Total parenteral nutrition

1. TOTAL PARENTERAL
NUTRITION
P By-Dr Rajender Kumar
Moderator-Lt Col Arvind Misra

2. DEFINATION
 Provision of nutrition for metabolic requirements and
growth through the parenteral route.
 The concept of parenteral nutrition existed way back in
1660 when oils and wines were given intravenously

3.  1852 by Bidder and Schimdt
 The importance of protein administration for nitrogen
balance, weight gain and general well being
 (2). In 1966, Dudrick –
 Implanting a catheter in the superior vena cava of beagle
puppies
 Used subsequently in an infant with short bowel syndrome
 He summed up the indications for TPN very simply, by saying
that it should be given in babies "who cannot eat, should not
eat and cannot eat enough."

5. Indications for TPN neonates
1. Gestation <30 weeks and / or birth
weight <1000g
2. Gestation >30 weeks, but unlikely to
achieve full feeds, due to respiratory
distress syndrome,
bronchopulmonary dysplasia.
3. Severe IUGR
4. Necrotising enterocolitis
5. GI tract problems like short bowel
syndrome, intractable diarrhea.
6. After surgical correction of GI
malformations likeTEF, intestinal
obstruction, malrotation with volvulus
omphalocoele, gastroschisis

6. Guidelines
The American Society for Parenteral and Enteral Nutrition
(ASPEN) and the Indian Society for Parenteral and Enteral Nutrition
(ISPEN)
a) Use PN only when
 oral intake is grossly inadequate
 or when tube feeding is not possible due to
poor tolerance
 or psychological reasons.
b) Whenever possible, use PPN supplementing the inadequate enteral intake.
c) When PN is indicated and when the patient is not critically ill and it is required
for a period <2 Weeks, a peripheral venous access is preferable.
d) In critically ill patients, compromised haemodynamically and/or requiring PN
for > 2 weeks, a central venous access is preferable.
e) Peripheral PN should not be considered if the glucose concentration in the
infusate exceeds 10-12%. Any concentration of lipids can be infused peripherally

7. Team approach to parenteral nutrition
 PN has become increasingly complex
 Careless use due to inadequate understanding or
poor supervision- results -devastating complications
 septicemia
 metabolic imbalances

8.  TPN should only be used in units where
 (i) there is full time medical coverage,
 (ii) trained nursing staff who can be relied upon for proper
care of IV lines,
 (iii) facilities to prepare solutions correctly under laminar flow
hood
 (iv) appropriate laboratory backup and
 (v) appropriate equipment including infusion pumps

12. (1) Protein as crystalline aminoacids
(2) Fats as lipids
(3) Carbohydrate as glucose
(4) Electrolytes–Sodium, potassium, chloride, calcium and magnesium
(5) Metals/Trace elements–Zinc, copper, manganese, chromium, selenium
(6) Vitamins A, C, D, E, K, thiamine, riboflavin, niacin, pantothenic acid,
pyridoxine, biotin, choline and folic acid

13. GOALS
NUTRI RDA REMARKS DOSAGE SOURCE
Calories : BMR - 50%,
activity - 25%,
growth - 12%,
specific dynamic
action (SDA) - 5%
and faecal loss -
8%
Bed ridden -only
2/3 of the RDA
Fever, illness- add
10% cal cal
Newborn 110-125 kcal/kg/day
Children 100-110 kcal/kg/day
Up to 0.7-0.8 kcal/ml (through P
Vein)
hypertonic glucose(1gm=4Cal), isotonic
fat emulsion, amino acid solution
Fluids roughly 1 ml for
each calorie/(HS
FORMULA)
SIADH- 2/3rd : 70-150 ml/kg LBW babies require more fluid
Glucose 15-30 g/kg/day 10% dextrose
ml/kg/day x 0.07
will give
mg/kg/min
Dose—10-30 g/kg/day
Up to 10—12% glucose(periph. Vein)
s 10%, 20%, 25%, or 50% glucose
Protein 1.5-2 g/kg/day RF-0.25-0.5 g/kg 2-5 g/kg/day. Crystalline amino acids like Aminosyn -
Abbott, Freamin III - McGaw, Travasol
10% - Baxter, Aminodrip, Vamin (7%),
Astymin 9% and Proteinsteril 6%
Fat 1-3 g/kg/day fat 30% of total
calories
0.5 g/kg can meet EFA expensive and
needs separate IV line
Liposyn with 10% safflower oil, egg
yolk lecithin and glycerol, and
Intralipid with 10% soyabean oil
instead of safflower oil
Vit.&
mineral
s
As per RDA multivitamins and
minerals like iron,
zinc etc., increases
during illness
Zinc 200 mg Copper 20 mg Chromium
0.2 mg Manganese 5 mg Selenium 1.5
mg

22. Model Calculation TPN
for a 10-month-old baby with 5 kg weight

23. preparation of parenteral nutrition sol. for
infants

25. equipment
LAMINAR FLOW

26. CLEANING OF LF BEFORE USE
STEP1 =TFR/DAY
STEP2= Substract fluid
required for medication
STEP3= AA+LIPID+GLUCOSE

27. Wear head cap, mask, sterile gown,gloves spread the sterile sheet over LF
Additional person holds the bottle of tpn med
clean the port of bottle with triple swab tecnique

28. 1st syringe = iv intralipid
3 swab clean tecnique
intra lipid suspension+multivitamin
2nd syringe

29. Separate labelling for lipd & AA
lipid & mvi infuse separetly from
aminovein, glucose, electrolytes
can be mixed at site of infusion with 3 way separate colour coding for different babies
take prepared TPN in a sterile sheet to bed side

30. TPN connection
IV LIPID+MVI
Aminovein+dextrose+ electrolytes

32. Monitoring

33. Complications
 a) Catheter related –
 Perforation
 Kinking
 Thrombosis
 Air embolism
 Pneumothorax
 Cardiac arrhythmias
 b) Metabolic like
 Hyperglycaemia
 Electrolyte and acid-base
imbalance
 Azotaemia
 Hyperammonaemia
 Aminoaciduria
 Fatty liver
 Hyperbilirubinaemia
 Cholestasis etc
c) Nutritional like
•Weight loss
•Vitamin, mineral, EFA, and phosphate
deficiency
•Hypervitaminosis
•Hypermanganesaemia,
•Metabolic bone disease etc.
d) Sepsis: is a major complication that should
be prevented
•The complications are high in untrained hands.

34.  Contraindications for TPN
 Hyperbilirubinaemia
 Azotaemia
 Shock
 Thrombocytopenia
 Extreme prematurity and RDS
 Intralipid is contraindicated in
 Jaundice
 Bleeding due to hypercoagulability
 Thrombocytopenia