Parenteral Nutrition

Review

Esther Lejtman RD LDN, CNSC

Colby Miller Pharm.D., BCPS
Melissa Parson Pharm.D.
Objectives
 Parenteral Nutrition Indications
 Content of Parenteral Nutrition
 Calories, electrolytes, additives, lipid emulsions,
insulin
 Associated laboratory values
 Complications of Parenteral Nutrition
 New form and Orderset
 Updated Policy and Procedure
Definition of Parenteral Nutrition
The administration of complete and
balanced nutrition by intravenous infusion
in order to support anabolism, body weight
maintenance or gain, and nitrogen
balance, when oral or enteral nutrition are
not feasible or are inadequate
Indications for TPN
 Malabsorption syndromes, such as short bowel
syndrome
 Conditions requiring complete bowel rest for
prolonged periods
 Pre and post-operative support in patients with
pre-existing malnutrition, in who GI function is
impaired
 Malignancy undergoing treatment, surgery,
radiation, chemo who are unable to obtain
adequate nutrition by an enteral route
Indications for TPN
 NPO
 Wellnourished patients > 7-10 days
 Moderately malnourished patients > 5 days
 Severely malnourished patients 1-3 days
 High output fistula
 Failed enteral feeding
TPN is generally NOT indicated…
 When an inpatient has a functioning GI
tract
 TPN therapy is expected to be less than 5
days
 Prognosis does not warrant aggressive
nutrition support
TPN
 Can meet 100% of patients needs
 Requires central access and a designated
port for TPN
Indication for PPN
 Alternative to central venous catheterization with
selected patients with limited metabolic
requirements, with suitable peripheral veins who
can tolerate the fluid volume required with
peripheral administration
 Not possible to provide adequate calories by
peripheral route, particularly in critically ill and
hypermetabolic patients
 Greater than 5 days but less than 14 days
PPN
 Uses peripheral vein
 Maximum osmolarity is 900 mOsm/L
 Per policy, limit to 7 days or less
 Higher volume to infuse maximum
nutrients
 Studies do not support usage of PPN vs.
TPN
Osmolarity Calculation
 For PPN- do not exceed 900 mOsm/L
 (Gm of amino acids/ L x 10) +
 (Gm of Dextrose/ L x 5) +
 Sum of mEq of electrolytes x 2
Methods to Estimate Caloric
Requirements
 Various equations exist to determine energy
requirements
 Most take into account gender, age, ht, wt to
determine BEE and are multiplied by activity and
stress factors
 Weight based estimations can also be used
based on severity of illness , in general 20-35
kcals/kg will be appropriate
 The dietitian in his/her assessment will use the
most appropriate formula and stress factor
Protein requirements
 Based on pts baseline nutritional status
and degree of stress/catabolism
 Well nourished with low stress 1-1.2 gm/kg
 Moderate stress 1.2-1.5 gm/kg
 Severe stress 1.5-2.0 gm/kg

If there is renal impairment and pt is not on

dialysis, requirements are lower
Non protein calories
 Adequate calories must be given from a non
protein source to allow the protein to be used for
anabolism
 2/3 of these calories from carbohydrates and 1/3
from fats is generally recommended
1 gm dextrose=3.4 kcals
1 gm protein=4 kcals
1 gm 20%lipids=10 kcals or 2 kcal/ml
Minimal Volume Calculation
 Gm proteinX10
 CHO calories/2.38
 200 ml for electrolytes

example 350 gm CHO (1190 kcals),105 gm

protein=1750 ml volume (73 ml/hr)
Lipid Emulsions
Lipid Emulsions
 250 ml 20% fat emulsion @ 21ml/hr over
12 hours
 Provides 500 kcal and 50g fat
 Good energy source in times of stress
 We no longer offer the 500 ml bag of 20%
lipids or 10% lipids on the new form
Lipid emulsions
 Calories provided by fat should be < 30% of total
calories and <1 gm/kg body weight
 Primarily omega-6 fatty acids (polyunsaturated
fats)
 Can be immunosuppressive when given in excess
 Can be administered via peripheral line
 Contains safflower, soybean oil, glycerin and egg
yolk (watch allergies)
Lipid emulsions
 Hold lipids if TG > 400 mg/dL. If TG
increase to >1000 there is a risk for
pancreatitis

 Propofol is a fat calorie source (1.1

kcal/mL) and should be included in total
daily calories
TPN Standard Additives
 Multivitamin
 Vitamin A 1 mg, vitamin D 5 mcg, vitamin E 10 mg,
vitamin C 200mg, B12 5 mcg, thiamine 6mg, niacin
40mg, pyridoxine 6mg, pantothenic acid 15mg,
riboflavin 3.6mg, folic acid 0.6mg, biotin 60 mcg,
vitamin K 0.15mg
 Vitamin K 0.85mg
 Trace Elements
 Zinc5mg, copper 1mg, manganese 0.5mg,
chromium 10 mcg, selenium 60 mcg
TPN Standard Additives
 When adding additional trace elements or
vitamins to the TPN/PPN (ie Zinc or ascorbic
acid) the amount written in the blank space will
be in addition to the amount in the MTE-5or the
MVI
 There is an option not to order the .85 mg Vit K
(.15 mg is in the MVI)
 There is an option for Cholestatic Trace
Elements in cases of hyperbilirubinemia (No Cu
or Mn )
TPN Standard Additives
First Day TPN
 D 15 AA 6 @ 42 ml/hr without lipids
 Provides 150g CHO and 60g protein per
1000 ml
Will be stated in gm vs percentages on
the new form
 Avoids hyperglycemia and assures fluid
tolerance
First Day TPN
Day 2 TPN
 If fingersticks are acceptable (<180 mg/dL),
advance to day 2 TPN
D15AA6 at 52 ml/hr or newly stated 188 gm
dextrose and 75 gm protein in 1250 ml
At this point can go to goal TPN with adequate
glycemic management. Should not exceed 5 mg
dextrose/kg/min or 4 mg/kg/min in critical care
Goal blood sugar on stable TPN is <150mg/dL
Day 2 TPN
Cycling of TPN

 Cycling is done when a patient will be on

TPN for a prolonged period of time
 Taper from 24-20, 20-16, 16-12 hour cycle
 May also use 24-18, 18-12 taper cycle if
patient has stable, monitored blood sugars
 Taper helps to avoid extreme blood sugar
fluctuations
Discontinuing TPN
 Run at ½ goal rate for two hours
 If rate ≤ 25 mL/hr, discontinue TPN
 If rate > 25 mL/hr, continue to decrease
rate by ½ for two hours and discontinue
when rate ≤ 25 mL/hr.
 Check blood glucose within 1-2 hours after
discontinuation
Sudden Discontinuation of TPN
 Loss of access, sugars ≥ 300, etc
 Give dextrose containing fluids at a rate to
prevent hypoglycemia (for at least 4-6
hours or until new bag hung)
 If disconnected from lumen for any reason,
do not readminister same bag
 Can hang 10% dextrose
Nutrition Labs
 Triglycerides
 Monitor lipid and carbohydrate tolerance
 High dextrose can elevate TG and lead to fatty liver
 If TG > 400, hold lipid x 1 day and recheck before
restarting (ideally, should be checked 4 hrs after
lipid infusion)
 If TG are >400 for over 10-14 days, there is a risk of
essential fatty acid deficiency so give 50 gm lipid or
~1 gm/kg 2x/week to prevent
Nutrition Labs
 Pre Albumin
 Negative acute-phase hepatic protein that binds
Thyroxine and Retinol-Binding protein.
 Decreases in times of stress and inflammation
 Half-life is 2-3 days
 Low levels lead to increase in LOS, mortality and
recovery time
 Normal: 16-36 mg/dL
 Mild depletion: 14-17 mg/dL
 Moderate depletion: 10-14 mg/dL
 Severe depletion: < 10 mg/dL
Nutrition Labs
 Pre Albumin
 Monitoran increase in visceral protein status
and/or improvements in patient’s clinical
condition
 Will not increase (regardless of nutrition support)
when patient is in hypermetabolic, hypercatabolic
state
 Increase should occur when acute inflammation/

stress resolves
Nutrition Labs
 C-Reactive Protein
 Positiveacute-phase protein that can
measure degree of inflammation/stress
response
 Normal level : < 11 mg/dL
 Helps to determine whether nutritional labs
(prealbumin) are indicative of nutritional status
Refeeding Syndrome
 Intracellular shift of phosphorus, potassium,
and magnesium in response to a rise in insulin
due to influx of nutrients
 Fatoxidation (used during fasting states for energy
production) does not require phosphorus
 If phos, K, Mg are low, replete before TPN
 Administer volume and energy slowly
 Rationale for first dose TPN
 If Phos is below 1.5, do not hang TPN
Refeeding Syndrome
Complications
 Sodium retention, expansion of cellular
space
 Arrhythmia, CHF
 Liver dysfunction
 Confusion, coma, weakness
 Acute respiratory failure
 Constipation and Ileus
Risks for Refeeding Syndrome
 Anorexia
 Kwashiorkor or marasmus
 Chronic malnutrition
 Chronic alcoholism
 Morbid Obesity with massive weight loss
 Significant stress and depletion
 NPO 7+ days (take into account if pt was eating
PTA)
Complications of Overfeeding
 Excessive protein provision can lead to azotemia,
hypertonic dehydration, and metabolic acidosis
 Excessive carbohydrate provision can lead to
hyperglycemia,hypercapnia,refeeding syndrome,
hypertriglyceridemia, hepatic steatosis
 Excessive lipid infusion can lead to
hypertriglyceridemia
Hyperglycemia

 One of the most common complications of PN

 Can result from too may calories (dextrose)
 No more than 150-200g dextrose on 1st day of
PN (per guidelines)….. D15 at 42 ml/hr = 150g
dextrose
 Order set has sliding scale included
 Q4-6 hours during 1st 3-5 days of PN
Insulin and TPN
 Basal insulin for diabetics who previously
received insulin or oral agents
 0.1 units regular insulin / gram dextrose
 If glucose > 200 mg/dL, may consider 0.15
units/ gram dextrose
 If glucose > 300 mg/dL, hold TPN until
glucose < 200 mg/dL
Insulin and TPN
 If hyperglycemia persists and 0.3 units/ gram
dextrose is in bag, insulin “outside” the bag
 Do not exceed 3 units of insulin per 10 grams
dextrose
 Adjust amount of insulin in bag from the amount
of SSI patient received in past 24 hours
 2/3 of previous days SSI
Electrolyte Management
Electrolyte Management
Procedure for Ordering TPN
 Complete TPN order set with all initial TPN
orders
 Complete and scan/fax paper order daily
 ORDERS DUE TO PHARMACY BY 1300pm
 If you write it, you make sure pharmacy receives it.

 Standard hang time is 2100pm

 Infuse over 24 hours (unless cycled)
 Dedicate one port exclusively for TPN