Total Parenteral Nutrition (TPN);

Theory & Concept

Dr. Syed Wasif Gillani
Monash University Sunway Campus (MUSC)
Malaysia
Def. :a method of feeding
patients by infusing a
mixture of all necessary
nutrients into the
circulatory system, thus
bypassing the GIT.

Also referred to as:

intravenous nutrition,
parenteral
alimentation, and
artificial nutrition.
The gut should always be the preferred route
for nutrient administration.

• Therefore, parenteral nutrition is indicated

generally when there is severe gastro-
intestinal dysfunction (patients who cannot
take sufficient food or feeding formulas by
the enteral route) . 3
Categories of PN
• If enteral feeding is
completely stopped or
ineffective, Total
Parenteral Nutrition is
used (TPN).

• If enteral feeding is just

“not enough” ,
supplementation with
Partial Parenteral
Nutrition (PPN) is
indicated.

4
 INDICATIONS
• In well-nourished adults, 7
- 10 days of starvation with
conventional intravenous
support (using 5% dextrose
solutions) is generally
accepted.
• If the period of starvation is
to extend beyond this time,
or the patient is not well-
nourished, Total Parenteral
Nutrition (TPN) is necessary
to prevent the potential
complications of
malnutrition.
5
 Indications for TPN
Short-term use
• Bowel injury, surgery, major trauma or burns
• Bowel disease (e.g. obstructions, fistulas)
• Severe malnutrition
• Nutritional preparation prior to surgery.
• Malabsorption - bowel cancer
• Severe pancreatitis
• Malnourished patients who have high risk of
aspiration
Long-term use (HOME PN)
• Prolonged Intestinal Failure
• Crohn’s Disease
• Bowel resection
6
 Partial Parenteral Nutrition:
• PPN can be used to
supplement Ordinary or
Tube feeding esp. in
malnourished patients.

Indications:
• Short bowel syndrome
• Malabsorption
disorders
• Critical illness or
wasting disorders
7
 Enteral versus parenteral nutrition
• As far as gastrointestinal failure
is concerned, long term
parenteral nutrition is a life-
saving procedure.
• Enteral nutrition has the
advantage over parenteral
nutrition of lower % of
infectious complications.
• Parenteral nutrition has been
shown to lead to changes in
intestinal morphology and
function and an increase in
permeability (with higher % of
bacterial translocation) 8
 Nutritional Requirements
• Energy: Glucose
Lipid
• Amino acids (Nitrogen)
• Water and electrolytes
• Vitamins
• Trace elements

9
 Requirements:
Energy
�Energy
� Basal energy requirements are a function of the
individual's weight, age, gender, activity level and the
disease process.
� The estimation of energy requirements for parenteral
nutrition relies on predictive equations.
� Hospitalized adults require approximately 25-30 kcal/
kgBW/day.
� However, these requirements may be greater in patients
with injury or infection.
10
 Energy Requirements
Patient condition Basal Approximate energy
metabolic Requirement
rate (kcal/kg/day)
No postoperative Normal 25-30
complications, GIT
fistula without infection
Mild peritonitis, long-bone 25% above 30-35
fracture, mild to moderate normal
injury, malnourished
Severe injury or infection 50% above 35-45
normal
Burn 40-100% of total body Up to 100% 45-80
surface above normal 11
 Requirements:
Energy Sources: Glucose
�Energy
• The most common source of parenteral
energy supply is glucose, being:
� Readily metabolized in most patients,
� provides the obligatory needs of the
substrate , thus reducing
gluconeogenesis and sparing
endogenous protein.
� 1 gm of glucose gives 4 Kcals.
• Most stable patients tolerate rates of 4-5
mg.kg-1.Min-1, but insulin resistance in
critically ill patients may lead to
hyperglycemia even at these rates, so insulin
should be incorporated acc. to blood sugar
levels.
12
 Requirements:

Energy Sources: Glucose

�Energy

Route
• Glucose in 5% solution can be
safely administered via a
peripheral vein, but higher
concentrations require a central
venous line.

• 20, 25, or even 50 % solutions

are needed to administer
meaningful amounts of energy
to most patients for proper
volume administration.
13
Requirements:
Energy Sources: Lipid
�Energy

• Fat mobilization is a major response

to stress and infection.

• Triacylglycerols are an important

fuel source in those conditions,
even when glucose availability is
adequate.

• Need to be restricted in patients

with hypertriglyceridemia.
14
 Requirements:
Energy Sources: Lipid
�Energy

• Lipids are also a source for the essential fatty acids

which are the building blocks for many of the
hormones involved in the inflammatory process as well
as the hormones regulating other body functions.

• Ideally, energy from fat should not exceed 40% of the

total (usually 20-30%).

15
 Requirements:
Energy Sources: Lipid
�Energy

• Fat emulsions can be safely administered via peripheral

veins, provide essential fatty acids, and are
concentrated energy sources for fluid-restricted
patients.

• They are available in 10, 20 and 30% preparations.

• Though lipids have a calorific value of 9Kcal/g, the

value in lipid emulsions is 10Kcal/g due to the contents
of glycerol and phospholipids.
16
 Requirements:
Nitrogen
�Nitrogen
• Protein (or amino acids,
the building blocks of
proteins) is the functional
and structural component
of the body, so fulfilling
patient’s caloric needs
with non-protein calories
(fat and glucose) is
essential.

• Protein requirements for

most healthy individuals
are 0.8 g/kg/day. 17
 Requirements:
Nitrogen
�Nitrogen
• With disease, poor food intake, and inactivity, body
protein is lost with the resultant weakness and muscle
mass wasting.

• Critically ill patients may need as high as 1.5-2.5 g

protein/kg/day depending on the disease process:
(major trauma or burn > infection or after surgery > standard )

• The amount should be reduced in patients with kidney

or liver disease. 18
 Requirements:
Nitrogen
�Nitrogen
Daily Protein requirements

Condition Example requirement

Basic requirements Normal person 0.5-1g/Kg
Slightly increased Post-operative, cancer, 1.5g/Kg
requirements inflammatory
Moderately increased Sepsis, polytrauma 2g/Kg
requirements
Highly increased Peritonitis, burns, 2.5g/Kg
requirements
Reduced requirements Renal failure, hepatic 0.6g/Kg
encephalopathy 19
 Requirements:
Nitrogen
�Nitrogen
Nitrogen Balance =
Protein intake in grams ÷ 6.25 – UUN (in grams) + 3
• The nitrogen lost in urine derives primarily from amino
acids released by protein breakdown in response to
catabolic mediators that include stress hormones
(corticosteroids, catecholamines) and cytokines.

• It is a way to assess the sufficiency of protein intake for the

patient.

20
 Requirements:
Nitrogen
�Nitrogen

• Parenteral amino acid solutions provide all known

essential amino acids.

• Available a.a. preparations are 3.5 - 15 % (ie

contains 3.5-15 gms of protein or a.a.s/100 mL
solution).

• 1gm of protein = 0.16 gm of N2.

21
 Requirements:
� Nitrogen

• Special a.a. solutions are also

available containing higher levels of
certain a.a.s, 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.

22
 Requirements:
Nitrogen
�Nitrogen
• Arginine was added to enteral
formulae claiming positive
effects on immune function
and length of hospital stay.

• In some clinical trials,

glutamine-enriched solutions
improved nitrogen balance
and gut morphology.
23
 Requirements:
Fluids and electrolytes
�Fluids

• 20–40 mL/kg - daily – young

adults
• 30 mL/kg – daily – older
adults
• Sodium, potassium, chloride,
calcium, magnesium, and
phosphorus ( as per the
table)
• Daily lab tests to monitor
electrolyte status 24
 Requirements:
Fluids and electrolytes
�Fluids

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
Chloride/Acetate So a to maintain acid-base balance
(normally 0.5 mmol for Cl - , & 0.1mEq for Acetate)
25
 Requirements:
Fluids and electrolytes
�Fluids
• Normalization of acid-base
balance is a priority and constant
concern in the management of
critically ill patients.

• Most electrolytes can be safely

added to the parenteral amino
acid/dextrose solution.

• Sodium bicarbonate in high

concentrations will tend to
generate carbon dioxide at the
acidic pH of the amino
acid/glucose mix.

26
Requirements:
Vitamins
�Vitamins
• These requirements are usually
met when standard volumes of a
nutrient mix are provided.

• Increased amounts of vits are

usually provided to severely ill
patients.

• Vitamins are either fat soluble

(A,D,E,K) or water soluble (B,C).
Separate multivitamin
commercial preparations are now
available for both.
27
 Requirements:
Vitamins
�Vitamins
• Multivitamin formulations for
parenteral use for adult patients
usually contain 12 vitamins at levels
estimated to provide daily
requirements.

• Additional amounts can be

provided separately when indicated.

• Most adult vitamin formulae do not

contain vitamin K, which is added
according to the patient’s
coagulation status.
28
Requirements:
Trace minerals
�Trace
• These are essential
component of the parenteral
nutrition regimen.
• A multi-element solution is
available commercially, and can
be supplemented with
individual minerals.

• may be toxic at high doses.

• Iron is excluded, as it alters

stability of other ingredients.
So it is given by separate
injection (iv or im).
29
 Requirements:
Trace minerals
�Trace
• minerals excreted via the liver, such as copper and
manganese, should be used with caution in patients with
liver disease or impaired biliary function.

Mineral Recommended dietary Suggested daily

allowance (RDA) for daily intravenous intake
oral intake (mg) (mg)
Zinc 15 2.5-5
Copper 2-3 0.5-1.5
Manganese 2.5-5 0.15-0.8
Chromium 0.05-0.2 0.01-0.015
Iron 10 (males)-18 (females) 3 30
 Osmolarity:

• PPN: Maximum of 900 milliosmoles / liter

• TPN: as nutrient dense as necessary (>900

m.osmol and up as high as 3000).

• Amino acids (10 m.osmol/gm), dextrose (5

m.osmol/gm) and electrolytes (2 m.osmol /mEq)
contribute most to the osmolarity, while lipids
give 1.5 m.osmol/gm.

31
 Application:
�The Solution

• Manually mixed in
hospital pharmacy or
nutrition-mixing
service,

• premixed solutions,

• Separate
administration for
every element alone
in a separate line. 32
 Application:
�Venous access
• PPN: (<900 m.osmol/L): a peripheral line can be enough.
• TPN: Central venous access is fundamental,
Ideally, the venous line should he used
exclusively for parenteral nutrition.
Catheter can be placed via the subclavian vein, the
jugular vein (less desirable because of the high rate of
associated infection), or a long catheter placed in an arm
vein and threaded into the central venous system (a
peripherally inserted central catheter line)
Once the correct position of the catheter has been
established (usually by X ray), the infusion can begin. 33
34
 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).
35
 Monitoring
�Policy: to monitor:
1- Effecacy: 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.
4- Detection of infection:
Clinical (activity, temp, symptoms)
WBC count (total & differential)
Cultures 36
Monitoring

Monitoring

37
 Complications of TPN
• Sepsis
• Pneumothorax
• Air embolism
• Clotted catheter line
• Catheter displacement
• Fluid overload
• Hyperglycemia
• Rebound Hypoglycemia

38
 Complications of TPN
�Catheter-related complications
o Catheter sepsis: which can be localized or systemic (skin
portal, malnutrion, poor immunity).

ccc by: fever, chills, ±drainage around the catheter

entrance site, Leukocytosis, +ve cultures (blood &
catheter tip).

ttt:1- exclusion of other causes of fever

2- short course of anti-bacterial and antifungal
therapy (acc. to C&S)
3- Catheter removal may be required
39
 Complications of TPN
Catheter sepsis (Cont.):
Prevention: a rigorous program of catheter care:
� Only i.v. nutrition solutions are administered through the
catheter, no blood may be withdrawn from the catheter.
� Catheter disinfection and redressing 2 to 3 times weekly.
� The entrance site is inspected for signs of infection and if
present, culture is taken or the catheter is removed.

� Other catheter-related complications:

Thromboembolism, pneumothorax, vein or artery
perforation, and superior vena cava thrombosis

40
 Complications of TPN
� Metabolic Complications
o Hyperglycemia (an elevated blood
sugar): Associated with the infusion of
excess glucose in the feeding solution
or the diabetic-like state in the patient
associated with many critical illnesses.
It can result in an osmotic diuresis
(abnormal loss of fluid via the kidney),
dehydration, and hyperosmolar coma.
ttt: decrease the amount of infused
glucose (to<4 mg/kg/min) OR insulin
can be administered (either S.C. inj. or
incorporation in the infusion bag).
41
 Complications of TPN
�Metabolic Complications
o Hypertriglyceridemia (High S. Triglycerides)
Associated with excess infusion of fat emulsion.

N.B. Infusion of both glucose and fat emulsion in

excess may result in pulmonary insufficiency.
Excess glucose infusion –> excess carbon dioxide
(CO2) production a result of glucose metabolism.
Excess lipid infusion --> the lipid particles may
accumulate in the lungs and reduce the diffusion
capacity of respiratory gases.
42
 Complications of TPN
�Metabolic Complications

o liver toxicity (also know as parenteral nutrition cholestasis):

It causes severe cholestatic jaundice, elevation of
transaminases, and may lead to irreversible liver damage
and cirrhosis.
Multiple causes have been proposed, including high infusion
rates of aromatic amino acids, high proportion of energy
intake from glucose, e.t.c..
There is no specific treatment, other than anticholestatic
therapy.
43
 Complications of TPN
�Metabolic Complications

o Intestinal bacterial translocation:

The lack of direct provision of nutrients to the intestinal epithelia
during total parenteral nutrition �Trophism and altered
permeability of the GI mucosa, thus compromising any
potential recovery of the patient’s ability for enteral feeding,
and allowing bacterial entery to blood stream � sepsis

Prevention is to provide a minimal enteral nutrition supply to

avoid or minimize this risk.

44
 Complications of TPN
�Metabolic Complications
o Other metabolic complications:
Electrolyte imbalance, mineral imbalance, acid-base
imbalance, toxicity of contaminants of the parenteral
solution.

45
 Complications of TPN
�Mechanical Complications
Catheters and tubing may become clotted or twist and
obstruct.
Pumps may also fail or operate improperly.

46
 HOME PARENTERAL NUTRITION
• Patients who are unable to eat and absorb adequate
nutrients for maintenance over the long term may be
candidates for home parenteral nutrition e.g. extensive
Crohn's disease, mesenteric infarction, or severe
abdominal trauma.

• patients must be able to master the techniques associated

with this support system, be motivated, and have adequate
social support at home.

47
 HOME PARENTERAL NUTRITION
• A patient who is judged to be a candidate for home
parenteral nutrition requires an indwelling Silastic
catheter designed for long-term permanent use.

• The nutrient solutions are prepared weekly and

delivered to the patient's home.

• The patient sets up the infusion system and

attaches the catheter to the delivery tubing in the
evening for infusion over the next 12-16 h. The
intravenous nutrition is terminated by the patient
the next morning. 48
49
Among the indications for parentral nutrition

• Short bowl syndrome,

• Surgical GIT resection followed by more than 5 days
fasting in a cachectic patient,
• Polytrauma,
• Intractable malabsorption,
• Prolonged mechanical ventilation

50
For energy requirements
• hospitalized adults require approximately 25-30
kcal/kg/day
• A single measurement of energy expenditure by
indirect calorimetry will provide a reliable estimate
of average requirements.
• The most common source of parenteral energy
supply is glucose.
• Glucose in 5% solution can be safely administered
via a peripheral vein,
• With severe infection or injury, basal metabolic rate
rises about 25% above normal
51
Regarding Nitrogen balance
• A 70 Kgs normal adult male requires about 60 gms
of protein daily
• Stress induces catabolic state and hence, a positive
Nitrogen balance
• Special amino acid solutions containing higher
levels of branched-chain amino acids (valine,
leucine and isoleucine) are useful in the
management of liver diseases.
• With renal failure, reduction of the amino acid load
is recommended.
• Glutamine is essential for gut function.
52
During Monitoring of TPN
• Hyperglycemia can be tolerated so long as there is
no ketosis
• New-onset glucose intolerance in patients receiving
TPN may represent an early sign of sepsis.
• Serum levels of electrolytes including magnesium
and phosphorus should be checked daily until
stabilized, then two times daily.
• Overfeeding the patients markedly increases
metabolic and respiratory complications.
• Indirect calorimetry is very useful in mechanically
ventilated patients with an FiO2 greater than 50%.
53
Complications of parentral nutrition
• The most frequent catheter-related complication is SVC
thrombosis
• Catheter sepsis is characterized by the classic signs of
infection: chills, fever, and white blood cell count is
usually elevated
• Hyperglycemia is a very serious, relatively common,
problem
• Excessive infusion of aromatic amino acids, glucose, and
lipids may lead to the development of liver toxicity
(cholestasis).
• Excess glucose infusion leads to excess O2 consumption,
while with lipid infusion, the lipid particles may
accumulate in the lungs and reduce the diffusion capacity
of respiratory gases.
54