Transcript Parentral Nutration

Heba Elkholy, Pharm. D
A. Senior Clinical Pharmacist, SKMC
Goals
 To provide a brief explanation about TPN.
 To illustrate one common problem which could
occur when writing TPN prescription and how it
could be avoided.
 To discuses the current Canadian guidelines
recommendation supported by evidence based.
 To briefly go through some calculations related to
PPO TPN at SKMC
Total Parenteral Nutrition
 Normal Diet
 Protein
 Carbohydrates
 Fat
 Vitamins
 Minerals
 Water
Total Parenteral Nutrition
Normal Diet TPN
 Protein………………...Amino Acids
 Carbohydrates…….Dextrose
 Fat……………………….Lipid Emulsion
 Vitamins………………Multivitamin Infusion
 Minerals……………….Electrolytes and
Trace Elements
Carbohydrate-CHO
 The most commonly used carbohydrate
energy substrate is dextrose.
 1gm dextrose= 3.4 kcal/g.
 According to the United States
Pharmacopoeia (USP), dextrose are acidic,
with a pH ranging from 3.5 to 6.5, and vary in
osmolarity depending upon their
concentration.
Carbohydrate-CHO
 Higher dextrose concentrations (greater than
10%) are generally reserved for central
venous administration
 the propensity to cause thrombophlebitis in
peripheral veins.
Use your brain
True or false?
Dextrose 10% can be given as peripheral?
Protein
 Crystalline amino acids .
 4 kcal/g.
 essential and nonessential amino acids.
Electrolytes
 Daily Electrolyte Requirements
 Sodium 1–2 mEq/kg
 Chloride As needed to maintain acid–base




balance
Acetate As needed to maintain acid–base
balance
Calcium 10–15 mEq
Magnesium 8–20 mEq
Phosphate 20–40 mmol
How to Measure the Energy
requirement?
Harris–Benedict Equation
 Men: Energy expenditure= 66 + 13.75 (wt in
kg)+ 5 (ht) in cm -68 (age)
 Women: Energy expenditure= 655 + 9.6 (wt in
kg)+ 1.8 (ht in cm) -4.78 (age)
Energy for critically ill
patient
 Swinmer: RMR (Kcal/day)= BSA (941)-
age(6.3)+T (104)+RR(24)+Vt (804)-4243.
Penn State: RMR (Kcal/day)= HBE
(0.85)+Ve(33)+Tm (175)-6433
Special population
 Spontaneously Breathing Patients
 IJEE (s) = 629 − 11(A) + 25(W) − 609(O)
 Ventilator-Dependent Patients
 IJEE (v)=1784−11(A) + 5(W) + 244(S) +
239T+804(B).
TPN complication
 Underfeeding:
 Decreased respiratory muscle strength
 Decreased ventilatory drive
 Failure to wean from mechanical ventilation
 Impaired organ function
 Immunosuppression
 Poor wound healing
 Increased risk of nosocomial infection
TPN complication
 Overfeeding:
 Hyperglycemia
 Azotemia
 Hypertriglyceridemia
 Electrolyte imbalance
 Immunosuppression
 Alterations in hydration status
 Hepatic steatosis
osmolarity
 Osmolarity is dependent on the dextrose, amino
acid, and electrolyte Content.
 PN is a hypertonic to body fluid.
 Inappropriate administration can lead to venous
thrombosis , thrombophlebitis, and
extravasation.
 For Peripheral TPN, maximum allowed
osmolarity is 900 mosm/L.
Use your brain
Which of the following may increase the risk of
phlebitis with peripherally administered
parenteral nutrition (PPN)?
 A. Osmolarity ≤900 mOsm/L
 B. Potassium 100 mEq/L
 C. Intravenous fat emulsion (IVFE)
piggybacked with PPN.
 D. Addition of heparin to the PPN
When is TPN recommended?
Criteria for 2007 A.S.P.E.N Guidelines
 Patient has failed EN trial with appropriate tube
placement (postpyloric).
 When EN is contraindicated or the intestinal tract has
severely diminished function due to the following:
• Paralytic ileus
• Mesenteric ischemia
• Small bowel obstruction
• GI fistula except when enteral access may be placed
posterior to the fistula.
Critically ill patients
 Gut failure in critically ill patients is common.
 In critically ill patients, PN is indicated if EN is not
possible, and hypermetabolism is expected to
last more than 4 to 5 days.
 Critically ill patients requiring PN are those who
are: hemodynamically stable and have:
 a paralytic ileus.
 acute GI bleeding.
 Complete bowel obstruction
Problem
 What problem could occur when
mixing TPN?
Calcium – Phosphorus compound
 Calcium and phosphorus are common
essential electrolytes in PN solutions .
 If mixing in high conc.…… insoluble precipitate
of ca-phosphate compound could occur.
 PE secondary to ca-phosphate ppt. has been
reported.
Calcium-Phosphate compatibility
 Factors which affect stability
 Additive concentration
 Choice of calcium salt
 Order of mixing
 Amino acid product (brand)
 Amino acid concentration
 Dextrose Concentration
 Temperature (not what you think)
 Storage time
 Addition of l-cysteine (neonatal)
Case report
 Microvascular Pulmonary Emboli Secondary to
Precipitated Crystals in a Patient Receiving Total
Parenteral Nutrition,
 21-year-old man receiving immunosuppressive
therapy and TPN developed fever, shortness of
breath, and chest tightness.
 This patient’s calcium-phosphate product was at
times as high as 47.5 mmol/L

CHEST 1999; 115:892–895).
 In response to this, the Food and Drug
Administration (FDA) issued a safety alert
warning of the hazards of TPN and offered
guidelines that may help prevent future
morbidity.
Different image of lung
poorly marginated micronodules throughout all lung zones
Calcium-Phosphate compatibility
How to minimize calcium phosphate precipitation
 Additive concentration……..……....use lower the conc.
 Choice of Ca ……..…..…...use Ca Gluconate, not CaCl2
 Order of mixing…....add phosphate first, calcium last
 Amino acid product …Aminosyn best, FreAmine worst
 Amino acid concentration……….…use higher AA conc.
 Dextrose concentration………use higher Dextrose conc.
 Temperature………………………………………….…Refrigerate
 Storage time……………………....Minimized storage time
 l-cysteine (neonatal) ……..greatly increases solubility
How can the physician help?
 Please, Keep the total amount of calcium and
phosphorus less than 45meq/L.
Calcium-Phosphate compatibility
 Ca-Po4 chart
What are we doing regarding
Pediatric patients?
Compatibility of calcium and phosphate in four parenteral nutrition
solutions for preterm neonates, LUIS PEREIRA-DA-SILVA, M.D.,
NURMAMODO, et al , Am J Health-Syst Pharm. 2003; 60:10414.
An inorganic source of phosphorus (monobasic sodium
phosphate,NaH2PO4 27.5%) was used in mixtures A and C,
while an organic source (sodium glycerophosphate [Glycophos]
was used in mixtures B and D.
Organic phosphates have been recommended as sources of
phosphorus in PN solutions for premature infants because of
their higher compatibility with calcium than inorganic
phosphates.
What is new?
Glutamine
 amino acid that is reported to become
“conditionally essential” during critical illness.
 It is vital fuel for rapidly dividing cells such as
fibroblasts, reticuloendothelial cells, malignant
cell, and gut epithelial cells.
Glutamine
 clinical conditions, such as exercise, trauma, and
sepsis, the body’s glutamine requirement
exceeds its ability to synthesize glutamine; this
leads to a fall in plasma and intracellular
glutamine which increased mortality.
Glutamine evidence-base
 Efficacy of glutamine dipeptide-supplemented
total parenteral nutrition in critically ill patients:
a prospective, double-blind randomized trial.
 Method:
53 assigned to Glu-TPN and 64 to S-TPN.

Critical Care 2008, 12(Suppl 2):P146.
Glutamine evidence-base
Result:
 Less new infections occurred in Glu-TPN
patients: nosocomial pneumonia 8.04 versus
29.25 episodes-urinary tract infections 2.5 versus
16.7 episodes.
 no differences in the incidence of catheterrelated sepsis, primary bacteremia and intraabdominal infections.
Glutamine evidence-base
 Conclusion:
Glu-TPN used in critically ill patients for longer
than 3 days significantly reduces the incidence of
nosocomial pneu-monias and urinary tract
infections, and decreases the severity of organ
failures.
Glutamine in different studies
 glutamine supplementation reduces length of stay,
particularly among surgical patients.
 parenteral glutamine supplementation nutrition led to a
statistically significant decrease in infectious
complications and insulin resistance in critically ill
patients.
 The use of intravenous glutamine supplementation in
critically ill patients on total
parenteral nutrition is currently the standard of care.
Canadian Clinical Practice
Guidelines,January 8th 2007
 Based on 4 level 1 studies and 5 level 2 studies,
when parenteral nutrition is prescribed to
critically ill patients, parenteral supplementation
with glutamine, where available, is
recommended.
 There are insufficient data to generate
recommendations for intravenous glutamine in
critically ill patients who are receiving enteral
nutrition.
TPN at SKMC
TPN at SKMC
 Calculation of Peripheral TPN:
 2.75%=2.75gm /100ml= 27.5gm/1L.
 Each 1gm AA give 4gm Kcal,
 1L of 2.75%AA has 110 kcal
 10% dextrose= 10gm/100ml= 100gm/1L
 Each 1gm dextrose give 3.4Kcal
 1L of 10% dextrose= 340 Kcal
 Total calories PPN = 110+ 340=450Kcal
TPN at SKMC
 Calculation of central TPN:
 5%=5gm /100ml= 50gm/1L.
 Each 1gm AA give 4gm Kcal,
 1L of 2.75%AA has 200 kcal
 25% dextrose= 25gm/100ml= 250gm/1L
 Each 1gm dextrose give 3.4Kcal
 1L of 10% dextrose= 850 Kcal
 Total calories central = 850+ 200=1050Kcal
Finally
 Potential complications can be minimized if special
attention is paid to each step of the preparation and
administration of total parenteral nutrition
solutions.
 Cooperation between physician, pharmacist ,
dietitian and nurse results in the best outcome for
those patients who are candidates for TPN
administration.
The End
 Thanks for your attention