For patients with nutritional support

1. Total Parenteral Nutrition
Fatemeh Dabaghzadeh
Clinical Pharmacy Specialist
KMU
1

2. • Parenteral nutrition (PN) is indicated in patients
with a non functioning gastrointestinal tract
• Venous access site
– Peripheral veins
– Central veins
2

3. 3

4. Peripheral veins
• Parenteral nutrition expected for: more than 10 days
• Patient has fairly low energy and protein needs owing to
minimal stress
• Osmolarity of these formulations is 600 to 900 mOsm/L
– Low concentrations of dextrose (5%–10%) and amino
acids (3%–5%)
4

5. Peripheral veins
• Lipids may protect the vein against irritation through
dilution and a buffering effect.
• A common complication (up to 70%) of peripheral
parenteral nutrition is phlebitis
• Site rotations (at least every 48–72 hours)
5

6. Central veins
Preferred for patients
• Whose GI tracts are nonfunctional or should be at rest for
more than 7days,
• Who have limited peripheral venous access, or
• Who have energy and protein needs that cannot be met
with peripheral nutrient formulations
• Osmolarity can be greater than 2,000 mOsm/L
– high concentrations of dextrose (20%–35%), amino acids (5%–
10%)
6

7. Components of TPN Formulations
 Macronutrients:
Calorie: Dextrose 5%, 10%, 20%, 50%, 70%
Intralipid 10%, 20%, 30%
Protein: Aminofusion 5%, 10%
 Micronutrients:
Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
Vitamin (A, E, C, B, Folic acid)
7

8. Energy Requirements
Hospitalized patient, mild stress 20–25 kcal/kg/d
Moderate stress, malnourished 25–30 kcal/kg/d
Severe stress, critically ill 30–35 kcal/kg/d
Estimation of Protein Requirements
US recommended dietary allowance 0.8 g/kg/d
Hospitalized patient, minor stress 1–1.2 g/kg/d
Moderate stress 1.2–1.5 g/kg/d
Severe stress 1.5–2 g/kg/d
8

9. 9

10. 10

11. Dextrose
60% to 70% of the total energy
3.4 kcal of energy per gram
Protein
4 kcal of energy per gram
Lipids
30% to 40% of the total daily calories
Each gram yields 10 kcal of energy
Water
30 to 35 mL/kg/day
mL/day =1,500 mL+ [(20 mL/kg)(W −20 kg)]
11
Nutrients

12. Compalications of TPN
12

13. EFAD
• A small amount of lipid is necessary to prevent essential
fatty acid deficiency (EFAD)
• The essential fatty acids, linoleic and α-linolenic, are
those that cannot be synthesized by humans
• Clinical symptoms of EFAD are dry, thickened, scaly
skin, hair loss, poor wound healing, and
thrombocytopenia, which may be observed after a few
weeks to months of lipid free parenteral feedings
13

14. Refeeding syndrome
• Occur when malnourished patients receive a concentrated
source of calories via parenteral or enteral nutrition
• Complications
– Severe hypophosphatemia
– Hypokalemia
– Hypomagnesemia
– Vitamin deficiencies
– Fluid intolerance
– Glucose alterations may occur
14

15. Overfeeding
• Overfeeding should be avoided in all patients, especially
those with respiratory concerns
• Overfeeding with carbohydrates results in carbon dioxide
retention that may lead to acid–base disturbance
• Limit dextrose infusions rate to less than 4 mg/kg/minute
(7 g/kg/day)
• Daily lipid intake: maximum of 1 g/kg/day
– 0.11 mg/kg/hour to prevent impaired hepatic, pulmonary,
immune and platelet function
– Serum triglyceride concentration of 400 mg/dL is acceptable 15

16. Stability
• Lipid:
– A decrease in pH and the addition of divalent cations
(Mg2+,Ca2+) increase fat particle size
– The use of a 1.2-μm filter is recommended to protect
against the infusion of enlarged lipid particles.
16

17. Microbial growth
• TNA or dextrose/amino acid formulations to hang for up
to 24 hours.
• The hang time for lipids when administered alone is 12
hours
17

18. Hyperglycemia
• Adding insulin to the parenteral nutrient formulation is to
begin with 0.1 units of regular insulin per gram of
dextrose
• Insulin therapy should be considered if serum glucose
concentrations exceed 150 mg/dL for stable patients and
120 mg/dL for critically ill patients.
18

19. Initiation of infusion
• For administering parenteral nutrient formulations
containing hypertonic dextrose is to begin at a slow
infusion rate of less than 250 g during the first 24 hours
for most patients and less than 150 g for patients with
known diabete mellitus or hyperglycemia
• The infusion is increased slowly during the next 24 to 48
hours to the goal infusion rate
19

20. Addition of medications
• In some specific circumstances
– Regular insulin
– Antibiotics
– Chemotherapeutic agents
– Histamine type 2 (H2)-receptor antagonists
– Heparin
• The routine addition of medications to parenteral nutrient
formulations is discouraged
20

21. 21

22. Acute renal failure
Protein dose: 0.6 to 1g/kg/day
Fluid: less than 1200 ml/d
22

23. Hepatic failure
• Hepatic encephalopaty:
– Protein restriction: 0.6 to 0.8 kg/day
– Increased BCAAs: (Leu., Isoleu., Val.) and
decreased AAAs: (Pheny., Tyr., Tryp.)
23

24. Obesity
• Obesity is defined as weight exceeding of 120% of ideal
body weight (IBW) or a body mass index (BMI) of
greater than 27 kg/m²
• Adipose tissue is not metabolically active
• About on fourth of the adipose tissue is composed of
some supporting tissue that is metabolically active
• Adjusted weight = (0.25) (Actual weight – IBW) + IBW
24

25. Case 1
D.C a 38 y.o man with a 12-year history of chron,s disease
is admitted to surgery ward of Imam hospital in Sari 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.
25

26. Case 1
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?
26

27. BEE= 66.47+13.75×60+5×180-6.76×38=1535 kcal/d
TEE= 1535×1.2×1.2 = 2200 kcal/d
Energy: 35 × 60= 2100
Intralipid = 30%, 40% * 1740= 522 to 696 kcal/ 10= 52.2. 69.6 g
Dextrose = 60%, 70%* 1740= 1044 to 1218/ 3.4= 307 to 358 g
14 vial glucose 50%
Aminofusion = 1.2, 1.5 * 60=72 to 90 g, 360 kcal,
Water = 35 * 60= 2100 ml
Case 1
27

28. Case 2
•
‫خانمي‬
51
‫سابقه‬‫از‬‫شکايت‬‫با‬‫الغر‬‫و‬‫ساله‬
3
‫زن‬‫و‬‫کاهش‬ ‫و‬‫غذا‬ ‫دن‬‫ر‬‫خو‬‫از‬‫پس‬‫شديد‬ ‫درد‬ ‫ماهه‬
30
‫کند‬‫مي‬ ‫اجعه‬‫ر‬‫م‬ ‫بيمارستان‬‫به‬‫پوندي‬
.
‫هم‬‫دليل‬‫به‬‫که‬‫شود‬‫مي‬ ‫معلوم‬‫سي‬‫ر‬‫بر‬‫از‬‫پس‬
‫با‬‫شديد‬ ‫درد‬‫ين‬
‫کند‬‫مي‬‫مصرف‬ ‫غذا‬ ‫ناچيزي‬‫مقدار‬ ‫ز‬‫و‬‫ر‬‫در‬‫يکبار‬‫فقط‬‫شود‬‫مي‬‫گرسنه‬ ‫اينکه‬‫وجود‬
.
‫ي‬‫ر‬‫تا‬
‫پزشکي‬‫خچه‬
‫م‬‫ايسکمي‬‫دليل‬‫به‬‫ايلوئم‬‫از‬‫قسمتي‬‫برداشتن‬‫احي‬‫ر‬‫ج‬‫سابقه‬ ‫و‬‫معده‬ ‫زخم‬‫بيانگر‬‫او‬
‫باشد‬‫ي‬
.
‫بيمار‬
‫طي‬‫او‬‫زن‬‫و‬‫کاهش‬‫که‬‫کند‬‫مي‬‫ذکر‬
3
‫است‬‫داشته‬‫ادامه‬‫اخير‬‫ماه‬
.
‫يک‬‫نشانگر‬‫يکي‬‫ز‬‫في‬ ‫معاينه‬
‫ن‬‫ز‬
‫است‬‫ها‬‫شانه‬ ‫في‬‫و‬‫تر‬‫ا‬‫و‬‫پوستي‬‫ير‬‫ز‬‫بي‬‫ر‬‫چ‬ ‫کاهش‬ ‫با‬‫الغر‬
.
•
‫او‬‫قد‬
5
‫و‬‫فوت‬
4
‫او‬‫زن‬‫و‬‫و‬ ‫اينچ‬
89
‫است‬‫پوند‬
.
‫او‬‫زن‬‫و‬‫ايلوئم‬‫احي‬‫ر‬‫ج‬‫زمان‬‫در‬
91
‫که‬‫بوده‬‫پوند‬
‫است‬‫او‬‫معمولي‬ ‫زن‬‫و‬‫واقع‬‫در‬
.
28

29. ‫او‬ ‫زمايشگاهي‬‫ا‬‫تستهاي‬
:
Na: 135 mEq/L (135-145) Glucose: 87 mg/dl (85-110)
K: 4 mEq/L (3.5-5)
Ca: 8.2 mg/dl (8.5-10)
Cl: 100 mEq/L (100-110)
Mg: 2 mg/dl (1.6-2.2)
HCO3-: 25 mEq/L (24-30)
P: 3 mg/dl (2.5-4.5)
BUN: 4 mg/dl (8-20)
Total Protein: 6 g/dl (6.8-8.3)
Creatinine: 0.6 mg/dl (0.8-1.2) Albumin: 4 g/dl (3.5-5)
WBC: 6800 /mm3 (4000-12000) Prealbumin: 21 mg/dl
(15-40)
‫ده‬‫و‬‫ر‬‫ين‬‫ژ‬‫ن‬‫ا‬ ‫بيمار‬‫اين‬‫تشخيص‬
(
‫انتر‬‫ز‬‫م‬ ‫ايسکمي‬
)
‫باشد‬‫مي‬
.
Case 2
29

30. •
‫يابي‬‫ز‬‫ار‬
:
•
‫نمود‬ ‫يابي‬‫ز‬‫ار‬ ‫ا‬‫ر‬‫بيمار‬‫اي‬‫تغذيه‬‫وضعيت‬‫بايد‬‫ابتدا‬
.
‫است‬‫مطرح‬ ‫او‬‫اي‬‫ر‬‫ب‬‫مشکل‬ ‫دو‬
:
•
‫ايلوئم‬‫بودن‬‫ناقص‬‫بدليل‬‫ناکافي‬‫جذب‬‫ديگري‬‫و‬‫کافي‬‫ان‬‫ز‬‫مي‬‫به‬‫تغذيه‬‫عدم‬‫يکي‬
.
‫ا‬
‫مدت‬‫طي‬ ‫و‬
3
،‫ماه‬
30
‫اکنون‬‫و‬‫داشته‬‫زن‬‫و‬ ‫کاهش‬‫پوند‬
%
75
‫دارد‬ ‫ا‬‫ر‬‫خود‬‫معمول‬‫زن‬‫و‬
.
•
‫طي‬‫او‬‫واقع‬‫در‬
3
‫ماه‬
%
25
‫شود‬‫مي‬‫محسوب‬‫شديد‬ ‫کاهش‬‫يک‬‫که‬‫داشته‬‫زن‬‫و‬ ‫کاهش‬
.
•
‫س‬ ‫هاي‬‫تئين‬‫و‬‫پر‬‫بودن‬‫نرمال‬‫و‬ ‫ها‬‫شانه‬ ‫در‬‫عضله‬‫و‬‫پوستي‬‫ير‬‫ز‬‫بي‬‫ر‬‫چ‬‫کاهش‬ ‫به‬‫توجه‬‫با‬
‫توان‬‫مي‬‫رمي‬
‫اسموس‬‫ر‬‫ما‬ ‫نوع‬‫از‬‫شديد‬ ‫تغذيه‬‫سوء‬ ‫او‬‫که‬‫فت‬‫گ‬
(Marasmus)
‫دارد‬
.
•
‫نخو‬‫خود‬‫وضعيت‬‫اصالح‬‫زمان‬‫تا‬‫و‬ ‫دارد‬‫احي‬‫ر‬‫ج‬‫به‬‫نياز‬‫خود‬‫ده‬‫و‬‫ر‬ ‫درد‬‫رفع‬‫اي‬‫ر‬‫ب‬ ‫بيمار‬‫اين‬
‫اهد‬
‫د‬‫ر‬‫بخو‬‫غذا‬‫توانست‬
.
‫به‬ ‫نياز‬‫اين‬‫بنابر‬
TPN
‫داشت‬‫خواهد‬
.
Case 2
30

31. •
‫نياز‬‫د‬‫ر‬‫مو‬‫تئين‬‫و‬‫پر‬‫و‬‫کالري‬
•
‫اوست‬‫حرکت‬‫و‬‫پايه‬‫متابوليسم‬ ‫اي‬‫ر‬‫ب‬ ‫ژي‬‫انر‬‫مين‬‫تا‬‫اوليه‬‫هدف‬
.
‫بايد‬‫ابتدا‬
BEE
‫نمود‬‫حساب‬‫ا‬‫ر‬
:
?
=
BEE (Kcal/day )
•
‫او‬‫فعاليت‬ ‫ر‬‫تو‬‫فاک‬ ،‫کند‬‫مي‬‫حرکت‬ ‫بيمار‬‫اينکه‬‫به‬‫توجه‬‫با‬
%
30
(
1.3
)
‫پس‬‫است؛‬
:
TEE Kcal/day = BEE x 1/3 = ?
•
‫اينکه‬‫به‬‫توجه‬‫با‬
‫خاصي‬‫استرس‬‫ز‬‫هنو‬ ‫بيمار‬
(
‫احي‬‫ر‬‫ج‬‫مثل‬
)
‫ندارد‬
‫تئي‬‫و‬‫پر‬ ‫نياز‬‫پس‬ ،
‫او‬‫ني‬
1-1/2
g/kg
‫مي‬
‫باشد‬
.
Case 2
31

32. Case 2
• Calories = ?
• Intralipid = ?
• Aminofusion = ?
• Dextrose = ?
32