By: E. Salehifar
(Clinical Pharmacist)

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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

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Enteral Nutrition ( Physiologic, less expensive)
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Parenteral Nutrition
- GI should not be used (Obstruction, Pancraitis)
- GI can not be used ( Vomiting, Diarrhea,
Resection of intestine, IBD)

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Peripheral Parenteral Nutrition
(15 lit D5W/day for a 70 kg !!!)
Central Parenteral Nutrition
(TPN)
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Needs CV-line to administer hyperosmolar solutions

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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

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Normal/mild stress level: 20-25 kcal/kg/day
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Moderate stress level: 25-30 kcal/kg/day
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Severe stress level: 30-40 kcal/kg/day
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Pregnant women in second or third trimester:
Add an additional 300 kcal/day

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30-40 mL/kg

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Maintenance: 0.8-1 g/kg/day
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Normal/mild stress level: 1-1.2 g/kg/day
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Moderate stress level: 1.2-1.5 g/kg/day
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Severe stress level: 1.5-2 g/kg/day
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Burn patients (severe): Increase protein until significant wound healing achieved
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Solid organ transplant: Perioperative: 1.5-2 g/kg/day

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Acute (severely malnourished or hypercatabolic):
1.5-1.8 g/kg/day
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Chronic, with dialysis: 1.2-1.3 g/kg/day
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Chronic, without dialysis: 0.6-0.8 g/kg/day
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Continuous hemofiltration: ≥ 1 g/kg/day

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Acute management when other treatments have failed:
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With encephalopathy: 0.6-1 g/kg/day
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Without encephalopathy: 1-1.5 g/kg/day
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Chronic encephalopathy
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Use branch chain amino acid enriched diets only if unresponsive to pharmacotherapy
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Pregnant women in second or third trimester
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Add an additional 10-14 g/day

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Initial: 20% to 40 % of total calories (maximum:
60% of total calories or 2.5 g/kg/day)
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Note: Monitor triglycerides while receiving intralipids.
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Safe for use in pregnancy
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I.V. lipids are safe in adults with pancreatitis if triglyceride levels <400 mg/dL

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)

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20%, 50% ( from CV-line)
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3.4 kcal/g
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60-70% of calorie requirements should be provided with dextrose

D20W
D30W
D40W
For 1000 ml solution
D50W
250 ml
D10W
750 ml
D5W
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333 ml
500 ml
555 ml
750 ml
778 ml
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500 ml
-----
250ml
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667 ml
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446 ml
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222 ml

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Hypersensitivity to corn or corn products
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Hypertonic solutions in patients with intracranial or intraspinal hemorrhage

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Infuse 10% dextrose at same rate and monitor blood glucose for hypoglycemia

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10%, 20% ( from peripheral or CV-line)
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1.1 kcal/ml (10%), 2 kcal/ml (20%)
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30-40% of calorie requirements should be provided with Intralipid

1022 Kcal/L
345 mosmol/L
1080 Kcal/L

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Hypersensitivity to fat emulsion or any component of the formulation; severe egg or legume (soybean) allergies
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Pathologic hyperlipidemia, lipoid nephrosis, pancreatitis with hyperlipemia (TG>400 mg/dl)

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400 Kcal/L
1030 mosmol/L
200 kcal/L
590 mosmol/L

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Hypersensitivity to one or more amino acids
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Severe liver disease or hepatic coma

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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.

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?

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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)
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Dext 50%= ? 2200 – 550= 1650 kcal
1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 g Dext
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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):
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Na: 80-100 mEq (50 - 100 ml NaCl 5%)
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K: 60-80 mEq (30 ml KCl)
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Cl: 50-100 mEq
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Mg: 8-16 mEq (5 -10 ml MgSo4 20%)
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Ca: 5-10 mEq (10-20 ml Ca Gluconate 10%)
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P04: 15-30 mEq
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Acetate: 50-100 mEq

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Vitamins:
A, D, E, Water soluble vitamins
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Trace Elements:
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Zn, Se, Cu, Cr, Mn
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↓ Zn
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Delayed ulcer healing, Dermatitis, Alopcia (5α reductase),
Diarrhea
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↓ Se:
Low activity of SOD & Deiodinase
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Max infusion rate of dextrose: 0.5g/kg/h (to avoid hyperglycemia, glycosuria, fatty liver, hyperosmolar coma)
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K should be added to dextrose solutions
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Slow starting & slow tapering of Dext 50%
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If BS>200, Insulin should be added
 some brands of lipids can be mixed with
Dext+Aminifusion in the same IV container

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Intralipid contraindications:
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Severe egg allergy
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Hyperlipidemia
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Special aminoacid products:
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Hepatamine: for Hepatic Failure
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↑ branched chain aa ( leu, isoleu, val)
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Nephramine: for Renal Failure
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Primarily essential aa with lower concentrations

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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
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2-3 times a week: CBC, Ca, P, Mg
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Weekly: Alb, Pre-Alb, LFT, INR, Nitrogen Balance

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INS
Heparin
H2-blocker
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Alb
Aminophylline
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Vit K & Bicarbonate should not be added

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Endocrine & metabolic
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Fluid overload, hypercapnia, hyperglycemia, hyper-
/hypokalemia, hyper-/hypophosphatemia, refeeding syndrome
Hepatic
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Cholestasis, cirrhosis (<1%), gallstones, liver function tests increased, pancreatitis, steatosis, triglycerides increased
Renal
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Azotemia, BUN increased
Infectious
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Bacteremia, catheter-induced infection, exit-site infections
Other: Pneumothorax, Thrombophlebitis

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In patients with long-standing or severe malnutrition
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Is a medical emergency, consist of:
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Electrolyte disturbances (eg, potassium, phosphorus)
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Respiratory distress
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Cardiac arrhythmias, resulting in cardiopulmonary arrest
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Do not overfeed patients; caloric replacement should match as closely as possible to intake

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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