TOTAL PARENTRAL
NUTRITION
SANTHOSH
DEFINITION
Administration of a nutritionally adequate
hypertonic solution consisting of dextrose,
proteins, fats, minerals ,vitamins and trace
elements through an intravenous catheter.
INDICATIONS
High output abdominal fistulas
Bowel obstruction
Short bowel syndrome
Very severe crohns disease or ulcerative colitis
Major abdominal surgeries
Bowel ischemia
High risk of aspiration
CONT
Small bowel ileus
Massive GI bleeding
Multiorgan failure
Severe burns
Severe malnutrition
Peritonitis
Severe pancreatitis
CONTRAINDICATIONS
Cardiac failure
Blood dyscrasias
Shock
Severe liver failure
Fluid electrolyte imbalance
COMPONENTS OF TPN
Carbohydrates
Fats
Amino acids
Minerals
Vitamins (A,D,E,K), water soluble vitamins
Ca,mg, and other trace elements.
CARBOHYDRATE REQUIREMENTS
40 to 50 %
Dextrose
It has the nitrogen sparing effect
Disadvantages:
Low calorie value
Increased co2 production
Thrombophlebitis
ENERGY REQUIREMENTS
Patient condition
Basal
metabolic
rate
Approximate energy
Requirement
(kcal/kg/day)
No postoperative
complications, GIT
fistula without infection
Normal
25-30
Mild peritonitis, long-bone
fracture, mild to moderate
injury, malnourished
25% above
normal
30-35
Severe injury or infection
50% above
normal
35-45
Burn 40-100% of total body Up to 100%
45-80
surface
above normal
FAT
40 to 50%
Requirement is 3g/kg/day
CONTENTS:
Soya bean oil
Sunflower oil
Egg yolk phosholipids
Glycerin
CONT
Advantages:
High calorie
Prevents hyperglycemia
Less co2 production
Less insulin production
Reduce thrombophlebitis
Prevents essential FA deficiency
CONT
Disadvantages
Sepsis
Fat embolism
Fat over load
Delayed gastric emptying
Hypertriglyceridaemia
High cost
PROTEINS
Amino acids are essential components of PN
10 to 20%
Standard AA solution contains 40 to 50%
essential amino acids and 50% non essential
amino acids.
REQUIREMENTS:
Nitrogen
Daily Protein requirements
Condition
Basic requirements
Slightly increased
requirements
Example
Normal person
Post-operative, cancer,
inflammatory
requirement
0.5-1g/Kg
1.5g/Kg
Moderately increased
requirements
Sepsis, polytrauma
2g/Kg
Highly increased
requirements
Peritonitis, burns,
2.5g/Kg
Reduced requirements Renal failure, hepatic
encephalopathy
0.6g/Kg
CONT.
Parenteral
amino acid solutions provide all
known essential amino acids.
Available amino acid preparations are 3.5 - 15 % (ie contains
3.5-15 gms of protein ).
1gm of protein = 0.16 gm of N2.
CONT..
Advantages
Protein synthesis
Reduce rate of protein catabolism
Disadvantages
Hepatic insufficency
Renal failure
Increased rate of infusion cause vomiting,
fever
headache,
CONT..
Special
AA solutions are also available containing
higher levels of certain amino acids, most
commonly the branched-chain ones (valine, leucine
and isoleucine), aimed at the management of liver
diseases, sepsis and other stress conditions.
Conversely,
solutions containing fewer a.a.s
(primarily the essential ones) are available for
patients with renal failure.
CONT
Arginine was added to enteral formulae claiming positive
effects on immune function.
Glutamine-enriched solutions improved nitrogen balance and
gut morphology.
FLUID REQUIREMENT
Fluids and electrolytes
Nutrient
Requirements (/Kg/day)
Water
20-40 mL
Sodium
0.5-1.0 mmol
Potassium
0.5-1.0 mmol
Magnesium
0.1-0.2 mmol
Calcium
0.05-0.15mmol
Phosphate
0.2-0.5mmol
GOALS OF TPN
To maintain nutritional status by providing all
nutrients for ongoing metabolic functions.
To increse protein synthesis
To reduce protein breakdown
To prevent weight loss
To minimize deleterious effects of catabolism
CONT
To boost immune function and improve wound
healing
To maintain acid base balance and electrolyte
disturbances
To improve cardiac and respiratory functions
NUTRITIONAL REQUIREMENTS
FLUID REQUIREMENTS:
1500ml for 20kg+20ml/kg for additional weight.
ENERGY REQUIREMENTS:
REE(Kcal/day)=25*weight in kg
APPLICATION:
Initiation of Therapy
TPN infusion is usually initiated at a rate of 25 to
50 mL/h. This rate is then increased by 25 mL/h
until the predetermined final rate is achieved.
Administration
To ensure that the solution is administered at a
continuous rate, an infusion pump is utilized to
administer the solution. In hospitalized patients,
infusion usually occurs over 22-24 h/day. In
ambulatory home patients, administration usually
occurs overnight (12-16 h).
ROUTES FOR TPN ADMINISRATION
CENTRAL VENOUS CATHETERS
( COMMONLY USED)
PERIPHERALLY INSERTED CENTRAL
CATHETERS (PICC)
CENTRAL VENOUS CATHETERS
Most commonly used route
Can be inserted via SUBCLAVIAN VEIN,
INTERNAL OR EXTERNAL JUGULAR VEIN.
Advantages:
Hypertonic solutions
Placed for 6weeks
Multiple lumen
Disadvantage
Increase infection rate
Inserted in theater
PICC LINE
Advantages:
Bed side technique
Avoid multiple venous cannulations
low risk of phlebitis
Disadvantages:
costly
Line blockage and sepsis
thrombosis
mal position
MONITORING TPN
ADMINISTRATION
Patients weight
Intake and output
TPN blood work:
Electroytes, urea, creatinine, glucose,
bilurubin, albumin ,platelets, LFT ,ca, mg,
phosphate and micronutrients
MONITORING
1- Daily: electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl.
Sugar, body weight, Hb.
2- Complications: ALT, AST, Bil, BUN, total proteins and
fractions.
3- General: Input- Output chart,patient weight.
4- Detection of infection:
Clinical (activity, temp, symptoms)
WBC count (total & differential)
Cultures
COMPLICATIONS
Mechanical
Air embolism
Pneumothorax
Bleeding
Catheter displacement
Sepsis
Thrombosis,
Thrombophlebitis.
CONT.
METABOLIC:
Early
Hyperglycemia
hypoglycemia
hyperlipidemia Hypo/hypernatremia
Hypo/hyperkalemia
Hypercalcemia
refeeding syndrome
CONT.
Late
Hepatic dysfunction
Steatosis, cholestatic jaundice
Cholelithiasis, acalculous cholecystitis
Fluid over load
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