Total Parenteral Nutrition (TPN)

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What is Total Parenteral Nutrition (TPN)
Hyperalimentation?
 Definitions
 Composition
 Candidats
 Calculation
 Methods of administration
 Monitoring

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What is Total Parenteral Nutrition (TPN)
Hyperalimentation?
 TPN : is the administration of concentrated glucose & amino acid
solutions via a central or large diameter peripheral vein.
 TPN therapy is necessary when the GI tract cannot be used or is not
used to meet the Patient nutritional needs.
 TPN solutions may contain 20%-60% glucose and 3.5% to 10%
protein (in the form of amino acids) in addition to various amounts
of electrolytes, vitamins, minerals, & trace elements.
 These solutions can be modified, depending on the presence of
organ system impairment and/or the specific nutritional needs of
the Patient.
 To provide necessary amounts of fat and the fat soluble vitamins
(A, D, E, and K), intralipids are often administered 2-3x a week
along with TPN (monitor triglyceride levels)
 TPN is often used in hospital, long term care, and subacute care,
but is also frequently used in the home-care setting.

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What is Total Parenteral Nutrition (TPN)
Hyperalimentation?
TPN or Hyperalimentation is the IV
infusion of a nutritionally, complete
formula, including
◦ amino acids (protein/nitrogen)
◦ dextrose (carbohydrate/glucose)
◦ fat emulsions (fatty acids)
◦ vitamins
◦ electrolytes
◦ minerals
◦ trace elements

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(Purpose of TPN)

Why TPN?
• Promote wound healing
• Avoid malnutrition
• Examples: severe burns, sepsis, cardiac
conditions, trauma, liver failure, GI conditions
impairing absorption, anorexia nervosa
• Nutrition through the GI tract is best & should
be used when the Patient GIT is functional
before initiating parental nutrition
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Candidates for TPN
Patient unable to take nutrition orally or
enterally
Who are at risk of malnutrition because of
actual or anticipated prolonged inability to
ingest, digest, or absorb nutrients
Patient who are severely injured

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Expected Outcomes
• Expected Outcomes
1. Patient will achieve/maintain ideal body weight
2. Patient will achieve/maintain fluid & electrolyte balance
3. Patient will maintain serum glucose levels at less than
200mg
4. Patient will remain free of local & systemic infections

TPN Expected Outcomes

1. Patient will achieve/maintain ideal body weight
Wt gain is usually between 1 & 2 pounds per week
Wt is an indicator of how well the Patient is doing nutritionally
& determines fluid volume
A wt gain greater than 1 pound per day indicates fluid retention

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Expected Outcomes
2. Patient will achieve/maintain fluid & electrolyte balance
• Patient who have
◦ electrolyte disturbances,
◦ elevated blood glucose level,
◦ renal dysfunction, or hepatic dysfunction
may require their TPN therapy to be adapted by composition or volume
(requires MD order)
3. Patient will maintain serum glucose levels at less than 200mg
– Serum glucose level less than 200mg will reflect a metabolic tolerance to
the concentrated glucose solution in TPN
4. Patient will remain free of local & systemic infections
– Ensures that TPN is infusing into the vein rather than into surrounding
tissues & there are no signs of an access device infection

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unexpected Outcomes
Unexpected Outcomes & Related to Interventions
Exit site infection indicated by :
There is redness, swelling, & tenderness around the venous access site.
Action: Notify MD. Apply warm compress, Antibiotic therapy may begin

systemic infection indicated by :

Patient develops fever, malaise, chills, signs of exit site infection may also
be present.
Action: Notify MD & consult about the need to obtain cultures of exit
site or blood. Antibiotic therapy may begin.

stops flowing or flows at a rate slower than ordered:

Venous access device may have become occluded with fibrin or
particulate matter.
Action: Report occlusion to MD. If the device is a surgically placed
device, a thrombolytic agent may be ordered

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Unexpected Outcomes
Unexpected Outcomes & Related Interventions

Patient has weight gain bout 1 pound per day.

Taut skin turgor & dependent edema may be present. Crackles over lung
fields. Symptoms indicate fluid retention rather than restoration of
body proteins.

Serum glucose is greater than 200mg.

Indicates Patient intolerance to glucose load in TPN solution. May
document need for addition of insulin to the TPN, modification of
TPN solution, or sliding scale insulin coverage

Serum electrolytes are out of normal range.

The electrolyte levels in the solution may need to be adjusted

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TPN Evaluation
TPN Evaluation
We must be monitor the following:
1. daily weights
2. I &O & evaluate for fluid overload or dehydration
3. finger stick blood sugar q6h or as ordered
4. sign and symptoms of infection, either at infusion site (redness,
swelling, tenderness, or drainage) or systemic signs of infection
(fever, elevated WBC & malaise)
Complications of Central Parenteral Nutrition
• Air Embolism
• Infection – Localized infection or system infection
• Hyperglycemia or Hypoglycemia
• Pneumothorax
• Arterial Laceration

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TPN Evaluation
Estimation of Energy Expenditure
•The traditional method of assessing energy expenditure is to first
calculate basal energy expenditure (BEE), which is the amount of
energy (kilocalories (kcal) needed to support basic metabolic
functions in a state of complete rest.
•BEE is most commonly calculated using the Harris-Benedict equations.

2) Alternatively, BEE can be estimated at 20 to 25 kcal/kg per day.

•Resting energy expenditure (REE) is the energy expended in the post-
absorptive state is approximately 10% greater than BEE.
•Determination of BEE or REE does not include additional energy needed
for stress or activity. The Harris-Benedict equation can be modified
to include stress and physical activity factors, or these variables can
be estimated at
◦ 30 to 35 kcal/kg per day for moderate stress and
◦ up to 45 kcal/kg per day for severe stress as in the following table.

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Basal Energy Expenditure (BEE} Harris-Benedict Equations
BEE-men (kcal/day) = 66.47 + 13.75 W + 5.0 H - 6.76 A .
BEE-women (kcal/day) = 655.10 + 9.56 W + 1.85 H – 4 A
or "
20-25 kcal/kg/day
Total Energy Expenditure (TEE)
TEE (kcal/day) = BEE x Stress factor x
____________________________________________
Stress or Injury Factors (% increase above BEE)
Major surgery 10-20,
Infection 20 ,
Fracture 20-40,
Trauma 40-60"
Sepsis 60,
Burns 60-100
Activity Factors (% increase above BEE)
Confined to bed 20
Out of bed 30

Or No stress 28 Kcal/kg/day,
 mild stress 30 Kcal/kg/day ,
 moderate stress 35 Kcal/kg/day ,
 severe stress 40 Kcal/kg/day. 15
Protein requirement
Table: Estimation of protein requirement

US RDA 0.8 g/kg/day

Hospitalized patient
minor stress 1.0-1.2 g/kg/day
Moderate stress 1.2-1.5 g/kg/day
Sever stress 1.5-2.0 g/kg/day
____________________________________
RDA = recommended dietary allowance.

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•Estimation of Protein Goals
•Estimation of protein needs
also must be included in nutritional assessment, where it
calculated based on body weight, degree of stress, and
disease state.
•The RDA for the United States is 0.8 g/kg per day.
•Hospitalized patients with minimal stress who are well nourished
need 1.0 to 1.2 g/kg / day for maintenance of lean body mass.
•The requirement for protein intake may be as high as 2.0 g/kg
per day for a patient in a hyper-metabolic, hyper-catabolic
state secondary to trauma or buns.
•In addition, patients with renal or hepatic dysfunction may
require a decrease in protein intake as a result of altered
metabolism.

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Components of Parenteral Nutrient Formulations

Parenteral nutrient formulations are mixtures containing:

 carbohydrate,
 protein,
 lipids,
 water,
 electrolytes,
 vitamins, and
 trace minerals.
These admixtures must be prepared under aseptic conditions.
Although parenteral feeding is an important adjuvant therapy for many
disease states, errors have occurred in managing this complex
therapy resulting in patient harm and death.
In 1994 the FDA issued a Safety Alert after two deaths related to errors
in compounding parenteral nutrient formulations occurred.
guidelines have been developed for parenteral nutrition therapy.

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•Carbohydrate
•Dextrose in water is the most common carbohydrate for IV use. It is
available commercially in concentrations ranging from 2.5 to
70%. These dextrose solutions are mixed with other components
of the parenteral nutrient formulation and diluted to various final
concentrations.
•IV dextrose is monohydrated and provides 3.4 kcal/g.
•Glycerol also is available (as a 3% mixture with 3% amino acids) for
administration as a peripheral parenteral nutrient formulation.
Glycerol has a caloric density of 4.3 kcal/g.
•Other carbohydrates such as fructose, sorbitol, and invert sugar have
been used:
◦ used investigationally in parenteral nutrient formulations
◦ are associated with adverse effects and
◦ are not available commercially.

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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
20%, 50% ( from CV-line)
60-70% of calorie requirements should be
provided with dextrose
30-40 mL/kg fluid per day

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•Lipid
•Lipid is supplied as o/w emulsions
either soybean oil or a mixture of soybean and safflower oils (long-chain FAs (12 to 24 carbon).

The soybean oil emulsion is available in three conc: 10%, 20% and 30%.

The 10% and 20% IV lipid emulsions may be administered concurrently (IV piggyback) with
dextrose/ amino acid solutions .

•The 30% IV lipid emulsion is hypotonic and should not be used for IV
piggyback administration. It is used restricted on formulations that
combine dextrose, amino acids and lipid in the same container.

•Lipid has a caloric density of 9 kcal/g, the caloric density of the IV lipid
emulsions is increased by the addition of glycerol and egg
phospholipids. These components are added as emulsifiers and to adjust
the osmolarity.

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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
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Lipid
•The phospholipids are derived from egg yolks;
therefore, IV lipids are contraindicated in
patients with severe egg allergies, especially egg
yolk allergies.
•Medium-chain triglycerides (MCTs) are used
investigationally.
•MCTs are 6 to 10 carbons in length and provide 8.3
kcal/g. Mixtures of long-chain and medium-
chain triglycerides are commercially available.

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 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

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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)

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•(protein) Amino Acids
•Protein for parenteral administration is available as synthetic amino
acids and serves as the source of nitrogen.
Amino acid concentrations of 3.5 to 20% are available commercially and
vary slightly from one product to another in the amounts of each
amino acid.
•Generally, amino acid products are mixtures of essential, nonessential,
and semiessential amino acids, are modified for specific disease
states.
For example, in patients with hepatic failure contains increased amounts
of the branched-chain amino acids, and decreased amounts of the
aromatic amino acids.
•Protein formulations designed for patients undergoing physiologic stress
are supplemented with branched-chain amino acids, but have
normal amounts of the other amino acids.

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•Amino Acids
•Amino acid products for patients with renal failure either
have increased amounts of the essential amino acids or
provide only essential amino acids.
•Amino acid products designed to meet the needs of neonates
are also available.
Protein or amino acids have a caloric density of 4 kcal/g.
Traditionally, protein calories were not always included in
the calculation of energy needs for patients receiving
parenteral nutrient formulations. Ideally, protein is used
for tissue repair and not oxidized for energy. Today, the
conventional wisdom is to include the protein calories in
these calculations.

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 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

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 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

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

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•Micronutrients
•Micronutrients are the electrolytes, vitamins, and trace
minerals needed for metabolism. These nutrients are
available from various manufacturers as either single
entities or in combinations. For example, the trace
element zinc is available commercially as a single trace
element product or as a combination product with the
other trace elements, copper, chromium, manganese,
and selenium.
•The following table summarizes available nutrients and
their caloric density.

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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)

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 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
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
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BEE= 66.47+13.75×60+5×180-6.76×38=1535 kcal/d
TEE= 1535×1.2×1.2 = 2200 kcal/d
Intralipid 10%= ? 2200 × 30%= 660 kcal
1ml ≡ 1.1 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)

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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

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• 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)

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 Table: Caloric density of intravenous nutrients
-----------------------------------------------------------------------
Nutrient Kcal/g Kcal/ml
Amino acids 4 0
Amino acids 5% - 0.2
Amino acids 10% - 0.4
Dextrose 3.4 -
Dextrose 10% - 0.34
Dextrose 50% - 1.7
Dextrose 70% - 2.38
Fat 10 -
Fat emulsion 10% - 1.1
Fat emulsion 20% - 2
Fat emulsion 30% - 3
Glycerol 4.3 -
Glycerol 3% - 0.129
Medium-chain triglycerides 8.3 -

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 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

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