Transcript TOTAL PARENTERAL NUTRITION

Total Parenteral Nutrition
Basic Components
Prot./Carb./Fat /Elect./ Trace/ Vit.
Stability and Compatibility
Drug-Nutrient Interactions
Temperature and pH
Labeling
Sterility & Stability
Storage and Packaging
Infusion Pumps & Filtering
Laboratory Monitoring
Compliance
Adjusting Therapy
The pharmacist initiating,
maintaining, and monitoring
the therapy’s affect on the
patient’s metabolic condition.
Assess the stability and the
compatibility of the parenteral
nutrition solution.
Pharmacist-Physician- Nurse-Dietitian
• In 1960s Drs. Wilmore and
Dudrick researched on central
venous for growth in infant,
elderly patients with catabolic
medical conditions Originally
termed hyperalimentation
• Replaced with TPN, which is
more descriptive of the
technique
Psychological Impacts
• Its horrible watching others
eat when you cannot.
• Feelings of dependency and
immobility can occur.
• Can be countered by
intermittent or nocturnal
feeding.
Indicated when adequate
nutrition cannot be
maintained via GIT.
Nasogastric Tube
Indications of TPN
Carcinoma
extensive burns
Geriatric refuse to eat
Young anorexic patients
Surgical patients who should not
be fed orally [NPO]
GIT motility disorder
Severe vomiting, when enteral
feeding cannot be tolerated
TPN
IV administration of
calories, nitrogen and all
other nutrients in sufficient
quantities to achieve tissue
synthesis and anabolism.
Peripheral Parenteral Nutrition
Nutrients are supplied
via a peripheral vein,
usually a vein in the
arm. Another term for
PPN is peripheral
venous nutrition (PVN)
Peripheral venous nutrition (PVN)
PVN is used when a patient is
unable to ingest adequate calories
enterally or when central venous
nutrition is not feasible.
Concentration
4.25% amino acid+ 10% dextrose
IV fat emulsion should be run
simultaneously with the PVN to
minimize thrombophlebitis.
Urine 1.5 L
Perspiration 1.0 L.
=Average compensation of
water should be 2.5 L
daily.
Four methods to calculate fluid
requirements include:
1234-
1500mL for first 20 kg body
weight, then 20mLkg-1
1500mLm-2
30mLkg-1 of body weight
1.2 mLKcal-1
TPN Solutions
To provide essential
nutrients in normal daily
fluid requirements [3L].
Hypertonic solutions
-1
(>2000 mOsmL )
is needed.
To
minimizes vascular
damage and risk of
phlebitis or thrombosis,
TPN solutions must be
infused into a large
diameter central vein,
with rapid dilution by
high blood flow.
TPN Infusion
The amino acids + dextrose
solution with additives is mixed
in a one bag per day system.
The fat emulsions are a
separate solution.
Starting and weaning the TPN
should be done gradually.
The starting rate should be no
more than 50 mLhr-1 for 4-6 hrs.
TPN Infusion
The rate can be increased
25% every 4-6 hrs.
Weaning is accomplished
by decreasing the rate by
25% every 4-6 hrs.
Blood glucose monitoring
is recommended every six
hrs after TPN initiation.
Catheter
These catheters are usually
divided into:
1- Non-tunneled catheters,
2- Tunneled catheters, and
3- Implanted ports.
Catheter
Non-tunneled catheters
They are usually placed in the subclavian,
jugular, or femoral for a short term therapy
of < 8 weeks.
Insertion of these catheters should be done
with sterile technique.
Chest X-ray to assures the correct
placement of the catheter and the absence
of insertion complications.
The tip of the catheter must be in the
superior or inferior vena cava.
Catheter
Non-tunneled catheters
They are usually placed in
the subclavian, jugular, or
femoral for a short term
therapy of < 8 weeks.
Catheter
Non-tunneled catheters
Insertion of these catheters should be
done with sterile technique.
Chest X-ray to assures the correct
placement of the catheter and the
absence of insertion complications.
The tip of the catheter must be in the
superior or inferior vena cava.
Surgically placed catheter into
infraclavicular percutaneous
subclavian to superior vena cava.
In infants and small children, it my be
through a catheter into the jugular
vein.
Hickman®, Groshong, Broviac®,
Catheters
Tunneled Catheters
Long term therapy > 8 weeks.
They are placed in the in the O.R.
These catheters are made of
.
The catheter is placed in the chest area,
tunneled under the skin and enters a
large vein and then is threaded into the
superior vena cava.
Infusaport, Port-a-cath Catheters
Implanted Ports
These catheters are placed in
the O.R.
Intermittent therapies but can
be used for TPN infusion both in
the hospital and in the home
setting.
The septum of these catheters
is sutured under the skin in the
subcutaneous tissue. The
silicone catheter that attaches
to the septum is then threaded
into a major vein.
Dressing Changes and Catheter Care
Central venous dressing should be
changed at least once a week or
more frequently based on patient
condition/ need.
Initial dressing change should be
completed within 48 hours after
placement of catheter.
Medical aseptic technique is
absolutely essential in the
management of TPN.
Components of TPN
•Fluids
•Carbohydrate
as dextrose (3.4 kcal/g)
•Protein as amino acids (4 kcal/g)
•lipids (10-11 kcal/g)
•Electrolytes
•Vitamins
•Trace minerals
Components of TPN
Dextrose and lipids to provide
energy.
70%-85% of calories from dextrose
Protein for tissue synthesis and
repair.
15%-30% from lipids.
utritional assessment
Determine the appropriate amount
of calories needed for the patient by
assessing height, weight, ideal body
weight and % of weight loss.
• Calculation of patient
requirements calculated using
Harris-Benedict
• basal requirement- 25kcal/kg
body weight
DESIGNING THE TPN FORMULA
Estimate Basal Energy Expenditure
(BEE)
Harris-Benedict equation:
• For women the formula is:
= 655.1 + (9.56 * weight in kg) + (1.86 *
height in cm) - (4.68 x age)
• For Men:
= 66.67+ (13.75 x weight in kg) + (5 x
height in cm) - (6.76x age)
Total Daily Expenditure(TDE)
• TDE= BEE* Activity*Stress
• Activity
• BED=1.2
• Ambulatory=1.3
•
•
•
•
•
Stress:
Surgery: 1.2
Infection: 1.4-1.6
Trauma: 1.3-1.5
Burns: 1.5-2.1
• non-stressed (ambulatory)30 kcal/kg body weight
• mild stress (malnourished)35-40kcal/kg body weight
• severe injury or sepsis- 4560kcal/kg body weight
• severe burns- up to
80kcal/kg body weight
• infants up to
200kcal/kg
body weight
Standard TPN Solution
Final concentration :4.25% aa 25%
dex.
Calorie: nitrogen ratio is 125:1.
Additives
Electrolytes are included when
ordering the standard TPN
solution. It is possible to order an
electrolyte-free solution and then
order the more appropriate
electrolytes for the patient.
Total Parenteral Components
 Macronutrients

Non-Protein Calories


Carbohydrate - dextrose
Fat IV Long Chain Fatty Acids
 Micronutrients



Electyrolytes - Na, K, Ca, Mg, P, Cl,
acetate
Vitamins - all accept K and B12 which are
given separately intramuscular
Trace Metals - Zn, Cu, Cr, Mn (No Fe)
Carbohydrate Requirements
• 3.4 kcal/g
• Enternal nutrition: 4.0 kcal/g
0.8 g/kg/day = unstressed patient
1.0 g/kg/day = mildly stressed patient
1.2 g/kg/day = renal dialysis
1.5 g/kg/day = Moderately stressed
2.0 g/kg/day = Severely steressed
3.0 g/kg/day = Burned patient
INSOLUBLE
UNDIGESTED IN BLOOD.
15-24 g of nitrogen
-1
day
g. SYNTHETIC AMINO ACIDS
6.25
g. usable Nitrogen
Protein- requirements usually
estimated empirically:
non-stressed 0.5-1g/kg mild
stress 1.2-1.4 g/kg
moderate stress 1.5-2.0g/kg
severe stress 2.0-2.5g/kg
Protein Solutions
Standard formulas
EAA (40%) and
NEAA (60%)
available as 3-15%
solutions
Protein Solutions
Renal formula
provides only EAA
Protein Solutions
Hepatic Formula
Protein Solutions
Stress Formula
provides highest valine,
isoleucine, leucine
Amino Acid Solutions
Protein is provided as a
crystalline amino acid
solution. 500 ml bottles
are standard.
Solutions vary in amino
acid concentration and
amino acid composition.
|
SYNTHETIC AMINO ACIDS
FREAMINE
TRAVASOL
AMINOSYN
arbohydrates
Carbohydrates
Hydrous Dextrose (glucose)

Provides 3.4 kcalg-1
1
L D5W =170 kcal,
 1 L D25W = 850 kcal
Final dextrose concentrations
5-10% (peripheral)
 35% (central)
 D5W=252 mOsmL-1,
 D25%=1263 mOsmL-1

INTRAVENOUS LIPIDS
Fat Emulsions
Only O/W emulsions can be given by IV.
After 2 weeks of TPN
Dry scaly skin, hair loss, impaired wound
healing
Fat provides 9 kcal/g
Components
soybean (50% linoleic)
safflower (72%)
glycerol
water
egg yolk phospholipid
Fat Emulsion 10%
Actions
Indications
Dosage
Drug
Incompatibilites
Fatty acids in To prevent
ADULTS: 100 Do not add any
emulsion form fatty acid
mg/min for the other medication
used as a
deficiency for first 15-30 min to the infusion.
source of
patients
then increase
calories and to requiring
to 2-3 ml/min if
provide
parenteral
no reaction.
essential fatty nutrition, and Give only 500
acids
to reverse a
ml (50 gm) first
known
24 hrs, in no
deficency state reaction
characterized increase
by scaly skin
following day.
Do not exceed
2.5gm/kg/day
INTRAVENOUS LIPIDS
• Intravenous lipids have the highest
caloric density of any components of
parental nutrition
• Intralipid is composed of soybean oil,
egg yolk phospholipids, and glycerol.
The major fatty acids are linoleic 54%,
oleic 26%, palmitic 9% and linolenic 8%
Linoleic acid
If a patient has been on TPN for 2 weeks
Dry Scaly Skin,
Hair loss,
Impaired Wound healing.
Soybean-oil emulsion (Intralipid)
Safflower-oil emulsion (Liposyn)
Essential Fatty Acids
500 mL BIW
or TIW
Emulsion Destabilization of TPN
Creaming–accumulation of particles at the top
of the emulsion.
Aggregation–clumping of triglyceride
particles within the emulsion.
Coalescence–fusion of small triglyceride
particles into larger particles.
Cracking–separation of the oil and water
components of the emulsion.
Electrolyte
Sodium
Potassium
Guidelines for Electrolyte Requirements
Electrolyte
Sodium
Potassium
Chloride
Magnesium
Calcium
Phosphorus
Amount/1000 Calories
40-50 mEq
30-40 mEq
40-50 mEq
8-12 mEq
2-5 mEq
15-25 mEq
Recommended Daily Adult Doses of Parenteral Trace
Elements
Trace Element
Dose
Zinc
2.5-4.0 mg
Copper
0.5-1.5 mg
Chromium
10-15 ug
Manganese
150-800 ug
Selenium
40-80 ug
A
D
E
Niacin
B1[Thiamine]
B2[Riboflavin]
C
Panthenol
acid
MVI
2
5
mg
8000
U
800
U
4
U
80
mg
40
mg
8
mg
400
mg
mg Folic
Vit. K & . Vit B12
MVI
separately
I.M.
Vit. K
10 mg
-1
week
Vit. B12
100 g
-1
week
TPN Interventions
Warm to room temp 1 hr prior to use
Hang TPN alone
Dextrose concentration > 10%
given through a central line
Change TPN bag and filter every 24
hours
Ordering and Mixing PN Solutions
The physician writes the Rx TPN prescription.
The pharmacist mixes the TPN solution using
aseptic technique. Prescriptions are
compounded by mixing the solutions at a 1:1
dextrose-to-amino acid ratio and placing in 1-L
bags. Alternatively, lipids can be mixed with the
dextrose/amino acid solution, referred to as the
3-in-1 total nutrient admixture (TNA).
Administration
TPN should always be given via an infusion
pump.
The pharmacist may be consulted regarding
drug compatibility for simultaneous
administration of two or more drugs through a
single lumen of the catheter.
Avoid the administration of blood products into
the lumen designated for parenteral nutrition.
Heparin Flush
When parenteral nutrition infusion is being
cycled, a heparin flush is needed to maintain
patency of central venous catheter when
solution is not infusing.
Initial Considerations
TPN infusion should start slowly so that
the body has time to adapt to both the
glucose load and the hyperosmolarity of
the solution, and to avoid fluid overload.
A pump controls the infusion rate of the
TPN solution.
There are specific steps in the inititiation
procedure to follow regarding the
initiation of TPN infusion.
• Infusion Pumps:
• Electronic ambulatory infusion
pumps are commonly used in
the home setting.
• These pumps are lightweight
and portable and can be
programmed to deliver
continuous infusions,
intermittent infusions or single
dose medications.
• Many pumps have the capacity
to taper the rate of an infusion.
• Multichannel pumps allow for
the administration of several
different infusions at one time.
General PN Initiation Procedures
Start with 1 L of TPN solution during the
first 24 hours (42 mL/hr as a start rate)
Increase volume by 1 liter each day until
the desired volume is reached
Monitor blood glucose and electrolytes
closely
Pump administer TPN at a steady rate
Don't attempt to catch up if
administration gets behind.
Continuous vs. Cyclic
cyclic TPN
the patient is fed at night.
Cyclic TPN helps prevent
hepatotoxicity that can
develop with long-term
TPN and the fasting
period allows essential
fatty acids to be released
Renal failure Nephramine
Balance of both essential and
nonessential amino acids.
Nephramine contains only essential
amino acids
Recommended only to decrease net
urea synthesis for short periods of
time.
Close monitoring of serum ammonia
levels is important.
Hepatamine liver failure
Patients with chronic liver disease
are usually malnourished.
Complications:
GIT bleeding and infection.
Standard TPN should be used if the
patient does not have hepatic
encephalopathy.
can be used with patients with
hepatic encephalopathy. It is a
liver-specific amino acid mixture.
Novamine Catabolic patient
Metabolic respone to injury, burn or sepsis generates a
neuroendocrine response that induces hypermetabolism,
proteolysis, insulin resistance with hyperglycemia, and a
depletion of lean body mass.
In a catabolic state nutritional support is extremely
important. Patients should be fed within 48-72 hours of
insult to optimize the patient’s metabolic state.
Nutritional requirements should be calculated.
The optimal protein requirement of a critically ill patient is
1.5 to 2.0 gm/kg/day.
NITROGEN BALANCE = Protein intake in gram - UUN + 3
6.25
UUN = urine urea nitrogen
Novamine is a high concentration amino acid which can be
used for the catabolic patient with a fluid restriction.
Glucose metabolism can be altered in the critically ill
patient. Metabolism of glucose can increase CO2
production and O2 consumption. The use of IV fat emulsion
as the main calorie source is encouraged in these patients.
Mechanics of Administering
Titrate up slowly to allow pancreas to adapt to
hypertonic dextrose load
Give 1/3 of max rate on day 1, 2/3 on day 2
and full infusion on day 3
Taper to allow pancreas to adapt to withdrawal of
hypertonic dextrose
Infuse D10 if TPN abruptly discontinued
Use filters (0.22 ).
Fat can’t run through filters
CLEAN ROOM
• The clean room is a
limited-access area,
which is separated
from the other
pharmacy operations
to minimize the potential for contamination. All
products are prepared using the Class 100
laminar flow cabinets
IV Admixture Environment
• To provide sterility and pyrogen-free, proper
environment is a must
• Prepare admixture under laminar-flow filter
• Air filter through High Efficiency Particulate Air
(HEPA) flowing at 90fpm and remove 99.97%
particles of 3 .
• Air flow either horizontal or vertical
• HEPA filter must be replace every 6 months
• Technician or operators must wash hands,
gloved and require gowning
• Options For Compounding :
• Manual or gravity preparation
involves the use of transfer sets and
syringes to separately add
components to the empty container.
• Automated compounders are more
commonly used to admix components
under computer-assisted control.
Lipids can then be added to some of
these products.
The Automix
pumps dextrose,
amino acids,
water, or fat, into
an empty
polyvinyl
chloride bag
The Micromix adds electrolytes and trace
elements to the parenteral nutrition solution
Withdraw additional
additives manually
Eight Steps
Harris-Bendict equation
TDE
G of Amino-acids
# of Kcal supplied by aminoacids
30% of daily Kcal Lipids
G of lipids
G of Carb.
Daily fluid requirement
Calc pp 220
Step One
58 Y, 5 ft,3 inch 140 Lb, no-stress,
mobile
• For women the formula is:
= 655.1 + (9.56 * weight in kg) + (1.86 *
height in cm) - (4.68 x age)
= 655.1 + (9.56 * 63.63 kg) + (1.86 *
160 cm) - (4.68 x 58)= 1289.62 Kcal
Step Two
58 Y, 5 ft,3 inch 140 Lb, no-stress,
mobile
• For women the formula is:
= 655.1 + (9.56 * weight in kg) + (1.86 *
height in cm) - (4.68 x age)
= 655.1 + (9.56 * 63.63 kg) + (1.86 * 160
cm) - (4.68 x 58)= 1289.62 Kcal
TDE= 1289.62 Kcal * 1.3= 1676.5 Kcal
Step THREE
58 Y, 5 ft,3 inch 140 Lb, no-stress,
mobile
• Protein requirement (g)
• 63.63 kg* 0.8 gkg-1 = 50.91 gday-1
Step Four
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
• Protein requirement (Kcal)
• = 50.91 gday-1* 4 Kcalg-1= 203.64
Kcalday-1
Step Five
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Lipid requirement (Kcal) 35%
= 1676.5 Kcal* 0.35 = 502.95 Kcal
Step six
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Lipid requirement (g)
=502.95 Kcal* 1g lipid /11 kcal
= 45.72 g lipid
Step Seven (1)
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Fluid Requirement (mL)
30 mL* 63.63 kg/kg = 1909.09 mL
Step Seven (2)
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Fluid Requirement (mL)
1.2 mL* 1676.5 Kcal= 2011.8 mL
Step Seven(3)
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Fluid Requirement (mL)
1500 mL* 50 kg+( 13.63kg* 30 ml) =
1908.09 mL
Step Seven (4)
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
BSA=
(63.63)0.425*(63*2.54)0.725*0.007184
=1.66 m2
Fluid Requirement (mL)
1500 mL* 1.66 m2= 2490 mL
Step Seven
58 Y, 5 ft,3 inch 140 Lb, no-stress, mobile
Fluid Requirement (mL)
2490 mL+1909.09 mL+ 1908.09 mL
+ 2011.8 mL/4=
• Temperature and pH:
• Temperatures below freezing or above room
temperature may result in destabilization of the
lipid emulsion.
• pH below 5.3 or the addition of additives with a
pH of 5.0 may also destabilize the emulsion.
• Temperature & calcium-phosphorus stability.
• As the temperature increases, there is an increase in the
rate of dissociation of calcium and phosphorus from
their salts. This allows more free calcium and
phosphorus to be precipitated.
• Labeling:
• The American Society of Enteral and
Parenteral Nutrition (ASPEN) addressed
the issue of standard labeling for PN
solutions in its recent guidelines. Labels for
PN admixtures should include amount per
day of base formula, electrolyte additives,
micronutrients and medications, quantity
per liter for those who admix in 1L volumes,
and dosing weight. Auxiliary labels may be
helpful when PN orders are written in a
different format than the standard label.
• Storage and Packaging:
• TPN solutions should always be transported
and stored under controlled-temperature
refrigeration.
• TPN solutions are delivered from the
pharmacy to the patient’s home, a cooler
with cooler blocks should be used.
• Refrigerators should be checked to make
sure the temperature is constant and that
adequate space is available for storing PN
solutions and supplies.
• Filtering:
• Use of a filter during the administration of
PN solutions may prevent complications
arising from any particulate matter,
microprecipitates or microorganisms
potentially present.
• A 0.2 -1.2-m filter should be used for TPN
solutions with amino acids and dextrose.
• Filters should be replaced every 24 hours.
• A clogged filter, indicates some type of
problem with the TPN solution, such as
contamination of the solution,
precipitation, cracking or incompatibilities.
What happens if a patient misses
a dose?
TPN treatment is set at a specific
time on a regular basis. If the
patient misses his or her
treatment, take a soon as possible.
* You should never double up on doses at the
same time*
Monitoring
Blood work must be drawn to establish baseline lab
values, which include:
electrolytes,
creatinine,
triglycerides,
BUN,
phosphorous,
glucose,
albumin,
magnesium,
CBC + differential,
carbon dioxide, and
total protein
Monitoring
Blood work must be drawn to establish baseline lab
values, which include:
electrolytes,
creatinine,
triglycerides,
BUN,
phosphorous,
glucose,
albumin,
magnesium,
CBC + differential, carbon dioxide, and
total protein Thereafter, monitoring can be
performed 2-3 times per week.
•other include body weight and temperature.
Monitoring of the TPN Patient
Recommended patient care
monitoring
Vital signs every eight hours
Intake and output
Daily weights
Blood sugars every six hours until
the patient’s glucose is stable and
then at least every day. Baseline
Monitoring Considerations
The initial TPN prescription is based only on estimates
of the patient's kcalorie, protein, and micronutrient
needs. The patient's weight, protein, and micronutrient
status must be monitored to ensure the prescription's
adequacy.
Ionized Ca++ = (measured serum Ca) + [4.0 - actual albumin (g/dL)] x 0.8
AAssessment considerations include:
•Maximum weight gain in anabolism is 1/4 to 1/2
pound per day. More than that indicates fluid retention.
•Adjust calcium lab values in hypoalbuminemic
patients as follows:
Monitoring of the TPN Patient
Acute condition, unstable patient, early
nutrition support
Electrolytes, BUN, SCr: 3-7 times per week
Calcium, magnesium, phosphate: 1-3 times
per week
LFT’s, TP, ALB: once weekly or every other
week
Triglycerides: weekely or as appropriate for
IV fat emulsion use.
Monitoring of the TPN Patient
Stable hospitalized patient,
prolonged parenteral nutrition
support
Electrolytes, BUN, SCr: 1-3 times
per week
Calcium, magnesium, phosphate:
once weekly or every other week
LFT’s TP, ALB: every 2-4 weeks
CBC/ differential, PLC RBC indices:
every 2-4 weeks
• Daily
•
•
•
•
Body weight
Vital Signs
Fluid intake
Nutritional
intake
• Output (urine,
other losses)
• Serum
Electrolytes
(Na, K, Cl,
HCO3, BUN,
Creatinine)
• Weekly
•
•
•
•
Albumin
Total Protein
Transthyretin
Liver
Association
Test (AST, ALT,
Alkaline
Phosphate,
GGT, Bilirubin,
Nitrogen
balance)
Monitoring
Measurement
Normal value
Comments
Total iron binding capacity
250 - 450 mcg/dL
Reliable measures of visceral
protein status
Iron
20 -160 mcg/dL
Transferrin saturation
20%-45%
Albumin
3.7 - 5.2 g/dL
Markers of nutritional status
Saturation levels less than
15% indicate iron deficiency
Monitoring
Electrolytes
Normal value
Comments
Phosphate
2.5 - 5.0 mg/dL
Excess or rapid initiation of TPN
may result in severe
hyperphosphatemia.
Magnesium
1.6 - 2.4 mEq/L
Serum concentrations may not
reflect intracellular
deficiencies or losses
Calcium
4.4 - 5.1 mEq/L
Long-term TPN may result in
osteoporosis if losses are not
replaced
Sodium
135 -147 mEq/L
Excessive fluid loss without
adequate replacement or fluid
deficits may cause abnormalities in
serum sodium
Potassium
3.5 - 5.0 mEq/L
Severe malnourishment results in
depletion of intracellular
potassium stores; renal failure or
excess administration may cause
hyperkalemia
Monitoring
Glucose
65 - 115 mg/dL
Hyper- or hypoglycemia are
common complications of PN.
Blood glucose should be checked
daily, 1hr after infusion is stopped
CBC and differential
Deficiencies of trace elements or
vitamins may result in anemias
Carbon dioxide
21 - 31 mEq/L
Excess bicarbonate losses may
result in acidosis; vomiting, loss
of gastric fluids or prolonged use
of diuretics may cause alkalosis
BUN
8 - 18 mg/L
Serum creatinine
0.6 - 1.2 mg/L
Urinary output
Used to monitor a patient’s renal
and fluid status.
Daily temperature
Used to monitor for infection
Weekly weights
Useful as a marker for nutritional
goals
Complications
Infection
Infection can occur at the PN catheter
insertion site. Dressings must be changed
daily.
Technical Complications
Technical complications include pneumothorax
and hemothorax that can result if the chest
wall is perforated with catheter needle.
Metabolic Complications
A number of metabolic complications can
occur.
Infectious Complications
• Two sources of infectious complications are:
• catheter-related and
• solution infusate contamination
• Catheter-related remain the most serious infection
• Infusate is not very common, but admixture of
intravenous fluid must follow strict guidelines to
prevent contamination
Sepsis and TPN
Serious and crucial complication.
Poor technique of catheter care
and feed.
Mechanical Complications
Clotted Catheter
Venous Thrombosis
Air Embolism
Precipitation
Air Embolism and TPN
This occurs as a result of air
entering the central line
during set change or catheter
insertion.
Central Venous Catheters: Mechanical Complications
Tracheal/esophageal injury
Bleeding
Arterial injury
Thrombosis of major vein
Cardiac arrhythmia
Cardiac perforation
Endocarditis
Pulmonary embolism
Nerve injury
Thoracic laceration
Complications of TPN
Central line insertion can lead to:
Pneumothorax
Brachial plexus injury
Arterial puncture
Thoracic duct injury
Complications of TPN
• Nutritional deficiencies such as
hypophosphatemia,
hypomagnesemia or vitamin and
mineral deficiencies may occur.
• Thus parentral feeds have to be
made nutritionally complete by
aseptic admixture in pharmacy.
Terminating the Infusion
Gradual termination prevents
rebound hypoglycemia, especially for
diabetic, septic, and stressed patients.
TTTTThe endocrine system adjusts
to a continuous infusion of dextrose by
secreting a certain level of insulin. If
the dextrose supply is withdrawn
suddenly, the insulin level will not
adjust right away, resulting in a
relative insulin excess and
hypoglycemia.
Transitioning to Tube Feeding
The TPN infusion should be continued
when the tube feeding begins..
If the gut hasn't been used for two or
more weeks, enteral feeding tolerance
may be compromised.
TPN infusion can be decreased in
proportion to the increase in tube
feeding.
• Drug incompatibilities,
drug-nutrient interactions
and destabilization of
lipids can all adversely
affect the stability of
parenteral nutrition
solutions.
Medications That Are Compatible
Aminophylline
Ampicillin
Calcium gluconate
Cefazolin
Cefotaxime
Cefoxitin
Ceftazidime
Ceftriaxone (7% loss
in 48 hrs at 20C)
Cefuroxime
Cimetidine
Medications that are incompatible with
Parenteral nutrition solutions:
1.
2.
3.
4.
5.
6.
Acyclovir
Amphotericin B
Diazepam
Phenytoin
Bactrim
Metronidazole
Therapeutic Incompatibility
Antagonistic and synergistic effect
Penicillin and cortisone
antagonize heparin
leading to anticoagulant
An increase in amino acid
concentration will
decrease Theophylline
level
Anticoagulants
Anticoagulants drugs
are used in TPN in
order to reduce or
prevent any tendency
toward intravascular or
incardiac clotting.
Physical Complications
Haze detected
Particles detected
Color changes,
Changes from clear to cloudy,
Emitting of gas
Physical Complications
•IN ACIDIC pH
• Na DIPHENYL HYDANTOIN
•Na PHENOBARBITAL
• IN ALKALINE pH
•Ca + Na H CO3
• DRAMAMINE + Na H CO3
NITROGLYCERIN
HEAT SENSITIVE
LIGHT SENSITIVE
OXIDATION SENSITIVE
HIGHLY ADSORPABLE TO PVC
Change in pH can change solubility
Antibiotics can remain active in 24 hours at the
pH of 6.5, but at pH 3.5 it will be destroy.
Potassium Penicillin G buffered at pH 6.0-6.5,
when added to dextrose, water or NaCl
injection it must also be at buffer 6.0-6.5 to
assure activity of antibiotic.
• Furosemide X D5W
• Verapamil X any (cillin)
• Bleomycin X D5W
• Enalaprilat X Phenytoin Na
• Morphine Sulfate X Acyclovir &
Furosemide
• Meperidine X Cilastatin
Erythromycin + electrolyte
Decarbazine + heparin
Furosemide + D5W
Verapamil + any cillin Na flush
Bleomycin + D5W
Morphine sulfate + acyclovir + furosemide
Morphine + Cilastatin
Cyclosporine * plastic bags
Polyvinyle chloride leaches 33mg of
diethylhexyl phthalate in 48 hours in a
glass container
Don’t dilute or mix Valium and/or
Phenytoin Na because when
administered, will make patient bleed.
• NOT RECOMMENDED
•CEPHALOTHIN SODIUM (KEFLIN)
AMPICILLIN SODIUM IN D5W
POTENCY DECLINE TO 70%
STABILITY OF FROZEN ANTIBIOTIC
FOLLOWED BY MICROWAVE
RADIATION.
Unstable in Plastic
Bleomycin Sulfate
Carmustine
Clonazepan
CYCLOSPORIN
Diazepan
Droperiodel
Nitroglycerin
Procainamide
Vitamin A
Warfarin Sodium
Insulin
MINIMIZATION OF INCOMPATIBILITIES
FRESHLY PREPARED
FEW ADDITIVES
KNOWLEDGEABLE
MAKE THEM AWARE
ASEPTIC TECHNIQUE
KEEP FILE
Blood urea nitrogen (BUN)
Protein intake is effectively utilized.
BUN suggests the nitrogen from the
protein source is being converted to urea.
Overfed protein,
Renal insufficiency.
Serum creatinine (Sr.Cr.):
Breakdown product of muscle used as a
measure of renal function.
Transferrin:
An iron binding protein present in the blood,
involved in the transport of iron
Visceral Proteins:
Circulating proteins that are synthesized in
the liver, such as albumin, pre-albumin and
transferrin.
www.nyschp.org/the_pharmacist/0998/09
www.ascp.com/public/pubs/tcp/1999/apr/monnut.shtn
www.unc.edu/courses/phar 0511/parenterals/text.htm
www.ajj.com/services/pblshng/msnj/cconline/0614516
www.pharmj.com
www.yahoo.com
www.cc.nih.gov
www.critcare.1hsc.on
www.nyschp.org
www.ascp.com
www.kumc.edu