TOTAL PARENTERAL NUTRITION

BY : DR. KALPESH R FALDU

GUIDE TO TOPIC : DR.V.J.ANAND

DEFINITION

TOTAL PARENTERAL NUTRITION IS DEFINED AS THE INTRAVENOUS PROVISION OF ALL NUTRITIONAL REQUIREMENTS, WITHOUT THE USE OF THE GASTROINTESTINAL TRACT.

Parenteral Nutrition

Graphic source: http://www.rxkinetics.com/tpntutorial/1_4.html

General Conditions Suggesting Initiation of Nutrition Support

   ▪    Poor nutritional status (oral intake <50% of energy needs)   

▪    Catabolic disease (burn, sepsis, pancreatitis)   

▪    Significant weight loss (>10%)    ▪    Anticipated duration of artificial nutrition

longer than 7 days    ▪    More than 7 days' inanition    ▪    Nonfunctioning gastrointestinal tract    ▪    Serum albumin <3 g/dL in the absence of

an inflammatory state

INDICATIONS FOR TPN

Proximal intestinal fistula Inflammatory bowel disease Massive intestinal resection(<100 cm

small bowel remains) Paralytic ileus/obstruction Severe pancreatitis Practically all patients requiring nutrition

support but can’t tolerate enteral feeds, or C/I to enteral feeding.

Total Parenteral Nutrition

GENERAL INDICATIONS Patient who can’t eat Patient who won’t eat Patient who shouldn’t eat Patient who can’t eat enough

“If the gut works, use it.”

Total Parenteral Nutrition

A.S.P.E.N Guidelines *(Indication for nutritional support)

Severe stress or malnutrition NPO > 4-5 days Moderate stress or malnutrition NPO > 7-10 days Non-stressed / normal nourished NPO > 10 days No indication for TPN < 4 days

Contraindications

Functional and accessible GI tract Patient is taking oral diet Prognosis does not warrant aggressive

nutrition support (terminally ill) Risk exceeds benefit Patient expected to meet needs within

14 days

Total Parenteral Nutrition NOMENCLATURE

TPN: Total Parenteral Nutrition IVH: Intravenous Hyperalimentation TNA: Total Nutrient Admixture 3-In-1 Admixture All-In-One Admixture PPN: Peripheral Parneteral Admxtiure

Methods of Nutritional Assessment  

  ▪    Clinical history    Weighing, subjective assessment   

   ▪    Indirect calorimetry    Oxygen consumption, determination of respiratory quotient   

▪    Anthropomorphic measurements    Ideal body weight, skinfold thickness   

▪    Biochemical measurements    Albumin, transferrin, prealbumin   

▪    Measurement of nitrogen balance    ▪    Measurements of immunologic

function

Nutritional Indices

Body mass index (BMI)BMI = weight (kg)/[height (m)]2 = 703 × weight (lb)/[height (in.)]2

BMI: normal 18.5–24.9, overweight 25–29.9, obese 30–40, morbid obesity >40Prognostic nutritional index (PNI)PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)DH: >5 mm induration = 2; 1–5 mm induration = 1; anergy = 0PNI: >50% = high risk for complications; 40%–49% = intermediate risk; <40% = low riskNutrition risk indexNRI = 15.19 (Alb) + 41.7 [weight (kg)/ideal weight (kg)]NRI: <100 = malnourishedCatabolic index (CI)CI = UUN - [0.5 (dietary nitrogen intake in g)]CI: 0 = no significant stress; 0–5 = mild stress; >5 = moderate to severe stress

Anthropomorphic Measurements

Creatinine-height index, Triceps skinfold thickness Midarm muscle circumference calculation of Ideal body weight (IBW)

(when usual body weight, or weight of the patient before the onset of illness, is unknown)

•    For males: 106 lb for the first 5 ft and 6 lb for each inch thereafter.   

•    For females: 100 lb for the first 5 ft and 5 lb for each inch thereafter.

Biochemical Measurements

Serum albumin of less than 3.5 g/dL (35 g/L) in a stable, hydrated patient; half-life is 14 to 20 days.

Serum prealbumin may be a more useful indicator of acute changes: 10 to 17 mg/dL corresponds to mild depletion, 5 to 10 mg/dL to moderate depletion, and less than 5 mg/dL to severe depletion; half-life is 2 to 3 days.

Serum transferrin of less than 200 mg/dL; half-life is 8 to 10 days.

Parenteral Nutrition (PN) Definition Delivery of nutrients intravenously,

e.g. via the bloodstream. Central Parenteral Nutrition: often called

Total Parenteral Nutrition (TPN); delivered into a central vein

Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral vein

A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p. 97

PN Central Access

May be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting

Peripherally inserted central catheters (PICC) are inserted via the cephalic and basilic veins

Central access required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume

VENOUS SITES FOR ACCESS TO THE SUPERIOR VENA CAVA

PICC Lines (peripherally inserted central catheter)

PICC lines may be used in ambulatory settings or for long term therapy

Used for delivery of medication as well as PN

Inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into the superior vena cava

Can remain in place for up to 1 year with proper maintenance and without complications

PN: Peripheral Access

PN may be administered via peripheral access when

Therapy is expected to be short term (10-14 days)

Energy and protein needs are moderate Formulation osmolarity is <600-900

mOsm/L Fluid restriction is not necessary

A.S.P.E.N. Nutrition Support Practice Manual, 2005; p. 94

Macronutrients: Carbohydrate Source: Monohydrous dextrose Properties: Nitrogen sparing

Energy source3.4 Kcal/gHyperosmolar

Recommended intake:2 – 5 mg/kg/min50-65% of total calories

Total Parenteral Nutrition

Carbohydrate Max rate of glucose oxidation: 5 – 7

mg/kg/min Max dextrose rate stable patients: Not

>7 mg/kg/min Max dextrose rate critical care patient:

Not > 4 mg/kg/min

Macronutrients: CarbohydratePotential Adverse Effects: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems Hyperglycemia

Macronutrients: Amino Acids

Source: Crystalline amino acids— standard or specialty

Properties: 4.0 Kcal/gEAA 40–50% NEAA 50-

60%Glutamine / Cysteine

Recommended intake:0.8-2.0 g/kg/day15-20% of total calories

Macronutrients: Amino Acids

Potential Adverse Effects:

Increased renal solute load

Azotemia

Macronutrients: Amino Acids Specialized Amino Acid Solutions

Branched chain amino acids (BCAA)Essential amino acids (EAA)

Not shown to improve patient outcome More expensive than standard solutions

Macronutrients: Lipid Source: Safflower and/or

soybean oil Properties: Long chain triglycerides

Isotonic or hypotonicStabilized emulsions

9 Kcals/g Prevents essential fatty

acid deficiency Recommended intake:

0.5 – 1.5 g/kg/day (not >2 g/kg) 12 – 24 hour infusion rate

Macronutrients: Lipids

Requirements 4% to 10% kcals given as lipid meets

EFA requirements; or 2% to 4% kcals given as linoleic acid

Generally 500 mL of 10% fat emulsion given two times weekly or 500 mL of 20% lipids given once weekly will prevent EFAD

Usual range 25% to 35% of total kcals Max. 60% of kcal or 2 g fat/kg

Macronutrients: Lipids

Potential Adverse Effects: Egg allergy Hypertriglyceridemia Decreased cell-mediated immunity (limit

to <1 g/kg/day in critically ill immunosuppressed patients)

Abnormal LFTs

Parenteral Base SolutionsParenteral Base Solutions Carbohydrate

Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixing

Amino acids Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20%

solutions 8.5% and 10% generally used for manual

mixing Fat

10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in

mixing TNA, not for direct venous delivery)

Carbohydrate Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixing

Amino acids Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20%

solutions 8.5% and 10% generally used for manual

mixing Fat

10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in

mixing TNA, not for direct venous delivery)The A.S.P.E.N. Nutrition Support Practice Manual, 2nd edition, 2005, p. 97; Barber et al. In ASPEN, The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001.

Other RequirementsOther Requirements Fluid—30 to 50 ml/kg (1.5 to 3

L/day) Sterile water is added to PN

admixture to meet fluid requirements Electrolytes

Use acetate or chloride forms to manage metabolic acidosis or alkalosis(in patients with normal electrolytes

acetate : chloride 1:2) Vitamins: multivitamin formulations Trace elements

Fluid—30 to 50 ml/kg (1.5 to 3 L/day)

Sterile water is added to PN admixture to meet fluid requirements

Electrolytes Use acetate or chloride forms to

manage metabolic acidosis or alkalosis(in patients with normal electrolytes

acetate : chloride 1:2) Vitamins: multivitamin formulations Trace elements

Electrolytes/Vitamins/Trace Elements Because parenterally-administered

vitamins and trace elements do not go through digestion/absorption, recommendations are lower than DRIs

Salt forms of electrolytes can affect acid-base balance

Adult Parenteral Multivitamins

New FDA requirements published in 2000 replacing NAG-AMA guidelines

Increased B1, B6, vitamin C, folic acid, added Vitamin K

MVI Adult (Mayne Pharma) and Infuvite (MVI-13) from Baxter contain Vitamin K and are consistent with the new FDA guidelines

MVI-12 (Mayne Pharma) does not contain Vitamin K (added separately 10 mg once a week)

Total Parenteral NutritionTrace Elements

Recommendations per NAG Zinc Poor wound healing Copper Anemia Chromium Glucose Intolerance Manganese ?? Selenium Keshan’s Disease

Parenteral Nutrition Vitamin Guidelines

Vitamin FDA Guidelines*

A IU 3300 IU

D IU 200 IU

E IU 10 IU

K mcg 150 mcg

C mg 200

Folate mcg 600

Niacin mg 40

Vitamin FDA Guidelines*

B2 mg 3.6

B1 mg 6

B6 mg 6

B12 mg 5.0

Biotin mcg 60

B5 dexpanthenol mg

15

*Federal Register 66(77): April 20, 2000

Daily Trace Element Supplementation for Adult PN

Selenium 60 mcg

Chromium 10-15 mcg

Copper 0.3-0.5 mg

Manganese 60-100 mcg

Zinc 2.5-5.0 mg

ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49, 1998

Daily Electrolyte Requirements Adult PN

Electrolyte PN Equiv RDA

Standard Intake

Calcium 10 mEq 10-15 mEq

Magnesium 10 mEq 8-20 mEq

Phosphate 30 mmol 20-40 mmol

Sodium N/A 1-2 mEq/kg + replacement

Potassium N/A 1-2 mEq/kg

Acetate N/A As needed for acid-base

Chloride N/A As needed for acid-base

ASPEN: Safe practices for parenteral nutrition formulations. JPEN 22(2) 49, 1998

PN Contaminants

Components of PN formulations have been found to be contaminated with trace elements

Most common contaminants are aluminum and manganese

Aluminum toxicity a problem in pts with renal compromise on long-term PN and in infants and neonates

Can cause osteopenia in long term adult PN patients

ASPEN Nutrition Support Practice Manual 2005; p. 109

PN Contaminants

FDA requires disclosure of aluminum content of PN components

Safe intake of aluminum in PN is set at 5 mcg/kg/day

PN Contaminants Manganese toxicity has been reported

in long term home PN patients May lead to neurological symptoms Manganese concentrations of 8 to 22

mcg/daily volume have been reported in formulations with no added manganese

May need to switch to single-unit trace elements that don’t include manganeseASPEN Nutrition Support Practice Manual 2005; p. 98-99

Peripheral Parenteral Nutrition

Hyperosmolar solutions cause thrombophlebitis in peripheral veins

Limited to 800 to 900 mOsm/kg (MHS uses 1150 mOsm/kg w/ lipid in the solution)

Dextrose limited to 5-10% final concentration and amino acids 3% final concentration

Electrolytes may also be limited Use lipid to protect veins and

increase calories

Peripheral Parenteral Nutrition New catheters allow longer support via

this method In adults, requires large fluid volumes to

deliver adequate nutrition support (2.5-3L) May be appropriate in mild to moderate

malnutrition (<2000 kcal required or <14 days)

More commonly used in infants and children

Controversial

Contraindications to Peripheral Parenteral Nutrition

Significant malnutrition Severe metabolic stress Large nutrition or electrolyte needs

(potassium is a strong vascular irritant) Fluid restriction Need for prolonged PN (>2 weeks) Renal or liver compromise

From Mirtallo. In ASPEN, The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001, 222.

EQUATIONS

HARRIS-BENEDICT EQUATION :

BEE in kilocalories per day for men equals 66.4 + [13.7 × weight (kg)] + [5 × height (cm)] – [6.8 × age (years)].

BEE in kilocalories per day for women equals 65.5 + [9.6 × weight (kg)] + [1.7 × height (cm)] – [4.7 × age (years)].

NORMAL ADULT : 20-25 KCAL/KG/DAY

Stress Factors Used in Calculation of Total Energy Expenditure

Clinical condition Stress factor Starvation 0.80–1.00 Elective operation 1.00–1.10 Peritonitis or other infections 1.05–1.25 Adult respiratory distress syndrome sepsis 1.30–1.35 Pancreatitis 1.30–1.80

Estimates of protein requirements

The appropriate calorie:nitrogen ratio is approximately 150:1 (calorie:protein ratio of 24:1)

1.5 g protein per kilogram body weight should be provided daily

Twenty-four–hour nitrogen balance is calculated by subtracting nitrogen loss from nitrogen intake.

Nitrogen intake is the sum of nitrogen delivered from enteral and parenteral feedings. Nitrogen is lost through urine, fistula drainage, diarrhea, and so on. The usual approach is to measure the urine urea nitrogen (UUN) concentration of a 24-hour urine collection and multiply by urine volume to estimate 24-hour urinary loss.

Nitrogen loss equals 1.2 × [24-hour UUN (g per day)] + 2 g per day as a correction factor to account for nitrogen losses in stool and skin exfoliation.

Estimated Protein Requirements in Various Disease States

Clinical condition Protein requirements (g/kg ideal body weight/day)

Healthy, nonstressed 0.80 Simplified estimates  

Mild metabolic stress (elective hospitalization) 1.00–1.10

Moderate metabolic stress (complicated postoperative care, infection)

1.20–1.40 Severe metabolic stress (major trauma,

pancreatitis, sepsis) 1.50–2.50

Compounding Methods

Total nutrient admixture (TNA) or 3-in-1 Dextrose, amino acids, lipid, additives are

mixed together in one container Lipid is provided as part of the PN

mixture on a daily basis and becomes an important energy substrate

2-in-1 solution of dextrose, amino acids, additives Typically compounded in 1-liter bags Lipid is delivered as piggyback daily or

intermittently as a source of EFA

Advantages of TNA

Decreased nursing time Decreased risk of touch contamination Decreased pharmacy prep time Cost savings Easier administration in home PN Better fat utilization in slow, continuous

infusion of fat Physiological balance of macronutrients

Disadvantages of TNA

Diminished stability and compatibility IVFE (IV fat emulsions) limits the amount

of nutrients that can be compounded Limited visual inspection of TNA;

reduced ability to detect precipitates

ASPEN Nutrition Support Practice Manual 2005; p. 98-99

3 IN 1 ADMIXTURE

PROTEIN (AMINO ACIDS) (10%; 4 kcal/g)

CARBOHYDRATE (DEXTROSE) (70%; 3.4 kcal/g)

FAT (LIPID EMULSION OF SOYBEAN/SAFFLOWEROIL) (20%; 9 kcal/g)

 Suggested Sequence for the Initiation of Parenteral Nutrition Therapy

PARAMETER DAY 1 DAY 2 DAY 3

Volume (mL/24 hr) 1000 1000-1500 1500-2000

Calories (% of goal) 50% 75%, may add fat 100% Dextrose (g/24 hr) 100-150 150-200 200-

350 Amino acids (% of total) 50%-100% 100% 100%, check

BUN Fat No Perhaps Often (3%-5%, 30-50

g/24 hr)

Insulin Give separately Add 50% to TPN Add 50% to TPN

Initiation of PN

Adults should be hemodynamically stable, able to tolerate the fluid volume necessary to deliver significant support, and have central venous access

If central access is not available, PPN should be considered (more commonly used in neonatal and peds population)

Start slowly(1 L 1st day; 2 L 2nd day)

ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: formulation As protein associated with few

metabolic side effects, maximum amount of protein can be given on the first day, up to 60-70 grams/liter

Maximum CHO given first day 150-200 g/day or a 15-20% final dextrose concentration

In pts with glucose intolerance, 100-150 g dextrose or 10-15% glucose concentration may be given initially

ASPEN Nutrition Support Practice Manual 2005; p. 98-99

Initiation of PN: Formulation

Generally energy and protein needs can be met in adults by day 2 or 3

In neonates and peds, time to reach full support relates inversely to age, may be 3-5 days

Initiation of PN: Formulation

Dextrose content of PN can be increased if capillary blood glucose levels are consistently <180 mg/dL

IVFE in PN can be increased if triglycerides are <400 mg/dL

ASPEN Nutrition Support Practice Manual 2005; p. 109

PN Administration:Transition to Enteral Feedings in Adults

Controversial In adults receiving oral or enteral

nutrition sufficient to maintain blood glucose, no need to taper PN

Reduce rate by half every 1 to 2 hrsor switch to 10% dextrose IV) may prevent rebound hypoglycemia (not necessary in PPN)

Monitor blood glucose levels 30-60 minutes after cessation

PN Administration:Transition to Enteral Feedings in Pediatrics

Generally tapered more slowly than in adults as oral or enteral feedings are introduced and advanced

Generally PN is continued until 75-80% of energy needs are met enterally

ASPEN Nutrition Support Practice Manual 2005; p. 109

Medications That May Be Added to Total Nutrient Admixture (TNA)

Phytonadione Selenium Zinc chloride Levocarnitine Insulin

Metoclopromide Ranitidine Sodium iodide Heparin Octreotide

Infusion Schedules

Continuous PN Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous access

Continuous PN

Advantages Well tolerated by most patients Requires less manipulation

decreased nursing time decreased potential for “touch”

contamination

Continuous PN

Disadvantages Persistent anabolic state

altered insulin : glucagon ratios increased lipid storage by the liver

Reduces mobility in ambulatory patients

Infusion Schedules Cyclic PN

The intermittent administration of PN via a central or peripheral venous access, usually over a period of 12 – 18 hours

Patients on continuous therapy may be converted to cyclic PN over 24-48 hours

Cyclic PN

Advantages Approximates normal physiology of

intermittent feeding Maintains:

Nitrogen balance Visceral proteins

Ideal for ambulatory patients Allows normal activity Improves quality of life

Routine physiologic and laboratory monitoring

Clinical: Daily fluid balance, body weight, evidence of

infection Laboratory:    Baseline: Electrolytes, BUN, creatinine, glucose,

calcium, magnesium, inorganic phosphate, liver function (bilirubin, alanine transaminase, aspartate transaminase, alkaline phosphatase), triglyceride, albumin, prothrombin time  

Every 6 to 12 hours: Glucose, usually for the initial 3 to 5 days or until stable   

Daily until stable: Electrolytes, BUN, creatinine, glucose, calcium, magnesium, PO4   

Weekly: Liver function, triglyceride, albumin, prothrombin time

Home TPN

Safety and efficacydepend on: Proper selection of patients Adequate discharge planning/education Home monitoring protocols

Home TPN

Patient selection Reasonable life expectancy Demonstrates motivation, competence,

compliance Home environment conducive to sterile

technique

Home TPN

Cost effective Quicker discharge from hospital Improved rehabilitation in the

home Reduced hospital readmissions

Common Indications for PN in Peds

Surgical GI disorders Intractable diarrhea of infancy Short bowel syndrome Inflammatory bowel disease Intractable chylothorax Intensive cancer treatment

Pediatric Energy Needs in PN No consensus exists as to how to

determine energy needs of hospitalized children

RDAs are intended for healthy children but can use for healthy/acutely ill children and monitor response

Can estimate REE using WHO equation and add stress factors, monitor clinical course

Indirect calorimetry recommended in difficult cases

RDAs for Energy and ProteinCategory Age (yr) Energy

(kcal/kg/d)Protein(g/kg/d)

Infants 0.0-0.5 108 2.2Children 1-3 102 1.2

4-6 90 1.1

7-10 70 1.0

Females 11-14 47 1.0

15-18 40 0.8

Males 11-14 44 1.0

15-18 45 0.9

Recommended Dietary Allowances, 10th ed. 1989. National Academy Press, Washington, DC

WHO Equations to predict REE from body weight

Sex/Age Range (years) Equation to Derive REE (kcal/d)

Males 0-3 (60.0 x wt) – 54

Males 3-10 (22.7 x wt) + 495

Males 10-18 (17.5 x wt) + 651

Females 0-3 (6.1 x wt) – 51

Females 3-10 (22.5 x wt) + 499

Females 10-18 (12.2 x wt) + 746

Increase WHO REE by stress factors

Fever Increase 13% per degree C

Cardiac Failure 15-25%

Traumatic Injury 20-30%

Severe respiratory distress or broncho-pulmonary dysplasia

25-30%

Severe sepsis 45-50

Olson, D. Pediatric Parenteral Nutrition. In Sharpening your skills as a nutrition support dietitian. DNS, 2003.

Trauma/Critically Ill Peds

Age in years Kcals/kg G/pro/kg

0-1 90-120 2.0-3.5

1-6 75-90 1.8-3.0

7-12 50-75 1.5-2.5

13-18 30-60 1.0-2.0

Pediatric PN: Fluids

Standard calculation: 100 kcal/kg for infant 3-10 kg 1000 kcal + 50 kcal/kg for every kg over 10

kg for a child 10-20 kg 1500 kcal + 20 kcal/kg for every kg over 20

kg for a child over 20 kg 1 mL fluid/kcal/d + adjustments for fever,

diarrhea, stress, etc.

ASPEN BOD Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26;26SA, 2001

Pediatric PN: Carbohydrate

Carbohydrate should comprise 45-50% of caloric intake in infants and children (C)

For neonates, CHO delivery in PN should begin at 6-8 mg/kg/minute of dextrose and advanced to 10-14 mg/kg/minute. (B)

ASPEN BOD Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26;28-29SA, 2001

Daily Electrolyte and Mineral Requirements for Peds Pts

Electrolyte Infants/Children Adolescents

Sodium 2-6 mEq/kg Individualized

Chloride 2-5 mEq/kg Individualized

Potassium 2-3 mEq/kg Individualized

Calcium 1-2.5 mEq/kg 10-20 mEq

Phosphorus 0.5-1 mmol/kg 10-40 mmol

Magnesium 0.3-0.5 mEq/kg 10-30 mEq

National Advisory Group. Safe practices for parenteral nutrition formulations JPEN 1998;22:49-66

Total Parenteral NutritionCompatibility

Insulin Reports of up to 50% of insulin is lost to

adsorption to TPN bag, tubing and filter Insulin loss due to adsorption to EVA systems

probably only 5-15%. However: Addition of insulin to TPN is

considered physically compatible and therapeutically appropriate

Tomato theory (dose is titrated)

Total Parenteral NutritionCompatibility

Insulin Practical Guidelines Minimum dose = 10 U / bag Dose in 10 U increments Avoid putting too much in TPN

Suppliment with sliding scale Add ½ of previous day’s SS to TPN

Total Parenteral NutritionCompatibility

Insulin Sliding Scale

Capillary Glucose mg/dL

IDDM NIDDM(STRESS)

200-250 3 5

251-300 6 10

301-350 9 15

351-400 12 20

TPN Complications

MECHANICAL Pneumothorax – air Hemothorax - blood Hydrothorax - solution (TPN) Intravascular Misplacement - often IJ Catheter Embolism - sheared tip Air Embolism Venous Thrombosis

TPN ComplicationsGlucose Metabolism

Hyperglycemia HHCN: Hyperglycemic, hyperosmolar,

nonketotic coma Renal threshold for glucose = 180 mg/dl One episode of hyperglycemia may affect

the outcome in critical care patient

TPN ComplicationsGlucose Metabolism

Hyperglycemia: Prevention and Treatment Start TPN at 50 ml/hr or with 10% dextrose Advance rate at 25 ml/hr each day Do not overfeed (<5-7mg/kg/min) Check BS at least daily Do not advance if BS > 200 mg/dl If > 200 give insulin to control BS

then advance May decrease the % of total calories from dextrose

TPN ComplicationsGlucose Metabolism

Rebound Hypoglycemia May occur if TPN interrupted for > 30 min Endogenous and exogenous insulin

Prevention Taper TPN before stopping (1/2 rate x 1-2

hours) Hang D10%

TPN ComplicationsGlucose Metabolism

CO2 Retention Occurs in pts with resp. dz. (ie. COPD) Occurs with overfeeding Especially if primary source of calories

dextrose Prevention

Feed per nutritional assessment Provide mixed substrate

TPN ComplicationsProtein Metabolism

Azotemia Occurs in pts with renal failure Prevention: restrict protein

ARF: 0.5-0.8gm/kg/dCRF: 0.8-1 gm/kg/d

Dialysis Specialized AA formulations??

TPN ComplicationsProtein Metabolism

Hyperammonemia and Hepatic Encephalopathy (HE) Occurs in pts with liver failure Restrict protein as necessary

ie. 0.5 gm/kg/d Treat HE with lactulose or antibiotic enemas For HE consider Hepatamine

TPN ComplicationsFat Metabolism

Essential Fatty Acid Deficiency EFA = linoleic acid Cause: TPN without fat Prevention: Give IV fat emulsion

Hyperlipidemia If trig too high (>400 mg/dL) give IV fat

emulsion for EFA only

TPN ComplicationsAbnormalities of LFT’s

Elevated liver function tests AST (SGOT) also from heart ALT (SGPT) more specific LDH and Bilibrubin

Possible cause: fatty infiltrates of liver (hepatic steatois) Exceed rate of glucose metabolism

5-7 mg/kg/min Less risk with cyclic infusion

(ie. 12hr on 12 hr off) Prevention

Keep rate < 5mg/kg/min Provide mixed substrates (Lipids) Provide calories per nutritional assessment

Possible cause: Cholestatis

TPN ComplicationsFluid and Electrolyte Disorders

Fluid and virtually any electrolyte Refeeding Syndrome

Low serum levels of intracellular electrolytes Hpokalemia Hypomagnesemia Hypophosphatemia

Setting: Malnourished patients Serum lytes may be normal but TBS are low Prevention: Daily lytes when starting TPN Make electrolyte adjustments

TPN ComplicationsSeptic Complications

Usually catheter related Not commonly from contaminated TPN Most common bacteria: Staph sp. Most common fungi: Candida sp. Prevention: Monitor for S&S of infection Proper catheter care

celemin

 Parameter CELEMIN 5S CELEMIN 10 PLUS

CELEMIN HEPA

CELEMIN NEPHRO

 Total Energy (kcal)

400 400 320 280

 Amino Acids (g/L)

50 g 100 80 70

 Nitrogen (g/L)

7.25 g 16 12.90 10.80

 Carbohydrates (g/L)

50 g - - -

 Electrolytes - Present - -

 Osmolarity (mOsmol/L)

800 1040 770 635 

celemin

 Product  Strength  Features  Presentation

CELEMIN 5S

CELEMIN 10 PLUS

CELEMIN HEPA

CELEMIN NEPHRO 

5% Amino acid with 5% Sorbitol

10% Amino acids with Electrolytes

8% Amino acids

7% Amino acids  

•Contains all essential & non- essential Amino acidsWHO recommended ratio of EAA : NEAA Rich in ArginineInsulin independent source of carbohydrate "sorbitol". Administration through peripheral vein

•Contains all essential & non- essential Amino acidsWHO recommended ratio of EAA : NEAARich in Arginine & electrolytesLeads to protein sparing effect.Administration through central vein

•42 % Branched ChainAmino AcidsAdequate protein supply during hepatic insufficiencyAdministration through peripheral vein •61% Essential Amino acidsAdequate protein supply during renal insufficiencyAdministration through peripheral vein  

200/500ml in Glass Bottle  

HERMIN-T

CompositionI NJ - EACH 100 ML - L-ISOLEUCINE 560 MG+L-

LEUCINE 1250 MG+ LYSINE 1100 MG+L-METHIONINE 350 MG+L-THREONINE 650 MG+ L-PHENYLALANINE 935 MG+L-TRYPTOPHAN 130 MG+L-VALINE 450 MG+ L-ARGININEHCL 955 MG+L-ASPARTIC ACID 380 MG+L-CYSTEINE 1 MG+L-GLUTAMIC ACID 650 MG+L-PROLINE 330 MG+L-SERINE 220 MG+ L-TYROSINE 35 MG+L-ALANINE 620 MG+GLYCINE 1070 MG+ XYLITOL 5000 MG

KABIVEN® G19%

  2566 mL 2053 mL 1540 mL 1026 mL

Glucose (19%) 1316 mL 1053 mL 790 mL 526 mL

Amino acids and electrolytes (Vamin 18 Novum®)

750 mL 600 mL 450 mL 300 mL

Fat Emulsion (Intralipid® 20%)

500 mL 400 mL 300 mL 200 mL

kabiven

2566 mL 2053 mL 1540 mL 1026 mL

•Amino acids (g) 85 68 51 34

•Nitrogen (g) 13.5 10.8 8.1 5.4

•Fat (g) 100 80 60 40

•Carbohydrates - glucose (dextrose) (g)

250 200 150 100

•Energy content        

- Total (kcal) 2300 1900 1400 900

- None protein (kcal)

2000 1600 1200 800

•Electrolytes        

•Electrolytes        

- sodium (mmol) 80 64 48 32

- potassium (mmol) 60 48 36 24

- magnesium (mmol)

10 8 6 4

- calcium (mmol) 5 4 3 2

- phosphate (mmol) 25 20 15 10

- sulfate (mmol) 10 8 6 4

- chloride (mmol) 116 93 70 46

- acetate (mmol) 97 78 58 39

infusion rate: The maximum infusion rate for glucose is 0.25 g/kg/h. Amino acid dosage should not exceed 0.1 g/kg/h. Fat dosage should not provide more than 0.15 g/kg/h. The infusion rate should not exceed 2.6 mL/kg b.w./hour

(corresponding to 0.25 g glucose, 0.09 g amino acid and 0.1 g fat/kg b.w.). The recommended infusion period is 12-24 hours.

Maximum daily dose 40 mL/kg b.w./day. This is equal to one bag (largest size) to a 64

kg-patient and will provide 1.3 g amino acids/kg b.w./day (0.21 g N/kg b.w./day), 31 kcal/kg b.w./day non-protein energy (3.9 g glucose/kg b.w./day and 1.6 g fat/kg b.w./day).

The maximum daily dose varies with the clinical condition of the patient and may even change from day to day.

Contraindications Hypersensitivity to egg-, soya- or peanut protein or to any of the ingredients Severe hyperlipaemia Severe liver insufficiency Severe blood coagulation disorders Inborn errors of amino acid metabolism Severe renal insufficiency without access to haemofiltration or dialysis Acute shock Hyperglycaemia, which requires more than 6 units insulin/h Pathologically elevated serum levels of any of the included electrolytes General contraindications to infusion therapy: acute pulmonary oedema,

hyperhydration, decompensated cardiac insufficiency and hypotonic dehydration Haemophagocytotic syndrome Unstable conditions (e.g. severe post-traumatic conditions, uncompensated

diabetes, acute myocardial infarction, metabolic acidosis, severe sepsis and hyperosmolar coma)

Due to composition, Kabiven G19% is not suitable for use in new-borns or infants under 2 years of age.