2. Total Parenteral Nutrition (TPN)
By: E. Salehifar
(Clinical Pharmacist)

3. 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

5. 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)

6. Parenteral Nutrition
Peripheral Parenteral Nutrition (15 lit D5W/day for a 70 kg !!!)
Central Parenteral Nutrition (TPN)
Needs CV-line to administer hyperosmolar solutions

7. Estimation of energy expenditure
Harris-Benedict equations:
BEE (men) (kcal/day): W+5H-6.76A
BEE (women) (kcal/day): W+1.85H-4.68A
TEE (kcal/day):
BEE × Stress factor × Activity factor
Stress factors: Surgery, Infection: Trauma: Sepsis: Burns: 1.6-2
Activity factors: sedentary: 1.2 , normal activity: 1.3, active: 1.4 , very active: 1.5
 Stress factor = 1.5 for trauma, stressed, or surgical patients and underweight (to promote weight gain); 2.0 for severe burn patients

8. Stress level Normal/mild stress level: 20-25 kcal/kg/day
Moderate stress level: kcal/kg/day
 Severe stress level: kcal/kg/day
 Pregnant women in second or third trimester: Add an additional 300 kcal/day

9. Carbohydrate (dextrose)
5 g/kg/day or 3.5 mg/kg/minute (maximum rate: 4-7 mg/kg/minute)
Minimum recommended amount: 400 calories/day or 100 g/day

10. Fluid: mL/day
30-40 mL/kg

11. Protein (amino acids) Maintenance: 0.8-1 g/kg/day
Normal/mild stress level: g/kg/day
Moderate stress level: g/kg/day
Severe stress level: g/kg/day
Burn patients (severe): Increase protein until significant wound healing achieved
Solid organ transplant: Perioperative: g/kg/day

12. Protein need in Renal failure
Acute (severely malnourished or hypercatabolic): g/kg/day
Chronic, with dialysis: g/kg/day
Chronic, without dialysis: g/kg/day
 Continuous hemofiltration: ≥ 1 g/kg/day

13. Protein need in Hepatic failure
 Acute management when other treatments have failed:
With encephalopathy: g/kg/day
Without encephalopathy: 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 g/day

14. 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

15. Components of TPN Formulations
Macro:
Calorie: Dextrose 20%, 50%
Intralipid 10%, 20%
Protein: Aminofusion 5%, 10%
Micro:
Electrolytes (Na, K, Mg, Ca, PO4)
Trace elements (Zn, Cu, Cr, Mn, Se)

16. Dextrose 20%, 50% ( from CV-line) 3.4 kcal/g
60-70% of calorie requirements should be provided with dextrose

17. For 1000 ml solution D50W D10W D5W D20W D30W D40W 250 ml 750 ml ------

18. Dextrose: Contraindications
Hypersensitivity to corn or corn products
Hypertonic solutions in patients with intracranial or intraspinal hemorrhage

19. Abrupt withdrawal
Infuse 10% dextrose at same rate and monitor blood glucose for hypoglycemia

20. 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

21. 1022 Kcal/L
345 mosmol/L
1080 Kcal/L

22. 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)

23. Aminofusion 5%, 10% ( from CV-line) 1-1.5 g/kg/day
Should not be used as a calorie source

24. 200 kcal/L
590 mosmol/L
400 Kcal/L
1030 mosmol/L

26. Amino acids: Contraindications
Hypersensitivity to one or more amino acids
Severe liver disease or hepatic coma

27. 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, nausea & vomiting for 7 days 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 6 month ago.

28. 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?

29. 1g dextrose ≡ 3.4 kcal 1650 : 3.4= 485 g Dext
BEE= ×60+5× ×38=1535 kcal/d
TEE= 1535×1.2×1.2 = 2200 kcal/d
Intralipid 10%= ? × 30%= 660 kcal
1ml ≡ 1.1 kcal : 1.1 = 600 ml ( 500ml)
Dext 50%= ? – 550= 1650 kcal
1g dextrose ≡ 3.4 kcal : 3.4= 485 g Dext
50g ≡ 100 ml g ≡ 970ml (1000ml)
Aminofusion 10 %= ? g/kg/d × 60 kg= 90g/day 10g ≡ 100 ml 90g ≡900 ml (1000ml)

30. Electrolytes (daily requirements for TPN):
Na: mEq ( ml NaCl 5%)
K: mEq (30 ml KCl)
Cl: mEq
Mg: 8-16 mEq (5 -10 ml MgSo4 20%)
Ca: 5-10 mEq (10-20 ml Ca Gluconate 10%)
P04: mEq
Acetate: mEq

33. Amp B Complex + Amp Vit C Zn, Se, Cu, Cr, Mn
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)

36. 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

37. 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

38. 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

39. Adding other drugs to TPN
INS
Heparin
H2-blocker
Alb
Aminophylline
Vit K & Bicarbonate should not be added

40. Complications Endocrine & metabolic Hepatic Renal Infectious
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

41. 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

43. 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