Title: Total Parenteral Nutrition (TPN)
1In the name of GOD
Total Parenteral Nutrition (TPN)
Presented by Shadi Farsaei (Assistand professor
of pharmacotherapy)
2Indication
- Inability to absorb nutrients via the GI tract
because of one or more of the following - Massive small bowel resection
- Intractable vomiting when adequate EN is not
expected for 7-14 days. - Severe diarrhea
- Bowel obstruction
- GI fistulae PN is indicated for patients with
prolonged inadequate nutritional intake longer
than 5-7 days who are not candidates for EN.
3- Cancer antineoplastic therapy, radiation
therapy, or HSCT - moderately to severely malnourished patients
receiving active anticancer treatment who are not
candidates for EN. - PN is unlikely to benefit patients with advanced
cancer whose malignancy is unresponsive to
treatment. - PN is appropriate for patients undergoing HSCT
who are malnourished and who are anticipated to
be unable to ingest and/or absorb adequate
nutrients for 7-14 days. - Pancreatitis severe pancreatitis with prolonged
inadequate nutritional intake longer than 5-7
days who are not candidates for EN. PN should be
used when EN exacerbates abdominal pain, ascites,
or fistula output.
4- Critical care
- whom EN is contraindicated or is unlikely to
provide adequate nutritional requirements within
5-10 days. - Organ failure (liver, renal, or respiratory)
moderate to severe catabolism when EN is
contraindicated. - Burns whom EN is contraindicated or is unlikely
to provide adequate nutritional requirements
within 4-5 days. - Perioperative PN
- Preoperative for 7-14 days for patients with
moderate to severe malnutrition who are
undergoing major GI surgery, if the operation can
be safely postponed. - Postoperative for patients in whom EN is
contraindicated or is unlikely to provide
adequate nutritional requirements within 7-10
days.
5- Eating disorders anorexia nervosa and severe
malnutrition who are unable or unwilling to
ingest adequate nutrition.
6- Adult PN therapy is not an emergent intervention
and should not be initiated until the patient is
hemodynamically stable. - In general, adults who are not candidates for
enteral nutrition should be considered candidates
for PN after 7 to 14 days of suboptimal
nutritional intake.
7Patient Assessment
- Nutrition History malnutrition
- Weight History
- 5 of usual weight within 1 month, or 10 of
usual weight within 6 months - Physical Examination
- Anthropometry
- Biochemical Assessment
8Visceral Proteins for Nutrition Assessment
1. Brown RO, Bradley JE, Bekemeyer WB, Luther RW.
Effect of albumin supplementation during
parenteral nutrition on hospital morbidity.
Critical care medicine. 198816(12)1177-82. 2. Ko
retz RL. Intravenous albumin and nutrition
support going for the quick fix. JPEN Journal of
parenteral and enteral nutrition.
199519(2)166-71. 3. Rubin H, Carlson S, DeMeo
M, Ganger D, Craig RM. Randomized, double-blind
study of intravenous human albumin in
hypoalbuminemic patients receiving total
parenteral nutrition. Critical care medicine.
199725(2)249-52.
9Peripheral line
- 700-900 mOsmol
- Chang IV each 2-3 d
- Dextrose 10
- Aminoacid 5 Energy lt 1 kcal/ml
- Intralipid ?
- Dilution of dextrose/aminofusion with Intralipid
10Parenteral Nutrition
- Peripheral Parenteral Nutrition (15 lit D5W/day
for a 70 kg !!!) - Central Parenteral Nutrition (TPN)
- needs CV-line to administer hyperosmolar
solutions
Osmolarity (Dex 50) (Aminoacid 100)
150 mOsm for electrolytes,
11Subclavian PICC Jugular Femoral (more infection
!)
PICC Peripherally inserted central catheter
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14Peripheral Vein thrombophelebitis
- Hydrocortisone 5 mg/L
- Heparin 1000 U/L
- Topical nitroglycerin
- Concurrent administration of intralipid ?
- Decreases osmolarity, buffers the pH, and
improves peripheral vein tolerance, it does not
eliminate the risk of thrombophlebitis.
15Estimation of energy expenditure
- Weight metabolic state
-
- Harris-Benedict equations
- BEE (M) (kcal/day) 66.4713.75W5H-6.76A
- BEE (F) (kcal/day) 65.519.56W1.85H-4.68A
- BEE 20-25 kcal/kg/day
- TEE (kcal/day)
- BEE Stress factor Activity
factor
16- Stress factors
- Surgery 1.1-1.2
- Infection 1.2
- Trauma 1.5
- Sepsis 1.6
- Burns 1.6-2
- Activity factors
- Confined to bed 1.2
- Out of bed 1.3
- Normal activity 1.5
17Estimation of protein requirement
Hypermetabolic/hypercatabolic state secondary to
trauma or burn 2 g/kg/day
18Components of TPN Formulations
- Macro
- Calorie Dextrose 20, 50
- Intralipid 10, 20
- Protein Aminofusion 5, 10
- Fluid
- Micro
- Electrolytes (Na, K)
- Minerals (Mg, Ca, PO4)
- Trace elements (Zn, Cu,
Cr, Mn, Se) - Vit (A, E, C,
B, Folic acid)
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22Dextrose
- 20, 50 (from CV-line)
- 3.4 kcal/g
- 60-70 of calorie requirements should be provided
with dextrose
23Special Considerations
- Max infusion rate of dextrose 0.5 g/kg/h (to
avoid - hyperglycemia, glycosuria, fatty liver,
hyperosmolar coma) - Max rate of dextrose metabolism 5 mg/kg/min or
7 g/kg/d - K should be added to dextrose solutions
- If BS gt 200, Insulin should be added
- 0.1 U/g Dextrose
24Aminofusion
- 5, 10 (from CV-line)
- 1-1.5 g/kg/day
- Should not be used as a calorie source
25Estimation of Protein Requirements
- RDA
0.8 g/kg/day - Hospitalized patient, minor stress 11.2
g/kg/day - Moderate stress 1.21.5
g/kg/day - Severe stress 1.52
g/kg/day
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29- Na 43 mmol/L
- K 25 mmol/L
- Mg 2.6 mmol/L
- Acetate 59 mmol/L
- Cl 57 mmol/L
- H2PO4 9 mmol/L
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31Intralipid
- 10, 20 (from peripheral or CV-line)
- 30-40 of calorie requirements should be provided
with Intralipid - Serum TG level must be lt 400 mg/dl
- Max. 2.5 g/kg or 60 total calories
-
321022 Kcal/L 345 mOsmol/L
331080 Kcal/L
1 liter contains A- Active
constituents - Glycerine (glycerol)
25g - Phospholipids from egg
6g - Soya beans
100g B- Other Constituents -
Sodium Oleate, Sodium hydroxide water Total
energy 1080Kcal/L
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35An important solution
- Concentrate isotonic solution
- Source of essential FFA
- Substitute for CHO for ventilated pts.
36Caloric density of intravenous nutrients
37- Electrolytes (daily requirements for TPN)
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39Recommended adult daily dose of parenteral
vitamins
40Available dosage form for parenteral rout
- Amp Vit A 50000 IU
- Amp Vit D 300,000U
- Amp Vit K 1, 10 mg ??!!
- Amp Vit E 100 IU
- Amp Vit C 500 mg
- Amp Vit B complex
- Amp Vit B12 100, 1000 mcg
- Amp Soluvit (Fressenius)
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45Vitalipid
INDICATIONS Vitalipid N Adult is indicated as a
supplement in complete intravenous nutrition to
meet the daily requirements of the fat-soluble
vitamins A, D2, E and K1. As above, Vitalipid N
Infant is indicated in paediatric patients up to
11 years of age.
46- The vitamins are soluble in the oil phase of the
emulsion, which has the composition corresponding
to that of Intralipid 10. - The daily maintenance dosage of the vitamins A,
D2, E and K1 are supplied during intravenous
nutrition when - (i) 10 mL of Vitalipid N Adult are added to 500
mL Intralipid 10 or 20. - (ii) 1 mL of Vitalipid N Infant per kg bodyweight
per day up to a maximum of 10 mL is added to
Intralipid 10 or 20.
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52The recommended dose is 1 mL Peditrace/kg body
weight/day for infants and children with a
weight of up to 15 kg. The basic requirements of
trace elements are covered by a daily dose of 15
mL to children weighing more than 15 kg Infusion
time The infusion time should not be less than 8
hours. The infusion should be given at a very
slow rate.
53water
- ml/day 1500 ml (IBW-20) 20
- 30-35 ml/kg
- Average healthy adult 5 L/d
- Fluid restricted 2 L/d
- Emesis, diarrhea, agitation, ventilation, fever
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56Monitoring
- Baseline
- Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT, INR,
TG, LFT, Alb - Daily Wt, V/S, I/O, Na, K, BUN, Cr, Glu
- 2-3 times a week CBC, Ca, P, Mg
- Weekly Alb, LFT, INR
57References
- Mirtallo, J., D. Johnson, et al. (2004). "Safe
practices for parenteral nutrition." Journal of
Parenteral and Enteral Nutrition 28(6) S39-S70. - Koda-Kimble, Mary Anne, and Brian K. Alldredge.
Applied Therapeutics The Clinical Use of Drugs.
Baltimore Wolters Kluwer Health/Lippincott
Williams Wilkins, 2013. - DiPiro, Joseph T. Pharmacotherapy A
Pathophysiologic Approach. New York McGraw-Hill
Medical, 2011. ..