BY THE NAME OF ALLAH THE MOST BENEFICENT AND THE MOST MERCIFUL
Definition: Total parenteral nutrition ("TPN"), means the administration of complete and balanced nutrition by intravenous infusion in order to support anabolism, body weight maintenance or gain, and nitrogen balance, when oral or enteral nutrition are not feasible or are inadequate. Also referred to as Intravenous nutrition, parenteral alimentation, and artificial nutrition.
Indications for TPN Short-term use• Bowel disease (e.g. obstructions, fistulas > 1500ml/day).• Nutritional preparation prior to surgery.• Severe pancreatitis.• Malnourished Patient—Inadequate intake for > 7 days.• Unintentional weight loss > 10% or weight is > 20% below ideal body weight.• Inability to use GI tract—For greater than 7 days.• Major trauma or burns.• Long-term use (HOME PN)• Prolonged Intestinal Failure(e.g mesenteric infarction)• Crohn’s Disease• Bowel resection(short gut )
Energy: Glucose and LipidsAmino acids (Nitrogen)Water and electrolytesVitaminsTrace elements
Requirements EnergyEnergy requirement = BEE x activity factor x injury factor . Basal energy expenditure(BEE) is calculated =25-30 kcal/ kgBW/day.(Harris Benedict formula)ACTIVITY FACTOR:•1.2 Confined to bed•1.3 AmbulatoryINJURY FACTOR:•Uncomplicated patient1•Postoperative state 1.1•Fractures 1.2•Sepsis 1.3•Peritonitis 1.4•Multiple trauma 1.5•Multiple trauma and Sepsis 1.6•Burns 30 - 50% 1.7•Burns 50 - 70% 1.8•Burns 79 - 90% 2
Requirements Glucose• Most stable patients tolerate rates of 4-5 mg.kg-1.Min-1, but insulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin should be incorporated acc. to blood sugar levels. Route• Glucose in 5 – 15 % solution can be administered via a peripheral vein, but higher concentrations require a central venous line.
Requirements Energy Sources: Lipid• Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted patients.• They are available in 10, 20 and 30% preparations.• Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is 10Kcal/g due to the contents of glycerol and phospholipids.
Requirements: Protein : Protein is the functional and structural component ofthe body, so fulfilling patient’s caloric needs with non-protein calories (fat and glucose) is essential. Protein requirements for most healthy individualsare 0.8 g/kg/day. But it varies in different conditions.
Requirements Protein: Daily Protein requirements Condition Example requirementBasic requirements Normal person 0.5-1g/KgSlightly increased requirements Post-operative, cancer, 1.5g/Kg inflammatoryModerately increased Sepsis, polytrauma 2g/KgrequirementsHighly increased requirements Peritonitis, burns, 2.5g/KgReduced requirements Renal failure, hepatic 0.6g/Kg encephalopathy•Parenteral amino acid solutions provide all known essentialamino acids.•Available A.A preparations are 3.5 - 15 % (ie contains 3.5-15gms of protein or A.As/100 mL solution).
Requirements Protein:•Special a.a. solutions are also available containing higherlevels of certain a.a.s, most commonly the branched-chainones (valine, leucine and isoleucine), aimed at themanagement of liver diseases, sepsis and other stressconditions.•Conversely, solutions containing fewer a.a.s (primarilythe essential ones) are available for patients with renalfailure.
RequirementsFluids and electrolytes: Nutrient Requirements (/Kg/day) Water 20-40 mL Sodium 0.5-1.0 mmol Potassium 0.5-1.0 mmol Magnesium 0.1-0.2 mmol Calcium 0.05-0.15mmol Phosphate 0.2-0.5mmolChloride/Acetate So as to maintain acid-base balance (normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)
Requirements Vitamins Vitamins are either fat soluble (A,D,E,K) or watersoluble (B,C). Separate multivitamin commercialpreparations are now available for both. Most adult vitamin formulae do not contain vitamin K,which is added according to the patient’s coagulationstatus.
Requirements Trace minerals These are essential component of the parenteralnutrition regimen. A multi-element solution is available commercially, andcan be supplemented with individual minerals. May be toxic at high doses. Iron is excluded, as it alters stability of otheringredients. So it is given by separate injection (iv or im).
OsmolarityPPN: Maximum of 1000 mosmoles / liter.TPN: as nutrient dense as necessary (1000 - 3000)mosmoles/liter.
• Total calories required = BEE x activity factor x injury factor x weight = 25 x 1.2 x 1.2 x 40 = 1440 kcal/day• Glucose(50-60 %): Out of 100 kcal glucose should give = 60 kcal 1440 ------------------------------- = 60/100x1440 = 864 kcal 1ml 25% glucose = 1kcal 864 ml/day of 25% glucose Lipids(25-40%): out of 100 kcal lipids should give = 40 kcal 1440 kcal --------------------- = 40/100x1440 = 576 1ml 20% lipid sol = 2kcal ml of 20% lipid required = 576/2 = 288 ml Protein: 1.5g per kg per day 1.5x40 = 60 g/day 5g A.A is contained in = 100ml 5% sol. 1g------------------------- = 100/5 60g----------------------- = 100/5x60 = 1200 ml/ day
ApplicationThe SolutionSingle bottle +Systems“All-in-one” mixtures2- or 3-chamber bags +
First week LaterUrine measurementsGlucose dailySpecific gravity and osmolarity Daily DailyGeneral measurementsInput & output Daily DailyPrevention and detection of infectionClinical observation (activity, Daily Dailytemperature, symptoms )TLC & DLC As indicated As indicatedCultures As indicated As indicated
Complications of TPNAbout 5 to 10% ofpatients havecomplications related tocentral venous access.Catheter-related sepsisoccurs in about ≥ 50% ofpatients. Glucoseabnormalities(hyperglycemia orhypoglycemia) or liverdysfunction occurs in >90% of patients. *(The Merck Manual)
Catheter related: Problem of insertion Problem of care • Failure to cannulate. . Sepsis • Pneumothorax. . Infective endocarditis • Haemothorax. . Air embolism • Arterial puncture. . Line/cardiac thrombosis • Brachial plexus injury. . Catheter migration/ • Mediastinal hematoma. embolism • Thoracic duct injury.•
Complications of TPN Catheter sepsisPrevent by :Only i.v. nutrition solutions are administered through thecatheter, no blood may be withdrawn from the catheter.Catheter disinfection and redressing 2 to 3 times weekly.Detect by : Fever, chills, ±drainage around the catheterentrance site, Leukocytosis, +ve cultures (blood & cathetertip).Treat by : 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
Complications of TPN Metabolic Complicationso Hyperglycemia :Associated with the infusion of excess glucose in the feeding solution or the diabetic-like state in the patient associated with many critical illnesses. Management: 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).
Complications of TPNMetabolic Complications Hypertriglyceridemia Associated with excess infusion of fat emulsion.• Can cause pulmonary insufficiency.
Complications of TPN Metabolic Complicationso Hepatic complications (also known as parenteral nutrition cholestasis): It causes severe cholestatic jaundice, elevation of transaminases, and may lead to irreversible liver damage and cirrhosis. Multiple causes have been proposed, including high infusion rates of aromatic amino acids, high proportion of energy intake from glucose, e.t.c.. There is no specific treatment, other than anticholestatic therapy.
HOME PARENTERAL NUTRITION Patients who are unable to eat and absorb adequate nutrients for maintenance over the long term may be candidates for home parenteral nutrition e.g. extensive Crohns disease, mesenteric infarction, or severe abdominal trauma. patients must be able to master the techniques associated with this support system, be motivated, and have adequate social support at home.
” وقل عس ى أن يهادينل ي ربل ي ألقر ادَ من هذا رشادا“ ادَ ْلُ ه ْ ادَ ادَ ادَ ه ْ ادَ ه ْ نِ ادَ نِ ادَ يِّ ادَ ه ْ ادَب نِ ه ْ ادَ ادَ ادَ ادَ ”ً And say it may be that my Lord guide me to the nearest of the rational