Total Parenteral Nutrition (TPN)

1. In the name of GOD Total Parenteral Nutrition (TPN) Presented by: ShadiFarsaei (Assistand professor of pharmacotherapy)

2. Indication • Inability to absorb nutrients via the GI tract because of one or more of the following: • Massive small bowel resection • Intractable vomiting when adequate EN is not expected for 7-14 days. • Severe diarrhea • Bowel obstruction • GI fistulae: PN is indicated for patients with prolonged inadequate nutritional intake longer than 5-7 days who are not candidates for EN.

3. Cancer: antineoplastic therapy, radiation therapy, or HSCT • moderately to severely malnourished patients receiving active anticancer treatment who are not candidates for EN. • PN is unlikely to benefit patients with advanced cancer whose malignancy is unresponsive to treatment. • PN is appropriate for patients undergoing HSCT who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for 7-14 days. • Pancreatitis: severe pancreatitis with prolonged inadequate nutritional intake longer than 5-7 days who are not candidates for EN. PN should be used when EN exacerbates abdominal pain, ascites, or fistula output.

4. Critical care • whom EN is contraindicated or is unlikely to provide adequate nutritional requirements within 5-10 days. • Organ failure (liver, renal, or respiratory): moderate to severe catabolism when EN is contraindicated. • Burns: whom EN is contraindicated or is unlikely to provide adequate nutritional requirements within 4-5 days. • Perioperative PN • Preoperative: for 7-14 days for patients with moderate to severe malnutrition who are undergoing major GI surgery, if the operation can be safely postponed. • Postoperative: for patients in whom EN is contraindicated or is unlikely to provide adequate nutritional requirements within 7-10 days.

5. Eating disorders: anorexia nervosa and severe malnutrition who are unable or unwilling to ingest adequate nutrition.

6. Adult PN therapy is not an emergent intervention and should not be initiated until the patient is hemodynamically stable. • In general, adults who are not candidates for enteral nutrition should be considered candidates for PN after 7 to 14 days of suboptimal nutritional intake.

7. Patient Assessment • Nutrition History: malnutrition • Weight History • 5% of usual weight within 1 month, or 10% of usual weight within 6 months • Physical Examination • Anthropometry • Biochemical Assessment

8. Visceral Proteins for Nutrition Assessment 1. Brown RO, Bradley JE, Bekemeyer WB, Luther RW. Effect of albumin supplementation during parenteral nutrition on hospital morbidity. Critical care medicine. 1988;16(12):1177-82. 2. Koretz RL. Intravenous albumin and nutrition support: going for the quick fix. JPEN Journal of parenteral and enteral nutrition. 1995;19(2):166-71. 3. Rubin H, Carlson S, DeMeo M, Ganger D, Craig RM. Randomized, double-blind study of intravenous human albumin in hypoalbuminemic patients receiving total parenteral nutrition. Critical care medicine. 1997;25(2):249-52.

9. Peripheral line • 700-900 mOsmol • Chang IV each 2-3 d • Dextrose 10% • Aminoacid 5% Energy < 1 kcal/ml • Intralipid ? • Dilution of dextrose/aminofusion with Intralipid

10. Parenteral Nutrition • Peripheral Parenteral Nutrition (15 lit D5W/day for a 70 kg !!!) • Central Parenteral Nutrition (TPN) • needs CV-line to administer hyperosmolar solutions Osmolarity: (%Dex × 50) + (%Aminoacid × 100) 150 mOsmfor electrolytes, …

11. Subclavian PICC Jugular Femoral (more infection !) PICC: Peripherally inserted central catheter

14. Peripheral Vein thrombophelebitis • Hydrocortisone 5 mg/L • Heparin 1000 U/L • Topical nitroglycerin • Concurrent administration of intralipid? • Decreases osmolarity, buffers the pH, and improves peripheral vein tolerance, it does not eliminate the risk of thrombophlebitis.

15. Estimation of energy expenditure Weight & metabolic state Harris-Benedict equations: • BEE (M) (kcal/day) : 66.47+13.75W+5H-6.76A • BEE (F) (kcal/day) : 65.51+9.56W+1.85H-4.68A • BEE: 20-25 kcal/kg/day • TEE (kcal/day): BEE × Stress factor × Activity factor

16. Stress factors: • Surgery: 1.1-1.2 • Infection: 1.2 • Trauma: 1.5 • Sepsis: 1.6 • Burns: 1.6-2 Activity factors: • Confined to bed: 1.2 • Out of bed: 1.3 • Normal activity: 1.5

17. Estimation of protein requirement Hypermetabolic/hypercatabolic state secondary to trauma or burn: 2 g/kg/day

18. Components of TPN Formulations Macro: Calorie: Dextrose 20%, 50% Intralipid 10%, 20% Protein: Aminofusion 5%, 10% Fluid Micro: Electrolytes (Na, K) Minerals (Mg, Ca, PO4) Trace elements (Zn, Cu, Cr, Mn, Se) Vit (A, E, C, B, Folic acid)

22. Dextrose • 20%, 50% (from CV-line) • 3.4 kcal/g • 60-70% of calorie requirements should be provided with dextrose

23. Special Considerations • Max infusion rate of dextrose: 0.5 g/kg/h (to avoid hyperglycemia, glycosuria, fatty liver, hyperosmolar coma) • Max rate of dextrose metabolism : 5 mg/kg/min or 7 g/kg/d • “K” should be added to dextrose solutions • If BS > 200, Insulin should be added • 0.1 U/g Dextrose

24. Aminofusion • 5%, 10% (from CV-line) • 1-1.5 g/kg/day • Should not be used as a calorie source

25. Estimation of Protein Requirements • RDA 0.8 g/kg/day • Hospitalized patient, minor stress 1–1.2 g/kg/day • Moderate stress 1.2–1.5 g/kg/day • Severe stress 1.5–2 g/kg/day

29. Na 43 mmol/L • K 25 mmol/L • Mg 2.6 mmol/L • Acetate 59 mmol/L • Cl 57 mmol/L • H2PO4 9 mmol/L

31. Intralipid • 10%, 20% (from peripheral or CV-line) • 30-40% of calorie requirements should be provided with Intralipid • Serum TG level must be < 400 mg/dl • Max. 2.5 g/kg or 60% total calories

32. 1022 Kcal/L 345 mOsmol/L

33. 1080 Kcal/L 1 liter contains: A-     Active constituents: -          Glycerine (glycerol) 25g -          Phospholipids from egg 6g -          Soya beans 100g B-     Other Constituents: -          Sodium Oleate, Sodium hydroxide & water Total energy= 1080Kcal/L

35. An important solution • Concentrate isotonic solution • Source of essential FFA • Substitute for CHO for ventilated pts.

36. Caloric density of intravenous nutrients

37. Electrolytes (daily requirements for TPN):

39. Recommended adult daily dose of parenteral vitamins

40. Available dosage form for parenteral rout • Amp Vit A: 50000 IU • Amp Vit D: 300,000U • Amp Vit K: 1, 10 mg ??!! • Amp Vit E: 100 IU • Amp Vit C: 500 mg • Amp Vit B complex • Amp Vit B12: 100, 1000 mcg • Amp Soluvit (Fressenius)

45. Vitalipid INDICATIONS Vitalipid N Adult is indicated as a supplement in complete intravenous nutrition to meet the daily requirements of the fat-soluble vitamins A, D2, E and K1. As above, Vitalipid N Infant is indicated in paediatric patients up to 11 years of age.

46. The vitamins are soluble in the oil phase of the emulsion, which has the composition corresponding to that of Intralipid 10%. • The daily maintenance dosage of the vitamins A, D2, E and K1 are supplied during intravenous nutrition when: • (i) 10 mL of Vitalipid N Adult are added to 500 mL Intralipid 10% or 20%. • (ii) 1 mL of Vitalipid N Infant per kg bodyweight per day up to a maximum of 10 mL is added to Intralipid 10% or 20%.