Group IV

The Youngster Group!!!

Total Parenteral Nutrition
 PARENTERAL – infusion of nutrient solutions into the
bloodstream.
 ENTERAL – feeding via the gut: normal eating, infusion of
formulas via a tube inserted into the upper GIT.

 TPN - Is the practice of feeding a person intravenously,

bypassing the usual process of eating and digestion.
 The person receives nutritional formulas containing salts,
glucose, amino acids, lipids and added vitamins.
 Is provided when the GIT is nonfunctional
- Interruption in its continuity
- Absorptive capacity is impaired
ENTERAL VERSUS TPN
ENTERAL
 Maintains the digestive and
absorptive functions of the
GIT
 Sustains immnunologic
barrier which the gut
provides, preventing enteric
organisms from invading the
body.
PARENTERAL
 Indicated to prevent the
adverse effects of
malnutrition in patients who
are unable to obtain adequate
nutrients by oral and enteral
routes.
ENTERAL VERSUS TPN
ENTERAL
 The nutrient and
immunologic functions of the
gut are supported by luminal
nutrients and by the normal
gastrointestinal hormones,
blood flow, and neural
stimulation, all of which are
activated by enteral feeding.
PARENTERAL
 Other indications:
Short gut syndrome, prolonged
ileus,or bowel obstruction
 More costly
 More hazardous
COMPLICATIONS:
Infection ( bacterial, fungal) –
indwelling central venous
catheter
Pneumothorax
Accidental arterial puncture
ENTERAL VERSUS TPN
ENTERAL PARENTERAL
 Oral intake Liver failure – related to fatty
 Anorexia, impairmant of liver ( glucose excess in TPN
swallowing, distal bowel solutions)
disease ( tube enteral Venous thrombosis and
feeding) priapism (Fat infusion)
Acute cholecystitis – complete
unusage of GIT resulting in
bile stasis in the gallbladder
ENTERAL VERSUS TPN
ENTERAL PARENTERAL
 METABOLIC
Hypokalemia
Hypophosphatemia
Hypomagnesemia
Hypoglycemia – abrupt
cessation of TPN
Hyperglycemia – start of
therapy (insulin added to
TPN); related to infection
 Question 1: Is the disease process likely to cause
nutritional impairment?
YES

Question 2: Is the patient malnourished or

strongly at risk for malnutrition?

YES
Question 3: Would preventing or treating the malnutrition with SNS
improve the prognosis and quality of life?

YES
Question 4: What are the fluid energy,
protein, and micronutrient
requirements, and can these
be provided enterally?
YES
Question 5: Can the requirement be met through
oral foods and liquid supplements?
NO
Question 5: Does the
Patient require total
parenteral nutrition?
NO
Risks and discomfort of SNS
outweight potential benefits. Explain
issue to patient or legal surrogate.
Support patient with general comfort
measures including oral food and liquid
supplements if desired.

YES NO
Request central Request permission to begin
venous line (CVL) supplemental enteral feeding with
parenteral nutrition via a peripheral vein,
if tolerated of a CVL.
YES NO
Request central Request permission to begin
venous line (CVL) supplemental enteral feeding
with parenteral nutrition via a
peripheral vein, if tolerated of a
CVL.

Question 6: What type of CVL?

Likely duration Likely duration

several weeks several months or years

Subclavian catheter Buried externalized

or PICC CVL or subcutaneous
infusion part
TPN INDICATIONS
 Indicated for patients whose GIT is not functional.

 Anticipation of undernutrition (<50% of

metabolic needs met) for > 7 days.

 Given before and after treatment to severely

undernourished patient who cannot ingest large
volumes of oral feedings and are being prepared
for surgery, radiation therapy, or chemotherapy.
TPN INDICATIONS
 Reduces morbidity and mortality after major surgery,
severe burns and head trauma, especially in patients
with sepsis.

 Disorders requiring complete bowel rest ( some stages

of Crohn’s disease, ulcerative colitis, severe
pancreatitis), pediatric GI disorders ( congenital
anomalies, prolonged diarrhea).
TPN INDICATIONS
 Short – term TPN – used if a person’s digestive system
has shut down (peritonitis), and is at a low enough
weight to cause concerns about nutrition during an
extended hospital stay.
 Long-term TPN – to treat people suffering the
extended consequences of an accident or surgery or
digestive disorder.
TPN NUTRITIONAL CONTENT
FLUID REQUIREMENT- estimated by adding the
normal daily requirement to any abnormal loss.
- 30-40mL/kg/day (adult)
- 120mL/kg/day(children)
ENERGY REQUIREMENT
- Unstressed patient – 25kcal/kg/day
- Mildly stressed – 30kcal/kg/day
- Moderately stressed – 35kcal/kg/day
- Severely stressed – 40kcal/kg/day
TPN NUTRITIONAL CONTENT
 PROTEIN REQUIREMENTS
1-2 g/kg/day(adult)
2.5-3.5g/kg/day(children)
ESSENTIAL FATTY ACIDS
VITAMINS
MINERALS
Parenteral requirement of some vitamins and minerals
may be higher than enteral requirements
TPN NUTRITIONAL CONTENT
 Micronutrients are delivered into the systemic rather
than the portal circulation, bypassing the liver and
rapidly excreted into the urine.
 Many patients who require parenteral support have
enteric losses that can result in sodium, potassium,
chloride, and bicarbonate wasting and in loss of
divalent cations and vitamins that normally have an
enterohepatic circulation.
 Tubing and delivery bags and exposure to oxygen and
light can also destry vitamins (vit. A)
SITES OF VENOUS ACCESS
 A. Distal tip of catheter best placed in midpotion of
superior vena cava
 B. Enters venous system via:
1. Percutaneous stick into the subclavian, external or
internal jugular or antecubital vein.
2. Cutdown site on external jugular (via common facial
vein) femoral, axillary, or intercostal vein.
C. All catheters can be tunneled subcutaneously to a distal
site, which
1. May provide a barrier to skin organisms infcting the line
2. Places exit site at convenient place for self-care in patients
at home.
SOLUTIONS
 Basic TPN solutions are prepared using sterile
techniques.
 Patients with renal insufficiency and are not receiving
dialysis or who have liver failure – reduced protein
content and a high percentage of essential AA.
 Patients with heart or kidney failure – volume intake
must be limited.
 Patients with respiratory failure – lipid emulsion must
provide most of non protein calories.
 Neonates – lower dextrose concentrations ( 17 to 18%).
 AMINOGLEBAN – AA (hepatic encephalopathy)
 AMINOSTERIL – AA ( children and PT)
 INTRAPID – Pre op. Post-op., cachexia, burns
 KABIVEN – AA, glucose, electrolytes
 MORIAMIN S2 – AA (protein – calorie malnutrition)
 VITRIMIX - vitamins, glucose, lipids
 VAMIN – vitamins, glucose, AA, electrolytes
DELIVERY
 Chronic TPN is performed through central venous
catheter.
 In infants, umbilical vein is sometimes used.
DELIVERY
 The preferred method of delivering TPN is with a
medical infusion pump.
 A sterile bag of nutrient solution, between 500mL and
4 L is provided.
 The pump infuses a small amount ( 0.1 to 10mL/hr)
continuously to keep vein open.
 FEEDING SCHEDULE – varies but common regimen
ramps up the nutrition over one hour
DELIVERY
 Then levels off the rate for a few hours and then ramps
it down over a final hour in order to stimulate a normal
metabolic response resembling meal time. This is
done over 12 to 14 hours rather than intermittently
during the day.
CARE OF CATHETER
-Sterile techniques must be used during insertion and
maintenance
-TPN line should not be used for any other purpose.
-External tubing should be changed q24 h with the first
bag of the day.
- Dressings should be kept sterile and are usually
changed q48h using strict sterile techniques
- TPN given outside the hospital, patients nust be
taught to recognize symptoms of infection, and
qualified home nursing must be arranged.
MONITORING
 Progress should be followed on a flowchart.
 Interdisciplinary nutrition team, if feasible, should
monitor the patient.
 Weight, CBC, electrolytes, BUN monitored daily.
 Blood glucose q6h till stable.
 I&O
 Liver function tests, serum albumin, prothrombin
time, urine osmolality; Ca, Mg and phosphate 2xa
week.
 Full nutritional assessment
THANK YOU!