T P N Indications for TPN therapy Design of TPN regimen Metabolic complications and treatments Peripheral Parenteral nutritional support

Practice Guidelines MalnutritionA.S.P.E.N. BOARD OF DIRECTORSInadequate nutrient for 7 days Weight loss 10 Enteral tube feeding and PN should be combined Parenteral nutrition should be used alone1.PN support cannot, should not, or will not eat adequately to maintain their nutrient stores. 2. PPN may be used in selected patients 3. TPN support is necessary

JPEN 17Ssuppl 46 SA,1993

Practice Guidelines Parenteral Nutrition PPN used in selected patients a.Partial or total nutrition support for up to 2 weeks in patients

b. Who cannot ingest or absorb oral nutrients

c. When central parenteral nutrition is not feasible.

J P E N 17 Suppl 410 SA, 1993.

Practice Guidelines Parenteral Nutrition T P N support a.Parenteral feeding is indicated for longer than 2 weeksb. Peripheral venous access is limitedc. Nutrient needs are large d. Fluid restriction is requirede.The benefits of TPN support outweigh the risks.

Ref J P E N 17 Suppl 410 SA, 1993.

A Standardized PN Sol,n Rx, Use, Processing, and Material Cost Implications a. 73 of pt,s receiving standardized TPN solutionb.Prescribing error frequency was 0 c.Decreased processing and compounding time by 55 d.Decreased material cost by 19 e.70-80of adult patients tolerate standardized solutions without adverse metabolic complications

Hospital Pharmacy, 21;July 1986

Suggested Nutrient intake for Adult patients on PNASPEN nutrition support practice manual 9-2, 1998

Protein Requirements for Adult Patients 1. 15 25 of Total Calories

2. Non-protein Calorie to Nitrogen Ratio 80 - 100 kcal 1 / gm . N Severe Stress 150 - 200 kcal 1 / gm . N Moderate St

3. Nutritional vs. Metabolic Support

22nd Clinical Congress, ASPEN 1998

Non-Protein Calories RequirementsG l u c o s e1. Maximum capacity 7 mg/kg/min or 10 gm/kg/day2. Optimal infusion rate 4 mg/kg/min or 5.76 gm/kg/day3. Critically ill the recommended infusion rate 5 gm/kg/day4. 50-60of total calories22nd Clinical Congress, ASPEN 1998

Non-Protein Calories RequirementsF a t1. Maximum capacity 1.0-2.0 gm/kg/day2. Critically ill the maximum recommended infusion rate1.0 gm/kg/day3. 10-25of total calories4. Run fat initially at 1 ml/min 15-30 min5. 2-4of total calories must be from EFA22nd Clinical Congress, ASPEN 1998

Electrolytes Requirements for Adult Patients 1. Sodium 30 55 mEq/liter2. Potassium 60 90 mEq/day3. Chloride 30 55 mEq/day4. Calcium 6 12 mEq/day5. Magnesium 16 20 mEq/day6. Acetate 45 70 mEq/day7. Phosphorus 18 28 mM/dayRefa. Maxwell Kleeman,s Clinical Disorders of Fluid and Electrolyte Metabolism ,5th , 1994 . b. Allin I. Arieff , M.D. Fluid, Electrolyte, and Acid-Base Disorders . 2nd Ed 1995 .

Vitamin Formulation For Children Aged 11 Years, Older and Adults

VitaminsAdult RDA in USAAMA RecommendedRecommendationFor the Critically IllVitamin AIUVitamin DIU4000 - 500040033002002500 10000400Vitamin EIUVitamin Cmg12 - 154510.0100.04001000Folic acidmcgNiacinmg40012 - 20400.040.02000200Vitamin B2mgVitamin B1mg1.1 1.81.0 1.53.63.01010Vitamin B6mgVitamin B12mcg1.6 2.034.05.02020 mgPantothenic acidmgBiotinmcg5 10150 - 30015.060.01005 mgVitamin Kmg1. 1 10 mg/wk2. Antibiotics 10 mg/3-4days

Essential Trace ElementsNAG/AMA Suggested Daily IV Intake

ElementStableAcute CatabolicGI LossesZn2.5 4.0 mgAdditional2 mgAdd 12.2 mg/L small Bowel fluid lost17.1 mg/kg of stool or ileostomy outputCu0.5 1.5 mg--Cr10 15 mcg-20 mcgMn1.150.8 mg--

: Nutrition Support Overfeeding Respiratory AcidosisParenteral Nutrition Acidosis Metabolic AcidosisJ. Nutrition 1999: 129. 290S-294S

Guidelines to Maximize Benefits and Minimize Complications of PN11. Avoid calorie and glucose overload a. 25 to 30 kcal/kg/day b. 2 to 4 mg dextrose/kg/min

2. Avoid fat overload a. 30of total energy requirements b. Provide as a continuous infusion

Guidelines to Maximize Benefits and Minimize Complications of PN23. Avoid protein catabolism a. 1.5 to 2.0 gm protein/kg/day b. BCAA-enriched formulations may offer - Hepatic encephalopathy and significant RF4. Avoid micronutrient deficiencies a. 10 ml of MVI-12/day b. 3 ml of trace mineralsMTE-5 c. 10 mg Vitamin K/weekRef1. Cerra FB. Diet, nutrition and immunity, 199439-50 2. Nutrition Support Theory and Therapeutics , 1997

The Potential Hazards of Overfeeding1 Glucose1. Hyperglycemia a. Hyperosmolar state b. Osmotic diuresis c. Dehydration d. Immunosuppression2. Hepatic steatosis3. Ventilatory alterations4. Increased resting energy expenditureRef 1. Nutrition Support Theory and Therapeutics 1st Ed , P4711997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.

The Potential Hazards of Overfeeding2 Lipid1. Immunosuppression RES Blockade2. Increased prostaglandin production3. Hypercholesterolemia4. Hyperlipidemia5. Impaired liver function 6. Ventilatory alterationsRef 1. Nutrition Support Theory and Therapeutics 1st Ed , P4711997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.

The Potential Hazards of Overfeeding3 Amino Acid1. Ureagenesis

2. Hyperchloremic acidosis

3. Ventilatory alterations

4. Increased resting energy expenditure 1. Nutrition Support Theory and Therapeutics 1st Ed , P4711997 2. The Metabolic Hazards of Overfeeding Critically Ill Patients, ASPEN, 1997.

Metabolic Complications and Treatment1Hyperglycemia1. Slow infusion rate

2. Give insulin 0.1 U of insulin /g of dextrose/liter

3. Increase fat emulsion therapy

Peripheral T P N(Patient Criteria for P-TPN)1. Good venous access

2. Mild to moderate stress

3. Not fluid restricted

4. Able to tolerate fat emulsion

5. Expected to resume enteral feeding within 5-7 days

NPO 5-7 5-7 NPO PPNPPN

Glycal-Amin3% Amino Acid and 3% Glycerin injection with Electrolytes

COPD Pulmonary stress SIRSTPNGlycal-Amin3% Amino Acid and 3% Glycerin injection with Electrolytes

Glycal-Amin3% Amino Acid and 3% Glycerin Injection With ElectrolytesPPN TPN TPN infusion pump tapering

J. Payne-James: JPEN 1993; 17: 468-478First Choice for Total Parenteral Nutrition:The Peripheral Route