Supplementary Nutritional Support - Total Parenteral Nutrition - TPN SNS

1. SUPPLEMENTARY
NUTRITIONAL
SUPPORT
Dr Chandrashekar K
Associate Professor,
Dept of Medicine,
KIMS, Hubballi

2. HISTORY
• Early 1960s, the use of intravenous nutrition
was restricted to high concentrations of
dextrose and electrolytes.
• 1962, Wretlind and colleagues developed lipid
infusions as the principle source of calories for
parenteral feeding.

3. •1966, Dudrick and Rhoads developed parenteral
nutrition (PN) for patients who had lost their small
bowel.
•1976, Solassol and Joyeux developed the three-in-
one mixture by putting sugars, lipids and amino
acids in a single bag.
• 1978, Shils and colleagues and Jeejeebhoy and
colleagues developed ‘home based’ PN to reduce
costs.

4. Human nutrition is the provision to obtain the
essential nutrients necessary to support life
and health
Nutrients are the substances that are not
synthesized in sufficient quantity in the body
and therefore must be supplied from diet

5. • Protein (Amino acids)
• Fat
• Carbohydrate
• Dietary fiber
• Water and electrolytes
• Vitamins
• Minerals
• Trace elements

6. • Patients should be assessed for PEMas well as specific
nutrient deficiencies
• Evidence of malabsorption
• Symptoms of specific nutrient deficiencies
• Look for factors which may increase metabolic stress
(infection, inflammation, malignancy)
• Functional status (bed ridden, suboptimally active,
fully active)

7. Look for tissue depletion(loss of body fat and
skeletal muscle wasting)
Assess muscle function (strength testing of
individual muscle groups)
Fluid status: dehydration or fluid overload
Look for sources of protein or nutrient losses:
large wounds, burns, nephrotic syndrome,
chronic diseases, GI losses of nutrients,
surgical drains.
Lab parameters: plasma albumin, electrolytes,
vitamins and minerals

9. ENERGY PARAMETERS
• 1 Cal (1 kcal) = 4.128 KJ
• Carbohydrates : 4 kcal/g
• Fats : 9 kcal/g
• Proteins : 4 kcal/g
• Alcohol : 7 kcal /g

10. UTILIZATION OF ENERGY IN MAN
• Basal metabolic rate
• Specific dynamic action
• Physical activity.

11. BMR
• BMR is defined as the minimum amount of energy
required by the body to maintain life at complete
physical and mental rest in the post absorptive state
(12 hr after last meal)
Normal values of BMR :
• For an adult man :
35–38 kcal/sq.m/hr; 1600kcal/day
• For an adult woman :
32-35 kcal/sq.m/hr. 1400kcal/day

12. ESTIMATING ENERGY REQUIREMENTS
Harris-Benedict equations :
• Men: BEE = 66.47 + 13.75W + 5.00H − 6.76A
• Women: BEE = 65.10 + 9.56W + 1.85H − 4.68A
Where ,
• W is weight in kilograms,
• H is height in centimeters,
• A is age in years.
• BEE is Basal Energy Expenditure

13. TEE= BEE+ Stress Factor + Activity Factor
1.1 = without evidence of significant physiologic stress
1.4 = marked stress such as sepsis or trauma
Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
Obese or Super obese Add 15-20 kcal/kg
ESTIMATING ENERGY REQUIREMENTS

14. Factors affecting BMR
• Surface area : directly proportional
• Sex : males 5% more than females
• Age : infants highest
• Physical activity : directly proportional
• Hormones : thyroid
• Climate and temperature : inversely proportional
• Starvation : reduces in starvation
• Fever : increases
• Diseases : increases
• Race : eskimos have high BMR

15. Significance of BMR
• Calculate the calorie requirement of an
individual
• Planning of diets

16. RDA
Nutrient Male Female
Water (litre/day) 3.7 2.7
Carbohydrate (g/day) 130 130
Fibre (g/day) 38 25
Protein (g/d) 56 46
Calcium (mg/d) 1000 1000
Iodine (μg/d) 150 150
Iron (mg/d) 8 18
Magnesium (mg/d) 400-420 310-320
Phosphorus (mg/d) 700 700
Zinc (mg/d) 11 8
Sodium (g/d) 1.5 1.5
Potassium (g/d) 4.7 4.7
Chloride (g/d) 2.3 2.3
Harrisons Principles of Internal medicine , 19th E , chapter nutrition

17. RDA
Nutrient Male Female
Vitamin A (μg/d) 900 700
Vitamin C (mg/d) 90 75
Vitamin D (μg/d) 15 15
Vitamin E (mg/d) 15 15
Vitamin K (μg/d) 120 90
Thiamin (mg/d) 1.2 1.1
Riboflavin (mg/d) 1.3 1.1
Niacin (mg/d) 16 14
Vitamin B6 (mg/d) 1.3 1.3
Folate (μg/d) 400 400
Vitamin B12 (μg/d) 2.4 2.4
Pantothenic Acid (mg/d) 5 5
Biotin (μg/d) 30 30
Harrisons Principles of Internal medicine , 19th E , chapter nutrition

18. Supplementary Nutritional Support
• Enteral SNS is the provision of liquid formula
meals through a tube placed into the gut
• Parenteral SNS is the direct infusion of
complete mixtures of crystalline amino acids,
dextrose, triglyceride emulsions, and
micronutrients into the bloodstream through
a central venous catheter or via a peripheral
vein

19. INDICATIONS FOR SPECIALIZED
NUTRITIONAL SUPPORT
• PEM is already present at the time of hospital
admission and remains unimproved or worsens
during the ensuing hospital stay
• INANITION (exhaustion caused by lack of
nourishment)
• INFLAMMATION
• INACTIVITY

20. Common reasons for PEM worsening
• Refusal of food because of anorexia, nausea,
pain, or delirium,
• Communication barriers,
• An unmet need for hand-feeding of patients
with physical or sensory impairment,
• Disordered or ineffective chewing or
swallowing,
• Prolonged periods of physician-ordered fasting

21. Metabolic states
• Hypometabolic state : relatively less stressed but
mildly catabolic and chronically starved individual
who, with time, will develop cachexia/marasmus.
• Hypermetabolic state : stressed from injury or
infection is catabolic (experiencing rapid
breakdown of body mass) and is at high risk for
developing acute malnutrition/ kwashiorkor if
nutritional needs are not met and/or the illness
does not resolve quickly

23. Nitrogen Balance = N input - Noutput
N input
N output
= (protein in g / 6.25)
= 24h urinary urea nitrogen + non-urinary
N losses
+4 to + 6 : Net anabolism
+1 to - 1 : Homeostasis
- 2 to - 1 : Net catabolism

24. ENTERAL
NUTRITION
PARENTERAL
NUTRITION

25. Does the patient has PEM ? Or is at the risk of PEM ?

27. Enteral Nutrition (Definition)
• Nutritional support via placement through
the nose, esophagus, stomach, or
intestines (duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT !
—Exhaust all oral diet methods first.

28. GOLDEN RULE
THE GUT SHOULD ALWAYS BE THE PREFERRED
ROUTE FOR NUTRIENT ADMINISTRATION
Enteral feeding also supports gut function by :
• Stimulating splanchnic blood flow,
• Neuronal activity,
• IgA antibody release, and
• Secretion of gastrointestinal hormones that stimulate gut trophic
activity.
• These factors support the gut as an immunologic barrier against
enteric pathogens.

35. Enteral nutrition is associated with fewer complications than
parenteral nutrition and is less expensive to administer
However, the use of enteral nutrition alone often does not
achieve caloric targets.
In addition, underfeeding is associated with weakness,
infection, increased duration of mechanical ventilation,
increased duration of hospital stay and death.
Combining parenteral nutrition with enteral nutrition
constitutes a strategy to prevent nutritional deficit but
may risk overfeeding which has been associated with liver
dysfunction, infection, and prolonged ventilatory support.

37. Parenteral Nutrition (Definition)
• Components are in elemental or “pre-digested” form
–PROTEIN as AMINO ACIDS
–CARBOHYDRATES as DEXTROSE
–FAT as LIPID EMULSION
–ELECTROLYTES, VITAMINS AND
MINERALS

38. •Parenteral nutrition should be considered if energy
intake has been inadequate for more than 7-10 days and
enteral feeding is not feasible
•It involves the continuous infusion of a hyperosmolar
solution containing carbohydrates, proteins, fat and
other necessary electrolytes through an indwelling
catheter

39. Macronutrients: Carbohydrate
• Source:
• Properties:
Monohydrous Dextrose
Nitrogen sparing
Energy source
3.4 Kcal/g
Hyperosmolar
• Recommended intake:
2 – 5 mg/kg/min
50-65% of total calories

40. Macronutrients: AminoAcids
• Source:
• Properties:
Crystalline amino acids—
standard or specialty
4.0 Kcal/g
EAA 40–50%,
NEAA50-60%
• Recommended intake:
0.8 g/kg/day
15-20% of total calories
Potential Adverse Effects:
•Increased renal solute load
•Azotemia

41. Additional protein intake :
burn injuries, open wounds,
protein losing Enteropathy / Nephropathy.
A lower protein intake :
chronic renal insufficiency who are not
treated by dialysis hepatic encephalopathy
Each gram of nitrogen lost or gained represents : 30 g
of lean tissue.

42. •Requirement 3 g/kg/day
•30-40 percent of nutrition
•Liver can synthesize most fatty acids, but cant produce
omega-3 and omega-6 fatty acid series.
•Linoleic acid least 2% and
•Linolenic acid at least 0.5%
of daily caloric intake to prevent essential fatty acid
deficiency

43. Parenteral Fats
• Parenteral fat : 20% and 30% emulsions
• All-in-one mixture
• Max. 60% of kcal or 2 g fat/kg
• 500 mL of 20% lipids given once weekly will
prevent EFAD

44. By caloric intake : 1ml/calorie
Example: 1800 calorie diet = 1800 calories x
1ml= 1800ml
By body weight and age : average requirement is
30 ml/kg/d
•16-55 years 35 ml/kg/d
•56-65 years 30 ml/kg/d
•> 65 years 25 ml/kg/d

45. Parenteral Nutrition (Types)
• Delivery of nutrients intravenously, e.g. via
the bloodstream.
– Central Parenteral Nutrition: often called
Total Parenteral Nutrition (TPN); delivered into
a central vein
– Peripheral Parenteral Nutrition (PPN):
delivered into a smaller or peripheral vein

47. Common Indications for PN
• Patient has failed EN with appropriate tube
placement
• Severe acute pancreatitis
• Severe short bowel syndrome
• Mesenteric ischemia
• Paralytic ileus
• Small bowel obstruction
• GI fistula unless enteral access can be placed
distal to the fistula or where volume of output
warrants trial of EN

48. Contraindications
• Functional and accessible GI tract
• Patient is taking oral diet
• Patient expected to meet needs within 14 days

49. Peripheral Parenteral Nutrition
• Generally intended as supplement to oral feeding
• And is not optimal for critically ill pts
• New catheters allow longer support via
this method
• More commonly used in infants and children
• Temporary nutritional supplementation with
PPN may be useful

50. • Significant malnutrition
• Severe metabolic stress
• Large nutrition or electrolyte needs (potassium
is a strong vascular irritant)
• Fluid restriction
• Need for prolonged PN (>2 weeks)
• Renal or liver compromise
Contraindications to PPN

51. TOTAL PARENTERAL
NUTRITION (TPN)
Provides complete nutritional support via a central
catheter
The solution, volume of administration, and additives
are individualized based on an assessment of the
nutritional requirements.
Nutrition delivered by PICC or CVC (tunneled or non
tunneled)

53. ADVANTAGES DISADVANTAGES
Bed side technique
Avoids complications
of central venous
catheter
Avoid multiple venous
Cannulations
Hypertonic solutions
can be given
Trained personnel is
Needed
Line blockage
Mal position
Phlebitis
Line sepsis
Thrombosis

54. NON TUNNELLED V/S TUNNELLED CENTRAL
VENOUS CATHETERS

55. INFUSION TECHNIQUE AND PATIENT
MONITORING
• Solutions with an osmolarity >900-1000
mOsm/L (e.g., those which contain >3% amino
acids and 5% glucose [290 kcal/L]) are poorly
tolerated peripherally.
• Peripheral PN may be enhanced by small
amounts of heparin (1000 U/L) and co-
infusion with parenteral fat to reduce
osmolarity

56. FORMULATIONS FOR TPN
• Emulsions, or admixtures of nutrients that are
administered in an elemental form.
• 2-in-1 or 3-in-1 formulations available with
carbohydrate + amino acids +/- lipid emulsions
• Additives like : insulin, H2 blockers, vitamins
can be added

57. Calculations
Water = 25 to 35 ml / kg /day = 30x70 = 2100 ml / day
Calculating the requirement of TPN
formulation for a 70 year old patient :

58. For 2 in 1 formula ( without lipid )

60. Compounding Methods
• Total nutrient admixture (TNA) or 3-in-1
– Dextrose, amino acids, lipid, additives are
mixed together in one container
• 2-in-1 solution of dextrose, amino acids,
additives
– Lipid is delivered as piggyback daily or
intermittently as a source of EFA

61. Advantages of TNA
(Total nutrient admixture)
• Decreased nursing time
• Decreased pharmacy prep time
• Cost savings
• Easier administration in home PN
• Physiological balance of macronutrients

62. Disadvantages of TNA
• Diminished stability and compatibility

63. PN Compounding Machines:

65. Initiation of PN
• Adults should be hemodynamically stable, able
to tolerate the fluid volume necessary to
deliver significant support, and have central
venous access
• If central access is not available, PPN should
be considered (more commonly used in
neonatal and peds population)
• Start slowly
(1 L 1st day; 2 L 2nd day)

66. Initiation of PN: formulation
• As protein associated with few metabolic
side effects, maximum amount of protein
can be given on the first day, up to 60-70
grams/liter
• Maximum CHO given first day 150-200
g/day or a 15-20% final dextrose
concentration
• In pts with glucose intolerance, 100-150 g
dextrose or 10-15% glucose concentration
may be given initially

67. Intensive Insulin and Glycemic
Control
• Hyperglycemia increases inflammation and
has deleterious effects on the immune,
respiratory, renal, and nervous systems
• NICE-SUGAR trial established that a slightly
more moderate approach (i.e., maintaining
blood glucose levels<180 mg/dL) yielded
much of the benefits of tighter protocols,
without decreased morbidity and mortality
from hypoglycemia

68. Infusion Schedules
• Continuous PN
Non-interrupted infusion of a PN solution over 24
hours via a central or peripheral venous access
• Well tolerated by most patients
• Requires less manipulation

69. Infusion Schedules
• Cyclic PN
– The intermittent administration
over a period of 12 – 18 hours
– Patients on continuous
therapy may be converted to
cyclic PN over 24-48 hours

70. Home TPN
• Patient selection
–Reasonable life expectancy
–Demonstrates motivation, competence,
compliance
–Home environment conducive to sterile
technique

71. Complications
Of TPN
Mechanical
metabolicinfectious
COMPLICATIONS
OF TPN
MECHANICAL
METABOLICINFECTIVE

72.  Air embolism
 Pneumothorax
 Hemothorax
 Cardiac tamponade
 Injuries to arteries and veins
 Injury to thoracic duct
 Brachial plexus injury

76. Infections :
 Catheter related sepsis is most common life
threatening complication
Causes:
 Staph epidermidis and staph aureus,
 Enterococcus,
 Candida,
 Ecoli, psuedomonas,
 Klebsiella

77. PN Administration:Transition to
Enteral Feedings in Adults
•In adults receiving oral or enteral nutrition sufficient to
maintain blood glucose, need to taper PN
•When the patient can satisfy 75% of his or her caloric
needs with oral intake
•Reduce rate by half every 1 to 2 hrs or switch to 10%
dextrose IV) may prevent rebound hypoglycemia (not
necessary in PPN)
•Monitor blood glucose levels 30-60 minutes after
cessation

79. •Strict asepsis
•24-hr TPN prepared at a time
•Changing infusion sets daily
•New amino acid, lipid bottles daily
•Separate IV access for other drugs
•Serum Na, K on alt. days; renal parameters
biweekly; LFT, triglycerides weekly

80. Clinimix : dextrose + AA
Clinimix E : dextrose + AA + Electrolytes
Kabiven : 3 in 1 formulation
Vitrimix : Dextrose + AA
Intralipid : 20% lipid
Celepid : 20 % lipid
Celemin : AA 10 %

85. References :
1.Harrison’s : Textbook of Internal Medicine
2.Bailey and love : Text book of Surgery
3.Sabiston : Text book of Surgery
4.Maingot’s : Text book of Surgery