Total parenteral nutrition

Clinical Pharmacy and Therapeutics -II
Total Parenteral Nutrition
PRESENTED BY :
IFRAH ARIF
ROLL # PPHS20E007
PRESENTED TO:
DR. M. ROUF AKRAM
M.PHIL PHARMACEUTICS
COLLEGE OF PHARMACY, UOS, SARGODHA

CONTENTS
1) INTRODUCTION
2) TOTAL PARENTRAL NUTRITION
3) TYPES OF PATIENTS REQUIRE TPN
4) INDICATIONS FOR TPN
5) COMPOSITION OF TPN SOLUTION
6) CALCULATIONS
7) ROUTE OF ADMINISTERATION
8) COMPLICATIONS OF TPN
9) REFEEDING SYNDROME
10) MONITORING OF PATIENTS ON TPN
11) ROLE OF PHARMACIST IN TPN
12) REFERENCES
12/5/2020 CLINICAL PHARMACY AND THERAPEUTICS-II 2

INTRODUCTION
MALNUTRITION
Malnutrition can be described as a deficiency, excess, or imbalance of
energy, protein, and other nutrients that causes measurable adverse effects
on body tissue, size, shape, composition, function and clinical outcome.
NUTRITION
A diet that provide us energy and includes all the nutrients like
carbohydrates, fats, proteins, vitamins,minerals,electrolytes and fluids.
TYPES OF NUTRITION
Enteral nutrition
Parenteral nutrition

PARENTRAL NUTRITION
Parenteral nutrition (PN) is intravenous administration of nutrition,
which may include protein, carbohydrate, fat, minerals and
electrolytes, vitamins and other trace elements for patients who
cannot eat or absorb enough food through tube feeding formula or by
mouth to maintain good nutrition status.
Achieving the right nutritional intake in a timely manner can help
combat complications and be an important part of a patient’s
recovery. Parenteral nutrition is sometimes called Total Parenteral
Nutrition (TPN).

HISTORY OF PARENTERAL THERAPY
1657: First recorded injection
Christopher Wren
1855: First cutaneous injection of drugs using hypodermic needles.
Dr. Alexander Wood
1920s: Proof microbial growth resulting in infections.
Dr. Florence Seibert
1926: Inclusion in the national formulary.
1931: Commercial intravenous solution (Baxter).
1946: Organization of parenteral drugs association.
1961: Development of laminar flow concept.
1965: Development of total parenteral nutrition (TPN).

TYPES OF PARENTRAL NUTRITION
Partial or peripheral parenteral nutrition(PPN)
Simultaneous IV nutrition with enteral nutrition.
Provide only part of daily patients requirements.
Given by peripheral route
Total parenteral nutrition(TPN)
Feeding a patient solely via IV route
Provide all of the patients daily requirements
Given by central route.

TYPES OF PATIENTS REQUIRE TPN
Unconscious
Elder
Have clinical illness
Paediatrics
Burned
Patient has failed EN with appropriate tube placement.
Severe acute pancreatitis
Severe short bowel syndrome
 Mesenteric ischemia
Paralytic ileus
Small bowel obstruction

INDICATIONS FOR TPN
PN is a nutritionally balanced aseptically prepared or sterile
physicochemically stable solution or emulsion for intravenous
administration.
It is indicated when:
•Patients are malnourished or at the risk of malnutrition.
•GI tract is inaccessible.
•GI tract is Perforated or non-functional.
•When enteral nutrition is inadequate or unsafe.
PN should be considered if enteral route is not likely to be possible
for more than 5 days.

COMPOSITION OF TPN SOLUTION
1. MACRONUTRIENTS
2. MICRONUTRIENTS
Macronutrients: Carbohydrate
Source: Monohydrous dextrose
Properties: Nitrogen sparing Energy source 3.4 Kcal/g Hyperosmolar
Recommended intake: 2 – 5 mg/kg/min 50-65% of total calories
Potential Adverse Effects:
• Increased minute ventilation
• Increased CO2 production
• Increased O2 consumption
• Lipogenesis and liver problems
• Hyperglycemia

Macronutrients: Amino Acids
Source: Crystalline amino acids— standard or specialty
 To balance the patient's amino acid requirements and the chemical
characteristics of the amino acids (solubility, stability and
compatibility), a range of commercially available licensed solutions
has been formulated containing a range of amino acid profiles.
Recommended intake: 0.8-2.0 g/kg/day 15-20% of total calories
 Increased renal solute load
 Azotemia

Macronutrients: Lipid
Source: Safflower and/or soybean oil
• Properties: Long chain triglycerides Isotonic or hypotonic Stabilized
emulsions 10 Kcals/g Prevents essential fatty acid deficiency
• Recommended intake: 0.5 – 1.5 g/kg/day (not >2 g/kg) 12 – 24 hour infusion
rate
• Egg allergy
• Hypertriglyceridemia
• Decreased cell-mediated immunity (limit to <1 g/kg/day in critically ill
immunosuppressed patients)
• Abnormal LFTs

Parenteral Base Solutions
Carbohydrate – Available in concentrations from 5% to
70% – D30, D50 and D70 used for manual mixing
• Amino acids – Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20%
solutions – 8.5% and 10% generally used for manual
mixing
• Fat – 10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml
30% emulsions = 3 kcal/ml (used only in mixing TNA, not
for direct venous delivery)

Other Requirements
Fluid—30 to 50 ml/kg (1.5 to 3 L/day) – Sterile water is
added to PN admixture to meet fluid requirements
Electrolytes – Use acetate or chloride forms to manage
metabolic acidosis or alkalosis
Vitamins: multivitamin formulations
Trace elements

CALCULATIONS OF TPN

ROUTES OF ADMINISTERATION
PERIPHERAL LINES
Arm veins
For <10% Dextrose solution only
PN may be administered via peripheral access when Therapy is expected to be
short term (10-14 days)
 Energy and protein needs are moderate
Formulation osmolarity is <600-900 mOsm/L
Fluid restriction is not necessary

CENTRALVENOUS CATHETERS
Subclavian or internal Jugular vein is catheterized
Used when peripheral veins are unsuitable
Used when patient requires high concentration solution for high energy
requirements.

PERIPHERALLY INSERTED CENTRAL CATHETERS
(PICC)
•Inserted into cephalic vein then threaded up towards the
heart into right subclavian vein.
•Infuse either central or peripheral solution
•A PICC line is one type of catheter used to access the large
veins in your chest (central venous catheter). Examples of
other types of central venous catheters include implantable
ports and central lines.

PICC lines may be used in ambulatory settings or for long term therapy
 Used for delivery of medication as well as PN
 Inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into
the superior vena cava
 Can remain in place for up to 1 year with proper maintenance and without complications

COMPLICATIONS
Line sepsis
This is a serious and potentially life-threatening condition.
Monitoring protocols should ensure that signs of infection are
identified early and a local decision pathway should be in place to
guide efficient diagnosis and management.
Management will depend upon the type of line and the source of
infection.
Alternative sources of sepsis should be considered. Initially, the
PN is usually stopped.

Line occlusion
 Line occlusion may be caused by a number of factors, including:
Fibrin sheath forming around the line, or a thrombosis blocking the tip
Internal blockage of lipid, blood clot or salt and drug precipitates
Line kinking
Management will depend on the cause of the occlusion; in general, the aim is to save
the line and resume feeding with minimum risk for the patient.
The use of locks and flushes with alteplase (for fibrin and thrombosis), ethanol (for
lipid deposits) and dilute hydrochloric acid (for salt and drug precipitates) may be
considered. In some cases, the lines may need to be replaced.

Examples of complications during parenteral nutrition
Catheter-related
Thrombophlebitis (peripheral)
Catheter-related infection (local or systemic)
Venous thrombosis
Line occlusion(lipid, thrombus, particulate, mechanical)
Metabolic-related
Hyperglycemia or hypoglycemia
Electrolyte imbalance
Lipid intolerance
Refeeding syndrome
Dehydration or fluid overload

Specific nutritional deficiency or overload
Liver disease or biliary disease
Gastro-intestinal atrophy
Metabolic bone dysfunction(in long term)
Thrombocytopenia

REFEEDING SYNDROME
Refeeding syndrome can be defined as potentially fatal shifts in
fluids and electrolytes that may occur in malnourished patients
receiving artificial refeeding( whether enterally or parenterally).
It is the metabolic complication.
Hypokalaemia, hypoglycemia, sodium and fluid retention may
develop in this syndrome.

Specific disease states
Liver
Although abnormal liver function tests associated with short-term
PN are usually benign and transient, liver dysfunction in long-term
PN patients is one of the most prevalent and severe complications.
The content of PN should be examined and care should be taken not
to overfeed with glucose and/or lipid.
 Low-sodium, low-volume feeds are indicated if there is ascites.
Cyclic feeding appears useful, especially in steatosis.

Renal failure
Fluid and electrolyte balance demand close attention, and guidelines for
nutrition in adult renal failure are available.
 A low volume and poor quality urine output may necessitate a concentrated PN
formulation with a reduction in electrolyte content, particularly a reduction in
potassium and phosphate.
In the polyuric phase or the nephrotic syndrome, a higher volume formulation
may be required.
If there is fluid retention, ideal body weight should be used for calculating
requirements rather than the actual body weight.

Pancreatitis
Acute pancreatitis is a metabolic stress that requires high-level
nutritional support and pancreatic rest to recover. Guidelines for
nutrition in acute pancreatitis are available (Gianotti et al., 2009).
While enteral nutrition stimulates the pancreas, PN does not appear
to. Hyperglycaemia may occur and require exogenous insulin.

Cardiac failure
Cardiac failure and multiple drug therapy may limit the volume of PN that can
be infused. Concentrated formulations are used and, as a consequence of the
high tonicity, administered via the central route. Close electrolyte monitoring
and adjustment is required. Cardiac drugs may affect electrolyte clearance.
Diabetes mellitus Diabetic
Patients can generally be maintained with standard dual-energy regimens. It is
important to use insulin to manage blood glucose rather than reduce the
nutritional provision of the feed. Close glucose monitoring will guide
exogenous insulin administration.

MONITORING OF PATIENTS ON TPN
Progress of patients with a TPN line should be followed on a
flowchart. Weight, complete blood count, electrolytes, and blood
urea nitrogen should be monitored often (eg ,daily for inpatients).
Plasma glucose should be monitored every 6 hours until patients
and glucose levels become stable. Fluid intake and output should be
monitored continuously. When patients become stable, blood tests
can be done much less often.

Liver tests should be done. Plasma proteins (eg, serum albumin)
prothrombin time, plasma and urine osmolality, and calcium,
magnesium, and phosphate should be measured twice/week.If
possible, blood tests should not be done during glucose infusion.
Full nutritional assessment (including BMI
calculation and anthropometric measurements) should be repeated at
2-week intervals.

ROLE OF PHARMACIST IN TPN

REFERENCES
1. Katoue MG. Role of pharmacists in providing parenteral nutrition support: current insights and future
directions. Integr Pharm Res Pract. 2018 Oct 2;7:125-140. doi: 10.2147/IPRP.S117118. PMID:
30324089; PMCID: PMC6173269.
2. Solomon DM, Emery EZ, Kavelak HL, Pontiggia L, Hollands JM, Bingham AL. Impact of
Implementation of the American Society for Parenteral and Enteral Nutrition Model for Parenteral
Nutrition Order Writing and Review on Competency, Attitudes, and Perceptions. Nutr Clin Pract. 2019
Aug;34(4):597-605. doi: 10.1002/ncp.10237. Epub 2019 Jan 15. PMID: 30644606.
3. http://www.nutritioncare.org/about_clinical_nutrition/what_is_parenteral_nutrition/#:~:text=Parenteral
%20nutrition%20(PN)%20is%20intravenous,to%20maintain%20good%20nutrition%20status.
4. Khursheed N Jeejeebhoy, Total parenteral nutrition: potion or poison?, The American Journal of
Clinical Nutrition, Volume 74, Issue 2, August 2001, Pages 160–
163, https://doi.org/10.1093/ajcn/74.2.160
5. Elson, C.O., Layden, T.J., Nemchausky, B.A. et al. An evaluation of total parenteral nutrition in the
management of inflammatory bowel disease. Digest Dis Sci 25, 42–48 (1980).
https://doi.org/10.1007/BF01312731

6. Joseph I. Boullata, David Berlana, Magdalena Pietka, Stanislaw Klek, Robert Martindale, Use of
Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects, Journal of Parenteral
and Enteral Nutrition, 10.1002/jpen.1737, 44, S1, (S74-S81), (2020).
7. A.S.P.E.N. Nutrition Support Practice Manual, 2005; p. 94
8. Barber et al. In ASPEN, The Science and Practice of Nutrition Support: A Case-Based Core Curriculum.
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9. Bethune, K., Allwood, M., Grainger, C., et al., 2001. Use of filters during the preparation and
administration of parenteral nutrition: position paper and guidelines prepared by a British Pharmaceutical
Nutrition Group Working Party. Nutrition 17, 403–408.
10. De Meijer, V.E., Gura, K.M., Le, H.D., 2009. Fish oil-based emulsions prevent and reverse parenteral
nutrition associated liver disease: the Boston experience. J. Parent. Ent. Nutr. 33, 541–547.
11. Clinical Pharmacy and Therapeutics Edited by Roger Walker bPharm, Phd, FRPharmS, FFPH Professor of
Pharmacy Practice, Welsh School of Pharmacy, Cardiff University, Cardiff UK

Total parenteral nutrition

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