Total Parenteral Nutrition

(TPN)
By: E. Salehifar
(Clinical Pharmacist)
 Malnutrition
 Incidence: 50 % of hospitalized patients
 Common causes:
- Hypermetabolic states: Trauma, Infection,
Major surgery, Burn
- Poor nutrition
 Consequences: Weakness, Decreased wound
healing, increased respiratory failure, decreased
cardiac contractility, infections (pneumonia,
abscesses), Prolonged hospitalization
 Nutritional Support
 Enteral Nutrition ( Physiologic, less expensive)
 Parenteral Nutrition

- GI should not be used (Obstruction, Pancraitis)

- GI can not be used ( Vomiting, Diarrhea,
Resection of intestine, IBD)
 Parenteral Nutrition
 Peripheral Parenteral Nutrition
(15 lit D5W/day for a 70 kg !!!)
 Central Parenteral Nutrition
(TPN)
 Needs CV-line to administer
hyperosmolar solutions
Estimation of energy expenditure
Harris-Benedict equations:
 BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A
 BEE (women) (kcal/day): 655.1+9.56W+1.85H-4.68A
 TEE (kcal/day):
BEE × Stress factor × Activity factor
 Stress factors: Surgery, Infection: 1.2 Trauma: 1.5
Sepsis: 1.6 Burns: 1.6-2
 Activity factors: sedentary: 1.2 , normal activity: 1.3,
active: 1.4 , very active: 1.5
 Stress level
 Normal/mild stress level: 20-25 kcal/kg/day
 Moderate stress level: 25-30 kcal/kg/day

 Severe stress level: 30-40 kcal/kg/day

 Pregnant women in second or third trimester:

Add an additional 300 kcal/day
 Fluid: mL/day
 30-40 mL/kg
 Protein (amino acids)
 Maintenance: 0.8-1 g/kg/day
 Normal/mild stress level: 1-1.2 g/kg/day
 Moderate stress level: 1.2-1.5 g/kg/day
 Severe stress level: 1.5-2 g/kg/day
 Burn patients (severe): Increase protein until
significant wound healing achieved
 Solid organ transplant: Perioperative: 1.5-2
g/kg/day
 Protein need in Renal failure
 Acute (severely malnourished or hypercatabolic):
1.5-1.8 g/kg/day
 Chronic, with dialysis: 1.2-1.3 g/kg/day
 Chronic, without dialysis: 0.6-0.8 g/kg/day
 Continuous hemofiltration: ≥ 1 g/kg/day
 Protein need in Hepatic failure
 Acute management when other treatments have
failed:
 With encephalopathy: 0.6-1 g/kg/day
 Without encephalopathy: 1-1.5 g/kg/day

 Chronic encephalopathy
 Use branch chain amino acid enriched diets only if
unresponsive to pharmacotherapy
 Pregnant women in second or third trimester
 Add an additional 10-14 g/day
 Fat
 Initial: 20% to 40 % of total calories (maximum:
60% of total calories or 2.5 g/kg/day)
 Note: Monitor triglycerides while receiving
intralipids.
 Safe for use in pregnancy
 I.V. lipids are safe in adults with pancreatitis if
triglyceride levels <400 mg/dL
Components of TPN Formulations
Macro:
Calorie: Dextrose 20%, 50%
Intralipid 10%, 20%
Protein: Aminofusion 5%, 10%
Micro:
Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
 Dextrose
 20%, 50% ( from CV-line)
 3.4 kcal/g

 60-70% of calorie requirements should be

provided with dextrose
 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: Contraindications
 Hypersensitivity to corn or corn products
 Hypertonic solutions in patients with intracranial
or intraspinal hemorrhage
 Abrupt withdrawal
 Infuse 10% dextrose at same rate and monitor
blood glucose for hypoglycemia
 Intralipid
 10%, 20% ( from peripheral or CV-line)
 1.1 kcal/ml (10%), 2 kcal/ml (20%)

 30-40% of calorie requirements should be

provided with Intralipid
1022 Kcal/L
345 mosmol/L
1080 Kcal/L
 Intralipid: Contraindication
 Hypersensitivity to fat emulsion or any
component of the formulation; severe egg or
legume (soybean) allergies
 Pathologic hyperlipidemia, lipoid nephrosis,
pancreatitis with hyperlipemia (TG>400 mg/dl)
 Aminofusion
 5%, 10% ( from CV-line)
 1-1.5 g/kg/day

 Should not be used as a calorie source

400 Kcal/L 200 kcal/L

1030 mosmol/L 590 mosmol/L

 Amino acids: Contraindications
 Hypersensitivity to one or more amino acids
 Severe liver disease or hepatic coma
 Case
 D.C a 38 y.o man with a 12-year history of
crohn’s disease is admitted to surgery ward of
Imam hospital in Sari for a compliant of
increasing abdominal pain, nausea & vomiting
for 7 days and no stool output for 5 days.
Because of N & V, he has been drinking only
liquids during the past weeks. His crohn disease
had several exacerbations during the past 2 years
and 10 cm of his ileum has been resected 6
month ago.
 case (continue)
Drugs: Mesalamine 1000 mg qid + prednisolone
10mg/d. Abdominal x-ray is consisting with
bowel obstruction. Exploratory laparotomy
was performed and 25 cm of his ileum
resected. Bowel sounds are absent. He has a
right subclavian CV-line. Considering that his
Ht=180cm, Wt=60kg (6 month ago: 70 kg)
and Age=38 y.o, what is your recommended
TPN formula for him?
 BEE= 66.47+13.75×60+5×180-6.76×38=1535 kcal/d
 TEE= 1535×1.2×1.2 = 2200 kcal/d
 Intralipid 10%= ? 2200 × 30%= 660 kcal
1ml ≡ 1.1 kcal 660 : 1.1 = 600 ml ( 500ml)
 Dext 50%= ? 2200 – 550= 1650 kcal
1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 g Dext
50g ≡ 100 ml 485 g ≡ 970ml (1000ml)
 Aminofusion 10 %= ? 1.5 g/kg/d × 60 kg=
90g/day 10g ≡ 100 ml 90g ≡900 ml (1000ml)
Electrolytes (daily requirements for TPN):
 Na: 80-100 mEq (50 - 100 ml NaCl 5%)

 K: 60-80 mEq (30 ml KCl)

 Cl: 50-100 mEq

 Mg: 8-16 mEq (5 -10 ml MgSo4 20%)

 Ca: 5-10 mEq (10-20 ml Ca Gluconate 10%)

 P04: 15-30 mEq

 Acetate: 50-100 mEq

 Vitamins:
A, D, E, Water soluble vitamins
 Trace Elements:
 Zn, Se, Cu, Cr, Mn
 ↓ Zn
 Delayed ulcer healing, Dermatitis, Alopcia (5α reductase),
Diarrhea

↓ Se: Low activity of SOD & Deiodinase

 Amp B Complex + Amp Vit C
MV Therapeutic ( Zn, Cu, Mn)
 Special Considerations
 Max infusion rate of dextrose: 0.5g/kg/h (to
avoid hyperglycemia, glycosuria, fatty liver,
hyperosmolar coma)
 K should be added to dextrose solutions
 Slow starting & slow tapering of Dext 50%
 If BS>200, Insulin should be added
 some brands of lipids can be mixed with
Dext+Aminifusion in the same IV container
 Special Considerations
 Intralipid contraindications:
 Severe egg allergy
 Hyperlipidemia

 Special aminoacid products:

 Hepatamine: for Hepatic Failure
 ↑ branched chain aa ( leu, isoleu, val)
 Nephramine: for Renal Failure
 Primarily essential aa with lower concentrations
 Monitoring:
 Baseline: Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT,
INR, TG, LFT, Alb, Pre-Alb
 Daily: Wt, V/S, I-O, Na, K, BUN, Cr, Glu,
Sign/Symptoms of infection
 2-3 times a week: CBC, Ca, P, Mg
 Weekly: Alb, Pre-Alb, LFT, INR, Nitrogen Balance
 Adding other drugs to TPN
 INS
 Heparin
 H2-blocker
 Alb
 Aminophylline
 Vit K & Bicarbonate should not be added
 Complications
 Endocrine & metabolic
 Fluid overload, hypercapnia, hyperglycemia, hyper-
/hypokalemia, hyper-/hypophosphatemia, refeeding
syndrome
 Hepatic
 Cholestasis, cirrhosis (<1%), gallstones, liver function tests
increased, pancreatitis, steatosis, triglycerides increased
 Renal
 Azotemia, BUN increased
 Infectious
 Bacteremia, catheter-induced infection, exit-site infections
 Other: Pneumothorax, Thrombophlebitis
 Refeeding syndrome
 In patients with long-standing or severe
malnutrition
 Is a medical emergency, consist of:
 Electrolyte disturbances (eg, potassium, phosphorus)
 Respiratory distress

 Cardiac arrhythmias, resulting in cardiopulmonary

arrest
 Do not overfeed patients; caloric replacement
should match as closely as possible to intake
 Conclusion
 Malnutrition is a common problem &
Nutritional support is indicated in many
hospitalized patients
 Enteral nutrition is better, but some patients
with GI problems need TPN
 Dextrose & Intralipid should be used as calorie
sources and Aminofusion as aminoacid source
 Special monitoring should be considered for
patients especially I-O, Na, K and Glu