The patient requires total parenteral nutrition (TPN) due to small bowel resection and inability to tolerate oral intake. The recommended TPN formula includes 3 bottles of Aminovel to provide 75g of protein and 1500ml of fluid, 2 bottles of Lipofundin for 900kcal and 500ml fluid, 1 bottle of 25% dextrose water for 1000kcal, and 15 ampoules of 25% dextrose water for the remaining 300kcal. This meets the patient's calculated energy and fluid requirements while avoiding fluid overload. Electrolytes including sodium and potassium are also sufficiently provided in this regimen.

1. TOTAL PARENTERAL
NUTRITION
by
Dr Humayun Israr
Resident surgical unit 2
DHQ Teaching hospital Sahiwal

2. Definition
The provision of all nutritional requirements
without the use of GI Tract.
TPN may reduce morbidity and mortality
after major surgery, severe burns and
head trauma, especially in patients with
sepsis.
TPN is often used in hospitals , long term
care and sub-acute care and infrequently
is used in the home care setting.

4. Goals:

i
To decrease adverse effect of catabolism
To support ongoing metabolism
To improve immune cardiac and respiratory
function
To maintain glycogen reserve
To maintain acid base and electrolyte
metabolism

5. Indications:
Patients whose GI tract is not functional.
(gut is obstructed , short ,fistulated ,inflammed ,ileus)
e.g 50% of metabolic needs met for <7 days
Undernourished patients who cannot ingest large
volumes of oral feedings and are being prepared for
surgery , radiation therapy or chemotherapy .
Disorders requiring complete bowel rest
- crohn’s disease
- ulcerative colitis
- severe pancreatitis
-IBD
pediatric GI disorders
-cong anomalies
-prolonged diarrhea

6. Contraindication
s:
CCF
Uncontrolled Diabetes Mellitus
Fat metabolism disturbances

7. Nutritional
contents:
Water
30-40 ml/kg/day
Energy
20-30 Kcal/kg/day
Amino acids
1.0-2.0 g/kg/day
Essential fatty acids
Vitamins and minerals
Children require different fluid requirments i-e
-for 1st 10 kg fluid given per kg is 100ml
-for next 10kg fluid given per kg is 50ml
-from onwards per kg fluid given is 20ml
Children needs more energy (120 Kcal/kg/day) and amino acids
(2.5-3.5 g/kg/day)

8. Energy Requirments:
 Basal Energy Expenditure (BEE) is a
function of individual’s
weight ,age ,gender ,activity level and
disease process.
Patients
condition
• No postop complication,GI
fistula e out infection
• Mild pertonitis, long bone
frac, mild to mod injury,
malnourished
• Severe injury or infection
• Burn (40-100% of body
surface)
BMR
• Normal
• 25% above normal
• 50% above normal
• 100% above normal
Approx energy requirment
• 25-30
• 30-35
• 35-40
• 40-45

9. Energy
Requirments:
The most common source of parenteral
energy is GLUCOSE
-readily metabolizes in most patients
-low calorie value
-1g Glucose provides 4 Kcals energy
-spares endogenous proteins
-more CO2 production

10. Lipids:
Lipids can be safely administered via veins
-it provides essential fatty acids
-high calorie value
-1g lipid provides 9-10 Kcal energy
-prevents hyperglycemia
-decreased CO2 prod
-decreased insulin prod

11. Lipids:
Lipids should be given in precisely
calculated values to avoid
-hypertriglyceridemia
-sepsis
-fat embolism
-fat overload
-hepatic dysfunction
-pancreatitis

12. Proteins(nitroge
n):
Proteins (aminoacids ) are functional and
sturctural component of body so caloric
needs must be met by non-protein
calories (fat and glucose)
Protein requirment: 0.8-1 g/kg/day for
healthy individual
With disease factor and inactivity protein
requirment is as follow

13. Proteins(nitrogen)
:
Condition
• Basic requirments
• Slightly increased
requirments
• Moderately increased
requirments
• Highly increased
requirments
• Reduced requirments
example
• Normal person
• Post-op,cancer,
inflammation
• Sepsis, polytrauma
• Peritonitis, burns
• Renal failure, hepatic
encaph,
requirment
• 0.5-1g/kg
• 1.5 g/kg
• 2g/kg
• 2.5 g/kg
• 0.6g/kg

14. Nitrogen
:
Nitrogen balance= protein intake÷6.25-
uun(gm)+3
It is the way to assess the sufficiency of
protein intake for the patient
1 gm protein= 0.16gm N2
BCAA given in liver disease , sepsis and
other stress conditions
Special a.a.s containing fewer a.a are used
in renal failure

15. Fluid and
electrolytes:20-40 ml/kg daily__ young adults
30ml/kg __ older adults
Daily lab tests to monitor electrolyte status
• REQUIRMENTS (/kg/day)NUTRIENTS
• 20-40ml
• 1.0-1.5 mmol
• 0.5-1.0 mmol
Water
Sodium
Potassium
• 0.1-0.2 mmol
• 0.05-0.15 mmol
• 0.2-0.5 mmol
• 0.5mmol
Magnesium
Calcium
Phosphate
Chloride

16. Vitamins:
12 vitamins are required for normal metabolic functioning of the body
including
3 fat soluble vitamins (A, D,E )
Vit K is administered separately as
1mg/kg/day
9 water soluble vitamins
-thiamine (B1)
-riboflavin (B2)
-niacin (B3)
-pantothenic acid(B5)
-pyridoxine (B6)
-biotin(B7)
-cyanocobalamin (B12)
-folic acid
-ascorbic acid (C)

17. Vitamins:

18. Trace elements:
Zn , copper , manganese,
chromium ,selenium given in daily
required amounts
Minerals
Suggested
daily iv
requirments
Zn
Cu
Mn
Cr
Se
2.5-5mg
0.5-1.5mg
150-800 µg
10-15 µg
20-60 µg

19. Osmorality:
PPN <900 mosm/l
TPN >900 mosm/l upto 3000 mosm/l
-aminoacids __ 10 mosm/gm
-dextrose __ 5 mosm/gm
-electrolytes __ 2 mosm/mEq
-lipids __ 1.5 mosm/gm

20. Components of TPN:
MACRO
Dextrose (available
in 3 formulations)
-5% DW (200kcal/l)
-10%
DW(400kcal/l)
-25%
DW(1000kcal/l)
60-70% of calorie
requirements
should be provided
with dextrose

21. Components
of TPN:
Lipid emulsion is
available as LIPOFUNDIN
-1L provides 1980 kcal
of energy
-local formulation of
250ml bottle have
450kcal energy
-contains soyabean oil,
MCT,egg yolk
phospholipids and
glycerol
30-40% of calorie
requirements should be
provided with lipid
emulsions

22. Components
of TPN:
Aminoacids and electrolytes
are given in formulation of
AMINOVEL (500ml bottle
provides 100kcal energy)
Each 1000 mL contains: 50g
proteins
D-Sorbitol: 100.0 g
L-Alanine: 6.0 g
L-Arginine: 6.2 g
L-Histidine: 1.0 g
L-Isoleucine: 3.2 g
L-Leucine: 2.4 g
L-Lysine: 2.0 g
L_Methionine: 3.0 g
L-Phenylalanine: 4.0 g
L-Proline: 2.0 g
L-Threonine: 2.0 g

23. Components of TPN:
L-Tryptophan: 1.0 g
L-Valine: 3.2 g
Glycine (Aminoacetic acid): 14.0 g
Ascorbic acid: 400.0 mg
Inositol: 500.0 mg
Nicotinamide: 60.0 mg
Pyridoxine HCl: 40.0 mg
Riboflavin Sodium Phosphate: 2.5 mg
Sodium: 35 mEq
Potassium: 25 mEq
Magnesium: 5 mEq
Acetate: 35 mEq
Malate: 22 mEq

24. Components of TPN:
Chloride: 38 mEq
Water for Injection: q.s.
Free AA: 5% (w/v)
Essential AA (E): 20.8 (w/v)
Non-Essential AA (N): 29.2 (w/v)
E/N: 0.7
Total Nitrogen: 8.0 g/L
Osmolarity: 1320 mOsm/L
The usual adult dosage of Aminovel 600 is 500 ml via
intravenous infusion over 4-6 hours (20-30 drops/min).
The dosage may be adjusted according to the patient’s
condition, body weight and age. The infusion rate
should be slowed in elderly and severely ill patients.

25. Components
of TPN:
MULTIVITAMINS
-For vitamin deficiency
multivitamin inj can b
given 1xOD
-Inj Multibionta 10ml
-it contains
Nicotinamide 30mg,
Vitamin A 5500IU, Vitamin
B2 10mg, Vitamin B1
10mg,Vitamin E 10mg,
Ascorbic Acid:100mg,
Calcium Pantothenate
20mg, Calcitriol 500IU,
Cyanocobalamin 8mcg,
Folic Acid 200mcg,
Pyridoxine 5mg

26. Components of TPN:
MEDICATIONS:
Insulin
- can be given s/c based on sliding scale
-once stable , give 2/3 total requirments in
TPN
__ alternate regimes
- 0.1 unit per g dextrose in TPN
- 1 unit insulin metabolizes 4g of
dextrose

27. To do list before starting TPN:
Nutritional assessment
Venous access evaluation
Baseline weight
Baseline lab investigations

28. Nutritional
Assessment:
Proper history about diet and weight loss
Physical examination regarding muscle
wasting, peripheral edema, easy bruising
and vit def etc
Anthropometric measures
-Age
-Gender
-Height(cm)
-BMI (kg/m2)__{Quetelet’s index}
weight in kgs/height in m2

29. Nutritional Assessment:
-BEE as per haris benedicts equation
Male= 66.5+(13.8×wt)+(5×ht in cm)-
(6.8×age)
Female=655+(9.6×wt)+(1.8×ht in cm)-
(4.7×age)
-Total daily caloric requirment=BEE×activity
factor×injury factor

30. Nutritional Assessment:
Activity factor
Comatosed 1.1
Bed ridden 1.2
Out of bed 1.3
Normal 1.5
Injury factor
Minor 1
Fracture 1.2-1.6
Head trauma 1.6-1.8
Wound healing 1.2-1.6
Sepsis 1.4-1.8
Burns 1.8-2
If underweight= total calorie + 500

31. Venous
Access:
Due to high osmolarity TPN needs venous
access to a large central line with fast
flow to avoid thrombophlebitis
-subclavian approach
-internal jugular approach
- Femoral
(All drains to SVC)

32. Types of
CVC’s
Single/multi lumen
catheters
-for short term use
(1-3weeks)
-jugular,
subclavian, femoral
routes
-single lumen
prefered
-flush after every
use
-change dressing
after 24hrs

33. Types of
CVC’s:
PICC
- for
intermediate time
span(<6 months)
-Midline
(cephalic,basilic,
axillary tip)
-Central (SVC)

34. Types of
CVC’s:
TUNNELED
-right atrial central
catheter
-for long term use
(> 6months)
IMPLANTED
-surgically
inserted
- donot have exit
site
- for long term
use

35. Monitoring of feeding regimes:
DAILY
-body weight -fluid balance(input+output)
-temperature -CBC , Rfts, Electrolytes
-Blood glucose -electrolyte content,vol of urine +urine n
intestinal losses
WEEKLY
-LFTS , PT, APTT ,INR -ABGs
-Ca++ , PO4- , Mg++ -Albumin
-thiamine -urine n plasma osm
-TGs
FORTNIGHTLY
-Vit B12 -Folate
-Iron -Lactate
-Trace elements( CU, Mn, Zn)

36. CASE SENERIO:
A 38 y.o man with a 12-year history of
crohn’s disease is admitted to surgery
unit 2 of DHQ teaching hospital sahiwal
for a compliant of increasing abdominal
pain, nausea & vomiting for 7 days
and no stool output for 5 days. Because
of N & V, he has been drinking only
liquids during the past weeks. His crohn
disease had several exacerbations during
the past 2 years and 10 cm of his ileum
has been resected 6 month ago.

37. Continued:
Drugs: Mesalamine 1000 mg qid +
prednisolone 10mg/d. Abdominal x-ray is
consisting with bowel obstruction.
Exploratory laparotomy was performed
and 25 cm of his ileum resected.
Bowel sounds are absent. He has a
right subclavian CV-line. Considering
that his Ht=180cm, Wt=60kg (6
month ago: 70 kg) and Age=38 y.o,
what is your recommended TPN formula
for him?

38. 
BEE= 66.5+(13.8×wt)+(5×ht in cm)-(6.8×age)
 BEE= 66.5+(13.8×60)+(5×180)-(6.8×38)
 BEE=66.5+828+900-258.4=1536.1 kcal/d
 TEE= 1536.1×1.2×1.2 = 2212 kcal/d
 AMINOVEL (for body built)
 60x1.2= 72g
 1 bottle of aminovel provides 500ml fluid and
25g proteins
 So 3 bottles of aminovel should b given
 It covers 1500ml fluid req +75g proteins as
per required

39.  LIPID(LIPOFUNDIN) 40% of total kcal=884.8kcal
 1 bottle of lipofundin(250ml) gives 450kcal approx
 So Two bottles should b given which provides 900 kcal + 500ml fluid
 Fluid requirment
 60x40=2400ml +insensible losses of about 600ml=3000ml
 1500ml (aminovel)+ 500ml (lipofundin)+1000ml DW=3000ml
 DEXTROSE WATER 60% of total kcal=1327.2
 1 bottle of 25% DW gives 1000kcal energy
 Further 300kcal provided by amp of 25% DW to avoid
fluid overload
 1 amp of 25% DW have 5g dextrose so 5x4=20kcal
 Remaining 300 kcal are given as 15 amp of 25% DW

40.  Na+
 Daily req =60x1=60mmol/day
 aminovel contains 35meq(mmol) Na+ /L
 So 1500ml aminovel contains 35+17.5= 53mmol/day
 So three bottles fullfill requirment of Na
 No further need to add Na+
 K+
 Daily req= 0.8x60=48 approx 50 mmol/day
 Aminovel contains 25meq K+/L
 S0 3 bottles provide 38mmol of K+
 As the patient presented with vomiting 1kcl ampule can b
added to 1L DW to over come losses and remaining
requirment

41.  VITAMINS
 Inj multibionta 10ml amp 1xOD
 INSULIN
 Daily Bsr monitoring gives idea for insulin addition
 If there is no hyperglycemia there is no need to add
insulin
 If bsr exceeds 150, insulin can b given according to s/
s or can be added as follow
 1 unit neutralizes 4g dextrose
 dextrose in g= 250+75= 325
 325÷4=81.25units/day

42. Summary:
 So for this patient total calculated TPN is
given as follow
Inj Aminovel 500ml IV over 8 hourly
Inj 25% DW + 15 amp of 25% DW + 1Kcl
+ 80 units R insulin x OD
Inj Lipofundin 250ml x BD
Inj Multibionta 10ml 1xOD

44. Complications:
TECHNICAL
BIOCHEMICAL
OTHERS

45. Technical:
-Air Embolism
-Pneumothorax
-Bleeding
-Infection due to catheter (both blood and tip
of catheter is sent for culture to confirm
infection really is catheter induced)
-Aterial puncture
-Catheter displacement
-Sepsis
-Blockage

46. Biochemical:
GLUCOSE ABNORMALITIES
-hyperglycemia
-hypoglycemia
SERUM ELECTROLYTES N MINERALS
-Hyponatremia
-hypernatremia
-hypokalemia
-hyperkalemia
-fluid overload( >1kg/day increase in body wt)
-metabolic bone disease (TPN>3months)
ADVERSE REACTION TO LIPID
-hepatomegally,splenomegaly,^liver
enzymes,thrombocytopenia,leucopenia

47. Others:
HEPATIC COMPLICATIONS:
-liver dysfunc ( due to cholestasis n infl,
reduce protein delivery)
-painful hepatomegaly (due to fat
accu, reduce glucose intake)
-hyperammonemia
Signs: lethargy, twitching , gen seizures
Rx: arginine (0.5-1 mmol/kg/day)

48. Others:
GALLBLADDER COMPLICATIONS:
-cholilithiasis
-gallbladder sludge
-cholecystitis
(all due to prolonged gall bladder stasis)
Tx:
-stimulate contractions by giving 20-30% fats and
reducing glucose several hours
-oral feed also help
-tx with metronidazole, ursodeoxycholic acid,
phenobarbital may help

49. Refeeding Syndrome:
Definition:
A syndrome consisting of metabolic disturbances that occur
as a result of reintroduction of nutrition to patients who are
starved or severely malnourished.
Patients who have had negligible nutrient intake for 5
consecutive days are at risk of refeeding syndrome.
occurs within four days of starting to feed.
Patients can develop fluid and electrolyte imbalances such as
hypophasphatemia
neurologic, pulmonary, cardiac, neuromuscular, and
hematologic complications.

50. Symptoms
:

51. Pathophysiology
:

52. Treatment:

53. THANKYOU