TOTAL PARENTERAL

NUTRITION:

By:
Group 4
I. OBJECTIVES
• To acquire knowledge and skills in nutritional support
• To compute for the nutritional requirements for a specific
patient
• To compound total parenteral nutrition solution
Total parenteral nutrition (TPN)
• TPN is a way of supplying all the nutritional needs of the
body by bypassing the digestive system and dripping
nutrient solution directly into a vein.
II. DISCUSSION
• Nutrient are substances that must be supplied by the
diet, because they are not synthesized in the body in
sufficient amounts.
II. DISCUSSION
• Energy providing nutrients are:
 Carbohydrates
 Proteins
 Fats
 Vitamins
 Minerals
 water
II. DISCUSSION
• Different routes nutrients can be introduced in the
body:
 Enteral – feeding via tube placed in the gut to deliver liquid
formulas containing all essential nutrients.
 Parenteral – infusion of complete nutrients solutions into the
bloodstream via peripheral vein or central venous.
Parenteral Nutrition types:
• Peripheral Parenteral Nutrition (PPN) – parenteral
nutrition that can be provided via catheter in a peripheral
vein that should be chosen for short-term nutritional
support (<14 days)
Parenteral Nutrition types:
• Central parenteral nutrition or Total Parenteral
Nutrition (TPN)
• by tunnelling subclavian, cephalic vein or internal jugular.
• for long term use (>30 days)
COMPUTATION:
A. Energy requirements / Caloric Requirement:
A. 1 Harris – Benedict Equation (Basal Energy
Expenditure (BEE) / Basal Metabolic Energy (BME) /
Resting Energy Expenditure (REE)
Male:
BEE = 66.67+[13.75xWeight/kg]+[5xHeight/cm]-
[6.76xAge/years] (The answer has a unit of kilocalorie
(Kcal) )
Female :
BEE = 655.1+[9.56xWeight/kg]+[1.86xHeight/cm]-
[4.68xAge/years] (The answer has a unit of kilocalorie
(Kcal) )
COMPUTATION:
A.2 Total Daily Expenditure (TDE)
TDE = BEE x activity factor x stress factor
Activity factors:
Confine to bed 1.2
Ambulatory 1.3
B. Protein Requirements
Protein gives 4kcal per 1g
Unstressed patients 0.8g/kg
Mildly stressed patients 0.8 to 1g/kg
Renal dialysis patients 1.2g/kg
Moderately stressed patients 1.1 to 1.5g/kg
Severely stressed patients (trauma) 1.5 to 2g/kg
Severely burned patients 3g/kg
COMPUTATION
C. Lipid (Fat) Requirements
- 30% to 40% of the total daily calories or TDE
- Lipids provide 9kcal/g
- 10% lipid emulsion provides 11 kcal/g
-20% to 30% lipid emulsion provides 10 kcal/g
D. Carbohydrates Requirements
- Provide 3.4 kcal/g of parenteral carbohydrate solutions
such as dextrose which is commonly used as source for
carbohydrates
- Carbohydrates consist of the remaining calories from
proteins and lipids have been added.
COMPUTATION
E. Fluid Requirements
E.1 Age
Neonates 120 to 180 ml/kg
150 ml/kg (200 max)
E.2 Weight 1000ml+50ml/kg in excess of
< 10 kg 10 kg
10 to 20 kg 1500ml+20ml/kg in excess of
> 20 kg 20 kg
E.3 BSA 1500ml/m2
E.4 Caloric Requirement 1.2 ml/kcal
COMPUTATION
F. Vitamins and Minerals
III. PRACTICE PROBLEM
1. The daily caloric requirement for a 201-lb 76 year old
female has been determined to be 2088.82 kcal/day.
Calculate the protein, carbohydrate, lipid (30% TDC), and
fluid requirements for parenteral nutrition, assumin no
stress or disease factors.
III. PRACTICE PROBLEM
• A 30 year old male severely burned patient is to be
administered total parenteral nutrition. The patient weighs
80 kg and stands 5’8”. Prepare a TPN solution based on
the patient needs. Use upper limit for requiremnets
expressed in range. 30% lipid emulsion is to be used.
III. PRACTICE PROBLEM
• A patient has the ff. profile:
a. Sex: Male c. Height: 175cm
b. Age: 45 years d. Weight: 85kg
e. Compute for the nutritional requirements including fluid of the
patient assuming that he has no disease that would alter her
nutritional requirements. For requirements given in range, use the
lower limit. Use 10% lipid emulsion as a source of lipid and D 50W
as a source of carbohydrates.
• A geriatric patient is an older adult seeking medical care.
QUESTIONS
Which component of a total nutrient admixture should
be added last before storing it in a refrigerator?
• Calcium.
• If calcium is added last, the PN formulation will contain
the final volume, including all other nutrients. The chance
of calcium causing a precipitate will be decreased
because of all other components (e.g. phosphorus) are
diluted in the entire volume of the PN
What are the contraindications for
parenteral nutrition?
• Where gastrointestinal feeding is possible. Almost always
this is the best route to provide nutrition to the patient
• Patients with good nutritional status in whom only short
term TPN support is anticipated.
• Irreversibly decerebrate patients.
• Lack of specific therapeutic goal: TPN should NOT be
used to prolong life if death is inevitable
• Severe cardiovascular instability or metabolic
derangements. These should be corrected before
attempting intravenous hyperalimentation.
• Infants with less than 8 cm of small bowel as it has been
conclusively proved that they cannot adapt to enteral
feeding despite prolonged periods of TPN
Enumerate the monitoring parameters for
parenteral nutrition.
What are the complications associated
with parenteral nutrition?
• Dehydration and electrolyte Imbalances
• Thrombosis (blood clots)
• Hyperglycemia (high blood sugars)
• Hypoglycemia (low blood sugars)
• Infection
• Liver Failure
• Micronutrient deficiencies (vitamin and minerals)
What are the ways to prevent incompatibility when
compounding a PN formulation?
• Measures taken to prevent adverse events related to
incompatibilities include the use of filters during infusion,
specially 0.22 um filters for 2-in1 solutions and 1.2um
filters for 3-in-1 admixtures. For compounded parenteral
nutrition solutions components should be added in the
same order every time and contact between incompatible
solutions should be minimized.