{"id":839,"date":"2020-02-17T22:17:11","date_gmt":"2020-02-17T16:47:11","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=839"},"modified":"2020-02-17T22:17:11","modified_gmt":"2020-02-17T16:47:11","slug":"total-parenteral-nutrition","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/total-parenteral-nutrition\/","title":{"rendered":"Total Parenteral Nutrition"},"content":{"rendered":"\n<p><strong>Total Parenteral Nutrition<\/strong><\/p>\n\n\n\n<p>Parenteral Nutrition&nbsp; is pharmacological therapy, where nutrients, vitamins, electrolytes and medications are delivered through venous route, to those patients whose GIT is not functional or unable to tolerate enteral nutrition<\/p>\n\n\n\n<p>Parenteral nutrition is process of supplying nutrients via the intravenous route<\/p>\n\n\n\n<ul><li>Total parenteral nutrition (TPN)<ul><li>Peripheral parenteral nutrition (PPN)<\/li><\/ul><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"284\" height=\"252\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-353.png?w=284\" alt=\"\" class=\"wp-image-863\" \/><\/figure>\n\n\n\n<p><strong>Goals of Parenteral Nutrition<\/strong><\/p>\n\n\n\n<ul><li>Maintain or improve <strong>nutritional status<\/strong><\/li><li>Minimize deleterious effects of catabolism<\/li><li>Boost <strong>immune system<\/strong><\/li><li>Improve<strong> CVS and respiratory function<\/strong><\/li><li><strong>Acid\/base and electrolyte balance<\/strong><\/li><li><strong>Rehabilitation<\/strong><\/li><\/ul>\n\n\n\n<p><img loading=\"lazy\" decoding=\"async\" width=\"284\" height=\"252\" src=\"\"><strong>Calorie\/Protein Yields<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>1 Gm protein = 4 kcals<ul><li>1 Gm fat = 9 kcals<\/li><\/ul><ul><li>1 Gm dextrose = 3.4 kcals<\/li><\/ul><ul><li>1 Gm nitrogen = 6.25gm protein<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>Peripheral Parenteral Nutrition<\/strong><\/p>\n\n\n\n<ul><li>Peripheral vein<\/li><li>Short period &lt; 2 weeks<\/li><li>Osmolarity &lt; 900 mOsm\/L<\/li><li>Lipid is an important component<\/li><\/ul>\n\n\n\n<p><strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Indications<\/strong><\/p>\n\n\n\n<ul><li>Parenteral nutrition for short period<\/li><li>Central venous catheter insertion not possible<\/li><li>Sepsis in patient on TPN<\/li><\/ul>\n\n\n\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <strong>Contraindications<\/strong><\/p>\n\n\n\n<ul><li>Patients with increased energy requirements<\/li><li>Patients who are on fluid restrictions<\/li><li>Critically ill patients who will not tolerate large volume of PPN<\/li><\/ul>\n\n\n\n<p><strong>Total Parenteral Nutrition<\/strong><\/p>\n\n\n\n<ul><li>More effective compared to PPN<\/li><li><strong>Via Superior venacava or Inferior venacava<\/strong><\/li><li>Dextrose used 50-70%, therefore hypertonic and irritant<\/li><li>Catheter is made of polyurethrane (short period) and silicon rubber (long period)<\/li><li>It can be Short term TPN or Long Term TPN \u2013 \u201cTunneled\u201d<\/li><li><strong>System of Delivery :<\/strong><br>&#8211; Multiple bottle system<br>&#8211; Three in one system<\/li><li><strong>Duration<\/strong><br>&#8211; Continuous : reserved for critically ill patients<br>&#8211; Cyclic<\/li><\/ul>\n\n\n\n<p><strong>Indications of Parenteral Nutrition<\/strong><strong><\/strong><\/p>\n\n\n\n<p><strong>General Indications <\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>Inadequate nutrition for least 7-10 days<\/li><li>Pre-existing severe malnutrition with inadequate oral or enteral feed<\/li><\/ul>\n\n\n\n<p><strong>Anticipated or actual inadequate oral feeds<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li><strong>&nbsp;<u>Conditions impairing absorption of nutrients<\/u><\/strong><\/li><li>Entercutaneous fistula<\/li><li>Short bowel syndrome<\/li><li>Effects of radiation and chemotherapy<\/li><li><strong>&nbsp;<u>Need for bowel rest<\/u><\/strong><\/li><li>Pancreatitis<\/li><li>Inflammatory bowel disease<\/li><li>Ischemic bowel<\/li><li>Peritonitis<\/li><li>Pre and post-operative status<\/li><li><strong>&nbsp;<u>Motility disorders<\/u><\/strong><\/li><li>Inability to achieve or maintain enteral access<\/li><li>Significant multi organ failure<\/li><\/ul>\n\n\n\n<p><strong>Nutrition requirements<\/strong><\/p>\n\n\n\n<p><strong>Resting Energy Expenditure<\/strong><\/p>\n\n\n\n<p>Simple body weight formula :<\/p>\n\n\n\n<p>Resting energy expenditure (REE) {kcal\/day}=25 \u00d7 Wt(kgs)<\/p>\n\n\n\n<p>Harris Benedict equation<\/p>\n\n\n\n<ul><li>REE(men)= 66+(13.7\u00d7 Wt) + (5 \u00d7 H(cms)) &#8211; (6.7\u00d7A(yrs))<\/li><\/ul>\n\n\n\n<ul><li>REE(women)= 655+(9.6\u00d7 Wt) + (1.8 \u00d7 H(cms)) &#8211; (4.7\u00d7A(yrs))<\/li><\/ul>\n\n\n\n<p><strong>Carbohydtrates<\/strong><\/p>\n\n\n\n<ul><li>Mainly Dextrose<\/li><li>1gm=3.4Kcal<\/li><li>Variable concentration : 5-70%<\/li><li>Osmolarity: 252-1900 mOsm\/L<\/li><\/ul>\n\n\n\n<p><strong>Advantages<\/strong><\/p>\n\n\n\n<ul><li>Cost<\/li><li>Calories<\/li><li>Nitrogen sparing effect<\/li><\/ul>\n\n\n\n<p><strong>Disadvantages<\/strong><\/p>\n\n\n\n<ul><li>Calories as compared to lipids are low<\/li><li>Increased CO<sub>2<\/sub> production<\/li><li>Thrombophlebitis<\/li><\/ul>\n\n\n\n<p><strong>Fats<\/strong><\/p>\n\n\n\n<ul><li>Administered as <strong>&nbsp;emulsions<\/strong><\/li><li>Soybean and sunflower oil<\/li><li>Egg yolk phospholipids \u2013 emulsifying agent<\/li><li>Glycerin \u2013 Isotonicity with plasma<\/li><li>1gm = 9 Kcal<\/li><li>Available as 10, 20 &amp; 30%<\/li><li><img loading=\"lazy\" decoding=\"async\" width=\"297\" height=\"173\" src=\"\" alt=\"Text Box: Disadvantages\n\u2022\t\u2191 Triglycerides\n\u2022\t\u2191 Sepsis\n\u2022\tFat embolism\n\u2022\tRare complications - dyspnea\n\">Requirements 20-30% of total REE<\/li><\/ul>\n\n\n\n<p><strong>Advantages<\/strong><\/p>\n\n\n\n<ul><li>Calories<\/li><li>Glucose and nitrogen sparing<\/li><li>Less carbon dioxide<\/li><li>Prevention of EFA deficiency<\/li><li>Less risk of thrombophlebitis<\/li><\/ul>\n\n\n\n<p><strong>Contraindications<\/strong><\/p>\n\n\n\n<ul><li>Hyperlipidemia TG &gt; 350 mg\/dl<\/li><li>Acidosis pH &lt; 7.3<\/li><li>Anemia<\/li><li>Intravascular coagulation<\/li><li>Impaired circulation<\/li><\/ul>\n\n\n\n<p><strong>Duration :<\/strong><\/p>\n\n\n\n<ul><li>If used to prevent EFA deficiency \u2013 3-4days\/week<\/li><li>If used as calorie source \u2013 daily<\/li><\/ul>\n\n\n\n<p><strong>Proteins<\/strong><\/p>\n\n\n\n<ul><li>1gm = 4 Kcal<\/li><li>50% EAA + 50% NEAA \u2013 standard preparation<\/li><li>Concentration range 3 \u2013 15%<\/li><\/ul>\n\n\n\n<p><strong>Advantages<\/strong><\/p>\n\n\n\n<ul><li>Calorie supplement<\/li><li>Protein synthesis<\/li><li>Decreases rate of catabolism<\/li><\/ul>\n\n\n\n<p><strong>Contraindications<\/strong><\/p>\n\n\n\n<ul><li>Hepatic insufficiency<\/li><li>Renal failure<\/li><li>Metabolic or respiratory alkalosis<\/li><\/ul>\n\n\n\n<p>Monitor Nitrogen balance = Nitrogen intake &#8211; Nitrogen loss<\/p>\n\n\n\n<p>Nitrogen loss = {(24 \u2013 urine urea Nitrogen&nbsp; + 4) \u00d7 6.25 }<\/p>\n\n\n\n<p>+ve Nitrogen&nbsp; balance = anabolism<\/p>\n\n\n\n<p>-ve Nitrogen balance = catabolism<\/p>\n\n\n\n<p><strong>Disease specific modifications<\/strong><\/p>\n\n\n\n<ul><li>Hepatic insufficiency<\/li><\/ul>\n\n\n\n<p>Branched chain amino acids (BCAA ) = leucine, isoleucine &amp; valine<\/p>\n\n\n\n<ul><li>Renal Failure<\/li><\/ul>\n\n\n\n<p>Large amount of Essential amino acids(EAA)<\/p>\n\n\n\n<ul><li>Volume overload<\/li><\/ul>\n\n\n\n<p>15% concentrated amino acid solution<\/p>\n\n\n\n<p><strong>Special formulations<\/strong><\/p>\n\n\n\n<p>Immunomodulators<\/p>\n\n\n\n<ul><li>Glutamine<\/li><li>Omega 3 Fatty Acid<\/li><li>Arginine<\/li><li>Vitamins<\/li><li>Electrolytes<\/li><li>Trace elements<\/li><\/ul>\n\n\n\n<p><strong>Complications of&nbsp; TPN<\/strong><\/p>\n\n\n\n<ul><li>Acid-base imbalance<\/li><li>Dehydration<\/li><li>Elevated serum triglycerides<\/li><li>Failure to induce anabolism<\/li><li>High serum lipid concentrations<\/li><li>Hyperammonemia<\/li><li>Hyperglycemia or hypoglycemia<\/li><li>Hypoalbuminemia<\/li><li>Imbalance of electrolytes<\/li><li>Liver toxicity<\/li><li>Catheter Sepsis<\/li><\/ul>\n\n\n\n<p><strong>Designing Parenteral Nutrition formula<\/strong><\/p>\n\n\n\n<p>3 steps<\/p>\n\n\n\n<ol type=\"1\"><li>Calculation of daily requirements<\/li><li>Convert requirement into prescription<\/li><li>To prepare PN solution as per prescription<\/li><\/ol>\n\n\n\n<p><strong>Step 1<\/strong><\/p>\n\n\n\n<ul><li>Fluid requirements = 35ml\/Kg<\/li><li>35 \u00d7 Wt(60kgs) = 2100ml<\/li><li>Calorie = 25 Kcal\/kg\/day = 25 \u00d7 60 = 1500Kcal\/day<\/li><li>Proteins needed for a stable patient is 1gm\/kg = 60gms\/day<\/li><li><img loading=\"lazy\" decoding=\"async\" width=\"287\" height=\"165\" src=\"\" alt=\"Text Box: So for a 60 kg adult:\nFluid = 2100 ml\nProteins = 60 gms\nLipids = 50 gms\nDextrose = 202 gms\n\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1gm = 4 Kcal<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;60gms = 240 Kcal<\/li><li>Fats = 30% of energy = 30% of 1500 Kcal = 450 Kcal<\/li><li>1gm = 9 Kcal<\/li><li>Therefore 450 Kcal = 450 \/ 9 =&nbsp; 50gms<\/li><li>Carbohydrates = 1500 \u2013 (450 + 240) = 810 Kcal<\/li><li>1gm Carbohydrate = 4 kcal<\/li><li>Therefore 810 Kcal = 810 \/ 4 =&nbsp; 202.5gms<\/li><\/ul>\n\n\n\n<p><strong>Step 2<\/strong><strong><\/strong><\/p>\n\n\n\n<p><strong>Determine volume of lipid emulsion<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>Select 10 % emulsion<\/li><li>Fluid volume (ml) = amount of substance (gms) \/ concentration (%) \u00d7 100<\/li><li>50 \/ 10 \u00d7 100 = 500ml<\/li><li>500ml of 10% emulsion of fat<\/li><\/ul>\n\n\n\n<p><strong>Determine volume of proteins (10%)<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>Fluid volume (ml) = amount of substance (gms) \/ concentration (%) \u00d7 100<\/li><li>60 \/ 10 \u00d7 100 = 600ml<\/li><li>600ml of 10% solution of amino acid<\/li><\/ul>\n\n\n\n<p><strong>Determine concentration and volume of dextrose<\/strong><strong><\/strong><\/p>\n\n\n\n<ul><li>&nbsp;Fluid volume (ml) = amount of substance (gms) \/ concentration (%) \u00d7 100<\/li><li>2100 \u2013 (500 + 600 ) = 1000ml<\/li><li>1000 = 20 \/ concentration (%) \u00d7 100<\/li><li>Concentration = 20 \/ 1000 \u00d7 100&nbsp; = 20%<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><\/td><\/tr><tr><td><\/td><td><img loading=\"lazy\" decoding=\"async\" width=\"227\" height=\"123\" src=\"\" alt=\"Text Box: Prescription\n500ml of 10% lipid emulsion\n600ml of 10% protein solution\n1000ml of 20% dextrose\n\"><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><strong>&nbsp;<\/strong><\/p>\n\n\n\n<p><strong>Osmolarity limits<\/strong><\/p>\n\n\n\n<ul><li>Peripheral: 600-900 mOsm\/L<ul><li>Total: &gt; 1800 mOsm\/L<\/li><\/ul><\/li><\/ul>\n\n\n\n<p>Increased osmolarity limits allows for increased concentrations of dextrose and amino acids to be delivered<\/p>\n\n\n\n<p><strong>Osmolarity of additivies (per 1% final concentrations)<\/strong><\/p>\n\n\n\n<ul><li>Amino acids: 100 mOsm\/L<ul><li>Dextrose: 50 mOsm\/L<\/li><\/ul><ul><li>Lipids: 1.7 mOsm\/L<\/li><\/ul><ul><li>Electrolytes: 1-1.4 mOsm\/meq<\/li><\/ul><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><\/td><\/tr><tr><td><\/td><td><img loading=\"lazy\" decoding=\"async\" width=\"330\" height=\"198\" src=\"\" alt=\"Text Box: Recommended Trace Element\n\u2022\tChromium \n\u2022\tCopper \n\u2022\tManganese \n\u2022\tZinc\n\u2022\tSelenium\n\n\"><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><strong>Common Additions to TPNs<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"242\" height=\"158\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-354.png?w=242\" alt=\"\" class=\"wp-image-864\" \/><\/figure>\n\n\n\n<p><strong>Precautions<\/strong><\/p>\n\n\n\n<ul><li>Phosphates are&nbsp; injected first and are never mixed with calcium and magnessium<\/li><li>Then add amino acids, dextrose, lipids, and water<\/li><li>Then add the other electrolytes<\/li><li>TPN must be inspected after mixing to look for precipitates<\/li><\/ul>\n\n\n\n<p><strong>Transition to enteral or oral feeds<\/strong><\/p>\n\n\n\n<ul><li>Ultimate goal = switch to oral<\/li><li>Gradual not abrupt<\/li><li>Once patient can take 60% of total calorie requirements orally, Parenteral Nutrition can be stopped<\/li><li>Before stopping Parenteral Nutrition infusion rate is decreased to 50% for 2-4hrs<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Total Parenteral Nutrition Parenteral Nutrition&nbsp; is pharmacological therapy, where nutrients, vitamins, electrolytes and medications are delivered through venous route, to those patients whose GIT is not functional or unable to tolerate enteral nutrition Parenteral nutrition is process of supplying nutrients via the intravenous route Total parenteral nutrition (TPN) Peripheral parenteral nutrition (PPN) Goals of Parenteral[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/839"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=839"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/839\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=839"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=839"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=839"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}