parenteral Nutrition services Part 1 IIUM

Parenteral Nutrition

1. PARENTERAL NUTRITION
SERVICES
Part 1
By:
Mohamed Hassan Elnaem PharmD, PhD
Assistant Professor
Department of Pharmacy Practice, KOP, IIUM.

2. Learning
Outcomes
By the end of this
learning activity,
students should be
able to:
1.State parenteral nutrition definition and
indications.
2.Identify the main components for PN and their
requirements.
3.Compare between different types of PN
compounding.

3. 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

4. Who requires nutritional support?

5. Types of
Nutrition
support
Enteral Nutrition (EN)
➢Long-term nutrition:
•Gastrostomy
•Jejunostomy
➢Short-term nutrition:
•Nasogastric feeding
•Nasoduodenalfeeding
•Nasojejunalfeeding
Parenteral Nutrition (PN)
➢Peripheral Parenteral
Nutrition(PPN)
➢Total Parenteral
Nutrition (TPN)

6. Routes of
Administration

7. Parenteral Nutrition
Is the provision of nutrients intravenously.
used in patients who cannot meet their nutritional goals by oral or enteral route.
When the gut is not functional.
used for long-term nutrition support in the home setting.
The principal forms of PN are (PPN) and (TPN).

8. PN Specific
indications
PN therapy is part of
routine care in patients
who cannot eat or
absorb nutrients
through the GI tract
because of:
✓Massive bowel resection & Diseases of the small
bowel
✓Radiation enteritis.
✓Malnourished patients undergoing high- dose
chemotherapy/radiation therapy.
✓Patients with severe necrotizing pancreatitis when
EN is not possible.
✓Malnourished patients with AIDS who have
intractable diarrhea.

9. PN Specific
indications
✓Severely catabolic patients whose gut cannot be
used within 5 to 7 days.
✓After major surgery & In patients with
enterocutaneous fistulas.
✓In patients with IBD (Chron’s Disease, Ulcerative
colitis) & those with hyperemesis gravidarum.

11. Malnutrition
Risk
Screening
●is a rapid process performed to identify subjects at
nutritional risk.
●should be performed within the first 24 -48 hours
after first contact and thereafter at regular intervals
using an appropriate validated tools.
oESPEN suggests the use of Nutrition Risk Screening-
2002 (NRS- 2002) and the Malnutrition Universal
Screening Tool (MUST).
oFor older persons ESPEN recommends the use of the
Mini Nutritional Assessment (MNA)either in its full
or short form (MNA-SF).
oSASMEC NUTRITIONAL RISK SCREENING FORM

12. Malnutrition Universal Screening Tool (MUST)

15. Nutritional
Assessment
●Body weight and BMI
●Biochemical indices
●History (medical, nutrition, social and
psychological)
●Subjective Global Assessment could be
used to facilitate the procedure.

17. Nutrition Goals
Theprimarygoalistoprovidepatientswith
adequatecaloriesandproteinstoprevent
malnutritioncomplications.
A normal diet provides individuals with a mix
of carbohydrates, fats and proteins.
TPNmustprovidepatientswiththesesame
dietarycomponentsnecessaryforenergyand
tissuedevelopment.

18. Nutritional Care Plan
Energy, nutrient
and fluid
requirements
Measureable
nutrition goals
(immediate and
long-term)
Instructions for
implementing
the specified
form of nutrition
therapy
Most appropriate
administration
route
The method of
nutrition access
Anticipated
duration of
therapy
Monitoring and
assessment
parameters
Discharge
planning and
training at home
(if appropriate)

19. Components of
TPN
●Water /fluid
●Electrolytes
●Vitamins
●Trace elements
Protein(aminoacids);
Carbohydrates(glucose);
Fatasalipidemulsion

20. PN Nutrition Therapy

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

22. 1. Fluid requirements
•Increased in
➢Fever
➢Fistulas
➢Diarrhea
➢NG suction
▪Decreased in
➢Renal failure
➢Congestive heart failure
➢Cirrhotic ascites
➢Pulmonary disease

23. •Adult
–2 –3 L / 24H or
–30 –45 ml/kg/24H (ICU prefer 25ml/kg/day) or
–1 ml / kcal input
•Pediatric
–Recommendation (Adapted from J.G Timmer)
Age BW* (kg) Vol. (ml/kg/day)
0 –3 mos. 3 –6 150
3 –12 mos. 6 –10 110
1 –5 yrs 10 –20 90
5 –10 yrs 20 –33 75
10 –15 yrs 33 –55 50

24. •Maintenancefluidneedscanbeestimatedusingseveralmethods.The
simplestmethoduses30to45mL/kg/day(average=35ml)asthebasis.
•Example:35mL/kg/dayx60kg=2100mL/day
•Additionalfluidmustbeprovidedforincreasedlossessuchasvomiting,
nasogastric(NG)tubeoutput,diarrhea,orlargeopenwounds.

25. 2. Calorie Estimation
Total Calorie Need = BMR x Activity Factor x Injury Factor
Activity Factor
1.2 Confined to bed
1.3 Out of bed (mobile)
Injury Correction Factor
1.3 non-stressed, nutritionally sound patients
1.4 minimally stressed, inflammatory bowel disease,
cancer, elective surgery, and moderate skeletal trauma
1.5 moderate stress, orthopedic surgery, sepsis,
burns and major skeletal trauma
1.6 severe stress, multiple trauma, sepsis and multisystem
surgery
1.7 extremely stress, severe head injury, acute
respiratory distress syndrome, thermal burn, sepsis
2.1 major thermal injury

27. ❑Energyexpenditurecanbedeterminedmoreaccuratelybyindirect
calorimetry,whichmeasuremetabolicratebydeterminingthepatient's
breathingrespiratorygasexchange.Thisisthemeasuredenergy
expenditure(MEE).
❑Indirectcalorimetryisconsideredthegoldstandardforenergy
expendituredetermination.Itisespeciallyvaluableintheenergy
assessmentofcriticallyillorobesepatients.

28. Non-Protein Calorie (NPC) : N Ratio
●Dividetotalnon-proteincaloriesbygramsofnitrogen(1gN=6.25g
protein).Theratioshouldpromoteoptimumnitrogenutilizationforthe
synthesisofprotein
●Desirable NPC:N Ratios:
•80:1 the most severely stressed patients
•100:1 severely stressed patients
•125:1 Moderate stress
•150:1 unstressed patient
e.g.80 grams protein & 2250non-protein kcals per day
80g protein/ 6.25 = 12.8g N 2250 /12.8 = 176 NPC:N = 176:1

29. 3. Glucose
•Usuallyasdextrosemonohydrate(G50%)
•1gm=4kcal
•RepresentsthemostimportantCHOforIV
therapy(Sometissues&organcovertheir
energyneedsexclusivelyfromglucose).
•Reboundhypoglycemiaifahighglucose
infusionrateabruptlydiscontinuedorifexcess
ofinsulinisgiven.

30. 4. Lipid
•Represents30-35%ofourdailycalorieintake
•1gm=10kcal
•Administerintheformoflipidemulsionsthat
used:
Asasourceofenergy
Fortheprovisionoftheessentialfattyacids,
linoleicandalpha-linoleicacid.

31. •Lipidsareenergyrichandcanbeinfuseddirectlyintotheperipheral
veinssincetheyarerelativelyisotonicwithblood.
•4% to 10% kcals given as lipid meets EFA requirements
•Generally500mLof10%fatemulsion(Intralipid10%®),giventwotimes
weeklyor500mLof20%lipids(Intralipid20%®)givenonceweeklywill
preventEFAD.
•Max. 60% of kcal or 2 g fat/kg

32. ●Reduced risk of hyperglycemia
●Prevention of fatty infiltration of the liver
●Reduced metabolic and respiratory stress
●Facilitate fluid restriction(lipid is a concentrated source of energy)
●Maintenance of normal function of the immune system
Benefits of combined glucose and lipids

33. How much CHO & Fats?
❑Fats usually from 25 to 30% of calories
★Not more than 40 to 50%
★Increase usually in severe stress
★Aim: serum TG <350 mg/dl or 3.95 mmol/ l
❑CHO usually form 70- 75 % of calories

34. 5. Protein
•1g protein = 4 kcal
•Requirementdependsontypeandseverityof
illness,nutritionalstatusandageofpatient
•Composedofaminoacidsthatcanbeclassified
intoessential,non-essential&conditionally
essential.
•Stresssituationsuchasoperations,traumaor
consumptivediseasegiverisetoadditional
proteinrequirement

35. •Consequences of protein depletion
–Reduced plasma proteins -Reduce muscle mass
–Diminished immune response -Diminished organ function
•Tobalancethepatient'saminoacidrequirementsandthechemical
characteristicsoftheaminoacids(solubility,stabilityandcompatibility),a
rangeofcommerciallyavailablelicensedsolutionshasbeenformulated
containingarangeofaminoacidprofiles.
•E.g.,Aminoplasmal, Aminovenaredesignedforadultpatients.

36. 6. Micronutrients
•Micronutrientshaveakeyroleinintermediary
metabolism,asbothco-factorsandco-
enzymes.
•Alsoplayanessentialroleinthefreeradical
scavengingsystem
•Forexample,zincisrequiredbyover200
enzymesystemsandaffectsmanydiverse
bodyfunctionsincludingacid–basebalance,
immunefunctionandnucleicacidsynthesis.

38. ➢Inorganicelementspresentinthebody
requiredinsmallamountstomaintainoptimal
health.
E.g.chromium,iron,fluoride,iodine,cobalt,
copper,manganese,molybdenum,nickel,zinc,
etc
➢TErequirementvarywithage,clinicaland
metabolicstatus,andthedegreeoflossesvia
theGItract
E.g.Peditrace®, Addamel®
6.1.Trace
elements

39. ❏Fat-solublevitaminsarestoredinthebody
fat,whereasexcesswater-solublevitamins
arerenally-cleared.
❏Water-solublevitaminsdeficiencystates
revealthemselvesfirst,incaseofinadequate
provision.
❏Patientsonlong-termPNshouldhavevitamin
Dlevelsmeasuredevery6months.tohelp
protectagainstosteoporosiswhichisawell
recognizedcomplicationofhomePN.
E.g.Soluvit-N®
6.2.
Vitamins

40. ●Requirementsvarywithage,clinicalcondition,
bloodbiochemistryandrenalfunction
●Providingadequatesupplyofcalciumand
phosphatecanbeachallengeduetosolubility
problems:
–ThesolubilityispHdependentanddepends
ontheaminoacidscomposition
6.3.
Electrolytes

41. Administration
•PN can be administered through peripheral
or central veins based on:
Duration
Vein condition (patency)
Volume –any fluid restriction?
Components of PN

42. PERIPHERAL ACCESS CENTRAL ACCESS
❑Given through peripheral vein
(Easier)
❑Short term PN only
❑lower calorie need
❑Osmolarity< 900mOsm/L
❑Less incidence of sepsis
❑Mild stressed patients
❑Needs large amounts of fluid
❑Contraindications to central PN
❑Catheter is inserted directly into the large
vein such as superior vena cava
❑Long term PN
❑higher calorie need
❑HigherOsmolarity
❑Allows faster rate of infusion
❑Need specialization for catheter insertion
❑To be performed in aseptic condition
❑More complication

43. Compounding Methods
Total nutrient admixture (TNA) or 3-in-1:
–Dextrose, amino acids, lipid,
additives are mixed in one
container
–Lipid is provided as part of the
PN mixture daily.
2-in-1 solution of dextrose, amino acids, additives :
–Typically compounded in 1- liter bags
–Lipid is delivered as piggyback daily or
intermittently as a source of EFA

46. References
●Parenteral Nutrition Handbook.
●ESPEN guidelines on definitions and terminology of clinical nutrition
(2017)