Total Total ParenteralParenteral Nutrition (TPN)Nutrition (TPN)

By: E. SalehifarBy: E. Salehifar

(Clinical Pharmacist)(Clinical Pharmacist)

MalnutritionMalnutrition Incidence:Incidence: 50 % of hospitalized patients 50 % of hospitalized patients Common causes:Common causes: - Hypermetabolic states: Trauma, - Hypermetabolic states: Trauma,

Infection, Major surgery, Burn Infection, Major surgery, Burn - Poor nutrition - Poor nutrition Consequences:Consequences: Weakness, Decreased Weakness, Decreased

wound healing, increased respiratory wound healing, increased respiratory failure, decreased cardiac contractility, failure, decreased cardiac contractility, infections (pneumonia, abscesses), infections (pneumonia, abscesses), Prolonged hospitalizationProlonged hospitalization

Nutritional SupportNutritional Support

Enteral Nutrition ( Physiologic, less Enteral Nutrition ( Physiologic, less expensive)expensive)

Parenteral Nutrition Parenteral Nutrition

- GI should not be used (Obstruction, - GI should not be used (Obstruction, Pancraitis)Pancraitis)

- GI can not be used ( Vomiting, - GI can not be used ( Vomiting, Diarrhea, Resection of intestine, Diarrhea, Resection of intestine, IBD)IBD)

Parenteral NutritionParenteral Nutrition Peripheral Parenteral Peripheral Parenteral

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

Central Parenteral Central Parenteral Nutrition (TPN)Nutrition (TPN) Needs CV-line to Needs CV-line to

administer hyperosmolar administer hyperosmolar solutionssolutions

Estimation of energy Estimation of energy expenditureexpenditure

Harris-Benedict equations:Harris-Benedict equations: BEE (men) (kcal/day): BEE (men) (kcal/day): 66.47+13.75W+5H-66.47+13.75W+5H-

6.76A6.76A BEE (women) (kcal/day): BEE (women) (kcal/day): 655.1+9.56W+1.85H-655.1+9.56W+1.85H-

4.68A4.68A TEE (kcal/day):TEE (kcal/day):

BEE × Stress factor × Activity factorBEE × Stress factor × Activity factor Stress factors: Stress factors: Surgery, Infection: 1.2 Trauma:

1.5 Sepsis: 1.6 Burns: 1.6-2 Activity factors: Activity factors: sedentary: 1.2 , normal activity:

1.3, active: 1.4 , very active: 1.5

Stress levelStress level

Normal/mild stress level: 20-25 Normal/mild stress level: 20-25 kcal/kg/daykcal/kg/day

Moderate stress level: 25-30 Moderate stress level: 25-30 kcal/kg/daykcal/kg/day

  Severe stress level: 30-40 kcal/kg/daySevere stress level: 30-40 kcal/kg/day   Pregnant women Pregnant women in second or third in second or third

trimester: Add an additional trimester: Add an additional 300 300 kcal/daykcal/day

Fluid: mL/day

30-40 mL/kg

Protein (amino acids)Protein (amino acids)

Maintenance: 0.8-1 g/kg/dayMaintenance: 0.8-1 g/kg/day Normal/mild stress level: 1-1.2 g/kg/dayNormal/mild stress level: 1-1.2 g/kg/day Moderate stress level: 1.2-1.5 g/kg/dayModerate stress level: 1.2-1.5 g/kg/day Severe stress level: 1.5-2 g/kg/daySevere stress level: 1.5-2 g/kg/day Burn patients (severe): Increase protein Burn patients (severe): Increase protein

until significant wound healing until significant wound healing achievedachieved

Solid organ transplant: Perioperative: Solid organ transplant: Perioperative: 1.5-2 g/kg/day1.5-2 g/kg/day

Protein need in Renal Protein need in Renal failurefailure

Acute (severely malnourished or Acute (severely malnourished or hypercatabolic): 1.5-1.8 g/kg/dayhypercatabolic): 1.5-1.8 g/kg/day

Chronic, with dialysis: 1.2-1.3 Chronic, with dialysis: 1.2-1.3 g/kg/dayg/kg/day

Chronic, without dialysis: 0.6-0.8 Chronic, without dialysis: 0.6-0.8 g/kg/dayg/kg/day

  Continuous hemofiltration: ≥ 1 Continuous hemofiltration: ≥ 1 g/kg/dayg/kg/day

Protein need in Hepatic Protein need in Hepatic failurefailure

  AcuteAcute management when other management when other treatments have failed:treatments have failed: With encephalopathy: 0.6-1 g/kg/dayWith encephalopathy: 0.6-1 g/kg/day Without encephalopathy: 1-1.5 g/kg/dayWithout encephalopathy: 1-1.5 g/kg/day

ChronicChronic encephalopathy encephalopathy Use Use branch chain amino acid branch chain amino acid enriched diets enriched diets

only if unresponsive to pharmacotherapyonly if unresponsive to pharmacotherapy Pregnant women in second or third Pregnant women in second or third

trimestertrimester Add an additional 10-14 g/dayAdd an additional 10-14 g/day

FatFat

Initial: Initial: 20% to 40 % 20% to 40 % of total calories of total calories (maximum: 60% of total calories or (maximum: 60% of total calories or 2.5 g/kg/day)2.5 g/kg/day) Note: Note: Monitor triglycerides Monitor triglycerides while while

receiving intralipids.receiving intralipids. Safe for use in pregnancySafe for use in pregnancy I.V. lipids are safe in adults with I.V. lipids are safe in adults with

pancreatitis if triglyceride levels pancreatitis if triglyceride levels <400 mg/dL<400 mg/dL

Components of TPN Components of TPN FormulationsFormulations

Macro:Macro:

Calorie:Calorie: Dextrose 20%, 50%Dextrose 20%, 50%

Intralipid 10%, 20%Intralipid 10%, 20%

Protein:Protein: Aminofusion 5%, 10% Aminofusion 5%, 10%

Micro:Micro:

Electrolytes (Na, K, Mg, Ca, PO4)Electrolytes (Na, K, Mg, Ca, PO4)

Trace elements (Zn, Cu, Cr, Trace elements (Zn, Cu, Cr, Mn, Se)Mn, Se)

DextroseDextrose

20%, 50% ( from CV-line)20%, 50% ( from CV-line) 3.4 kcal/g3.4 kcal/g 60-70% of calorie requirements 60-70% of calorie requirements

should be provided with should be provided with dextrosedextrose

For 1000 ml solution

D50W D10W D5W

D20W 250 ml 750 ml ------

333 ml ------ 667 ml

D30W 500 ml 500 ml ------

555 ml ----- 446 ml

D40W 750 ml 250ml ------

778 ml ------ 222 ml

Dextrose: Dextrose: ContraindicationsContraindications

Hypersensitivity to corn or corn Hypersensitivity to corn or corn productsproducts

Hypertonic solutions in patients with Hypertonic solutions in patients with intracranial or intraspinal intracranial or intraspinal hemorrhagehemorrhage

Abrupt withdrawalAbrupt withdrawal

Infuse 10% dextrose at same rate Infuse 10% dextrose at same rate and monitor blood glucose for and monitor blood glucose for hypoglycemiahypoglycemia

IntralipidIntralipid

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

1.1 kcal/ml (10%), 2 kcal/ml 1.1 kcal/ml (10%), 2 kcal/ml (20%)(20%)

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

1022 Kcal/L

345 mosmol/L1080 Kcal/L

Intralipid: Intralipid: ContraindicationContraindication

Hypersensitivity to fat emulsion or Hypersensitivity to fat emulsion or any component of the formulation; any component of the formulation; severe egg or legume (soybean) severe egg or legume (soybean) allergiesallergies

Pathologic hyperlipidemia, lipoid Pathologic hyperlipidemia, lipoid nephrosis, pancreatitis with nephrosis, pancreatitis with hyperlipemia (TG>400 mg/dl)hyperlipemia (TG>400 mg/dl)

AminofusionAminofusion

5%, 10% ( from CV-line)5%, 10% ( from CV-line) 1-1.5 g/kg/day1-1.5 g/kg/day Should not be used as a Should not be used as a

calorie sourcecalorie source

200 kcal/L

590 mosmol/L

400 Kcal/L

1030 mosmol/L

Amino acids: Amino acids: Contraindications Contraindications

Hypersensitivity to one or more Hypersensitivity to one or more amino acidsamino acids

Severe liver disease or hepatic comaSevere liver disease or hepatic coma

CaseCase D.C a 38 y.o man with a D.C a 38 y.o man with a 12-year history 12-year history

ofof crohn’s diseasecrohn’s disease is admitted to is admitted to surgery ward of Imam hospital in Sari for surgery ward of Imam hospital in Sari for a compliant of increasing abdominal a compliant of increasing abdominal pain, pain, nausea & vomitingnausea & vomiting for 7 daysfor 7 days and no stool output for 5 days. Because and no stool output for 5 days. Because of N & V, he has been drinking only of N & V, he has been drinking only liquids during the past weeks. His crohn liquids during the past weeks. His crohn disease had several exacerbations during disease had several exacerbations during the past 2 years and the past 2 years and 10 cm of his ileum 10 cm of his ileum has been resectedhas been resected 6 month ago.6 month ago.

case (continue) case (continue)

Drugs: Mesalamine 1000 mg qid + Drugs: Mesalamine 1000 mg qid + prednisolone 10mg/d. Abdominal x-ray is prednisolone 10mg/d. Abdominal x-ray is consisting with consisting with bowel obstructionbowel obstruction. . Exploratory laparotomy was performed Exploratory laparotomy was performed and and 25 cm of his ileum resected25 cm of his ileum resected.. Bowel sounds are absentBowel sounds are absent. He has a . He has a right subclavian right subclavian CV-lineCV-line.. Considering Considering that his that his Ht=180cmHt=180cm, , Wt=60kgWt=60kg (6 month (6 month ago: 70 kg) andago: 70 kg) and Age=38 y.oAge=38 y.o, , what is what is your recommended TPN formula for him?your recommended TPN formula for him?

BEE=BEE= 66.47+13.75×60+5×180-6.76×38=1535 66.47+13.75×60+5×180-6.76×38=1535 kcal/dkcal/d

TEE=TEE= 1535 1535×1.2×1.2 = 2200 kcal/d×1.2×1.2 = 2200 kcal/d Intralipid 10%=Intralipid 10%= ? 2200 × 30%= 660 ? 2200 × 30%= 660

kcalkcal 1ml ≡ 1.1 kcal 660 : 1.1 = 600 ml ( 1ml ≡ 1.1 kcal 660 : 1.1 = 600 ml ( 500ml500ml)) Dext 50%=Dext 50%= ? 2200 – 550= 1650 kcal ? 2200 – 550= 1650 kcal

1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 g Dextg Dext

50g ≡ 100 ml 485 g ≡ 970ml (50g ≡ 100 ml 485 g ≡ 970ml (1000ml1000ml)) Aminofusion 10 %=Aminofusion 10 %= ? 1.5 g/kg/d × 60 ? 1.5 g/kg/d × 60

kg= 90g/day 10g ≡ 100 ml 90g ≡900 kg= 90g/day 10g ≡ 100 ml 90g ≡900 ml (ml (1000ml1000ml))

Electrolytes (daily requirements for Electrolytes (daily requirements for TPN):TPN):

Na: 80-100 mEq (50 - 100 ml NaCl Na: 80-100 mEq (50 - 100 ml NaCl 5%)5%)

K: 60-80 mEq (30 ml KCl)K: 60-80 mEq (30 ml KCl) Cl: 50-100 mEqCl: 50-100 mEq Mg: 8-16 mEq (5 -10 ml MgSo4 20%)Mg: 8-16 mEq (5 -10 ml MgSo4 20%) Ca: 5-10 mEq (10-20 ml Ca Gluconate Ca: 5-10 mEq (10-20 ml Ca Gluconate

10%)10%) P04: 15-30 mEqP04: 15-30 mEq Acetate: 50-100 mEqAcetate: 50-100 mEq

Vitamins:Vitamins: A, D, E, Water soluble vitamins A, D, E, Water soluble vitamins

Trace Elements: Trace Elements: Zn, Se, Cu, Cr, MnZn, Se, Cu, Cr, Mn

↓ ↓ ZnZn Delayed ulcer healing, Dermatitis, Alopcia (5Delayed ulcer healing, Dermatitis, Alopcia (5αα

reductase), Diarrheareductase), Diarrhea

↓ ↓ SeSe: : Low activity of SOD & DeiodinaseLow activity of SOD & Deiodinase

Amp B Complex + Amp Vit Amp B Complex + Amp Vit CC

MV Therapeutic ( Zn, Cu, Mn)MV Therapeutic ( Zn, Cu, Mn)

Special ConsiderationsSpecial Considerations

Max infusion rate of dextrose: 0.5g/kg/h (to Max infusion rate of dextrose: 0.5g/kg/h (to avoid hyperglycemia, glycosuria, fatty avoid hyperglycemia, glycosuria, fatty liver, hyperosmolar coma)liver, hyperosmolar coma)

KK should be added to dextrose solutions should be added to dextrose solutions Slow starting & slow tapering of Dext 50%Slow starting & slow tapering of Dext 50% If BS>200, Insulin should be addedIf BS>200, Insulin should be added some brands of lipids can be mixed with some brands of lipids can be mixed with

Dext+Aminifusion in the same IV containerDext+Aminifusion in the same IV container

Special ConsiderationsSpecial Considerations

Intralipid contraindications: Intralipid contraindications: Severe egg allergy Severe egg allergy HyperlipidemiaHyperlipidemia

Special aminoacid products:Special aminoacid products: Hepatamine:Hepatamine: for Hepatic Failure for Hepatic Failure

↑ ↑ branched chain aa ( leu, isoleu, val)branched chain aa ( leu, isoleu, val) NephramineNephramine:: for Renal Failure for Renal Failure

Primarily essential aa with lower Primarily essential aa with lower concentrationsconcentrations

Monitoring:Monitoring:

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

Daily:Daily: Wt, V/S, I-O, Na, K, BUN, Cr, Glu, Sign/Symptoms of infection

2-3 times a week:2-3 times a week: CBC, Ca, P, Mg Weekly:Weekly: Alb, Pre-Alb, LFT, INR,

Nitrogen Balance

Adding other drugs to Adding other drugs to TPNTPN

INSINS HeparinHeparin H2-blockerH2-blocker AlbAlb AminophyllineAminophylline

Vit K & Bicarbonate should not be Vit K & Bicarbonate should not be addedadded

ComplicationsComplications Endocrine & metabolicEndocrine & metabolic

Fluid overload, hypercapnia, hyperglycemia, Fluid overload, hypercapnia, hyperglycemia, hyper-/hypokalemia, hyper-/hypophosphatemia, refeeding hyper-/hypokalemia, hyper-/hypophosphatemia, refeeding syndromesyndrome

HepaticHepatic Cholestasis, cirrhosis (<1%), gallstones, liver function Cholestasis, cirrhosis (<1%), gallstones, liver function

tests increased, pancreatitis, steatosis, triglycerides tests increased, pancreatitis, steatosis, triglycerides increasedincreased

RenalRenal Azotemia, BUN increasedAzotemia, BUN increased

InfectiousInfectious Bacteremia, catheter-induced infection, exit-site infectionsBacteremia, catheter-induced infection, exit-site infections

Other: Pneumothorax, ThrombophlebitisOther: Pneumothorax, Thrombophlebitis

Refeeding syndromeRefeeding syndrome

In patients with long-standing or severe In patients with long-standing or severe malnutrition malnutrition

Is a medical emergency, consist of:Is a medical emergency, consist of: Electrolyte disturbances (eg, potassium, Electrolyte disturbances (eg, potassium,

phosphorus)phosphorus) Respiratory distressRespiratory distress Cardiac arrhythmias, resulting in Cardiac arrhythmias, resulting in

cardiopulmonary arrestcardiopulmonary arrest Do not overfeed patients; caloric Do not overfeed patients; caloric

replacement should match as closely as replacement should match as closely as possible to intakepossible to intake

ConclusionConclusion

Malnutrition is a common problem & Malnutrition is a common problem & Nutritional support is indicated in many Nutritional support is indicated in many hospitalized patients hospitalized patients

Enteral nutrition is better, but some Enteral nutrition is better, but some patients with GI problems need TPNpatients with GI problems need TPN

Dextrose & Intralipid should be used as Dextrose & Intralipid should be used as calorie sources and Aminofusion as calorie sources and Aminofusion as aminoacid sourceaminoacid source

Special monitoring should be considered Special monitoring should be considered for patients especially I-O, Na, K and Glu for patients especially I-O, Na, K and Glu