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

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.

Indications for TPNIndications 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 )

Energy: Glucose and LipidsAmino acids (Nitrogen)Water and electrolytesVitaminsTrace elements

RequirementsRequirements EnergyEnergy 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

RequirementsRequirementsGlucose(50-60 % of total energy)

RequirementsRequirementsGlucose• 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.

RequirementsRequirementsLipids(30-40 %)

RequirementsRequirementsEnergy 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.

Requirements: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.

RequirementsRequirementsProtein: Daily Protein requirements

Condition Example requirement

Basic requirements Normal person 0.5-1g/Kg

Slightly increased requirements Post-operative, cancer, inflammatory

1.5g/Kg

Moderately increased requirements

Sepsis, polytrauma 2g/Kg

Highly increased requirements Peritonitis, burns, 2.5g/Kg

Reduced requirements Renal failure, hepatic encephalopathy

0.6g/Kg

•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).

RequirementsRequirements 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.

RequirementsRequirements Fluids and electrolytes:

NutrientNutrient Requirements (Requirements (/Kg/day)/Kg/day)

WaterWater 20-40 mL20-40 mL

SodiumSodium 0.5-1.0 mmol0.5-1.0 mmol

PotassiumPotassium 0.5-1.0 mmol0.5-1.0 mmol

MagnesiumMagnesium 0.1-0.2 mmol0.1-0.2 mmol

CalciumCalcium 0.05-0.15mmol0.05-0.15mmol

PhosphatePhosphate 0.2-0.5mmol0.2-0.5mmol

Chloride/AcetateChloride/Acetate So as to maintain acid-base balance So as to maintain acid-base balance (normally 0.5 mmol for Cl(normally 0.5 mmol for Cl-- , & 0.1mEq for Acetate) , & 0.1mEq for Acetate)

RequirementsRequirements 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.

RequirementsRequirements

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).

RequirementsRequirements Trace minerals

Mineral Mineral Recommended dietary Recommended dietary allowance (RDA) for daily allowance (RDA) for daily

oral intake (mg) oral intake (mg)

Suggested daily Suggested daily intravenous intake intravenous intake

(mg) (mg)

Zinc Zinc 15 15 2.5-5 2.5-5

Copper Copper 2-3 2-3 0.5-1.5 0.5-1.5

Manganese Manganese 2.5-5 2.5-5 0.15-0.8 0.15-0.8

Chromium Chromium 0.05-0.2 0.05-0.2 0.01-0.015 0.01-0.015

Iron Iron 10 (males)-18 (females) 10 (males)-18 (females) 3 3

OsmolarityOsmolarity

PPN: Maximum of 1000 mosmoles / liter.

TPN: as nutrient dense as necessary (1000 - 3000) mosmoles/liter.

• 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 = 1kcal864 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 = 2kcalml of 20% lipid required = 576/2 = 288 ml

Protein: 1.5g per kg per day1.5x40 = 60 g/day

5g A.A is contained in = 100ml 5% sol.1g------------------------- = 100/560g----------------------- = 100/5x60 = 1200 ml/ day

ApplicationApplication

The Solution

Single bottleSystems

“All-in-one” mixtures

2- or 3-chamber bags +

+

LocationSubclavian VeinsInternal Jugular VeinsFemoral VeinsBrachial Veins

TypesNon-tunneled TunneledCordis HickmanSwan Ganz Broviac Double Lumen PortacathTriple LumenPICC

Application 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.

First week Later

Energy balanceweight Daily Daily

Metabolic variablesBlood 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, APTT)

Weekly Weekly

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, Copper

Monthly

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, temperature, symptoms )

Daily Daily

TLC & DLC As indicated As indicated

Cultures As indicated As indicated

Complications of TPNComplications of TPNAbout 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)

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.

•

Feeding regimen related:

Complications of TPNComplications of TPN

Catheter sepsisPrevent 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

Complications of TPNComplications 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).

Complications of TPNComplications of TPN

Metabolic Complications Hypertriglyceridemia Associated with excess

infusion of fat emulsion.• Can cause pulmonary insufficiency.

Complications of TPNComplications of TPNMetabolic 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.

HOME PARENTERAL NUTRITIONHOME 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.

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