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TOTAL PARENTERAL NUTRITION By: Satheesh jogala M Pharm (1st sem) Industrial pharmacy St Peter’s Institute of Pharmaceutical Scienes Vidyanagar, Hanamkonda




INTRODUCTION "Parenteral" means administered any other way except by the mouth."Nutrition" means feeding."Parenteral nutrition" means feeding someone via their blood stream, "intravenously“ "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. TPN is also called hyperalimentation, is the practice of feeding a person without using the gut. It is normally used during surgicalrecoveries. It has been used for patients in coma, although enteric (tube) feeding is usually adequate, and less prone to complications

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CONDITIONS Inflammatory bowel disease Fistula >1500 cc output per day Obstruction of GI tract Acute pancreatitis Major gastrointestinal surgery Ischemic bowel INDICATIONS 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


COMPONENTS Carbohydrates: (Dextrose 3.4Kcal/gm) Fat: 9 kcal/gm Proteins: (non-calorie) 4Kcal/gm Electrolytes: Na 60-150 meq K 40-140 meq Ca 3-30 meq Mg 10-30 meq Phos. 30-50 millimoles

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Trace elements: Zinc 2.5-4 mg Copper 0.5-1.5mg Chromium 10-15 mcg Manganese 0.15-0.8 mg Vitamins A, D, C, E, Pyridoxine, Cobalamine, Riboflavin, Thiamin, Pantothenic acid, Biotin, folacin, Niacin.


CALCULATIONS Macronutrient Concentrations in PN Solutions Macronutrient concentrations (%) = the grams of solute/100 ml of fluid D70 has 70 grams of dextrose per 100 ml. 10% amino acid solution has 10 grams amino acids/100 ml of solution 20% lipids has 20 grams of lipid/100 ml of solution

Protein content calculations : 

Protein content calculations To calculate the grams of protein supplied by a TPN solution, multiply the total volume of amino acid solution (in ml*) supplied in a day by the amino acid concentration. Example Protein Calculation 1000 ml of 8% amino acids: 1000 ml x 8 g/100 ml = 80g Or 1000 x .08 = 80 g

Calculation of Dextrose Calories : 

Calculation of Dextrose Calories Calculate grams of dextrose: Multiply the total volume of dextrose solution (in ml) supplied in a day by the dextrose concentration. This gives you grams of dextrose supplied in a day. Multiply the grams of dextrose by 3.4 (there are 3.4 kcal/g dextrose) to determine kcalories supplied by dextrose in a day.

Sample Dextrose Calculation : 

Sample Dextrose Calculation 1000 ml of D50W (50% dextrose) 1000 ml x 50g / 100 ml = 500g dextrose OR 1000 ml x .50 = 500g dextrose 500g dextrose x 3.4 kcal/g = 1700 kcal

Calculation of Lipid Content : 

Calculation of Lipid Content To determine Kcalories supplied by lipid , multiply the volume of 10% lipid (in ml) by 1.1; multiply the volume of 20% lipid (in ml) by 2.0. If lipids are not given daily, divide total Kcalories supplied by fat in one week by 7 to get an estimate of the average fat Kcalories per day.

Calculating the Osmolarity of a Parenteral Nutrition Solution : 

Calculating the Osmolarity of a Parenteral Nutrition Solution Multiply the grams of dextrose per liter by 5. Example: 100 g of dextrose x 5 = 500 mOsm/L Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L Multiply the grams of lipid per liter by 1.5. Example: 40 g lipid x 1.5 = 60. Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2 Example: 80 X 2 = 160 Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L


CENTRAL VENOUS CATHETERS Location Subclavian Veins Internal Jugular Veins Femoral Veins Brachial Veins Types Non-tunneled Tunneled Cordis Hickman Swan Ganz Broviac Double Lumen Portacath Triple Lumen PICC

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Mechanical Complications Clotted catheter Venous thrombosis Air embolism Precipitation Septic Complications Fever Hematogenous seeding Contaminated fluids Central line site Erythema, tenderness, or purulent rainage Common organisms Staph epidermidis & Staph aureus Diagnosis Blood culture with a Maki tip culture

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Prevention of Sepsis · Handwashing · Insertion Technique—aseptic technique · Skin cleansing at site of insertion · Keeping dressings dry, occlusive, and drainage-free · Changing lines over wire using sterile technique · Changing pulmonary artery catheters every five days · Use central venous catheters only when necessary · Not accessing TPN frequently Antibiotic-coated catheter · Routine changing of catheters · Silver-chelated catheters

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Mechanics for solution administration 1. Rates of administration The solution is generally started at 25 ml/hr and the rate is gradually increased. The purpose is to allow the body to adapt to the high concentration of sugar in the solution. In the presence of significant hyperglycemia, the rate should not be increased until control has been established. In a similar fashion, when the solution is discontinued, a tapering procedure much like the starting procedure, is used to prevent rebound hypoglycemia. If the solution must be discontinued abruptly for any reason, another solution of dextrose (5% or 10%) should be started to prevent hypoglycemia from occurring.

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2. Control Device To assure the accuracy of the infusion rate, TPN should be administered via an IV control device, preferably a volumetric pump. 3. Filters In the process of solution preparation, it is possible for a particulate matter (glass, fibers, etc.) to enter the solution. For this reason, inline filters are used in the administration of TPN solutions. A 0.22 micron filter will remove most particulates and any organisms which might be present in the solution.


COMPLICATIONS Complications are classified into 3 types. Metabolic complications Catheter complications Septic complications

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Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver, cholestasis) Metabolic bone disease Vascular access sepsis Refeeding syndrome: Symptoms Reduced serum levels of magnesium, potassium, and phosphorus Hyperglycemia and hyperinsulinemia Interstitial fluid retention Cardiac decompensation and arrest

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Prevention and treatment Monitor and supplement electrolytes, vitamins and minerals prior to and during infusion of PN until levels remain stable Initiate feedings with 15-20 kcal/kg or 1000 kcals/day and 1.2-1.5 g protein/kg/day Limit fluid to 800 ml + insensible losses (adjust per patient fluid tolerance and status)

Acid-Base Balance : 

Acid-Base Balance Balance chloride and acetate to maintain/achieve equilibrium The standard acetate/chloride ratio is 1:1 Increase proportion of chloride with metabolic alkalosis; increase proportion of acetate with metabolic acidosis

Metabolic Acidosis Etiology : 

Metabolic Acidosis Etiology Increased renal or GI loss of bicarbonate Addition of strong acid or under excretion of H+ ion Ketoacidosis Renal failure Lactic acidosis Excessive Cl- administration

Metabolic Acidosis Treatment : 

Metabolic Acidosis Treatment Determine and treat underlying cause Prove acetate forms of electrolytes with HCO3 losses Decrease chloride concentration

Metabolic Alkalosis Treatment : 

Metabolic Alkalosis Treatment Determine and treat underlying cause Increase Cl- when alkalosis is due to diuretics Metabolic Alkalosis Etiology loss of H+ ion from increased gastric losses Excessive base administration Contraction alkalosis


PRECAUTIONS Tell to doctor and pharmacist if the patient is allergic to any drugs. Tell to doctor and pharmacist what prescription and nonprescription medications are taking, especially dexamathasone (Decadron); medications for diabetes, high blood pressure, or heart disease; prednisone; tetracycline; and vitamins. Tell to doctor if patient have or have ever had diabetes or heart, kidney, liver, lung, or Addison's disease. Tell to doctor if patient is pregnant, plan to become pregnant, or are breast-feeding, so that the risks and benefits of receiving TPN can be discussed.

Side Effects : 

Side Effects Mouth sores, poor night vision, skin changes, fever or chills, stomach pain, difficulty breathing, rapid weight gain or loss, increased urination, upset stomach, vomiting, confusion,or memory loss,muscle weakness, twitching, or cramps, swelling of the hands, feet, or legs, thirst ,fatigue ,changes in heartbeat ,tingling in the hands or feet ,jumpy reflexes ,convulsions or seizures

Conclusion : 

Conclusion The goal in parenteral nutrition is to provide all required nutrients in a fluid volume that is well tolerated. The composition of TPN consists of carbohydrates, fats, proteins, electrolytes ,vitamins and other nutritional substances which are essential especially during the condition where the patient is unable to take the food orally. Although administration of TPN involves several contraindications ,it is most useful approach to meet the malnutrition.

References : 

References Sizer T. Standards and Guidelines for Nutritional Support of Patients in Hospitals. A report by a Working Party of the British Association for Parenteral and Enteral Nutrition, 1996.  Pennington CR, Parenteral Nutrition, Intestinal Failure, 2001; 23 497-511  Malnutrition Universal Screening Tool (MUST). Maluntrition Advisory Group A Standing Committee of BAPEN. 2003 Griffiths, RD et al. Six month outcome of Critically Ill patientys given Glutamine Supplemented Parenterla Nutrition. Nutrition, April 1997; Vol. 13 No. 4 p295-300

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5. Dynamics in normotensive and hypertensive conditions. JAMA 1948:137:1569  6. Solomon SM, Kirby DF. The refeeding syndrome: a review. JPEN 1990;14:90  7. Nasarway SA Jr. Hyperglycaemia during critical illness. JPEN 2006 May-Jun;30 (3): 254-8 Brozek J, Chapman CB, Keys A. drastic food restriction: effect on cardiovascular  8. National Institute for Health and Clinical Excellence (NICE).Nutrition support in adults. Clinical Guideline 32 February 2006

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