Done by :
Fatimah Al-Shehri
Pharmacy intern
King Abdul-Aziz University
Superviesd by :
Dr.Asmaa Tahaa.
- Introduction(Definition/indications/starting
criteria/composition TPN ).
- Clinical conditions warranting the use of TPN.
- Types of TPN Infusion .
- Cyclic versus continuous .
- Advantages and disadvantages of both.
- Monitoring .
- Home TPN.
- Case scenario.
TPN is the administration of a nutritionally
adequate hypertonic solution consisting of
glucose, protein hydrolysates, minerals, and
vitamins through an indwelling catheter into the
superior vena cava or other main veins.
Indications of TPN :
- Inadequate absorption.
- Gastrointestinal fistula.
- Bowel obstruction.
- Prolonged bowel rest.
- Severe malnutrition.
- Significant weight loss .
- Hypoproteinaemia when enteral therapy is not possible.
- Other disease states or conditions.
 Starting
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criteria:
1-If early EN is not feasible or available over the first 7 days
after admission.
More than 10% involuntary weight loss over a 2-3 months
period.
Less than 75% of ideal or usual body weight
Serum prealbumin less than 10 mg/dl serum transferrin less
than 100 mg/dl
History of inadequate oral intake for more than 7 days .
 Composition
of TPN solution:
1- Amino acids .
2-Dextrose .
3-Electrolytes.
4-Lipids.
5-Vitamines and minerals.
 DETERMINING
ENERGY NEEDS:
 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
 DETERMINE
THE PROTEIN NEEDS:
 Usually start with 0.8 g/Kg and add stress and
other factors as needed.
Renal failure:
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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
Hepatic failure:
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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

AMOUNT OF FLUIDS THE PATIENT NEEDS:
Methods to calculate fluid needs:
1-patients need a minimum of 30 cc fluid/Kg maintain
hydration: 30-50 cc/Kg is a good amount to aim.
 2- 100 cc free water/gram N intake + 1 cc/Kcal
provided.
 3- use 100 cc/Kg for first 10 Kg + 50 cc/Kg for the
second 10 Kg. + 20 cc/Kg for each additional Kg.

 THE AMOUNT OF FAT
NEEDED DEPENDS
ON THE TOTAL ENERGY NEED
 10%, 20% and 30% fat emulsion are available.
 10% fat emulsion has 1.1 Kcal/cc
 20% fat emulsion has 2.0 Kcal/cc
 30% fat emulsion has 3.0 Kcal/cc
 CARBOHYDRATE IS THE MAIN SOURCE
OF FUEL TO MEET ENERGY NEEDS:
 CHO is given as dextrose monohydrate, which
yields 3.4 Kcal/gram.
Condition:
Suggested criteria:
Hyperglycemia .
Glucose >300mg/dL
Azotemia.
BUN >100mg/dL
Hyperosmolarity.
Serum osmolality >350mosm/kg
Hypernatremia.
Na>150mEq/L
Hypokalemia.
K<3mEq/L
Hyperchloremic metabolic
acidosis.
Cl>115mEq/L
Cl<85mEq/L.
Hypochloremic metabolic
alkalosis .
Hypophosphatemia.
Phosphorous <2mg/dL
Continuous TPN .
Cyclic TPN.
Continuous TPN:
Typically initiated over
24 hour (infusion).
Advantages of continuous TPN:
1-Well tolerated by most patients.
2-Requires less manipulation.
3-Decreased nursing time.
4-Decreased potential for “touch” contamination.
Disadvantages on long term :
- Continuously connected to infusion equipment.
- Interfere with daily activities.
- Perpetually immobilize the patient.
Cyclic TPN:
It’s a type of TPN which administered on a cyclic,
discontinuous Basis infusion usually over 10–14
hours .
Indications :
widely employed in patients who receive PN long
term esp. patients on home health care settings.
-It involves daily interruption of PN, allowing patients
periodic freedom.
- Improves quality of life.
- Approximates normal physiology of intermittent
feeding.
-In hepatobiliary dysfunction switching to cyclic infusion
when total bilirubin is between 5 and 20 mg/dL
may lead to stabilization of bilirubin and liver function
tests .
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #97 Carol Rees Parrish, R.D., M.S., Series Editor
-It requires daily starting and stopping of infusions, during
which time the body must adapt to changes in blood
nutrients.
-It requires higher nutrient infusion rates to supply a similar
nutrient load over a shorter period of time.
- Fluid overload esp. in cardiac and renal patients .
-It may induce hypourecemia.
-Daily starting and stopping of PN infusion may increase the
risk of hyperglycemia and hypoglycemia.
- Increased potential for touch contamination.
- Increased nursing time.
Practical Gastroenterology . July 2011
Items of comparison :
Cyclic TPN :
Nitrogen balance :
Continuous
TPN :
Similar
Daily lipid oxidation:
Lower
Higher
Carbohydrate oxidation :
Higher .
Lower
Triglyceride secretion :
Similar
Total Energy expenditure:
Similar
Oxygen consumption :
Similar
Items of comparison :
Cyclic TPN :
Continuous
TPN :
Urinary volume:
Increased .
-
Excretion of urea, creatinine,
Na, Cl, Ca, phosphate, Mg.
Increased .
-
daily concentrations of
calcium, phosphate, and
vitamin D.
Similar .
Circulating concentrations of
counter -regulatory
Hormones.
Similar
insulin responses.
Greater .
- Critically ill, mechanically ventilated patients
may not be candidates for cyclic PN infusion.
Continuous and cyclic TPN
in hospital.
Monitoring patients receiving TPN:
Fluid balance:
Glucose
tolerance:
Weight:
Venous access:
Routine
biochemistry:
Monitor daily.
Initially levels checked every 4-6 hours; daily when stable.
Daily weights can show fluid changes.
Venous access site regularly checked for signs of infection,
phlebitis.
Serum Na, K, urea and creatinine checked daily initially.
Ca, Mg and P checked at least twice a week initially.
Trace elements zinc, copper, selenium checked monthly.
Vitamins B12, Folate, Vitamin A, Vitamin E checked monthly.
Urinalysis
Urinary levels of electrolytes useful when determining clinical
significance of plasma levels.
- Weight.
- Blood sugar .
- Temperature .
- Intake and output.
Documentation that the patients GIT is nonfunctional and this
condition is permanent .
The patient must also have documented evidence of inability to
tolerate enteral feeding ( malabsorption ,obstruction ).

A 66 year old women presented with abdominal pain ,nausea
,and vomiting .She had problems with poor appetite ,early
satiety and frequent nausea and vomiting following meals over
the past month. During that time she lost 8.5 kg .Her history
included Crohn's disease for 12 years ago and again 6 months
ago resulting in an ileostomy .She has noninsulin-dependent
diabetes mellitus that was diagnosed 6 years earlier .On
physical exam ,she was a slightly obese ,ill appearing women
who weighed 65kg and was 65 in tall. Admission lab values as
following:
.
Na=141mEq/L.
Total bilirubin=0.2mg/Dl.
K=3.6mEq/L.
ALT=22U/L.
Cl=95mEq/L.
AST=15 U/L.
CO2=32mEq/L.
ALP=118U/L.
BUN=7mg/Dl.
TG=125MG/dL .
Creatinine=1.2mg/Dl. Cholesterol=112 mg/dL .
Mg=1.6mEq/L.
Osmolarity=300mOsm/kg.
Glucose=189mg/dl.
Trsnsferrin= 105mg/dL.
Ca=7.4 mg/dl.
Prealbumin=5mg/dL.
Phosphorus=1.8mg/dL.
Abdominal scan findings demonstrates a partial /complete bowel
obstruction with pockets of fluid collections consistent with an
intraabdomianl abscess. At surgery the patient was found to have
a complete Crohn’s disease ,and a large suprapubic abscess.
 What
are the starting criteria for TPN in this
patients?
 Can we start the patient on a TPN ?
 Lipid
emulsion provides a major source of
calories in PPN formulations ?
-http://www.wenourish.com/docs/PE
5.04_Home_Monitoring_forTPN.pdf
- Guidelines on The Management of Enteral Tube Feeding in
Adults, Clinical Resource .
-Efficiency Support Team (2004)
http://www.inmo.ie/Article/PrintArticle/4377.
http://www.rxkinetics.com/tpntutorial/3_1.html.