This document discusses total parenteral nutrition (TPN). It begins by outlining the indications for TPN, including malnutrition and inability to meet nutritional needs enterally. The document then covers the components of TPN including carbohydrates, amino acids, lipids, electrolytes, vitamins and minerals. It discusses the methods of administering TPN including peripherally and through central lines. The document provides guidance on calculating nutritional requirements and initiating and monitoring TPN. Finally, it reviews potential complications of TPN including mechanical issues, metabolic disturbances, and infections.

1. TOTAL
PARENTERAL
NUTRITION
Presenter : Dr Bilal Zaib

2. Malnutrition can be
as common in
poverty as in wealth
One for the lack of
food, the other for
the lack of
knowledge of food

3. Aims and Objectives
To understand parenteral nutritio
Indications and contraindications
The routes of administration
Constituents
Calculate the requirements
Infusion schedules
Complications

4. MALNUTRITION
Acc to bailey and love almost 50 % surgical
patients suffer from malnutrition
Resulting in :
Increased morbidity and mortality
Delayed wound healing
Fistula formation
High chance of infections
Increased ventilatory support
Delayed callus formation
LONGER RECOVERY PERIOD AND PROLONGED DURATION OF
HOSPITAL STAY
Poor quality of life

5. Definition of nutrition
is the provision, to cells and organisms, of
the materials necessary (in the form of
food) to support life.

6. Essential nutrients
Proteins
Carbs
Fat
Vitamins
Minerals
Water and electrolytes
Trace elements

7. Assessment of nutritional status
patients should be assessed for PEM as well as specific nutrient deficiencies
HISTORY
1)Change in diet patterns
2)Unintentional weight loss
3)Evidence of malabsorption
4)Look for factors which may increase metabolic stress such as
infections inflammation malignancies.
EXAM & ANTHROPOMETRY
.Weight loss
.BMI (weight corrected for height)
BMI less than 14 are extremely underweight and should
be considered for admission To hospital for nutritional support
.look for tissue depletion (loss of fat and skeletal muscle wasting)
.fluid status for dehydration or overload
LAB PARAMETERS: plasma albumin , lymphocytes etc

9. Specialized nutritional support
Critical illness induces anorexia and the inability to eat normally
predisposing the patients to serious nutritional deficiencies so
provision of SNS is a major advancement in modern medicine
SNS is provided either enterally or parenterally and decision to use SNS
should be based on the likelihood that preventing PEM will increase the
chances of recovery , reduce infection rate , improve healing and shorten
the stay in hospital.
SNS should only be used only when potential benefits exceed risks and it
should be undertaken with consent of the patient

10. What are the types of
nutrition?
Enteral
Parenteral

11. ◗ Refers to feeding via a tube placed into the gut to deliver
liquid formulas containing all essential nutrients
◗ Preferred route because of benefits derived from
maintaining the digestive, absorptive and
immunological barrier function of GIT
◗ Enteral/tube feeding is useful in pts who have
functional GIT, but who cannot digest or ingest
adequate amount of nutrients
◗ Short term (<6 weeks) tube feeding can b
e
achieved by nasogastric, nasoduodenal or
nasojejunal tubes
Enteralfeeding

12. What is parenteral nutrition?
It involves the continuous infusion of a
hyperosmolar solution containing
carbohydrates, proteins, fat and other
necessary electrolytes through an indwelling
catheter inserted into (usually) SVC to meet
the nutritional needs of the patient.
PN through a peripheral vein is limited by
osmolality and volume constraints
Solutions that contain more than 3%
aminoacid and 5% glucose are poorly
tolerated peripherally

13. Parenteral Nutrition
Given through intravenous route
avoiding gastrointestines
Components are in elemental or “pre digested” form
P r o t e i n as amino acids
Car bohydr at e as dextrose
F a t as lipid emulsion
Electrolytes, vitamins andmInerals

15. What are the indications for
parenteral nutrition?

16. When should it not be used?
Functional and accessible GI tract
Patient is taking oral diet
Prognosis does not warrant
aggressive
nutritional support
(terminally ill)
Risk exceeds benefit
Patient expected to meet needs within
14 days

17. How can it be delivered?
C e n t r a l Parenteral Nutrition: oftencalled
Total Parenteral Nutrition (TPN);or total nutrient
admixture, delivered into a central vein
Peripheral Parenteral Nutrition(Ppn )
delivered into a smaller or peripheral vein

18. Peripheral parenteral nutrition
(PPN)
administered through a peripheral intravenous
catheter.
The osmolarity of PPN solutions generally is
limited
to 1,000 mOsm (approximately 12% dextrose
solution) to avoid phlebitis.
Thus, large volumes (>2,500 mL) are needed.
Temporary nutritional supplementation with PPN
may be useful
Generally intended as supplement to oral feeding
and is not optimal for critically ill pts

19. When can parenteral nutrition
be given through a peripheral
line?
Therapy is expected to be short term (
1
0
-
1
4
days)
Energy and protein needs are moderate
Formulation osmolarity is less than
600 -900 mosm/L
Fluid restriction is not necessary

20. Central Parenteral Nutrition
May be delivered via femoral lines, internal
jugular lines, and subclavian vein catheters in the
hospital setting
Peripherally inserted central catheters (PICC) are
inserted via the cephalic and basilic veins
Central access required for infusions that are toxic to
small veins due to medication, pH, osmolarity, and
volume

22. Central line (tunnelled)
Advantages: convenient exit site , long lasting
Disadvantages : removal needs dissection

24. PICC Lines (peripherally inserted
central catheter)
PICC lines may be used in ambulatory settings or for
long term therapy
Used for delivery of medication as well as PN
Inserted in the cephalic, basilic, median basilic, or median
cephalic veins and threaded into the superior vena cava
Can remain in place for up to 1 year with proper
maintenance and without complications

25. What does it contain?

26. YUMMY

27. Carbohydrate
Source: Monohydrous dextrose
Properties: Nitrogen sparing Energy source
3.4Kcal/g Hyperosmolar,Recommended intake 2
– 5 mg/kg/min 50-70% of total calories
Generally, because glucose is an
essential
tissue fuel, glucose and amino acids are
provided parenterally until the level of
resting
energy expenditure is reached. Fats are
added thereafter

28. Amino Acids
• Source: Crystalline amino acids
• Properties: 4.0 Kcal/g
EAA 40–50%, NEAA 50-60%
Recommended intake: 0.8-2.0 g/kg/day 10-15% of total calories
Additional protein intake may be needed to compensate
for
excess protein loss in specific patient population such as
burn injuries, open wounds, protein losing Enteropathy /
Nephropathy. A lower protein intake may be necessary in
patient with chronic renal insufficiency who are not
treated
by dialysis and certain patients with hepatic
encephalopathy

29. Amino Acids
SpecializedAminoAcid Solutions are also available such as
Branched chain amino acids (BCAA)
Essential amino acids (EAA)
More expensive than standard s
o
l
u
t
i
o
n
s
Protein or nitrogen balance provides a measure of feeding
efficacy of PN or EN
Nitrogen Balance = N input - N output
6.25 g protein provides 1 g of nitrogen as
100grams contains 16 g nitrogen
N input = (protein in g / 6.25)
N output = 24h urinary urea nitrogen + non-urinary
N losses
+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to – 1: Net catabolism

30. Lipids
Source: Safflower / soybean oil
Properties:
Long chain triglycerides/Medium chain trig
I s o t o n i c or hypotonic
S t a b i l i z e d emulsions
Prevents essential fatty acid defeciency
Recommended intake
0.5 – 1.5 g/kg/day (not >2 g/kg)
12 – 24 hour infusion rate

31. Lipids
 4% to 10% kcals given as lipid meets EFA
requirements; or 2% to 4% kcals given as linoleic
acid
 Generally 500 mL of 10% fat emulsion given two
times weekly or 500 mL of 20% lipids given once
weekly will prevent EFAD
 Usual range 25% to 35% of total kcals
 Max. 60% of kcal or 2 g fat/kg

33. Types of formulations
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 %

34. Fluid requirement
ESTIMATING ADULT FLUID REQUIREMENTS
By caloric intake : 1ml/calorie
Example: 1800 calorie diet = 1800 calories x
1ml= 1800ml
By body weight and age : average requirement
is 30 ml/kg/d
16-55 years 35 ml/kg/d
56-65 years 30 ml/kg/d
> 65 years 25 ml/kg/d

35. Electrolytes/Vitamins/Trace
Elements
Because parenterally-administered vitamins
and trace elements do not go through
digestion/absorption, recommendations are lower
than DRIs
Salt forms of electrolytes can affect cid-base
balance

36. Parenteral Nutrition Vitamin
Guidelines
Vitamin FDA
Guidelines*
A IU 3300 IU
D IU 200 IU
E IU 10 IU
K mcg 150 mcg
C mg 200
Folate
mcg
600
Niacin mg 40
Vitamin FDA
Guidelines*
B2 mg 3.6
B1 mg 6
B6 mg 6
B12 mg 5.0
Biotin mcg 60
B5 dexpanthenol
mg
15

37. Daily Electrolyte Requirements Adult PN
Electrolyte PN Equiv
RDA
Standard Intake
Calcium 10 mEq 10-15 mEq
Magnesium 10 mEq 8-20 mEq
Phosphate 30 mmol 20-40 mmol
Sodium N/A 1-2 mEq/kg + replacement
Potassium N/A 1-2 mEq/kg
Acetate N/A As needed for acid-base
Chloride N/A As needed for acid-base

39. How to calculate?
TEE( total energy expenditure) =
REE(resting
) + Stress Factor + Activity
Factor
Rest Energy Expenditure
Adults (18-65) 20-30 kcal/kg
Elderly (65+) 25 kcal/kg
For burns Patients 30-35kcal/kg
Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
Obese or Super obese 15-20 kcal/kg

40. For and adult of 80 kg
Total caloric req =( wt ) ( 25 kcal ) ( stress f 1.5)
= 3000kcal
70% CHO = 3000x0.7 = 2100 / 4 = 525 grams
20% lipids= 3000x0.2= 600/9 =66 g
10% proteins = 3000x0.1= 300 / 4= 75 g
1L of D25% contains 250 g
1L of D10% contains 100 g
1L of D5% contains 50 g of CHO so this patient needs 1L b.d of
D25%.
Lipofundin comes in 500ml 10% (contain 50 g) and 20% (100 g)
so this patient needs almost 650 ml OD
Aminovyl comes in 600 ml solution that contains 50 grams so
this patient needs 900 ml od.

41. Initiation of Parenteral
Nutrition
Adults should be hemodynamically
stable, able to tolerate the fluid
volume necessary to deliver
significant support, and have central
venous access
Start slowly
(1 L 1st day; 2 L 2ndday)

42. Initiation of Parenteral Nutrition
As proteins are associated with few
metabolic side effects, maximum amount of protein
can be given on the first day, up to 60-70 grams/liter
Maximum CHO given first day 150-200 g/day or
a 15-20% final dextrose concentration
In pts with glucose intolerance, 100-150 g dextrose
or 10-15% glucose concentration may be given
initially

43. Initiation of Parenteral
Nutrition
Dextrose content of PN can be
increased if capillary blood glucose
levels are consistently <180 mg/dL
Lipids can be increased if
triglycerides are <400 mg/dL

44. Parenteral Nutrition
INFUSION SCHEDULES

45. Infusion Schedules
Continuous Parenteral Nutrition
Non-interrupted infusion of a PN
solution over 24 hours via a central
venous access

46. Continuous Parenteral
Nutrition
Advantages
Well tolerated by most patients
Requires less manipulation
d e c r e a s e d nursing time
d e c r e a s e d potential for ‘touch’
contamination

47. Continuous Parenteral
Nutrition
Disadvantages
Persistent anabolic state
a l t e r e d insulin : glucagon ratios
i n c r e a s e d lipid storage by theliver
Reduces mobility in ambulatory p
a
t
i
e
n
t
s

48. Cyclic Parenteral Nutrition
The intermittent administration of PN via
a central or peripheral venous access,
usually over a period of 12 – 18 hours
Patients on continuous therapy may be
converted to cyclic PN over 24-48 hours

49. Cyclic Parenteral Nutrition
Advantages
Approximates normalphysiology
of intermittent feeding
I d e a l for ambulatory patients
A l l o w s normal activity
I m p r o v e s quality of life

50. Cyclic Parenteral Nutrition
Disadvantages
N o t tolerated by critically ill p
a
t
i
e
n
t
s
R e q u i r e s more nursing manipulation
I n c r e a s e d potential for "touch”
“contamination
I n c r e a s e d nursing time

51. monitoring
Daily
Vitals , weight ,input output record, hb,Rbs, rfts ,Na
,Potassium , chloride
Entry site of catheter
Weekly
Fbc,lfts,ca,mg,po4
Fortnightly
Zn,copper,selenium

52. ◗ Discontinuation of TPN should take place when the patient can
satisfy 75% of his or her caloric and protein needs with oral
intake or enteral feeding.
◗ To discontinue TPN, the infusion rate should be halved for 1
hour, halved again the next hour, and then discontinued.
◗ Tapering in this manner prevents rebound hypoglycemia
from hyperinsulinemia.
◗ It is not necessary to taper the rate if t
h
epatient
demonstrates glycemic stability
Discontinuation of TPN

53. Complications of
TPN
Mechanica[
metabolic
infections

54. Air embolism
 Pneumothorax
Hemothorax (a type of
pleural effusion in which
blood accumulates in the
pleural cavity).
Cardiac tamponade
(compression of the heart by
an
accumulation of fluid in the
pericardial sac).
Injuries to arteries and veins
Injury to thoracic duct
Mechanical complications…

55. ◗ Early or nutrient related
 hyperglycemia
 hypoglycemia
 hyperlipidemia
 refeeding syndrome
◗ late or related to long term administration
 hepatic dysfunction
Steatosis (accumulation of fat in the liver), steatohepatitis,
 Lipidosis (any disorder of lipid metabolism involving
abnormal accumulation of lipids, including GAUCHER'S
DISEASE)
Cholestasis (a decrease in bile flow due to impaired
secretion by hepatocytes),
cirrhosis
 biliary complications: cholecystitis (Inflammation of gall
bladder), cholelithiasis (Gallstones in biliary tract).
Metabolic bone disease: osteomalacia, osteopenia
METABOLIC COMPLI…….

56. ◗ Fluid overload
◗ Hypo/hypernatremia
◗ Hypercalcemia
◗ Hypo/hyperkalemia
Infection :
 Catheter related sepsis is most
common life threatening
complication
 Causes: staph epidermidis and
staph aureus, enterococcus,
candida, E coli, psuedomonas,
klebsiella etc in
immunocompromised pts

57. Thank you