total parenteral nutrition

1. Dr Abu Bakkar Khan
Resident surgeon
DHQ hospital Rawalpindi

2. If a 70 kg male with sedentary lifestyle is
put on TPN due to severe necrotizing
pancreatitis, what would be his total
energy expenditure?

3. Nutritional Support Types
 Enteral Nutrition: The type of feeding in which GI
tract is used.
Benefits: Physiologic, less expensive, well tolerated.
Types: Sip feeding, NG, Gastrostomy, Jejunostomy .
 Parenteral Nutrition : The type in which venous line
is used to meet the caloric requirement of the patient.

4. Parenteral nutrition is given in the cases where:
GI should not be used (Obstruction, Pancreatitis)
GI can not be used ( Vomiting, Diarrhea, Resection
of intestine, IBD, enterocutaneous fistula)

5. Parenteral Nutrition
 It is of mainly two types
1. Peripheral Parenteral Nutrition (PPN) .
2. Central Parenteral Nutrition (CPN)

6. Peripheral Parenteral Nutrition
(PPN)
 Administered through a peripheral intravenous line.
 Osmolarity should be limited to 1000 mOsm ( not
more than 12.5 % dextrose) to avoid phlebitis.
 Thus large volumes are needed.
 Generally used as supplement to oral feeding.

7. Total Parenteral Nutrition
 Provides complete nutritional support.
 Solutions , volume of administration and additives are
individualized based on assessment of nutritional
requirments.

8. Estimation of Total Energy
Expenditure(TEE)
 TEE (kcal/day):
BEE × Stress factor × Activity factor
 Stress factors:
1. Surgery: minor 1.1 major 1.2
2. Infection: mild 1.2 moderate 1.5 severe 1.8
3. Trauma: Skeletal 1.35 Blunt 1.35 Head injury 1.6
4. Burns: 40% 1.5 100% 2.1
 Activity factors:
Confined to bed : 1.2
Out of Bed : 1.3

9. Estimation of Basal Energy
Expenditure
 Basal Energy Expenditure (BEE ) : 25 x Weight (kg)
 For a 70 kg man, BEE would be: 25 x 70= 1750

10.  Other Factors:
Pregnancy : add 300kcal/day
Lactation : add 500kcal/day
Obese : add15-20 kcal/kg/day

11. Fluid requirements
 Estimation can be done by:
1. Caloric intake: 1ml/calorie. Foe example 1800calorie
diet will require 1800ml of fluid
2. By age and weight: average requirement is
30ml/kg/day.
16 to 55 years : 35ml/kg/day
56to 65 years : 30ml/kg.day
>65 years : 25ml/kg/day

12. Essential Nutrients
 Carbohydrates
 Fats
 Proteins
 Dietary Fibers
 Water & Electrolytes
 Vitamins
 Minerals
 Trace Elements

13. Carbohydrates
 5g/kg/day
 1gm = 4kcal
 Minimum recommended amount:300gm/day or
1200kcal/day
 60-70% of total nutrition.

14. Protein (amino acids)
 1gm=4kcal
 10-20% total nutrition
 Maintenance: 1 g/kg/day
 Metabolic stress (injury/illness): 1-1.5 g/kg/day
 ARF (undialyzed): 0.8 g/kg/day
 Dialysis: 1.2-1.4 g/kg/day
 Burn patients (severe): Increase protein until significant
wound healing is achieved
 Solid organ transplant: 1.5-2 g/kg/day
 Pregnant women in second or third trimester
 Add an additional 10-14 g/day

15. Fat
 Requirement 3g/kg/day
 1gm= 9kcal
 25-30% of total nutrition

16. Components of TPN Formulations
Macro:
Calorie: Dextrose 25%, 50%
Intralipid 10%, 20%
Protein: Aminofusion 5%, 10%
Micro:
Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)

17. Dextrose
25%, 50% ( from CV-line)
4 kcal/g
60-70% of calorie requirements should
be provided with dextrose

18. Intralipid
10%, 20% ( from CV-line)
1.1 kcal/ml (10%), 2 kcal/ml (20%)
30-40% of calorie requirements should
be provided with Intralipid

19. Aminofusion
5%, 10% ( from peripheral orCV-line)
1-1.5 g/kg/day
Should not be used as a calorie source

21. Electrolytes (daily requirements for TPN):
 Na: 80-100 mEq (50 - 100 ml NaCl 5%)
 K: 60-80 mEq (30 ml KCl)
 Cl: 50-100 mEq
 Mg: 8-16 mEq (5 -10 ml MgSo4 20%)
 Ca: 5-10 mEq (10-20 ml Ca Gluconate 10%)
 P04: 15-30 mEq
 Acetate: 50-100 mEq

24. Types of TPN formulations
 TPN formulation without lipid( 2-in-1 solution)
calories from dextrose ---- 75 to 80%
calories from amino acids----- 20 to 25%
 TPN formulation with lipids (3-in-1 solution)
calories from dextrose------ 55 to 60%
calories from lipids -------- 20%
calories from amino acids---20 to 25%

25. Administration of TPN
 Administration of TPN should be gradual. i.e.,
approx. 1000kcal is provided on 1st day. If there is
metabolic stability (normoglycemia), it is increased
gradually to the optimum caloric level over 1 to 2 days.
 TPN solutions are most commonly delivered as
continous infusion. A new bag of 1 in 3 formula is
given daily over 24 hours. Total infused volume should
be kept constant while nutritional content is
increased.

26. Special Considerations
 Max infusion rate of dextrose: 0.5 g/kg/h (to avoid
hyperglycemia, glycosuria, fatty liver, hyperosmolar
coma)
 Potassium should be added to dextrose solutions.
 Slow starting & slow tapering of Dext 50%
 If BSR>200, Insulin should be added
 some brands of lipids can be mixed with
Dext+Aminifusion in the same IV container

27. Special Considerations
 lipid contraindications:
 Severe egg allergy
 Hyperlipidemia
 Special aminoacid products:
 Hepatamine: for Hepatic Failure
 ↑ branched chain aa ( leu, isoleu, val)
 Nephramine: for Renal Failure
 Primarily essential aa with lower concentrations

28. Monitoring:
Weight, CBC, Na, K, BUN, Cr, BSR, Ca, P, Mg, PT, INR, TG,
LFT, Albumin,
 Daily: Weight, , Na, K, BUN, Sign/Symptoms of
infection
 2-3 times a week: CBC, Ca, P, Mg
 Weekly: Proteins,(Albumin, globulins), LFT, INR,
Nitrogen Balance

29. Refeeding syndrome
 It’s a combination of symptoms that occur in
severely malnourished patients when they are
re-fed after long-standing or severe malnutrition
 Is a medical emergency, consist of:
 Electrolyte disturbances (eg, potassium, phosphorus)
 Respiratory distress
 Cardiac arrhythmias, resulting in cardiopulmonary
arrest
 Do not overfeed patients; caloric replacement
should match as closely as possible to intake

30. Conclusion
 Malnutrition is a common problem & Nutritional
support is indicated in many hospitalized patients
 Enteral nutrition is better, but some patients with GI
problems need TPN
 Dextrose & Intralipid should be used as calorie sources
and Aminofusion as aminoacid source
 Special monitoring should be considered.