Download TPN-III-No acute stress

Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
LECTURE II
III) WOMAN IN NO ACUTE STRESS

S.F a 51-year-old cachectic woman, is admitted to the hospital
complaining of a 3-month history of severe abdominal pain after eating
and a 30-Ib weight loss.

Questioning reveals that she has felt hungry, but the pain after eating
is so severe she prefers not to eat. S.F. denies any nausea, vomiting,
or diarrhea.

Her medical history is significant for PUD.

Her surgical history is significant for removal of a small section of her
ileum and colon for ischemia 4 months ago.

Her current medication is nizatidine 150 mg PO BID. S.F social history
is significant for tobacco use, but she quit smoking 2 years ago.

Review of systems is positive only for the postprandial abdominal
pain.

S.F mostly eats one meal a day, consumes only 25 to 40% of that
meal.

Tolerance to food is no better if she eats liquids or solids.

Her weight loss has been continuous over the last 3 months.

Physical examination:
thin, wasting of subcutaneous fat in the
temporal area and squared appearing shoulders.

Her height is t 5'4" and her weight is 89 lb. At the time of her ileum and
colon resection, her weight was 119 Ib, which is her usual weight.

Admission laboratory values are as follows:

sodium (Na), 135 mEq/L (normal, 135 to 145); potassium (K), 4.0
mEq/L (normal, 3.5 to 5.0); chloride (Cl), 100 mEq/L (normal, 100 to
110); bicarbonate (HCO3 -), 25 mEq/L (normal, 24 to 30); blood urea
nitrogen (BUN), 4 mg/dL (normal, 8 to 20); creatinine, 0.6 mg/dL
(normal, 0.8 to 1.2); glucose 87 mg/dL, (normal, 85 to 110); calcium
(Ca), 8.2 mg/dL (normal, 8.5 to 10); magnesium (Mg), 2.0 mg/dL
(normal, 1.6 to 2.2); phosphorus (P), 3.0 mg/dL (normal, 2.5 to 4.5);
total protein, 6.0 g/dL (normal, 6.8 to 8.3); albumin, 4 g/dL (normal, 3.5
to 5.0); and prealbumin, 21 mg/dL (normal, 15 to 40). White blood cell
(WBC) count, 6,800/mm3 (normal, 4,000 to 12,000).

Based on history and physical findings, S.F working diagnosis is
intestinal angina also known as mesenteric ischemia.
1
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
PATIENT ASSESSMENT

Assessment of nutritional status requires evaluation of multiple
factors.

S.F nutritional history: Not eating because of the abdominal pain.

Recent ileum surgery raises the question of nutrient malabsorption.

Most striking: her weight loss of 30 pounds in 3 months or about 2.5
pounds per week (S.F is now 75% of her usual weight).

The loss of 25% of her original weight is a severe weight loss.

S.F physical findings of cachectic appearance, temporal wasting, and
loss of subcutaneous fat and muscle in her shoulders are significant.

No anthropometric measurements are available.

S.F visceral proteins (albumin & prealbumin) are within normal ranges.

In conclusion:
o
S.F is severely malnourished.
o
Her cachectic appearance with loss of subcutaneous fat and
muscle, but normal visceral proteins, would be best classified
as marasmus.
o
If S.F were to be faced with stress or injury (e.g., major
surgery, infection) necessitating use of visceral proteins for
energy production, she would likely exhibit characteristics of
both marasmus and kwashiorkor or mixed protein-calorie
malnutrition in which fat, muscle, and visceral proteins all are
depleted.
IS S.F A CANDIDATE FOR TPN THERAPY?

S.F is admitted to the hospital for tests to evaluate her severe
postprandial abdominal pain. Many of the expected diagnostic tests will
require that S.F remain NPO (not use GIT).

Although S.F appears to have a functioning GIT, her postprandial pain is
so severe it is doubtful she would eat much even if given the opportunity.

If the diagnosis of mesenteric ischemia is accurate, surgical correction
will be required.

With her malnourished state, inadequate nutrient intake for more than 7
days will result in further deterioration of her nutritional status.

Based on all that parenteral nutrition should be implemented.
2
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
GOALS OF THERAPY

During the first 3 days of hospitalization, S.F undergoes multiple
diagnostic tests to evaluate her abdominal pain.

An arteriogram reveals occlusion of her superior mesenteric artery that
supplies blood to her small and large intestines.

This occlusion compromises blood flow to the intestines when there is
increased demand for flow, such as after eating.

S.F. is to remain NPO until her surgery, which is scheduled in 4 days.

what is the goal of her nutrition therapy?

Although S.F has lost 30 pounds, the limited time before her surgery is
not adequate to replete her fat and lean body mass.

Her malnutrition occurred over several months and repletion may take
equally as long.

The benefits of preoperative parenteral nutrition remain unclear. Although
some reports describe a trend of improved outcome with preoperative
parenteral nutrition, other studies have not demonstrated clear benefit.

Ideally, preoperative parenteral nutrition should be administered for 7 to
10 days to be of any benefit in decreasing the complications associated
with surgery in severely malnourished patients.

Therefore, the goals for S.F nutrition therapy, at this time, are to maintain
her current nutritional status and prevent her from becoming more
malnourished.

If, however, parenteral nutrition is initiated and continued after surgery,
her calorie and protein goals should be adjusted at that time for the
additional stress of major surgery.

Finally, once she has recovered from surgery and is convalescing, a longterm goal of weight gain to her usual weight of 119 pounds is appropriate.
Calorie and Protein Goals

Calculate BEE

S.F actual weight of 89 pounds (40.5 kg) will be used

Using Harris-Benedict equation (females): S.F BEE = 1,104 kcal/day.

Modified for light hospital activity: = 1,104 x 1.3 = 1,435 kcal/day.

S.F does not require a factor for stress at this stage.

A simpler method to determine energy expenditure is by: (28-30
3
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
kcal/kg per day) = (28-30 x 40.5 kg) = 1,134 to 1,200 kcal/day.

Protein goals: weight, degree of stress, and disease state.

S.F at minimal stress:

Protein dose is 1.0 to 1.2 g/kg per day = 41 to 49 g/day = (i.e. 41-49 gm
amino acids (1 g of protein is equivalent to 1 g of amino acids).
LECTURE III
Formula design:

Design a peripheral parenteral nutrient base formulation for S.F. that
provides 1,300 total calories and 45 g of amino acids. The formulation
should provide 60% of the nonprotein calories as lipid and have maximum
dextrose and amino acid concentrations of 6 % and 3 %, respectively.
The macronutrient components available to prepare this formulation are
dextrose 20%, amino acids 8.5%, sterile water for injection, and IV lipids
10% and 20%.

Calories:
1. Amino acids = 180 protein calories (45 x 4.0)
2. Nonprotein calories 1,120 (1300-180) (Lipids and
carbohydrate).
3. 60% of the non protein calories as lipids = 672 (1,120 x
0.60) calories.
4. Dextrose = 448 (1120-672)

Amount
1. Amino acids 45 gm
2. Dextrose = 132 g of dextrose are required (448/3.4) 3.4 Kcal/g.

Volume:
1. Provide 45 g of amino acids as a 3% final concentration is calculated
to be 1,500 mL.
2. Provide 132 g of dextrose as a 6% concentration 2,200 mL.
(132 g x 1000 ml/60 gm)
3. To stay within the guidelines for maximum dextrose and amino acid
concentrations, the larger volume of 2,200 mL is used. Therefore, the
final dextrose and amino acid concentrations are 6% and 2%,
respectively.
4. The amount of fat to provide 672 kcal must be determined. Using 10%
4
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
lipid emulsion with a caloric density of1.1 kcal/mL will require 611 mL
or 336 mL of the 20% lipid emulsion (2 kcal/mL).

This parenteral nutrient formulation is compounded using dextrose
20% 660 mL (132 g) and amino acids 8.5% 530 mL (45 g) with sterile
water for injection added to achieve a final volume of 2,200 mL.

The IV lipid can be provided in various ways.
o
As a secondary infusion or "piggybacked" into .the dextrose/amino
acid solution.
o
If the 10% lipid emulsion is used, S.F fluid intake from her
parenteral feedings will be approximately 2,800 mL/day; using the
20% lipid emulsion 2,550 mL/day is necessary.
o
Alternatively, mix the entire daily requirements for lipid, dextrose
and amino acids in one large container or single daily bag. This is
called total nutrient. admixture (TNA), triple-mix, three-in-one, or
all-in-one.
o
It is the preferred method of administering parenteral nutrient
formulations via peripheral veins because:

The iso-osmotic lipids have a diluting effect as well as buffering
effect'"

Lipids increases the caloric density significantly with only a
slight increase in osmolarity.
o
S.F peripheral nutrient formulation should also contain standard
amounts of electrolytes, as well as a daily dose of IV multi vitamins
and trace elements.
FLUIDS

The institution uses a TNA system and S.F parenteral nutrient
formulation is provided in 2,200 mL/day. Will this meet S.F
maintenance fluid requirements?

Maintenance fluid needs can be estimated using several methods.
o
30 to 35 mL/kg per day as the basis.
o
1,500 mL for the first 20 kg body weight plus an additional 20
mL/kg for actual weight beyond the initial 20 kg.

Both methods provide estimates of fluid needs for basic maintenance,
and additional fluid must be provided for increased losses such as
vomiting, nasogastric (NO) tube output, diarrhea, or large open
5
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
wounds.

S.F fluid needs are estimated as follows:
= 1,500 mL + [(20 mL/kg) (40.5 kg - 20 kg)]
= 1,500 mL + (20 mL/kg)(20.5 kg) = 1,500 mL + 410 mL = 1,910 mL

Clearly, the peripheral parenteral nutrient formulation will more than
meet S.F needs, and the extra fluid intake may put her at risk for
becoming fluid overloaded, manifesting as hypervolemic, hypotonic
hyponatremia.

Therefore, she should be monitored for signs of fluid overload
(peripheral edema or shortness of breath, daily intake exceeding daily
output, hyponatremia, and rapidly increasing weight).
MONITORING AND MANAGEMENT OF COMPLICATIONS
o
What additional parameters should be monitored for patients receiving
peripheral parenteral nutrition?
o
The primary calorie source in peripheral parenteral feedings is lipids.
o
For S.F, 60% of the nonprotein calories are provided as lipid. However,
for adults the daily lipid intake should not exceed 2.5 g/kg per day.
o
S.F formulation provides approximately 65 g of lipid daily or 1.6 g/kg per
day.
o
It is also important to monitor serum triglycerides to assess tolerance to
this dose of IV lipid.
o
If the blood sample is obtained while the triglycerides are infusing, as with
the TNA formulation, a serum triglyceride concentration of <400 mg/d,
although elevated, is acceptable.
o
Hypertriglyceridermia sometimes can be noted quickly by gross
observation of the blood sample.
o
Forty-eight hours after S.F. begins peripheral parenteral nutrition, she
begins to complain that the arm where she has the IV for the feeding is
swollen, red, and painful. What is the most probable cause of these
complaints?
o
What measures can he taken to prevent this complication?
o
A common complication (up to 70%) of peripheral parenteral nutrition is
phlebitis that occurs within 72 hours.
o
Phlebitis usually is attributed to the acidic pH or hyperosmolarity of the
nutrient formulation.
6
Professor T Najjar
o
PHCL-474 (TPN)
Dept of clinical pharmacy
The osmolarity of typical peripheral parenteral feedings ranges from 600
to 900 mOsm/L.
o
Osmolarity of a dextrose/amino acid formulation can be approximated
quickly by multiplying the final dextrose concentration by 50 and the final
amino acid concentration by 100.
o
Alternatively, the osmolarity can be estimated by multiplying the number
of grams of dextrose by 5 and the number of grams of amino acids by 10
then dividing by the final volume in liters.
o
Approximately150 mOsm/L should be added for
contribution of
electrolytes, vitamins and trace elements.
o
Using the first method, a formulation of 6% dextrose and 2% amino acids
has an approximate osmolarity of 650 mOsm [(6% dextrose x 50 = 300
mOsm) + (2% amino acids x 100 = 200 mOsm) + 150 mOsm for
additives].
o
Although the concurrent administration of fat emulsions decreases
osmolarity, buffers the pH, and improves peripheral vein tolerance, it does
not totally eliminate the risk of thrombophlebitis.
o
Other efforts to minimize phlebitis include the addition of a combination of
heparin and hydrocortisone to the admixture.
o
Alternatively, a glycerol trinitrate patch may be applied near the peripheral
IV site to dilate the superficial veins, which constrict when there is
irritation.
o
S.F peripheral IV catheter should be removed and another one placed in
the other arm if she is to continue receiving her peripheral parenteral
nutrient formulation.
o
Methods to reduce thrombophlebitis should be initiated.
o
If S.F exhausts her peripheral venous access and continues to need
parenteral nutrition, placement of a central venous catheter should be
considered.
_________________________________________________________________
7
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
Formula design: Design a peripheral parenteral nutrient base formulation for S.F.
that provides 1,300 total calories and 45 g of amino acids. The formulation should
provide 60% of the nonprotein calories as lipid and have maximum dextrose and
amino acid concentrations of 6 % and 3 %, respectively. The macronutrient
components available to prepare this formulation are dextrose 20%, amino acids
8.5%, sterile water for injection, and IV lipids 10% and 20%.
calories
Calories
Amounts Required
required
Protein 180 = (45 x
4.0)
Non
1300-180 =
protein
1120
Amino
180 = (45 x
acids
4.0)
Dextrose
45 gm
448 = (1120-
(40%)
672)
Lipids
672 = 1,120
(60%)
x 0.60)
448/3.4 = 132 gm
- 10% =672/1.1 = 611
mL = 61. 2 gm
or
- 20% = 672/2 =
336 mL = 67.2 gm
1300
Total

Amount
1. Amino acids 45 gm
2. Dextrose = 132 g of dextrose are required
(448/3.4) …. 3.4 Kcal/g.

Volume:
1. Provide 45 g of amino acids as a 3% final
8
Professor T Najjar
PHCL-474 (TPN)
Dept of clinical pharmacy
concentration is calculated to be 1,500 mL.
2. Provide 132 g of dextrose as a 6% concentration 2,200
mL. (132 g x 1000 ml/60 gm
3. To stay within the guidelines for maximum dextrose
and amino acid concentrations, the larger volume of
2,200 mL is used. Therefore, the final dextrose and
amino
acid
concentrations
are
6%
and
2%,
respectively.

This parenteral nutrient formulation is compounded using dextrose
20% 660 mL (132 g) and amino acids 8.5% 530 mL (45 g) with sterile
water for injection added to achieve a final volume of 2,200 mL.

The IV lipid can be provided in various ways.
o
As a secondary infusion or "piggybacked" into .the dextrose/amino
acid solution. If the 10% lipid emulsion is used, S.F fluid intake
from her parenteral feedings will be approximately 2,800 mL/day;
using the 20% lipid emulsion 2,550 mL/day is necessary.
o
Alternatively, mix the entire daily requirements for lipid, dextrose
and amino acids in one large container or single daily bag. This is
called total nutrient. admixture (TNA), triple-mix, three-in-one, or
all-in-one and is the preferred method of administering parenteral
nutrient formulations via peripheral veins because:

The iso-osmotic lipids have a diluting effect as well as buffering
effect'"

Lipids increases the caloric density significantly with only a
slight increase in osmolarity.
9