Transcript Total Parenteral Nutrition (TPN)
Total Parenteral (TPN) Nutrition
By: E. Salehifar (Clinical Pharmacist)
Malnutrition
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)
Parenteral Nutrition
Peripheral Parenteral Nutrition (15 lit D5W/day for a 70 kg !!!) Central Parenteral Nutrition (TPN) Needs CV-line to administer hyperosmolar solutions
Estimation of energy expenditure
Harris-Benedict equations:
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
30-40 mL/kg
Fluid: mL/day
Protein (amino acids)
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
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
Acute failed: management when other treatments have With encephalopathy: 0.6-1 g/kg/day Without encephalopathy: 1-1.5 g/kg/day Chronic encephalopathy Use branch chain amino acid enriched diets only if unresponsive to pharmacotherapy Pregnant women in second or third trimester Add an additional 10-14 g/day
Fat
Initial: 20% to 40 % of total calories (maximum: 60% of total calories or 2.5 g/kg/day) 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: Protein: Micro:
Dextrose 20%, 50% Intralipid 10%, 20% Aminofusion 5%, 10% 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
D20W D30W D40W
For 1000 ml solution
D50W
250 ml
D10W
750 ml
D5W
----- 333 ml 500 ml 555 ml 750 ml 778 ml ----- 500 ml ---- 250ml ----- 667 ml ----- 446 ml ----- 222 ml
Dextrose: Contraindications
Hypersensitivity to corn or corn products Hypertonic solutions in patients with intracranial or intraspinal hemorrhage
Abrupt withdrawal
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
1022 Kcal/L 345 mosmol/L 1080 Kcal/L
Intralipid: Contraindication
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 1030 mosmol/L 200 kcal/L 590 mosmol/L
Amino acids: Contraindications
Hypersensitivity to one or more amino acids Severe liver disease or hepatic coma
Case
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,
for 7 days nausea & vomiting
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
month ago.
6
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?
BEE=
66.47+13.75
× 60+5 × 180-6.76
× 38=1535 kcal/d
TEE=
1535 × 1.2
× 1.2 = 2200 kcal/d 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)
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
Vitamins:
A, D, E, Water soluble vitamins
Trace Elements:
Zn, Se, Cu, Cr, Mn
↓ Zn
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
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
Intralipid contraindications:
Severe egg allergy Hyperlipidemia
Special aminoacid products:
Hepatamine:
for Hepatic Failure ↑ branched chain aa ( leu, isoleu, val) Nephramine: for Renal Failure Primarily essential aa with lower concentrations
Monitoring:
Baseline:
Wt, Na, K, BUN, Cr, Glu, Ca, P, Mg, CBC, PT, INR, TG, LFT, Alb, Pre-Alb
Daily:
Wt, V/S, I-O, Na, K, BUN, Cr, Glu, Sign/Symptoms of infection
2-3 times a week:
CBC, Ca, P, Mg
Weekly:
Alb, Pre-Alb, LFT, INR, Nitrogen Balance
Adding other drugs to TPN
INS Heparin H2-blocker Alb Aminophylline
Vit K & Bicarbonate should not be added
Complications
Endocrine & metabolic Fluid overload, hypercapnia, hyperglycemia, hyper /hypokalemia, hyper-/hypophosphatemia, refeeding syndrome Hepatic Cholestasis, cirrhosis (<1%), gallstones, liver function tests increased, pancreatitis, steatosis, triglycerides increased Renal Azotemia, BUN increased Infectious Bacteremia, catheter-induced infection, exit-site infections Other: Pneumothorax, Thrombophlebitis
Refeeding syndrome
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 Do not overfeed patients; caloric replacement should match as closely as possible to intake
Conclusion
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