PARENTERAL NUTRITION IN
HAEMATOPOIETIC STEM CELL
TRANSPLANTATION
BY
DR. IDEMUDIA J.O
DEPARTMENT OF CHEMICAL PATHOLOGY
UBTH, BENIN CITY
OUTLINE:
• INTRODUCTION
• INDICATIONS FOR TPN IN HAEMATOPOIETIC
STEM CELL TRANSPLANTATION
• TIMING OF TPN
• NUTRITIONAL CONTENT
• BEGINNING TPN ADMINISTRATION
• MONITORING
• COMPLICATIONS
• CONCLUSION
INTRODUCTION
• Parenteral nutrition is feeding a
person intravenously, bypassing
the usual process of eating and
digestion. The person receives
nutritional formulation that
contains nutrients such as salts,
glucose, amino acid, lipids,
vitamins etc.
• Parenteral nutrition is divided
into two; (1) Partial parenteral
nutrition in which case only part
of the daily nutritional
requirement is supplied,
supplementing an oral intake.
Many hospitalized patients are
given dextrose, electrolytes or
amino acid solutions by this
• (2) Total parenteral nutrition (TPN)
which supplies all daily nutritional
requirements of the person.
Because TPN solution is
concentrated and can cause
thrombosis of peripheral veins, a
central venous catheter is usually
required.
INDICATIONS FOR TPN IN HAEMATOPOIETIC STEM
CELL TRANSPLANTATION
Mucositis of the gastrointestinal tract:
• This is the main indication for TPN in patients
undergoing HSCT
• Usually develops within 7-10 days after
chemotherapy and radiotherapy during
conditioning of patient for BMT resulting in
oroesophageal mucositis and gastrointestinal
toxicity
• This may result in decreased oral intake of food,
nausea, vomiting, diarrhoea and decreased
nutrient absorption which may last up to 2-3weeks
after BMT
Increased energy demand by the
recipient
• Metabolic effects of the conditioning
regimens, and possible BMT
complications such as sepsis and
GVsHD
• Impaired glucose tolerance resulting
from steroid or cyclosporine
administration or effect of BMT on
pancreatic β cell function
TIMING of TPN
• TPN is often considered to be an
expensive procedure and it is therefore
started only when it becomes necessary
• In some centres TPN is initiated before
commencement of chemotherapy and
irradiation and continued up to day 28
post BMT while in other centres, TPN is
routinely initiated on day 1 after BMT
and continued for 15 – 21 days
NUTRITIONAL CONTENT
• TPN requires water (30 to 40
mL/kg/day), energy (3060kcal/kg/day, depending on
energy expenditure) amino acids
and lipids (1 to 2g/kg/day
depending on the degree of
catabolism) vitamins and
minerals.
BASIC ADULT DAILY REQUIREMENTS
FOR TOTAL PARENTERAL NUTRITION
NUTRIENT
AMOUNT
Water (/kg body wt/day)
30–40 mL
ENERGY (/kg body wt/day)
Medical patient
30 kcal
Postoperative patient
30–45 kcal
Hypercatabolic patient
45–60 kcal
AMINO ACIDS (/kg body wt/day)
Medical patient
1.0 g
Postoperative patient
2.0 g
Hypercatabolic patient
3.0 g
NUTRIENT
MINERALS
Acetate/gluconate
Calcium
Chloride
Chromium
Copper
Iodine
Magnesium
Manganese
Phosphorus
Potassium
SeleniumSome Trade
Sodium
Zinc
AMOUNT
90 mEq
15 mEq
130 mEq
15 μg
1.5 mg
120 μg
20 mEq
2 mg
300 mg
100 mEq
100 μg
100 mEq
5 mg
NUTRIENT
AMOUNT
VITAMINS
Ascorbic acid
100 mg
Biotin
60 μg
Cobalamin
5 μg
Folate (folic acid) 400 μg
Niacin
40 mg
Pantothenic acid 15 mg
Pyridoxine
4 mg
Riboflavin
3.6 mg
Thiamin
3 mg
Vitamin A
4000 IU
Vitamin D
400 IU
Vitamin E
15 mg
Vitamin K
200 μg
*Requirements for energy increase by 12% per 1° C of fever.
BEGINNING TPN ADMINISTRATION
• The first thing to do is to put a central
venous catheter in place, because the central
venous catheter needs to remain in place for
a long time, strict sterile technique must be
used during insertion and maintenance. The
TPN line should not be used for any other
purpose. The external tubing should be
changed every 24hours with the first bag of
the day. Dressing should be kept sterile and
are usually changed every 48hours using
strict sterile techniques.
• The solution is started slowly
at 50% of the calculated
requirements, using 5%
dextrose to make up the
balance of fluid requirements.
• MONITORING OF PATIENTS ON TPN
• Progress should be followed on a flowchart.
• Weight, electrolytes and blood urea nitrogen
should be monitored daily. Plasma glucose
concentration should be monitored every
6hours until patient’s blood glucose level
becomes stable, blood tests can be done
much less often.
• If there is hyperglycaemia, 1iu of insulin
should be added to every 10g of dextrose
solution
• Liver function tests, plasma total protein and
albumin, plasma and urine osmolality, plasma
calcium, magnesium and phosphate should be
done twice a week until the patient is stable.
• INDICES FOR MONITORING PATIENTS ON TPN
BMI =
≥30kg/m2- Obesity
25-29.9kg/m2 – over weight
<18.5kg/m2 – underweight
NITROGEN BALANCE
•
Is the difference between nitrogen
intake and nitrogen excretion. It is
one of the major indicators of
protein change and/or adequacy of
feeding in a controlled setting. In a
healthy adult anabolic and catabolic
rates are in equilibrium, and the
nitrogen balance approaches zero.
Nitrogen balance is calculated as:
24hour-protein intake (g)
6.25
24hour UUN+4
Total Volume of urine(L)
• Protein intake in grams is converted into
grams of nitrogen by dividing by a factor of
6.25.
• The factor of 4 represents non urinary losses
of nitrogen (e.g from skin, faeces, hair, and
nails)
COMPLICATIONS:
• About 5 to 10% of patients on TPN have
complications related to central venous
access, mainly sepsis.
. Glucose abnormalities (hyperglycaemia or
hypoglycaemia) or liver dysfunction occurs in
>90% of patients.
• TPN increases the risk of acute cholecystitis
due to complete unusage of gastrointestinal
tract, which may result in bile stasis in the gall
gladder.
ABNORMALITIES OF SERUM ELECTROLYTES
AND MINERALS
• This should be corrected by modifying
subsequent infusion or, if correction is
urgently required, by beginning appropriate
peripheral vein infusions.
• Volume overload: (Suggested by >1kg/day
weight gain).
• Metabolic bone disease: This occurs in
patients receiving TPN for > 3months. There is
severe pain in the back and lower extremities.
Treatment is to temporarily stop TPN.
• Adverse reaction to lipid emulsion: This
occurs in the form of dyspnoea, cutaneous
allergic reaction, nausea, head ache, back
pain, dizziness and sweating. They are
uncommon but may occur early, particularly if
lipids are given at >1.0kcal/kg/hour.
Temporary hyperlipidaemia may occur,
particularly in patients with kidney or liver
failure. Treatment is to either slow or
temporarily stop lipid emulsion infusion.
Conclusion:
Despite all the complications
associated with the use of TPN, its
benefits cannot be overlooked and if
all the necessary precautions are
taken, the complications can be
minimized.