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PRESENTED BY: IRFAN AHMED
PHARM.D 4TH PROF.
AKHTAR SAEED COLLEGE OF PHARMACEUTICAL SCIENCES
Components of TPN
Ordering and administration
Special considerations during preparations
In 1960s Drs. Wilmore and Dudrick researched on central venous for growth
in infant, elderly patients with catabolic medical conditions Originally
Replaced with TPN, which is more descriptive of the technique
IV administration of calories, nitrogen and all other nutrients in sufficient quantities to achieve tissue synthesis and
Peripheral Parenteral Nutrition
Nutrients are supplied via a peripheral vein, usually a vein in the arm. Another term for PPN is peripheral venous
PVN is used when a patient is unable to ingest adequate calories enterally or when central venous nutrition is not
4.25% amino acid+ 10% dextrose
IV fat emulsion should be run simultaneously with the PVN to minimize thrombophlebitis
THE GOLDEN RULE OF 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) .
Indicated when adequate nutrition cannot be maintained via GIT. Carcinoma
Geriatric refuse to eat
Young anorexic patients
Surgical patients who should not be fed orally
GIT motility disorder
Severe vomiting, when enteral feeding cannot
Components of TPN and their calculations
Carbohydrate as dextrose (3.4 kcal/g)
Protein as amino acids (4 kcal/g)
lipids (10-11 kcal/g)
Components of TPN
Dextrose and lipids to provide energy.
70%-85% of calories from dextrose
Protein for tissue synthesis and repair.
15%-30% from lipids
Determine the appropriate amount of calories needed for the patient by
assessing height, weight, ideal body weight and % of weight loss
Calculation of patient requirements calculated using Harris-Benedict
= 66.67+ (13.75 x weight in kg) + (5 x height in cm) - (6.76x age)
DESIGNING THE TPN FORMULA
Estimate Basal Energy Expenditure (BEE).
For women the formula is:
= 655.1 + (9.56 * weight in kg) + (1.86 * height in cm) - (4.68 x age)
Total Daily Expenditure(TDE)
non-stressed (ambulatory)- 30 kcal/kg body weight
mild stress (malnourished)- 35-40kcal/kg body weight
severe injury or sepsis- 45-60kcal/kg body weight
severe burns- up to 80kcal/kg body weight
infants up to 200kcal/kg body weight
INSOLUBLE AND UNDIGESTED IN BLOOD.
Protein- requirements usually estimated empirically.
non-stressed 0.5-1g/kg mild stress 1.2-1.4 g/kg
moderate stress 1.5-2.0g/kg
severe stress 2.0-2.5g/kg
EAA (40%) and
available as 3-15% solutions
Protein is provided as a crystalline amino acid solution. 500 ml bottles are
Solutions vary in amino acid concentration and amino acid composition
Intra venous lipids
Only O/W emulsions can be given by IV.
After 2 weeks of TPN
Dry scaly skin, hair loss, impaired wound healing
Fat provides 9 kcal/g
soybean (50% linoleic)
egg yolk phospholipid
Actions Indications Dosage Drug
Fatty acids in
form used as
a source of
to reverse a
d by scaly
the first 15-30
2-3 ml/min if
500 ml (50
gm) first 24
hrs, in no
day. Do not
Do not add
Intravenous lipids have the highest caloric density of any components of
Intralipid is composed of soybean oil, egg yolk phospholipids, and glycerol.
The major fatty acids are linoleic 54%, oleic 26%, palmitic 9% and linolenic
If a patient has been on TPN for 2 weeks
Dry Scaly Skin,
Impaired Wound healing.
Soybean-oil emulsion (Intralipid) Safflower-oil emulsion (Liposyn)
Recommended Daily Adult Doses of
Parenteral Trace Elements
Trace Element Dose
Zinc 2.5-4.0 mg
Copper 0.5-1.5 mg
Chromium 10-15 ug
Manganese 150-800 ug
Selenium 40-80 ug
A 8000 U
D 800 U
E 4 U
Niacin 80 mg
B1[Thiamine] 40 mg
B2[Riboflavin] 8 mg
C 400 mg
Folic acid 2 mg
Vitamin K & . Vitamin B12
Vitamin K 10 mg week-1
Vitamin B12 100 g week-1
Warm to room temp 1 hr prior to use
Hang TPN alone
Dextrose concentration > 10%
given through a central line
Change TPN bag and filter every 24 hours
Ordering and Mixing PN Solutions
The physician writes the Rx TPN prescription.
The pharmacist mixes the TPN solution using aseptic technique.
Prescriptions are compounded by mixing the solutions at a 1:1 dextrose-to-
amino acid ratio and placing in 1-L bags. Alternatively, lipids can be mixed
with the dextrose/amino acid solution, referred to as the 3-in-1 total
nutrient admixture (TNA).
TPN should always be given via an infusion pump.
The pharmacist may be consulted regarding drug compatibility for
simultaneous administration of two or more drugs through a single lumen of
Avoid the administration of blood products into the lumen designated for
When parenteral nutrition infusion is being cycled, a heparin flush is
needed to maintain patency of central venous catheter when solution is
TPN infusion should start slowly so that the body has time to adapt to both the glucose
load and the hyperosmolarity of the solution, and to avoid fluid overload.
A pump controls the infusion rate of the TPN solution.
There are specific steps in the inititiation procedure to follow regarding the initiation of
Electronic ambulatory infusion pumps are commonly used in the home setting.
These pumps are lightweight and portable and can be programmed to deliver
continuous infusions, intermittent infusions or single dose medications.
Many pumps have the capacity to taper the rate of an infusion.
Multichannel pumps allow for the administration of several different infusions at one time
General PN Initiation Procedures
Start with 1 L of TPN solution during the first 24 hours (42 mL/hr as a start rate)
Increase volume by 1 liter each day until the desired volume is reached
Monitor blood glucose and electrolytes closely
Pump administer TPN at a steady rate
Don't attempt to catch up if administration gets behind
Continuous vs. Cyclic TPN
the patient is fed at night.
Cyclic TPN helps prevent hepatotoxicity that can develop with long-term TPN
and the fasting period allows essential fatty acids to be released from fat
SPECAIL CONSIDERATIONS DURING
Mechanics of Administering
Titrate up slowly to allow pancreas to adapt to hypertonic dextrose load
Give 1/3 of max rate on day 1, 2/3 on day 2 and full infusion on day 3
Taper to allow pancreas to adapt to withdrawal of hypertonic dextrose
Infuse D10 if TPN abruptly discontinued
Use filters (0.22 m).
Fat can’t run through filters
The clean room is a limited-access area, which is separated from the other pharmacy
to minimize the potential for contamination. All products are prepared using the Class 100
laminar flow cabinets
IV Admixture Environment
To provide sterility and pyrogen-free, proper environment is a must
Prepare admixture under laminar-flow filter
Air filter through High Efficiency Particulate Air (HEPA) flowing at 90fpm and
remove 99.97% particles of 3 m.
Air flow either horizontal or vertical
HEPA filter must be replace every 6 months
Technician or operators must wash hands, gloved and require gowning
Temperature and pH:
Temperatures below freezing or above room temperature may result in destabilization of
the lipid emulsion.
pH below 5.3 or the addition of additives with a pH of 5.0 may also destabilize the emulsion.
Temperature & calcium-phosphorus stability.
As the temperature increases, there is an increase in the rate of dissociation of calcium and
phosphorus from their salts. This allows more free calcium and phosphorus to be
The American Society of Enteral and Parenteral Nutrition (ASPEN) addressed the issue of
standard labeling for PN solutions in its recent guidelines. Labels for PN admixtures should
include amount per day of base formula, electrolyte additives, micronutrients and
medications, quantity per liter for those who admix in 1L volumes, and dosing weight.
Auxiliary labels may be helpful when PN orders are written in a different format than the
Storage and Packaging
TPN solutions should always be transported and stored under controlled-temperature refrigeration.
TPN solutions are delivered from the pharmacy to the patient’s home, a cooler with cooler
blocks should be used.
Refrigerators should be checked to make sure the temperature is constant and that adequate
space is available for storing PN solutions and supplies.
Use of a filter during the administration of PN solutions may prevent complications arising from
any particulate matter, microprecipitates or microorganisms potentially present.
A 0.2 -1.2-m filter should be used for TPN solutions with amino acids and dextrose.
Filters should be replaced every 24 hours.
A clogged filter, indicates some type of problem with the TPN solution, such as contamination
of the solution, precipitation, cracking or incompatibilities
Blood work must be drawn to establish baseline lab values, which include:
CBC + differential,
carbon dioxide, and
total protein Thereafter, monitoring can be performed 2-3 times per week.
other include body weight and temperature.
Monitoring of the TPN Patient
Acute condition, unstable patient, early
Electrolytes, BUN, SCr: 3-7 times per week
Calcium, magnesium, phosphate: 1-3 times per week
LFT’s, TP, ALB: once weekly or every other week
Triglycerides: weekely or as appropriate for IV fat emulsion use.
Stable hospitalized patient,
prolonged parenteral nutrition support
Electrolytes, BUN, SCr: 1-3 times per week
Calcium, magnesium, phosphate: once weekly or every other week
LFT’s TP, ALB: every 2-4 weeks
CBC/ differential, PLC RBC indices: every 2-4 weeks
Drug incompatibilities, drug-nutrient interactions and destabilization of
lipids can all adversely affect the stability of parenteral nutrition solutions.
Medications that are incompatible with Parenteral nutrition solutions:
2. Amphotericin B
Antagonistic and synergistic effect
Penicillin and cortisone antagonize heparin leading to anticoagulant
An increase in amino acid concentration will decrease Theophylline level
Anticoagulants drugs are used in TPN in order to reduce or prevent any
tendency toward intravascular or in cardiac clotting
Changes from clear to cloudy, Emitting of gas
Change in pH can change solubility
Antibiotics can remain active in 24 hours at the pH of 6.5, but at pH 3.5 it will be destroy.
Potassium Penicillin G buffered at pH 6.0-6.5, when added to dextrose, water or NaCl injection it
must also be at buffer 6.0-6.5 to assure activity of antibiotic
MINIMIZATION OF INCOMPATIBILITIES
MAKE THEM AWARE
Hospital pharmacy by nadeem irfan bukhari