TPN (TOTAL PARENTRAL NUTRITION)

USES OF TPN
Patients with GIT disorders Patients with intact GIT but high nutritional needs (burns traumas) or cant be fed orally (in coma)

TYPES OF TPN

(central parentral nutrition) -Central vein as subclavian -Long term therapy and higher concentration of nutrients (dilution)

CPN

(peripheral parentral nutrition) -Peripheral vein -Not more than 2 weeks

PPN

PROBLEMS OF ADMINISTERING TPN IN CENTRAL VEIN

Sepsis Metabolic adverse effects (direct administration to blood) Need for monitoring vital signs and lab values (B.P.) Complexity in preparation (potential incompatibilities) and high contamination risk

GUIDELINES FOR PATIENT SAFETY IN USING INTRACLAVICULAR VEIN AS TPN SITE

Slow start for flow then increase gradually to prevent hyperglycemia Use terminal 0.22m filter (prevent contamination) Change IV set and filter every 24 hours Clean and inspect the catheter site every other day Use only TPN catheter for TPN (no piggyback medication/blood drawing through this line)

PATIENT STATE

Catabolic state -Use protein for energy more than a new protein can be made - Negative nitrogen balance

Anabolic state -patient is making more new protein than being used - Positive nitrogen balance TPN

Faulty wound healing, faulty immunological defenses, body system faliure

CALORIC REQUIREMENTS
Kilocalorie: amount of heat needed to raise the temperature of 1 kg of water from 0 to 1C. Harris Benedict equation: Estimates resting metabolic energy (RME) For males: RME = 66 + (13.7 * W) + (5 * H) (6.8 * A) For females: RME = 665 + (9.6 * W) + (1.8 * H) (4.7 * A) W : weight in kg H: height in cm A: age in years

RME is multiplied by stress factor according to the patients need: Mild stress (1.2-1.4) average 1.3 (non surgical hospitalized patient) Moderate stress (1.5-1.75) average 1.675 (severe infection) Severe stress (1.75-2) average 1.875 (burns) Calories may be administered by amino acids, carbohydrates and lipids (fats)

DAILY PROTEIN REQUIRED

The share of calories coming from amino acids is calculated as follows: Mild stress: 0.75 g protein/kg Moderate stress: 0.9 g protein/kg Severe stress: 1.25 g protein/kg Each 1 g protein gives 4 kcal The remaining calories are provided by carbohydrates (dextrose) 3.4 kcal/g OR lipid emulsions 10 kcal/g

DAILY FLUID REQUIREMENT

1500 ml for the first 20 kg + 20 ml/kg of actual weigh Increased In: Fever-Diarrahea-Fistulas-NG suction
-

Decreased In: Renal failure- CHF- Cirrhotic ascites-Pulmonary diseases

121 56 5 3

121 lb = 121/2.2 = 55 kg 53 = 63 * 2.54 = 160 cm RME = 665 + (9.6 * 55) + (1.8 *160) (4.7 * 56) = 1208 Kcal Multiply by 1.3 (mild stress) = 1208 * 1.3 = 1570 Kcal

CALCULATE THE DAILY REQUIREMENT OF PROTEIN AND MLS OF 50% DEXTROSE TO PROVIDE THE REMAINING CALORIES?
Since mild stressed therefore needed protein 0.75g 1 kg x 55 kg therefore x = 41.25 g And since 1 g protein provides 4 kcal, therefore 41.25 * 4 = 165 Kcal The remaining calories to be provided by dextrose = 1570 165 = 1405 Kcal Since 1g dextrose provides 3.4 Kcal, therefore 1405 Kcal will be provided by (1405/3.4) = 413.24 g dextrose Injection concentration is 50 g 100 ml 413.24 x (826ml)

COMPOSITION OF TPN SOLUTIONS

1- Proteins/amino acids Protein in diet
Enzymes in GIT

Polypeptides( protein hydrolysate)

Blood and liver enzymes

Proteins are insoluble and cant be digested in the blood, therefore for TPN the manufacturer provides them as

Amino acids

Potein hydrolysate (60% usable)

Amino acids (100% usable)

100 gm protein hydrolysate 6.25 gm L-alpha a.a.

60 gm L-alpha a.a. 1 gm usable nitrogen

For each 1 gm nitrogen There should be 200 calories average from non protein source (dextrose or fats) to be supplied in the TPN formulation

If we have a prescription for TPN Nitrogen 15 gm Non protein calories 3000 Kcal whats the amount of protein hydrolysate and dextrose to supply it? a) 6.25 gm L-alpha a.a. x 100 gm hydrolysate x 1 gm nitogen 15 gm x= 93.75 gm a.a. 60 gm a.a. 93.75 gm a.a.

x = 156.25 gm protein hydrolysate

Dextrose gives

3.4 Kcal 1 gm 3000 Kcal x x = 882 g dextrose

In the prescription we can observe that 15 g nitrogen required the presence of 3000 calories from non protein source

Optimum Nitrogen sparing so that the body doesnt deplete its protein stores by gluconeogenesis

3- Electrolytes and trace elements Such as K, Na, Fe, Cu Page 65: If in the prescription 35mEq of NaCl is needed, and the available source is a vial 5mEq/2ml how many mls should be added to the TPN solution? 5 mEq 2ml 35 mEq x x = 14 ml 4- Essential fatty acids mainly linoleic acid, available in the market as soyabean oil emulsion and safflower oil emulsion

The formula for a TPN solution calls for the addition of 2.7 mEq of Ca++ and 20 mEq of K+ per liter. a) How many mls of an injection containing 20 mg CaCl2 dihydrate per ml should be used? (given M.wt 147 mg, and atomic wt of Ca++ is 40) 1 mEq of Ca++ = Atomic wt/valency = 40/2 = 20 mg 1mEq 20 mg 2.7 mEq x x = 54 mg Ca++ 147 mg CaCl2 dihydrate x injection contains 20 mg 198.4 mg 40 mg Ca++ 54 mg Ca++ x=198.5mg 1ml x x = 9.92 mls

b) How many mls of a 15% w/v KCl injection should be used? (atomic wt K+ is 39 and Cl- is 35.5) Mwt KCl = 39 + 35.5 = 74.5 mgs 1 mEq K+ = atomic wt/valency = 39/1 = 39 mgs I need 20 mEq, therefore (20 x 39 = 780 mg) 74.5 mg KCl x 39 mg K+ 780 mg K+ x = 1490 mgs = 1.49 gm 100 ml x

Injection contains 15 g 1.49 g

x =9.93 ml

Problems number 3, 5, 7, 9 Pages 71-75