TPN

 Parenteral nutrition is by definition given IV.
 Feeding intravenously, bypassing the usual process

of eating and digestion
Partial parenteral nutrition (PPN)
Total parenteral nutrition (TPN)
 Partial parenteral nutrition supplies only part of
daily nutritional requirements, supplementing oral
intake. Many hospitalized patients are given
dextrose or amino acid solutions by this method.
 Total parenteral nutrition (TPN) supplies all daily
nutritional requirements. TPN can be used in the
hospital or at home. Because TPN solutions are
concentrated and can cause thrombosis of
peripheral veins, a central venous catheter is
usually required.
 Both used for the same cause which is to give the
nutrition requirements that a patient needs.
 The difference is that a TPN must be given through
a central venous catheter and the PPN may be given
through a regular IV.
 TPNs are preferred nutritional supplement for a
long time because it delivers through a central vein
 PPNs are only preferred partially because it is not
safe to use hyperosmolar solutions in peripheral
veins for a very long time.
 TPN comes in a higher concentration & it can only
be administer through a large vein such as the chest
or neck
 PPN comes in a lesser concentration that can be
delivered through a peripheral vein
 TPN is a intravenous fluid for patients in need of
nutrition requirements who are unable to eat or
cannot get enough nutrition from foods they eat.
 TPN will drip through a needle or catheter placed in
the central vein for 10-12 hours, once a day or five
times a week
TPN may be the only feasible option for patients
who do not have a functioning GI tract or who
have disorders requiring complete bowel rest,
such as the following:
 GI disease: Crohn’s disease, ulcerative colitis,
pancreatitis, malabsorption syndrome
 Major trauma: severe burns, septicaemia, acute
renal failure,intensive care patients
 Major abdominal surgery: severely malnourished
patients may benefit from early postoperative
parenteral nutrition if surgery has resulted in a non
functioning GIT
 Malignancy of the small bowel
 Radiation enteritis: TPN is considered if enteritis is
severe after treatment of a primary malignancy
 High dose chemotherapy, radiotherapy & bone
marrow transplantation: patients are often ill for a
limited time(3-6 weeks) & are unable to eat. TPN
can be adm during this period to ensure that the
patient’s nutritional reqmts are adequately met
 Several other conditions : moderately
malnutritioned patients prior to surgical treatment,
patients in a prolonged coma or AIDS patients
 Water
 Protein source
 Energy source: carbohydrates & possibly fats
 Electrolytes
 Trace elements
 Vitamins & minerals
 50% of body wgt
 requires water (30 to 40 mL/kg/day)
 TPN regimen provides this volume of fluid on a
daily basis
 Protein reqmts vary
 Depends on the metabolic status of the patient
 amino acids (1 to 2.0 g/kg/day, depending on the
degree of catabolism), children (up to 2.5 or 3.5
g/kg/day).
 Lack of nitrogen can result in poor wound healing &
affects the body defence mechanism
 Overcome by adm a suitable source of N2 to the patient
 This is achieved by giving aminoacid solns in a TPN
formulation
 30 to 60 kcal/kg/day, depending on energy expenditure
 Children: up to 120 kcal/kg/day
 Most calories are supplied as carbohydrate, ie, about 4 to 5
mg/kg/day of dextrose is given.
 Standard solutions contain up to about 25% dextrose, but the
amount and concentration depend on other factors, such as
metabolic needs and the proportion of caloric needs that are
supplied by lipids
 Commercially available lipid emulsions are often added to
supply essential fatty acids and triglycerides; 20 to 30% of
total calories are usually supplied as lipids. However,
withholding lipids and their calories may help obese patients
mobilize endogenous fat stores, increasing insulin sensitivity
 Fat component in a TPN formulation is adm in the form of an
oil in water emulsion
 Fat emulsions are isotonic with plasma, have neutral pH &
provide a high calorie source in a low volume.
 They are often used in cmbn with dextrose to
provide the necessary calorie content, thereby
avoiding the potential problems encountered with
excessive dextrose adm
 Also provide the patient with essential fatty acids &
also act as a vehicle for fat soluble vitamins which
may be required in the TPN formulation
 Include Na, K, Mg, Ca, phosphate, chloride
Trace Elements
 Act as metabolic cofactors, essential for
functioning of enzyme systems in the body
 Zn, Cu, Mn,Cr
 Fat soluble: A, D, E, K
 Water soluble: B1, B2, B3, B5, B6,B12, Folic acid
 Included in foods taken in orally & must therefore
be included in TPN formulations for patients on
long term parenteral nutrition
 Sodium: Helps control water distribution and
maintain a normal fluid balance
Potassium: Needed for cellular activity and tissue
synthesis
Magnesium: Helps absorb carbohydrates and protein
Calcium: Needed for bone and teeth development
also aids in clotting
 Phosphate: Minimizes the threat of peripheral
parenthesis
Chloride: Regulates the acid base equilibrium and
maintains osmotic pressure
Acetate: Added to prevent metabolic parenthesis
Trace elements: Help in wound healing and red
blood cells synthesis
Interferon: May be added as a iron supplement
Insulin: Metabolize high glucose load
Ascorbic acid: Helps in wound healing
Vitamin A: Maintaining integrity of skin and essential to
vision
Vitamin D: Essential for bones and maintenance of serum
calcium levels
Vitamin B complex: Helps in final absorption of
carbohydrates and protein
Folic acid: DNA formation and promotes growth and
development
Vitamin K: Helps prevent bleeding disorders
 For renal insufficiency not being treated with dialysis or
for liver failure: Reduced protein content and a high
percentage of essential amino acids
 For heart or kidney failure: Limited volume (liquid) intake
 For respiratory failure: A lipid emulsion that provides
most of nonprotein calories to minimize CO2 production
by carbohydrate metabolism
 For neonates: Lower dextrose concentrations (17 to 18%)
Nutrient Amount Amino acids (/kg
bodywt/day)
Water (/kg body 30–40 mL Medical patient 1.0 g

wt/day)
Postoperative patient 2.0 g
Energy* (/kg
body wt/day) Hypercatabolic 3.0 g
patient
Medical patient 30 kcal
Minerals
Postoperative 30–45 kcal
patient Acetate/gluconate 90 mEq
Hypercatabolic 45–60 kcal Calcium 15 mEq

patient
*Requirements for energy increase by 12% per 1°C of fever.

Chloride 130 mEq Sodium 100 mEq Pantothenic 15 mg
acid
Chromium 15 μg Zinc 5 mg
Pyridoxine 4 mg
Copper 1.5 mg Vitamins
Riboflavin 3.6 mg
Iodine 120 μg Ascorbic acid 100 mg
Thiamin 3 mg
Magnesium 20 mEq Biotin 60 μg
Vitamin A 4000 IU
Manganese 2 mg Cobalamin 5 μg
Vitamin D 400 IU
Phosphoru 300 mg Folate (folic 400 μg
s acid) Vitamin E 15 mg
Potassium 100 mEq Niacin 40 mg Vitamin K 200 μg
Selenium 100 μg
 TPNs are prepared in a laminar flow hood using
the aseptic technique.
 Basic TPN solutions are prepared using sterile
techniques, usually in liter batches according to
standard formulas. Normally, 2 L/day of the standard
solution is needed. Solutions may be modified based
on laboratory results, underlying disorders,
hypermetabolism, or other factors.
 A healthcare professional will place a special IV
line in the patient’s arm, upper chest, or neck.
Their TPN will be connected to a pump that
controls how fast the TPN goes into their vein.
 For patients requiring TPN for longer than 2
weeks, central venous access is needed
 A catheter is inserted into the subclavian vein
under anaesthesia
 Exit site on the lower chest wall, allowing patients
easy access for care of the catheter site
 Catheters can be made of materials like polyvinyl
chloride or silicone
 Permanent catheter(Hickman catheter)- long term
feeding
 Held in place by a dacron cuff- an internal woven
plastic to connect arteries & veins under the skin
 Aseptic techniques – to prevent contamination of
the catheter site
 Catheter sites used only for adm of TPN fluids &
not for blood sampling or adm of medicines
 To infuse TPN formulation into patient, a catheter
is connected via an extension set to a volumetric
infusion pump
 External tubing should be changed every 24 hr with
the first bag of the day.
 The solution is started slowly at 50% of the
calculated requirements, using 5% dextrose to
make up the balance of fluid requirements. Energy
and nitrogen should be given simultaneously.
 The amount of regular insulin given (added directly to the
TPN solution) depends on the plasma glucose level; if the
level is normal and the final solution contains 25% dextrose,
the usual starting dose is 5 to 10 units of regular insulin/L
of TPN fluid.
 Adult TPN preptns have volume ranging from 1500-
3000ml
 Infusion period varies from 24hrs in hosp
 8- 12 hrs for home patients
 fever or chills  muscle weakness,
 stomach pain twitching, or cramps
 difficulty breathing  swelling of the hands, feet,
 rapid weight gain or loss or legs
 increased urination
 thirst
 upset stomach
 fatigue
 vomiting
 changes in heartbeat
 confusion or memory loss

 tingling in the hands or feet
 jumpy reflexes
 convulsions or seizures
 Store in the refrigerator or freezer.
 Take the next dose from the refrigerator 4-6 hours
before using it; place it in a clean, dry area to allow
it to warm to room temperature.
 To store additional TPN in the freezer, always move
a 24-hour supply to the refrigerator for the next
day's use.
 Do not refreeze medications.
Receiving TPN in the vein or under the skin a
catheter related infection (an infection where the
needle enters the vein or skin).
 tenderness
 warmth
 irritation
 drainage
 redness
 swelling
 pain

TPN

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What are PPN and TPN and how do they differ?

When is TPN preferred over PPN?

 Parenteral nutrition is by definition given IV.

 Feeding intravenously, bypassing the usual process

Water (/kg body 30–40 mL Medical patient 1.0 g

Hypercatabolic 45–60 kcal Calcium 15 mEq

*Requirements for energy increase by 12% per 1°C of fever.

Potassium 100 mEq Niacin 40 mg Vitamin K 200 μg

 confusion or memory loss

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