Total Parenteral Nutrition - Definition, Procedure, Routes & Complications

1. Total Parenteral Nutrition
Ms.Nikethana R Nair, M.Sc (Nsg), MBA (HA), M.Sc (Psy), M.Phil
(HHSM),
NABH Assessor, Nursing Superintendent,
MMHRC - Madurai!

2. Introduction

3. DEFINITION
A method of feeding patients by infusing a
mixture of all necessary nutrients into the
circulatory system, thus bypassing the GIT.

4. Also referredto as
 Intravenous nutrition
 Parenteral alimentation &
 Artificial nutrition.

5. • The gut should always be the preferred route for
nutrient administration.
• Therefore, parenteral nutrition is indicated generally
when there is severe gastro-intestinal
dysfunction (patients who cannot take sufficient
food or feeding formulas by the enteral route) .

6. Criteriaof TPN
• If enteral feeding is completely stopped or
ineffective, Total Parenteral Nutrition is used (TPN).
• If enteral feeding is just “not enough” ,
supplementation with Partial Parenteral Nutrition
(PPN) is indicated.

7. Indications for TPN
Short-term use
• Bowel injury, surgery, major trauma or burns
• Bowel disease (e.g. obstructions, fistulas)
• Severe malnutrition
• Nutritional preparation prior to surgery.
• Malabsorption - bowel cancer
• Severe pancreatitis
• Malnourished patients who have high risk of aspiration
Long-term use (HOME PN)
• Prolonged Intestinal Failure
• Crohn’s Disease
• Bowel resection

8. Severe Malnutrition
• In well-nourished adults, 7 - 10 days of starvation
with conventional intravenous support (using 5%
dextrose solutions) is generally accepted.
• If the period of starvation is to extend beyond this time,
or the patient is not well-nourished, Total Parenteral
Nutrition (TPN) is necessary to prevent the potential
complications of malnutrition.

9. Nutritional Requirements
• Energy: Glucose
Lipid
• Amino acids (Nitrogen)
• Water and electrolytes
• Vitamins
• Trace elements

10. Patient's Needs
1. Metabolic needs
2. Clinical history
3. Blood work

11. What Central PN solution?
• 3 – in – 1 PN - Total Nutrient Admixture
• Consists of dextrose, amino acids,
intravenous fat emulsion, electrolytes,
vitamins, minerals & trace elements.

12. What Peripheral PN solution?
• Lower concentrations of dextrose & amino acids
may be administered through peripheral veins
• PPN will usually involve a more diluted formula
with fewer calories and is only recommended

13. Advantage
• Potentially life-saving when GI tract cannot be
used or when oral/parenteral nutrition cannot
meet nutrient requirements of patient.

14. Disadvantages
• Costly
• Long term risk of liver dysfunction, kidney
and bone disease & nutrient deficiencies

15. Routes Of Administration
• Provision of nutrients intravenously
– Central
– Peripheral

16. Application - Central Venous Access
• Catheter can be placed via the
a. Sub Clavian Vein &
b. The Jugular Vein: Less desirable because of the high rate of
associated infection, or
Note: Once the correct position of the catheter has been established
(usually by X ray), the infusion can begin.

17. Peripheral Line
A peripherally inserted central catheter line:
(PICC Line): A long catheter placed in an arm
vein and threaded into the central venous system.

18. Purpose: Central Parenteral Nutrition (CPN): Central VenousAccess
1. Utilization of large central veins for the administration
of a patient’s complete nutrient needs
2. Preferred Route
3. Can deliver daily requirement for kcals, protein,
micronutrients in concentrated volumes

19. Benefits of PICC Line
1. Access to central vein is not possible
2. Can accommodate hypertonic fluids
3. Lower risk of phlebitis
4. Easier to insert than central line

20. Nurses Role
• Its an stat order
• Check with the pharmacy with the availability of the
pack as written by the physician
• Counter check with what name it is reflected in the HIS
& then rise it
• Once the feed comes it should be started without any
delay
• Preparation must be done in an sterile method i.e. in the
medication preparation area.

21. Compression on the pack must be like: Compression on the first
compartment by keeping it on a flat surface, the pressure merges the 2
compartments & the contents gets mixed & then compress the merged
compartment, the pressure aids the contents to merge with the 3’rd
compartment. Mix it well.

22. Articles Required
• Hand Care
• Alcohol swab
• Poshi flush
• Transparent dressing (to change the dressing of the central line
or PICC Line)
• Gauze Pack – 2
• AHD – 1000 (Strictly use only AHD – 1000)

23. Application
Initiation of Therapy
TPN infusion is usually initiated at a rate of 25
to 50 mL/h. This rate is then increased by 25
mL/h until the predetermined final rate is
achieved.
Administration
To ensure that the solution is administered at a
continuous rate, an infusion pump is utilized to
administer the solution. In hospitalized patients,
infusion usually occurs over 22-24 h/day. In
ambulatory home patients, administration

24. Initiation of Therapy - Protocol
• Physicians Order :
1. 40 ml for 2 hours
2. After 2 hours 60 ml/hour is the constant rate that
is been maintained.

25. Calculation (Example)
• A Packet contains 1000 ml
• Initial rate if doctor is advising 40 ml for 2 hours
means: 80 ml for 2 hours gets over.
• So therefore 1000 ml – 80 ml = 920ml
• Formula: Total volume in bag
ml/hour
• 920 ml in bag/60 ml/hour = 15.3 hours
• So the balance amount in the bag must go within 15
hours & 30 mins

26. Special Consideration
• If in case the TPN is discontinued, then it should wrapped in
the new pharmacy cover after wiping it fully & especially
with the alcohol swab in the line inserted area
• It should be labeled with the patients sticker
• Use hand care when performing the procedure
• Then store it in the refrigerator, do not freeze it.

27. Special Consideration
• Validity for the pack is 24 hours. Eg: If the Pack is opened at 8
am & its been discontinued at around 3pm, it can be packed well
& kept in the refrigerator until next day 8am. If incase its not
been used then it should be discarded.
• If the TPN is continued from 7pm onwards then it should be as
per the rate ordered by the physician (60ml/hour) until next day
morning 8am & the remaining amount should be discarded.
• Should keep the feed out for 15 minutes & then connect it for the
patient.
• No catch up feed should be done.

28. Monitoring
1. Efficacy: Electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar,
body weight, Hb.
2. Complications: ALT – Alanine Amniotransferase (SGPT), AST -
Aspartate aminotransferase), Bil, BUN, total proteins and fractions.
3. General: Input- Output chart.
4. Detection of infection:
 Clinical (activity, temp, symptoms)
 WBC count (total & differential)
 Cultures

29. MMHRC Protocol
• Site: Central Line - X Ray - 6Hours
• Bag: 1000ml & 2000ml for central line & 1000ml
for Peripheral Line
• Flow Rate: 30ml - 1000ml & 100ml - 2000ml
• Investigations:
Everyday - GRBS
7th Day - LFT & TGS
48 hrs - RFT & Electrolytes once

30. Complications of TPN
• Sepsis
• Pneumothorax
• Air embolism
• Clotted catheter line
• Catheter displacement
• Fluid overload
• Hyperglycemia
• Rebound Hypoglycemia

31. Complicationsof TPN
Catheter-related complications
 Catheter sepsis: which can be localized or systemic (skin portal,
malnutrition, poor immunity).
 Symptoms: Fever, chills, ±drainage around the catheter entrance
site, Leukocytosis, +ve cultures (blood & catheter tip).
Treatment:
1. Exclusion of other causes of fever
2. Short course of anti-bacterial and antifungal therapy (acc. to
C&S)
3. Catheter removal may be required

32. Cathetersepsis(Cont.):
Prevention: A rigorous program of catheter care:
 Only I.V. nutrition solutions are administered through the
catheter, no blood may be withdrawn from the catheter.
 Catheter disinfection and redressing 2 to 3 times weekly.
 The entrance site is inspected for signs of infection and if
present, culture is taken or the catheter is removed.
 Other catheter-related complications:
Thromboembolism, pneumothorax, vein or artery perforation,
and superior vena cava thrombosis

33. Metabolic Complications
Hyperglycemia (an elevated blood sugar):
 Associated with the infusion of excess glucose in the feeding
solution or the diabetic-like state in the patient associated with
many critical illnesses.
 It can result in an osmotic diuresis (abnormal loss of fluid via
the kidney), dehydration, and hyperosmolar coma.
Treatment: Decrease the amount of infused glucose (to<4
mg/kg/min) OR insulin can be administered (either S.C. inj. or
incorporation in the infusion bag).

34. MetabolicComplications
 Hypertriglyceridemia (High S. Triglycerides): Associated with excess infusion of
fat emulsion.
Cause: Infusion of both glucose and fat emulsion in excess may result in pulmonary
insufficiency.
Excess glucose infusion –> excess carbon dioxide (CO2) production a result of
glucose metabolism.
Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce
the diffusion capacity of respiratory gases.

35. Metabolic Complications
Liver toxicity (also know as parenteral nutrition
cholestasis): It causes severe cholestatic jaundice,
elevation of transaminases, and may lead to irreversible
liver damage and cirrhosis.
Cause: Multiple causes have been proposed, including
high infusion rates of aromatic amino acids, high
proportion of energy intake from glucose, e.t.c.
Treatment: There is no specific treatment, other than
anticholestatic therapy.

36. Metabolic Complications
 Intestinal bacterial translocation:
The lack of direct provision of nutrients to the intestinal epithelia
during total parenteral nutrition Trophism and altered permeability
of the GI mucosa, thus compromising any potential recovery of the
patient’s ability for enteral feeding, and allowing bacterial entery to
blood stream  sepsis
Treatment: Prevention is to provide a minimal enteral nutrition supply
to avoid or minimize this risk.

37. Metabolic Complications
Other metabolic complications:
Electrolyte imbalance, mineral imbalance, acid-base
imbalance, toxicity of contaminants of the parenteral
solution.

38. Mechanical Complications
 Catheters and tubing may become clotted or twist
and obstruct.
 Pumps may also fail or operate improperly.