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Total Parenteral Nutrition Total Parenteral Nutrition (TPN)(TPN)

In the name of GODIn the name of GOD

Presented by:Presented by:Shadi Farsaei (Assistand professor of Shadi Farsaei (Assistand professor of pharmacotherapy)pharmacotherapy)

INDICATION

Inability to absorb nutrients via the GI tract because of one or more of the following:Massive small bowel resectionIntractable vomiting when adequate EN

is not expected for 7-14 days. Severe diarrheaBowel obstructionGI fistulae: PN is indicated for patients

with prolonged inadequate nutritional intake longer than 5-7 days who are not candidates for EN.

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Cancer: antineoplastic therapy, radiation therapy, or HSCTmoderately to severely malnourished patients receiving

active anticancer treatment who are not candidates for EN.PN is unlikely to benefit patients with advanced cancer

whose malignancy is unresponsive to treatment. PN is appropriate for patients undergoing HSCT who are

malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for 7-14 days.

Pancreatitis: severe pancreatitis with prolonged inadequate nutritional intake longer than 5-7 days who are not candidates for EN. PN should be used when EN exacerbates abdominal pain, ascites, or fistula output.

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Critical carewhom EN is contraindicated or is unlikely to provide

adequate nutritional requirements within 5-10 days.Organ failure (liver, renal, or respiratory): moderate

to severe catabolism when EN is contraindicated. Burns: whom EN is contraindicated or is unlikely to

provide adequate nutritional requirements within 4-5 days.

Perioperative PNPreoperative: for 7-14 days for patients with

moderate to severe malnutrition who are undergoing major GI surgery, if the operation can be safely postponed.

Postoperative: for patients in whom EN is contraindicated or is unlikely to provide adequate nutritional requirements within 7-10 days. 4

Eating disorders: anorexia nervosa and severe malnutrition who are unable or unwilling to ingest adequate nutrition.

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Adult PN therapy is not an emergent intervention and should not be initiated until the patient is hemodynamically stable.

In general, adults who are not candidates for enteral nutrition should be considered candidates for PN after 7 to 14 days of suboptimal nutritional intake.

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PATIENT ASSESSMENTNutrition History: malnutrition Weight History

5% of usual weight within 1 month, or 10% of usual weight within 6 months

Physical ExaminationAnthropometry Biochemical Assessment

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Visceral Proteins for Nutrition Assessment

1. Brown RO, Bradley JE, Bekemeyer WB, Luther RW. Effect of albumin supplementation during parenteral nutrition on hospital morbidity. Critical care medicine. 1988;16(12):1177-82.2. Koretz RL. Intravenous albumin and nutrition support: going for the quick fix. JPEN Journal of parenteral and enteral nutrition. 1995;19(2):166-71.3. Rubin H, Carlson S, DeMeo M, Ganger D, Craig RM. Randomized, double-blind study of intravenous human albumin in hypoalbuminemic patients receiving total parenteral nutrition. Critical care medicine. 1997;25(2):249-52.

PERIPHERAL LINE

700-900 mOsmol Chang IV each 2-3 d

Dextrose 10% Aminoacid 5% Energy < 1 kcal/ml Intralipid ?

Dilution of dextrose/aminofusion with Intralipid

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PARENTERAL NUTRITION

Peripheral Parenteral Nutrition (15 lit D5W/day for a 70 kg !!!)

Central Parenteral Nutrition (TPN)

- needs CV-line to administer hyperosmolar solutions

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Osmolarity: (%Dex × 50) + (%Aminoacid × 100)

150 mOsm for electrolytes, …

PICC: Peripherally inserted central catheter

SubclavianPICCJugularFemoral (more infection !)

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PERIPHERAL VEIN THROMBOPHELEBITISHydrocortisone 5 mg/LHeparin 1000 U/L Topical nitroglycerinConcurrent administration of intralipid ?

Decreases osmolarity, buffers the pH, and improves peripheral vein tolerance, it does not eliminate the risk of thrombophlebitis.

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ESTIMATION OF ENERGY EXPENDITUREWeight & metabolic state Harris-Benedict equations: BEE (M) (kcal/day) : 66.47+13.75W+5H-6.76A BEE (F) (kcal/day) : 65.51+9.56W+1.85H-4.68A BEE: 20-25 kcal/kg/day

TEE (kcal/day): BEE × Stress factor × Activity factor

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Stress factors:Surgery: 1.1-1.2 Infection: 1.2 Trauma: 1.5 Sepsis: 1.6 Burns: 1.6-2

Activity factors: Confined to bed: 1.2 Out of bed: 1.3 Normal activity: 1.5

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17Hypermetabolic/hypercatabolic state secondary to trauma or burn: 2 g/kg/day

Estimation of protein requirement

COMPONENTS OF TPN FORMULATIONS

Macro:

Calorie: Dextrose 20%, 50% Intralipid 10%, 20% Protein: Aminofusion 5%, 10% Fluid

Micro: Electrolytes (Na, K)

Minerals (Mg, Ca, PO4) Trace elements (Zn, Cu, Cr, Mn, Se) Vit (A, E, C, B, Folic acid) 18

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DEXTROSE 20%, 50% (from CV-line)

3.4 kcal/g

60-70% of calorie requirements should be provided with dextrose

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SPECIAL CONSIDERATIONS

Max infusion rate of dextrose: 0.5 g/kg/h (to avoid hyperglycemia, glycosuria, fatty liver, hyperosmolar coma) Max rate of dextrose metabolism : 5 mg/kg/min or 7 g/kg/d “K” should be added to dextrose solutions If BS > 200, Insulin should be added 0.1 U/g Dextrose

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AMINOFUSION

5%, 10% (from CV-line)

1-1.5 g/kg/day

Should not be used as a calorie source

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ESTIMATION OF PROTEIN REQUIREMENTS

RDA 0.8 g/kg/day

Hospitalized patient, minor stress 1–1.2 g/kg/day

Moderate stress 1.2–1.5 g/kg/day

Severe stress 1.5–2 g/kg/day

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Na 43 mmol/L K 25 mmol/L Mg 2.6 mmol/L Acetate 59 mmol/L Cl 57 mmol/L H2PO4 9 mmol/L

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INTRALIPID 10%, 20% (from peripheral or CV-line)

30-40% of calorie requirements should be provided with Intralipid

Serum TG level must be < 400 mg/dl

Max. 2.5 g/kg or 60% total calories

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1022 Kcal/L345 mOsmol/L

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1080 Kcal/L

1 liter contains:A-     Active constituents:-          Glycerine (glycerol) 25g-          Phospholipids from egg 6g-          Soya beans 100gB-     Other Constituents:-          Sodium Oleate, Sodium hydroxide & waterTotal energy= 1080Kcal/L

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AN IMPORTANT SOLUTION

Concentrate isotonic solution

Source of essential FFA

Substitute for CHO for ventilated pts.

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Caloric density of intravenous nutrients

Electrolytes (daily requirements for TPN):

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Recommended adult daily dose of parenteral vitamins

AVAILABLE DOSAGE FORM FOR PARENTERAL ROUT Amp Vit A: 50000 IU Amp Vit D: 300,000U Amp Vit K: 1, 10 mg ??!! Amp Vit E: 100 IU Amp Vit C: 500 mg Amp Vit B complex Amp Vit B12: 100, 1000 mcg Amp Soluvit (Fressenius)

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VITALIPID

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INDICATIONSVitalipid N Adult is indicated as a supplement in complete intravenous nutrition to meet the daily requirements of the fat-soluble vitamins A, D2, E and K1.As above, Vitalipid N Infant is indicated in paediatric patients up to 11 years of age.

The vitamins are soluble in the oil phase of the emulsion, which has the composition corresponding to that of Intralipid 10%.

The daily maintenance dosage of the vitamins A, D2, E and K1 are supplied during intravenous nutrition when: (i) 10 mL of Vitalipid N Adult are added to 500 mL

Intralipid 10% or 20%. (ii) 1 mL of Vitalipid N Infant per kg bodyweight per day

up to a maximum of 10 mL is added to Intralipid 10% or 20%.

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The recommended dose is 1 mL Peditrace/kg body weight/day for infants and children with a weight of up to 15 kg. The basic requirements of trace elements are covered by a daily dose of 15 mL to children weighing more than 15 kg

Infusion time:The infusion time should not be less than 8 hours. The infusion should be given at a very slow rate.

WATER

ml/day = 1500 ml + (IBW-20) × 20 30-35 ml/kg

Average healthy adult : 5 L/d

Fluid restricted: ≤ 2 L/d

Emesis, diarrhea, agitation, ventilation, fever

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MONITORING: Baseline:

Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT, INR, TG, LFT, Alb

Daily: Wt, V/S, I/O, Na, K, BUN, Cr, Glu

2-3 times a week: CBC, Ca, P, Mg

Weekly: Alb, LFT, INR

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REFERENCES Mirtallo, J., D. Johnson, et al. (2004).

"Safe practices for parenteral nutrition." Journal of Parenteral and Enteral Nutrition 28(6): S39-S70.

Koda-Kimble, Mary Anne, and Brian K. Alldredge. Applied Therapeutics: The Clinical Use of Drugs. Baltimore: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013.

DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw-Hill Medical, 2011. …..

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