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

THANK U