Hospital Pharmacy Rotation

Done by: Anessa Aisha Ohoud Under Supervision of: Dr/Ahmed fallata

TPN Basic concept Stability and compatibility Components Complications OUTLINES Basic concept TPN Stability and compatibility Components Complications

Definition: Total Parenteral Nutrition (TPN) is the administration of Glucose, Amino acid, Intralipid, Electrolyte (Na, K, Cl, Mg, Ca, and PO4), Trace Elements (Zn, Cu, Mn, Se, and Cr) and Vitamins (water and fat soluble) in a concentrated form through central or peripheral routes.

GOAL OF THERAPY -To provide nutrients in a safe and effective manner. -To provide energy and substrate to continue growth rate and promote healing. -To decrease or minimize catabolism of visceral protein mass. -Reduce catabolism & Allow anabolism. -Build up and storage.

If the gut works, use it If the gut works partially, use it partially

Indications: 1- patient with an inability to absorb nutrients via the gastrointestinal tract. This includes severe malabsorption, short bowel syndrome, intractable vomiting or diarrhea, and radiation enteritis, etc. 2- patients with severe acute pancreatitis requiring bowel rest.

Cont… 3- severe malnutrition or catabolism when the gastrointestinal tract is not usable within 5 days. 4- patient where adequate enteral nutrient intake cannot be established within 7 to 10 days. 5- patient without ability to be enterally fed who will benefit from preoperative nutrition support to boost immune function.

Contraindication 1- Patients who have a functional and usable gastrointestinal tract capable of absorption of adequate nutrients. 2- Treatment anticipated for less than 5 days in patients without severe malnutrition. 3- When the risks of parenteral nutrition is judged to exceed potential benefits.

Routes of administration: 1-Peripheral venous access: Maximum Osmolarity in Neonates=1100/L Pediatric=1000/L Adult=900/L Advantages: Does not require surgery Less risk of sepsis No risk of mechanical complications Disadvantages: High risk of thrombophlebitis Painful 2-Central venous access: Usual Osmolarity>2000mOsmol Advantages: - Can provide full nutritional support No risk of thrombophlebitis No pain Disadvantages: Requires surgery More risk of sepsis High risk of mechanical complication

Parentral Nutrition Components MACRONUTRIENT MICRONUTRIENT

MACRONUTRIENT: 1-Water Adult requirements: Pediatrics requirements: -1500 ml/meter square -35 ml/kg/d -1500 ml/d+20 ml/kg/d for each kg>20 kg Pediatrics requirements: Based on the body weight 0-10 kg =100 ml/kg/d(4 ml/kg/h) 10-20 kg =1000 ml+50ml/kg/d Any kg> 20kg =1500 ml+20ml/kg/day

2- Dextrose -Use as energy sources. -It is needed for Central Nervous System and for red and white blood cells. -It is very important for wound healing. -It is available in concentration of 2.5%-70%.

CONT… 1gm of dextrose =3.4 kcal Adult dose: 2 mg/kg/min up to 5 mg/kg/min Pediatric dose: 6 mg/kg/min up to 16 mg/kg /min

Can we accept a TPN order without Dextrose? Protein is not utilized without dextrose. NO

3-Protein (Amino Acids): Amino acids used as source of protein. It is available in conc. From 6.5%-16%. Product containing only essential amino acids have been formulated for renal failure. BCAA (branched chain amino acids) are used for hepatic encephalopathy or in severely stressed patients.

Usual dose of amino acids: For adult: 0.5-2 gm/kg/day. For pediatric: 0.5-3 gm/kg/day.

Can we accept a TPN order without protein? NEVER

4-Lipid Emulsion: Use as energy sources. Use to provide essential fatty acid.

Why we used lipid 20% more than 10%? More condense calories. Less phospholipids. Less cholesterol. less triglyceride . Containing Olive oil. There are 2in1 and 3in1 solution (why?) BECAUSE :

Lipid monitoring parameter: Serum triglyceride. CBC. Liver function test.

MICRONUTRIENT: They are necessary components for maintenance of cellular function include Acid-Base balance and cellular growth. 1-Electrolytes:

The quantity of electrolytes which should be added to the TPN depend on: The patient existing electrolyte imbalance. The existing of abnormal sources of electrolyte loss: as in diarrhea , nasogastric suction or in fistula

Adult basic requirements: Sodium : 70-100 mmol /d . Potassium : 70-100 mmol / d. Calcium : 5-7 mmol / d . Magnesium :8-10 mmol / d. Phosphate : 10-15 mmol / d.

Pediatric basic requirements: Sodium : 2-4 mmol /kg / d . Chloride : 2-4 mmol /kg / d . Potassium : 2-4 mmol /kg/ d. Calcium : 0.25-1 mmol /kg/ d . Magnesium :0.25-0.5 mmol /kg / d. Phosphate : 0.5-1 mmol /kg / d.

2-VITAMINS: They are necessary for the maintenance of normal metabolism and cellular function of the body. There are two types of vitamin: 1- Fat-Soluble Vitamin (A, D, E, K) stored in body fat tissue. 2- Water-Soluble Vitamin. Vitamins are added according to RDA.

Role of vitamins: Vitamin B-complex: Vitamin C: Fat soluble vitamins: co-enzyme in absorptive ,metabolic,and transfer processes. Vitamin C: require for collagen synthesis and wound healing. Fat soluble vitamins: For vision , Ca and phosphate balance also as antioxidant.

Maximum Duration of the TPN without vitamins: NEONATE: ADULT: PEDIATRIC: 7 5 2 DAYS DAYS DAYS

3-Trace Elements: They are required in very small amount for biochemical and physiologic function. They include: Zinc, copper ,manganese , chromium , selenium.

Trace elements have role in: - Nerve conduction. - Muscle contraction. - Membrane transport. - Mitochondria stabilizing. -and also in the protein and nucleic acid synthesis.

Maximum Duration of the TPN without trace elements: PEDIATRIC: NEONATE: ADULT: 17 7 3 DAYS DAYS DAYS

NO TPN without: - K or phosphate. - Lipid for up to 5 days. - Multivitamin for up to 7 days. - Trace elements for up to 10 days. TPN without:

4-ADDITIONAL ADDITIVE AS NEEDE : INSULIN: For hyperglycemia when glucose is spilling in urine. HEPARIN: To promote blood circulation especially with peripheral TPN and to prevent thrombophlebitis. HYDROCORTISONE: To prevent thrombophlebitis in patients receiving peripheral TPN.

Cont… ACETATE: For acidosis. ZINC: Extra amount is needed for patient with sever stress, diarrhea, ileostomy output. IRON DEXTRAN: For prophylaxis and treatment of anemia.

MONITORING GUIDELINES

Baseline studies: Na, K, Cl, CO2, BUN, creatinine, Ca, PO4, Mg. - Cholesterol, triglycerides, albumin, transferrin, or prealbumin, PT, complete blood count, and liver functions. - Blood glucose levels several times first few days.

Baseline studies: - Electrolytes daily first 2-3 days, then 2-3 times per week. - Fluid balance daily until stable. Weights daily until stable then 2-3 times per week. - Evaluate nitrogen balance weekly or as needed . - Visceral protein status should be evaluated as needed .

TPN COMPLICATIONS

COMMON METABOLIC COMPLICATIONS: Glucose intolerance: -Start with no more than 150 grams dextrose. -Increase by 50-75 g per day if blood sugars are stable and less than 200 mg/dl. -Reassess number of calories and grams of dextrose for possible adjustment before ordering insulin. -Regular insulin may be added to parenteral solution.

METABOLIC COMPLICATINS 2. Electrolyte imbalances: can be corrected by modifying the electrolytes in the parenteral formula. 3. Hyperlipidemia: can sometimes be corrected by slowing or stopping the lipid infusion. Decreasing amounts of dextrose is sometimes helpful. 4. Essential fatty acid deficiency: can be corrected by increasing the lipid solution.

FREQUENT INFECTIOUS COMPLICATIONS Fever: decision to remove a central catheter must be individualized. Examine the patient and obtain appropriate cultures. Watch for 24 hours and if source of infection is not apparent at the end of that time, remove catheter. 2. Clotted catheters: can be cleared with 5000 units of Urokinase infused into the catheter.

TPN TERMINATION: TPN solutions can be discontinued several different ways based on the situation and strength of solution. 2. PPN may be discontinued as desired without tapering. 3. If TPN needs to be stopped more quickly, it can be tapered by halving the rate of infusion each hour. (Why?) 4. If TPN is abruptly terminated, infuse a 10% dextrose solution .

Ready to use TPN NuTRIflex® System: The NuTRIflex® System is the "ready to use" multi chamber bag system for total parenteral nutrition (TPN). The 2- and 3-chamber bags of the NuTRIflex® System offer the metabolic and technical advantages of an all-in-one system. They have a long shelf life without the necessity of cooling during transport and storage.

The NuTRIflex® System Even though the NuTRIflex® System consists of standardized TPN regimens, the wide product range combined with the possibility of making additions, allows highly flexible adaptation to specific patient needs.

How to use NuTRIflex® System: 1-Always start by pressing the upper left chamber to mix with the lower chamber. 2-Added electrolytes and trace elements via the additive port (red cap) 3-Finally, press the upper right chamber containing lipid emulsion to mix with the lower chamber and add vitamins.

How to use NuTRIflex® System: 4-Mix thoroughly before inserting the giving IV set. 5-To save space, fold the bag and hang it on the drip stand using the loop.

The benefit of NuTRIflex® System Convenient Makes clinical nutrition easy, Reduces work load. Cost-effective Reduces total costs for TPN. Safe Prevents therapeutic errors.

Stability and Compatibility of TPN: 1- Macronutrient: Studies have shown that dextrose, amino acid solutions are chemically stable for 1to2 month if stored in the refrigerator and protected from light. When amino acid solutions stored at room temperature.As a result the solution will have a color change to dark brown color.

2-Electrolytes: As the calcium and phosphrous concentration increase, the likelihood of calcium phosphorus precipitation becomes greater. Addition of lipid to the parentral nutrition solution is a problem for calcium and phosphrous solubility (why?). Sodium bicarbonate should not be added to parentral nutrition solution because calcium carbonate crystal may be formed.

Factors which worsen calcium phosphrous solubility: -Addition of calcium chloride -Body heat -Lower amino acid concentration -Addition of lipid -Increase concentration of calcium and phosphrous. -Incorrect order of mixing

3-Drugs: Rarely drug incompatibilities are an issue. However when access is limited drug compatibility becomes an issue. Some of drugs known to be incompatible with parentral nutrition solutions: Acyclovir, Cyclosporin, Morphin, metronidazole, Phenytoin, Aminophylline and tetracycline……etc.

Take home messages: The main goal of TPN is to provide nutrients in a safe and effective manner. We can not accept TPN without dextrose or amino acid. lipid 20% used more than 10%. Vitamins are added according to RDA.

Cont… There are 2 types of TPN complications. Ready to use system most convenient, cost-effective and safe one. Addition of lipid to the parentral nutrition solution is a problem for calcium and phosphrous solubility.

Finally, NO TPN may be safer than TPN Incomplete Non-balanced Non-monitored Non-calculated TPN

Little Nutrition is Good, Too much is Lethal

References: Thankyou -www.nutrition.com -http://www.nutritionpartner.com/index.cfm -www.clinnutr.org -www.eatright.org/ -www.hostindia.com/ispen Thankyou