Total Pareteral and Enteral nutrion ,indications .Advantages and Disadvantages .when to use Gut and whe to use Pereteral route for nutrition.

1. 1

2. CLINICAL PHARMACY
FORMULATION OF DRUGS ETERNAL AND PARENTERAL NUTRITION
Presented By: Shazia Ashraf
Pharm .D, M.phill, Ph.D. Pharmaceutics Department Of Pharmaceutics
The Islamia University Bahawalpur

3. Outline
A.Total Parenteral Nutrition (TPN)
• Background /History of PN
• Nutrients Requirement per Day
• Definition of Total Parenteral Nutrition
• Objectives
• Indications
• Contraindications
• Planning a TPN
• Stopping a TPN
• Prescription in Infants
• Recommendations

4. Outline
B.ENTERAL NUTRITION or TUBE FEEDING
• Advantages of Enteral Feeding
• Indications for enteral tube feeding
• General characteristics of enteral diets
• Types of Enteral Feeding Tubes
• Methods of Enteral Nutrition Administration
• Enteral Nutrition Formulas
• Contraindications for Enteral Nutrition
• Complications of Tube Feedings

5. A.Total Parenteral Nutrition (TPN)
1. History of Parenteral Nutrition:
Until the early 1960s, the use of IV nutrition was restricted to high
concentrations of dextrose and electrolytes.
• In 1962, Wretlind & Colleagues developed lipid infusion as the principal
source of calories for parenteral feeding.
• In 1966, Dudrick & Rhoads developed parenteral nutrition for patients
who had lost their small bowel.
• In 1976 Solassol and Joyeux developed the three in one mixture by
putting sugars, amino acids and lipids in a single bag.
• In 1976 Shils and colleagues & J.J. Bhoy and colleagues developed
home PN to reduce Costs.

6. 2. Nutrition:
Nutrition is the process by which substances in food are
transformed into body tissues and provide energy for the full
range of physical and mental activities that make up human
life.
2.1. Nutrients:
Nutrients are the substances that are not synthesized in the
human body ---- Must be supplied through diet.
• Macronutrients (Carbs, Proteins, Fats, Fibers & Water)
• Micronutrients (Vitamins, Minerals & Trace elements)

7. 2.2. Nutrients Requirement per Day
Calories- 25kcal/kg
• Proteins: 0.8 – 2 kg/day
• Carbohydrates: Min 75-100 g/day
• Fats: Min 500 mL of 20% lipid emulsion per week to prevent EFA deficiency
• Water: 30-40 mL/kg/day + extra for any fluid loss+ 500ml/day/degree Celsius
rise in temperature.
• Electrolytes
 Na-60-80 mEq/day
 K- 30-60 mEq/day
 Cl- 80-100 mEq/day
 Ca- 15-20 mEq/day
 Mg- 15-25 mEq/day
 PO4-3 – 12-24 mEq/day
• Vitamins & micronutrients – Traces

8. 3. Definition of Total Parenteral
Nutrition
Total Parenteral Nutrition is a
formulation of nutritional components
for intravenous delivery. Included are
carbohydrates, amino acids, fats
including essential fatty acids,
electrolytes, vitamins, minerals, trace
elements, water and other additives.

9. 9
Types of TPN Formulation
 TPN formulation without lipid (2-in-1 solution)
• Calories from amino acids- 20 to 25%
• Calories from dextrose- 75-80%
 TPN formulation with lipid ( 3-in-1 solution)
• Calories from amino acids- 20 to 25%
• Calories from lipids- 20%
• Calories from dextrose- 55 to 60 %

10. 4. Objectives:
• To provide nutritional support via intravenous
route when oral or enteral routes are inadequate,
in accessible or non-functional.
• To minimize the potential catheter related,
metabolic and infectious complications associated
with TPN.

11. 5. Indications:
The golden rule of nutrition is “If the gut
works, use it.”
However, if the gut is unable to perform its
functions then we move towards TPN.
5.1. General Indications
5.2. Specific Indications

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• Patients who can’t eat
• Patients who can’t eat enough
5.1. General Indications
5.2. Specific Indications
• Documented inability to absorb inadequate nutrients via the
GIT
• Complete bowel obstruction or intestinal pseudo-obstruction
• Persistent GI hemorrhage
• Major surgery where enteral nutrition is not expected to
resume in 7-10 days
• Intensive chemotherapy

13. 6. Contraindications
• Functional GI tract
• Inability to obtain venous access
• A prognosis that does not warrant
aggressive nutrition support
• When the risks of parenteral nutrition are
judged to exceed the potential benefits.

14. 7. Planning a TPN
1. Calculate Energy/Caloric Requirements
2. Determine Macronutrients
3. Determine Micronutrients
4. Monitoring
5. Complications

15. 7.1. Energy/Caloric Requirements
Kcal is unit used in metabolism studies
“It is the amount of heat required to raise the temperature of 1kg of water by 1oC.”
1Kcal=1000cal
Caloric demand varies in terms upon physical state and medical condition. This is
calculated by Harris-Benedict equation
Harris-Benedict equation
This is usually used to measure basal energy expenditure (BEE) requirements for non-
protein calories. It is also referred as,
• RME= Resting metabolic energy
• REE= Resting energy expenditure

16. For Male:
BEE=66.67+ [13.75 x Wt (kgs)] + [5 x height (cm)] –[6.76 x age(yrs)]
For Female:
BEE=655.1+ [9.56 x Wt (kgs)] + [1.86 x height (cm)] –[4.68 x age(yrs)]

17. Pediatric Nutrition:
• In children caloric requirement /kg are higher because of their higher
BMR (basal metabolic rates)
• BMR is approximately 50-55kcal/kg/day in infancy.
• It declines to about 20-25 kcal/kg/day during adolescence.
• For children less than 3 years old.
 A modified version of Harris-Benedict equation has been developed by
Coldwell-Kennedy
REE= 22 + (31 x Weight in kg) + (1.2 x height in cm)

18. 7.2. Determination of Macronutrients:
a. Protein needs
• Protein requirements based on Stress & Body Weight. Protein needs are
determined by the patients, usually start with 0.83 gm/Kg and add stress and
other factors as needed.

19. Example:
A malnourished 70 Kg man may need 84 gm protein per
day (70 Kg X 1.2 gm/Kg).
Note:
Prolonged TPN solution should contain 2 amino acids: Glutamine
(most abundant amino acid in the blood that protects the gut
epithelia tissue lining. Choline helps protect the liver from hepatic fat
deposits that hinder its function.

20. b. Fluid Requirements
On case by case basis fluid requirements can be change
• It may be increased (dehydrated, burn patients)
• It may be decreased (renal failure, CHF patients) Daily normal requirement is 2-3
L/day for an adult.
For neonates, infants, adolescents and children without abnormal water losses, the
approximate daily water requirement may be calculated by:
1.Based on age: 2.Based on weight:
A factor of 30mL/kg body weight is used to estimate a patient’s daily fluid requirements.
Based on body surface area:
= m2 x 1500mL/day/m2
Based on caloric requirements
=1.2ml/kcal x kcal/day

21. c. Lipids
• The proportion of lipid calories provided is restricted to 30% of total
daily calories. Lipids are generally provided in the form of
emulsions that contain carbohydrate bas emulsifying agent which
also contribute to caloric content.
• Fat emulsions are commonly available in 250 and 500cc bottles.

22. d. Carbohydrates
• Carbohydrates are the primary source of cellular
energy.
• Carbohydrate requirement=3-5g/kg/day.
• In formulas for parenteral nutrition, dextrose provides
3.4kcal of energy/g.
• How many Kcal required of crabs can be determined
by:
Total kcal-fat kcal= carbohydrate

23. 7.3. Determination of Micronutrients
• Electrolytes
• Vitamins
• Trace elements
Vitamins:
• 1amp multivitamin per bag of TPN is
added but does not include vit-K.

24. Trace elements:
• Trace elements like Zn, Cr, Cu, and Mn may also be
added.
• Zinc 440 μg/kg/day at 135 ml/kg/day
• Selenium 2.7 μg/kg /day at 135 ml/kg/day
• Iodine 1.08 μg/kg /day at 135 ml/kg/day

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Final Volume of TPN
Since the fluid needs are 2,100 – 3,600 cc/day, with protein needs of 84 gm/day:
your formulation for your 70 Kg patient will be:
• 10% amino acids 840 cc
• D50W dextrose 750 cc
• 10% lipid 750cc
• Total volume: 2,340 cc/day
You need to add 70-150 cc fluid for electrolytes, vitamins, and additives to give a
final volume of say 2490 ml/day.

26. Administration
• TPN is usually used for 10 to 12 hours a day, five to seven
times a week. Most TPN patients administer the TPN
infusion on a pump during the night for 12-14 hours so that
they are free of administering pumps during the day.
• TPN can also be used in both the hospital or at home.

27. 7.4. Monitoring
• TPN administration requires careful clinical and laboratory
monitoring.
• Adequate growth is best determined by linear growth as weight
gain can reflect an increase in total body water rather than
tissue accretion.
• In addition to routine observations the following are required for
short term TPN use.

28. 7.5. Complications
Following complications are commonly
associated with TPN
• Mechanical Complications
• Metabolic Complications
• Infectious Complications

29. a. Mechanical Complications Related to
vascular access technique:
• air embolism
• arterial injury
• bleeding
• Venous thrombosis
• Catheter occlusion

30. b. Metabolic Complications
Abnormalities related to excessive or inadequate
administration:
• hyper / hypoglycemia
• electrolyte abnormalities
• acid-base disorders
• hyperlipidemia

31. c. Infectious Complications
• Insertion site contamination
• Catheter contamination
• improper insertion technique
• contaminated TPN solution
• contaminated tubing
• Secondary contamination
• Septicemia (blood poisoning)

32. 8. Stopping a TPN
Gradual termination prevents rebound
hypoglycemia, especially for diabetic, septic,
and stressed patients.
• The endocrine system adjusts to a continuous
infusion of dextrose by secreting a certain level
of insulin.
• If the dextrose supply is withdrawn suddenly,
the insulin level will not adjust right away,
resulting in a relative insulin excess and
hypoglycemia.

33. 9. Prescription in Infants
• Premature infants tolerate TPN from day 1 of post-
natal life. Parenteral nutrition can be delivered using
standardized or individualized bags.
• Individualized prescription should only be done after
consultation with the consultant on service.
• Starter Parenteral Nutrition Suitable for:
 preterm infants within the first 24-48 hours of life
 Term infants with fluid restriction and renal
impairment.
Standard Preterm Parenteral Nutrition:
Standard solution for preterm infants after 24-48 hours of age.

34. 10. Recommendations:
Preoperative TPN:
• Only to severely malnourished patients
• 7-10days pre-op Postoperative TPN:
• Patients who experience complication
resulting in inability to tolerate oral diet for
• 7-10 days in previously well-nourished
patients
• 5-7 days in malnourished patients

35. ENTERAL
NUTRITION
or
TUBE FEEDING

36. B. Enteral nutrition
Enteral nutrition, or tube feeding, is a liquid food composed of
carbohydrates, fat, protein, micronutrients and fluid which enters the human
body through a tube in the nose, mouth, stomach or small intestine.
1.Advantages of Enteral Feeding
1.Safer
2. It is more physiologic.
3. Less expensive.
4. Fewer side effects as compared to parenteral nutrition.

37. 2.Indications for enteral tube feeding
Indication for feeding Example
Unconscious patient Head injury, ventilated patient
Swallowing disorder post-CVA
Physiological anorexia Liver disease (particularly with
ascites)
Upper GI obstruction Esophageal stricture
Partial intestinal failure inflammatory bowel disease
Increased nutritional
requirements
Cystic fibrosis, renal disease
Psychological problems Severe depression or anorexia
nervosa

38. 3.General characteristics of enteral diets
• Adults
 15-20% of energy from proteins
 25-40% of energy from lipids
 40-60% of energy from carbohydrates
 1kcal/1ml
 85% water
• Children
 10-15% of energy from proteins
 30-50% of energy from lipids
 50-60% of energy from carbohydrates
 Proportion of energy from proteins ,lipids and carbohydrates
depends on the age of the child 0.65-1kcal/1ml
 80-90% water

39. 4.Feeding Routes
• There are several types of enteral feeding
tubes. They are usually made of polyurethane
or silicone.
• Feeding tubes are usually classified by the site
of placement.
• Tubes can be placed:
 Manually
 Endoscopically
 Surgically

40. • Feeding Tubes
• Are made from soft, flexible
materials (usually silicone,
polyurethane, or polyvinyl) and
come in a variety of lengths and
diameters.
• The outer diameter of a feeding tube is
measured in French units, in which
each unit equals 1/3 millimeter; thus, a
“12 French” feeding tube has a 4-
millimeter diameter.
MIC-G Tube

41. 4.Feeding Routes
4.1-Orogastric tube (OGT)
 Through the mouth to stomach.
 Short-term use.
 Lower incidence of sinusitis than
NGTs.
 Not tolerated for long periods of
time in alert patients; tube may
damage teeth.
There are five main types of enteral
feeding, including:

42. 4.3.-Nasoenteric tube
 starts in the nose and ends in the
intestines (subtypes include NJ,ND)
Short-term use.
 Smaller diameter than NGTs and less
patient discomfort;
 may be used in delayed gastric
emptying. May be difficult to position as
infusion pump is needed.
4.2.Nasogastric tube (NGT)
• through nostril into the
stomach.

43. 4.5.Gastrostomy tube
Gastrostomy tube is inserted through a
small incision in the abdomen, directly into
the stomach.
 Long-term use
 Compared with oral and nasal route, this
technique is more invasive
4.4.Oroenteric tube
• through the mouth and into the intestines.

44. 4.4.Methods of Enteral Nutrition Administration
The 2 most common methods of EN
administration include continuous and
bolus feedings.
1-Continuous Feeding
• Continuous feeding is preferred by most
ICUs,
• Continuous feeding provides EN by
electric enteral feeding pump over 24
hours, which is generally initiated at a
rate of
 20–50 mL/h and advanced to goal rate
by 10–25 mL/h every 4–24 hours.

45. 2-Bolus Feeding
• Bolus feeding is administered via syringe
or gravity drip over a short period, Bolus
feedings should consist of 250 - 300 mL
given over 15 minutes, followed by 25-60
mL water which helps prevent
dehydration and clogging of the tube.
• At least 3 hours should elapse between
each bolus feeding
• One advantage of bolus feeding is that
medication can be separately
administered from feeding. from Springer Nature

46. Residual Volume
Checking "Residuals"
• Before each bolus feeding, gastric
contents should be suctioned out and
returned to the stomach before a new
feeding is administered to ensure that
minimal residue remains from the
previous feeding.
• Residual volume should be checked
every 3-5 hours when feeding is by
continuous drip.
• Excess residual volume (>100 -150 mL)
may indicate an obstruction or some
other problem that must be corrected
before feeding can be continued.

47. 4.5.Enteral Nutrition Formulas
Factors to consider when selecting the Formula include:
 Age
 Fluid status
 GI function
 Food allergies
 Diet preferences

48. Types of enteral formulas
1.Standard formulas
2.Elemental formulas
3.Specialized formulas
4.Modular formulas

49. 1.Standard Formulas
• Called polymeric formulas, are provided to individuals
who can digest and absorb nutrients without difficulty.
They contain intact proteins extracted from milk or
soybeans (called protein isolates) or a combination of
such proteins. The carbohydrate sources include modified
starches, glucose polymers (such as maltodextrin), and
sugars.
• A few formulas, called blenderized formulas, are made
from whole foods and derive their protein primarily from
pureed meat or poultry.

50. 2.Elemental Formulas
• Called hydrolyzed, chemically defined, or
monomeric formulas, are prescribed for
patients who have compromised
digestive or absorptive functions.
Elemental formulas contain proteins and
carbohydrates that have been partially or
fully broken down to fragments that
require little (if any) digestion.
• The formulas are often low in fat and
may contain medium chain triglycerides
(MCT) to ease digestion and absorption.

51. Table: Macronutrient Sources in Standard and Elemental Formulas
Types of Formula Protein Sources Carbohydrate sources Fat Sources
Standard
formulas
• Intact proteins such
as casein ,whey
,lactalbumin and
soy protein isolates
• Milk protein
concentrates
• Egg white
• Corn syrup solids
• Hydrolyzed cornstarch
• Sucrose
• Fructose
• Vegetable oils
(such as corn oil,
soybean oil)
• MCT
• Palm kernel oil
Elemental
formulas
• Hydrolyzed casein ,
whey, lactalbumin
or soy protein
• Crystalline amino
acids
• Hydrolyzed cornstarch
• Maltodextrin
• Fructose
Vegetable oil( such
as corn oil,
soybean oil and
canola oil)
MCT

52. 3.Specialized Formulas
• Called disease-specific formulas, are
designed to meet the nutrient needs of
patients with particular illnesses.
Products have been developed for
individuals with liver, kidney, and lung
diseases; glucose intolerance and
metabolic stress.
• Specialized formulas are generally
expensive and their effectiveness is
controversial.

53. 4.Modular Formulas
• are sometimes prepared for patients who
require specific nutrient combinations to
treat their illnesses. Vitamin and mineral
preparations are also included in these
formulas so that they can meet all of a
person’s nutrient needs.
• In some cases, one or more modules are
added to other enteral formulas to adjust
their nutrient composition.

54. 4.6.Formula Characteristics
• Formulas vary in their nutrient and energy densities so that they can
supply the required nutrients in different volumes of fluid.
1.Macronutrient Composition
• The amounts of protein, carbohydrate, and fat in enteral formulas vary
substantially . The protein content of most formulas ranges from 12 to
20 percent of total kcalories; note that protein needs are high in patients
with severe metabolic stress, whereas protein restrictions are necessary
for patients with chronic kidney disease.
• Carbohydrate and fat provide most of the energy in enteral formulas;
standard formulas generally provide 40 to 60 percent of kcalories from
carbohydrate and 30 to 40 percent of kcalories from fat

55. 2.Energy Density
The energy density of enteral formulas ranges from 0.5 to 2.0
kcalories per milliliter of fluid. Standard formulas provide 1.0 to
1.2 kcalories per milliliter and are appropriate for patients with
average fluid requirements. Formulas that have higher energy
densities can meet energy and nutrient needs in a smaller
volume of fluid and therefore benefit patients who have high
nutrient needs or fluid restrictions. Individuals with high fluid
needs can be given a formula with low energy density or be
supplied with additional water via the feeding tube or
intravenously.

56. 3.Fiber Content
• Fiber-containing formulas can be helpful for
improving fecal bulk and colonic function, treating
diarrhea or constipation, and maintaining blood
glucose control. Conversely, fiber-containing
formulas are avoided in patients with acute
intestinal conditions or pancreatitis, and before or
after some intestinal examinations and surgeries.

57. 4.Osmolality
• Refers to the moles of osmotically active solutes (or
osmoles) per kilogram of solvent. An enteral formula
with an osmolality similar to that of blood serum (about
300 milliosmoles per kilogram) is an isotonic formula,
whereas a hypertonic formula has an osmolality greater
than that of blood serum. Most enteral formulas have
osmolalities between 300 and 700 milliosmoles per
kilogram; generally, elemental formulas and nutrient-
dense formulas have higher osmolalities than standard
formulas.

58. 4.7.Formula Selection
Generally, the best formula is one that meets the patient’s medical and
nutrient needs with the lowest risk of complications and the lowest cost.
The vast majority of patients can use standard formulas. A person with a
functional, but impaired, GI tract may require an elemental formula.
Factors that influence formula selection include:
1. Nutrient and energy needs
2. Fluid requirements
3. The need for fiber modifications
4. Individual tolerances

59. 1. Nutrient and energy needs
• As with patients consuming regular diets, an
adjustment in macronutrient and energy intakes
may be necessary for tubefed patients.
• For example, patients with diabetes may need to
control carbohydrate intake, critical-care patients
may have high protein and energy requirements,
and patients with chronic kidney disease may
need to limit their intakes of protein and several
minerals.

60. 2.Fluid requirements
• High nutrient needs must be met using
the volume of formula a patient can
tolerate.
• If fluids are restricted, the formula should
have adequate nutrient content and
energy density to deliver the required
nutrients in the volume prescribed.

61. 3. The need for fiber modifications
• The choice of formulas is narrower if
fiber intake needs to be high or low.
Formulas that provide fiber may be
helpful for managing diarrhea,
constipation, or hyperglycemia in some
patients; other patients may need to
avoid fiber due to an increased risk of GI
obstructions.

62. 4.Individual tolerances
• ( food allergies and sensitivities). Most
formulas are lactose- free, because
many patients who need enteral
formulas have some degree of lactose
intolerance.
• Many formulas are also gluten-free and
can accommodate the needs of
individuals with celiac disease (gluten
sensitivity).

63. 4.8.Administration of Medicine
• The feeding tube should be flushed with 30 ml of water
or saline before and after administration of a drug.
Liquid forms of medication should be used if possible.
• Some medications can be added to the TF formula, but
drug-nutrient interactions may occur. Some drugs can
cause the formula to clump and clog the feeding tube.
• Placement of the feeding tube can affect drug action.
Some drugs require the acidic environment of the
stomach to be dissolved, and therefore may not be well
absorbed if the feeding tube is placed in the intestine.

64. 4.9.Feeding Systems
• Formulas are available in open feeding systems
and closed feeding systems. With an open feeding
system, the formula needs to be transferred from
its original packaging to a feeding container.
• Examples include formulas that are packaged in
cans or bottles, concentrates that need to be
diluted, and powders that require reconstitution. In
a closed feeding system, the formula is
prepackaged in a container that can be connected
directly to a feeding tube.

65. 4.9.Feeding Systems
• Closed systems are less likely to become
contaminated, require less nursing time, and
can hang for longer periods of time than open
systems. Although closed systems cost more
initially, they may be less expensive in the
long run because they prevent bacterial
contamination and thus avoid the costs of
treating infections.

66. 4.10.Oral Use of Enteral Formulas
• enteral formulas can fully meet a person’s nutritional needs. In most cases,
however, patients drink enteral formulas to supplement their diets when they
are unable to consume enough food to meet their needs.
• Enteral formulas provide a reliable source of nutrients and add energy and
protein to the diets of malnourished patients. Those who are weak or
debilitated may also find it easier to manage formulas than meals.
• These products are sometimes used as nutrition supplements or convenient
meal replacements by healthy individuals. The products are available in
ready-to-drink liquid form or in powdered forms that must be reconstituted
with water or milk

67. 67
4.11.Suggested monitoring Schedule for Enteral Feeding
Parameter Acute Patient Stable Patients
electrolytes Daily 1-2*/wk.
CBC Daily 1-2*/wk.
Glucose level 3*/day more often if poor
control
3*/day. Less often If good
control
Creatinine and Urea levels Daily Weekly or twice a week
Nitrogen balance As needed for concern of
underfeeding or protein
malnutrition
As needed for concern of
underfeeding or protein
malnutrition
Urine output Daily (30ml/hour urine output) Daily
Body weight Daily 2-3*/wk.

68. 4.12.Contraindications for tube feedings
These include:
•Intestinal obstruction or hypomotility of the intestine.
•Severe diarrhea.
•Severe acute pancreatitis or shock.
•When prognosis does not warrant aggressive nutritional support.
Complications of Tube Feedings
• Regurgitation of fluids is a possible complication, especially if the formula
enters the stomach much faster than it is emptied.
• If fluids are regurgitated and enter the lungs, a fatal infection or aspiration
pneumonia, can develop.

69. 69
REFERENCES
• Calculating Parenteral Feedings
HSCI 368, D. Chen-Maynard, PhD,
RD
• Total parenteral nutrition in the
surgical patient: a meta-analysis.
Can J Surg 2001, 44:102-
http://health.csusb.edu/dchen/368%
20stuff/TPN% 20calculation.htm
•
http://clincalc.com/TPN/Macronutri
ents.aspx

70. THANK YOU
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