TOTAL PARENTERAL NUTRITION

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TOTAL PARENTERAL NUTRITION
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Total Parenteral Nutrition

• GENERAL INDICATIONS
• TPN FORMULATION
• STABILITY
• COMPATIBILITY

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Total Parenteral Nutrition

• GENERAL INDICATIONS
• Patient who cant eat
• Patient who wont eat
• Patient who shouldnt eat
• Patient who cant eat enough
• If the gut works, use it.

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Total Parenteral Nutrition

• A.S.P.E.N Guidelines
• Severe stress or malnutrition NPO gt 4-5 days
• Moderate stress or malnutrition NPOgt7-10 days
• Non-stressed/normal nourished NPO gt 10 days
• No indication for TPN lt 4 days
• Based on opinion of authors
• A.S.P.E.N. Board of Directors Guidelines for
  the use of parenteral nutrition in hospitalized
  patients. JPEN 10441-445 1986
• Also see
• A.S.P.E.N. Board of Directors Guidelines for
  the use of parenteral and enteral nutrition in
  adult and pediatric patients. JPEN 26 No.1,
  Supplement January-February 2001

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Total Parenteral Nutrition

• NOMENCLATURE
• TPN Total Parenteral Nutrition
• IVH Intravenous Hyperalimentation
• TNA Total Nutrient Admixture
• TPN Total Parenteral Nutrition
• 3-In-1 Admixture
• All-In-One Admixture
• PPN Peripheral Parneteral Admxtiure

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FYI

• Aoccdrnig to rscheearch at an Elingsh uinevtisy,
  it deosnt mttaer waht oredr the ltteers in a
  wrod apeapr. The olny iprmoetnt tihng is taht
  the frist and lsat ltteers are in the rghit
  pclae. The rset can be a toatl mses and you can
  still raed it wouthit a porbelm. This is bcuseae
  we do not raed ervey lteter by itslef but the
  wrod as a wlohe.
• INITSERETNG!!

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Total Parenteral Nutrition

• CENTRAL CATHETER
• TPN Osmolarity
• generally 1000-2000 mOsm/L
• Subclavian
• Internal Jugular
• PICC
• Hickman
• Groshong

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Total Parenteral NutritionTotal 1868 mOsm/L
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Total Parenteral Nutrition

• GOAL IN TPN FORMULATION
• Provide all a patients required nutrients in a
  fluid volume that is well tolerated.

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Total Parenteral Nutrition

• Normal Diet
• Protein
• Carbohydrates
• Fat
• Vitamins
• Minerals
• Water

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Total Parenteral Nutrition

• Normal Diet TPN
• Protein...Amino Acids
• Carbohydrates.Dextrose
• Fat.Lipid Emulsion
• VitaminsMultivitamin Infusion
• Minerals.Electrolytes and Trace
  Elements

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Total Parenteral NutritionWater Requirements
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Total Parenteral Nutrition

• Water Requirements
• Maintenance 30-40 ml/kg/d
• Generally 2-3 L per day
• Sometimes TPN must be concentrated

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Total Parenteral Nutrition

• Carbohydrate
• Give 60-80 of non-protein calories as dextrose
• Dextrose concentration generally ranges from
  20-25
• 20 680 Kcal/L
• 25 850 Kcal/L

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Total Parenteral Nutrition

• Carbohydrate
• Max rate of glucose oxidation
• 5 7
  mg/kg/min
• Max dextrose administration rate
• Stable patients Not gt7 mg/kg/min
• Critical care patient Not gt 4 mg/kg/min

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Total Parenteral Nutrition

• Amino Acids
• Ideal Amino Acid Solution
• 5050 Ratio of EssentialNonessential AA
• Wide Variety of Nonessential AA
• Minimum of Glycine
• Substantial amounts of Branch Chained AA
• Generally considered therapeutically
  interchangeable.

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Total Parenteral NutritionElectrolytes
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Total Parenteral NutritionElectrolytes

• Electrolyte salts commercially available
• Sodium chloride
• Sodium acetate
• Sodium phosphate
• Potassium chloride
• Potassium acetate
• Potassium phosphate
• Calcium gluconate
• Calcium chloride (not recommended)
• Magnesium sulfate
• Magnesium chloride
• Incompatible Sodium bicarbonate

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Total Parenteral NutritionTrace Elements

• Recommendations per NAG
• Zinc Poor wound healing
• Copper Anemia
• Chromium Glucose Intolerance
• Manganese ??
• Selenium Keshans Disease

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Total Parenteral NutritionTrace Elements

• Why not iron?
• Stores of 3-4 gm.
• Average daily loss of 1 mg.
• Other trace elements
• Molybdenum
• Iodine
• Cobalt
• Vanadium
• Nickel
• Flouride
• contained in MTE-7

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Total Parenteral NutritionVitamins

• Recommendations per NAG
• Multivitamin Infusion 10 ml
• Contain all essential vitamins
• MVI-Adult(Mayne) or Infuvite (Baxter)
• Fat soluble A, D, E, K
• Water soluble Thiamine, Riboflavin, Niacin,
  Pantothenic Acid, Pyridoxine, C, Folic Acid, B12,
  Biotin
• In 2004 Vitamin K added per FDA recommendations

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Total Parenteral NutritionFormulation

• Standardization vs Customization
• Standardization
• Meets requirements of most patients
• Assists physician in order writing
• Reduces errors (writing, transcription and order
  entry)
• Increases pharmacy efficiency
• Cost savings

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Total Parenteral NutritionFormulation

• Patient Specific (Customization)
• Consistent with current recommendations
• Can be accomplished with and without automated
  compounder

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Total Parenteral NutritionFormulation

• Gravity Transfer
• Standard Solutions Available
• Amino Acid Dextrose
• 5 10
• 8.5 30
• 10 50
• 15 75
• Peripheral
• Protein Restriction Liver Failure, Renal Failure
• Standard TPN
• Critical Care (Hypercatabolic)
• Fluid Restriction

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Total Parenteral NutritionFormulation

• Automated Compounder
• Automix..Baxter
• Nutramix.Abbott
• Exacta Mix.Baxa
• Hyperformer.B.Braun
• Pinnacle.B.Braun
• Class 100 Environment (ISO 5)

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Total Parenteral Nutrition

• Stability
• Under refrigeration and before addition of
  vitamins
• 2-in-1 up to 30 days
• 3-in-1 up to 10 days

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Total Parenteral NutritionCompatibility

• Calcium-Phosphate compatibility
• Factors which affect stability
• Additive concentration
• Choice of calcium salt
• Order of mixing
• Amino acid product (brand)
• Amino acid concentration
• Dextrose Concentration
• Temperature (not what you think)
• Storage time
• Addition of l-cysteine (neonatal)

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Total Parenteral NutritionCompatibility

• How to minimize calcium phosphate precipitation
• Additive concentration......use lower the
  conc.
• Choice of Ca salt......use Ca Gluconate, not
  CaCl2
• Order of mixing....add phosphate first, calcium
  last
• Amino acid product Aminosyn best, FreAmine
  worst
• Amino acid concentration.use higher AA conc.
• Dextrose concentrationuse higher Dextrose
  conc.
• Temperature.Refrigerate
• Storage time....Minimized storage time
• l-cysteine (neonatal) ..greatly increases
  solubility

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Total Parenteral NutritionCompatibility

• Normal range for serum calcium is
• 8.5 to 10.5 mg/dL.
• Additional calcium is often added to TPN
  unnecessarily.
• 40 of calcium is protein bound.
• Only the free calcium is physiologically active.
• In hypoalbunemia the free calcium may be normal
  although the total serum calcium (measured value)
  may be low.
• How do you estimate free calcium?

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Total Parenteral NutritionCompatibility

• Correction of Calcium in Hypoalbunemia
• Corrected Ca
• Observed Ca 0.8 (Normal albumin Observed
  albumin)
• Observed Ca 0.8 (4.0 Observed albumin)
• Example
• Serum albumin 2.8 Serum calcium 7.9
  mg/dL
• What is the corrected calcium?
• Should this patient receive additional
  calcium in the TPN?
• Corrected Ca 7.9 0.8 (4.0 2.8)
• 8.9 mg/dL
• Additional calcium not warranted.

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Total Parenteral NutritionCompatibility

• Insulin
• Reports of up to 50 of insulin is lost to
  adsorption to TPN bag, tubing and filter
• Insulin loss due to adsorption to EVA systems
  probably only 5-15.
• However Addition of insulin to TPN is considered
  physically compatible and therapeutically
  appropriate
• Tomato theory (dose is titrated)

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Total Parenteral NutritionCompatibility

• Insulin
• Practical Guidelines
• Minimum dose 10 U / bag
• Dose in 10 U increments
• Avoid putting too much in TPN
• Supplement with sliding scale
• Add ½ of previous days SS to TPN

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Total Parenteral NutritionCompatibility
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Total Parenteral NutritionCompatibility 2-in-1

• H2 Antagonists C
• Iron Dextran C
• Heparin C
• Albumin C
• Morphine Sulfate C
• Hydrochloric Acid C
• Many Antibiotics C (Y-Site)
• Amphotericin B I
• Aminophylline I
• Sodium Bicarbonate I