Transcript Total Parenteral Nutrition (TPN) (Intravenous Nutrition)

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‫َ َ ْ ُ َّ َ َ ْ َّ‬
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‫((ذ ِلكما ِمما علم ِني رِبي ۚ ِإ ِني تركت ِملة قو ٍم َّل‬
‫ُ ْ ُ َن َّ َ ُ ْ َ ُ ْ َ ُ و َ‬
‫اَّلل وهم ِباْل ِخر ِة هم َا ِِر ن ))‬
‫يؤ ِمنو ِب ِ‬
‫صدق هللا العظيم‬
Ain-Shams university
Faculty of Medicine
Department of Anesthesiology, ICU, and Pain
management
CME Program – ICU course
Def. :a method of feeding patients by
infusing a mixture of all necessary
nutrients into the circulatory system,
thus bypassing the GIT.
Also referred to as:
intravenous nutrition,
parenteral alimentation, and
artificial nutrition.
The gut should always be the preferred
route for nutrient administration.
 Therefore, parenteral nutrition is indicated
generally when there is severe gastrointestinal dysfunction (patients who cannot
take sufficient food or feeding formulas by
the enteral route) .
 If
enteral feeding is completely stopped
or ineffective, Total Parenteral Nutrition
is used (TPN).
 If enteral feeding is just “not enough”
, supplementation with Partial
Parenteral Nutrition (PPN) is indicated.
In well-nourished adults, 7 - 10 days of
starvation with conventional
intravenous support (using 5% dextrose
solutions) is generally accepted.
 If the period of starvation is to extend
beyond this time, or the patient is not wellnourished, Total Parenteral Nutrition
(TPN) is necessary to prevent the
potential complications of malnutrition.
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Short-term use
Bowel injury, surgery, major trauma or burns
Bowel disease (e.g. obstructions, fistulas)
Severe malnutrition
Nutritional preparation prior to surgery.
Malabsorption - bowel cancer
Severe pancreatitis
Malnourished patients who have
high risk of
aspiration
Long-term use (HOME PN)
Prolonged Intestinal Failure
Crohn’s Disease
Bowel resection
 PPN
can be used to supplement Ordinary
or Tube feeding esp. in malnourished
patients.
Indications:
 Short bowel syndrome
 Malabsorption disorders
 Critical illness or wasting disorders
As far as gastrointestinal failure is concerned,
long term parenteral nutrition is a life-saving
procedure.
 Enteral nutrition has the advantage over
parenteral nutrition of lower % of infectious
complications.
 Parenteral nutrition has been shown to lead
to changes in intestinal morphology and
function and an increase in permeability (with
higher % of bacterial translocation)

 Energy:
Glucose
Lipid
 Amino acids (Nitrogen)
 Water and electrolytes
 Vitamins
 Trace elements
Energy
 Basal
energy requirements are a function
of the individual's weight, age, gender, activity
level and the disease process.
 The estimation of energy requirements for
parenteral nutrition relies on predictive
equations.
 Hospitalized adults require approximately 2530 kcal/ kgBW/day.
 However, these requirements may be greater
in patients with injury or infection.
Patient condition
Basal
metabolic
rate
Approximate energy
Requirement
(kcal/kg/day)
No postoperative
complications, GIT
fistula without infection
Normal
25-30
Mild peritonitis, long-bone
fracture, mild to moderate
injury, malnourished
25% above
normal
30-35
Severe injury or infection
50% above
normal
Up to 100%
above
normal
35-45
Burn 40-100% of total
body surface
45-80
 Energy
Sources: Glucose
The most common source of parenteral energy
supply is glucose, being:
Readily metabolized in most patients,
provides the obligatory needs of the substrate , thus
reducing gluconeogenesis and sparing endogenous
protein.
1 gm of glucose gives 4 Kcals.
Most stable patients tolerate rates of 4-5 mg.kg1.Min-1, but insulin resistance in critically ill patients
may lead to hyperglycemia even at these rates, so
insulin should be incorporated acc. to blood sugar
levels.
 Energy
Sources: Glucose
Route
 Glucose in
5% solution can be safely
administered via a peripheral vein, but higher
concentrations require a central venous line.
 20, 25, or even 50 % solutions are needed to
administer meaningful amounts of energy to
most
patients
for
proper
volume
administration.
Energy
Sources: Lipid
 Fat
mobilization is a major response
to stress and infection.
 Triacylglycerol's are an important
fuel source in those conditions, even
when glucose availability is adequate.
 Need
to be restricted in patients with
hypertriglyceridemia.
 Energy
 Lipids
Sources: Lipid
are also a source for the essential
fatty acids which are the building blocks
for many of the hormones involved in
the inflammatory process as well as the
hormones
regulating
other
body
functions.
 Ideally, energy from fat should not
exceed 40% of the total (usually 2030%).
 Energy
Sources: Lipid
Fat emulsions can be safely administered via
peripheral veins, provide essential fatty acids,
and are concentrated energy sources for fluidrestricted patients.
 They are available in 10, 20 and 30%
preparations.
 Though lipids have a calorific value of 9Kcal/g,
the value in lipid emulsions is 10Kcal/g due to
the contents of glycerol and phospholipids.

Nitrogen
 Protein
(or amino acids, the building
blocks of proteins) is the functional and
structural component of the body, so
fulfilling patient’s caloric needs with nonprotein calories (fat and glucose) is
essential.
 Protein requirements for most healthy
individuals are 0.8 g/kg/day.
 Nitrogen
With disease, poor food intake, and inactivity,
body protein is lost with the resultant
weakness and muscle mass wasting.
 Critically ill patients may need as high as 1.52.5 g protein/kg/day depending on the
disease process:
(major trauma or burn > infection or after surgery >
standard)
 The amount should be reduced in patients
with kidney or liver disease.

 Nitrogen
Daily Protein requirements
Condition
Basic requirements
Slightly increased
requirements
Moderately
increased
requirements
Highly increased
requirements
Reduced
requirements
Example
Normal person
Post-operative, cancer,
inflammatory
Sepsis, polytrauma
requirement
0.5-1g/Kg
1.5g/Kg
Peritonitis, burns,
2.5g/Kg
Renal failure, hepatic
encephalopathy
0.6g/Kg
2g/Kg
 Nitrogen
Nitrogen Balance =
Protein intake in grams ÷ 6.25 – UUN (in
grams) + 3


The nitrogen
amino acids
response to
stress
lost in urine derives primarily from
released by protein breakdown in
catabolic mediators that include
hormones
(corticosteroids,
catecholamines) and cytokines.
It is a way to assess the sufficiency of protein
intake for the patient.
 Nitrogen

Parenteral amino acid solutions provide all
known essential amino acids.

Available a.a. preparations are 3.5 - 15 % (ie
contains 3.5-15 gms of protein or a.a.s/100 mL
solution).

1gm of protein = 0.16 gm of N2.
 Nitrogen
Special a.a. solutions are also available
containing higher levels of certain a.a.s,
most commonly the branched-chain ones
(valine, leucine and isoleucine), aimed at
the management of liver diseases, sepsis
and other stress conditions.
 Conversely, solutions containing fewer
a.a.s (primarily the essential ones) are
available for patients with renal failure.

Nitrogen
 Arginine
was added to enteral formulae
claiming positive effects on immune
function and length of hospital stay.
 In
some clinical trials, glutamineenriched solutions improved nitrogen
balance and gut morphology.
Fluids
and electrolytes
 20–40 mL/kg - daily – young adults
 30 mL/kg – daily – older adults
 Sodium, potassium, chloride,
calcium, magnesium, and
phosphorus ( as per the table)
 Daily lab tests to monitor electrolyte
status
 Fluids
and electrolytes
Nutrient
Water
Sodium
Potassium
Magnesium
Calcium
Phosphate
Requirements (/Kg/day)
20-40 mL
0.5-1.0 mmol
0.5-1.0 mmol
0.1-0.2 mmol
0.05-0.15mmol
0.2-0.5mmol
Chloride/Acetat
e
So a to maintain acid-base balance
(normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)
 Fluids
and electrolytes
Normalization of acid-base balance is a
priority and constant concern in the
management of critically ill patients.
 Most electrolytes can be safely added to the
parenteral amino acid/dextrose solution.
 Sodium bicarbonate in high concentrations
will tend to generate carbon dioxide at the
acidic pH of the amino acid/glucose mix.

Vitamins
These requirements are usually met when
standard volumes of a nutrient mix are
provided.
 Increased amounts of vits are usually
provided to severely ill patients.
 Vitamins are either fat soluble (A,D,E,K) or
water soluble (B,C). Separate multivitamin
commercial
preparations
are
now
available for both.

Vitamins
Multivitamin formulations for parenteral use
for adult patients usually contain 12 vitamins
at levels estimated to provide daily
requirements.
 Additional
amounts can be provided
separately when indicated.
 Most adult vitamin formulae do not contain
vitamin K, which is added according to the
patient’s coagulation status.

 Trace
minerals
These are essential component of the
parenteral nutrition regimen.
A
multi-element
solution
is
available
commercially, and can be supplemented with
individual minerals.
 may be toxic at high doses.
 Iron is excluded, as it alters stability of other
ingredients. So it is given by separate injection
(iv or im).

 Trace

minerals
minerals excreted via the liver, such as copper and
manganese, should be used with caution in patients
with liver disease or impaired biliary function.
Mineral
Recommended dietary
allowance (RDA) for
daily oral intake (mg)
Suggested daily
intravenous intake
(mg)
Zinc
15
2.5-5
Copper
Manganese
2-3
2.5-5
0.5-1.5
0.15-0.8
Chromium
Iron
0.05-0.2
10 (males)-18 (females)
0.01-0.015
3
PPN: Maximum of 900 milliosmoles / liter
 TPN: as nutrient dense as necessary
(>900 m.osmol and up as high as 3000).
 Amino acids (10 m.osmol/gm), dextrose (5
m.osmol/gm) and electrolytes (2 m.osmol
/mEq) contribute most to the osmolarity,
while lipids give 1.5 m.osmol/gm.

 The
Solution

Manually mixed in hospital pharmacy or
nutrition-mixing service,

premixed solutions,

Separate administration for every element
alone in a separate line.
 Venous
access
 PPN: (<900 m.osmol/L): a peripheral line can be
enough.
 TPN: Central venous access is fundamental,
Ideally, the venous line should he usedexclusively for
parenteral nutrition.
Catheter can be placed via the subclavian vein, the
jugular vein (less desirable because of the high rate
of associated infection), or a long catheter placed in
an arm vein and threaded into the central venous
system (a peripherally inserted central catheter line)
Once the correct position of the catheter has been
established (usually by X ray), the infusion can
begin.
 Initiation
of Therapy
TPN infusion is usually initiated at a rate of 25 to
50 mL/h. This rate is then increased by 25 mL/h
until the predetermined final rate is achieved.
 Administration
To ensure that the solution is administered at a
continuous rate, an infusion pump is utilized to
administer the solution. In hospitalized patients,
infusion usually occurs over 22-24 h/day. In
ambulatory home patients, administration usually
occurs overnight (12-16 h).
 Policy:
to monitor:
1- Effecacy: electrolytes (S. Na, K, Ca, Mg, Cl,
Ph), acid-base, Bl. Sugar, body weight, Hb.
2- Complications: ALT, AST, Bil, BUN, total
proteins and fractions.
3- General: Input- Output chart.
4- Detection of infection:
Clinical (activity, temp, symptoms)
WBC count (total & differential)
Cultures
Monitoring
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Sepsis
Pneumothorax
Air embolism
Clotted catheter line
Catheter displacement
Fluid overload
Hyperglycemia
Rebound Hypoglycemia
 Catheter-related
complications
Catheter sepsis: which can be localized or systemic
(skin portal, malnutrion, poor immunity).
ccc by: fever, chills, ±drainage around the catheter
entrance site, Leukocytosis, +ve cultures (blood &
catheter tip).
ttt:1- exclusion of other causes of fever
2- short course of anti-bacterial and antifungal
therapy (acc. to C&S)
3- Catheter removal may be required
Catheter sepsis (Cont.):
Prevention: a rigorous program of catheter care:
 Only i.v. nutrition solutions are administered through
the catheter, no blood may be withdrawn from the
catheter.
 Catheter disinfection and redressing 2 to 3 times
weekly.
 The entrance site is inspected for signs of infection and
if present, culture is taken or the catheter is removed.
 Other catheter-related complications:
Thromboembolism, pneumothorax, vein or artery
perforation, and superior vena cava thrombosis
Metabolic Complications
o Hyperglycemia
(an elevated blood sugar):
Associated with the infusion of excess glucose
in the feeding solution or the diabetic-like state
in the patient associated with many critical
illnesses.
It can result in an osmotic diuresis (abnormal
loss of fluid via the kidney), dehydration, and
hyperosmolar coma.
ttt: decrease the amount of infused glucose (to<4
mg/kg/min) OR insulin can be administered
(either S.C. inj. or incorporation in the infusion
bag).

Metabolic
Complications
Hypertriglyceridemia (High S. Triglycerides)
Associated with excess infusion of fat emulsion.
N.B. Infusion of both glucose and fat emulsion in
excess may result in pulmonary insufficiency.
Excess glucose infusion –> excess carbon
dioxide (CO2) production a result of glucose
metabolism.
Excess lipid infusion --> the lipid particles may
accumulate in the lungs and reduce the
diffusion capacity of respiratory gases.
o
 Metabolic
o
Complications
liver toxicity (also know as parenteral nutrition
cholestasis):
It causes severe cholestatic
jaundice, elevation of transaminases, and may
lead to irreversible liver damage and cirrhosis.
Multiple causes have been proposed,
including high infusion rates of aromatic amino
acids, high proportion of energy intake from
glucose, e.t.c..
There is no specific
anticholestatic therapy.
treatment,
other
than
 Metabolic
Complications
o Intestinal bacterial translocation:
The lack of direct provision of nutrients to the
intestinal epithelia during total parenteral
nutrition Trophism and altered permeability
of the GI mucosa, thus compromising any
potential recovery of the patient’s ability for
enteral feeding, and allowing bacterial entery to
blood stream  sepsis
Prevention is to provide a minimal enteral
nutrition supply to avoid or minimize this risk.
Metabolic
o Other
Complications
metabolic complications:
Electrolyte imbalance, mineral
imbalance, acid-base imbalance,
toxicity of contaminants of the
parenteral solution.
Mechanical
Complications
Catheters and tubing may become
clotted or twist and obstruct.
Pumps may also fail or operate
improperly.
Patients who are unable to eat and absorb
adequate nutrients for maintenance over the
long term may be candidates for home
parenteral nutrition e.g. extensive Crohn's
disease, mesenteric infarction, or severe
abdominal trauma.
 patients must be able to master the techniques
associated with this support system, be
motivated, and have adequate social support at
home.


A patient who is judged to be a candidate for home
parenteral nutrition requires an indwelling Silastic
catheter designed for long-term permanent use.

The nutrient solutions are prepared weekly and
delivered to the patient's home.

The patient sets up the infusion system and
attaches the catheter to the delivery tubing in the
evening for infusion over the next 12-16 h. The
intravenous nutrition is terminated by the patient the
next morning.
‫ب ِم ْن َهذَا‬
‫“ َوقُ ْل َ‬
‫ع َ‬
‫سى أ َ ْن يَ ْه ِديَ ِني َر ِبي أل َ ْق َر َ‬
‫َرشَدا”‬
Among the indications for
parentral nutrition
 Short
bowl syndrome, T
 Surgical GIT resection followed by more
than 5 days fasting in a cachectic
patient, T
 Polytrauma, F
 Intractable malabsorption, T
 Prolonged mechanical ventilation F
For energy requirements





hospitalized adults require approximately 25-30
kcal/kg/day T
A single measurement of energy expenditure by
indirect calorimetry will provide a reliable estimate
of average requirements. F
The most common source of parenteral energy
supply is glucose. T
Glucose in 5% solution can be safely administered
via a peripheral vein, T
With severe infection or injury, basal metabolic rate
rises about 25% above normal F
Regarding Nitrogen balance
 A 70 Kgs normal adult male requires about 60 gms of
protein daily T
 Stress induces catabolic state and hence, a positive
Nitrogen balance F
 Special amino acid solutions containing higher levels of
branched-chain amino acids (valine, leucine and
isoleucine) are useful in the management of liver
diseases. T
 With renal failure, reduction of the amino acid load is
recommended. T
 Glutamine is essential for gut function. F
During Monitoring of TPN
 Hyperglycemia can be tolerated so long as there is
no ketosis F
 New-onset glucose intolerance in patients receiving
TPN may represent an early sign of sepsis. T
 Serum levels of electrolytes including magnesium
and phosphorus should be checked daily until
stabilized, then two times daily. F
 Overfeeding
the patients markedly increases
metabolic and respiratory complications. T
 Indirect calorimetry is very useful in mechanically
ventilated patients with an FiO2 greater than 50%. F
Complications of parentral nutrition





The most frequent catheter-related complication is
SVC thrombosis F
Catheter sepsis is characterized by the classic
signs of infection: chills, fever, and white blood cell
count is usually elevated T
Hyperglycemia is a very serious, relatively common,
problem T
Excessive infusion of aromatic amino acids,
glucose, and lipids may lead to the development of
liver toxicity (cholestasis). T
Excess glucose infusion leads to excess O2
consumption, while with lipid infusion, the lipid
particles may accumulate in the lungs and reduce
the diffusion capacity of respiratory gases. F