Total Parenteral Nutrition

Paul Tang, MD, DPAMS

 Malnutrition
 Risk factor of nutrition-related
complications:
 Loss of 10% of the usual weight, OR
 Current weight <90% of IBW
 Types
 Marasmus – decrease caloric intake; adequate
protein-calorie ratio
 Kwashiorkor – adequate intake of calories
along with a poor protein intake
 Mixed
 Introduction
 The primary goal - to provide patients with adequate
calories and protein to prevent malnutrition and its
associated complications.
 Must provide patients with these dietary components:
1. Protein in the form of amino acids
2. Carbohydrates in the form of glucose
3. Fat as a lipid emulsion
other dietary components, including:
4. Water
5. Electrolytes
6. Vitamins
7. Trace minerals
 Patient selection
General indications
 Requiring long-term (>10 days) supplemental
nutrition .
 Requiring total nutrition because of severe gut
dysfunction or inability to tolerate enteral feedings.

Specific indications
 High-dose chemotherapy or radiation therapy.

 Severe necrotizing pancreatitis

 Severe malnutrition and nonfunctional gut.

 Patients with AIDS with intractable diarrhea.

 Severely catabolic patients whose gut cannot be

used within 5 to 7 days
 Fluid requirements
 Before TPN is initiated, and throughout the
duration of TPN therapy, careful assessment of
fluid status is imperative.
Increased in Decreased in
Fever Renal failure
Congestive heart
Fistulas
failure
Diarrhea Cirrhotic ascites
NG suction Pulmonary disease
Calorie and protein requirements
 Amino acids are not routinely used for basic energy
requirements.
 Dextrose and lipids are typically used to provide a
patient's energy needs
 The preferred mixture combines 70%-85% of
calories from dextrose and 15%-30% from lipids.
Micronutrient requirements
 Electrolytes
 Initial electrolyte doses in a PN order must be
individualized for each patient.
 Starting doses of electrolytes should be at
maintenance levels and evaluated daily during
initial startup of PN therapy.
 Macronutrient requirements
Standard Range Maximum

Infants = 90 - 100
Calories Children = 70 - 100
Adults = 40
kcal/kg/day Adolecents = 40 - 55
Adults = 28 - 30

Infants = 2.0 - 2.5

Protein Children = 1.5 - 2.0
Adults = 2.0
g/kg/day Adolecents = 0.8 - 2.0
Adults = 0.8 - 1.0

Dextrose rate 4 - 5 mg/kg/min 7 mg/kg/min

Fat 15 - 30% kcal 60% kcal
Vitamins
 Vitamins are an essential component of a patient's
daily PN regimen because they are necessary for
normal metabolism and cellular function.
 Adult multivitamin preparations contain the daily
requirements for all vitamins except Vitamin K.

Trace elements
 Trace elements are metabolic cofactors essential for
the proper functioning of several enzyme systems.
 In patients with renal impairment, selenium,
chromium, and molybdenum may be omitted.
 In patients with severe hepatic disease, manganese
and copper may be withheld.
Special populations: Pulmonary disease
 The goal of nutritional therapy in these
patients is to provide adequate
carbohydrate calories to meet energy needs,
but not to produce unacceptably high levels
of CO2.
 Increase the proportion of calories supplied
by fat and to restrict the administration of
carbohydrate to 4 mg/kg/min. Protein needs
should be estimated at 1.5 g/kg/day.
 Special populations: Diabetes

 Diabetes is neither a relative nor an

absolute contraindication to TPN, but
careful monitoring of therapy to avoid
hyperglycemia is obligatory.
 In both diabetic and nondiabetic patients,
any benefit of TPN is compromised
significantly by persistent hyperglycemia.
Special populations: Acute renal failure
 Patients are are hypercatabolic,
hypermetabolic, and frequently afflicted by
coexisting multiple-system organ failure.
Therefore, nutritional substrates should be
administered in accordance with metabolic
needs.
 Patients must be assessed carefully for signs
of fluid overload and electrolyte
abnormalities.
 Protein is provided at approx, 1 –
1.2g/kg/day, and dialysis is used as indicated
to control uremia.
 Special populations: Hepatic disease
 Lipid, carbohydrate, protein, and vitamin
metabolism is sharply altered in patients
with hepatic failure. Lipid clearance is
defective, with decreased lipolytic activity,
increased triglyceridemia, and decreased
removal of free fatty acids.
 Glucose intolerance and insulin resistance,
which are prevalent in this patient
population, may occur in approximately
80% of patients with cirrhosis.
 Special populations: Cardiac disease
 In addition to prolonged malnutrition, patients
with long-standing cardiac disease are
vulnerable to a typical wasting (cardiac
cachexia).
 Calories should be provided to satisfy, not
exceed, daily energy needs.
 The total volume of TPN solution is generally
restricted to 1000 to 1500 mL/day in patients
with severe congestive heart failure secondary
to valvular dysfunction, coronary artery disease,
or cardiomyopathy.
 Management of TPN
TNA stability
 Stability generally refers to the loss or
degradation of the admixed nutrients over
time.
 Compatibility relates to the physical and
chemical interaction between nutrients.
 Stability and compatibility issues are especially
important for 3-in-1 or total nutrient
admixtures (TNA).
 Destabilization of the lipid component of a
TNA formulation can occur under certain
conditions.
Creaming - accumulation of triglyceride particles
at the top of the emulsion.
Aggregration - clumping of triglyceride particles within the emulsion.
Coalescense - fusion of small triglyceride
particles into larger particles.
 Management of TPN
 All TNAs should be closely inspected for signs of
lipid destabilization prior to use and during
infusion.
 Any TNA with signs of destabilization should not be
used.
 Factors which affect TNA destabilization, including:
1. Amino acid concentration
2. pH of the formulation
3. Dextrose concentration
4. Concentration of the electrolytes
5. Order of mixing
 Peripheral Parenteral Nutrition
 Nutritional support delivered via peripheral vein
 Used to nourish patients who are either already
malnourished or who are at risk
 Considered “Nitrogen-sparing” therapy
 Usually used for up to 2 weeks
 Provides dextrose in 10% solution and amino
acids 1.75-3.5%
 Fat emulsions can be given via a peripheral line
 PPN admixtures are formulated so that the final
osmolarity is maintained at or below 900
mOsm/L.
 Peripheral Parenteral Nutrition
Advantages
 Avoids insertion and maintenance of central
catheter
 Delivers less hypertonic solution than central
TPN
 Reduces chance of metabolic complications
 Increases caloric source

Disadvantages
 Not used in nutritionally deplicted patients
 Not used in volume-restricted patients
 Does not usually increase patient’s weight
 May cause phlebitis
 Total Parenteral Nutrition
 Provided via central line due to
hyperosmolarity (1800-3000 mOsm/L)
 Administered at rates not to exceed
200mL/hr
 Dextrose 20%-70% is administered as
calorie source
 Used for prolonged periods in malnutrition
states: months to years
 Total Parenteral Nutrition
 Reverses starvation and achieves tissue
synthesis, repair, and growth
 All TPN solutions must be filtered: 0.2-
micron filter is used for dextrose and
amino acid solutions; a 1.2-micron filter
must be used for lipids
 Must have a dedicated lumen
 Total Parenteral Nutrition
Advantages
 Long term use
 For patients with large caloric and nutrient needs
 Provides calories, restores nitrogen balance and
replaces essential vitamins, electrolytes and
minerals
 Promotes tissue synthesis, wound healing, and
normal metabolic function
 Allows bowel rest and healing
 Nutritionally complete
 Total Parenteral Nutrition
Disadvantages
 Ma require a minor surgical procedure to

insert catheter or port

 May cause metabolic complications

 Fat emulsions may not be used effectively

in a severely stressed patient

 Risk of pneumothorax or hemothorax
 Monitoring
 Once PN has been initiated for a patient, a
variety of metabolic complications may develop.
For this reason, diligent monitoring is necessary.
 Blood chemistry
 Lytes, BUN, creatinine
 Triglycerides
 CBC w/diff
 PT, PTT
 Glucose
 Weight
 I&O
 Nitrogen balance
 Mechanical complications
 Primarily related to the initial placement of a
central venous catheter. Improper placement
may cause pneumothorax, vascular injury with
hemothorax, brachial plexus injury or cardiac
arrhythmia.
 Venous thrombosis is one of the two most
common problems that occur.
 Signs include distended neck veins and swelling
of the face and ipsilateral arm.
 Infectious complications
 PN imposes a chronic breech in the body's
barrier system.
 The mortality rate from catheter sepsis may be
as high as 15%.
 The primary preventive measures include
adhering to strict aseptic procedure while
establishing access and providing care of the
dressing and line, and prohibiting the use of the
TPN line for other purposes.
 Metabolic complications of PN

Early complications Late complications

Volume overload Essential fatty acid deficiency

Hyerglycemia Trace mineral deficiency

Refeeding syndrome Vitamin deficiency

Hypokalemia Metabolic bone disease

Hypophosphatemia Hepatic steatosis

Hypomagnesemia Hepatic cholestasis

Hyperchloremic acidosis
love this Doctor
Q: Doctor, I've heard that cardiovascular
exercise can prolong life; is this true?

A: Your heart is only good for so many

beats, and that's it... don't waste them
on exercise. Everything wears out
eventually. Speeding up your heart will
not make you live longer; that's like
saying you can extend the life of your
car by driving it faster. Want to live
longer? Take a nap.
Q: Should I cut down on meat and eat more
fruits and vegetables?
A: You must grasp logistical efficiencies.
What does a cow eat? Hay and corn. And
what are these? Vegetables. So a steak
is nothing more than an efficient
mechanism of delivering vegetables to
your system. Need grain? Eat chicken.
Beef is also a good source of field grass
(green leafy vegetable). And a pork chop
can give you 100% of your
recommended daily allowance of
vegetable products.
Q: Should I reduce my alcohol intake?

A: No, not at all. Wine is made from fruit.

Brandy is distilled wine, that means they
take the water out of the fruity bit so you
get even more of the goodness that way.
Beer is also made out of grain. Bottoms
up!

Q: How can I calculate my body/fat ratio?

A: Well, if you have a body and you have

fat, your ratio is one to one. If you have
two bodies, your ratio is two to one, etc.
Q: What are some of the advantages of
participating in a regular exercise
program?
A: Can't think of a single one, sorry. My
philosophy is: No Pain...Good!

Q: Aren't fried foods bad for you?

A: YOU'RE NOT LISTENING!!! .. Foods are
fried these days in vegetable oil. In fact,
they're permeated in it. How could
getting more vegetables be bad for you?
Q: Will sit-ups help prevent me from
getting a little big around the middle?
A: Definitely not! When you exercise a
muscle, it gets bigger. You should only be
doing sit-ups if you want a bigger
stomach.

Q: Is chocolate bad for me?

A: Are you crazy? HELLO Cocoa beans!
Another vegetable!!! It's the best feel-
good food around!
Q: Is swimming good for your figure?
A:   If swimming is good for your
figure, explain whales to me.

Q: Is getting in-shape important for my

lifestyle?
A: Hey! 'Round' is a shape!
 Facts
1. The Japanese eat very little fat -
and suffer fewer heart attacks
than Americans.
2. The Mexicans eat a lot of fat -
and suffer fewer heart attacks
than Americans.
3. The Chinese drink very little red
wine  - and suffer fewer heart
attacks than Americans.