Transcript Hospital Pharmacy Rotation TPN Principle

Done by:
Anessa
Aisha
Ohoud
Under Supervision of: Dr/Ahmed fallata
OUTLINES
Basic concept
Components
TPN
Complications
Stability and
compatibility
Definition:
Total Parenteral Nutrition (TPN) is the
administration of Glucose, Amino acid, Intralipid,
Electrolyte (Na, K, Cl, Mg, Ca, and PO4), Trace
Elements (Zn, Cu, Mn, Se, and Cr) and Vitamins
(water and fat soluble) in a concentrated form
through central or peripheral routes.
GOAL OF THERAPY
-To provide nutrients in a safe and effective
manner.
-To provide energy and substrate to continue
growth rate and promote healing.
-To decrease or minimize catabolism of visceral
protein mass.
-Reduce catabolism & Allow anabolism.
-Build up and storage.
If the gut works,
use it
If the gut works partially,
use it partially
Indications:
1- patient with an inability to absorb nutrients via
the gastrointestinal tract.
This includes severe malabsorption, short bowel
syndrome, intractable vomiting or diarrhea, and
radiation enteritis, etc.
2- patients with severe acute pancreatitis requiring
bowel rest.
Cont…
3- severe malnutrition or catabolism when the
gastrointestinal tract is not usable within 5 days.
4- patient where adequate enteral nutrient intake
cannot be established within 7 to 10 days.
5- patient without ability to be enterally fed who will
benefit from preoperative nutrition support to
boost immune function.
Contraindication
1- Patients who have a functional and usable
gastrointestinal tract capable of absorption of
adequate nutrients.
2- Treatment anticipated for less than 5 days in
patients without severe malnutrition.
3- When the risks of parenteral nutrition is judged
to exceed potential benefits.
Routes of administration:
1-Peripheral venous access:
2-Central venous access:
Maximum Osmolarity in
Neonates=1100/L
Pediatric=1000/L
Adult=900/L
Advantages:
- Does not require surgery
- Less risk of sepsis
- No risk of mechanical
complications
Disadvantages:
- High risk of
thrombophlebitis
- Painful
Usual Osmolarity>2000mOsmol
Advantages:
- Can provide full nutritional
support
- No risk of thrombophlebitis
- No pain
Disadvantages:
- Requires surgery
- More risk of sepsis
- High risk of mechanical
complication
Parentral Nutrition Components
MACRONUTRIENT
MICRONUTRIENT
MACRONUTRIENT:
1-Water
Adult requirements:
Pediatrics requirements:
-1500 ml/meter square
-35 ml/kg/d
Based on the body
weight
0-10 kg =100 ml/kg/d(4
ml/kg/h)
-1500 ml/d+20 ml/kg/d
for each kg>20 kg
10-20 kg =1000
ml+50ml/kg/d
Any kg> 20kg =1500
ml+20ml/kg/day
2- Dextrose
-Use as energy sources.
-It is needed for Central Nervous System
and for red and white blood cells.
-It is very important for wound healing.
-It is available in concentration of 2.5%-70%.
CONT…
1gm of dextrose =3.4 kcal
Adult dose:
2 mg/kg/min up to 5 mg/kg/min
Pediatric dose:
6 mg/kg/min up to 16 mg/kg /min
Can we accept a TPN order without
Dextrose?
NO
• Protein is not utilized without dextrose.
3-Protein (Amino Acids):
 Amino acids used as source of protein.
 It is available in conc. From 6.5%-16%.
 Product containing only essential amino acids have
been formulated for renal failure.
 BCAA (branched chain amino acids) are used
for hepatic encephalopathy or in severely
stressed patients.
Usual dose of amino
acids:
 For adult:
0.5-2 gm/kg/day.
 For pediatric:
0.5-3 gm/kg/day.
Can we accept a TPN order without protein?
NEVER
4-Lipid Emulsion:
 Use as energy sources.
 Use to provide essential fatty acid.
Why we used lipid 20% more than
10%?
20%




More condense calories.
Less phospholipids.
Less cholesterol.
less triglyceride .
 Containing Olive oil.
There are 2in1 and 3in1 solution (why?)
Lipid monitoring parameter:
 Serum triglyceride.
 CBC.
 Liver function test.
MICRONUTRIENT:
1-Electrolytes:

They are necessary components for maintenance
of cellular function include Acid-Base balance and
cellular growth.
The quantity of electrolytes
which should be added to the
TPN depend on:
 The patient existing electrolyte imbalance.
 The existing of abnormal sources
of electrolyte loss: as in diarrhea , nasogastric
suction or in fistula
Adult basic requirements:
 Sodium : 70-100 mmol /d .
 Potassium : 70-100 mmol / d.
 Calcium : 5-7 mmol / d .
 Magnesium :8-10 mmol / d.
 Phosphate : 10-15 mmol / d.
Pediatric basic requirements:
 Sodium : 2-4 mmol /kg / d .
 Chloride : 2-4 mmol /kg / d .
 Potassium : 2-4 mmol /kg/ d.
 Calcium : 0.25-1 mmol /kg/ d .
 Magnesium :0.25-0.5 mmol /kg / d.
 Phosphate : 0.5-1 mmol /kg / d.
2-VITAMINS:
• They are necessary for the maintenance
of normal metabolism and cellular function
of the body.
 There are two types of vitamin:
1- Fat-Soluble Vitamin (A, D, E, K) stored in
body fat tissue.
2- Water-Soluble Vitamin.
• Vitamins are added according to RDA.
Role of vitamins:
 Vitamin B-complex:
co-enzyme in absorptive ,metabolic,and transfer
processes.
 Vitamin C:
require for collagen synthesis and wound healing.
 Fat soluble vitamins:
For vision , Ca and phosphate balance
also as antioxidant.
Maximum Duration of the TPN
without vitamins:
NEONATE:
ADULT:
PEDIATRIC:
7
DAYS
5
DAYS
2
DAYS
3-Trace Elements:
 They are required in very small amount for
biochemical and physiologic function.
 They include:
Zinc, copper ,manganese , chromium , selenium.
Trace elements have role in:
- Nerve conduction.
- Muscle contraction.
- Membrane transport.
- Mitochondria stabilizing.
-and also in the protein and nucleic acid synthesis.
Maximum Duration of the TPN without
trace elements:
ADULT:
17
DAYS
PEDIATRIC:
7
DAYS
NEONATE:
3
DAYS
TPN without:
NO
- K or phosphate.
- Lipid for up to 5 days.
- Multivitamin for up to 7 days.
- Trace elements for up to 10 days.
4-ADDITIONAL ADDITIVE AS NEEDE :
INSULIN:
For hyperglycemia when glucose is spilling in urine.
HEPARIN:
To promote blood circulation especially with peripheral
TPN and to prevent thrombophlebitis.
HYDROCORTISONE:
To prevent thrombophlebitis in patients receiving
peripheral TPN.
Cont…
ACETATE:
For acidosis.
ZINC:
Extra amount is needed for patient with sever
stress, diarrhea, ileostomy output.
IRON DEXTRAN:
For prophylaxis and treatment of anemia.
Baseline studies:
- Na, K, Cl, CO2, BUN, creatinine, Ca, PO4, Mg.
- Cholesterol, triglycerides, albumin, transferrin, or
prealbumin, PT, complete blood count, and liver
functions.
- Blood glucose levels several times first few days.
Baseline studies:
- Electrolytes daily first 2-3 days, then 2-3 times per
week.
- Fluid balance daily until stable. Weights daily until stable
then 2-3 times per week.
- Evaluate nitrogen balance weekly or as needed .
- Visceral protein status should be evaluated as needed .
COMMON METABOLIC COMPLICATIONS:
1. Glucose intolerance:
-Start with no more than 150 grams dextrose.
-Increase by 50-75 g per day if blood sugars are
stable and less than 200 mg/dl.
-Reassess number of calories and grams of dextrose
for possible adjustment before ordering insulin.
-Regular insulin may be added to parenteral solution.
METABOLIC COMPLICATINS
2. Electrolyte imbalances: can be corrected by
modifying the electrolytes in the parenteral
formula.
3. Hyperlipidemia: can sometimes be corrected by
slowing or stopping the lipid infusion. Decreasing
amounts of dextrose is sometimes helpful.
4. Essential fatty acid deficiency: can be corrected
by increasing the lipid solution.
FREQUENT INFECTIOUS COMPLICATIONS
1. Fever: decision to remove a central catheter
must be individualized. Examine the patient and
obtain appropriate cultures. Watch for 24 hours
and if source of infection is not apparent at the
end of that time, remove catheter.
2. Clotted catheters: can be cleared with 5000 units
of Urokinase infused into the catheter.
TPN TERMINATION:
•
TPN solutions can be discontinued several
different ways based on the situation and
strength of solution.
2. PPN may be discontinued as desired without
tapering.
3. If TPN needs to be stopped more quickly, it can
be tapered by halving the rate of infusion each
hour. (Why?)
4. If TPN is abruptly terminated, infuse a 10%
dextrose solution .
Ready to use TPN NuTRIflex® System:
• The NuTRIflex® System is the
"ready to use" multi chamber bag
system for total parenteral
nutrition (TPN).
• The 2- and 3-chamber bags of
the NuTRIflex® System offer
the metabolic and technical
advantages of an all-in-one
system.
• They have a long shelf life
without the necessity of cooling
during transport and storage.
The NuTRIflex® System
• Even though the NuTRIflex® System
consists of standardized TPN regimens, the
wide product range combined with the
possibility of making additions, allows highly
flexible adaptation to specific patient needs.
How to use NuTRIflex® System:
1-Always start by pressing the upper
left chamber to mix with the lower
chamber.
2-Added electrolytes and trace
elements via the additive port (red
cap)
3-Finally, press the upper right
chamber containing lipid emulsion to
mix with the lower chamber and
add vitamins.
How to use NuTRIflex® System:
4-Mix thoroughly before inserting the
giving IV set.
5-To save space, fold the bag and hang
it on the drip stand using the loop.
The benefit of NuTRIflex® System
• Convenient Makes clinical nutrition
easy, Reduces work load.
• Cost-effective Reduces total costs for
TPN.
• Safe Prevents therapeutic errors.
Stability and Compatibility of TPN:
1- Macronutrient:
Studies have shown that dextrose, amino acid
solutions are chemically stable for 1to2 month if
stored in the refrigerator and protected from
light.
When amino acid solutions stored at room
temperature.As a result the solution will have a
color change to dark brown color.
2-Electrolytes:
• As the calcium and phosphrous concentration
increase, the likelihood of calcium phosphorus
precipitation becomes greater.
• Addition of lipid to the parentral nutrition solution
is a problem for calcium and phosphrous solubility
(why?).
• Sodium bicarbonate should not be added to
parentral nutrition solution because calcium
carbonate crystal may be formed.
Factors which worsen calcium phosphrous
solubility:
-Addition of calcium chloride
-Body heat
-Lower amino acid concentration
-Addition of lipid
-Increase concentration of calcium and phosphrous.
-Incorrect order of mixing
3-Drugs:
Rarely drug incompatibilities are an issue. However
when access is limited drug compatibility becomes
an issue.
Some of drugs known to be incompatible with
parentral nutrition solutions:
Acyclovir, Cyclosporin, Morphin, metronidazole,
Phenytoin, Aminophylline and tetracycline……etc.
Take home messages:
• The main goal of TPN is to provide nutrients in a
safe and effective manner.
• We can not accept TPN without dextrose or amino
acid.
• lipid 20% used more than 10%.
• Vitamins are added according to RDA.
Cont…
• There are 2 types of TPN complications.
• Ready to use system most convenient, costeffective and safe one.
• Addition of lipid to the parentral nutrition solution
is a problem for calcium and phosphrous solubility.
Finally,
NO TPN may be safer than
Incomplete
Non-balanced
Non-monitored
Non-calculated
TPN
Little Nutrition is Good,
Too much is
Lethal
References:
-www.nutrition.com
-http://www.nutritionpartner.com/index.cfm
-www.clinnutr.org
-www.eatright.org/
-www.hostindia.com/ispen