Lecture Presentation in Basic Intravenous Therapy Seminar regards anothe type of IV fluid the TPN, nutrition in this regard given intravenously, how to go about, the considerations and precautions in giving TPN

1. BASIC INTRAVENOUS THERAPY TRAINING PROGRAM TOTAL PARENTERAL NUTRITION (TPN) Solutions Used in TPN

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14. PARENTERAL NUTRITION Hill et. al. (1977) Lancet 1: 687

27. PARENTERAL NUTRITION < 70% 70 – 79% 80 – 90% % ideal body weight anergy reactive reactive Cell – mediated immunity < 800 800 - 1199 1200 - 2000 Total lymphocyte count, mm 3 > 10% over 6 months > 7.5% over 3 months > 5% over 1 month Weight loss < 100 100 - 149 150 - 200 Transferrin, mg/dL < 2.1 2.1 – 2.7 2.8 – 3.4 Albumin, g/dL < 80% 80 – 89% 90 – 95% % usual body weight Severe Moderate Mild PROTEIN – CALORIE DEFICIENCY

33. PARENTERAL NUTRITION Bistrian BR, et.al. Cellular Immunity in semi-starved states in hospitalized adults. Am. J. Clin. Nutr. 1975; 28: 1148 Elwyn DH. Nutrional Requirements of Adult Surgical Patients: Crical Care Medicine 1980; Vol. 8, No. 1: 9-20 Lee HA. Methods of Assessment IN: Johnston IDA and Lee HA, eds Development in Clical Nutrion Tunbridge Wells. MCS Consultants 1979; 75-78 800 – 1200 /mm Moderate malnutrition < 800 /mm 1200 – 2000 /mm Severe malnutrition Mild malnutrition TOTAL LYMPHOCYTE COUNT 16 - 20 12 - 16 8 - 12 Nitrogen (gms) 2000 – 3000 2000 - 2500 1500 - 2000 Energy (kcals) Highly increased Moderately increased Normal Total Daily Body Requirement GUIDELINES TO ENERGY AND NITROGEN REQUIREMENTS

40. PARENTERAL NUTRITION = 110 – 120 kcal/kgDBW/day 1. Infants 45.0 heavy 40.0 moderate 35.0 light 30.0 sedentary 27.5 bed rest Kcal/kgDBW/day Activity Level: Kraus Method 4. Adults: * Average for both sexes = 50 kcals/kgDBW/day 45 50 16 – 19 years old 50 55 13 – 15 years old Girls Boys 3. Adolescents: = 1000 + (100 x age, years) 2. Children ACTIVITY FACTORS

41. PARENTERAL NUTRITION 1.30 – 1.80 Pancreatitis 1.30 – 1.55 Liver Failure 1.30 Acute Renal Failure 1.30 – 1.55 - with major operation 1.20 – 1.30 - with dialysis or sepsis 0.80 – 1.00 - without sepsis Cardiopulmonary Disease 1.20 – 1.30 Bone Marrow transplant 1.30 – 1.35 ARDS or Sepsis 1.05 – 1.25 Peritonitis or other infections 1.00 – 1.10 Elective Surgery 0.80 – 1.00 Starvation Stress Factor Clinical Conditions: DISEASE STRESS FACTORS

42. PARENTERAL NUTRITION Liver failure Severe burn 45 kcals/kgDBW/day Severe Stress Sever infection Fracture 35 kcals/kgDBW/day Moderate Stress Mild infection Elective surgery 25 kcals/kgDBW/day Mild Stress Examples Energy Requirement Simplified Estimate DAILY ENERGY EXPENDITURE

46. PARENTERAL NUTRITION * Rice another food group added by FNRI 100 - 2 23 80 ½ cup *RICE 45 5 - - 5 1 tsp Fat 55 75 3 3 7 7 - - 30 30 1 ounce 1 ounce Meat, low fat Meat,med fat 70 - 2 15 varies Bread 40 - - 10 varies Fruit 25 - 2 5 100 ½ cup Vegetables 80 179 - 10 8 8 12 12 240 240 1 cup 1 cup Milk, non-fat Milk, whole Energy (kcal) Fat (gm) Protein (gm) Carbohydrate (gm) Weight (gm) Measure Food Exchange COMPOSITION OF FOOD EXCHANGE LIST

54. PARENTERAL NUTRITION 20.0 – 120.0 150.0 – 300.0 Molybdenum, μ g 15.0 – 30.0 50.0 – 200.0 Chromium, μ g 2.0 – 5.0 2.0 – 5.0 Manganese, mg 0.15 0.15 Iodine, mg 0.3 – 0.5 2.0 – 3.0 Copper, mg 3.0 – 12.0 15.0 Zinc, mg 1.0 – 2.0 10 Iron, mg 0.3 0.3 Magnesium, gm 3.0 – 4.0 2.0 – 3.0 Chloride, gm 1.0 – 3.0 1.0 – 3.0 Sodium, gm 3.0 – 4.0 2.0 – 5.0 Potassium, gm 0.4 – 0.8 0.8 – 1.2 Phosphorus, gm 0.2 – 0.4 0.8 – 1.2 Calcium, gm 2.0 – 4.0 1.0 – 2.0 Essential fatty acids, % kcal Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL

55. PARENTERAL NUTRITION 200.0 70.0 – 140.0 Vitamin K, μ g 10.0 – 15.0 8.0 – 10.0 Vitamin E, mg 5.0 – 10.0 10.0 Vitamin D, μ g 1000.0 1000.0 Vitamin A, μ g 3.0 3.0 Cobalamin, μ g (Vit B12) 400.0 400.0 Folic acid, μ g 4.0 2.0 Pyridoxine, mg (Vit B6) 15.0 5.0 Panthotenic acid, mg 60.0 60.0 Biotin, μ g (Vit H) 40.0 18.0 Niacin, mg (Nicotinic acid) 3.60 1.60 Riboflavin, mg (Vit B2) 3.0 1.40 Thiamine, mg (Vit B1) 100.0 60.0 Ascorbic Acid, mg (Vit C) 50.0 – 100.0 50.0 – 200.0 Selenium, μ g Parenteral Enteral Daily Requirement, Adult range Nutrients DAILY REQUIREMENT OF FATTY ACIDS, VITAMINS, & MINERAL

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73. The preferred method of delivering TPN is with a medical infusion pump A sterile bag of nutrient solution, between 500 mL and 4 L is provided The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open Feeding schedules vary, but one common regimen ramps up the nutrition over a few hours, levels off the rate for a few hours, and then ramps it down over a few more hours, in order to simulate a normal set of meal times.

80. Intravenous (IV) lines are often placed into a vein in the hand, foot, or scalp of babies who are too sick to get all of their feedings and fluids by mouth. The belly button also has a large vessel that may be used for intravenous fluids. Sometimes a large IV called a central line or PICC line is placed by sterile technique or by surgery to provide long-term, highly concentrated intravenous fluid.

84. SAMPLE REGIMEN FOR PARENTERAL NUTRITION: Osmolality = 720 mosmol/kg water (mmol) Non-protein kcal : Nitrogen = 202 : 1 20 80 35 3.0 7.5 55 65 100 200 9.4 1900 2150 (8.0 μ J) 3040 (9.0 μ J) Total = 9.4 gm N 1 vial Solivito N 10 Vitlipid N Adult 15 100 1100 1100 1000 Intralipid 10% 20 15 15 10 Addiphos 100 400 400 1000 Glucose 10% 20 20 10 KCl 15% 20 13 1.5 5 10 Addamel 55 1.5 2.5 20 50 - 100 9.4 400 650 1000 Vamin 9 gm Zn μ mol Cl P Mg Ca K Na Fat (gm) Glucose (gm) Nitrogen (gm) Non-protein Energy (kcal) Total Energy (kcal) Quantity (ml) Preparations A. PPN – 9 gm Nitrogen, 2200 kcal (1900 non-protein kcal)

85. SAMPLE REGIMEN FOR PARENTERAL NUTRITION: Osmolality = 720 mosmol/kg water (mmol) Non-protein kcal : Nitrogen = 142 : 1 20 135.5 37.5 3.8 8.8 92.5 97.5 100 250 14.1 2000 2375 (8.4 μ J) 3055 (9.9 μ J) Total = 14.1 gm N 1 vial Solivito N 20 Vitlipid N Adult 7.5 100 1000 1000 500 Intralipid 10% 30 22.5 22.5 15 Addiphos 100 400 400 1000 Glucose 10% 40 40 20 KCl 15% 20 13 1.5 5.0 10 Addamel 82.5 2.25 3.75 30 75 - 150 14.1 600 975 1500 Vamin 9 gm Zn μ mol Cl P Mg Ca K Na Fat (gm) Glucose (gm) Nitrogen (gm) Non-protein Energy (kcal) Total Energy (kcal) Quantity (ml) Preparations B. TPN – 9 gm Nitrogen, 2100 kcal (1800 non-protein kcal)

90. Dr. Ronald Sanchez - Magbitang Thank You !