Total Parenteral

Nutrition
(TPN)
 Parenteral Nutrition

Feeding a person
Intravenously –
bypassing
Usual process of
Eating and digestion

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 Parenteral Nutrition

• Components are in elemental or “pre-

digested” form
– Protein as amino acids

– CHO as dextrose (Macronutrients)

– Fat as lipid emulsion

– Electrolytes, vitamins and minerals

(micronutrients)
 Parenteral Nutrition
• Delivery of nutrients intravenously, e.g. via
the bloodstream.
– Central Parenteral Nutrition: often called Total
Parenteral Nutrition (TPN)/hyperalimentation;
delivered into a central vein
– Peripheral Parenteral Nutrition (PPN):
delivered into a smaller or peripheral vein
 Indications for PN
• When Specialized Nutrition Support (SNS) is indicated,
EN should generally be used in preference to PN.
• When SNS is indicated, PN should be used when the
gastrointestinal tract is not functional or cannot be
accessed and in patients who cannot be adequately
nourished by oral diets or EN. The anticipated
duration of PN should be >7 days

ASPEN Board of Directors. JPEN 26;19SA, 2002.; ASPEN Nutrition Support Practice
Manual, 2005, p. 108
 Conditions That Require Other
Nutrition Support
• Enteral

—Impaired ingestion

—Inability to consume adequate nutrition orally

—Impaired digestion, absorption, metabolism

—Severe wasting or depressed growth

• Parenteral

—Gastrointestinal incompetency

—Hypermetabolic state with poor enteral tolerance or

accessibility
Conditions That Often Require
Nutritional Support –cont’d
 Indications for Total Parenteral Nutrition

• GI non functioning

• NPO (nothing per orem) >5 days

• GI fistula (abnormal opening)

• Acute pancreatitis

• Short bowel syndrome

• Malnutrition with >10% to 15 % weight loss

• Nutritional needs not met; patient refuses food

 Contraindications

• Functional and accessible GI tract

• Patient is taking oral diet

• Prognosis does not warrant aggressive

nutrition support
• Risk exceeds benefit

• Patient expected to meet needs within 14 days

 Advantages—Parenteral Nutrition

• Provides nutrients when less than

2 to 3 feet of small intestine remains

• Allows nutrition support when GI intolerance

prevents oral or enteral support

 Key Questions When Designing
TPN
• When designing a TPN solution, you need to consider

these questions:

• 1. What is the patient’s energy need? (Kcal required/day)

• 2. How much protein/nitrogen does the patient need in a

day?

• 3. How much fluid can the patient tolerate and need?

• 4. How much fat emulsion can be given/tolerated?

• 5. How much dextrose is needed? Dextrose

concentration?

• 6. Which electrolytes are needed and how much?

– Which vitamins and mineral are needed and how much?

– What is the osmolality of the solution?

– What is the route of feeding used?

 Energy Source (Kcal) and
Recommended Intake
• Carbohydrate

• Source: Monohydrous dextrose

• Properties: Nitrogen sparing
• Energy source

3.4 Kcal/g
Recommended intake:
2 – 5 mg/kg/min
50-65% of total calories
 Energy Source (Kcal) and
Recommended Intake
• Amino Acids / Protein
• Source: Crystalline amino acids—Standard or specialty
• Properties:
EAA 40–50% NEAA 50-60% , Glutamine / Cysteine
o Energy Source

4.0 Kcal/g
• Recommended intake:
0.8-2.0 g/kg/day , 15-20% of total calories
To determine protein needs, a nonprotein kcalorie to nitrogen ratio of 80:1 to 150:1 is
used
• 80:1 (the most severely stressed patients)
• 100:1 (severely stressed patients)
• 150:1 (unstressed patient)
 Energy Source (Kcal) and
Recommended Intake
• Lipids

• Source: Safflower and/or soybean oil

• Properties: Long chain triglycerides, Isotonic or hypotonic, Stabilized

emulsions

Energy Source

10 Kcals/g

Prevents essential fatty acid deficiency

• Recommended intake: 0.5 – 1.5 g/kg/day (not >2.5 g/kg)

12 – 24 hour infusion rate
 Determine Energy Needs

• Two methods

• In-Direct Calorimetry method

• = Basal Energy Expenditure x activity factor x stress factor.

• Kcals per kilogram body weight according to weight and activity classification.

• Estimate energy needs (kcals) using BEE x AF x IF

• BEE = 1000 kcals

AF=1.2

IF = 1.2

• Energy needs = 1000 x 1.2 x 1.2 = 1440 kcal/day

Activity Factor (AF) Injury Factor (IF)
Bedrest 1.2 Minor Surgery 1.1
Ambulatory 1.3 Major surgery 1.1 - 1.2
Mild infection 1.0 - 1.2
Anabolic Factor Mod. infection 1.2 - 1.4
Mild wieght loss 1.05 Severe infection 1.4 - 1.8
Mod. weight loss 1.10 Skeletal trauma 1.2 - 1.35
Severe weight loss 1.15 Blunt trauma 1.15 - 1.35
Head trauma 1.4
Head trauma* 1.6
< 20% BSA burns 1.0 - 1.5
20 - 40% BSA burns 1.5 - 1.85
> 40% BSA burns 1.85 - 1.95
• Activity Levels Defined:

• 1. Sedentary: confined to chair or bedrest

• 2. Light: Mostly seated or standing, with arm movements

• 3. Moderate: Frequent movements involving arms and

legs, walking briskly

• 4. Marked: Walking uphill, activities requiring intermittent

but frequent spurts of energy.
 Non-Stressed Patients Stressed Patients

Activity Level* Health Status kcal/kg

Weight Status

1 2 3 4

Basal energy needs 25 - 30

Overweight 20 25 30 35

Normal weight 25 30 35 40 Ambulatory (st. maintenance) 30 - 35

Malnutrition with mild stress 40

Underweight 30 35 40 45
Severe injuries / sepsis 50 - 60
Extensive burns 80
 Harris Benedict Equation

• The Harris Beneditc Equation (HBE) is one of over 200 equations

for estimating basal energy expenditure (BEE). The HBE is a
regression equation taking into consideration gender, height, weight
and age.

• Men

• BEE (kcal/d) = 66.5 + (13.8 x W) + (5.0 x H) - (6.8 x A)

• Women

• BEE (kcal/d) = 655.1 + (9.1 x W) + (1.8 x H) - (4.7 x A)

• Where W = weight in kg

• and H = height in cm
• Male; W=60 kg; H=150 cm; A=30 years
• BEE (kcal/d) = 66.5 + (13.8 x 60) + (5.0 x
150) - 6.8 x 30)
• 66.5 + 828 + 750 - 204 = 1440
• Normal need: 25-30 Kcal/kg/day
• Elective surgery: 28-30 kcal/kg/day
• Severe injury: 30-40 kcal/kg/day
• Extensive trauma/burn: 45-55 kcal/kg/day
 Determine Fluid needs

• 100 ml for first 10 Kg = 1000mL

• 50mL for next 10 Kg = 500 mL

• 20mL per Kg for each additional Kg

• = 65 – 20 = 45 Kg

• = 45 x 20 = 900

• = 900 + 1500 = 2400 mL

 Determining Protein Needs

• Patient protein needs is determined by multiplying IBW in

kilograms by a factor appropriate for the patient's condition
• IBW: 120lb; 54.5 kg (120/2.2)
Moderate stress (factor = 1.5 from chart)
• 54.5 kg x 1.5 g/kg = 81.75 (82) grams of protein/day

• Or usually it is calculated with a range 0.83gm/Kg - 2.5gm/Kg –

for malnourished – 1.2gm/Kg
• About 22 non-protein kcal/kg are needed for every 1 gram
protein/kg in order to promote protein utilization.
Adults Pediatrics
Requirement* Requirement*
Health States Age (y)
g/Kg Normal Stressed
Normal 0.8 - 1.0 0.0 - 0.5 2.0 2.2 - 3.0
Moderately
stressed
(infarction, 1.0 - 2.0 0.5 - 1.0 1.6 1.6 - 3.0
fracture,
surgery)
Severely
Stressed
2.0 - 2.5 1-3 1.2 1.2 - 3.0
(burns, multiple
fractures)
Renal Disease 4-6 1.1 1.1 - 3.0
Predialysis 0.6 - 0.8 7 - 10 1.0 1.0 - 2.5
Hemodialysis 1.1 - 1.4 11 - 14 1.0 1.0 - 2.5
Peritoneal
1.2 - 1.5 15 - 24 0.85 1.0 - 2.5
dialysis
• The non-protein energy to N ratio is based on the premise that

sufficient energy must be ingested before protein will be used

for tissue maintenance and repair. The ratio of 100-150 Kcal: 1
gm N in stressful condition promote anabolism and 250-300
Kcal: 1 gm N is adequate for normal body maintenance.

• If your 50 Kg patient needs 1500 Kcal and you want an

Energy:N ratio of 150:1, how many grams of N are you going

to need? 1500 Kcal ¸ 150 Kcal/gm N = 10 gm N
 Calculating Protein Content

• To calculate the grams of proteins supplied by a TPN solution

• Multiply the total volume of amino acid solution (ml) supplied
in a day by amino acid conc.
For example
1000mL of 8% amino acids
= 1000 x 8g / 100mL = 80g
Calculation of Dextrose content

o To determine Kcal from dextrose solution in TPN

o First calculate grams of dextrose

o = 1000mL of D50W

o = 1000 x 50 / 100 = 500g

o There are 3.4 Kcal per gram of dextrose

To get Kcal supplied by dextrose in a day

= 500g x 3.4 kcal/g = 1700Kcal
 Calculation of Lipid Content

• Lipid emulsion

Contain glycerol not pure fat (9 Kcal per g)

• To calculate Kcal provided by lipid

multiply the volume of 10% lipid in mL by 1.1

= 500mL of 10% lipid, 500mL x 1.1 Kcal/mL = 550Kcal
multiply volume of 20% lipid in mL by 2
= 500mL of 20% lipid, 500mL x 2 Kcal/mL = 1000Kcal
 Order of Mixing

• 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
Calculation of Nitrogen Balance

• Steps to Calculate Nitrogen Balance

1 Determine nitrogen lost in urine by a 24 hour urinary urea nitrogen test.

2 Add 4* to the UUN to account for non-urinary losses of nitrogen.

3 Determine nitrogen intake by dividing the daily protein intake by 6.25

4 N-bal = value from #3 - value from #2

5 * 4 g is used to estimate the nitrogen losses from non-urine sources

(sweat feces, etc.)

• Protein intake: 90 g
24 hour UUN: 20 g N
• 20 + 4 = 24 g N (total output)
N intake = 90 / 6.25 = 14.4 g N
• N-balance = 14 - 24 = -10 g N

• This person is losing 10 x 6.25 = 62.5 g protein

per day.
• If the nitrogen balance is 0, the person is
consuming the correct amount of protein for
maintenance.
• If the nitrogen balance is negative, increase
the protein intake by a factor determined by
multiplying the nitrogen balance figure by
6.25.
 Osmolarity Calculation for a
TPN solution:

1. Multiply the grams of dextrose per liter by 5.

Example: 50 g of dextrose x 5 = 250 mOsm/L

2. Multiply the grams of protein per liter by 10.

Example: 30 g of protein x 10 = 300 mOsm/L

3. Fat is isotonic and does not contribute to osmolarity.

4. Electrolytes further add to osmolarity.

Total osmolarity = 250 + 300 = 500 mOsm/L

Osmolarity (mOsm/L) = (grams dextrose / liter) x 5] + [grams
amino acid / liter) x 10] + [(mEq cations / liter) x 2]
• Electrolytes should be calculated based on
the individual needs (lab values) and standard
guidelines.
• Suggested electrolyte requirements/1000 Kcal
are: Na 40-50 mEq; K 40 mEq; Mg 8-12 mEq;
Ca 2-5 mEq and Phosphates 15-25 mM.
 Calculation of Calories
• Nutritional energy values are measured in Kcal
 Example - 1
• How many calories are represented in 1 Liter solution containing 20%
dextrose, 12.5% protein and 5% fat.

• 1000 x 0.125 = 125 g of protein

• 1000 x 0.20 = 200 g of dextrose

• 1000 x 0.05 = 50 g of fats

• Find Kcal

• = 125 x 4.10 = 512.5 Kcal

• = 200 x 3.4 = 680 Kcal

• = 50 x 9 = 450 Kcal
 Nitrogen
• Essential component of every tissue and organ
• Required for protein synthesis
• 1 gram of nitrogen is contained in 6.25 g of
protein or amino acids
• Grams of Nitrogen = grams of proteins in a
solution / 6.25
 Calorie : Nitrogen ratio

• Calculated by dividing total non-nitrogen

calories with grams of nitrogen being
provided.
• Opitmum ratio is between 100 – 200 non-
nitrogen calories per gram of nitrogen
 Example - 1
• Calculate Calorie:Nitrogen ratio of a TPN solution
consisting of 500mL of 50% dextrose and 500mL of
8.5% amino acid solution
• Non-protein calorie = 500 x 0.5 x 3.4 = 850 Kcal
• Grams of amino acid = 500 x 0.085 = 42.5 g
• Grams of nitrogen = 42.5 / 6.25 = 6.8 g
• Ratio of non-protein calorie to grams of nitrogen
• = 850 / 6.8 N = 125:1