TOTAL PARENTERAL NUTRITION

Presenter:
Dr. Shaik Mohammed Akram
Junior Resident

Moderator:
Dr. AJITHA M B
Professor and HOD
Department of General Surgery
BMCRI
PARENTERAL NUTRITION

● Parenteral nutrition is the intravenous administration of nutrition outside

of the gastrointestinal tract.
● In addition to enteral feeding -supplemental parenteral
nutrition
● Total parenteral nutrition(TPN) is when IV-administered
nutrition is the only source of nutrition the patient is receiving. It is
used to provide nutrients directly into the bloodstream
when a patient is unable to eat or absorb nutrients
through the digestive tract. It involves the intravenous
infusion of a nutrient-rich solution that typically includes:
● Carbohydrates (often in the form of glucose)
● Proteins (usually in the form of amino acids)
● Fats (in the form of lipid emulsions)
TPN can be categorized based on several
factors including the duration of therapy,
the type of nutrient infusion, and the route
of administration.
1. Based on duration:
short-term TPN
long-term TPN
2. Based on nutrient infusion:
continuous TPN
cyclic TPN
3. Based on route of administration:
central TPN
peripheral TPN (PPN)
INDICATIONS FOR USING TPN IN ADULTS

1. Patients with short-bowel syndrome secondary to massive small-bowel

resection (<100 cm without colon or ileo-cecal valve or <50 cm with intact
ileocecal valve and colon)
2. Patients with enteroenteric, enterocolic, enterovesical, or high-output
enterocutaneous fistulas (>500 mL/d).
3. Surgical patients with prolonged paralytic ileus after major operations (>7 to
10 days)
4. Hypercatabolic states due to sepsis, polytrauma, and major fractures
5. Patients with normal bowel length but with malabsorption
6. Patients with granulomatous colitis, ulcerative colitis, or tuberculous enteritis
in whom major portions of the absorptive mucosa are diseased.
7. Failure for any enteral nutrition for 7 – 10 days.
TPN involves a carefully prepared nutrient
solution that must be handled, stored, and
administered with care.

Packaging: TPN solutions are typically

packaged in sterile, fl exible bags made from
materials like polyolefi n or multilayer plastics.
These bags are designed to prevent
contamination and preserve the integrity of the
nutrients.
In some cases, especially for certain components
like lipids or specifi c additives, TPN may be
provided in glass or plastic bottles.

Labelling: Each TPN bag or bottle is labeled

with detailed information including the
composition (carbohydrates, proteins, fats,
vitamins, and minerals), expiration date.
Storage: Most TPN solutions need to be stored in a
refrigerator from 2°C to 8°C if they are not being used
immediately. This helps maintain stability and prevent
microbial growth.
Once prepared, TPN solutions are often allowed to reach
room temperature usually from 20°C to 25°C before
administration. They should generally not be stored at
room temperature for more than 24 hours.

Handling: Because the central venous catheter needs

to remain in place for a long time, strict sterile
technique must be used during insertion and
maintenance of the TPN line. The TPN line should not be
used for any other purpose. Dressings should be kept
sterile and are usually changed every 48 hours using
strict sterile techniques. A dedicated nurse should be
present to maintain the sterile environment.
TPN solutions should never be frozen, as this can
damage the solution and alter its eff ectiveness.
TPN is used as a substitute for oral nutrition
when a patient cannot eat or absorb nutrients
through the GI tract and enteral nutrition such
as nasogastric tubes, gastrostomy tubes, and
jejunostomy tubes when enteral feeding is not
possible such as in short bowel syndrome,
bowel obstruction.

Before the development of total parenteral

nutrition management of patients is limited to
intravenous fl uids, electrolytes infusions
and enteral feeding.
TPN was developed by Dr. Stanley Dudrick
allowing for the intravenous administration of a
complete nutrient solution, including proteins,
fats, and carbohydrates to patients.
ADMINISTRATION OF TPN

● Central venous catheter :

directly into the superior vena
cava or right atrium.

● Peripherally inserted central

catheter ( PICC ): inserted into
basilic (most commonly used),
cephalic, brachial or median
cubital vein of the arm.
NICE Guidelines for parenteral nutrition
Patients identified as being malnourished-
● BMI < 18.5 kg/m2
● Unintentional weight loss of > 10% over 3-6 months
● BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6
months

AT RISK of malnutrition-
● eaten nothing or little > 5 days, who are likely to eat little for a
further 5 days
● poor absorptive capacity
● high nutrient losses
● Hypercatabolic state
COMPONENTS OF TPN

● 3 - litre bag with 3 compartments

● i)Dextrose (15% w/v)
● ii)Aminoacids, both essential and non-essential
(10% w/v) with electrolytes
● iii)Lipid emulsion (20%w/v). Emulsion contain
soyabean oil, medium chain triglycerides, egg
lecithin, glycerol.

● 2000kcal
MICRONUTRIENT SUPPLEMENTATION WITH TPN

● Folic acid 15mg -once or twice a week - and other vitamins

are given daily.
● Patients requiring long-term parenteral nutrition- (over many
months) single-dose injection of vitamin B12.
● Phosphate -20–30 mmol phosphate daily.

Electrolytes recommendation per liter of parenteral nutrition:

Sodium: 100 to 150 mEq
Magnesium: 8 to 24 mEq
Calcium: 10 to 20 mEq
Potassium: 50 to 100 mEq
Phosphorus: 15 to 30 mEq
ASSESSMENT OF PATIENTS ON TPN

● Daily assesment of Vitals , input/ output

monitoring, electrolytes and body weight.
● Micronutrients such as zinc, copper, selenium,
ferritin, folate and vitamins B12 and vitamin D - 28
days and every 3 months in patients on long-term
parenteral nutrition.
● TPN is generally contraindicated in the following
conditions:

• Patients with critical cardiovascular instability or

metabolic instabilities; such instabilities require
correction before administering intravenous nutrition.
• When gastrointestinal feeding is possible
• When the nutritional status is good, only short-term
TPN is needed
• TPN should not be used to prolong life when death is
unescapable.
 USE IN SPECIFIC
PATIENTS
Patients with renal impairment
● To promote positive nitrogen balance in acute kidney injury, clinicians should adjust protein
intake according to catabolic rate, renal function, and dialysis losses. Common laboratory
abnormalities associated with prolonged RRT include hypophosphatemia, hypokalemia, and
hypomagnesemia. Hence, electrolyte intake in patients should be adjusted by monitoring serum
concentrations. Trace elements should be monitored and supplemented as there are increased
requirements during ESRD, critical illness, and extensive effluent losses during renal
replacement therapy(RRT)

Patients with Hepatic Impairment

● Rapid initiation of parenteral nutrition is recommended in moderately or severely malnourished
cirrhotics who cannot be nourished sufficiently by either oral or enteral route. Parenteral
nutrition is recommended in patients with unprotected airways and encephalopathy (HE) due to
the risk of aspiration in these patients.
COMPLICATIONS OF TPN

● IV ACCESS COMPLICATIONS
● LINE COMPLICATIONS
● METABOLIC COMPLICATIONS
IV ACCESS COMPLICATIONS

PNEUMOTHORAX
● Most common during insertion of subclavian line.
● Incidence - 0.5-1% of the cases.
● Diagnosed by chest X-ray
● Managed by insertion of chest drain.
LINE MISPLACEMENT
● Correct place of insertion if the tip is in the inferior third of
SVC or at the aortocaval junction.
LINE COMPLICATIONS

LINE SEPSIS
● Occurs in 15% of the patients.
● Catheter entry sites should be checked daily.
● Suspected line sepsis -paired blood cultures from the line and
a separate peripheral site
● Use of the line should be stopped until culture results are
available.
● Positive cultures will require line removal and
commencement of antibiotics.
LINE THROMBOSIS-
● Occurs in major veins
● Associated with line sepsis
● Results in SVC occulsion and pulmonary embolism
● Treatment- anticoagulants, fibrinolysis of SVC
LINE BLOCKAGE-
● Regular line fushing after manipulation
● Unclogged by locking the affected line with heparinized
saline or thrombolytic agent.
METABOLIC COMPLICATIONS

REFEEDING SYNDROME
● Complication of enteral and parenteral feeding
● occurs in the first days after feeding is commenced in
patients who have been severely malnourished.
● Patients who are due to start nutritional support need to be
screened for the risk of refeeding syndrome.
RISK OF REFEEDING SYNDROME
PATHOPHYSIOLOGY OF REFEEDING SYNDROME
CLINICAL FEATURES OF REFEEDING SYNDROME

● Arrythmias
● Muscle weakness
● Respiratory or cardiac failure
● Oedema
● Lethargy
● seizures
● Most severe - fatal
PREVENTION OF REFEEDING SYNDROME

● Nutritional support -maximum of 10 kcal/kg per

day
● Increase levels slowly to meet full needs by 4–7
days.
● Frequent monitoring and replacement of the
electrolytes.
● Nutritional support supplements like thiamine,
vitamin B12, multivitamins and trace elements.
LIVER DYSFUNCTION-
● Present in 25% of the patients
● Fatty liver is a common complication
● Intestinal failure-associated liver disease (IFALD)
● Cholestatic changes
● Fibrosis and cirrhosis of liver.
METABOLIC BONE DISEASE AND VITAMIN DEFICIENCIES:
● Osteoporosis and osteomalacia
● anemia
● hair loss
● neurological symptoms.
RECOMMENDED SCHEDULE FOR MONITORING FEEDING REGIMEN

Daily Observations including:

● pulse, blood pressure and temperature
● body weight fluid balance, including volume of urine and/or urine and
intestinal losses
● quantity and type of food consumed, if allowed to eat
Plasma levels:
● sodium, potassium,
● urea and creatinine
● blood glucose
● magnesium and phosphate (if at risk of refeeding syndrome)
● liver function tests
● C-reactive protein
Weekly to fortnightly :
● full blood count
● calcium, zinc, copper
● plasma proteins including albumin
● thiamine
● triglycerides
● vitamin B12
● folic acid
3–6 monthly
● Ferritin
● Selenium
● manganese
● 25-hydroxyvitamin D
TOXICITY

● Generally, the toxicity of TPN is related to the individual toxicity of its

components. Increased caloric amounts due to TPN glucose and lipid excess
can lead to hepatic toxicity.
● This risk can be decreased by using decreased glucose and greater lipid
content. A glucose infusion rate greater than 5 mg/Kg/min can result in a
fatty liver because increased glucose in the blood induces hepatic
lipogenesis, and increased glucose levels induce increased insulin levels,
leading to more lipogenesis. This effect is preventable by decreased dextrose
dosage to less than 5mg/kg/min.
• Long-term usage of TPN, ranging from weeks to months,
can be associated with the rare complication of
manganese toxicity. High manganese concentration leads
to its deposition in the liver, brain, and bone. However,
the brain is most likely to be aff ected as manganese will
deposit and aff ect the globus pallidus and striatum of the
basal ganglia. Manganese preferentially aff ects
dopaminergic neurons in the basal ganglia, resulting in
extrapyramidal symptoms similar to parkinson's disease.

Peroxide formation in parenteral nutrition happens when

exposed to light.
Hence, photoprotection of parenteral nutrition products is
needed from the compounding process and continuing
until the entire PN is administered
RECENT ADVANCE

• The use of parenteral nutrition to address cancer-related cachexia varies

widely across healthcare systems, countries. The decision to initiate
nutritional support must be made carefully, considering patient-specific
factors such as functional status and life expectancy.
• There is a recent study that total parenteral nutrition treatment improves
the nutrition status of gynecological cancer patients by improving serum
albumin level
CONCLUSION

• It is important to identify the principal indications for TPN, who

would benefit from therapy.
• Differentiating TPN as a short-term intervention with specific
measurable goals versus planning for indefinite TPN is an
essential step.
• Risks and benefits of TPN should be considered before
administering.