TOTAL PARENTERAL NUTRITION

TOTAL PARENTERAL NUTRITION Total Parenteral Nutrition     GENERAL INDICATIONS TPN FORMULATION STABILITY COMPATIBILITY Total Parenteral Nutrition  GENERAL INDICATIONS • Patient who can’t eat • Patient who won’t eat • Patient who shouldn’t eat • Patient who can’t eat enough “If the gut works, use it.” Total Parenteral Nutrition      A.S.P.E.N Guidelines* Severe stress or malnutrition NPO > 4-5 days Moderate stress or malnutrition NPO > 7-10 days Non-stressed / normal nourished NPO > 10 days No indication for TPN < 4 days *Based on opinion of authors. Also see: A.S.P.E.N. Board of Directors: Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26: No.1, Suppliment January-February 2001 Total Parenteral Nutrition  NOMENCLATURE • TPN: Total Parenteral Nutrition • IVH: Intravenous Hyperalimentation • TNA: Total Nutrient Admixture • TPN: Total Parenteral Nutrition • 3-In-1 Admixture • All-In-One Admixture • PPN: Peripheral Parneteral Admxtiure FYI Aoccdrnig to rscheearch at an Elingsh uinevtisy, it deosn’t mttaer waht oredr the ltteers in a wrod apeapr. The olny iprmoetnt tihng is taht the frist and lsat ltteers are in the rghit pclae. The rset can be a toatl mses and you can still raed it wouthit a porbelm. This is bcuseae we do not raed ervey lteter by itslef but the wrod as a wlohe. INITSERETNG!! Total Parenteral Nutrition  CENTRAL CATHETER • TPN Osmolarity generally 1000-2000 mOsm/L      Subclavian Internal Jugular PICC Hickman Groshong Total Parenteral Nutrition Total= 1868 mOsm/L Dextrose 25% 1263 mOsm/L Amino Acids 4.5% 425 mOsm/L Lytes 180 mOsm/L Total Parenteral Nutrition  GOAL IN TPN FORMULATION “Provide all a patient’s required nutrients in a fluid volume that is well tolerated.” Total Parenteral Nutrition  Normal Diet • Protein • Carbohydrates • Fat • Vitamins • Minerals • Water Total Parenteral Nutrition Normal Diet TPN • Protein………………...Amino Acids • Carbohydrates…….Dextrose • Fat……………………….Lipid Emulsion • Vitamins………………Multivitamin Infusion • Minerals……………….Electrolytes and Trace Elements Total Parenteral Nutrition Water Requirements Sources Water Food Oxidation 1500 ml 800 ml 300 ml Losses Urine Stool Skin 1500 ml 200 ml 500 ml Resp. Tract Total 2600 ml Total 400 ml 2600 ml Total Parenteral Nutrition  Water Requirements • Maintenance: 30-40 ml/kg/d • Generally 2-3 L per day • Sometimes TPN must be concentrated Total Parenteral Nutrition  Carbohydrate • Give 60-80% of non-protein calories as dextrose • Dextrose concentration generally ranges from 20-25% • 20% = 680 Kcal/L • 25% = 850 Kcal/L Total Parenteral Nutrition  Carbohydrate • Max rate of glucose oxidation: 5 – 7 mg/kg/min • Max dextrose rate stable patients: Not >7 mg/kg/min • Max dextrose rate critical care patient: Not > 4 mg/kg/min Total Parenteral Nutrition Amino Acids  Ideal Amino Acid Solution • 50:50 Ratio of Essential:Nonessential AA • Wide Variety of Nonessential AA • Minimum of Glycine • Substantial amounts of Branch Chained AA  Generally considered therapeutically interchangeable. Total Parenteral Nutrition Electrolytes Elect. Na K Ca Mg Phos. Daily Requirement Standard Concentration 60-150 meq 40-240 meq 3-30 meq 10-45 meq 30-50 mM 35-50 meq/L 30-40 meq/L 5 meq/L 5-10 meq/L 12-15 mM/L Total Parenteral Nutrition Trace Elements • Recommendations per NAG • Zinc Poor wound healing • Copper Anemia • Chromium Glucose Intolerance • Manganese ?? • Selenium Keshan’s Disease Total Parenteral Nutrition Trace Elements Why not iron? • Stores of 3-4 gm. • Average daily loss of 1 mg. Other trace elements: Molybdenum*  Iodine*  Cobalt  Vanadium  Nickel  Flouride *contained in MTE-7  Total Parenteral Nutrition Vitamins  Recommendations per NAG • Multivitamin Infusion 10 ml • Contain all essential vitamins • MVI-Adult(Mayne) or Infuvite (Baxter) • Fat soluble: A, D, E, K • Water soluble: Thiamine, Riboflavin, Niacin, Pantothenic Acid, Pyridoxine, C, Folic Acid, B12, Biotin • In 2004 Vitamin K added per FDA recommendations Total Parenteral Nutrition Formulation Standardization vs Customization  Standardization • Meets requirements of most patients • Assists physician in order writing • Reduces errors (writing, transcription and order entry) • Increases pharmacy efficiency • Cost savings Total Parenteral Nutrition Formulation  Patient Specific (Customization) • Consistent with current recommendations • Can be accomplished with and without automated compounder Total Parenteral Nutrition Formulation  Gravity Transfer Standard Solutions Available Amino Acid • 5% • 8.5% • 10% • 15% Dextrose 10% 30% 50% 75% Total Parenteral Nutrition Formulation  Automated Compounder • Automix • Nutramix • Baxa • Hyperformer  Class 100 Environment Total Parenteral Nutrition  Stability • Under refrigeration and before addition of vitamins • 2-in-1: up to 30 days • 3-in-1: up to 10 days Total Parenteral Nutrition Compatibility  Calcium-Phosphate compatibility • Factors which affect stability          Additive concentration Choice of calcium salt Order of mixing Amino acid product (brand) Amino acid concentration Dextrose Concentration Temperature (not what you think) Storage time Addition of l-cysteine (neonatal) Total Parenteral Nutrition Compatibility How to minimize calcium phosphate precipitation  Additive concentration……..……....use lower the conc.  Choice of Ca ……..…..…...use Ca Gluconate, not CaCl2  Order of mixing…....add phosphate first, calcium last  Amino acid product …Aminosyn best, FreAmine worst  Amino acid concentration……….…use higher AA conc.  Dextrose concentration………use higher Dextrose conc.  Temperature………………………………………….…Refrigerate  Storage time……………………....Minimized storage time  l-cysteine (neonatal) ……..greatly increases solubility Total Parenteral Nutrition Compatibility Insulin • Reports of up to 50% of insulin is lost to adsorption to TPN bag, tubing and filter • Insulin loss due to adsorption to EVA systems probably only 5-15%. • However: Addition of insulin to TPN is considered physically compatible and therapeutically appropriate • Tomato theory (dose is titrated) Total Parenteral Nutrition Compatibility Insulin • Practical Guidelines • Minimum dose = 10 U / bag • Dose in 10 U increments • Avoid putting too much in TPN   Suppliment with sliding scale Add ½ of previous day’s SS to TPN Total Parenteral Nutrition Compatibility Insulin Sliding Scale Capillary Glucose mg/dL IDDM 200-250 251-300 301-350 351-400 3 6 9 12 NIDDM (STRESS) 5 10 15 20 Total Parenteral Nutrition Compatibility 2-in-1           H2 Antagonists Iron Dextran Heparin Albumin Morphine Sulfate Hydrochloric Acid Many Antibiotics Amphotericin B Aminophylline Sodium Bicarbonate C C C C C C C (y-site) I I I