Total Parenteral

Nutrition (TPN)

Prof. Apt. Diana Laila Ramatillah, M. Farm, Ph.D

• Parenteral nutrition (PN) is the feeding of a
person intravenously, bypassing the usual
process of eating and digestion.

• The person receives nutritional formulae that

contain nutrients such as glucose, salts, amino
acids, lipids and added vitamins and dietary
minerals.
• Nutritional Support is a method of
providing nutritional supplement through:

• Oral feeding – utilizing oral route

• Enteral feeding - directly into the gastrointestinal
tract
• Parenteral nutrition - directly into the systemic
circulation
Parenteral Nutrition (PN)
Who requires nutritional support?

• Patients already with malnutrition

• Patients at risk of malnutrition -

surgery/trauma/sepsis
Malnutrition
• Malnutrition is a medical condition caused by an improper or
insufficient diet.

• Malnutrition is a state in which a deficiency of nutrients such as

energy, protein, vitamins and minerals causes measurable
adverse effects on body composition, function or clinical
outcome.

• Malnutrition Definition
• Malnutrition is the condition that develops when the body
does not get the right amount (↓ or ↑) of the vitamins,
minerals, and other nutrients it needs to maintain healthy
tissues and organ function.

• Under nutrition (deficiency of one or more essential nutrients)

• Over nutrition (an excess of a nutrient or nutrients)
Patients at risk of
malnutrition

• Any disease state which Depleted reserves

• Complicating condition like Impaired bowel function
• Need for prolonged bowel rest
• Critical Illness
• Treatment
• Socioeconomic condition that results in decreased
• nutrient intake
• Cannot eat for > 5 days
Prevalence of Malnutrition
• Estimated prevalence of malnutrition on admission to
four hospitals came out to be 20%. (Edington et al., 2000)

• Prevalence of malnutrition in hospitalized patients in

Singapore was 29% (Anthropometric procedure was
adopted). (Lim et al., 2012)

• Based on Subjective Global Assessment (SGA) screening

tool, 88%
• of 143 patients undergoing pancreatic resection at St.
Andrea Hospital, Italy were at medium-high risk of
malnutrition.

• At present, 32 screening tools have been identified in

literature according to one meta-analysis. (van
Bokhorst-de van der Schueren et al., 2014)
Nutrition screening
 The Joint Commission on Accreditation of Healthcare
Organizations standards require a nutrition screening
typically within 24 to 72 hours of hospital admission.

 Patients determined not to be at risk for malnutrition

should be re-evaluated every 7 to 14 days.

 Patients determined to be at risk for malnutrition need

a nutrition assessment and care plan.
Purpose of Screening?
Gold Standard?
• No gold standard

• Studying the validity of a tool is usually done versus a gold

standard. In the absence of a perfect gold standard for
malnutrition, studies use different reference methods to
validate their tools.

• Roughly the following main reference methods were

identified:
• - objective assessment by a professional
• - nutritional assessment and anthropometry
• - another screening or assessment tool
• - other reference methods
Malnutrition Universal Screening
Tool (MUST)
Malnutrition Universal Screening
Tool (MUST)
Cut-off values for MUST:
Formula to calculate NRI risk
score
Conclusion
• One size does NOT fit all!

• Know what you want to measure:

• – Nutritional status?
• –Outcome?
• – Responsiveness to nutritional intervention?
• – Know which population you want to measure in

• Then choose your tool!!

How do we detect malnutrition?
How do we detect malnutrition?

Nutritional Assessment

• 1. History.
• 2. Physical examination.
• 3. Anthropometric measurement.
• 4. Laboratory Investigations.
1. History
•  Dietary history.
•  Significant weight loss within last 6 months.
• >15% loss of body weight compare with ideal
body
• weight.
•  Beware the patient with ascites/edema.
2. Physical Examination
•  BMI (<19 or >10% decrease in body weight).
•  Evidence of muscle wasting.
•  Depletion of subcutaneous fat.
•  Peripheral edema, ascites.

•  Features of vitamin deficiency. e.g. nail and mucosal changes.

•  Easy bruising & Echymosis
•  Easy to detect >15% loss of weight.
Nutritional Assessment -
Physical Signs
• Hair – Lusterless (loss of shining), thin, sparse, hair shafts.
• Face - Redness and scaling of nasolabial folds
• Eyes - Pale conjunctiva, poor dark adaptation, Intraocular
hemorrhage
• Lips - Bilateral angular stomatitis
• Tongue - Raw tongue, glossitis
• Gums - Pale, spongy, bleeding
• Skin & Nails - Purpura, desquamatory dermatitis, koilonychia
• Musculoskeletal system - Wasting, knock knees, beading of ribs, bow
legs,
• Cardiac system -cardiomegaly, tachycardia
• Nervous system - confusion, bilateral loss of ankle and knee jerks
• Gastrointestinal system - Hepatomegaly
Nutritional Assessment

• Many vitamin deficiencies remain undetected

• Signs of classical deficiency may not be apparent

in all clinical situations e.g.
• where vitamins play a preventative role
• in severe illnesses (unrelated to vitamin deficiencies)
where the anti-oxidant vitamins may be rapidly
consumed by the disease itself.
Nutritional Assessment –
Vitamins deficiencies

• Fat soluble
• Vitamin A xerophthalmia, keratomalacia
• Vitamin D rickets & osteomalacia (adult)
• Vitamin E haemolytic anemia
• Vitamin K increased clotting time
Nutritional Assessment –
Vitamins deficiencies
• Water Soluble
• Vitamin B1 Beriberi, Wernicke-Korsakoff
• Niacin Pellagra (dry, scaly and atrophy)
• Folic acid Megaloblastic anemia
• Vitamin B12 Pernicious and megaloblastic
anemia, neuropathy
• Vitamin C Scurvy
3. Anthropometry

•  Physical examination for

nutritional status.
•  Sites for skin-fold thickness
measurement.
•  Measurements taken only
on right side of body.
•  Sites: triceps, biceps, sub-
scapular or suprailliac.
How it’s done..

• Mark site
• Pinch just below mark
• Calipers must be
• perpendicular to skin fold
• Read off to nearest mm
• Within two seconds
• Repeat procedure twice
• Sum up skinfolds
4. Lab Investigation

•  Albumin (<30 g/dL)

•  Pre-albumin (<12mg/dL)
•  Transferrin (<150mmol/L)
• Total lymphocyte count (<1500/mm3)
Prealbumin or Transthyretin (TTR) is a
serum and cerebrospinal fluid carrier of the
thyroid hormone thyroxine (T4) and retinol
binding protein bound to retinol.
Tests reflecting specific
nutritional deficits

•  Renal function: urea, creatinine, fluid balance.

•  LFTs; serum albumin is marker of nutritional
status;
•  Total protein.
•  Electrolytes: Na, K, Cl, Ca, P, Mg.
•  Blood count.
•  Hb, RBC indices.
•  Iron, folate & B12 status.
•  Immunocompetence.
•  Lipid profile.
TYPES OF NUTRITIONAL
SUPPORT

• Algorithm

• Types

1.Oral
2.Enteral
3.Parenteral
Nutritional Supplements
Algorithm
Types of nutritional support

• Nutritional support is a method of providing

nutritional
• supplement through:
•  Oral feeding-utilizing oral route
•  Enteral feeding-directly into GIT
•  Parenteral nutrition-directly into systemic
circulation.
Oral feeding-utilizing oral route

• Elemental monomeric formulas contain nitrogen in the form of free

amino acids and small amounts of fat (<5% of total calories) and are
• hyperosmolar.
• Semielemental (oligomeric) formulas contain hydrolyzed protein in
the form of small peptides and sometimes free amino acids.
• Polymeric formulas are appropriate for most patients. They contain
nitrogen in the form of whole proteins and include blenderized food,
milk-based, and lactose-free formulas. Lactose-free formulas (e.g.,
Ensure) are the most commonly used polymeric formulas in
hospitalized patients.

Borderline substances – for more

information refer BNF
appendix-7
Enteral Nutrition

• Nutritional support via placement through the nose,

• esophagus, stomach, or intestines (duodenum or jejunum).
• —Tube feedings
• —Must have functioning GI tract
• —IF THE GUT WORKS, USE IT!
• —Exhaust all oral diet methods first.
• Whenever possible, oral/enteral rather than parenteral feeding
• should be used in patients who need nutritional support.
Use the GIT whenever
possible!
Advantages

• Enteral nutrition helps to maintain the structural and

functional
• integrity of the GI tract in different ways:
 Prevents atrophy of the intestinal mucosa and pancreas
 Preserves mucosal digestive and pancreatic secretary enzyme
activity
 Maintains GI immunoglobulin A (IgA) secretion
 Prevents cholelithiasis
 Maintains gut mucosal physiology
 Promotes peristalsis
 No bacterial translocation
 Less complications

 Intake easily/accurately monitored

 Provides nutrition when oral is not possible or adequate

 Costs less than parenteral nutrition

 Supplies readily available

 Increased compliance with intake

Short-term (<6 weeks) tube feeding can be achieved by
placement of a soft, small-bore nasogastric or nasoenteric
feeding tube.
 These tubes are made of silicone or polyurethane and do not
cause the tissue irritation and necrosis associated with larger
polyvinylchloride tubes.
 Nasogastric feeding is usually the most appropriate route

Long-term (>6 weeks) tube feeding usually requires a gastrostomy

or jejunostomy tube that can be placed endoscopically,
radiologically, or surgically, depending on the clinical situation
and local expertise.
Contraindications

• The intestinal tract cannot be used effectively in some

patients
• due to:
•  Persistent nausea or vomiting
•  Intolerable postprandial abdominal pain or diarrhea
•  Mechanical obstruction or severe hypomotility
•  Severe malabsorption
Feeding schedules
tolerate
 Patients who have feeding tubes in the stomach can often
intermittent bolus or gravity feedings, in which the total
amount of daily formula is divided into four to six equal
portions.

 Bolus feedings are given by syringe as rapidly as tolerated.

 Gravity feedings are infused over 60 minutes. The patient's upper body should be
elevated by 45 degrees during and for at least 2 hours after feeding.
Tubes should be flushed with water after each feeding.
• Continuous feeding can often be started at 30 mL/hr
• and advanced by 10 mL/hr every 6 hours until the
feeding goal is reached.
•  Continuous feeding should always be used when feeding
• directly into the duodenum or jejunum to avoid
distention, abdominal pain, and dumping syndrome.

Gastric dumping syndrome, or rapid gastric

emptying is a condition where ingested foods
bypass the stomach too rapidly and enter the small
intestine largely undigested.
Disadvantages

•  Mechanical complications—tube migration; tube obstruction

•  Risk of aspiration pneumonia

•  Increased risk of bacterial contamination

•  Metabolic risks eg: hyperglycemia

•  GI side effects (Diarrhea, nausea, vomiting etc.)

•  Costs more than oral diets

•  Less “palatable/normal”

• Labor-intensive assessment, administration, tube patency and

site care, monitoring
Complications
(12% overall complication rate)

• Mechanical complications:
• Nasogastric feeding tube misplacement
• Erosive tissue damage
• Tube occlusion
• Aspiration pneumonia: Aspiration pneumonia is
• bronchopneumonia that develops due to the entrance of
• foreign materials into the bronchial tree, usually oral or gastric
• contents (including food, saliva, or nasal secretions).
• High-risk patients
• —Poor gag reflex (pharyngeal reflex or laryngeal spasm)
• —Depressed mental status
3. GI complications
 Nausea
 Vomiting
 Abdominal pain
4. Metabolic complications: Hyperglycemia, overhydration.
5. Intestinal ischemia/necrosis: Caution should be
used if enterally feeding critically ill patients
requiring vasopressors for blood pressure
support.
Monitoring
What can we give in tube feeding?

• Blenderised feeds

• Commercially prepared
feeds
• Polymeric
• eg Isocal, Ensure, Jevity
• Monomeric / elemental
• eg Vivonex
Commercial Products

Powder form – need to dilute and measured

according to the desired strength
Commercial Products

Preparation
ready for use –
in solution
form
Enteral Nutrition (EN) is better than Parenteral
Nutrition (PN)
Total Parenteral Nutrition (TPN)
Introduction

• Total Parenteral Nutrition (TPN)

refers to nutrition provided via
intravenously without passing
through gastrointestinal tract (GIT).

• Patients who are unable to consume

nutrients for a period of
• time by oral or enteral routes
require parenteral nutritional
• therapy to prevent the adverse
effects of malnutrition.
Parenteral Nutrition

• Allows greater caloric intake

BUT

• Is more expensive
• Has more complications
• Needs more technical expertise
ADVANTAGES

• Provides nutrition when GI tract not functional

• Provides nutrition when access to GI tract not
possible
• Can boost selected nutritional intake in the
short-term
DISADVANTAGES

• Risk of infection associated with TPN

• Risk of central line placement
• Metabolic complications
• Sequelae of dormant gut
• Cost RM vs benefit may be dubious
Who will benefit from parenteral
nutrition?

Patients with/who

• Abnormal gut function

• Cannot consume adequate amounts of nutrients by
enteral feeding
• Are anticipated to not be able to eat orally by 5
days
• Prognosis warrants aggressive nutritional support
CONDITIONS WHERE TPN
IS USED
• Short-gut syndrome
• Inflammatory bowel disease
• Fistula
• Obstruction of GI tract
• Ischemic bowel disease
• Acute pancreatitis
• Major gastrointestinal surgery
Two main routes of parenteral
nutrition
• Central Parenteral Nutrition
• Peripheral Parenteral Nutrition

Both differ in
• composition of feed
• primary caloric source
• potential complications
• method of administration
Selection of route
Central Parenteral Nutrition

• Catheter is inserted directly into the large vein

such as superior vena cava
• Allows higher tonicity of the TPN solution
• Allows faster rate of infusion (usually >1,500 mOsm/L)
• Allows higher calories
• Have longer self-life
Venous Access for central TPN

Need venous access to a “large” central line with

fast flow to avoid thrombophlebitis

• Long peripheral line

• subclavian approach
• internal jugular approach Superior Vena Cava
• external jugular approach
Rate of Infusion of Central TPN

• Start at 40 – 60 ml/hr
• Increase the rate gradually with 5 – 10 ml/hr
increment
• Maximum rate could be achieved in 24 – 48 hrs
• To discontinue – taper the rate gradually to 60
ml/hr over 24 to 48 hrs
• In emergency – d/c TPN abruptly and replaced
with D10% at the same rate.
Peripheral Parenteral Nutrition

Given through peripheral vein

• short term use
• mildly stressed patients
• low caloric requirements
• needs large amounts of fluid
• contraindications to central TPN
Peripheral route (PPN)

• Given through peripheral line

• Peripheral parenteral nutrition is often considered to

• have limited usefulness because of the high risk of
thrombophlebitis.

• •Appropriate adjustments in the management of

peripheral parenteral nutrition can increase the life of a
single infusion site to >10 days.
Algorithm for the diagnosis and treatment of catheter
occlusion (thrombotic and non-thrombotic)
Factors improve tolerance to
peripheral lines

• Aseptic insertion and line care

• Selection of large vessel with good blood flow (eg:
Cephalic vein)
• Fine polyurethane catheter
• Glyceryl trinitrate patch distal to insertion site, over tip to
vasodilate vein
• Regular replacement of catheter, using alternate arms
(12 hourly)
• Low tonicity infusion
Peripheral versus Central PN

PPN CPN
• Using peripheral lines • Using central venous route
• Short term use. • Long term use
• Low caloric requirements. • High caloric requirements.
• Low tonicity infusion • Allows higher tonicty
• Allows lower rate of infusion
• Allows faster rate of
• Cheaper infusion.
• Contraindication to central • Have longer shelf-life.
TPN.
• Expensive
• Provide at least 50% of total
energy as a lipid emulsion
Components of TPN

In addition to the water, six main groups of

nutirients need to be incorporated in a PN
regimen
Macronutrients
 Carbohydrates
 Amino acids
 Fat
} Energy

Micronutrients
 Electrolytes
 Trace elements
 Vitamins
TERIMAKASIH