TOTAL PARENTERAL

NUTRITION
DEFINITION
TOTAL PARENTERAL NUTRITION IS
DEFINED AS THE INTRAVENOUS
PROVISION OF ALL NUTRITIONAL
REQUIREMENTS, WITHOUT THE USE OF
THE GASTROINTESTINAL TRACT.
Parenteral Nutrition
Graphic source: http://www.rxkinetics.com/tpntutorial/1_4.html
General Conditions Suggesting
Initiation of Nutrition Support
Poor nutritional status (oral intake <50%
of energy needs)
Catabolic disease (burn, sepsis,
pancreatitis)
Significant weight loss (>10%)
Anticipated duration of artificial nutrition
longer than 7 days
More than 7 days' inanition
Nonfunctioning gastrointestinal tract
Serum albumin <3 g/dL in the absence of
an inflammatory state

INDICATIONS FOR TPN
Proximal intestinal fistula
Inflammatory bowel disease
Massive intestinal resection(<100 cm small
bowel remains)
Paralytic ileus/obstruction
Severe pancreatitis
Practically all patients requiring nutrition
support but cant tolerate enteral feeds, or C/I
to enteral feeding.
Total Parenteral Nutrition
GENERAL INDICATIONS
Patient who cant eat
Patient who wont eat
Patient who shouldnt eat
Patient who cant eat enough
If the gut works, use it.

Total Parenteral Nutrition
A.S.P.E.N Guidelines *(Indication for nutritional
support)
Severe stress or malnutrition NPO > 4-5 days
Moderate stress or malnutrition NPO > 7-10 days
Non-stressed / normal nourished NPO > 10 days
No indication for TPN < 4 days
Contraindications
Functional and accessible GI tract
Patient is taking oral diet
Prognosis does not warrant aggressive
nutrition support (terminally ill)
Risk exceeds benefit
Patient expected to meet needs within 14 days
Total Parenteral Nutrition
NOMENCLATURE
TPN: Total Parenteral Nutrition
IVH: Intravenous Hyperalimentation
TNA: Total Nutrient Admixture
3-In-1 Admixture
All-In-One Admixture
PPN: Peripheral Parneteral Admxtiure
Methods of Nutritional
Assessment
Clinical history Weighing, subjective
assessment
Indirect calorimetry Oxygen
consumption, determination of respiratory
quotient
Anthropomorphic measurements Ideal
body weight, skinfold thickness
Biochemical measurements Albumin,
transferrin, prealbumin
Measurement of nitrogen balance
Measurements of immunologic function

Nutritional Indices

Body mass index (BMI)
BMI = weight (kg)/[height (m)]
2
= 703 weight (lb)/[height
(in.)]
2

BMI: normal 18.524.9, overweight 2529.9, obese 3040,
morbid obesity >40
Prognostic nutritional index (PNI)
PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)
DH: >5 mm induration = 2; 15 mm induration = 1; anergy = 0
PNI: >50% = high risk for complications; 40%49% =
intermediate risk; <40% = low risk
Nutrition risk index
NRI = 15.19 (Alb) + 41.7 [weight (kg)/ideal weight (kg)]
NRI: <100 = malnourished
Catabolic index (CI)
CI = UUN - [0.5 (dietary nitrogen intake in g)]
CI: 0 = no significant stress; 05 = mild stress; >5 = moderate
to severe stress
Anthropomorphic Measurements

Creatinine-height index,
Triceps skinfold thickness
Midarm muscle circumference
calculation of Ideal body weight (IBW) (when
usual body weight, or weight of the patient
before the onset of illness, is unknown)
For males: 106 lb for the first 5 ft and 6 lb
for each inch thereafter.
For females: 100 lb for the first 5 ft and 5 lb
for each inch thereafter.
Biochemical Measurements

Serum albumin of less than 3.5 g/dL (35 g/L) in a
stable, hydrated patient; half-life is 14 to 20 days.
Serum prealbumin may be a more useful indicator
of acute changes: 10 to 17 mg/dL corresponds to
mild depletion, 5 to 10 mg/dL to moderate
depletion, and less than 5 mg/dL to severe
depletion; half-life is 2 to 3 days.
Serum transferrin of less than 200 mg/dL; half-life
is 8 to 10 days.

Parenteral Nutrition (PN)
Definition
Delivery of nutrients intravenously, e.g. via
the bloodstream.
Central Parenteral Nutrition: often called Total
Parenteral Nutrition (TPN); delivered into a
central vein
Peripheral Parenteral Nutrition (PPN):
delivered into a smaller or peripheral vein


A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p. 97

PN Central Access
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
VENOUS SITES FOR ACCESS TO
THE SUPERIOR VENA CAVA
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
PN: Peripheral Access
PN may be administered via peripheral access
when
Therapy is expected to be short term (10-14
days)
Energy and protein needs are moderate
Formulation osmolarity is <600-900 mOsm/L
Fluid restriction is not necessary
A.S.P.E.N. Nutrition Support Practice Manual, 2005; p. 94
Macronutrients: Carbohydrate
Source: Monohydrous dextrose
Properties: Nitrogen sparing
Energy source
3.4 Kcal/g
Hyperosmolar
Recommended intake:
2 5 mg/kg/min
50-65% of total calories
Total Parenteral Nutrition
Carbohydrate
Max rate of glucose oxidation: 5 7
mg/kg/min
Max dextrose rate stable patients: Not >7
mg/kg/min
Max dextrose rate critical care patient: Not > 4
mg/kg/min
Macronutrients: Carbohydrate
Potential Adverse Effects:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems
Hyperglycemia

Macronutrients: Amino Acids
Source: Crystalline amino acids
standard or specialty
Properties: 4.0 Kcal/g
EAA 4050% NEAA 50-
60%
Glutamine / Cysteine
Recommended intake:
0.8-2.0 g/kg/day
15-20% of total calories

Macronutrients: Amino Acids
Potential Adverse
Effects:
Increased renal solute
load
Azotemia

Macronutrients: Amino Acids
Specialized Amino Acid Solutions
Branched chain amino acids (BCAA)
Essential amino acids (EAA)
Not shown to improve patient outcome
More expensive than standard solutions
Macronutrients: Lipid
Source: Safflower and/or soybean oil
Properties: Long chain triglycerides
Isotonic or hypotonic
Stabilized emulsions
9 Kcals/g
Prevents essential fatty acid
deficiency
Recommended intake:
0.5 1.5 g/kg/day (not >2
g/kg) 12 24 hour infusion
rate

Macronutrients: Lipids
Requirements
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
Macronutrients: Lipids
Potential Adverse Effects:
Egg allergy
Hypertriglyceridemia
Decreased cell-mediated immunity (limit to <1
g/kg/day in critically ill immunosuppressed
patients)
Abnormal LFTs

Parenteral Base Solutions
Carbohydrate
Available in concentrations from 5% to 70%
D30, D50 and D70 used for manual mixing
Amino acids
Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions
8.5% and 10% generally used for manual mixing
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml
30% emulsions = 3 kcal/ml (used only in mixing
TNA, not for direct venous delivery)
The A.S.P.E.N. Nutrition Support Practice Manual, 2
nd
edition,
2005, p. 97; Barber et al. In ASPEN, The Science and Practice of
Nutrition Support: A Case-Based Core Curriculum. 2001.

Other Requirements
Fluid30 to 50 ml/kg (1.5 to 3
L/day)
Sterile water is added to PN
admixture to meet fluid requirements
Electrolytes
Use acetate or chloride forms to
manage metabolic acidosis or
alkalosis(in patients with normal
electrolytes
acetate : chloride 1:2)
Vitamins: multivitamin formulations
Trace elements
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 acid-base
balance
Adult Parenteral Multivitamins
New FDA requirements published in 2000
replacing NAG-AMA guidelines
Increased B1, B6, vitamin C, folic acid,
added Vitamin K
MVI Adult (Mayne Pharma) and Infuvite
(MVI-13) from Baxter contain Vitamin K and
are consistent with the new FDA guidelines
MVI-12 (Mayne Pharma) does not contain
Vitamin K (added separately 10 mg once a
week)

Total Parenteral Nutrition
Trace Elements
Recommendations per NAG
Zinc Poor wound healing
Copper Anemia
Chromium Glucose Intolerance
Manganese ??
Selenium Keshans Disease

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*
B
2 mg
3.6
B
1 mg
6
B
6 mg
6
B
12 mg
5.0
Biotin
mcg
60
B5 dexpanthenol
mg

15
*Federal Register 66(77): April 20, 2000
Daily Trace Element Supplementation
for Adult PN
Selenium 60 mcg
Chromium 10-15 mcg
Copper 0.3-0.5 mg
Manganese 60-100 mcg
Zinc 2.5-5.0 mg
ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49,
1998
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
ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49, 1998
PN Contaminants
Components of PN formulations have been
found to be contaminated with trace
elements
Most common contaminants are aluminum
and manganese
Aluminum toxicity a problem in pts with renal
compromise on long-term PN and in infants
and neonates
Can cause osteopenia in long term adult PN
patients
ASPEN Nutrition Support Practice Manual 2005; p. 109

PN Contaminants
FDA requires disclosure of aluminum content
of PN components
Safe intake of aluminum in PN is set at 5
mcg/kg/day

PN Contaminants
Manganese toxicity has been reported in
long term home PN patients
May lead to neurological symptoms
Manganese concentrations of 8 to 22
mcg/daily volume have been reported in
formulations with no added manganese
May need to switch to single-unit trace
elements that dont include manganese
ASPEN Nutrition Support Practice Manual 2005; p. 98-99
Peripheral Parenteral Nutrition
Hyperosmolar solutions cause
thrombophlebitis in peripheral veins
Limited to 800 to 900 mOsm/kg (MHS uses
1150 mOsm/kg w/ lipid in the solution)
Dextrose limited to 5-10% final
concentration and amino acids 3% final
concentration
Electrolytes may also be limited
Use lipid to protect veins and increase
calories
Peripheral Parenteral Nutrition
New catheters allow longer support via
this method
In adults, requires large fluid volumes to deliver
adequate nutrition support (2.5-3L)
May be appropriate in mild to moderate
malnutrition (<2000 kcal required or <14 days)
More commonly used in infants and children
Controversial

Contraindications to Peripheral
Parenteral Nutrition
Significant malnutrition
Severe metabolic stress
Large nutrition or electrolyte needs (potassium
is a strong vascular irritant)
Fluid restriction
Need for prolonged PN (>2 weeks)
Renal or liver compromise
From Mirtallo. In ASPEN, The Science and Practice of Nutrition Support: A
Case-Based Core Curriculum. 2001, 222.

EQUATIONS
HARRIS-BENEDICT EQUATION :

BEE in kilocalories per day for men equals 66.4 +
[13.7 weight (kg)] + [5 height (cm)] [6.8
age (years)].
BEE in kilocalories per day for women equals
65.5 + [9.6 weight (kg)] + [1.7 height (cm)]
[4.7 age (years)].
NORMAL ADULT : 20-25 KCAL/KG/DAY
Stress Factors Used in Calculation
of Total Energy Expenditure
Clinical condition Stress factor
Starvation 0.80
1.00
Elective operation 1.00
1.10
Peritonitis or other infections
1.051.25
Adult respiratory distress syndrome
sepsis 1.30
1.35
Pancreatitis 1.30
1.80
Estimates of protein
requirements
The appropriate calorie:nitrogen ratio is approximately 150:1
(calorie:protein ratio of 24:1)
1.5 g protein per kilogram body weight should be provided
daily
Twenty-fourhour nitrogen balance is calculated by
subtracting nitrogen loss from nitrogen intake.
Nitrogen intake is the sum of nitrogen delivered from enteral
and parenteral feedings. Nitrogen is lost through urine, fistula
drainage, diarrhea, and so on. The usual approach is to
measure the urine urea nitrogen (UUN) concentration of a 24-
hour urine collection and multiply by urine volume to estimate
24-hour urinary loss.
Nitrogen loss equals 1.2 [24-hour UUN (g per day)] + 2 g
per day as a correction factor to account for nitrogen losses
in stool and skin exfoliation.

Estimated Protein Requirements in
Various Disease States
Clinical condition Protein
requirements (g/kg
ideal body weight/day)
Healthy, nonstressed
0.80 Simplified estimates
Mild metabolic stress (elective hospitalization)

1.001.10
Moderate metabolic stress (complicated
postoperative care, infection)
1.201.40
Severe metabolic stress (major trauma,
pancreatitis, sepsis)
1.502.50
Compounding Methods
Total nutrient admixture (TNA) or 3-in-1
Dextrose, amino acids, lipid, additives are
mixed together in one container
Lipid is provided as part of the PN mixture on a
daily basis and becomes an important energy
substrate
2-in-1 solution of dextrose, amino acids,
additives
Typically compounded in 1-liter bags
Lipid is delivered as piggyback daily or
intermittently as a source of EFA
Advantages of TNA
Decreased nursing time
Decreased risk of touch contamination
Decreased pharmacy prep time
Cost savings
Easier administration in home PN
Better fat utilization in slow, continuous
infusion of fat
Physiological balance of macronutrients
Disadvantages of TNA
Diminished stability and compatibility
IVFE (IV fat emulsions) limits the amount of
nutrients that can be compounded
Limited visual inspection of TNA; reduced
ability to detect precipitates
ASPEN Nutrition Support Practice Manual 2005; p. 98-99

3 IN 1 ADMIXTURE
PROTEIN (AMINO ACIDS)
(10%; 4 kcal/g)
CARBOHYDRATE (DEXTROSE)
(70%; 3.4 kcal/g)
FAT (LIPID EMULSION OF
SOYBEAN/SAFFLOWEROIL)
(20%; 9 kcal/g)
Suggested Sequence for the Initiation of
Parenteral Nutrition Therapy
PARAMETER
DAY 1 DAY 2 DAY 3
Volume (mL/24 hr) 1000 1000-1500 1500-
2000
Calories (% of goal) 50% 75%, may add fat 100%
Dextrose (g/24 hr) 100-150 150-200 200-350
Amino acids (% of total) 50%-100% 100% 100%, check
BUN
Fat No Perhaps Often (3%-5%, 30-50
g/24 hr)
Insulin Give separately Add 50% to TPN Add 50% to
TPN
Initiation of PN
Adults should be hemodynamically stable,
able to tolerate the fluid volume necessary to
deliver significant support, and have central
venous access
If central access is not available, PPN should
be considered (more commonly used in
neonatal and peds population)
Start slowly
(1 L 1st day; 2 L 2nd day)

ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: formulation
As protein 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
ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: Formulation
Generally energy and protein needs can be
met in adults by day 2 or 3
In neonates and peds, time to reach full
support relates inversely to age, may be 3-5
days

Initiation of PN: Formulation
Dextrose content of PN can be increased if
capillary blood glucose levels are consistently
<180 mg/dL
IVFE in PN can be increased if triglycerides
are <400 mg/dL

ASPEN Nutrition Support Practice Manual 2005; p. 109
PN Administration:Transition to Enteral
Feedings in Adults
Controversial
In adults receiving oral or enteral nutrition
sufficient to maintain blood glucose, no need
to taper PN
Reduce rate by half every 1 to 2 hrs
or switch to 10% dextrose IV) may prevent
rebound hypoglycemia (not necessary in
PPN)
Monitor blood glucose levels 30-60 minutes
after cessation
PN Administration:Transition to Enteral
Feedings in Pediatrics
Generally tapered more slowly than in adults
as oral or enteral feedings are introduced and
advanced
Generally PN is continued until 75-80% of
energy needs are met enterally
ASPEN Nutrition Support Practice Manual 2005; p. 109

Medications That May Be Added to
Total Nutrient Admixture (TNA)
Phytonadione
Selenium
Zinc chloride
Levocarnitine
Insulin
Metoclopromide
Ranitidine
Sodium iodide
Heparin
Octreotide
Infusion Schedules
Continuous PN
Non-interrupted infusion of a PN solution over
24 hours via a central or peripheral venous
access
Continuous PN
Advantages
Well tolerated by most patients
Requires less manipulation
decreased nursing time
decreased potential for touch contamination
Continuous PN
Disadvantages
Persistent anabolic state
altered insulin : glucagon ratios
increased lipid storage by the liver
Reduces mobility in ambulatory patients
Infusion Schedules
Cyclic PN
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
Cyclic PN
Advantages
Approximates normal physiology of intermittent
feeding
Maintains:
Nitrogen balance
Visceral proteins
Ideal for ambulatory patients
Allows normal activity
Improves quality of life
Routine physiologic and laboratory monitoring
Clinical:
Daily fluid balance, body weight, evidence of
infection
Laboratory:
Baseline: Electrolytes, BUN, creatinine, glucose,
calcium, magnesium, inorganic phosphate, liver
function (bilirubin, alanine transaminase,
aspartate transaminase, alkaline phosphatase),
triglyceride, albumin, prothrombin time
Every 6 to 12 hours: Glucose, usually for the
initial 3 to 5 days or until stable
Daily until stable: Electrolytes, BUN, creatinine,
glucose, calcium, magnesium, PO
4

Weekly: Liver function, triglyceride, albumin,
prothrombin time

Home TPN
Safety and efficacy
depend on:
Proper selection of patients
Adequate discharge planning/education
Home monitoring protocols
Home TPN
Patient selection
Reasonable life expectancy
Demonstrates motivation, competence,
compliance
Home environment conducive to sterile technique


Home TPN
Cost effective
Quicker discharge from hospital
Improved rehabilitation in the home
Reduced hospital readmissions
Common Indications for PN in
Peds
Surgical GI disorders
Intractable diarrhea of infancy
Short bowel syndrome
Inflammatory bowel disease
Intractable chylothorax
Intensive cancer treatment
Pediatric Energy Needs in PN
No consensus exists as to how to determine
energy needs of hospitalized children
RDAs are intended for healthy children but can
use for healthy/acutely ill children and monitor
response
Can estimate REE using WHO equation and
add stress factors, monitor clinical course
Indirect calorimetry recommended in difficult
cases
RDAs for Energy and Protein
Category Age (yr) Energy
(kcal/kg/d)
Protein
(g/kg/d)
Infants 0.0-0.5 108 2.2
Children 1-3 102 1.2
4-6 90 1.1
7-10 70 1.0
Females 11-14 47 1.0
15-18 40 0.8
Males 11-14 44 1.0
15-18 45 0.9
Recommended Dietary Allowances, 10
th
ed. 1989. National Academy Press,
Washington, DC
WHO Equations to predict REE
from body weight
Sex/Age Range (years) Equation to Derive REE
(kcal/d)
Males 0-3 (60.0 x wt) 54
Males 3-10 (22.7 x wt) + 495
Males 10-18 (17.5 x wt) + 651
Females 0-3 (6.1 x wt) 51
Females 3-10 (22.5 x wt) + 499
Females 10-18 (12.2 x wt) + 746
Increase WHO REE by stress
factors
Fever Increase 13% per degree
C
Cardiac Failure 15-25%
Traumatic Injury 20-30%
Severe respiratory
distress or broncho-
pulmonary dysplasia
25-30%
Severe sepsis 45-50
Olson, D. Pediatric Parenteral Nutrition. In Sharpening your skills as a nutrition
support dietitian. DNS, 2003.

Trauma/Critically Ill Peds
Age in years Kcals/kg G/pro/kg
0-1 90-120 2.0-3.5
1-6 75-90 1.8-3.0
7-12 50-75 1.5-2.5
13-18 30-60 1.0-2.0
Pediatric PN: Fluids
Standard calculation:
100 kcal/kg for infant 3-10 kg
1000 kcal + 50 kcal/kg for every kg over 10 kg for
a child 10-20 kg
1500 kcal + 20 kcal/kg for every kg over 20 kg for
a child over 20 kg
1 mL fluid/kcal/d + adjustments for fever, diarrhea,
stress, etc.
ASPEN BOD Guidelines for the use of parenteral and enteral nutrition
in adult and pediatric patients. JPEN 26;26SA, 2001
Pediatric PN: Carbohydrate
Carbohydrate should comprise 45-50% of
caloric intake in infants and children (C)
For neonates, CHO delivery in PN should
begin at 6-8 mg/kg/minute of dextrose and
advanced to 10-14 mg/kg/minute. (B)
ASPEN BOD Guidelines for the use of parenteral and enteral nutrition in adult
and pediatric patients. JPEN 26;28-29SA, 2001

Daily Electrolyte and Mineral
Requirements for Peds Pts
Electrolyte Infants/Children Adolescents
Sodium 2-6 mEq/kg Individualized
Chloride 2-5 mEq/kg Individualized
Potassium 2-3 mEq/kg Individualized
Calcium 1-2.5 mEq/kg

10-20 mEq
Phosphorus 0.5-1 mmol/kg 10-40 mmol
Magnesium 0.3-0.5 mEq/kg 10-30 mEq
National Advisory Group. Safe practices for parenteral nutrition formulations JPEN 1998;22:49-66
Total Parenteral Nutrition
Compatibility
Insulin
Reports of up to 50% of insulin is lost to adsorption
to TPN bag, tubing and filter
Insulin loss due to adsorption to EVA systems
probably only 5-15%.
However: Addition of insulin to TPN is considered
physically compatible and therapeutically appropriate
Tomato theory (dose is titrated)
Total Parenteral Nutrition
Compatibility
Insulin
Practical Guidelines
Minimum dose = 10 U / bag
Dose in 10 U increments
Avoid putting too much in TPN
Suppliment with sliding scale
Add of previous days SS to TPN
Total Parenteral Nutrition
Compatibility


Insulin Sliding Scale
Capillary Glucose
mg/dL
IDDM NIDDM
(STRESS)
200-250 3 5
251-300 6 10
301-350 9 15
351-400 12 20
TPN Complications
MECHANICAL
Pneumothorax air
Hemothorax - blood
Hydrothorax - solution (TPN)
Intravascular Misplacement - often IJ
Catheter Embolism - sheared tip
Air Embolism
Venous Thrombosis
TPN Complications
Glucose Metabolism
Hyperglycemia
HHCN: Hyperglycemic, hyperosmolar, nonketotic
coma
Renal threshold for glucose = 180 mg/dl
One episode of hyperglycemia may affect the
outcome in critical care patient


TPN Complications
Glucose Metabolism
Hyperglycemia: Prevention and Treatment
Start TPN at 50 ml/hr or with 10% dextrose
Advance rate at 25 ml/hr each day
Do not overfeed (<5-7mg/kg/min)
Check BS at least daily
Do not advance if BS > 200 mg/dl
If > 200 give insulin to control BS
then advance
May decrease the % of total calories
from dextrose


TPN Complications
Glucose Metabolism
Rebound Hypoglycemia
May occur if TPN interrupted for > 30 min
Endogenous and exogenous insulin
Prevention
Taper TPN before stopping (1/2 rate x 1-2 hours)
Hang D10%
TPN Complications
Glucose Metabolism
CO2 Retention
Occurs in pts with resp. dz. (ie. COPD)
Occurs with overfeeding
Especially if primary source of calories dextrose
Prevention
Feed per nutritional assessment
Provide mixed substrate





TPN Complications
Protein Metabolism
Azotemia
Occurs in pts with renal failure
Prevention: restrict protein
ARF: 0.5-0.8gm/kg/d
CRF: 0.8-1 gm/kg/d
Dialysis
Specialized AA formulations??







TPN Complications
Protein Metabolism
Hyperammonemia
and Hepatic Encephalopathy (HE)
Occurs in pts with liver failure
Restrict protein as necessary
ie. 0.5 gm/kg/d
Treat HE with lactulose or antibiotic enemas
For HE consider Hepatamine






TPN Complications
Fat Metabolism
Essential Fatty Acid Deficiency
EFA = linoleic acid
Cause: TPN without fat
Prevention: Give IV fat emulsion
Hyperlipidemia
If trig too high (>400 mg/dL) give IV fat emulsion for
EFA only





TPN Complications
Abnormalities of LFTs
Elevated liver function tests
AST (SGOT) also from heart
ALT (SGPT) more specific
LDH and Bilibrubin
Possible cause: fatty infiltrates of liver (hepatic steatois)
Exceed rate of glucose metabolism
5-7 mg/kg/min
Less risk with cyclic infusion
(ie. 12hr on 12 hr off)
Prevention
Keep rate < 5mg/kg/min
Provide mixed substrates (Lipids)
Provide calories per nutritional assessment
Possible cause: Cholestatis








TPN Complications
Fluid and Electrolyte Disorders
Fluid and virtually any electrolyte
Refeeding Syndrome
Low serum levels of intracellular electrolytes
Hpokalemia
Hypomagnesemia
Hypophosphatemia
Setting: Malnourished patients
Serum lytes may be normal but TBS are low
Prevention: Daily lytes when starting TPN
Make electrolyte adjustments
TPN Complications
Septic Complications
Usually catheter related
Not commonly from contaminated TPN
Most common bacteria: Staph sp.
Most common fungi: Candida sp.
Prevention: Monitor for S&S of infection
Proper catheter care
celemin
Parameter

CELEMIN 5S CELEMIN 10
PLUS
CELEMIN
HEPA
CELEMIN
NEPHRO
Total Energy
(kcal)
400 400 320 280
Amino Acids
(g/L)
50 g 100 80 70
Nitrogen (g/L) 7.25 g 16 12.90 10.80
Carbohydrates
(g/L)
50 g - - -
Electrolytes - Present - -
Osmolarity
(mOsmol/L)
800 1040 770 635
celemin
Product Strength
Features

Presentation
CELEMIN 5S
















CELEMIN 10
PLUS













CELEMIN HEPA









CELEMIN
NEPHRO
5% Amino acid
with 5% Sorbitol















10% Amino acids
with Electrolytes












8% Amino acids









7% Amino acids
Contains all
essential & non-
essential Amino
acids
WHO
recommended
ratio of EAA :
NEAA
Rich in Arginine
Insulin
independent
source of
carbohydrate
"sorbitol".
Administration
through peripheral
vein


Contains all
essential & non-
essential Amino
acids
WHO
recommended
ratio of EAA :
NEAA
Rich in Arginine &
electrolytes
Leads to protein
sparing effect.
Administration
through central
vein

42 % Branched
Chain
Amino Acids
Adequate protein
supply during
hepatic
insufficiency
Administration
through peripheral
vein
61% Essential
Amino acids
Adequate protein
supply during
renal insufficiency
Administration
through peripheral
vein
200/500ml in
Glass Bottle
HERMIN-T

CompositionI
NJ - EACH 100 ML - L-ISOLEUCINE 560 MG+L-
LEUCINE 1250 MG+ LYSINE 1100 MG+L-
METHIONINE 350 MG+L-THREONINE 650 MG+
L-PHENYLALANINE 935 MG+L-TRYPTOPHAN
130 MG+L-VALINE 450 MG+ L-ARGININEHCL
955 MG+L-ASPARTIC ACID 380 MG+L-
CYSTEINE 1 MG+L-GLUTAMIC ACID 650 MG+L-
PROLINE 330 MG+L-SERINE 220 MG+ L-
TYROSINE 35 MG+L-ALANINE 620
MG+GLYCINE 1070 MG+ XYLITOL 5000 MG

KABIVEN

G19%
2566 mL 2053 mL 1540 mL 1026 mL
Glucose (19%) 1316 mL 1053 mL 790 mL 526 mL
Amino acids
and
electrolytes
(Vamin 18
Novum

)
750 mL 600 mL 450 mL 300 mL
Fat Emulsion
(Intralipid

20%)
500 mL 400 mL 300 mL 200 mL
kabiven
2566 mL 2053 mL 1540 mL 1026 mL
Amino acids
(g)
85 68 51 34
Nitrogen (g) 13.5 10.8 8.1 5.4
Fat (g) 100 80 60 40
Carbohydrat
es - glucose
(dextrose) (g)
250 200 150 100
Energy
content

- Total (kcal) 2300 1900 1400 900
- None protein
(kcal)
2000 1600 1200 800
Electrolytes
Electrolytes
- sodium
(mmol)
80 64 48 32
- potassium
(mmol)
60 48 36 24
- magnesium
(mmol)
10 8 6 4
- calcium
(mmol)
5 4 3 2
- phosphate
(mmol)
25 20 15 10
- sulfate
(mmol)
10 8 6 4
- chloride
(mmol)
116 93 70 46
- acetate
(mmol)
97 78 58 39
infusion rate:
The maximum infusion rate for glucose is 0.25 g/kg/h.
Amino acid dosage should not exceed 0.1 g/kg/h.
Fat dosage should not provide more than 0.15 g/kg/h.
The infusion rate should not exceed 2.6 mL/kg b.w./hour
(corresponding to 0.25 g glucose, 0.09 g amino acid and 0.1
g fat/kg b.w.). The recommended infusion period is 12-24
hours.
Maximum daily dose
40 mL/kg b.w./day. This is equal to one bag (largest size) to a
64 kg-patient and will provide 1.3 g amino acids/kg b.w./day
(0.21 g N/kg b.w./day), 31 kcal/kg b.w./day non-protein
energy (3.9 g glucose/kg b.w./day and 1.6 g fat/kg b.w./day).
The maximum daily dose varies with the clinical condition of
the patient and may even change from day to day.

Contraindications
Hypersensitivity to egg-, soya- or peanut protein or to any of the ingredients
Severe hyperlipaemia
Severe liver insufficiency
Severe blood coagulation disorders
Inborn errors of amino acid metabolism
Severe renal insufficiency without access to haemofiltration or dialysis
Acute shock
Hyperglycaemia, which requires more than 6 units insulin/h
Pathologically elevated serum levels of any of the included electrolytes
General contraindications to infusion therapy: acute pulmonary oedema, hyperhydration,
decompensated cardiac insufficiency and hypotonic dehydration
Haemophagocytotic syndrome
Unstable conditions (e.g. severe post-traumatic conditions, uncompensated diabetes, acute
myocardial infarction, metabolic acidosis, severe sepsis and hyperosmolar coma)
Due to composition, Kabiven G19% is not suitable for use in new-borns or infants under 2 years
of age.