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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) * ... – PowerPoint PPT presentation

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Title: Total Parenteral Nutrition (TPN)


1
In the name of GOD
Total Parenteral Nutrition (TPN)
Presented by Shadi Farsaei (Assistand professor
of pharmacotherapy)
2
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.

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.

7
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

8
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.
9
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

10
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,
11
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.

15
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

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

17
Estimation of protein requirement
Hypermetabolic/hypercatabolic state secondary to
trauma or burn 2 g/kg/day
18
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

23
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

24
Aminofusion
  • 5, 10 (from CV-line)
  • 1-1.5 g/kg/day
  • Should not be used as a calorie source

25
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

32
1022 Kcal/L 345 mOsmol/L
33
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.

36
Caloric density of intravenous nutrients
37
  • Electrolytes (daily requirements for TPN)

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Recommended adult daily dose of parenteral
vitamins
40
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.
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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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.
53
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

57
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. ..
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