In the name of GOD
Total Parenteral Nutrition (TPN)
Presented by:
1
Shadi Farsaei (Assistand professor of pharmacotherapy)
INDICATION
 Inability
to absorb nutrients via the GI tract
because of one or more of the following:
 Massive small bowel resection
 Intractable vomiting when adequate EN is
not expected for 7-14 days.
 Severe diarrhea
 Bowel obstruction
 GI fistulae: PN is indicated for patients with
prolonged inadequate nutritional intake
longer than 5-7 days who are not candidates
for EN.
2
Cancer: antineoplastic therapy, radiation therapy, or
HSCT
 moderately to severely malnourished patients
receiving active anticancer treatment who are not
candidates for EN.
 PN is unlikely to benefit patients with advanced
cancer whose malignancy is unresponsive to
treatment.
 PN is appropriate for patients undergoing HSCT who
are malnourished and who are anticipated to be
unable to ingest and/or absorb adequate nutrients for
7-14 days.
 Pancreatitis: severe pancreatitis with prolonged
inadequate nutritional intake longer than 5-7 days who
are not candidates for EN. PN should be used when EN 3
exacerbates abdominal pain, ascites, or fistula output.

Critical care
 whom EN is contraindicated or is unlikely to provide
adequate nutritional requirements within 5-10 days.
 Organ failure (liver, renal, or respiratory): moderate
to severe catabolism when EN is contraindicated.
 Burns: whom EN is contraindicated or is unlikely to
provide adequate nutritional requirements within 4-5
days.
 Perioperative PN
 Preoperative: for 7-14 days for patients with
moderate to severe malnutrition who are undergoing
major GI surgery, if the operation can be safely
postponed.
 Postoperative: for patients in whom EN is
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contraindicated or is unlikely to provide adequate
nutritional requirements within 7-10 days.

 Eating
disorders: anorexia nervosa and
severe malnutrition who are unable or
unwilling to ingest adequate nutrition.
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
Adult PN therapy is not an emergent
intervention and should not be initiated until the
patient is hemodynamically stable.

In general, adults who are not candidates for
enteral nutrition should be considered candidates
for PN after 7 to 14 days of suboptimal
nutritional intake.
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PATIENT ASSESSMENT
 Nutrition
History: malnutrition
 Weight History
 5% of usual weight within 1 month, or 10%
of usual weight within 6 months
 Physical
Examination
 Anthropometry
 Biochemical Assessment
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Visceral Proteins for Nutrition Assessment
1.
Brown RO, Bradley JE, Bekemeyer WB, Luther RW. Effect of albumin
supplementation during parenteral nutrition on hospital morbidity. Critical care medicine.
1988;16(12):1177-82.
2.
Koretz RL. Intravenous albumin and nutrition support: going for the quick fix. JPEN
Journal of parenteral and enteral nutrition. 1995;19(2):166-71.
3.
Rubin H, Carlson S, DeMeo M, Ganger D, Craig RM. Randomized, double-blind study 8
of intravenous human albumin in hypoalbuminemic patients receiving total parenteral nutrition.
Critical care medicine. 1997;25(2):249-52.
PERIPHERAL LINE

700-900 mOsmol

Chang IV each 2-3 d
Dextrose 10%
 Aminoacid 5%
 Intralipid ?


Energy < 1 kcal/ml
Dilution of dextrose/aminofusion with Intralipid
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PARENTERAL NUTRITION

Peripheral Parenteral Nutrition (15 lit D5W/day for a 70 kg

Central Parenteral Nutrition (TPN)
-
needs CV-line to administer hyperosmolar solutions
!!!)
Osmolarity:
(%Dex × 50) + (%Aminoacid × 100)
150 mOsm for
electrolytes, …
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Subclavian
PICC
Jugular
Femoral (more infection !)
PICC: Peripherally inserted central catheter
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PERIPHERAL VEIN THROMBOPHELEBITIS
 Hydrocortisone
5 mg/L
 Heparin 1000 U/L
 Topical nitroglycerin
 Concurrent administration of intralipid ?

Decreases osmolarity, buffers the pH, and improves
peripheral vein tolerance, it does not eliminate the
risk of thrombophlebitis.
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ESTIMATION OF ENERGY EXPENDITURE
Weight & metabolic state
Harris-Benedict equations:
 BEE (M) (kcal/day) : 66.47+13.75W+5H-6.76A
 BEE (F) (kcal/day) : 65.51+9.56W+1.85H-4.68A
 BEE: 20-25 kcal/kg/day
 TEE
(kcal/day):
BEE × Stress factor × Activity factor
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Stress factors:
 Surgery: 1.1-1.2
 Infection: 1.2
 Trauma: 1.5
 Sepsis: 1.6
 Burns: 1.6-2
Activity factors:
 Confined to bed: 1.2
 Out of bed: 1.3
 Normal activity: 1.5
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Estimation of protein requirement
Hypermetabolic/hypercatabolic state
secondary to trauma or burn: 2 g/kg/day
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COMPONENTS
OF
TPN FORMULATIONS
Macro:
Calorie: Dextrose 20%, 50%
Intralipid 10%, 20%
Protein: Aminofusion 5%, 10%
Fluid
Micro:
Electrolytes (Na, K)
Minerals (Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
Vit (A, E, C, B, Folic acid)
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DEXTROSE
 20%,
 3.4

50% (from CV-line)
kcal/g
60-70% of calorie requirements should be
provided with dextrose
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SPECIAL CONSIDERATIONS

Max infusion rate of dextrose: 0.5 g/kg/h (to avoid
hyperglycemia, glycosuria, fatty liver, hyperosmolar
coma)

Max rate of dextrose metabolism : 5 mg/kg/min or 7
g/kg/d

“K” should be added to dextrose solutions

If BS > 200, Insulin should be added

0.1 U/g Dextrose
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AMINOFUSION

5%, 10% (from CV-line)

1-1.5 g/kg/day

Should not be used as a calorie source
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ESTIMATION OF PROTEIN
REQUIREMENTS
0.8 g/kg/day

RDA

Hospitalized patient, minor stress

Moderate stress
1.2–1.5 g/kg/day

Severe stress
1.5–2 g/kg/day
1–1.2 g/kg/day
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Na
K
 Mg
 Acetate
 Cl
 H2PO4

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25
2.6
59
57
9
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
mmol/L
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INTRALIPID
 10%,
20% (from peripheral or CV-line)
 30-40%
of calorie requirements should be
provided with Intralipid
 Serum
 Max.
TG level must be < 400 mg/dl
2.5 g/kg or 60% total calories
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1022 Kcal/L
345 mOsmol/L
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1080 Kcal/L
1 liter contains:
A- Active constituents:
Glycerine (glycerol)
25g
Phospholipids from egg
6g
Soya beans
100g
B- Other Constituents:
Sodium Oleate, Sodium hydroxide & water
Total energy= 1080Kcal/L
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AN IMPORTANT SOLUTION
 Concentrate
 Source
isotonic solution
of essential FFA
 Substitute
for CHO for ventilated pts.
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Caloric density of intravenous nutrients
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Electrolytes (daily requirements for TPN):
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Recommended adult daily dose of parenteral vitamins
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AVAILABLE DOSAGE FORM FOR
PARENTERAL ROUT
Amp Vit A: 50000 IU
 Amp Vit D: 300,000U
 Amp Vit K: 1, 10 mg ??!!



Amp Vit E: 100 IU
Amp Vit C: 500 mg
Amp Vit B complex
 Amp Vit B12: 100, 1000 mcg
 Amp Soluvit (Fressenius)

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VITALIPID
INDICATIONS
Vitalipid N Adult is indicated as a supplement in
complete intravenous nutrition to meet the daily
requirements of the fat-soluble vitamins A, D2, E
and K1.
As above, Vitalipid N Infant is indicated in
paediatric patients up to 11 years of age.
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The vitamins are soluble in the oil phase of the
emulsion, which has the composition corresponding to
that of Intralipid 10%.
 The daily maintenance dosage of the vitamins A, D2, E
and K1 are supplied during intravenous nutrition
when:

(i) 10 mL of Vitalipid N Adult are added to 500 mL
Intralipid 10% or 20%.
 (ii) 1 mL of Vitalipid N Infant per kg bodyweight per day up
to a maximum of 10 mL is added to Intralipid 10% or 20%.

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The recommended dose is 1 mL Peditrace/kg body
weight/day for infants and children with a weight of
up to 15 kg.
The basic requirements of trace elements are covered
by a daily dose of 15 mL to children weighing more
than 15 kg
Infusion time:
The infusion time should not be less than 8 hours.
The infusion should be given at a
very slow rate.
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WATER
ml/day = 1500 ml + (IBW-20) × 20
 30-35 ml/kg


Average healthy adult : 5 L/d

Fluid restricted: ≤ 2 L/d

Emesis, diarrhea, agitation, ventilation, fever
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MONITORING:


Baseline:
Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT, INR, TG, LFT,
Alb

Daily: Wt, V/S, I/O, Na, K, BUN, Cr, Glu

2-3 times a week: CBC, Ca, P, Mg

Weekly: Alb, LFT, INR
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REFERENCES
 Mirtallo,
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J., D. Johnson, et al. (2004).
"Safe practices for parenteral nutrition."
Journal of Parenteral and Enteral
Nutrition 28(6): S39-S70.
 Koda-Kimble, Mary Anne, and Brian K.
Alldredge. Applied Therapeutics: The Clinical
Use of Drugs. Baltimore: Wolters Kluwer
Health/Lippincott Williams & Wilkins, 2013.
 DiPiro, Joseph T. Pharmacotherapy: A
Pathophysiologic Approach. New York:
McGraw-Hill Medical, 2011. …..