Total prentral nutrition

1. TOTAL PARENTRAL
NUTRITION
PRESENTED BY: IRFAN AHMED
PHARM.D 4TH PROF.
AKHTAR SAEED COLLEGE OF PHARMACEUTICAL SCIENCES

2. components
 History
 Definition
 Indications
 Components of TPN
 calculation
 TPN interventions
 Ordering and administration
 Infusion pumps
 Special considerations during preparations
 Monitoring
 Incompatibilities

3. History
 In 1960s Drs. Wilmore and Dudrick researched on central venous for growth
in infant, elderly patients with catabolic medical conditions Originally
termed hyperalimentation
 Replaced with TPN, which is more descriptive of the technique

4. TPN
 IV administration of calories, nitrogen and all other nutrients in sufficient quantities to achieve tissue synthesis and
anabolism.
 Peripheral Parenteral Nutrition
Nutrients are supplied via a peripheral vein, usually a vein in the arm. Another term for PPN is peripheral venous
nutrition (PVN).
 PVN is used when a patient is unable to ingest adequate calories enterally or when central venous nutrition is not
feasible.
 Concentration
 4.25% amino acid+ 10% dextrose
 IV fat emulsion should be run simultaneously with the PVN to minimize thrombophlebitis

5. THE GOLDEN RULE OF NUTRITION
The gut should always be the preferred route for nutrient administration.
Therefore, parenteral nutrition is indicated generally when there is severe
gastro-intestinal dysfunction (patients who cannot take sufficient food or
feeding formulas by the enteral route) .

6. Indications
Indicated when adequate nutrition cannot be maintained via GIT. Carcinoma
extensive burns
Geriatric refuse to eat
Young anorexic patients
Surgical patients who should not be fed orally
[NPO]
GIT motility disorder
Severe vomiting, when enteral feeding cannot
be tolerated

7. Components of TPN and their calculations
 Fluids
 Carbohydrate as dextrose (3.4 kcal/g)
 Protein as amino acids (4 kcal/g)
 lipids (10-11 kcal/g)
 Electrolytes
 Vitamins
 Trace minerals

8. Components of TPN
 Dextrose and lipids to provide energy.
 70%-85% of calories from dextrose
 Protein for tissue synthesis and repair.
 15%-30% from lipids
 Determine the appropriate amount of calories needed for the patient by
assessing height, weight, ideal body weight and % of weight loss

9. CALCULATIONS
 Calculation of patient requirements calculated using Harris-Benedict
 Harris-Benedict equation

10. FOR MEN
 For Men:
 = 66.67+ (13.75 x weight in kg) + (5 x height in cm) - (6.76x age)
 DESIGNING THE TPN FORMULA
Estimate Basal Energy Expenditure (BEE).

11. For women
 For women the formula is:
 = 655.1 + (9.56 * weight in kg) + (1.86 * height in cm) - (4.68 x age)

12. Total Daily Expenditure(TDE)
TDE= BEE* Activity*Stress
 Activity
 BED=1.2
 Ambulatory=1.3
 Stress:
 Surgery: 1.2
 Infection: 1.4-1.6
 Trauma: 1.3-1.5
 Burns: 1.5-2.1

13. Total Daily Expenditure(TDE)
TDE= BEE*Activity*Stress
 non-stressed (ambulatory)- 30 kcal/kg body weight
 mild stress (malnourished)- 35-40kcal/kg body weight
 severe injury or sepsis- 45-60kcal/kg body weight
 severe burns- up to 80kcal/kg body weight
 infants up to 200kcal/kg body weight

14. Carbohydrates in TPN
 Hydrous Dextrose (glucose)
 Provides 3.4 kcalg-1
 1 L D5W =170 kcal,
 1 L D25W = 850 kcal
 Final dextrose concentrations
 5-10% (peripheral)
 35% (central)
 D5W=252 mOsmL-1,
 D25%=1263 mOsmL-1

15. Protein requirments
 INSOLUBLE AND UNDIGESTED IN BLOOD.
 Protein- requirements usually estimated empirically.
 non-stressed 0.5-1g/kg mild stress 1.2-1.4 g/kg
 moderate stress 1.5-2.0g/kg
 severe stress 2.0-2.5g/kg

19. Protein Solutions
 Standard formulas
 EAA (40%) and
 NEAA (60%)
 available as 3-15% solutions
 Protein is provided as a crystalline amino acid solution. 500 ml bottles are
standard.
 Solutions vary in amino acid concentration and amino acid composition

20. Intra venous lipids
 FAT emulsions
 Only O/W emulsions can be given by IV.
 After 2 weeks of TPN
 Dry scaly skin, hair loss, impaired wound healing
 Fat provides 9 kcal/g
 Components
 soybean (50% linoleic)
 safflower (72%)
 glycerol
 water
 egg yolk phospholipid

21. Actions Indications Dosage Drug
Incompatibilite
s
Fatty acids in
emulsion
form used as
a source of
calories and
to provide
essential
fatty acids
To prevent
fatty acid
deficiency
for patients
requiring
parenteral
nutrition, and
to reverse a
known
deficency
state
characterize
d by scaly
skin
ADULTS: 100
mg/min for
the first 15-30
min then
increase to
2-3 ml/min if
no reaction.
Give only
500 ml (50
gm) first 24
hrs, in no
reaction
increase
following
day. Do not
exceed
2.5gm/kg/da
y
Do not add
any other
medication to
the infusion.

22. INTRAVENOUS LIPIDS
 Intravenous lipids have the highest caloric density of any components of
parental nutrition
 Intralipid is composed of soybean oil, egg yolk phospholipids, and glycerol.
The major fatty acids are linoleic 54%, oleic 26%, palmitic 9% and linolenic
8%
 If a patient has been on TPN for 2 weeks
 Dry Scaly Skin,
 Hair loss,
 Impaired Wound healing.
 Soybean-oil emulsion (Intralipid) Safflower-oil emulsion (Liposyn)

23. Electrolytes:
Guidelines for Electrolyte Requirements
Electrolyte Amount/1000
Calories
Sodium 40-50 mEq
Potassium 30-40 mEq
Chloride 40-50 mEq
Magnesium 8-12 mEq
Calcium 2-5 mEq
Phosphorus 15-25 mEq

24. Recommended Daily Adult Doses of
Parenteral Trace Elements
Trace Element Dose
Zinc 2.5-4.0 mg
Copper 0.5-1.5 mg
Chromium 10-15 ug
Manganese 150-800 ug
Selenium 40-80 ug

25. MVI
 A 8000 U
 D 800 U
 E 4 U
 Niacin 80 mg
 B1[Thiamine] 40 mg
 B2[Riboflavin] 8 mg
 C 400 mg
 Folic acid 2 mg

26. MVI
 Vitamin K & . Vitamin B12
 separately I.M.
 Vitamin K 10 mg week-1
 Vitamin B12 100 g week-1

27. TPN interventions
 Warm to room temp 1 hr prior to use
 Hang TPN alone
 Dextrose concentration > 10%
 given through a central line
 Change TPN bag and filter every 24 hours

28. Ordering and Mixing PN Solutions
 The physician writes the Rx TPN prescription.
 The pharmacist mixes the TPN solution using aseptic technique.
Prescriptions are compounded by mixing the solutions at a 1:1 dextrose-to-
amino acid ratio and placing in 1-L bags. Alternatively, lipids can be mixed
with the dextrose/amino acid solution, referred to as the 3-in-1 total
nutrient admixture (TNA).

29. ADMINISTRATION
 TPN should always be given via an infusion pump.
 The pharmacist may be consulted regarding drug compatibility for
simultaneous administration of two or more drugs through a single lumen of
the catheter.
 Avoid the administration of blood products into the lumen designated for
parenteral nutrition.
 Heparin Flush
 When parenteral nutrition infusion is being cycled, a heparin flush is
needed to maintain patency of central venous catheter when solution is
not infusing.

30. Initial Considerations
 TPN infusion should start slowly so that the body has time to adapt to both the glucose
load and the hyperosmolarity of the solution, and to avoid fluid overload.
 A pump controls the infusion rate of the TPN solution.
 There are specific steps in the inititiation procedure to follow regarding the initiation of
TPN infusion.
 Infusion Pumps:
 Electronic ambulatory infusion pumps are commonly used in the home setting.
 These pumps are lightweight and portable and can be programmed to deliver
continuous infusions, intermittent infusions or single dose medications.
 Many pumps have the capacity to taper the rate of an infusion.
 Multichannel pumps allow for the administration of several different infusions at one time

32. General PN Initiation Procedures
 Start with 1 L of TPN solution during the first 24 hours (42 mL/hr as a start rate)
 Increase volume by 1 liter each day until the desired volume is reached
 Monitor blood glucose and electrolytes closely
 Pump administer TPN at a steady rate
 Don't attempt to catch up if administration gets behind
 Continuous vs. Cyclic TPN
the patient is fed at night.
Cyclic TPN helps prevent hepatotoxicity that can develop with long-term TPN
and the fasting period allows essential fatty acids to be released from fat
stores.

33. SPECAIL CONSIDERATIONS DURING
PREPARATIONS
 Mechanics of Administering
 Titrate up slowly to allow pancreas to adapt to hypertonic dextrose load
 Give 1/3 of max rate on day 1, 2/3 on day 2 and full infusion on day 3
 Taper to allow pancreas to adapt to withdrawal of hypertonic dextrose
 Infuse D10 if TPN abruptly discontinued
 Use filters (0.22 m).
 Fat can’t run through filters
 CLEAN ROOM
 The clean room is a limited-access area, which is separated from the other pharmacy
operations
 to minimize the potential for contamination. All products are prepared using the Class 100
laminar flow cabinets

34. IV Admixture Environment
 To provide sterility and pyrogen-free, proper environment is a must
 Prepare admixture under laminar-flow filter
 Air filter through High Efficiency Particulate Air (HEPA) flowing at 90fpm and
remove 99.97% particles of 3 m.
 Air flow either horizontal or vertical
 HEPA filter must be replace every 6 months
 Technician or operators must wash hands, gloved and require gowning

35. Temperature and pH:
 Temperatures below freezing or above room temperature may result in destabilization of
the lipid emulsion.
 pH below 5.3 or the addition of additives with a pH of 5.0 may also destabilize the emulsion.
 Temperature & calcium-phosphorus stability.
 As the temperature increases, there is an increase in the rate of dissociation of calcium and
phosphorus from their salts. This allows more free calcium and phosphorus to be
precipitated
Labeling:
 The American Society of Enteral and Parenteral Nutrition (ASPEN) addressed the issue of
standard labeling for PN solutions in its recent guidelines. Labels for PN admixtures should
include amount per day of base formula, electrolyte additives, micronutrients and
medications, quantity per liter for those who admix in 1L volumes, and dosing weight.
Auxiliary labels may be helpful when PN orders are written in a different format than the
standard label.

36. Storage and Packaging
TPN solutions should always be transported and stored under controlled-temperature refrigeration.
 TPN solutions are delivered from the pharmacy to the patient’s home, a cooler with cooler
blocks should be used.
 Refrigerators should be checked to make sure the temperature is constant and that adequate
space is available for storing PN solutions and supplies.
Filtering:
 Use of a filter during the administration of PN solutions may prevent complications arising from
any particulate matter, microprecipitates or microorganisms potentially present.
 A 0.2 -1.2-m filter should be used for TPN solutions with amino acids and dextrose.
 Filters should be replaced every 24 hours.
 A clogged filter, indicates some type of problem with the TPN solution, such as contamination
of the solution, precipitation, cracking or incompatibilities

38. Monitoring
 Blood work must be drawn to establish baseline lab values, which include:
 electrolytes,
 creatinine,
 triglycerides,
 BUN,
 phosphorous,
 glucose,
 albumin,
 magnesium,
 CBC + differential,
 carbon dioxide, and
 total protein Thereafter, monitoring can be performed 2-3 times per week.
 other include body weight and temperature.

39. Monitoring of the TPN Patient
 Acute condition, unstable patient, early
nutrition support
 Electrolytes, BUN, SCr: 3-7 times per week
 Calcium, magnesium, phosphate: 1-3 times per week
 LFT’s, TP, ALB: once weekly or every other week
 Triglycerides: weekely or as appropriate for IV fat emulsion use.
 Stable hospitalized patient,
 prolonged parenteral nutrition support
 Electrolytes, BUN, SCr: 1-3 times per week
 Calcium, magnesium, phosphate: once weekly or every other week
 LFT’s TP, ALB: every 2-4 weeks
 CBC/ differential, PLC RBC indices: every 2-4 weeks

40. TPN incompatibilities
 Drug incompatibilities, drug-nutrient interactions and destabilization of
lipids can all adversely affect the stability of parenteral nutrition solutions.
 Medications that are incompatible with Parenteral nutrition solutions:
 1. Acyclovir
2. Amphotericin B
3. Diazepam
4. Phenytoin
5. Bactrim
6. Metronidazole

41. Therapeutic Incompatibility
Antagonistic and synergistic effect
 Penicillin and cortisone antagonize heparin leading to anticoagulant
 An increase in amino acid concentration will decrease Theophylline level
 Anticoagulants drugs are used in TPN in order to reduce or prevent any
tendency toward intravascular or in cardiac clotting
 Physical Complications
Haze detected
 Particles detected
 Color changes,
 Changes from clear to cloudy, Emitting of gas

42. Chemical Incompatibilities
 Change in pH can change solubility
 Antibiotics can remain active in 24 hours at the pH of 6.5, but at pH 3.5 it will be destroy.
 Potassium Penicillin G buffered at pH 6.0-6.5, when added to dextrose, water or NaCl injection it
must also be at buffer 6.0-6.5 to assure activity of antibiotic
 MINIMIZATION OF INCOMPATIBILITIES
 FRESHLY PREPARED
 FEW ADDITIVES
 KNOWLEDGEABLE
 MAKE THEM AWARE
 ASEPTIC TECHNIQUE
 KEEP FILE

43. Refernces
 Hospital pharmacy by nadeem irfan bukhari
 www.pharmj.com
 www.nyschp.org/the_pharmacist/0998/09
 Wikipedia
 Pharma.knwldgebank.com

44. Thank
you