basic principles of TPN

2. TOTAL PARENTERAL NUTRITION
-DR. RESHMI HARIKUMAR PILLAI
-GUIDE:DR. NEERA SAMAR
RNT MEDICAL COLLEGE AND MB GOVT HOSPITAL
DEPARTMENT OF MEDICINE
SEMINAR

3. SPECIALISED NUTRITIONAL SUPPORT
OPTIMISED
VOLUNTARY
NUTRITIONAL
SUPPORT
FORCED ENTERAL
NUTRITION
PARENTERAL
NUTRITION

4. OVERVIEW
•DEFINITION
•PRINCIPLES OF NUTRITION
•PLANNING OF PARENTERAL NUTRITION
•ADVANTAGES
•DISADVANTAGES
•DELIVERING PARENTERAL NUTRITION
•DESIGNING PARENTERAL NUTRITION FORMULA
•INITIATION OF PN
•MONITORING OF PN
•TERMINATION OF PN
•COMPLICATION
•NUTRITIONALASPECTS OF SPECIFIC DISEASE

5. DEFINITION
Total Parenteral Nutrition(TPN) is a modality of specialized nutritional
support and it encompasses delivery of a complete nutritional regimen
directly into the blood stream in the form of crystalline amino
acids,dextrose,triglyceride emulsions,minerals ,electrolytes and
micronutrients without the use of the gastrointestinal tract.

6. PRINCIPLES OF NUTRITION
•Avoid malnutrition
•If the bowel is functioning,use it
•Avoid overfeeding-hyperglycemia, hepatic steatosis, increased BUN, increased
CO2 production
•Limit protein wasting(Stress-Catabolic state) + Supply essential nutrients

7. EN IS PREFERRED OVER PN BECAUSE:
•Maintains mucosal protection
•EN Supplies gut preferred fuels
•More physiological; liver is not by passed
•Prevents cholelithiasis
•Fewer serious complications
•Less costly, low maintenance

8. CONTRAINDICATIONS TO ENTERAL NUTRITION:
•GI causes: Paralytic ileus, intestinal obstruction, severe GI bleed
•Cardiac cause: Hemodynamic instabililty(GI Ischemia)
•Lack of access: Unable to get safe access to GIT
•Complications of enteral feeding: Aspiration,intestinal ischemia

9. ADVANTAGE OF PARENTERAL NUTRITION OVER ENTERAL
NUTRITION:
•Ensured, desired volume of delivery of nutrition
•Improved metabolic, electrolyte, micronutrient management
•Better acid base manipulation
•Drug delivery capability

10. CONTRAINDICATIONS TO PARENTERALNUTRITION
GENERAL
•Enteral nutrition meets/exceeds
requirement
•Good nutritional support(short
term)
•Severe liver failure, cardiac failure
•Fluid and electrolyte imbalance
DISEASE SPECIFIC
•Avoid excess
carbohydrate:compromised
pulmonary function
•Avoid lipid
administration:TG>350mg/dl,
severe sepsis
•Hepatic encephalopathy/Renal
failure

11. GOALS OF PARENTERAL NUTRITION
•To maintain or improve nutritional status by providing all nutrients
•To minimize the deleterious effects of catabolism
•To boost immune function and wound healing
•To improve cardiac and respiratory muscle function by restoring glycogen storage
•To maintain or correct acid base and electrolyte disturbances
•To accelerate rehabilitation and improve the quality of life

12. PLANNING OF PARENTERAL NUTRITION

13. 1. Selection of patient
2. Calculation of nutritional requirement
3. Select and establish appropriate route of administration
4. Prescribe parenteral nutrition
5. Administration, monitoring and avoiding complications of parenteral nutrition

14. INDICATIONS OF PARENTERAL NUTRITION

15. •GENERAL INDICATIONS
-Inadequate oral / enteral nutrition for 7-10 days
-Preexisting severe malnutrition
•INADEQUATE ORAL/ENTERAL INTAKE
-Conditions which impair nutrient absorption
-Need for bowel rest
-Motility disorder
-Inability to achieve / maintain enteral access
•SIGNIFICANT MULTIORGAN SYSTEM DISEASE

16. NUTRITIONAL REQUIREMENTS
FLUID REQUIREMENT= Abnormal loss + Daily requirement (35ml/kg or 1500ml
for 20ml/kg body weight + 20ml/kg for additional weight)
ENERGY REQUIREMENT:
1. Calculation based on calories per kg body weight
2. Harris Benedict Equation(REE) + additional calories(activity/illness)
3. Energy expenditure with indirect calorimetry

18. TEE= REE X AF X DF X TF

19. ENERGYREQUIREMENTS OFAPATIENTON PN
50-70% Carbohydrate (1 gram dextrose= 3.4kcal)
20-30% Fat (1 gram lipid =9 kcal)
15-20% Protein (1 gram protein =4 kcal)
Mixture- Glucose: Fat=70:30(reduces CO2 production and thereby work of
breathing)
The benefits of constraining glucose, lipid and fluid volume provision justify
hypocaloric nutrition in the first 2 weeks of SNS.
AVOID OVERFEEDING !

20. CARBOHYDRATE
ADVANTAGE/FUNCTIONS:
•Low cost
•Supplies calories
•Nitrogen sparing effect
DISADVANTAGE
•Low calorie supply
•Increased CO2 production
•Thrombophlebitis
MOST CPN USE 50-70% conc diluted to 15-30%

21. DEXTROSE INFUSIONAND MONITORING
•Max rate of dextrose oxidation = 5mg/kg/min(7.2g/kg/day)
•Maintain blood glucose = 120-180 mg/dl
•Avoid excess glucose: Hyperglycemia, Hepatic steatosis, excess CO2 presentation
•Initial dose of glucose shouldnot exceed 200g/dayincrease dosing on a daily basis
until requirement is met

22. •GLUCOSE INFUSION RATE : (Shouldnot exceed)
-Non critically ill~ 500g(1700kcal)/day
-Critically ill ~350g(1200kcal)/day
•INSULIN:-Basal endogenous Insulin secretion= 30U/day
• - Non diabetic-10U regular Insulin/ 100g dextrose
-IDDM-Twice the -at home dosage
-NIDDM-20U/100g dextrose

24. FAT
•Lipid emulsion : IV source of fat, calories, EFA(linoleic/linolenic acid)
•CONTENTS: Long chain triglycerides, egg yolk phospholipids, glycerin
•CALORIC VALUE, PREPARATIONS AND REQUIREMENTS:
•Richest source of calories(9kcal/g)
•20-30% of total calories ; max dose 50g(500kcal)/day in critical illness ;infused 2-3
times weekly
•Lipid emulsions are usually added after the first week

25. FUNCTION/ADVANTAGE:
•Energy dense
•Protein/ Glucose sparing
•Less CO2 production
•Prevents EFA deficicency
•Reduced risk of thrombophlebitis
DISADVANTAGE
•Increased TG levels
•Sepsis
•Fat embolism
•C/I:TG>350mg/dl,
acidosis,anemia,DIC,obese

26. •To prevent EFA deficiency: 3-4 days a week
•Calorie source: Daily
•Rate of Infusion : 0.7kcal/kg/hour iv over 12 hours
•Monitor TG levels weeks  Discontinue if TG>400mg/dl
•Modified preparations: LCTs , MCTs

28. PROTEIN
•Calorie supplied = 4Kcal/g
•6.25g protein contain 1 g nitrogen
•Concentration of amino acids in standard made solutions : 3-15%
•15-20% of total energy intake should come from protein
•Protein requirement : 0.8-1.5g/kg/day
-Lower- ckd, HE
-Higher-massive burn,trauma,hypoproteinemia,protein losing enteropathy

30. ADVANTAGE
•Calorie supplementation
•Protein synthesis
•Reduces rate of protein catabolism
CONTRAINDICATIONS
•Hepatic insufficiency:
•Renal Failure:
•Exacerbation of metabolic or
respiratory alkalosis
•Excess proteinexcess
urea(hypertonic dehydration)

32. MONITOR ADEQUACY OF PROTEIN INTAKE BY NITROGEN BALANCE
NITROGEN BALANCE= NITROGEN INTAKE-NITROGEN LOSS
NITROGEN LOSS={[24-UREA NITROGEN + 4 ] X 6.25 }
POSITIVE NITROGEN BALANCE = ANABOLISM

33. RECOMMENDED DAILYPARENTERALREQUIREMENTS OFNUTRIENTS

34. DELIVERING PARENTERAL NUTRITION
•ROUTES: Peripheral v/s Central
•SYSTEMS:Multiple bottle solution v/s Three in one
•DURATION: Continuous v/s cyclical

35. PERIPHERALPARENTERALNUTRITION
Goal : Provide enough calories for a short period(<2 weeks) which can prevent
malnutrition
Composition : Osmolarity<900mOsm/L
Low concentrated dextrose(5-10%),amino acids, calorie dense
lipids(20%lipid emulsion)

36. Indication:-Requirement for short period(<2 weeks);central venous catheterization not
possible, Sepsis in patient with CPN
Contraindication: High nutritional requirement, need fluid restriction, critically ill who
cannot tolerate high vol of PPN

37. CENTRALPARENTERALNUTRITION
•Goal: Provide maintenance nutrition and correct existing deficits
•Composition: Variable. Dextrose(50-70%) and amino acids(8.5-10%);
Osmolarity-1000-1900mOsm/L
•Selection of catheter for CPN: Polyurethane-short term use/Silicone rubber(months to
years)

38. Site of Insertion of Catheter for CPN
1. Short term central access: Infraclavicular approach to Subclavian vein
2. Long term central access: Tunneled catheter and implanted subcutaneous ports
;stable for long term use; Placed in the SCV/IJV and fed into theSVC

40. 3. Percutaneous inserted central catheter(PICC)
For 1 week – 6 months; distance between site of skin entry and catheter tip
minimizes risk of infection
Catheter is inserted into a vein in the antecubital area and threaded in to the
subclavian vein with the catheter tip in the superior vena cava

42. SYSTEMS OF DELIVERING PARENTERALNUTRITION
MULTIPLE BOTTLE SYSTEM
•Separate bags infuse various
required nutrients
•Ease of adjustment to rapidly
changing needs
•Needs proper monitoring-risk of
hyperglycemia/hypertriglyceridemi
a,incompatibility due to improper
mixing
‘THREE IN ONE’ SYSTEM
•All the components are placed in a
single bag
•Time saving/cost saving /less
handling/better assimilation due to
slow rate of infusion
•Less stability/flexibility/absence of
transparent colour

45. DURATION OF DELIVERING PARENTERALNUTRITION
CONTINUOUS
•Slow continuous infusion of PN by
infusion pumps avoids volume
overload
•Avoids
hyperglycemia,hypertriglyceridemi
a
•Provides requirement all day
CYCLICAL
•PN delivered over 8-10 hours
•Free period of 12-16 hours
•Safe for stable chronically ill
patients who require long term
nutrient support

46. DESIGNING PARENTERAL NUTRITION
FORMULA
1. Calculation of daily requirement of PN
2. Convert Requirement into Prescription
3. To prepare PN solution as per prescription, or to select an optimal commercially
available formula to deliver prescribed nutrients

47. CALCULATION OF DAILYREQUIREMENT OF PN

48. •Fluid requirement: ~35ml/kg
So 35(ml/kg) x 60(kg) = 2100 ml/day
•Caloric requirement: ~25kcal/kg
So 25(kcal/kg) x 60(kg) = 1500 kcal/day
•Protein requirement:1g/kg body weight 1(g/kg) x 60(kg) =60gram/day
1gram=4kcal; 60gm60x4= 240kcal
•Fat requirement: 30% of total calories
0.3x1500=450kcal , 1g fat=9kcal 450/9=50g fat
Carbohydrate requirement:Total calorie-(fat + protein); 1500-
(240+450)=810kcal810/4=202g dextrose

49. CONVERT REQUIREMENTS INTO PRESCRIPTION

50. (1).Determine vol of lipid emulsion : We will select 10% lipid emulsion
Fluid volume(ml)=Amt of substance x 100 = 50x100 =500ml fat
conc of substance 10
(2).Determine vol of amino acid infusion: We will select 10% amino acid inf
Fluid volume(ml)=Amt of substance x 100 = 60x100 =600ml aa sol.
conc of substance 10
(3).Selection of dextrose infusion
Remaining solution=2100-(500+600)=1000ml
Fluid volume(ml)=Amt of substance x 100
conc of substance
1000(ml)=202.5gmx 100 ; Conc of substance =20%
conc of substance
1000ml of 20% dextrose

51. To prepare PN solution or to select an optimal formula for prescription
•PN solutions may be made as per prescription not always feasible
•One or combination of more than one solution can be made from commercially
available solutions

55. INITIATION OF PN
•Initiate slowly: Use a volumetric infusion pump: 50% of goal on first day, 75%on
day2 , and 100% on third to fourth day
•PN solution: High in dextrose INITIATE SLOWLY.Allows pancreatic beta cells to
adapt.
•Severely malnourished : Precipitation of Refeeding Syndrome(MONITOR
ELECTROLYTES)

56. MONITORING OF PN
•Record vitals Q4h
•CXR: Check catheter placement
•Serum biochemistry-prior to initiation, then daily ,biweekly/SOS thereafter
•Daily weight monitoring
•Catheter site care and dressing
•Monitor for complication

57. TERMINATION OF PN
•Once patient is able to take 50-60% energy intake orally /enterally PN may be
stopped
•Transition PNEN/oral nutrition should be gradual
•Donot discontinue PN abruptly.Reduce infusion rate to 50% for 1-2 hours before
discontinuing PN.
•Need for abrupt discontinuation of PN ; D10 to be given (prevent hypoglycemia).

58. COMPLICATION
MECHANICAL METABOLIC/GI INFECTIOUS
FIRST 48 HOURS MALPOSITION
HAEMO/PNEUMOTHORAX
AIR EMBOLISM
BLOOD LOSS
PUCTURE OF SCA
FLUID OVERLOAD
HYPERGLYCEMIA
HYPERPHOSPHATEMIA
HYPOKALEMIA
HYPOMAGNESEMIA
REFEEDING SYNDROME
---
FIRST 2 WEEKS CATHETER DISPLACEMENT
CATHETER THROMBOSIS
CATHETER OCCLUSION
AIR EMBOLISM
HYPERGLYCEMIA COMA
ACID BASE IMBALANCE
ELECTROLYTE IMBALANCE
CATHETER INDUCED SEPSIS
EXIT SITE INFECTION
3 MONTHS ONWARDS FRACTURE/TEAR OF
CATHETER
CATHETER THROMBOSIS
AIR EMBOLISM
BLOOD LOSS
EFA/VITAMIN/TRACE
ELEMENT DEFICIENCY
METABLIC BONE DISEASE
TUNNEL INFECTION
CATHETER INDUCED SEPSIS
EXIT SITE INFECTION

60. •Hyperglycemia:
Osmotic diuresis  Osmotic diuresis and glycosuriaHyperosmolar dehydration
Risk factor:excess/rapid administration/metabolic stress/obesity/DM
Slow administration (2-3 mg/kg/min) and decreased amount (100-150 g/day) of
initial infusion,reduced dextrose and increased lipid
Target-120-180mg/dl; (20U Insulin per litre of PN solution OR Insulin drip 2-
5U/hour)

61. Hypoglycemia:
Reactive hypoglycemia is uncommon
Abrupt stoppage of high glucose ,no insulin containing formulations
Prevention : Slowing the PN infusion rate to 50ml/hour (or replacing it with D10)
Paitent’s metabolic stress (or glucocorticoid dose) decreases without appropriate
downward adjustment of Insulin dose
Artefactual Hyperglycemia and Hyperkalemia:
Incorrect technique of blood sampling

62. Volume Overload:
Hypertonic i.v dextroseIntense Insulin response
Insulin:Antinatriuretic and antidiuretic hormonePotentiates sodium and water
retention
Prevention:
Slower rate of dextrose infusion
Limit sodium intake:20-30mmol/day

63. •Hyponatremia
Cause: Excess hypotonic fluid,Adrenal insufficiency, CHF ,SIADH
Treatment: Fluid restriction, diuretics
Hypertriglyceridemia
Rate of lipid infusion >Plasma triglyceride clearance capacity
Factors reducing TG clearance:Renal failure,sepsis,diabetes,multiorgan failure

64. •Refeeding syndrome
-Starvation : Body adapts to less carbohydrate and more fat metabolism
-Carbohydrate refeeding  Insulin Secretion(Antinatriuretic effect)  Cellular
uptake of electrolyte + ECFV expansion
-Precipitation of left heart failure
-Hallmark: Hypokalemia, hypomagnesemia, hypophosphatemia
-C/F: Fluid overload, muscular weakness, glucose intolerance, cardiac arrhythmia

65. -Prevention: -Start PN gradually
-Only 1/3 of basal energy needs should be given in first 24 hours
-Glucose < 150g/day , Na < 20mEq /day , Total fluid< 800ml/day.
-Monitor electrolytes

66. •Hepatic abnormality
-Generally benign and temporary
-Complication – Biochemical(Transaminitis) or Histological(steatosis)
-Provide 20-40% calories as fat, reduce dextrose , cycling of infusion(stopping for
atleast 8-10 hours per day)

67. •Catheter sepsis
-M/c life threatening complication -15%
-Femoral>IJV>SCV
-Same organism is grown from catheter tip as is recovered from blood and C/F of
infection resolve with removal of the catheter
-Entry of organism at catheter site,contamination of tubings

68. CATHETER RELATED SEPSIS
(1)Evaluate insertion site and culture any drainage
(2)Blood C/S from peripheral vein /CVC
(3)Begin empiric antibiotic therapy
Purulent discharge/abscess at insertion site : Remove the catheter !
-Aseptic,USG guided insertion technique,meticulous dressing , one port dedicated
solely to PN

69. NUTRITIONALASPECTS OF SPECIFIC DISEASE
•Critical Illness
•Cancer
•Cardiac disease
•Pulmonary disease
•AKI
•Liver Disease
•Pancreatitis
•IBD

70. CRITICAL ILLNESS
•Metabolic Alterations: Hypermetabolism, hyperglycemia with Insulin
resistance,accelerated lipolysis,net protein catabolism
•Early PN –Severely catabolic states/EN not possible for 5-7 days
•Nutrition- SUPPORTIVE NOT THERAPEUTICslows down net protein
catabolism
•Energy expenditure doesnot exceed 2000Kcal/day

71. NUTRITIONALREQUIREMENTS IN CRITICALLYILLAND STABLE PATIENTS
CITICALLY ILL PATIENTS STABLE PATIENTS
PROTEIN 1.2-1.5g/kg/day 0.8-1g/kg/day
CARBOHYDRATE Not>4mg/kg/min Not>7mg/kg/min
LIPID 1g/kg/day 1g/kg/day
TOAL CALORIES 25-30kcal/kg/day 30-35kcal/kg/day
FLUID Min needed to deliver adequate
macronutrients
30-40ml/kg/day

72. CANCER
•Indication:
Chemo/RT induced GI toxicity preventing oral/enteral intake for more than one week
•Not used routinely. Provided only if clinical improvement with quality survival is
expected

73. CARDIAC DISEASE
•Indication : Postoperative complications which prevent the use of the GIT
•Postop Cardiac surgery:Risk of volume overload, hyponatremia, metabolic
alkalosis,uremia
•Avoid CHF: Use max concentrated PN solutions ; fluid and salt restriction; Use of fat
emulsion (9kcal/g)
•On diuretics: Requirement of K, Mg, Zn increases

74. PULMONARY DISEASE
‘’DEATH FROM STARVATION IS DEATH FROM PNEUMONIA’’
•MalnutritionProtein(skeletal muscle) catabolismmuscle wastingrespiratory
failuredecreased ventilatory drive and hypoxia
•Malnutritionreduced pulmonary defense mechanisminfection
•Refeeding restores ventilatory drive

75. NUTRITIONALREQUIREMENTS
•Recommended energy intake = 1.7x resting energy expenditure
•Lipid-preferred source of energy ; provides more energy with less CO2 production-
reduces work of breathing
•Avoid overfeeding(Dextrose:lipid=70:30)
•Low carbohydrate formula-weaning of patients
•Protein intake=1g/kg/day
•ARDS;fluid restriction if hemodynamic status necessitates
•Avoid hypophosphatemia,hypocalcemia,hypomagnesemia

76. AKI
ARF TREATED CONSERVATIVELY:
•Adjust /restrict fluid intake as per urine output in oliguric individuals. Use of max
concentrated PN solutions
•Avoid hyperkalemia, hypermagnesemia, hyperphosphatemia
•Energy requirement: -Uncomplicated ARF:25kcal/kg/day
-Critically ill ARF: 25-35kcal/kg/day
•Protein: -Uncomplicated ARF:0.8g/kg/day
-Critically ill ARF: 1.5-1.8g/kg/day
•Avoid greater supplementation of protein uremia+assoc complications

77. ARF TREATED WITH RENAL REPLACEMENT THERAPY:
•Additional amino acid supply (compensates loss) : 0.2g/kg/day
•After regular dialysis is established, conventional mixture is used.
•Water soluble vitamin supplementation (Excess Viatmin C secondary oxalosis)

78. LIVER DISEASE
•Energy requirements:-Compensated cirrhosis:25-35kcal/kg/day
-Decompensated cirrhosis:35-45kcal/kg/day
•Protein requirements:-Compensated CLD:1g/kg/day
-Decompensated CLD:0.5g/kg/day;Use of BCAA
•Vitamin and micronutrient supplemenatation
•Fluid and salt restriction

79. PANCREATITIS
•80% cases are mild-can resume oral intake within 7 days
•20% cases-develop severe disease- need EN/PN
•Indications:-Paralytic ileus,pseudocyst,fistulae
-Enteral feeding leads to exacerbation of abdominal pain
•Start nutritional support within 48-72 hours of hospitalization
ENERGY 25-35 kcal/kg/day
PROTEIN 1.2-1.5 g/kg/day
CARBOHYDRATE 4-6g/kg/day
LIPID Up to 2g/kg/day

80. References
1. Practical Guidelines on Fluid Therapy , Sanjay Pandya ,2nd edition
2. Harrison’s Principles of Internal Medicine, 20th edition
3. Bailey and Love’s Short Practice of Surgery
4. Schwartz Principles of Surgery 11e
5. Paul Marino The ICU Book 4e

81. THANKYOU 