Total parental nutrition

1. Total Parenteral Nutrition
By
Dr Waseem Ashraf
Moderator:-
Dr Rouf Ahmad Wani
Deptt of General Surgery

2. What is TPN?
Parenteral nutrition: process of supplying nutrie
nts via the intravenous route
– Total parenteral nutrition (TPN)
– Peripheral parenteral nutrition (PPN)
TPN may reduce morbidity and mortality after m
ajor surgery, severe burns, and head trauma, es
pecially in patients with sepsis.
TPN is often used in hospital, long term care, an
d sub-acute care, and infrequently is used in the
home care setting.

3. Indications
Patients whose GI tract is not functional.
– e.g. 50% of metabolic needs met for < 7 days
Undernourished patients who cannot ingest large volu
mes of oral feedings and are being prepared for surge
ry, radiation therapy, or chemotherapy.
Disorders requiring complete bowel rest
– Crohn's disease
– ulcerative colitis
– severe pancreatitis
Pediatric GI disorders
– congenital anomalies
– prolonged diarrhea

4. The gut should always be the preferred route for nutrient administrat
ion.
Therefore, parenteral nutrition is indicated generally w
hen there is severe gastro-intestinal dysfunction (p
atients who cannot take sufficient food or feeding form
ulas by the enteral route) .

5. Goals
To decrease the adverse effects of catabolis
m
Support ongoing metabolism
To improve immune function, cardiac and res
piratory function
Maintain glycogen reserve
Maintain acid, base and electrolyte metabolis
m
5

6. Nutritional Content
Water
– 30 to 40 mL/kg/day
Energy
– 30 to 60 kcal/kg/day (depending on energy expenditure)
Amino acids
– 1 to 2.0 g/kg/day (depending on the degree of catabolism)
Essential fatty acids
Vitamins, and minerals
Children who need TPN may have different fluid requireme
nts and need more energy (120 kcal/kg/day) and amino aci
ds (2.5 to 3.5 g/kg/day).

7. Requirements:
Energy
 Basal energy requirements are a function of the individual's
weight, age, gender, activity level and the disease process.
 The estimation of energy requirements for parenteral nutrition r
elies on predictive equations.
 Hospitalized adults require approximately 25-30 kcal/ kgBW/da
y.
 However, these requirements may be greater in patients with inj
ury or infection.

8. Energy Requirements
Patient condition Basal metabolic
rate
Approximate energy
Requirement
(kcal/kg/day)
No postoperative
complications, GIT
fistula without infection
Normal 25-30
Mild peritonitis, long-bone fractur
e, mild to moderate injury, malno
urished
25% above nor
mal
30-35
Severe injury or infection 50% above nor
mal
35-45
Burn 40-100% of total body surf
ace
Up to 100% abo
ve normal
45-80

9. Requirements:
Energy Sources: Glucose
The most common source of parenteral energy supply is glucos
e, being:
 Readily metabolized in most patients,
 provides the obligatory needs of the substrate , thus reducin
g gluconeogenesis and sparing endogenous protein.
 1 gm of glucose gives 4 Kcals.
Most stable patients tolerate rates of 4-5 mg.kg-1.Min-1, but ins
ulin resistance in critically ill patients may lead to hyperglycemia
even at these rates, so insulin should be incorporated acc. to bl
ood sugar levels.

10. Energy Sources: Glucose
 Low calorie value
 Requires large volume
 Hyperglycemia
 More CO2 production
 Thrombophlebitis in conc above 10%
10
Requirements:

11. Requirements:
Energy Sources: Lipid
 Fat mobilization is a major response to stress and infect
ion.
 Triacylglycerols are an important fuel source in those co
nditions, even when glucose availability is adequate.
 Need to be restricted in patients with hypertriglycerid
emia.

12. Requirements:
Energy Sources: Lipid
Lipids are also a source for the essential fatty acid
s which are the building blocks for many of the hor
mones involved in the inflammatory process as wel
l as the hormones regulating other body functions.
Ideally, energy from fat should not exceed 40% of t
he total (usually 20-30%).

13. Requirements:
Energy Sources: Lipid
Fat emulsions can be safely administered via perip
heral veins, provide essential fatty acids, and are c
oncentrated energy sources for fluid-restricted pati
ents.
They are available in 10, 20 and 30% preparations.
Though lipids have a calorific value of 9Kcal/g, the
value in lipid emulsions is 10Kcal/g due to the cont
ents of glycerol and phospholipids.

14. Advantages
Energy Sources: Lipid
high calorie
Prevents hyperglycemia
Less co2 production
Less insulin production
14

15. Disadvantages
Energy Sources: Lipid
 Hypertriglyceridemia
 Sepsis
 Fat embolism
 Fat overload
 Hepatic dysfunction
 pancreatitis
15

16. Requirements:
Nitrogen
 Protein (or amino acids, the building blocks of protei
ns) is the functional and structural component of the
body, so fulfilling patient’s caloric needs with non-pr
otein calories (fat and glucose) is essential.
 Protein requirements for most healthy individuals ar
e 0.8 g/kg/day.

17. Requirements:
Nitrogen
 With disease, poor food intake, and inactivity, body prot
ein is lost with the resultant weakness and muscle mass
wasting.
 Critically ill patients may need as high as 1.5-2.5 g prote
in/kg/day depending on the disease process:
(major trauma or burn > infection or after surgery > standard)
• The amount should be reduced in patients with kidney o
r liver disease.

18. Requirements:
Nitrogen
Daily Protein requirements
Condition Example requirement
Basic requirements Normal person 0.5-1g/Kg
Slightly increased requirem
ents
Post-operative, cancer, inflam
matory
1.5g/Kg
Moderately increased requi
rements
Sepsis, polytrauma 2g/Kg
Highly increased requirem
ents
Peritonitis, burns, 2.5g/Kg
Reduced requirements Renal failure, hepatic enceph
alopathy
0.6g/Kg

19. Requirements:
Nitrogen
Nitrogen Balance =
Protein intake in grams ÷ 6.25 – UUN (in grams) + 3
 The nitrogen lost in urine derives primarily from ami
no acids released by protein breakdown in respons
e to catabolic mediators that include stress hormon
es (corticosteroids, catecholamines) and cytokines.
 It is a way to assess the sufficiency of protein intake
for the patient.

20. Requirements:
Nitrogen
• Parenteral amino acid solutions provide all known esse
ntial amino acids.
• Available a.a. preparations are 3.5 - 15 % (ie contai
ns 3.5-15 gms of protein or a.a.s/100 mL solution).
• 1gm of protein = 0.16 gm of N2.

21. Requirements:
Nitrogen
• Special a.a. solutions are also available containing
higher levels of certain a.a.s, most commonly the br
anched-chain ones (valine, leucine and isoleucine),
aimed at the management of liver diseases, sepsis
and other stress conditions.
• Conversely, solutions containing fewer a.a.s (primar
ily the essential ones) are available for patients with
renal failure.

22. Requirements:
Nitrogen
 Arginine was added to enteral formulae claiming po
sitive effects on immune function and length of hosp
ital stay.
 In some clinical trials, glutamine-enriched solutions i
mproved nitrogen balance and gut morphology.

23. Requirements:
Fluids and electrolytes
• 20–40 mL/kg - daily – young adults
• 30 mL/kg – daily – older adults
• Sodium, potassium, chloride, calcium, magnesium,
and phosphorus ( as per the table)
• Daily lab tests to monitor electrolyte status

24. Requirements:
Fluids and electrolytes
Nutrient Requirements (/Kg/day)
Water 20-40 mL
Sodium 0.5-1.0 mmol
Potassium 0.5-1.0 mmol
Magnesium 0.1-0.2 mmol
Calcium 0.05-0.15mmol
Phosphate 0.2-0.5mmol
Chloride/Acetate So a to maintain acid-base balance (nor
mally 0.5 mmol for Cl- , & 0.1mEq for Acetate)

25. Requirements:
Fluids and electrolytes
• Normalization of acid-base balance is a priority and
constant concern in the management of critically ill
patients.
• Most electrolytes can be safely added to the parent
eral amino acid/dextrose solution.
• Sodium bicarbonate in high concentrations will tend
to generate carbon dioxide at the acidic pH of the a
mino acid/glucose mix.

26. Requirements:
Vitamins
 These requirements are usually met when standard vol
umes of a nutrient mix are provided.
 Increased amounts of vits are usually provided to sever
ely ill patients.
 Vitamins are either fat soluble (A,D,E,K) or water solubl
e (B,C). Separate multivitamin commercial preparations
are now available for both.

27. Requirements:
Vitamins
Multivitamin formulations for parenteral use for adult
patients usually contain 12 vitamins at levels estimate
d to provide daily requirements.
Additional amounts can be provided separately when
indicated.
Most adult vitamin formulae do not contain vitamin K,
which is added according to the patient’s coagulation
status.

28. Requirements:
Trace minerals
 These are essential component of the parenteral n
utrition regimen.
 A multi-element solution is available commercially,
and can be supplemented with individual minerals.
 may be toxic at high doses.
 Iron is excluded, as it alters stability of other ingred
ients. So it is given by separate injection (iv or im).

29. Requirements:
Trace minerals
minerals excreted via the liver, such as copper and
manganese, should be used with caution in patients with
liver disease or impaired biliary function.
Mineral Recommended dietary all
owance (RDA) for daily or
al intake (mg)
Suggested daily intr
avenous intake (mg)
Zinc 15 2.5-5
Copper 2-3 0.5-1.5
Manganese 2.5-5 0.15-0.8
Chromium 0.05-0.2 0.01-0.015
Iron 10 (males)-18 (females) 3

30. Osmolarity:
PPN: Maximum of 900 milliosmoles / liter
TPN: as nutrient dense as necessary (>900
m.osmol and up as high as 3000).
Amino acids (10 m.osmol/gm), dextrose (5 m.
osmol/gm) and electrolytes (2 m.osmol /mEq)
contribute most to the osmolarity, while lipids
give 1.5 m.osmol/gm.

31. The Solution
Manually mixed in hospital pharmacy or nutrit
ion-mixing service
premixed solutions,
Separate administration for every element al
one in a separate line.

32. What to do before starting TPN
 Nutritional Assessment
 Venous access evaluation
 Baseline weight
 Baseline lab investigations

33. Nutritional Assessment
 History
 Physical examination
 Anthropometric measurements
 Laboratory investigations

34. Nutritional Assessment
History
 Dietary history
 Significant weight loss within last 6 months
 > 15% loss of body weight
 compare with ideal weight
 Beware in patient with ascites/ oedema
IBW

35. Physical Examination
• Evidence of muscle wasting
• Depletion of subcutaneous fat
• Peripheral oedema, ascites
• Features of Vitamin deficiency
• eg nail and mucosal changes
• Echymosis and easy bruising
• Easy to detect if >15% loss
Nutritional Assessment

36. Anthropometry
• Weight for Height comparison
• Body Mass Index [BMI <19]
• Triceps-skinfold (index of body fat)
• Mid arm muscle circumference(muscle mass)
• Bioelectric impedance
• Hand grip dynamometry
• Clinical Assessment score(SGA)
score of history and clinical examination
Nutritional Assessment

37. Lab investigations
• albumin < 30 mg/dl
• pre-albumin <12 mg/dl
• transferrin < 150 mmol/l
• total lymphocyte count < 1800 / mm3
• tests reflecting specific nutritional deficits
• eg Prothrombin time
• Skin anergy testing
• Urinary creatinine / height index
Nutritional Assessment

38. 38

39. Special Considerations
 Patients who have renal insufficiency and are
not receiving dialysis or who have liver failure requi
re solutions with reduced protein content and a hig
h percentage of essential amino acids.
 For patients with heart or kidney failure, volume (l
iquid) intake must be limited.
 For patients with respiratory failure, a lipid emulsi
on must provide most of non-protein calories to min
imize CO2 production by carbohydrate metabolism.
 Neonates require lower dextrose concentrations (1
7 to 18%).

40. Venous access
 PPN: (<900 m.osmol/L): a peripheral line can be en
ough.
 TPN: Central venous access is fundamental,
 Ideally, the venous line should he used
 exclusively for parenteral nutrition.
 Catheter can be placed via the subclavian vein, the
jugular vein (less desirable because of the high rate of as
sociated infection), or a long catheter placed in an arm vei
n and threaded into the central venous system (a peripher
ally inserted central catheter line)
 Once the correct position of the catheter has been e
stablished (usually by X ray), the infusion can begin.

41. Venous Access for TPN
Needs venous access to a “large” cent
ral line with fast flow to avoid thrombophle
bitis
• Long peripheral line
• subclavian approach
• internal jugular approach
• external jugular approach
Superior Vena Cava

43. Types of CVC
Single/multi-lumen CVC.
Peripherally inserted central catheters (
PICC lines).
Tunneled catheters.
Implanted venous devices or vascular a
ccess ports.

44. Central Venous Catheters
Catheters used for delivering TPN shoul
d be employed for that sole use.

45. Single/multi-lumen CVC
Usually short term.
Percutaneous insertion using jugular, su
bclavian or femoral routes.
Multi-lumen may have 2,3 or 4 lumens.
Single-lumen catheters are preferred.
Flush after every use.
Dressing change 24 hrs after insertion a
nd then as per policy.

46. Peripherally inserted central catheters (PICC
Lines)
PICC lines are designed to provide ven
ous access for short to long periods req
uiring iv therapy.
Increasing being used for patients recei
ving home care.
Can be established in our wards without
any difficulty.
Lifetime of 4 to 6 weeks.

47. Tunneled CVC
Hickman and Broviac CVC : right atrial c
entral catheters that are surgically insert
ed into the chest.
The catheter is tunneled under the ches
t tissue after it exits the vein so that exit
site is a distance from skin exit site.
For long-term use.

48. Implanted CVC
Port-a-cath : a surgically inserted centra
l line that does not have an external exit
site, uses a subcutaneous port.
Catheter ends in a reservoir that has a r
ubber diaphragm for a top that is implan
ted under the skin.

50. Peripheral Parenteral nutrition
It differs from central TPN in
• composition of feed
• primary caloric source
• potential complications
• method of administration

51. Formulations
Two Types of TPN:
 Solutions with lipids (3-in-1)
 Solutions without lipids (2-in-1)
Advantages of (3-in-1)
 Lower cost of preparation
 Less administration time for nurses
 Potentially reduced risk of sepsis

52. Formulations
Disadvantages to 3-in-1
 Precipitants cannot be seen
 Not stable as long as TPNs without lipids
Expiration date for 2-in-1 is 21 days
Expiration date for 3-in-1 is 7 days
 Can remain at room temperature for 24 ho
urs

53. 53

54. Steps in ordering TPN
Determine Total Fluid Volume
Determine Non-N Caloric needs
Determine Protein requirements
Decide how much fat & carbohy
drate to give
Determine Electrolyte and Trace
element requirements
Determine need for additives

55. Steps in ordering TPN
Determine Total Fluid Volume
Determine Caloric needs
Determine Protein requirements
Decide how much fat & carbohy
drate to give
Determine Electrolyte and Trace
element requirements
Determine need for additives

56. How much volume to give?
Cater for maintenance & on going losse
s
Normal maintenance requirements
 By body weight (25-35 ml/kg/day)
Add on going losses based on I/O char
t
Consider insensible fluid losses also
 e.g. add 10% for every 1oC rise in temperature

57. Steps in ordering TPN
Determine Total Fluid Volume
Determine Non-N Caloric needs
Determine Protein requirements
Decide how much fat & carbohy
drate to give
Determine Electrolyte and Trace
element requirements
Determine need for additives

58. Caloric requirements
Based on Total Energy Expenditure
 Can be estimated using predictive equation
s
TEE = REE + Stress Factor + Activity Factor
 Can be measured using metabolic chart

59. Caloric requirements
REE (BMR) Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W in kg) + (5H in cm) - 6.8Age
Females: REE= 65.5 + (9.6W in kg) + 1.8H in cm - 4.7Age
Schofield Equation
25 to 30 kcal/kg/day

60. Caloric requirements
Stress Factor
•Post op. pat. + 10%
•Malnutrition + 30%
•peritonitis + 15%
•soft tissue trauma +
15%
•fracture+ 20%
•fever (per oC rise) +
13%
•Moderate infection + 20
%
•Severe infection + 40%
•<20% BSA Burns + 50
%
•20-40% BSA Burns + 80
%
•>40% BSA Burns + 100
%

61. Caloric requirements
Activity Factor
Bed-bound + 20%
Ambulant + 30%
Active + 50%

62. How much CHO & Fats?
“Too much of a good thing causes pro
blems”
 Not more than 4 mg / kg / min Dextrose
(less than 6 g / kg / day)
Rosmarin et al, Nutr Clin Pract 1996,11:151-6
 Not more than 0.7 mg / kg / min Lipid
(less than 1 g / kg / day)
Moore & Cerra, 1991

63. How much CHO & Fats?
Fats usually form 25 to 30% of calories
 Not more than 40 to 50%
 Increase usually in severe stress
 Aim for serum TG levels < 350 mg/dl
CHO usually form 70-75 % of calories

64. How much protein to give?
 Based on calorie : nitrogen ratio
 Based on degree of stress & body weig
ht
 Based on Nitrogen Balance

65. How much protein to give?
Calorie : Nitrogen Ratio
Normal ratio is
150 cal : 1g Nitrogen
Critically ill patients
85 to 100 cal : 1 g Nitrogen

66. How much protein to give?
Based on Stress & BW
Condition Example requirement
Basic requirements Normal person 0.5-1g/Kg
Slightly increased requirem
ents
Post-operative, cancer, inflam
matory
1.5g/Kg
Moderately increased requi
rements
Sepsis, polytrauma 2g/Kg
Highly increased requirem
ents
Peritonitis, burns, 2.5g/Kg
Reduced requirements Renal failure, hepatic enceph
alopathy
0.6g/Kg

67. How much protein to give?
Based on Nitrogen Balance
Aim for positive balance of
1.5 to 2g / kg / day

68. Nitrogen Balance
Every gram of negative NB represents l
oss of approx. 30gms of lean muscle m
ass
For daily negative nitrogen balance of 1
0gms/day about 1.5kg of lean muscle m
ass will be lost over a 5 day period

69. Nitrogen Balance
Nitrogen Balance = N input - N output
1 g N = 6.25 g protein
N input = (protein in g / 6.25)
N output = 24h urinary urea nitrogen + no
n-urinary N losses
(estimated normal non-urinary Nitrogen lo
sses about 3-4g/d)

70. Approx. Nitrogen Balance
and lean muscle mass loss
Procedure N-loss Muscle los
s
(gms/day)
Herniotomy 3 90
Appendisectomy 6 180
Cholecystectomy 12 360
Esophagectomy 90 2700
Peritonitis 18 540
Sepsis 24 720

71. Steps to ordering TPN
Determine Total Fluid V
olume
Determine Protein requir
ements
Determine Non-N Calori
c needs
Decide how much fat &
carbohydrate to give
Determine Electrolyte an
d Trace element require
ments
Determine need for addit
ives

72. Electrolyte Requirements
Cater for maintenance + replacement nee
ds
Na+ 1 to 2 mmol/kg/d (or 60-120 meq/d)
K+ 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d)
Mg++ 0.35 to 0.45 meq/kg/d (or 10 to 20
meq /d)
Ca++ 0.2 to 0.3 meq/kg/d (or 10 to 15
meq/d)
PO4
2- 20 to 30 mmol/d

73. Trace Elements
Total requirements not well established
Commercial preparations exist to provide
RDA
 Zn 2-4 mg/day
 Cr 10-15 ug/day
 Cu 0.3 to 0.5 mg/day
 Mn 0.4 to 0.8 mg/day

74. Steps to ordering TPN
Determine Total Fluid V
olume
Determine Protein requir
ements
Determine Non-N Calori
c needs
Decide how much fat &
carbohydrate to give
Determine Electrolyte an
d Trace element require
ments
Determine need for addit
ives

75. Other Additives
Vitamins
 Give 2-3x that recommended for oral intak
e
 use 1 ampoule multivitamin per bag of TPN
 Multivitamin does not include Vitamin K
 can give 1 mg/day or 5-10 mg/wk

76. Other Additives
Medications
 Insulin
 can give s/c initially based on sliding scale
 once stable, give 2/3 total requirements in TPN & review
daily
 alternate regimes
 0.1 u per g dextrose in TPN
 10 u per liter TPN initial dose
 Other medications

78. The Solution
Manually mixed in hospital pharmacy or nutrit
ion-mixing service,
premixed solutions,
Separate administration for every element al
one in a separate line.

79. Caloric content of TPN
Parenteral glucose contains 3.4 kcal/g
Protein contains 4 kcal/g
Lipid contains 9 kcal/g

80. TPN for a 70 kg man
80

81. Example Calculation
For 70 kg man
 Caloric requirement : 30 x 70 = 2100 kcal
 Protein requirement : 1.5 x 70 = 105 g
 Provide 20-30 % of calories as lipid : 2100
x 0.2 = 420 kcal
 Then 420 / 9 = 47 g of lipid
 Calories from amino acid : 105 x4 = 420 kc
al
 Remaining calories : 2100-420-420 = 1260
kcal

82. Example Calculation
Make up the difference with dextrose :
1260 / 3.4 = 370 g dextrose
Final volume :
 Amino acids ( 10% stock solution) :
105g = 1050 ml
• Dextrose (70% stock solution) :
370g = 528 ml
• Lipids (20% stock solution) : 47g =235ml
• Total volume = 1813ml/day

83. Example Water Rx Calculation
Fluid needs for 70kg man :
70 x 30 = 2100 + 600 = 2700
TPN Rx provides 1813 ml fluid per day
2700 ml - 1813 ml = 887 ml additional st
erile water needed

84. 84

85. 85

86. Practice Calculation
You are now ready to order a TPN on 60
kg man with trauma

87. Monitoring for Complications
Malnourished patients at risk for refeeding sy
ndrome should have serum phosphorus, mag
nesium, potassium, and glucose levels monit
ored closely at initiation of SNS. (B)
In patients with diabetes or risk factors for glu
cose intolerance, SNS should be initiated with
a low dextrose infusion rate and blood and uri
ne glucose monitored closely. (C)
Blood glucose should be monitored frequently
upon initiation of SNS, upon any change in in
sulin dose, and until measurements are stabl
e. (B)

88. Monitoring for Complications
Serum electrolytes (sodium, potassium, chlori
de, and bicarbonate) should be monitored fre
quently upon initiation of SNS until measurem
ents are stable. (B)
Patients receiving intravenous fat emulsions s
hould have serum triglyceride levels monitore
d until stable and when changes are made in
the amount of fat administered. (C)
Liver function tests should be monitored perio
dically in patients receiving PN. (A)

89. Acute Inpatient PN Monitoring
Parameter Daily
Frequency
3x/week Weekly
Glucose Initially √
Electrolytes Initially √
Phos, Mg, BUN,
Cr, Ca
Initially √
TG √
Fluid/Is & Os √
Temperature √
T. Bili, LFTs Initially √

90. Inpatient Monitoring PN
Parameter Daily
Frequency
Weekly PRN
Body Weight Initially √
Nitrogen Balance Initially √
HGB, HCT √
Catheter Site √
Lymphocyte Count √ √
Clinical Status

91. Monitor—cont’d
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration (daily)
WBC and differential (as needed)
Cultures (as needed)

92. Monitoring: Nutrition
Serum Hepatic Proteins
Parameter t ½
Albumin 19 days
Transferrin 9 days
Prealbumin 2 – 3 days
Retinol Binding Protein ~12 hours

93. Less than 5%
Technical
Biochemical
Others
93
Complications

94. Complications
Technical
– Air embolism
– Pneumothorax
– bleeding
– Infection
– Arterial puncture
– Catheter displacement
– Sepsis
– blockage

95. Complications
Glucoseabnormalities are common.
– Hyperglycemia can be avoided by monitoring blood
glucose often, adjusting the insulin dose in the TPN
solution and giving subcutaneous insulin
– Hypoglycemia can be precipitated by suddenly disc
ontinuing constant concentrated dextrose infusions.
95

96. Complications
Abnormalities of serumelectrolytes and minerals
– should be corrected by modifying subsequent infu
sions or, if correction is urgently required, by begin
ning appropriate peripheral vein infusions.
– Vitamin and mineral deficiencies are rare if solutio
ns are given correctly. E
– elevated BUN may reflect dehydration, which can
be corrected by giving free water as 5% dextrose
via a peripheral vein.

97. Complications
Volume overload (suggested by > 1 kg/day weight gain)
– may occur when high daily energy requirements require large fluid vo
lumes.
Metabolic bone disease, or bone demineralization (osteoporosis or ost
eomalacia),
– develops in some patients receiving TPN for > 3 mo.
– Mechanism is unknown.
– Advanced disease can cause severe periarticular, lower extremity, a
nd back pain.
– Temporarily or permanently discontinuing TPN is the only known trea
tment.

98. Complications
Adverse reactions to lipidemulsions
 dyspnea, cutaneous allergic reactions, nausea, headache, ba
ck pain, sweating, dizziness
 uncommon but may occur early, particularly if lipids are given
at > 1.0 kcal/ kg/h.
 Temporary hyperlipidemia may occur, particularly in patients
with kidney or liver failure
– treatment is usually not required.
 Delayed adverse reactions to lipid emulsions include hepatom
egaly, mild elevation of liver enzymes, splenomegaly, thrombo
cytopenia, leukopenia, and, especially in premature infants wit
h respiratory distress syndrome, pulmonary function abnormal
ities.
– Temporarily or permanently slowing or stopping lipid emulsion infusio
n may prevent or minimize these adverse reactions.

99. Complications
Hepaticcomplications
– liver dysfunction
– painful hepatomegaly
– hyperammonemia.
– Transient liver dysfunction, evidenced by increased
transaminases, bilirubin, and alkaline phosphatase,
is common with the initiation of TPN.
– Delayed or persistent elevations may result from ex
cess quantities of amino acids.

100. – Contributing factors probably include cholestasis an
d inflammation.
– Progressive fibrosis occasionally develops.
 Reducing protein delivery may help.
– Painful hepatomegaly suggests fat accumulation; c
arbohydrate delivery should be reduced.
– Hyperammonemia can develop in infants.
 Signs include lethargy, twitching, and generalized
seizures. Correction consists of arginine
supplementation at 0.5 to 1.0 mmol/kg/day.
 For infants who develop any hepatic complication
, limiting amino acids to 1.0 g/kg/day may be nec
essary.
100

101. Gallbladder complications
– include cholelithiasis, gallbladder sludge, and cholecystitis.
– These complications can be caused or worsened by prolon
ged gallbladder stasis.
– Stimulating contraction by providing about 20 to 30% of cal
ories as fat and stopping glucose infusion several hours a
day is helpful.
– Oral or enteral intake also helps.
– Treatment with metronidazole, ursodeoxycholic acid, phen
obarbital, or cholecystokinin helps some patients with chole
stasis.
Complications

102. Refeeding Syndrome
Patients at risk are malnourished, partic
ularly marasmic patients
Can occur with enteral or parenteral nut
rition
Results from intracellular electrolyte shif
t

103. Refeeding Syndrome
Reduced serum levels of magnesium, p
otassium, and phosphorus
Hyperglycemia and hyperinsulinemia
Interstitial fluid retention
Cardiac decompensation and arrest

104. Refeeding Syndrome Prevention/Treatment
Monitor and supplement electrolytes, vitamins
and minerals prior to and during infusion of P
N until levels remain stable
Initiate feedings with 15-20 kcal/kg or 1000 kc
als/day and 1.2-1.5 g protein/kg/day
Limit fluid to 800 ml + insensible losses (adjus
t per patient fluid tolerance and status)

105. Defense Against PN Complications
Select appropriate patients to receive PN
Aseptic technique for insertion and site care of IV c
atheters
Do not overfeed
 Maintain glycemic control <150-170 mg/dl
 Limit lipids to 1 gm/kg and monitor TG levels
 Adjust protein based on metabolic demand and organ fu
nction
Monitor fluid/electrolyte/mineral status
Provide standard vitamin and trace element preps
daily

106. Stopping TPN
Stop TPN when enteral feeding can rest
art
Wean slowly to avoid hypoglycemia
 Give IV Dextrose 10% solution at previous
infusion rate for at least 4 to 6h
 Alternatively, wean TPN while introducing
enteral feeding and stop when enteral intak
e meets TEE

107. THANK YOU