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BMT Total Parenteral Nutrition PDF
BMT Total Parenteral Nutrition PDF
TPN Indications
TPN is indicated for any patient who is not expected to eat sufficiently for 3-5 days in severe
malnutrition, 5-7 days in mild or moderate malnutrition, and 7-10 days in well-nourished patients.
The most important causes leading to malnutrition in BMT patients are:
1. Nausea, vomiting, and diarrhea, catabolism and malabsorption associated with cytoreduction.
2. Taste alterations, electrolyte derangements, protein loosing associated with the course of
GVHD.
3. Cachexia due to the primary disease (recent weight loss & poor oral intake).
4. Poor nutritional intake due to mucositis associated with cytoreduction.
All patients should receive 25-35 Kcal/kg/day based on the degree of malnutrition and
tolerance to different macronutrients. Hypercatabolic patients i.e. sepsis, may not tolerate more
than 25-30 Kcal/kg/day due to pre-existing glucose intolerance, uremia, and/or
hypertriglyceridemia.
The goal of TPN therapy is to preserve the patients muscle mass. Weight gain with TPN is
almost impossible due to production of catabolic hormones associated with BMT stress.
Clinical and biochemical monitoring are necessary to reduce the chance of mechanical, septic,
metabolic, and hepatic complications of TPN.
Dextrose Dose
Do not advance dextrose doses until Potassium and Phosphates levels are corrected. (Due to
intracellular shifts)
Minimum dextrose dose per day (even in glucose intolerant patients) is 100-120g/day to avoid
catabolism.
Always take in consideration the dextrose load from the side IV maintenance and IVPBs when
calculating the total dextrose load.
The preferred IV maintenance with TPN is D5W 1/2NS, D5W 1/4NS, or D5W NS. Presence
of dextrose with IV fluid will prevent the risk of hypoglycemia if TPN is stopped abruptly or
accidentally (line leaking, accidental removal, bag leaking, going for procedure, etc.)
Do not allow glucose levels more than 11 mMol/L. Glucose intolerant patients should be
prescribed IV insulin sliding scale:
Example:
Mix by adding 100 units of regular insulin to 100ml Normal Saline:
Blood Glucose:
10.1 to 12 mMol/L:
1 unit (1ml)/hour
12.1 to 14 mMol/L:
2 units (2ml)/hour
14.1 to 16 mMol/L:
3 units (3ml)/hour
16.1 to 18 mMol/L:
4 units (4ml)/hour
18.1 to 20 mMol/L:
6 units (6ml)/hour
Call MD
Insulin may be added to TPN 1-2 days after starting sliding scale. Start by adding 2/3 of
insulin dose from sliding scale. Reduction of steroid doses, and/or resolved sepsis are
indications for random reduction of insulin doses with TPN.
More Potassium, Phosphates, and Magnesium are required during insulin therapy due to
intracellular shift of these ions.
Elevated transaminases levels 10-14 days after starting TPN is an indication to reduce dextrose
doses in TPN (dextrose-induced liponeogenesis leading to fatty liver).
Day 1: 0.5g/kg/d
Day 2: 1 g/kg/d
Reduce the dose to 0.5g/kg/day with elevated BUN (more than 30 mMol/L) unless on dialysis
therapy.
Protein dose is guided by monitoring BUN (daily), Nitrogen Balance (once weekly),
Prealbumin, and Transferrin (q sat).
Elevated LFTs and bilirubin may necessitate limiting protein dose to 1-1.2g/kg/day.
IV Lipid (Fat)
1. Day 1: 0.5g/kg/day
2. Day 2 and thereafter: 1g/kg/day
3. Limit the rate of infusion to 0.15g/kg/hour.
4. Limiting the dose to 1g/kg/day in BMT patients especially with febrile neutropenia may be
necessary due to possible inhibition of chemotaxis and phagocytosis by high lipid doses.
5. If TG less than 2 mMol/L: 1g/kg/d
6. If TG level is 2.1-3.9 mMol/L : 0.5-0.8g/kg/d. Do TG level q Sat & Wed.
7. If TG level is 4-5 mMol/L: 0.3-0.5g/kg/d. Do TG levels q Sat, Mon, Wed.
8. If TG level is more than 5 mMol/L: DC IV lipid and do TG levels q Sat, Mon, Wed.
9. The due time for IV lipid is around 0500 (after blood draw) and infused over 12-14 hours.
Minimum of 4 hours is required for clearance before drawing blood to avoid falsely elevated
triglyceride levels.
Electrolytes
Electrolytes are added based on levels.
Common Drugs causing electrolytes imbalances:
Furosemide: Hypokalemia, hypomagnesemia, hyponatremia, metabolic alkalosis.
Cyclosporine: Hypomagnesemia, Hyperkalemia, Hyperglycemia, Hypertriglyceridemia.
Amphotericin B: Hypokalemia, hypomagnesemia, renal tubular acidosis.
Steroids: Hypokalemia, hyperglycemia.
Aminoglycosides: Hyperkalemia (2nd to ARF).
Insulin: Hypokalemia, hypophosphatemia.
Spironolactone & Triamterene: Hyperkalemia, metabolic acidosis.
Trace Elements: (Zinc, Selenium, Copper, Chromium)
Additional dose of zinc for all BMT patients: 3-5mg/day, and in diarrhea: 17mg/L of stool loss.
Reduce the dose to half in patients with chronic renal failure as chromium, zinc, and selenium
are excreted renally.
Reduce the dose to half in patients with cholestasis as copper and manganese are excreted in
bile.
Fluid Considerations
The physician designates total fluid intake (TFI) in ml/hour. TPN and lipids are ordered at a
rate much lower than TFI to allow for antibiotics, blood products, and chemotherapy to be
given without exceeding maximum desired TFI. Catching up to the ordered TFI occurs with
D5W 1/4NS, D5W 1/2NS, or D5W NS (as per sodium need).
Plain NS, 1/2NS, 1/4NS can be ordered temporarily if patient is developing uncontrolled
glucose intolerance.
For peripheral parenteral nutrition, more fluid is needed to allow more calories provision as
dextrose concentration will be limited to 7.5% and Amino Acids to 2.5%. Total Osmolality of
the peripheral TPN should not exceed 900 mOsm/L.
No drugs must be co-infused with the same lumen of TPN or lipid without referring to TPN
and Medication Compatibility Guide that is posted in the nursing units.
IV Fat can be temporarily turned off when co-infusing a drug that is compatible with TPN but
not with lipid.
Team Responsibilities
Physician:
Orders: Start TPN, taper TPN, DC TPN, total fluid intake in ml/hour, designates
desired IV maintenance with TPN. (Note that new start TPN orders are accepted daily
excluding weekends. Any TPN order written after 1600 will be processed next day).
Enters ordered laboratory orders (by TPN pharmacist) into Integrated Clinical
Information System (ICIS).
TPN Pharmacist:
Daily writing of TPN orders to include lab evaluation, fluid needs, caloric and protein
needs.
Daily calculation of calories and protein (to include all sources of glucose from IVPB,
IV fluids, etc.)
Nursing staff:
Draws blood (turn off for one full minute before drawing all labs and avoid
contamination of the drawn blood with TPN).
TPN monitoring: Daily weights, intake and output, TPN infusion rates and times.
Ensure safe drug administration in regard to compatibility of drugs with TPN and
lipids.