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BY THE NAME OF ALLAH THE MOST BENEFICENT AND THE MOST MERCIFUL
Definition: Total parenteral nutrition ("TPN"),
means the administration of complete and balanced nutrition by intravenous infusion in order to support anabolism, body weight maintenance or gain, and nitrogen balance, when oral or enteral nutrition are not feasible or are inadequate. Also referred to as
Intravenous nutrition, parenteral alimentation, and artificial nutrition.
Indications for TPNIndications for TPN Short-term use• Bowel disease (e.g. obstructions, fistulas > 1500ml/day).• Nutritional preparation prior to surgery. • Severe pancreatitis.• Malnourished Patient—Inadequate intake for > 7 days.• Unintentional weight loss > 10% or weight is > 20% below
ideal body weight.• Inability to use GI tract—For greater than 7 days.• Major trauma or burns.• Long-term use (HOME PN)• Prolonged Intestinal Failure(e.g mesenteric infarction)• Crohn’s Disease• Bowel resection(short gut )
Energy: Glucose and LipidsAmino acids (Nitrogen)Water and electrolytesVitaminsTrace elements
RequirementsRequirements EnergyEnergy requirement = BEE x activity factor x injury factor . Basal energy expenditure(BEE) is calculated =25-30 kcal/ kg BW/day.(Harris Benedict formula)ACTIVITY FACTOR:•1.2 Confined to bed •1.3 Ambulatory
INJURY FACTOR:•Uncomplicated patient1•Postoperative state 1.1•Fractures 1.2•Sepsis 1.3•Peritonitis 1.4•Multiple trauma 1.5•Multiple trauma and Sepsis 1.6•Burns 30 - 50% 1.7•Burns 50 - 70% 1.8•Burns 79 - 90% 2
RequirementsRequirementsGlucose(50-60 % of total energy)
RequirementsRequirementsGlucose• Most stable patients tolerate rates of 4-5 mg.kg-1.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. Route
• Glucose in 5 – 15 % solution can be administered via a peripheral vein, but higher concentrations require a central venous line.
RequirementsRequirementsLipids(30-40 %)
RequirementsRequirementsEnergy Sources: Lipid
• Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted 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.
Requirements:Requirements:
Protein :
Protein is the functional and structural component of the body, so fulfilling patient’s caloric needs with non-protein calories (fat and glucose) is essential.
Protein requirements for most healthy individuals are 0.8 g/kg/day. But it varies in different conditions.
RequirementsRequirementsProtein: Daily Protein requirements
Condition Example requirement
Basic requirements Normal person 0.5-1g/Kg
Slightly increased requirements Post-operative, cancer, inflammatory
1.5g/Kg
Moderately increased requirements
Sepsis, polytrauma 2g/Kg
Highly increased requirements Peritonitis, burns, 2.5g/Kg
Reduced requirements Renal failure, hepatic encephalopathy
0.6g/Kg
•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.As/100 mL solution).
RequirementsRequirements Protein:
•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.
RequirementsRequirements Fluids and electrolytes:
NutrientNutrient Requirements (Requirements (/Kg/day)/Kg/day)
WaterWater 20-40 mL20-40 mL
SodiumSodium 0.5-1.0 mmol0.5-1.0 mmol
PotassiumPotassium 0.5-1.0 mmol0.5-1.0 mmol
MagnesiumMagnesium 0.1-0.2 mmol0.1-0.2 mmol
CalciumCalcium 0.05-0.15mmol0.05-0.15mmol
PhosphatePhosphate 0.2-0.5mmol0.2-0.5mmol
Chloride/AcetateChloride/Acetate So as to maintain acid-base balance So as to maintain acid-base balance (normally 0.5 mmol for Cl(normally 0.5 mmol for Cl-- , & 0.1mEq for Acetate) , & 0.1mEq for Acetate)
RequirementsRequirements Vitamins
Vitamins are either fat soluble (A,D,E,K) or water soluble (B,C). Separate multivitamin commercial preparations are now available for both.
Most adult vitamin formulae do not contain vitamin K, which is added according to the patient’s coagulation status.
RequirementsRequirements
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).
RequirementsRequirements Trace minerals
Mineral Mineral Recommended dietary Recommended dietary allowance (RDA) for daily allowance (RDA) for daily
oral intake (mg) oral intake (mg)
Suggested daily Suggested daily intravenous intake intravenous intake
(mg) (mg)
Zinc Zinc 15 15 2.5-5 2.5-5
Copper Copper 2-3 2-3 0.5-1.5 0.5-1.5
Manganese Manganese 2.5-5 2.5-5 0.15-0.8 0.15-0.8
Chromium Chromium 0.05-0.2 0.05-0.2 0.01-0.015 0.01-0.015
Iron Iron 10 (males)-18 (females) 10 (males)-18 (females) 3 3
OsmolarityOsmolarity
PPN: Maximum of 1000 mosmoles / liter.
TPN: as nutrient dense as necessary (1000 - 3000) mosmoles/liter.
• Total calories required = BEE x activity factor x injury factor x weight = 25 x 1.2 x 1.2 x 40 = 1440 kcal/day
• Glucose(50-60 %): Out of 100 kcal glucose should give = 60 kcal 1440 ------------------------------- = 60/100x1440 = 864 kcal
1ml 25% glucose = 1kcal864 ml/day of 25% glucose
Lipids(25-40%): out of 100 kcal lipids should give = 40 kcal
1440 kcal --------------------- = 40/100x1440 = 576
1ml 20% lipid sol = 2kcalml of 20% lipid required = 576/2 = 288 ml
Protein: 1.5g per kg per day1.5x40 = 60 g/day
5g A.A is contained in = 100ml 5% sol.1g------------------------- = 100/560g----------------------- = 100/5x60 = 1200 ml/ day
ApplicationApplication
The Solution
Single bottleSystems
“All-in-one” mixtures
2- or 3-chamber bags +
+
LocationSubclavian VeinsInternal Jugular VeinsFemoral VeinsBrachial Veins
TypesNon-tunneled TunneledCordis HickmanSwan Ganz Broviac Double Lumen PortacathTriple LumenPICC
Application Application
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.
First week Later
Energy balanceweight Daily Daily
Metabolic variablesBlood measurements
Serum electrolytes Daily 1-2 /week
RFTs 3 / week 2/week
Glucose Daily (initially 6hrly until stabilized) 3/week
Hemoglobin Weekly Weekly
LFT’s(including PT, APTT)
Weekly Weekly
Serum total protein 2/week Weekly
Serum triglycerides weekly weekly
Serum Ca+2 & PO4 3/week 2/week
Serum Magnesium 2/week weekly
Selenium, Zinc, Copper
Monthly
First week Later
Urine measurements
Glucose daily
Specific gravity and osmolarity Daily Daily
General measurements
Input & output Daily Daily
Prevention and detection of infection
Clinical observation (activity, temperature, symptoms )
Daily Daily
TLC & DLC As indicated As indicated
Cultures As indicated As indicated
Complications of TPNComplications of TPNAbout 5 to 10% of patients have complications related to central venous access.Catheter-related sepsis occurs in about ≥ 50% of patients. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients.
*(The Merck Manual)
Catheter related: Problem of insertion Problem of care
• Failure to cannulate. . Sepsis • Pneumothorax. . Infective
endocarditis• Haemothorax. . Air embolism• Arterial puncture. . Line/cardiac thrombosis• Brachial plexus injury. . Catheter
migration/• Mediastinal hematoma. embolism• Thoracic duct injury.
•
Feeding regimen related:
Complications of TPNComplications of TPN
Catheter sepsisPrevent by : 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. Detect by : Fever, chills, ±drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip).Treat by : 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
Complications of TPNComplications of TPN Metabolic Complications o Hyperglycemia :Associated with the infusion of excess
glucose in the feeding solution or the diabetic-like state in the patient associated with many critical illnesses.Management: 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).
Complications of TPNComplications of TPN
Metabolic Complications Hypertriglyceridemia Associated with excess
infusion of fat emulsion.• Can cause pulmonary insufficiency.
Complications of TPNComplications of TPNMetabolic Complications
o Hepatic complications (also known 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 treatment, other than anticholestatic therapy.
HOME PARENTERAL NUTRITIONHOME PARENTERAL NUTRITION
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.
ب�ي “ ر� د�ي�ن�ي ي�ه نأ� ى ع�س� و�ق�ل
� دا ش� ر� ذ�ا ه� م�ن ب� ر� قAnd say it may be that my Lord guide me to the nearest of the rational”أل�