Total Parenteral

Nutrition (TPN)
By: E. Salehifar
(Clinical Pharmacist)

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

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)

Parenteral Nutrition

Peripheral Parenteral
Nutrition (15 lit D5W/day
for a 70 kg !!!)
Central Parenteral
Nutrition (TPN)

Needs CV-line to administer

hyperosmolar solutions

Estimation of energy
expenditure

Harris-Benedict equations:
BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A
BEE (women) (kcal/day): 655.1+9.56W+1.85H4.68A
TEE (kcal/day):
BEE Stress factor Activity factor
Stress factors: Surgery, Infection: 1.2 Trauma:
1.5
Sepsis: 1.6
Burns: 1.6-2
Activity factors: sedentary: 1.2 , normal activity:
1.3, active: 1.4 , very active: 1.5

Stress level
Normal/mild stress level: 20-25
kcal/kg/day
Moderate stress level: 25-30
kcal/kg/day
Severe stress level: 30-40 kcal/kg/day
Pregnant women in second or third
trimester: Add an additional 300
kcal/day

Fluid: mL/day

30-40 mL/kg

Protein (amino acids)

Maintenance: 0.8-1 g/kg/day

Normal/mild stress level: 1-1.2 g/kg/day
Moderate stress level: 1.2-1.5 g/kg/day
Severe stress level: 1.5-2 g/kg/day
Burn patients (severe): Increase protein
until significant wound healing achieved
Solid organ transplant: Perioperative:
1.5-2 g/kg/day

Protein need in Renal

failure

Acute (severely malnourished or

hypercatabolic): 1.5-1.8 g/kg/day
Chronic, with dialysis: 1.2-1.3
g/kg/day
Chronic, without dialysis: 0.6-0.8
g/kg/day
Continuous hemofiltration: 1
g/kg/day

Protein need in Hepatic

failure

Acute management when other

treatments have failed:
With encephalopathy: 0.6-1 g/kg/day
Without encephalopathy: 1-1.5 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 10-14 g/day

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

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)

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

For

1000 ml solution

D50W
D20W
D30W
D40W

D10W

D5W

250 ml

750 ml

------

333 ml

------

667 ml

500 ml

500 ml

------

555 ml

-----

446 ml

750 ml

250ml

------

778 ml

------

222 ml

Dextrose:
Contraindications

Hypersensitivity to corn or corn

products
Hypertonic solutions in patients with
intracranial or intraspinal
hemorrhage

Abrupt withdrawal

Infuse 10% dextrose at same rate

and monitor blood glucose for
hypoglycemia

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

1022 Kcal/L
345 mosmol/L

1080 Kcal/L

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)

Aminofusion
5%,

10% ( from CV-line)

1-1.5 g/kg/day
Should not be used as a
calorie source

400 Kcal/L

200 kcal/L

1030 mosmol/L

590 mosmol/L

Amino acids:
Contraindications

Hypersensitivity to one or more

amino acids
Severe liver disease or hepatic coma

Case

D.C a 38 y.o man with a 12-year history

of crohns 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.

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?

BEE= 66.47+13.7560+5180-6.7638=1535
kcal/d

TEE= 15351.21.2 = 2200 kcal/d

Intralipid 10%= ?
1ml 1.1 kcal

2200 30%= 660 kcal

660 : 1.1 = 600 ml ( 500ml)

Dext 50%= ? 2200 550= 1650 kcal

1g dextrose 3.4 kcal 1650 : 3.4= 485 g
Dext
50g 100 ml
485 g 970ml ( 1000ml)
Aminofusion 10 %= ? 1.5 g/kg/d 60
kg= 90g/day 10g 100 ml 90g 900 ml
(1000ml)

Electrolytes (daily requirements for

TPN):
Na: 80-100 mEq (50 - 100 ml NaCl 5%)
K: 60-80 mEq (30 ml KCl)
Cl: 50-100 mEq
Mg: 8-16 mEq (5 -10 ml MgSo4 20%)
Ca: 5-10 mEq (10-20 ml Ca Gluconate
10%)
P04: 15-30 mEq
Acetate: 50-100 mEq

Vitamins:
A, D, E, Water soluble vitamins
Trace Elements:

Zn, Se, Cu, Cr, Mn

Zn

Delayed ulcer healing, Dermatitis, Alopcia (5

reductase), Diarrhea

Se: Low activity of SOD & Deiodinase

Amp B Complex + Amp Vit

MV Therapeutic ( Zn, Cu, Mn)

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

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

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

Adding other drugs to

TPN

INS
Heparin
H2-blocker
Alb
Aminophylline

Vit K & Bicarbonate should not be

added

Complications

Endocrine & metabolic

Hepatic

Azotemia, BUN increased

Infectious

Cholestasis, cirrhosis (<1%), gallstones, liver function tests

increased, pancreatitis, steatosis, triglycerides increased

Renal

Fluid overload, hypercapnia, hyperglycemia,

hyper-/hypokalemia, hyper-/hypophosphatemia, refeeding
syndrome

Bacteremia, catheter-induced infection, exit-site infections

Other: Pneumothorax, Thrombophlebitis

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

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