Parenteral Nutrition (PN)

Unit Farmasi TPN

Hospital Pakar Sultanah Fatimah
 FEED…FEED…FEED….

4. TOTAL
PARENTERAL 2. ENTERAL
NUTRITION

1. ORAL

3. ENTERAL
+
PARTIAL
PARENTERAL
NUTRITION
WHAT IS PN?
The administration of
complete and balanced
nutrition by intravenous
infusion in order to support
anabolism, body weight
maintenance or gain, and
nitrogen balance, when oral
or enteral nutrition are not
feasible or are inadequate
INDICATIONS FOR PARENTERAL NUTRITION

 Common indication for Parenteral Nutrition

◦ Inability to absorb adequate nutrients via the GI tract
 short bowel syndrome
 diseased bowel
 complete bowel obstruction or pseudo-obstruction
◦ Severe catabolism & GI tract unusable within 5-7days
◦ Enteral access not feasible, inadequate or not tolerated
◦ Pancreatitis with intolerance (eg pain) of jejunal nutrition
◦ High output fistula (>500ml) & no distal enteral access
CONTRA-INDICATIONS TO PARENTERAL
NUTRITION
 Functioning GI tract
 Treatment anticipated for < 5days in patients without severe malnutrition
 Inability to obtain venous access
 Poor prognosis that does not warrant aggressive nutrition support
 When the risk of PN are judged to exceed the potential benefits
COMPONENTS OF PARENTERAL NUTRITION
TPN

MACRONUTRIENTS MICRONUTRIENTS FLUIDS

PROTEIN
(Amino Acids) ELECTROLYTES
CARBOHYDRATE VITAMINS
(Dextrose) TRACE ELEMENTS
LIPID
 Types of PN Types of PN

Commercial PN Compounded PN

Central Line Peripheral Line Every component

individualized
according to patient
requirement
Periolimel
Olimel N9E
N4E
1600kcal
1050kcal

Smofkabiven
Peripheral
1300kcal

Show PN commercial bags.

Commercial PN Products
 3 chamber bags – before mix and after mix
 Expiry date of bag – if from pharmacy please check expiry date
at label
 Additive port – for pharmacy
 Administration port – for nurses
 Protect from light – use cover bag provided
 Use lipid filter provided
 Must run using infusion pump.
 Run according to infusion rate on pharmacy label.
 Any problem can call TPN pharmacy ext 640
Ordering PN in PhIS
 Flow
 Order before 11am
PN worksheet
 Example 1 worksheet
PN Preparation
 Only prepared inside cleanroom (controlled environment,
temperature, humidity, pressure)
 Pic of cleanroom suites
PN Preparation
 Only by trained Pharmacists / Pharmacist Asst.
 Full PPE to enter TPN Preparation room
 Pic of PPE to enter cleanroom.
PN Preparation
 Video of activities in cleanroom
PN dispensing to ward
 Pharmacists will call ward to inform when PN product ready
 Nurses should know names of patient on PN that day.
 If >2bags, need to bring 2 coldbox
PN administration
 By nurses in ward
 Proper PPE when administering PN to patients
 Aseptic technique when administering PN
 Video PN administration
 Complications of PN and safety measures
Possible Steps taken by Pharmacist Steps should be taken in
complications of ward
PN
Sepsis - PN prepared in cleanroom - Administer PN using
- Pharmacist trained in aseptic technique and wear
aseptic preparation PPE
- Filter provided to filter out - Practice catheter care
bacteria, fungi, spores bundle
LFT deranged - Use newer generation lipid - Run using infusion pump
- Double check calculation - Monitor Liver Function Test
of each component and (baseline and weekly)
infusion rate
 Complications of PN and safety measures
Possible Steps taken by Pharmacist Steps should be taken in ward
complications of PN
Refeeding - Start feeding slowly for high risk - Provide accurate body weight to
syndrome patient pharmacy
- Add multivitamins - Diet history
- Correct electrolyes if deranged - Monitor electrolyte (baseline)
Hyperglycemia -Double check infusion rate of - Monitor blood glucose level
dextrose (GM). GM QID if history DM.
• Parenteral Nutrition has changed so much since
- Start what
insulin you>learn
if GM in
10mmol/L
textbook.
• Don’t be afraid to order PN for patient who really need PN.
• PN is safe as long as all nurses and doctors cooperate with PN
Pharmacist and take steps to prevent / minimize complications.
 Any questions?