TPN101

1.  
Continuing Education

2.  Parenteral Nutrition must be considered when the patient
is malnourished and unable to obtain nutrients through
the gastrointestinal tract, either orally or through enteral
feedings.
 Golden Rule of Nutrition is: “If the gut works, use it”.
 Parenteral nutrition is a mixture of proteins and
carbohydrates, along with vitamins, minerals and
electrolytes that are administered IV to provide complete
nutrition.
o Parenteral nutrition is sometimes referred to as a 2-in-1 solution.
A fat emulsion (lipids) is often given with parenteral nutrition to
prevent the occurrence of essential fatty acid deficiency.
o When the lipids are added directly to the solution, it is called a 3-
in-1 solution.

3.  Parenteral Nutrition can be divided into two
types
o PPN (Partial Parental Nutrition)
o TPN (Total Parental Nutrition)

4.  Contains less than 10 % final concentration of dextrose
 Solution tonicity (concentration) is less than 500 mOsm/
liter
 May be administered through a larger peripheral vein
 Often given if a patient can tolerate enteral nutrition but
nutritional needs exceed what he/she can ingest through
the gut

5.  Contains 10% or greater concentration of Dextrose and
greater than 5% protein.
 Solution tonicity is 500 mOsm/ liter or greater
 Must be administered through a central line (tip
placement confirmed in the SVC)
 Designed to totally replace enteral intake
 Lipids may be administered separately via piggy back at
the hub or mixed directly into the solution (referred to as
a 3-in-1 formula)

6.  Universal principles that define the indications for nutritional
support include the following based on recommendations of
ASPEN guidelines.
o When specialized nutritional support is required, enteral
nutrition should generally be used in preference to PN
o PN should be used when the GI tract is not functional or
cannot be accessed and in patients who cannot be
adequately nourished by oral diets or enteral nutrition.
o Specialized nutrition support should be initiated in patients
with inadequate oral intake for 7-10 days. Or in those patients
in whom inadequate oral intake is expected over a 7-14 day
period.

7.  GI trauma
 Ileus
 Bowel obstruction
 Short bowel syndrome
 Severe mal-absorption
 Pancreatitis
 Inflammatory bowel disease requiring bowel rest
 Entercutaneous fistula
 Malignancy of the GI tract

8.  A functioning GI tract
 Inability to obtain appropriate IV access
 An unstable clinical condition or terminal disease for
which complication risk outweighs favorable response
 Allergies: Important to determine if patient has any
allergy to Amino acid or fat emulsions, corn or corn
products, eggs, soybeans and any drug allergies.
 Liver disease, kidney or heart failure
 Pregnancy
 Diabetes
 Unsafe environment or caregiver ability.

9. Protein
 Protein is considered the premiere macronutrient in PN solution.
 Protein is provided in PN solutions by the addition of crystalline
amino acids.
 The human body contains an estimated 10,000 to 50,000 different
types of proteins, all with a special function.
 Proteins are essential to cell function and structure.
 Proteins act as building blocks for muscles, tendons, enzymes,
hormones, and antibodies.
 A patient’s estimated protein requirement depends on age, level of
activity, nutritional status, renal function, hepatic function, and
presence or absence of hypermetabolism or stress.
 The daily protein requirement in healthy adults is 0.8g/Kg.
 During periods of stress , injury or infection, patients require an
increased amount of protein in the PN.

10. Amino Acids
Amino acids are classified either as essential or
nonessential amino acids.
Essential amino acids: Histidine, Isoleucine, Leucine,
Lysine, Methionine, Phenylalanine, Threonine, Valine
Nonessential amino acids: Alanine, Arginine, Asparagine,
Aspartic acid, Cysteine, Glumatic acid, Glutamine, Glycine,
Proline, Serine, Tyrosine

11. Carbohydrates
 Carbohydrates serve as the prime energy source and
provide 45% to 65% of daily energy needs.
 Nearly all dietary carbs are broken down into glucose
and oxidized for energy.
 They are classified as either simple or complex.
 The basic unit of carbohydrate metabolism in humans is
glucose.
 Each gram of carbohydrate provides 4 kcal of energy.

12. Lipids
 Fat emulsions are needed to prevent essential fatty acid
deficiency.
 Fat is the most calorically dense nutrient in PN
(approximately 9 kcal per gram) providing more than
twice the caloric density of carbohydrate and protein.
 They are composed of triglycerides, sterols, and
phospholipids.
 Their functions include insulation and support of organs;
precursors for steroid hormones, prostaglandin and
thromboxane; and carriers of essential nutrients such as
fat-soluable vitamins.
 Lipids may be ordered daily or on certain days of the
week in quantities sufficient to prevent essential fatty
acid deficiency.

13. Water
 The body consists of 50% to 60% water.
 The average healthy adult requires 2 to 3 L of fluid per day.
 Individual fluid requirements vary greatly and can fluctuate daily,
therefore accurate patient I&O records and weights are invaluable
in determining fluid requirements.
 Fluids are lost through the kidneys, lungs, bowel and skin.
 It is important to consider the patient’s cardiac, respiratory, and
renal status. Critically ill patients can easily become fluid
overloaded.
 Estimates of fluid maintenance requirements can be obtained
from body surface area (BSA).
 Continual assessment of the patient’s hydration status must be
taken during PN therapy.
 Monitoring hydration includes measuring daily I & O; assessing
for signs of cardiac, respiratory, and renal compromise; observing
for rapid weight changes; evaluating peripheral edema; and

14. Electrolytes
 Electrolytes play a critical role in almost all of the body’s
physiological functions.
 Electrolytes commonly used in a PN formula include
sodium, potassium, calcium, magnesium, chloride and
phosphorous.
 Electrolytes are included in the formula to meet daily
requirements and to correct any deficits.
 The management of electrolytes for patients can be one
of the most time-consuming aspects of monitoring and
managing nutritional support.
 It is very important to recognize the signs and smptoms
of deficiency.

15.  Vitamin A (retinol)
 Vitamin D
 Vitamin E (tocopherol)
 Vitamin K
*vitamins are only stable
at room temperature for
24 hours so they are
added to the PN solution
at the time of infusion.
 Vitamin B1 (thiamine)
 Vitamin B2 (riboflavin)
 Pantothenic acid
 Vitamin B6 (pyridoxine)
 Vitamin B12
(cyanocobalamin)
 Biotin, Niacin, Folic
acid, and
 Vitamin C (ascorbic
acid)
Fat Soluble
Vitamins
Water Soluble Vitamins

16. Trace Elements
 Copper
 Chromium
 Manganese
 Selenium
 Zinc
 Trace element requirements vary by age
 Some trace elements are added at the time of the
infusion due to stability

17. Additives to TPN
 Some medications are added to the PN solution at time
of administration due to decreased stability.
 Examples of common additives include, but are not
limited to:
 Insulin
 Famotadine
 Carnatine
 Vitamins
 Trace Elements
Plus any other additives deemed necessary by the
Physician or Pharmacist according to the patient’s
condition.

18.  Solutions should be compounded in a pharmacy using a
laminar flow hood to ensure sterility.
 Solutions should be refrigerated and removed 60
minutes before administration to minimize patient
discomfort from administration of chilled solution.
 Solutions must be infused or discarded within 24 hours
after hanging to minimize the risk of bacterial
contamination.