tpn

1. TotalTotal
ParenteralParenteral
NutritionNutrition
ByBy
Mohammed IsraruddinMohammed Israruddin

2. Def.Def. :a method of feeding patients by:a method of feeding patients by
infusing a mixture of all necessaryinfusing a mixture of all necessary
nutrients into the circulatory system,nutrients into the circulatory system,
thus bypassing the GIT.thus bypassing the GIT.
Also referred to as:Also referred to as:
intravenous nutrition,intravenous nutrition,
parenteral alimentation, andparenteral alimentation, and
artificial nutrition.artificial nutrition.

3. The gut should always be the preferredThe gut should always be the preferred
route for nutrient administration.route for nutrient administration.
Therefore, parenteral nutrition isTherefore, parenteral nutrition is
indicated generally when thereindicated generally when there
isis severe gastro-intestinalsevere gastro-intestinal
dysfunctiondysfunction (patients who cannot(patients who cannot
take sufficient food or feedingtake sufficient food or feeding
formulas by the enteral route) .formulas by the enteral route) .

4. Categories of PNCategories of PN
If enteral feeding isIf enteral feeding is completely stoppedcompletely stopped oror
ineffective,ineffective, Total Parenteral NutritionTotal Parenteral Nutrition isis
used (TPN).used (TPN).
If enteral feeding is justIf enteral feeding is just “not enough”“not enough” ,,
supplementation withsupplementation with Partial ParenteralPartial Parenteral
NutritionNutrition (PPN) is indicated(PPN) is indicated..

5. INDICATIONSINDICATIONS
In well-nourished adults,In well-nourished adults, 7 - 10 days7 - 10 days ofof
starvation with conventional intravenousstarvation with conventional intravenous
support (using 5% dextrose solutions) issupport (using 5% dextrose solutions) is
generally accepted.generally accepted.
If the period of starvation is to extendIf the period of starvation is to extend beyondbeyond
this timethis time,, or the patient isor the patient is not well-nourishednot well-nourished,,
Total Parenteral Nutrition (TPN) is necessaryTotal Parenteral Nutrition (TPN) is necessary
to prevent the potential complications ofto prevent the potential complications of
malnutrition.malnutrition.

6. Indications for TPNIndications for TPN
Short-term useShort-term use
Bowel injury, surgery,Bowel injury, surgery, major trauma or burnsmajor trauma or burns
Bowel disease (e.g.Bowel disease (e.g. obstructions, fistulas)obstructions, fistulas)
Severe malnutritionSevere malnutrition
Nutritional preparation prior to surgery.Nutritional preparation prior to surgery.
Malabsorption - bowel cancerMalabsorption - bowel cancer
Severe pancreatitisSevere pancreatitis
Malnourished patients who have high riskMalnourished patients who have high risk
of aspirationof aspiration
Long-term use (HOME PN)Long-term use (HOME PN)
Prolonged Intestinal FailureProlonged Intestinal Failure
Crohn’s DiseaseCrohn’s Disease
Bowel resectionBowel resection

7. Nutritional RequirementsNutritional Requirements
Energy: GlucoseEnergy: Glucose
LipidLipid
Amino acids (Nitrogen)Amino acids (Nitrogen)
Water and electrolytesWater and electrolytes
VitaminsVitamins
Trace elementsTrace elements

8. Requirements:Requirements:
EnergyEnergy
Hospitalized adults require approximatelyHospitalized adults require approximately 25-3025-30
kcal/ kg/day.kcal/ kg/day.
However, these requirements may beHowever, these requirements may be greatergreater inin
patients withpatients with injuryinjury oror infection.infection.

9. Energy RequirementsEnergy Requirements
Patient conditionPatient condition BasalBasal
metabolicmetabolic
raterate
Approximate energyApproximate energy
RequirementRequirement
(kcal/kg/day)(kcal/kg/day)
No postoperativeNo postoperative
complications, GITcomplications, GIT
fistula without infectionfistula without infection
NormalNormal 25-3025-30
Mild peritonitis, long-boneMild peritonitis, long-bone
fracture, mild to moderatefracture, mild to moderate
injury, malnourishedinjury, malnourished
25% above25% above
normalnormal
30-3530-35
Severe injury or infectionSevere injury or infection 50% above50% above
normalnormal
35-4535-45
Burn 40-100% of total bodyBurn 40-100% of total body
surfacesurface
Up to 100%Up to 100%
above normalabove normal
45-8045-80

10. Requirements:Requirements:
Energy Sources:Energy Sources: GlucoseGlucose
The most common source of parenteral energy supplyThe most common source of parenteral energy supply
isis glucoseglucose, being:, being:

Readily metabolized in most patients,Readily metabolized in most patients,

provides the obligatory needs of the substrate , thusprovides the obligatory needs of the substrate , thus
reducing gluconeogenesis and sparing endogenousreducing gluconeogenesis and sparing endogenous
protein.protein.

1 gm of glucose gives 4 Kcals.1 gm of glucose gives 4 Kcals.
Most stable patients tolerate rates ofMost stable patients tolerate rates of 4-5 mg.kg4-5 mg.kg-1-1
.Min.Min-1-1
,,
but insulin resistance in critically ill patients may leadbut insulin resistance in critically ill patients may lead
to hyperglycemia even at these rates, so insulinto hyperglycemia even at these rates, so insulin
should be incorporated acc. to blood sugar levels.should be incorporated acc. to blood sugar levels.

11. Requirements:Requirements:
Energy Sources:Energy Sources: GlucoseGlucose
RouteRoute
Glucose inGlucose in 5%5% solution can be safelysolution can be safely
administered via aadministered via a peripheral veinperipheral vein, but, but higherhigher
concentrationsconcentrations require arequire a centralcentral venous line.venous line.
20, 25, or even 50 %20, 25, or even 50 % solutions are needed tosolutions are needed to
administer meaningful amounts of energy toadminister meaningful amounts of energy to
most patients for proper volume administrationmost patients for proper volume administration..

12. Requirements:Requirements:
Energy SourcesEnergy Sources: Lipid: Lipid
Fat mobilization is a major response to stress andFat mobilization is a major response to stress and
infection.infection.
Triacylglycerols are an important fuel source inTriacylglycerols are an important fuel source in
those conditions, even when glucose availability isthose conditions, even when glucose availability is
adequate.adequate.
Need to beNeed to be restrictedrestricted in patients within patients with
hypertriglyceridemia.hypertriglyceridemia.

13. Requirements:Requirements:
Energy Sources:Energy Sources: LipidLipid
Ideally, energy from fat should not exceedIdeally, energy from fat should not exceed 40%40% of the totalof the total
(usually 20-30%).(usually 20-30%).
Fat emulsions can be safely administered viaFat emulsions can be safely administered via peripheralperipheral
veinsveins, provide, provide essential fatty acidsessential fatty acids, and are concentrated, and are concentrated
energy sourcesenergy sources for fluid-restricted patients.for fluid-restricted patients.
They are available inThey are available in 10, 20 and 30%10, 20 and 30% preparations.preparations.
Though lipids have a calorific value of 9Kcal/g, the value inThough lipids have a calorific value of 9Kcal/g, the value in
lipid emulsions islipid emulsions is 10Kcal/g10Kcal/g due to the contents of glyceroldue to the contents of glycerol
and phospholipids.and phospholipids.
Fat emulsions can be safely administered viaFat emulsions can be safely administered via peripheralperipheral
veinsveins, provide, provide essential fatty acidsessential fatty acids, and are concentrated, and are concentrated
energy sourcesenergy sources for fluid-restricted patients.for fluid-restricted patients.

14. Requirements:Requirements:
Energy Sources:Energy Sources:
LipidLipid
They are available inThey are available in 10,10,
20 and 30%20 and 30% preparations.preparations.
Though lipids have aThough lipids have a
calorific value of 9Kcal/g,calorific value of 9Kcal/g,
the value in lipid emulsionsthe value in lipid emulsions
isis 10Kcal/g10Kcal/g due to thedue to the
contents of glycerol andcontents of glycerol and
phospholipids.phospholipids.

15. Requirements:Requirements:
NitrogenNitrogen
Protein requirementsProtein requirements for most healthyfor most healthy
individuals areindividuals are 0.8 g/kg/day0.8 g/kg/day..
Critically ill patientsCritically ill patients may need as high asmay need as high as 1.5-1.5-
2.5 g protein/kg/day2.5 g protein/kg/day depending on the diseasedepending on the disease
processprocess
((major trauma or burn > infection or after surgery >major trauma or burn > infection or after surgery >
standardstandard))

16. Requirements:Requirements:
NitrogenNitrogen
Daily Protein requirementsDaily Protein requirements
ConditionCondition ExampleExample requirementrequirement
Basic requirementsBasic requirements Normal personNormal person 0.5-1g/Kg0.5-1g/Kg
Slightly increasedSlightly increased
requirementsrequirements
Post-operative, cancer,Post-operative, cancer,
inflammatoryinflammatory
1.5g/Kg1.5g/Kg
Moderately increasedModerately increased
requirementsrequirements
Sepsis, polytraumaSepsis, polytrauma 2g/Kg2g/Kg
Highly increasedHighly increased
requirementsrequirements
Peritonitis, burns,Peritonitis, burns, 2.5g/Kg2.5g/Kg
Reduced requirementsReduced requirements Renal failure, hepaticRenal failure, hepatic
encephalopathyencephalopathy
0.6g/Kg0.6g/Kg

17. Requirements:Requirements:
NitrogenNitrogen
Available a.a. preparationsAvailable a.a. preparations
areare 3.5 - 15 %3.5 - 15 % (i.e.(i.e.
contains 3.5-15 gms ofcontains 3.5-15 gms of
protein or a.a.s/100 mLprotein or a.a.s/100 mL
solution).solution).
1gm of protein =1gm of protein =
0.16 gm0.16 gm of Nof N2.2.

18. Requirements:Requirements:
Fluids and electrolytesFluids and electrolytes
20–40 mL/kg - daily – young20–40 mL/kg - daily – young
adultsadults
30 mL/kg – daily – older30 mL/kg – daily – older
adultsadults
Sodium, potassium, chloride,Sodium, potassium, chloride,
calcium, magnesium, andcalcium, magnesium, and
phosphorus ( as per thephosphorus ( as per the
table)table)
Daily lab tests to monitorDaily lab tests to monitor
electrolyte statuselectrolyte status

19. Requirements:Requirements:
Fluids and electrolytesFluids and electrolytes
NutrientNutrient Requirements (Requirements (/Kg/day)/Kg/day)
WaterWater 20-40 mL20-40 mL
SodiumSodium 0.5-1.0 mmol0.5-1.0 mmol
PotassiumPotassium 0.5-1.0 mmol0.5-1.0 mmol
MagnesiumMagnesium 0.1-0.2 mmol0.1-0.2 mmol
CalciumCalcium 0.05-0.15mmol0.05-0.15mmol
PhosphatePhosphate 0.2-0.5mmol0.2-0.5mmol
Chloride/AcetateChloride/Acetate So a to maintain acid-base balanceSo a to maintain acid-base balance
(normally 0.5 mmol for Cl(normally 0.5 mmol for Cl--
, & 0.1mEq for Acetate), & 0.1mEq for Acetate)

20. Requirements:Requirements:
VitaminsVitamins
These requirements are usually met when standardThese requirements are usually met when standard
volumes of a nutrient mix are provided.volumes of a nutrient mix are provided.

21. Requirements:Requirements:
Increased amounts of vitamins are usuallyIncreased amounts of vitamins are usually
provided to severely ill patients.provided to severely ill patients.
Vitamins are either fat soluble (A,D,E,K) orVitamins are either fat soluble (A,D,E,K) or
water soluble (B,C). Separate multivitaminwater soluble (B,C). Separate multivitamin
commercial preparations are now availablecommercial preparations are now available
for both.for both.

22. Requirements:Requirements:
vitaminsvitamins

23. Requirements:Requirements:
These areThese are essential component of the parenteralessential component of the parenteral
nutrition regimen andnutrition regimen and may be toxic at high doses.may be toxic at high doses.
Iron is excludedIron is excluded, as it alters stability of other, as it alters stability of other
ingredients and is given by separate injection (iv oringredients and is given by separate injection (iv or
im).im).
MineralMineral Recommended dietaryRecommended dietary
allowance (RDA) for dailyallowance (RDA) for daily
oral intake (mg)oral intake (mg)
Suggested dailySuggested daily
intravenous intakeintravenous intake
(mg)(mg)
ZincZinc 1515 2.5-52.5-5
CopperCopper 2-32-3 0.5-1.50.5-1.5
ManganeseManganese 2.5-52.5-5 0.15-0.80.15-0.8
ChromiumChromium 0.05-0.20.05-0.2 0.01-0.0150.01-0.015
IronIron 10 (males)-18 (females)10 (males)-18 (females) 33

24. Osmolarity:Osmolarity:
PPN: Maximum ofPPN: Maximum of 900900 milliosmoles / litermilliosmoles / liter
TPN: as nutrient dense as necessaryTPN: as nutrient dense as necessary (>900(>900
m.osmol and up as high asm.osmol and up as high as 30003000).).
Amino acids (10 m.osmol/gm), dextrose (5Amino acids (10 m.osmol/gm), dextrose (5
m.osmol/gm) and electrolytes (2 m.osmolm.osmol/gm) and electrolytes (2 m.osmol
/mEq) contribute most to the osmolarity, while/mEq) contribute most to the osmolarity, while
lipids give 1.5 m.osmol/gm.lipids give 1.5 m.osmol/gm.

25. Application:Application:
The SolutionThe Solution
Manually mixed in hospital pharmacy orManually mixed in hospital pharmacy or
nutrition-mixing service,nutrition-mixing service,
premixed solutions,premixed solutions,
Separate administration for every elementSeparate administration for every element
alone in a separate line.alone in a separate line.

26. Application:Application:
Venous accessVenous access
PPNPPN: (<900 m.osmol/L): a: (<900 m.osmol/L): a peripheral lineperipheral line can becan be
enough.enough.
TPNTPN:: Central venous access is fundamentalCentral venous access is fundamental,,
Ideally, the venous line should be usedIdeally, the venous line should be used
exclusively for parenteral nutrition.exclusively for parenteral nutrition.
Catheter can be placed via theCatheter can be placed via the subclaviansubclavian vein, thevein, the
jugularjugular vein (less desirable because of the high ratevein (less desirable because of the high rate
of associated infection), or aof associated infection), or a long catheter placed inlong catheter placed in
an arm veinan arm vein and threaded into the central venousand threaded into the central venous
system (a peripherally inserted central catheter line)system (a peripherally inserted central catheter line)
Once the correct position of the catheter has beenOnce the correct position of the catheter has been
established (usually by X ray), the infusion canestablished (usually by X ray), the infusion can
begin.begin.

27. Application:Application:
Initiation of TherapyInitiation of Therapy
TPN infusion is usually initiated at a rate ofTPN infusion is usually initiated at a rate of 25 to 5025 to 50
mL/hmL/h. This rate is then increased by 25 mL/h until the. This rate is then increased by 25 mL/h until the
predetermined final rate is achieved.predetermined final rate is achieved.
AdministrationAdministration
To ensure that the solution is administered at aTo ensure that the solution is administered at a
continuous rate, ancontinuous rate, an infusion pumpinfusion pump is utilized tois utilized to
administer the solution. In hospitalized patients,administer the solution. In hospitalized patients,
infusion usually occurs over 22-24 h/day. Ininfusion usually occurs over 22-24 h/day. In
ambulatory home patients, administration usuallyambulatory home patients, administration usually
occurs overnight (12-16 h).occurs overnight (12-16 h).

28. MonitoringMonitoring
Policy: to monitor:Policy: to monitor:
1-1- EffecacyEffecacy: electrolytes (S. Na, K, Ca, Mg, Cl,: electrolytes (S. Na, K, Ca, Mg, Cl,
Ph), acid-base, Bl. Sugar, body weight, Hb.Ph), acid-base, Bl. Sugar, body weight, Hb.
2-2- ComplicationsComplications: ALT, AST, Bil, BUN, total: ALT, AST, Bil, BUN, total
proteins and fractions.proteins and fractions.
3-3- General:General: Input- Output chart.Input- Output chart.
4-4- Detection of infection:Detection of infection:
Clinical (activity, temp, symptoms)Clinical (activity, temp, symptoms)
WBC count (total & differential)WBC count (total & differential)
CulturesCultures

29. MonitoringMonitoring

30. Complications of TPNComplications of TPN
SepsisSepsis
PneumothoraxPneumothorax
Air embolismAir embolism
Clotted catheter lineClotted catheter line
Catheter displacementCatheter displacement
Fluid overloadFluid overload
HyperglycemiaHyperglycemia
Rebound HypoglycemiaRebound Hypoglycemia

31. HOME PARENTERAL NUTRITIONHOME PARENTERAL NUTRITION
Patients who are unable to eat and absorb adequatePatients who are unable to eat and absorb adequate
nutrients for maintenance over the long term may benutrients for maintenance over the long term may be
candidates for home parenteral nutrition e.g. extensivecandidates for home parenteral nutrition e.g. extensive
Crohn's disease, mesenteric infarction, or severeCrohn's disease, mesenteric infarction, or severe
abdominal trauma.abdominal trauma.
patients must be able to master the techniquespatients must be able to master the techniques
associated with this support system, be motivated,associated with this support system, be motivated,
and have adequate social support at home.and have adequate social support at home.

32. HOME PARENTERAL NUTRITIONHOME PARENTERAL NUTRITION
A patient who is judged to be a candidate forA patient who is judged to be a candidate for
home parenteral nutrition requires an indwellinghome parenteral nutrition requires an indwelling
Silastic catheter designed for long-termSilastic catheter designed for long-term
permanent use.permanent use.
The nutrient solutions are prepared weekly andThe nutrient solutions are prepared weekly and
delivered to the patient's home.delivered to the patient's home.
The patient sets up the infusion system andThe patient sets up the infusion system and
attaches the catheter to the delivery tubing inattaches the catheter to the delivery tubing in
the evening for infusion over the next 12-16 h.the evening for infusion over the next 12-16 h.
The intravenous nutrition is terminated by theThe intravenous nutrition is terminated by the
patient the next morning.patient the next morning.