Total parenteral nutrition (TPN) involves administering complete nutrition intravenously when oral or enteral nutrition is not possible. It provides glucose, lipids, amino acids, fluids, electrolytes, vitamins and minerals. TPN is indicated for short-term use in conditions preventing GI tract use or long-term in intestinal failure. Requirements are calculated based on basal energy expenditure and patient factors. Complications include catheter-related infections, metabolic abnormalities like hyperglycemia, and liver dysfunction. Close monitoring of patients on TPN is required.

1. BY THE NAME OF ALLAH THE MOST BENEFICENT AND THE MOST MERCIFUL

3. 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.

4. 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 )

6. Energy: Glucose and Lipids
Amino acids (Nitrogen)
Water and electrolytes
Vitamins
Trace elements

7. Requirements
Energy
Energy requirement = BEE x activity factor x injury factor .
 Basal energy expenditure(BEE) is calculated =25-30 kcal/ kg
BW/day.(Harris Benedict formula)
ACTIVITY FACTOR:
•1.2 Confined to bed
•1.3 Ambulatory
INJURY 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

8. Requirements
 Glucose(50-60 % of total energy)

9. 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.

10. Requirements
 Lipids(30-40 %)

11. 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.

12. Requirements:
Protein :
Protein is the functional and structural component of
the body, so fulfilling patient’s caloric needs with non-
protein calories (fat and glucose) is essential.
Protein requirements for most healthy individuals
are 0.8 g/kg/day. But it varies in different conditions.

13. Requirements
Protein: Daily Protein requirements
Condition Example requirement
Basic requirements Normal person 0.5-1g/Kg
Slightly increased requirements Post-operative, cancer, 1.5g/Kg
inflammatory
Moderately increased Sepsis, polytrauma 2g/Kg
requirements
Highly increased requirements Peritonitis, burns, 2.5g/Kg
Reduced requirements Renal failure, hepatic 0.6g/Kg
encephalopathy
•Parenteral amino acid solutions provide all known essential
amino acids.
•Available A.A preparations are 3.5 - 15 % (ie contains 3.5-15
gms of protein or A.As/100 mL solution).

14. Requirements
Protein:
•Special a.a. solutions are also available containing higher
levels of certain a.a.s, most commonly the branched-chain
ones (valine, leucine and isoleucine), aimed at the
management of liver diseases, sepsis and other stress
conditions.
•Conversely, solutions containing fewer a.a.s (primarily
the essential ones) are available for patients with renal
failure.

15. Requirements
Fluids 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 0.2-0.5mmol
Chloride/Acetate So as to maintain acid-base balance
(normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)

16. Requirements
Vitamins
Vitamins are either fat soluble (A,D,E,K) or water
soluble (B,C). Separate multivitamin commercial
preparations are now available for both.
Most adult vitamin formulae do not contain vitamin K,
which is added according to the patient’s coagulation
status.

17. Requirements
Trace minerals
These are essential component of the parenteral
nutrition regimen.
A multi-element solution is available commercially, and
can be supplemented with individual minerals.
May be toxic at high doses.
Iron is excluded, as it alters stability of other
ingredients. So it is given by separate injection (iv or im).

18. Requirements
Trace minerals
Mineral Recommended dietary Suggested daily
allowance (RDA) for daily intravenous intake
oral intake (mg) (mg)
Zinc 15 2.5-5
Copper 2-3 0.5-1.5
Manganese 2.5-5 0.15-0.8
Chromium 0.05-0.2 0.01-0.015
Iron 10 (males)-18 (females) 3

19. Osmolarity
PPN: Maximum of 1000 mosmoles / liter.
TPN: as nutrient dense as necessary (1000 - 3000)
mosmoles/liter.

20. • 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

21. Application
The Solution
Single bottle
+
Systems
“All-in-one” mixtures
2- or 3-chamber bags +

22. Location
Subclavian Veins
Internal Jugular Veins
Femoral Veins
Brachial Veins
Types
Non-tunneled Tunneled
Cordis Hickman
Swan Ganz Broviac
Double Lumen Portacath
Triple Lumen
PICC

23. Application
Initiation of Therapy
TPN infusion is usually initiated at a rate of 25 to 50 mL/h.
This rate is then increased by 25 mL/h until the predetermined
final rate is achieved.

24. First week Later
Energy balance
weight Daily Daily
Metabolic variables
Blood measurements
Serum electrolytes Daily 1-2 /week
RFTs 3 / week 2/week
Glucose Daily (initially 6hrly until stabilized) 3/week
Hemoglobin Weekly Weekly
LFT’s(including PT, Weekly Weekly
APTT)
Serum total protein 2/week Weekly
Serum triglycerides weekly weekly
Serum Ca+2 & PO4 3/week 2/week
Serum Magnesium 2/week weekly
Selenium, Zinc, Monthly
Copper

25. First week Later
Urine measurements
Glucose daily
Specific gravity and osmolarity Daily Daily
General measurements
Input & output Daily Daily
Prevention and detection of infection
Clinical observation (activity, Daily Daily
temperature, symptoms )
TLC & DLC As indicated As indicated
Cultures As indicated As indicated

26. Complications of TPN
About 5 to 10% of
patients have
complications related to
central venous access.
Catheter-related sepsis
occurs in about ≥ 50% of
patients. Glucose
abnormalities
(hyperglycemia or
hypoglycemia) or liver
dysfunction occurs in >
90% of patients.
*(The Merck Manual)

27. 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.
•

28. Feeding regimen related:

29. Complications of TPN
Catheter sepsis
Prevent by :
Only i.v. nutrition solutions are administered through the
catheter, no blood may be withdrawn from the catheter.
Catheter disinfection and redressing 2 to 3 times weekly.
Detect by : Fever, chills, ±drainage around the catheter
entrance site, Leukocytosis, +ve cultures (blood & catheter
tip).
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

30. Complications of TPN
 Metabolic Complications
o 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).

31. Complications of TPN
Metabolic Complications
Hypertriglyceridemia Associated with excess
infusion of fat emulsion.
• Can cause pulmonary insufficiency.

32. Complications of TPN
 Metabolic Complications
o 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.

34. 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
Crohn's 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.

35. ‫” 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