Download Total Parenteral Nutrition (TPN)

Total Parenteral Nutrition
(TPN)
By: E. Salehifar
(Clinical Pharmacist)
Malnutrition
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Incidence: 50 % of hospitalized patients
Common causes:
- Hypermetabolic states: Trauma, Infection,
Major surgery, Burn
- Poor nutrition
Consequences: Weakness, Decreased wound
healing, increased respiratory failure, decreased
cardiac contractility, infections (pneumonia,
abscesses), Prolonged hospitalization
Nutritional Support
Enteral Nutrition ( Physiologic, less expensive)
 Parenteral Nutrition
- GI should not be used (Obstruction, Pancraitis)
- GI can not be used ( Vomiting, Diarrhea,
Resection of intestine, IBD)
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Parenteral Nutrition
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Peripheral Parenteral Nutrition
(15 lit D5W/day for a 70 kg !!!)
Central Parenteral Nutrition
(TPN)
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Needs CV-line to administer
hyperosmolar solutions
Estimation of energy expenditure
Harris-Benedict equations:
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BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A
BEE (women) (kcal/day): 655.1+9.56W+1.85H-4.68A
TEE (kcal/day):
BEE × Stress factor × Activity factor
Stress factors: Surgery, Infection: 1.2 Trauma: 1.5
Sepsis: 1.6
Burns: 1.6-2
Activity factors: sedentary: 1.2 , normal activity: 1.3,
active: 1.4 , very active: 1.5
Stress level
Normal/mild stress level: 20-25 kcal/kg/day
 Moderate stress level: 25-30 kcal/kg/day
 Severe stress level: 30-40 kcal/kg/day
 Pregnant women in second or third trimester:
Add an additional 300 kcal/day
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Fluid: mL/day
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30-40 mL/kg
Protein (amino acids)
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Maintenance: 0.8-1 g/kg/day
Normal/mild stress level: 1-1.2 g/kg/day
Moderate stress level: 1.2-1.5 g/kg/day
Severe stress level: 1.5-2 g/kg/day
Burn patients (severe): Increase protein until
significant wound healing achieved
Solid organ transplant: Perioperative: 1.5-2
g/kg/day
Protein need in Renal failure
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Acute (severely malnourished or hypercatabolic):
1.5-1.8 g/kg/day
Chronic, with dialysis: 1.2-1.3 g/kg/day
Chronic, without dialysis: 0.6-0.8 g/kg/day
Continuous hemofiltration: ≥ 1 g/kg/day
Protein need in Hepatic failure
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Acute management when other treatments have
failed:
With encephalopathy: 0.6-1 g/kg/day
 Without encephalopathy: 1-1.5 g/kg/day
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Chronic encephalopathy
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Use branch chain amino acid enriched diets only if
unresponsive to pharmacotherapy
Pregnant women in second or third trimester
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Add an additional 10-14 g/day
Fat
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Initial: 20% to 40 % of total calories (maximum:
60% of total calories or 2.5 g/kg/day)
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Note: Monitor triglycerides while receiving
intralipids.
Safe for use in pregnancy
I.V. lipids are safe in adults with pancreatitis if
triglyceride levels <400 mg/dL
Components of TPN Formulations
Macro:
Calorie: Dextrose 20%, 50%
Intralipid 10%, 20%
Protein: Aminofusion 5%, 10%
Micro:
Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)
Dextrose
20%, 50% ( from CV-line)
 3.4 kcal/g
 60-70% of calorie requirements should be
provided with dextrose
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For
1000 ml solution
D50W
D20W
D30W
D40W
D10W
D5W
250 ml
750 ml
------
333 ml
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667 ml
500 ml
500 ml
------
555 ml
-----
446 ml
750 ml
250ml
------
778 ml
------
222 ml
Dextrose: Contraindications
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Hypersensitivity to corn or corn products
Hypertonic solutions in patients with intracranial
or intraspinal hemorrhage
Abrupt withdrawal
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Infuse 10% dextrose at same rate and monitor
blood glucose for hypoglycemia
Intralipid
10%, 20% ( from peripheral or CV-line)
 1.1 kcal/ml (10%), 2 kcal/ml (20%)
 30-40% of calorie requirements should be
provided with Intralipid
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1022 Kcal/L
345 mosmol/L
1080 Kcal/L
Intralipid: Contraindication
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Hypersensitivity to fat emulsion or any
component of the formulation; severe egg or
legume (soybean) allergies
Pathologic hyperlipidemia, lipoid nephrosis,
pancreatitis with hyperlipemia (TG>400 mg/dl)
Aminofusion
 5%,
10% ( from CV-line)
 1-1.5 g/kg/day
 Should not be used as a calorie source
400 Kcal/L
200 kcal/L
1030 mosmol/L
590 mosmol/L
Amino acids: Contraindications
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Hypersensitivity to one or more amino acids
Severe liver disease or hepatic coma
Case
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D.C a 38 y.o man with a 12-year history of
crohn’s disease is admitted to surgery ward of
Imam hospital in Sari for a compliant of
increasing abdominal pain, nausea & vomiting
for 7 days and no stool output for 5 days.
Because of N & V, he has been drinking only
liquids during the past weeks. His crohn disease
had several exacerbations during the past 2 years
and 10 cm of his ileum has been resected 6
month ago.
case (continue)
Drugs: Mesalamine 1000 mg qid + prednisolone
10mg/d. Abdominal x-ray is consisting with
bowel obstruction. Exploratory laparotomy
was performed and 25 cm of his ileum
resected. Bowel sounds are absent. He has a
right subclavian CV-line. Considering that his
Ht=180cm, Wt=60kg (6 month ago: 70 kg)
and Age=38 y.o, what is your recommended
TPN formula for him?
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BEE= 66.47+13.75×60+5×180-6.76×38=1535 kcal/d
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TEE= 1535×1.2×1.2 = 2200 kcal/d
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Intralipid 10%= ? 2200 × 30%= 660 kcal
1ml ≡ 1.1 kcal
660 : 1.1 = 600 ml ( 500ml)
Dext 50%= ? 2200 – 550= 1650 kcal
1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 g Dext
50g ≡ 100 ml 485 g ≡ 970ml (1000ml)
 Aminofusion 10 %= ? 1.5 g/kg/d × 60 kg=
90g/day 10g ≡ 100 ml 90g ≡900 ml (1000ml)
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Electrolytes (daily requirements for TPN):
 Na: 80-100 mEq (50 - 100 ml NaCl 5%)
 K: 60-80 mEq (30 ml KCl)
 Cl: 50-100 mEq
 Mg: 8-16 mEq (5 -10 ml MgSo4 20%)
 Ca: 5-10 mEq (10-20 ml Ca Gluconate 10%)
 P04: 15-30 mEq
 Acetate: 50-100 mEq
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Vitamins:
A, D, E, Water soluble vitamins
Trace Elements:
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Zn, Se, Cu, Cr, Mn
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↓ Zn
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↓
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Delayed ulcer healing, Dermatitis, Alopcia (5α reductase),
Diarrhea
Se: Low activity of SOD & Deiodinase
Amp B Complex + Amp Vit C
MV Therapeutic ( Zn, Cu, Mn)
Special Considerations
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Max infusion rate of dextrose: 0.5g/kg/h (to
avoid hyperglycemia, glycosuria, fatty liver,
hyperosmolar coma)
K should be added to dextrose solutions
Slow starting & slow tapering of Dext 50%
If BS>200, Insulin should be added
some brands of lipids can be mixed with
Dext+Aminifusion in the same IV container
Special Considerations
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Intralipid contraindications:
Severe egg allergy
 Hyperlipidemia
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Special aminoacid products:
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Hepatamine: for Hepatic Failure
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↑ branched chain aa ( leu, isoleu, val)
Nephramine: for Renal Failure
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Primarily essential aa with lower concentrations
Monitoring:
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Baseline: Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT,
INR, TG, LFT, Alb, Pre-Alb
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Daily: Wt, V/S, I-O, Na, K, BUN, Cr, Glu,
Sign/Symptoms of infection
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2-3 times a week: CBC, Ca, P, Mg
Weekly: Alb, Pre-Alb, LFT, INR, Nitrogen Balance
Adding other drugs to TPN
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INS
Heparin
H2-blocker
Alb
Aminophylline
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Vit K & Bicarbonate should not be added
Complications
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Endocrine & metabolic
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Hepatic
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Azotemia, BUN increased
Infectious
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Cholestasis, cirrhosis (<1%), gallstones, liver function tests
increased, pancreatitis, steatosis, triglycerides increased
Renal
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Fluid overload, hypercapnia, hyperglycemia, hyper/hypokalemia, hyper-/hypophosphatemia, refeeding
syndrome
Bacteremia, catheter-induced infection, exit-site infections
Other: Pneumothorax, Thrombophlebitis
Refeeding syndrome
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In patients with long-standing or severe
malnutrition
Is a medical emergency, consist of:
Electrolyte disturbances (eg, potassium, phosphorus)
 Respiratory distress
 Cardiac arrhythmias, resulting in cardiopulmonary
arrest
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Do not overfeed patients; caloric replacement
should match as closely as possible to intake
Conclusion
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Malnutrition is a common problem &
Nutritional support is indicated in many
hospitalized patients
Enteral nutrition is better, but some patients
with GI problems need TPN
Dextrose & Intralipid should be used as calorie
sources and Aminofusion as aminoacid source
Special monitoring should be considered for
patients especially I-O, Na, K and Glu