Total Parenteral Nutrition (TPN)

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In the name of GOD
Total Parenteral Nutrition (TPN)
Presented by Shadi Farsaei (Assistand professor
of pharmacotherapy)
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Indication

• 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.

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• 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.

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• 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.

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• Eating disorders anorexia nervosa and severe
  malnutrition who are unable or unwilling to
  ingest adequate nutrition.

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• 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.

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Patient 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

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Visceral 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.
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Peripheral 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

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Parenteral 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,
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Subclavian PICC Jugular Femoral (more infection
!)
PICC Peripherally inserted central catheter
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Peripheral 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.

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Estimation 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

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• 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

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Estimation of protein requirement
Hypermetabolic/hypercatabolic state secondary to
trauma or burn 2 g/kg/day
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Components 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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Dextrose

• 20, 50 (from CV-line)
• 3.4 kcal/g
• 60-70 of calorie requirements should be provided
  with dextrose

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Special 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

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Aminofusion

• 5, 10 (from CV-line)
• 1-1.5 g/kg/day
• Should not be used as a calorie source

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Estimation 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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• 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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Intralipid

• 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

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1022 Kcal/L 345 mOsmol/L
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1080 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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An important solution

• Concentrate isotonic solution
• Source of essential FFA
• Substitute for CHO for ventilated pts.

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Caloric density of intravenous nutrients
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• Electrolytes (daily requirements for TPN)

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Recommended adult daily dose of parenteral
vitamins
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Available 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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Vitalipid
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.
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• 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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The 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.
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water

• 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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Monitoring

• 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

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References

• 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. ..