily because of epithelial integrity and inflammation (figure 1) [6].
Figure 1: Interactions between malnutrition and infection
Malnutrition can make a person more susceptible to infection, and infection also contributes to malnutrition, which causes a vicious cycle (figure 2). An inadequate dietary intake leads to weight loss, lowered immunity, mucosal damage, invasion by pathogens, and impaired growth and development in children. A sick person’s nutrition is further aggravated by diarrhea, malabsorption, loss of appetite, diversion of nutrients for the immune response, and urinary nitrogen loss, all of which lead to nutrient losses and further damage to defense mechanisms. This results in the reduction of dietary intake. In addition, fever increases both energy and micronutrient requirements. Malaria and influenza, for example, have mortality rates proportionate to the degree of malnutrition [7].
Figure 2: The “vicious cycle” of malnutrition and infection
Nutrition and intestinal function are intimately interrelated. The chief purpose of the gut is to digest and absorb nutrients so as to take care of life. Consequently, chronic gastrointestinal (GI) disease commonly leads to malnutrition and increased morbidity and mortality.
Practical Guidance for Nutritional Treatment
COMBIKLAS
Combiklas is the most versatile TPN designed by JW Lifesciences. It is a sterile hypertonic emulsion, for central venous administration, in a three chamber bag with no added sulfites (table 1).
Table 1: Three chambers of COMBIKLAS
CHAMBERS |
COMPOSITION |
ROLE |
Chamber 1 |
Dextrose solution |
It is for fluid replenishment and caloric supply |
Chamber 2 |
Amino acids solution with Electrolytes |
It comprises essential and nonessential amino acids provided with electrolytes |
Chamber 3 |
Intralipid® 20% (a 20% Lipid Injectable Emulsion) |
It is prepared for intravenous administration as a credit of calories and essential fatty acid |
Route of Administration (Peripheral and Central)
JW Lifesciences, introduced Combiklas in both variants peripheral parenteral nutrition (Peri) and total parenteral nutrition (Central). Depending on which vein to be used, this procedure is often referred to as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN) [12]. Total Parenteral Nutrition (TPN) and Peripheral Parenteral Nutrition (PPN) are provided to patients who do not have any other source of nutrition. Both the TPN and the PPN are provided through IV route (figure 3). Though the two are used to provide the required nutrition to a patient, they are different various ways (table 2).
Figure 3: Routes of Feeding
When a patient is on Total Parenteral Nutrition, he relies on it completely. On the other hand, Peripheral Parenteral Nutrition, or PPN, is only partial. This means that the patient may be getting nutrition from other sources along with the PPN.
Another difference that can be seen is that Total Parenteral Nutrition comes in a higher concentration, and can only be administered through a larger vein. On the contrary, Peripheral Parenteral Nutrition comes in a lesser concentration, and can be delivered through a peripheral vein. Generally, the TPN is administered in the larger vein in the chest or neck.
PPN is not a preferred nutritional supplement for a long time. This is because it is not safe to use hyperosmolar solutions in peripheral veins for a very long time. However, the TPN can be used for a longer duration as it is delivered through a central vein.
Total Parenteral Nutrition is given to patients who are suffering from digestive disorders, or who are having any extended consequences of surgery or accident. The Peripheral Parenteral Nutrition is prescribed if a person’s digestive system has been blocked, or if the patient is not getting enough nutrition during an extended stay in the hospital [13].
Table 2: Comparison Between TPN and PPN [14]
Parameter of Comparison |
Total Parenteral Nutrition (TPN) |
Peripheral Parenteral Nutrition (PPN) |
Meaning |
It is a process in which the patient is given nutrients through veins when they do not have other nutrition sources |
It is a process of providing supplements with the other source of obtaining/receiving nutrients |
Time period |
It is long-term therapy |
It is normally a fourteen days' process. It is a short-term therapy |
Alkalinity |
TPN is more caustic as it has minerals, glucose, and electrolytes |
It is not very caustic as compared to TPN |
Manage |
TPN can only be applied in larger veins near the chest or neck of the patient |
PPN can only be applied to be in a short vein in a patient body |
Operate |
TPN can be given to a person who has a digestive disorder, accident, or has critical surgery |
PPN can be given to a person whose digestive system has been blocked or unable to take a sufficient amount of nutrients from other sources |
Indication and Pack Specified Usage
Combiklas indication remains same for every variant of pack size available but the use of different pack size depends upon the patient’s medical condition. Some of the most discussed indications are mentioned below:
Available Pack Size
Benefits of Fulfilling the Nutritional Requirement of Patient Through TPN
The development of parenteral nutrition (PN) contraindicated a long-held belief that nutritional administration entirely through the veins was impossible, impractical, or unaffordable. The ability to supply nutrients to patients lacking a functional GI tract ultimately saved lives that would have otherwise been lost due to malnutrition.
The major advantages of parenteral nutrition are:
Macronutrient Composition
Patient with severe symptoms needs ICU admission and also after intensified conditions by extended stay during hospitalization; consequently, leads to the demand of nutritional therapy based on their health conditions. Following recommendation are based on international guidelines for critically ill patient treatment which must be considered:
Inclusion of lipids in IV nutrition prevents essential fatty acid (EFA) deficiency. Solutions that provide up to 4% of total calories from linoleic acid or 10% of total calories from safflower oil-based emulsions will meet daily EFA requirements. Patients who receive PN without lipids, usually those with an egg allergy, should be monitored for EFA deficiency.
Conclusion
MALNUTRITION among hospitalized patients has been associated with increased morbidity, prolonged hospital stay, and increased costs to the health care system.
Total parenteral nutrition does not influence the overall mortality rate of surgical or critically ill patients. It may be helpful in reducing the complication rate, especially in malnourished patients, but study results are influenced by patient population, use of lipids, methodological quality, and year of publication.
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