ADULT PARENTERAL NUTRITION

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ADULTPARENTERAL NUTRITION

• DOUGLAS L. SMITH, PHARM.D., BCNSP, BCOP
• Associate Professor, Dept. of Pharmacy Practice
• Shenandoah University Bernard J. Dunn School of
  Pharmacy

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Objectives

• Discuss the potential advantages disadvantages
  of parenteral nutrition (PN) as compared with
  enteral feeding.
• Determine appropriate indications for PN.
• Identify typical components of PN state the
  physiologic role.
• Given a patient case, calculate fluid, energy,
  protein goals for a non-stressed adult patient
  receiving PN.
• State four metabolic complications associated
  with PN.

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Total Parenteral Nutrition (TPN)

• Definition the IV administration of all
  nutrients necessary to maintain and promote
  synthesis of lean body mass.
• TPN total parenteral nutrition
• 3-in-1
• 2-in-1
• TNA - total nutrient admixture
• PPN peripheral parenteral nutrition
• Hyperal hyperalimentation

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History of Parenteral Nutrition

• 1600s Christopher Wren - goose quills
• 1930s infusion of protein hydrolysates
• 1952 Aubaniac - subclavian cannulation
• 1960s Dudrick - beagle pups
• 1968 baby girl - intestinal atresia

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TPN vs. Enteral Nutrition

• TPN
• Advantages
• easy to administer
• gut-sparing
• Disadvantages
• metabolic, mechanical, infectious
  complications
• translocation

• ENTERAL Nutrition
• Advantages
• gut - trophic
• Disadvantages
• GI adverse reactions
• aspiration risk
• complicated delivery

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Indications for TPN

• If the gut works use it!
• Nonfunctional GI tract
• Inability to absorb enough enterally
• Severe Pancreatitis
• Inadequate enteral absorption gt 7 days (gt5 days
  in severely catabolic pt)
• Major surgery in pt with malnutrition
• Intestinal obstruction, IBD or fistula

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TPN Substrate Comparison
CHO FAT PROTEIN GLYCOGEN ADIPOSE
MUSCLE/VISCERAL lt2000 Kcal
lt40,000 Kcal gt150,000 Kcal 3.4 Kcal/gm
9 Kcal/gm 4 Kcal/gm C - H - O
C - H - O C - H - O
(N) SHORT TERM LONG TERM
FUNCTIONAL ENERGY RES. ENERGY RES. BODY
MASS
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FLUID REQUIREMENTS

• 0 10 kg ? 100 mL/kg
• 11 20 kg ? 1000 mL 50 mL/kg (gt 10 kg)
• gt 20 kg ? 1500 mL
• 20 mL/kg x kg over 20 kg (for age lt 50)
• 15 mL/kg x kg over 20 kg (for age gt 50)

Holliday-Segar method
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Fluid Requirements Calculation EXAMPLE

• 72 yo 80 kg patient
• 1500 mL 15 mL/kg x (80-20) 1500 900
  2400 mL
• 45 yo 80 kg patient
• 1500 mL 20 mL/kg x (80-20) 1500 1200 2700
  mL

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CALORIC CONSIDERATIONS

• Weight- based
• Range (wt loss/maintenance/gain)
• Harris-Benedict equation
• WHO
• Indirect Calorimetry
• PATIENT ACUITY
• - Acute Care 25 - 30 Total Kcals/Kg
• - Critical Care lt 25 Total Kcals/Kg

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DEXTROSE
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PROTEIN CONSIDERATIONS

• Protein hydrolysates
• Crystalline (L)amino acids
• Essential vs. Nonessential amino acids (approx.
  50 ratio of each)
• FreAmine, Aminosyn Novamine,Travasol (B Braun,
  Hospira, Clintec Nutrition)
• Specialized amino acid preparations (branched
  chain, essential)

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ESSENTIAL NONESSENTIAL AAs

• EAAs NEAAs
• ISOLEUCINE ALANINE
• LEUCINE ARGININE
• LYSINE HISTIDINE
• METHIONINE PROLINE
• PHENYLALANINE SERINE
• THREONINE TYROSINE
• TRYPTOPHAN GLYCINE
• VALINE CYSTEINE
• branched chain aas conditionally
  essential in ARF

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PROTEIN REQUIREMENTS
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FAT CONSIDERATIONS
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ESSENTIAL FATTY ACID DEFICIENCY

• Trienetetraene ratio
• Linoleic ? arachadonic (tetraene)
• Oleic ? eicosatrienoic (triene)
• Supply at least 4 of cals as fat
• Symptoms of EFAD
• - Derm diffuse scaly dermatitis, alopecia
• - Heme thrombocytopenia, anemia
• - Immune poor wound healing

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LIPID EMULSION ADRS

• HYPERSENSITIVITY reactions - chills, back/chest
  pressure, dyspnea
• HEPATIC
• PANCREATIC
• PULMONARY
• RETICULOENDOTHELIAL

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Macronutrient Goals Remember This Slide

• Protein 1.5 g/kg/day
• Calories (total) 25 kcal/kg/day
• Dextrose 70 85 of kcals
• Lipids 15 30 of kcals
• Fluid 25 mL/kg/day (1 kcal/mL)

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ELECTROLYTES
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SODIUM Na

• Major extracellular cation
• Normal serum range 135 145 mEq/L
• Usual Adult PN dose
• 1 - 2 mEq/kg (60 -150mEq)
• lower in CHF, renal failure, liver failure
• Available salts
• chloride
• acetate
• phosphate
• lactate
• bicarbonate

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POTASSIUM

• Major intracellular cation
• Normal serum range 3.5 5 mEq/L
• Usual Adult PN dose
• 1 2 mEq/kg/d
• lower in renal failure
• Available salts
• acetate
• chloride
• phosphate

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Potassium Replacement1

• Severity Replacement Dosage
• Mild - Moderate 20 40 mEq
• (2.5 3.4 mg/dL)
• Severe 40 80 mEq
• (lt 2.5 mg/dL)
• 1 Kraft MD, Btaiche IF, Sacks GS Kudsk K.
  Treatment of electrolyte disorders in adult
  patients in the intensive care unit. Am J
  Health-Syst Pharm621663-1682.
• use lt50 of initial empirical dose in patients
  with renal insufficiency
• use CVC cardiac monitoring recommended for
  infusion rates gt 10mEq/hr max 80 mEq/L
  peripheral up to 120 mEq/L via CVC max infusion
  rate 40 mEq/hr

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CHLORIDE

• Major extracellular anion
• Normal serum range 96 106 mEq/L
• Usual Adult PN dose
• 1 2 mEq/Kg/d
• Balance w acetate
• lower in metabolic acidosis
• Available salts
• sodium
• potassium
• calcium

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MAGNESIUM

• Major intracellular cation (2nd to potassium)
• Normal serum range 1.5 2.2 mEq/L
• Co-factor in all enzyme reactions of phosphate
  transfer
• Usual Adult PN dose
• 8 20 mEq/day
• Available salts
• sulfate
• gluconate

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Magnesium Replacement1

• Severity Replacement Dosage
• Mild - Moderate 8 32 mEq (1-4 g MgSO4)
• (1 1.5 mg/dL) (up to 1 mEq/kg)
• Severe 32 64 mEq (4-8 g MgSO4)
• (lt 1mg/dL) (up to 1.5 mEq/kg)
• 1 Kraft MD, Btaiche IF, Sacks GS Kudsk K.
  Treatment of electrolyte disorders in adult
  patients in the intensive care unit. Am J
  Health-Syst Pharm621663-1682.
• use lt50 of initial empirical dose in patients
  with renal insufficiency use adjusted weight for
  obese patients

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CALCIUM

• Bone 99.5
• ECF 0.5
• Normal serum range 8.5 10.8 mg/dL
• Usual Adult PN dose
• 10 15 mEq/d
• corrected calcium (4-albactual) x 0.8
  Caactual
• ionized or free fraction 54 of serum Ca
• Available salts
• gluconate
• chloride - do not use calcium chloride!!!
• gluceptate

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PHOSPHATE

• Bone 85 of phosphate stores
• Major intracellular anion
• Normal serum range 2.6 4.5 mg/dL
• energy transfer ATP
• Usual Adult PN dose
• 20 40 mMol/day
• more in refeeding
• less in renal insufficiency
• Available salts
• sodium
• potassium - KPhos contains 3mMol P04 4.4mEq K
  /ml

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Phosphorus Replacement1

• Severity Replacement Dosage
• Mild 0.32 mMol/kg over 4 - 6h
• (2.3 3 mg/dL)
• Moderate 0.64 mMol/kg over 4 - 6h
• (1.6 2.2 mg/dL)
• Severe 1 Mol/kg over 8 12h
• (lt 1.5 mg/dL)
• 1Brown KA, Dickerson RN, Morgan L, et al. JPEN
  200630(3)209-214
• use K salt if serum K lt 4 use Na salt if K gt
  4

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ACETATE

• Balanced with chloride
• Converted to bicarbonate
• bicarbonate incompatible w 3-in-1 TPN
• Normal serum range 24 30 mEq/L
• Available salts
• sodium
• potassium
• Serum CO2 interpreted as dissolved HCO3-

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VITAMINS

• Water Soluble
• B1, B2, B3, B5, B6, C, B12, folate, biotin
• Fat Soluble
• A, D, E
• vit. K 150?g in IV multivitamin preparations

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TRACE ELEMENTS

• Zinc - wound healing
• Copper - hematopoeisis
• Manganese - enzyme activator, fat
  CHO metabolism
• Chromium - glucose tolerance factor
• Selenium - part of glutathione peroxidase antio
  xidant similar to vit E
• Iodine - thyroid hormone synthesis

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Micronutrient Goals Remember This Slide

• Calcium 10 mEq/day
• Magnesium 10 mEq/day
• Phosphorus 30 mMol/day
• Potassium 1 2 mEq/kg/day
• Sodium 1 2 mEq/kg/day
• Chloride/Acetate balance
• Multivitamins-13 10 mL/day
• Trace Elements-5 3 mL/day
• based on clinical status

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TPN COMPLICATIONS

• Septic
• catheter-related
• solution-related
• Mechanical
• catheter Insertion
• central Venous Thrombosis
• cardiac Perforation
• equipment personnel failure

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Personnel Failures

• Compounding
• data input Hopkins case (The Baltimore Sun)
• Hopkins Hospital sued in death of girl, 2.
  Malpractice claim based on
  improper IV solution
• careless attention to compatibility/solubility
• Equipment (programming, etc.)

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METABOLIC COMPLICATONS

• Hyperglycemia / Hypoglycemia
• Dehydration / Overhydration
• Electrolyte Imbalance
• Acidosis / Alkalosis
• Hyperammonemia
• LFT Abnormalities
• Anemia
• Hypervitaminosis / Hypovitaminosis