Total Parenteral Nutrition

NZR
Definition
 Parenteral Nutrition is partial or
total nutrition administered
intravenously.
 A peripheral or central vein is used
for access.
Parenteral Nutrition
• Total Parenteral Nutrition (TPN)
All nutrient needs are covered by
Intravenous way.
• Supplementary Parenteral Nutrition
Patient receives nutritional support partly
via GI-tract, and the rest via IV infusion.
Pertkiewicz, Szczygiel, Sobotka et al :
e-SPEN Clinical Nutrition and Metabolism, 2009; 4 : e161.
 ESPEN Guidelines, 2009

There is some agreement that PN,

administered to patients who also
tolerate EN or who are not
malnourished causes more harm than
benefit.
Braga, Ljungqvist, Soeters et al : ESPEN Guidelines on Parenteral Nutrition :
Surgery, Clinical Nutrition 2009, 28 : 378.
Indications
Parenteral Nutrition :
• Non-functional gastrointestinal tract or GI
failure
• Impossible to use the gastrointestinal tract

Palliative use in terminal patients is

controversial
 Indications
Parenteral Nutrition :
• Need for intestinal rest
• Due to limited GI tolerance, it is not
possible to give sufficient EN to meet
the patient’s total nutritional
requirement
 ESPEN Guidelines, 2009

In cases of prolonged gastrointestinal

dysfunction, PN should be given until
enteral function returns

Clin.Nutr. 2009, 28 :378 - 86

 Suggesting mandatory TPN
• Intestinal Obstruction
• Ileus
• Malabsorption
• Multiple fistulas with high output
• Intestinal ischemia

Braga, Ljungqvist, Soeters et al : ESPEN Guidelines on Parenteral

Nutrition : Surgery, Clinical Nutrition 2009, 28 : 379.
 Suggesting mandatory TPN
• Severe shock with impaired
splanchnic perfusion
• Fulminant sepsis

Braga, Ljungqvist, Soeters et al : ESPEN Guidelines on Parenteral

Nutrition : Surgery, Clinical Nutrition 2009, 28 : 379.
Contrandications :
Parenteral Nutrition
• Ability to adequately receive and
absorb necessary foods orally or by
gastric or enteral tube
• Hemodynamic instability
 ESPEN Guidelines, 2009
• When is preoperative PN
indicated ?
 ESPEN Guidelines, 2009
• The answer :
• In severely undernourished
patients, who cannot be orally or
enterally fed Grade A
 ESPEN Guidelines, 2009
• When is postoperative PN
indicated ?
 ESPEN Guidelines, 2009
Parenteral Nutrition is beneficial
• In undernourished patients in
whom EN is not feasible or not
tolerated.
• Grade A
 ESPEN Guidelines, 2009
Parenteral Nutrition is beneficial
• In patients with postoperative
complications impairing GI – function
who are unable to receive or absorb
adequate amounts of oral or enteral
feeding for at least 7 days.
• Grade A
 ESPEN Guidelines, 2009
Parenteral Nutrition is beneficial

• In patients who require

postoperative artificial nutrition,
EF or a combination of Enteral
and Supplementary Parenteral
Feeding is the first choice.
• Grade A
 ESPEN Guidelines, 2009
Parenteral Nutrition is beneficial
• Combinations of Enteral and PN should
be considered in patients in whom there
is an indication for nutritional support
and in whom > 60 % of Energy needs
cannot be met via the enteral route, eg.
High Output fistula
• Grade C
Abdominal Injury, Bowel rupture
Abdominal Cancer Surgery
Central Parenteral Nutrition
Selection depends on caloric requirements,
volume to be administered and patient condition,
as well as final concentration of components :
• Amino Acid > 5%
• Dextrose >20%
• Lipids
• Includes Vitamins, minerals, and trace elements
• Osmolality >700 mOsm/kg H2O
Peripheral Parenteral Nutrition
Selection of peripheral access depends on
clinical situation, requirements, tolerance to
volume, and final formula concentration
• Osmolality < 700 mOsm/kg H20
• Total kcal limited by concentration and ratio to
volume being administered
• Include ½ of the recommended electrolytes for
PN
Parenteral Nutrition

Start Low, Go Slow

PN : Types of Infusion
• Continous – Total volume of formula is
administered over a 24 hour period
• Cyclic – Volume is administered in one period,
with infusion adjustments and a period of rest
• Selection of infusion type depends on
patient’s condition
• Use a parenteral infusion pump
 Nutrients Requirements
Carbohydrate :
• Used as main Energy Substrate
• Given up to 50 – 60 % (70 %) of Total
calorie need
• Needed for maintaining anabolism of body
protein

TNT Mannual Versi-2

Formulas : Parenteral Nutrition
Dextrose
• Provides 3.4 kcal/g
• Can be the only source of energy
• Dextrose infusion rate should not exceed
5mg/kg/min
• Closely related to solution osmolality
Formulas : Parenteral Nutrition
Lipids
• Prevent Essential Fatty Acid deficiency
• Non-protein source of calorie.
• Recommended dose 1 g/kg/day
• Available in 10%, 20% and 30%
concentrations
 Formulas : Parenteral Nutrition
Lipids
• Includes as LCT or a mix of MCT/LCT at
10% and 20%
• Added to basic parenteral nutrition
solutions or administered individually
Formulas : Parenteral Nutrition
Lipids
• Less hyperglycemia
• Lower concentrations of serum insulin
• Less risk of hepatic damage
• High doses can interfere with immune
functions
• High infusion rates can affect respiratory
functions
Formulas : Parenteral Nutrition
Lipids
• Should be used with care in :
- Hyperlipidemia
- Symptomatic atherosclerosis
- Acute pancreatitis with
hypertriglyceridemia

TNT Mannual, Version 2.

Formulas : Parenteral Nutrition
Amino Acids
• Standard concentrations can vary
between 5% , 10 % and 15%
• Energy value of amino acids 4 kcal/g
• Nitrogen (g) = protein (g) / 6.25
 Nutrients Requirements
Protein (AA)
• Healthy individu : 0.8 – 1 g/KgBW/d
• Metabolic stress : 1.2 – 2 g/KgBW/d
• Renal failure : 0.6 – 0.8 g/KgBW/day.

TNT Mannual Versi-2

Amino Acids
Essential AA Nonessential AA
• Histidine • Arginine
• Leucine • Alanine
• Isoleucine • Asparagine
• Lysine • Aspartate
• Methionine • Cysteine
• Threonine • Glutamate
• Phenylalanine • Glutamine
• Tryptophan • Glycine
• Valine • Serine
• Proline
• Tyrosine
 Catabolic State
• Increased Energy Consumption
• Negative Nitrogen Balance
• Increased Glutamine consumption
• Derangements AA metabolism
• Increased BCAA oxidation

Choudry H.A, et al : BCAA – Enriched Nutritional Support in Surgical and Cancer

patients. J. Nutri. 2009.
 Glutamine
• Improved immune response
• Increased protein synthesis
• Improved Nitrogen balance
• Preserved gut barrier function
• Enhanced wound healing
• Reduced oxidative stress
• Conditionally Essential Amino Acid.
Gianotti L, Braga M et al, Nutr.Therapy & Met, 2010, 28 (2) :77 -85
TNT Mannual, Version 2.
Formulas : Parenteral Nutrition
Electrolytes
• Calcium, magnesium, phosporus, chloride,
potassium, sodium, and acetate
• Forms and amounts are titrated based on
metabolic status and fluid/electrolyte balance
• Must consider calcium-phosphate solubility
Formulas : Parenteral Nutrition
Vitamins and Minerals
• In general, amounts below daily
recommended intake for healthy people,
but none the less sufficient to cover
requirements, are added to oral or
enteral formulas
 Formulas : Parenteral Nutrition
Vitamins and Minerals
• Added daily to parenteral nutrition
• Acute illness, infection, preexisting
malnutrition, and excessive fluid loss
increase vitamin requirements
Formulas : Parenteral Nutrition
Trace Elements
• Include daily zinc, copper, chromium, and
manganese for patients with kidney or liver
failure
• Different requirements dictated by patient and
pathology
• Patients under extended parenteral nutrition
require the addition of iron and selenium
Market
• Carbohydrate : DXF bottle 500 ml,
calorie = 500 kcal/L.
• Lipid, 20 % Solution with volume 100
ml = 200 Kcal, and 250 mL = 500 Kcal.
• Amino acids : Volume 500 ml of 5 %
solution (= 25 g AA) or 10 % solution ( =
50 g AA)
Infusion plan : BW 50 Kg.
• Total calorie 1250 – 1500 kcal
• Volume 1500 – 2000 ml
• DXF : 1.000 ml = 500 Kcal
• Lipid 250 ml 500 kcal
• AA 10 % 500 ml 200 kcal
1.750 ml 1.200 kcal.
Parenteral Nutrition :
Complications
• Catheter-related
• Metabolic
• Gastrointestinal

TNT Mannual, Version 2.

Parenteral Nutrition :
Complications
Catheter-related
• Insertion
– Pneumothorax
– Chylothorax
– Hemothorax
– Air embolus
– Arterial puncture
– Nerve injury

TNT Mannual, Version 2.

Parenteral Nutrition : Complications

Catheter-related
• Mechanical
– Port catheter placement
– Phlebitis
– Thrombosis
– Catheter occlusion
– Rupture
– Embolus
TNT Mannual, Version 2.
Parenteral Nutrition : Complications

Catheter-related
• Infection
– Catheter insertion site
– Subcutaneous tunnel
– Colonization
– Bacteremia
– Sepsis

TNT Mannual, Version 2.

Parenteral Nutrition : Complications

Metabolic
• Hyper- or hypoglycemia
• Electrolyte imbalance
• Prerenal azotemia
• Abnormal acid-base balance
• Refeeding syndrome – measure P, Mg, K, and
glukose

TNT Mannual, Version 2.

Parenteral Nutrition : Complications

Gastrointestinal
• Liver function disorder
• Complication can be decreased by providing
small amounts of food enterally when possible

TNT Mannual, Version 2.

Parenteral Nutrition : Complications

Overfeeding
Administering more than 35 kcal/kg result in :
– Hepatic steatosis
– Hyperglycemia
– Prerenal azotemia
– Hypertriglyceridemia
– Increased CO2 production
– Respiratory distress syndrome

TNT Mannual, Version 2.

Monitoring Patient on Parenteral Nutrition

Metabolic Assessment
• Glucose • Body weight
• Fluid and • Nitrogen balance
electrolytes • Plasma protein
balance
• Creatinin / height
• Renal dan hepatic index
function
• Triglycerides and
cholesterol
Summary
• Parenteral nutrition supplies partial or total
nutrition by venous access
• Total parenteral nutrition components supply
all required nutrients
• Metabolic monitoring and changes in solution
components are needed to maintain adequate
metabolic balance
25 – 55% MALNOURISHED
HOSPITAL ADMISSION
M.McM, 76 yr, English.

Ivor Lewis procedure.

M,Mc.M, 76 yr, English.

Operation day.
Follow up