Total Parentaral Nutrition

1. GOD

2. Total Parenteral
Nutrition
Andisheh. Maneshi
Resident of pharmacotherapy
Tehran University of Medical
Sciences

3. Candidates for Receiving TPN
O obstruction in GI tract
O Surgery, trauma
O Chemotherapy, radiation therapy
O GI cancers
O IBD
O surgery or procedure requiring to be NPO (3-5
days…..7)
O Loss of appetite or no oral intake for past 5 days
O Absorption impairment
O Involuntary weight loss of ≥ 10% within last 3-6 months

4. Initial Patient Assessment
O Lab checks
O Physical assessment
O Nutritional history
O Consideration of other diseases
o Renal
o Hepatic
o Respiratory
o Cardiac
o metabolic

5. Lab Values
O Electrolytes
Na, K, Cl, Acetate, Phos, Mg, Ca
O Renal function evaluation
SrCr, BUN, urine output
O Liver function evaluation
ALT, AST, Alk Phos, Bili
O Protein status
Albumin, total protein, pre-albumin
O Lipid profile

6. Monitoring
O Daily lab values to be checked
Na, K, Cl, acetate, SrCr, FBS
O Twice weekly labs
Mg, Phos, Ca, CBC
O Weekly labs:
Albumin, LFTs, TG, INR
 Daily:
O in/out
O Pt’s weight
O IV site check for possible infection
O Checked of drug added to the regimen for possible physical
incompatibilities & interactions
Glucose to be checked every six hours and SSI

7. Calculations
OVolume : 40-60 cc/kg, More in N/V, Diarrhea, fever
OEnergy (Calorie): 20 -35 kcal/kg
OProtein: 0.6-2 g/kg/day
Oelectrolytes
O vitamins
Otrace elements

8. Calculations
Protein
O Calculation is based on:
O Renal function (max:1g/kg)
O Hepatic function(0.6 – 0.8 g/kg)
0.6-2 g/kg/day

9. Example
O Woman, 35Y/o, IBD, Diarhea, fistule, weight loss,
3lit 1/3,2/3
1. Cv Line (osmolarity)
2. V: 3lit
3. Calories:30kcal/kg/d= 1800cal (CHO, IL10%,
IL20%)
4. AA:2g/kg/d (10% (50/500cc), 5%(25/500cc)): 120g
70% CHO+30%li
Goal:
CHO:1800*2/3=1200/3.4=353g
IL: 1800*1/3=600/1.1=545 cc

10. Calculations: electrolytes
O Sodium: (135-145)1-2meq/kg/d
O Potassium:(3.5-5)1-2meq/kg/d
O Magnesium:(1.5-2.4) 8-20meq/d
O Phosphate:(2.5-4.5) 15-40 mmol/d
O Calcium: corrected with Alb
5-15meq/d
KCl 15% inj: 2meq/ml
NaCl 5% inj :0.86meq/ml
MgSO4 50% inj: 4meq/ml
CaGluconate 10% inj: 0.5meq/ml
NaPhos inj: 1mmmol ph, 2meq Na/m
1. NS
2. ½ NS
3. D5W
4. D10W
5. 1/3 ,2/3
6. D5/NS

11. O TPN: 24h(ideal)
Hyperglycemia, Tachycardia, ….
O Intralipead : 12h (infection)

12. Calculations
insulin
ORegular insulin :
OInsulin used in the previous day as SSI
(a fraction of ins added to next day
TPN)
OBased on grams of dextrose in the
solution

13. Calculations
vitamins
O B vitamins
O Ascorbic acid (Vit C)
O Vitamin A
O Vitamin D
O Vitamin E
O Vitamin K
 Soluvit
 Bcomplex

14. Calculations
trace elements
OCopper
OManganese
OSelenium
OZinc
OChromium
Adamel
Tracutil

15. TPN therapy complications
O Re-feeding syndrome :
Intracellular electrolyte shift
O hypoMg, hypoK, hypoPhos
O Hyperglycemia, hyper insulinemia
O Prevention:
start TPN with 50% of energy requirements for the 1st 2
days
O Electrolyte imbalance
O IV line infection/ bacteremia

16. Discontinuation of TPN
O As soon as GI is functional considering D/C process
O Titrate the TPN rate down by increasing the oral or
enteral feeding tolerance
O May use cyclic TPN for a few days before D/C or in
cases of long TPN therapy