Parenteral Nutrition

Dr, Allah Bakhsh Awan

Cife ta aaa poe

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 Learning Outcomes
¢ Introduction
* Goals
¢ Indications
¢ Requirements
¢ Calculations
* Compounding
¢ Administration
¢ Monitoring
¢ Complications
What is Parenteral Nutrition?

Intravenous administration of
Sufficient nutrients above the basal requirements
to achieve
Tissue synthesis, positive nitrogen balance and
anabolism
ayy
Specific patients unable to tolerate any form of
enteral feeding for long term basis.
 Goals of Parenteral Nutrition
s Positive Nitrogen Balance (weight gain /growth)
e To prevenl & Nitrogen balance (weigh! loss)
reese eels le eel me aa) ee laosdc
» Improve mental & physical function
» Restore normal body mass accelerate rehabilitation
» Reduce hospital stay
» Improve quality of life
Types of Parenteral Nutrition

eames litre Meeclici

ai Ccirc Melt) am (ee eah BD
» Total Parenteral Nutrition (TPN)
 Routes of Administration
* Peripheral route
* Limitations in calorie and yi ld build up due
osmolarity limitation (300 - 900 mOsm)

*« Central venous route

* When PN ts unable to cope with requirements
* Osmolarity limit up to 2500 mOsm
« PN More than 7 days
+ Peripheral access not possible
* More chances of Catheter related elek-iE
 Indications
* When enteral nutrition
* Not possible
* Inadequate
*« GI obstruction, Fistulae
« Severe Trauma or Burn
* Malabsorption states
- In neonates, esp. pre mature babies with low birth
weight
* NEC/ Inflammatory bowel disease
* Surgical patients (pre & post OP long term NPO)
else) ats ale) ea ieial ere)
 Main Components
e Water
e Source of Nitrogen
>» Amino acids
_ @ Energy Source (Non Nitrogenous)
Orrell rele (Dextrose, Sorbitol)
> Lipids
SAC Talia
Pi alsfoncoy (Vices
e Trace Elements *
Total Fluid Requirement
Essential component of PN
Depends of patient age and disease
condition.
30 to 140 mi/Kg/day
Neonates: At higher risk of Fluid
overload & Dehydration
Compensation of fluid required in
medications other than TPN
au Tie
Protocol for
D.O. Proteins Dextrose Lipids iN
TPN ss g/kg/d g/kgid = g/kg/d ~=—- Keall/kg/d
—
1.2 9 . 39
vA A 2 : eye)
3 2.3 12 URS) A
rl 2.9 1/2 Ae 76
5 2.9 15 1.5 oH
6 PLS, re 2.0 86
7 ye ts 2.9 86
3} 2.9 15 He 86
9 2.9 15 one) 86
2.9 15 3.0 86
<i
©
 (Continued)
D.O. Proteins Dextrose Lipids SN =
Ud) Be |] cele g/kgid = g/kg/d_—s Kcal/kg/d
11 vans) 15 o AU 86
174 2.9 15 Cae 86
Re 2.9 15 CRY) 86
ce) 2.9 15 3.0 86
15 2.9 ako) 3.5 oh
ute ra, 15 3.5 oh
 Se AS
¢ 25 Kcal of NNE are essential to save each g
of protein & to prevent catabolism
¢ Paediatrics:
Ss 10Kqg: 100 Kcal/Kg/day
10 to 20 Kg: 1000 Kcal + 50Kcal for every Kg
above 10Kg
20 to 30 Ka: 1500 Kcal + 20Kcal for every Kg
above 20 Kg
¢ Ideal: 60-65% from carbohydrates,
30-35% from lipids
 Stress Factors
Stressed and sick infants need more
energy (e.g. sepsis, surgery}
Caloric requirement under stress = main
requirement x stress factor
Major Surgery 1.2
sepsis 1.2
Trauma 1.4
Burn < 40% yi
 Nitrogen (Amino Acid)
requirement

« 1-12 months: 2-2.5 g/kg/day

¢ 1-8 years: 1.5-2 g/kg/day
¢ > 8 years: 1-1.5 g/kg/day
¢ Aminovel (5% Protein formulation)
« Aminoplasmil (5% Protein
formulation)
 Carbohydrates
¢ Dextrose through Peripheral Route: < 12.5 %
* Dextrose through Central Route: 25 %
« 1 gm Dextrose = 3.4 Kcal
¢ Rate of admin. should be kept below
7 mg/kg/min.
 ers | k
* Richest source of NNE
¢ Needed to prevent EFA deficiency
¢ 1 ml = 2 Kcal of NNE (20% lipid
emulsion)
¢ 1gm lipid = 9.6 Kcal
¢ Available as 10% & 20% lipid emulsion
 Electrolytes & Mineral
Requirements
Sodium: 2-4mEq/kg/day 0.9% NaCl, AA
preparation
Potassium 1-3 mEq/kg/day 7.84% KCl

Calcium 300 - 500 10% Ca Gluconate

mg/kg/day
Phosphorus 0.5 - 2.0 NakK-PO4
mMol/kg/day (Addiphos)
Magnesium 0.25-0.5 AA preparation
mEq/kg/day
Chloride 0-6 mEq/kg/day AApreparation,
NaCl, KCI,
Steps: ordering TPN to Patient
Administration
Reve OPN
{
Pharmacist’s Clinical Ward
Round /Follow-up

ROME CyL

| Monitoring
Compounding

|
Dispensed to Wards

|
Patlent Administration
OO eet eo ee eee
Ceuta
¢ Particulate Contamination
¢ Osmolarity
* Stability
¢ Compatibility
* Order of mixing
 Parenteral Nutrition Order

© TPN / PPN.
¢ Route of Administration.
¢ Day Of TPN, Date, Time.
¢ Patient Profile.
>» Name, age, Wt, MR #,Ward.
> Diagnosis.
»NPO, Oral feed.
 Baseline Lab Investigations

eae
« LFT
¢ Serum Electrolytes
¢ Lipid profile
es joyne
 Daily PN Requirements

Daily Fluid Requirement

Proteins
Lipids
Dextrose
Electrolytes
Vitamins & Trace Elements
Confirmation of patient’s wt. , missing lab
BTayen nye.
Calculation of [V diluents volume, their Na
& dextrose content,
Ifnecessary change IV diluent &/ volume.
Oral feed, volume & type, 1f being given.
Discussion with physician tn case of disease
specific PN formulation.
 Steps: ordering TPN to
Administration
PCT re a

|
Pharmacist’s Clinical Ward
Round ‘Follow-up ie

i AS Cae Cepe
la
Compouicing

Dispensed to Wards

|
ee ama et Clie ial
 PN Calculation

Volume of patient’s drug diluents, Na

content & dextrose
Calculate daily requirements
Calorie Workup (150 cal : 1g Nitrogen)
Osmolarity Calculation
 Important...

¢ Dextrose SEVaMotroseelas
cup ini me's
proceed to 10-14 mg/kg/min.
¢ Lipid 0.03-0.05gnv/kg/hour
To prevent EFA deficiency (0.5 gm/kg/d)
¢ When ever possible use dual source of
NNE.
 Disease Specific PN

¢ Renal Disorders.
¢ Respiratory Disorders.
¢ Hepatic Disorders.
¢ Cardiac Disorders.
 Technical Aspects

Aseptically prepared in Laminar Flow

Hood.
Compatibility.
Visually inspect for particulate matter.
Finally check to insure proper labeling.
A continuous sterility testing procedure.
 PN Compounding
LITT Ocal
Pee MCI EMIT ee Cemetary
Piggyback Method
Pe CREM IO CUCM EM el UAU etl MeniMMO mm MMTn hy
as a source OF EFA

Cea CotL
MAMI M Gerri Gone Oh PaO loliee
" Pm m GoM M CLC ME em Realms Ge tite eee
contiimer
ACCC Maem CMa eM MON A baie eR CS errr
UCC eC ected orit Ce
 Pharmaceutical Issues

> Physical Stability Problems

o Precipitation of solids (Ca-Po4)
o Cracking of lipid emulsion.
e Chemical Stability Problems
o Maillard Reaction
o Vitamin’s Degradation.
e Microbial Contamination
Palle ee ee ee
SeUmeMREIRET OIE @ aU CeLme eel (omer) Coan are bee than TAe nea ean
 Multi-chamber PN Bags
Two In one system Three In one system

Amino acid solution

A
4
Amine acid eolutlon \
Lipid emulsion
 Handling of TPN Bags
¢ Don't administer if you see any signs of
precipitation or ree Mire lacie
* Don't add any other medication to the bag
¢ Don't detach the burette/drip set from the
TPN bag
¢ Don't prick the bag
¢ Stop infusion immediately if there is any
puncture or leakage of the bag
 SEVEN eR NUMA ite
¢ Lipid exposed to light forms potentially
toxic lipid hydroperoxides, so _ lipid
syringes should be protected from light
by wrapping in foil
¢ Risk of bacterial colonization increases
after 12 hrs, lipid syringes should be
changed every 12 hours
 Administration Of PN
Maejiacll calito
HE Central Route
HE Periphegally inserted central catheter (PICC)

“Designate ie exclusively for TPN by a multi-lumen catheter

mitt emce, ilies oA Parenteral nutrition,” CDC

Don't administer medications concurrently or intermittently into

the same lumen as TPN

Infusion Control.
Co iVCS Tessar oe
VVV

Syringe Pumps.
IV Burette / IV sets.
 Clinical Review

Clinical examination
¢ Body weight
¢ Vital signs
¢ Fluid balance
¢ Catheter care
¢ Sepsis review
¢ Blood sugar profile
 Pate is
Renal Profile daily until stable, then 2x/wk
Cat, Na*, Kt daily until stable, then 2x/wk
Liver Function Test * weekly
Lipid Profile Oath
sey 4 Daily
Full Blood Count weekly, unless indicated
Monitoring For Complications

¢ Mechanical Complications
¢ Metabolic Complications
¢ Infectious Complications
 Stopping TPN
¢ Stop TPN when enteral feeding can restart
¢ Wean slowly to avoid Rebound hypoglycemia
¢ Give IV Dextrose 10% solution at previous
infusion rate for at least 4 to 6h
¢ Alternatively, wean TPN while introducing entera
feeding and stop when enteral intake 1s sufficient.
 EAICIHUCI al INULFILION

Allows greater caloric intake

BUT

Is more expensive
Has more complications
Needs more technical expertise
What is Nutritional Support?
“The provision of nutrients orally, enterally, or
parenterally with therapeutic intent. This
includes, but is not limited to, provision of
total enteral or parenteral nutrition support,
and provision of therapeutic nutirents to
maintain and /or restore optimal nutrition
RYH RW eMail ee
ASPEN, 2002
 Goals of Parenteral Nutrition
» To prevent Negative energy &
Nitrogen balance
» Positive Nitrogen Balance hi

» Growth
» Support till Adequate Enteral Intake
 Routes of Administration
¢ Central venous route
* When PN is unable to cope with
requirement
+ PN More than 7 days
* Peripheral access not possible
* More chances of Catheter related sepsis
¢ Peripheral route
« Limitations in calorie and nitrogen build up
Types of Parenteral Nutrition

meta ete iets es| eles

» Partial Parenteral Nutrition

‘(oaeahD

> lotal Parenteral Nutrition

Gin),
 * When enteral nutrition
« Nol possible
(eT
e ite tel=19
eee © | a) or=jtae
et t(o em ad (10 (=e
eel hc (oa ela elm oleae
* Malabsorption states
+ |In neonates, esp. preterms
> NEC
- Inflammatory bowel disease
- Surgical patients (pre & post OP longterm NPO)
* Severely malnounshed
 Indications for Initiating PN
Tamla
¢ BW < 1|.5kg (mostly PPN for BW > | kg)
* BW=1501 gto 1800g
* Expected NPO > 3 days
« BW > 1800 g
* Expected NPO > 5 days
 Main Components
» Water
» Source of Nitrogen
Pari alee: let] sf
» Energy Source1 »
» Carbohydrates (Dextrose, Sorbitol)
» Energy Source2
ae lee:
» Vitamins
» Electrolytes
» Trace Elements*
 Total Fluid Requirement
¢ Essential component of PN
¢ 7/0 to 140 mi/Kg/day
Neonates: At higher risk of Fluid
overload & Dehydration
* Compensation of fluid required in
medications other than TPN
 SPOS aCe
DOL Pyecian iyi OM emn actus

“ter at
r| f
a

APKC al
D.O, Proteins Dextrose Lipids is
TPN g/kg/d gikgid = g/kg/d ~— Kcal/kg/d
: 1.2 9 s 39
y 17 12 : Sts
c 23 12 as rk
4 ma: iy a 1s
5 ma is a 81
F oa: 15 2.0 ts
7 mas is ae ts
8 oes ie 3.0 Ns
: oa: ie ne 86
Te ome ie 3.0 ss
 (Continued)
D.O. Proteins Dextrose Lipids TT
TPN — g/kg/d gikg/id = g/kg/d_~—s Keal/kg/
fe
im 2.3 ate 3.9 91
12 2.3 he 3.9 ol
13 PS 15 FS) Si
14 a sie, 3.9 91
 Energy (NNE)
- 25 Kcal of NNE are essential to save each g
of protein & to prevent catabolism
¢ Paediatrics:
< 10Kq: 100 Kcal/Kg/day
10 to 20 Ka: 1000 Kcal + 50Kcal for every Kg
above 10Kg
20 to 30 Ka: 1500 Kcal + 20Kcal for every Kg
above 20 Kg
» Ideal: 60-65% from carbohydrates,
30-35% from lipids
 Stress Factors
« Stressed and sick infants need more
energy (€.g. sepsis, surgery)
* Caloric requirement under stress = main
requirement x stress factor
nV eolercill cel-19 Aa
* Sepsis 1.2
- Trauma ieee
* Burn<40% ys
 Nitrogen (A.Acid)
requireme n t i n P a e d i a t r i c s

© 1-12 months: 2-2.5 g/kg/day

- 1-8 years: 1.5-2 g/kg/day
e > 8 years: 1-1.5 g/kg/day
7
 Carbohydrates
* Dextrose through Peripheral Route: < 12.5 %
* Dextrose through Central Route: 25 %
¢ | gm Dextrose = 3.4 Kcal
* Rate of admin. should be kept below
Pei sa eave
 ark
Needed to prevent EFA deficiency
LBW infants have immature
mechanisms of fat metabolism
Infection, stress & Malnutrition inhibit
Lipid clearance
© 20% Lipid Emulsion preferred over 10%
Rate of Admin. :initially 0.03 to 0.05
gm/kg/hr, finally 0.1 to 0.19 q/kg/hr
1 ml = 2 Kcal of NNE
 Osmolarity
¢ Through Peripheral Route
300 to 900 mOsm/Litre
¢ Through Central Route
> 900 mOsm/Litre
 How do we know
what’s happening to the
patient??
 Monitoring of TPN
* Atstart of TPN
me Aan
¢ Electrolytes (Nat, K*, Ca™, PO,~ etc)
* Bicarbonate (HCO;>)
- BUN
« CBC
ae bys)ie
* Alkaline phosphatase :
ated h
* Total bilirubin
* Triglycerides
al ti menstteliile
actor
 Monitoring of TPN
* 24 Hours After TPN
* Body Weight
* Electrolytes (Na*, K*, Ca**, PO,~ etc)
* Bicarbonate (HCO,>)
1@
- BSR
* Renal function
pat <:vnilem piesa) ites
rate et
* Total bilirubin
* Triglyccrides
* Albumin
 Monitoring of TPN
¢ Every Day
¢ Body Weight
¢ Blood glucose
* CBC
¢ Serum Electrolytes
*LFTs .,
 Complications &
Their Management
 Non Metabolic
Complications
¢ Catheter related Sepsis
* Thrombophlebitis
« Thromboembolism
Complication Possible Cause Suggested
Management
Dehydration Inadequate fluid Start 2nd
support,unaccounted infusion of
fluid loss (e.g. 1 0)0] ge) e) a1 t=.
diarrhea, fistulae, fluid,e.g.
Ol=7E-1
1 (1g Ae NIE a m1 D/W5%,
T/2NS, NS.
mdaistel Mireles.
fluid
cre ]0l ee) antoinl ans
16/10 iad
accordingly.
Over Excess fluid Consider D/0%
hydration admin.; (can't use with
compromised PPN) or 20%
renal or cardiac lipid as calorie.
function witiate
diuretics. Limit
volume
Acidosis Excessive renalor Rule out DKA
Gl losses of base; and sepsis.
excessive Cl in Add acetate
PN to PN

Hypo Excessive PO4 Slowly t Cain

calcemia salts, low serum ma
elie) 6 onl ap prescription
Inadequate Ca in
mae
Hypo Excess losses (urinary 7 PO,
phosphat PQO,, in alkalosis, Mg, content
Sante diabetes mellitus, of PN
steroid & diuretic
therapy); cellular
uptake with induction
of anabolism
(Refeeding
syndrome).
5) RUemet
glycemia response. infection.
LL | CHO in PN.
approx. 25% Of Provide
EASES. eloleve(UrelteM ariel
Hypo Sudden Taper PN. Start
glycemia Withdrawalof D10%
conc. glucose.
Vore common
in children.
Cholestasis Lack of GI Promote
stimulation. enteral
sludge presentin feeding.
90% of pts on PN
for 406 weeks;
resolves with
resumption of
enteral feeding.
Weigh the need of TPN rationally
Take into account all intakes and looses by the
patient in your calculation as you can.
Day One: start by Half of the energy and nitrogen
gei8 [0] igen l=ian!
Build up day by day using successive increments 10-
20% or variable as per the units patients response
Maintain
Wean off with building up of enteral feed
stop when the adequate enteral feed is established
Always check the TPN Prescription for provision of
aallaaale
th
Amphasize aseptic handling at each and may jisl@
Prescribing PN
 Liver
Jaundice | proteins, Max.
/ Hyperbilirubinemia dextrose, | lipids

Heart
Congestive heart Restrict Fluid &
elles electrolytes
 Lungs
Chronic Obstructive (me BT=
ya tgor=
Pulmonary disease Max. Lipids
(COPD)
Respiratory Distress im DI=> qigel-i—
Syndrome (RDS) Max. Lipids
Concerns in Preparation of TPN
¢ Sterility
¢ Particulate Contamination
Osmolarity
Smell
oy as
« Compatibility
¢ Order of mixing ,
Concerns in Preparation of TPN
¢ Sterility
¢ Particulate Contamination
OTe tala
¢ Stability
« Compatibility
¢ Order of mixing
 Systems of TPN
|. Glucose System
> Also called two-in-one system
(Dextrose + Aminoacids)

2. Lipid System
> Piggyback Method
> Total nutrient admixture (TNA) method, also
called three-in-one
(Dextrose + Aminoacids + Lipids)
 MRO Ore t) e h OL Tae Poem etait

e Cem Germ ey met met emer limonay

* Clinical work up/ visi,at floor/follow-up visit
¢ Calculation and Checking of calculation
* Preparation of compounding order and label
* Assembling of calls and items required
* Washing And Scrubbing of hands
* Clearing and Mopping of hood
* Mopping of supplies
¢ UV irradiation of non medicinal supplies
 Hand washing and disinfection
* Gowning
* Systematic arrangement of supplies and order
* Compounding of TPN as per aseptic handling
a] Py an al i: Py

technique and principles of working under LFH

* Checking, labeling
* Placement in supply bags or trolleys
¢ Receiving by wards
*« Case wise Record keeping. consultation with
clinician and follow up
ETC is HRS TPN SOLUTION MIL.

eases a
Ay ___ ody wt
Fai Ae :

ecentl peripheral line

Amino acids: e/ke/day
Dextrose: wkeovduy
Electrolytes:
SU eee Recon
Potassium: |-Imeqke ‘diay
LO ar Peewee ainhe
Total NNE- keal'day
Rate of admin. RT Gb
OTe Ea Be a Lal
PE TitiCatt cut Ly
Do oot administer for more than 24 hrs
JP tae
[ute
aE ue Ld Trier
 nohtandling
aE
of TPN Bags
gett see any signs of
precipitation or heaps matter
¢ Don't add any other medication to the
bag
Don't detach the burette/drip set from
the TPN bag
Don't prick the bag
stop infusion immediately if net aerahy
puncture or leakage of the bag
Handling of Lipid Syringes
¢ Lipid exposed to light forms potentially
toxic lipid hydroperoxides, so lipid
syringes should be protected from light
by wrapping in foil
¢ Risk of bacterial colonisation increases
after 24 hrs, lipid syringes should be °
changed every 24 hours
Automated TPN Compounding System
 Lcntenmntenal
References
¢ Lippincott's Manual of Neonatal Care; 5" edition
« Manual of Nutritional Therapeutics
* Clinical Pharmacy & Therapeutics By Roger
Ae)
| og
« Hemi smiths Protocol for preterm & full term
neonates
¢ Protocol of South African Society of Parenteral &
Enteral Nutrition
Minimum goal - To prevent catabolism

CNS route — In patients receiving chemotherapy bez

their peripheral veins are collapsed

PPN - Patient is taking limited enteral nutrition but

not sufficient
TPN - Patient is NPO

NEC - Necrotizing Enterocolitis

Requirements vary based on age, body weight &

disease condition

Infants and neonates require more fluid bez they have

thin & more permeable skin so more chance of
dehydration & bez kidneys are not fully functional

12,5% Dextrose - 700 to 800 mOsm/L

25%, Dextrose - 1300 to 1400 mOsm/L

I>SR - Blood Sedimentation Rate

Weekly Monitoring - LFTs, Triglycerides, Lipid Profile

Stability issues - Maillard reaction, Calcium phosphate
precipitation

Refeeding Syndrome — Riger walker pg 118

Order of Mixing:
() Calcium and phosphate should be diluted before
adding
() Calcium should be dissolved in dextrose solution
C) Phosphate should be dissolved in normal saline
C1) Then mix both to prevent precipitation

Units are mmol for non-electrolytes and mEq for

electrolytes bez in body reactions occur at mole level
rather than at gram level,