1. Total Parenteral Nutrition7
Total Parenteral Nutrition

2. Conditions Requiring TPN
Cancer
AIDS
Crohn’s disease
Surgical removal of intestines
Severe diarrhea
Hyperemesis gravidarum (uncontrollable vomiting during pregnancy)

3. Conditions Requiring TPN (cont’d)
Premature neonate
Coma

4. Ingredients TPNs are extremely complex sterile compounds
May have up to 15 to 20 additives
Greater incidence of error or incompatibility
TPN bag volume: 500 ml to 4 L
Average patient receives 3 to 4 L/day

5. Ingredients (cont’d) TPNs prone to growth of microorganisms
Maintaining aseptic technique is essential

6. Ingredients (cont’d) Base solution
Dextrose: carbohydrates/sugar; provides calories
Amino acids: protein; build/maintain body tissue
Lipids: fat; energy storage
Sterile water: used to adjust TPN volume

7. Ingredients (cont’d) Additives
Electrolytes: sodium, potassium, chloride, phosphate, calcium, magnesium
Trace elements: zinc, copper, manganese, chromium
Vitamins

8. Fluid Maintenance
Physician decides total TPN volume & chooses base solutions
Fluid requirements based on weight or BSA
Factors affecting fluid amounts needed
Dehydration
Overhydration
Related conditions

9. Fluid Maintenance (cont’d)
Patients are monitored for
Fluid balance variations
Nutritional needs

10. Fluid Requirement Formula Based on Body Weight

11. Calories and Carbohydrates
Dextrose
Wide range of concentrations: 2.5 to 70%
50% & 70% are most common strengths for TPN
Each gram provides 3.45 kcal

12. Calories and Carbohydrates (cont’d)
Lipids
Prevent essential fatty acid deficiency
Contribute to total caloric content
Available in concentrations of 10%, 20%, 30%
10% & 20% may be infused directly into vein
30% must be mixed into TPN bag

13. Calories and Carbohydrates (cont’d)
Ideal caloric mix
50–80% dextrose
20–50% fat
Each gram of fat provides 9 kcal

14. Amino Acids Molecular units that make up proteins
Build, maintain, & repair body tissues
8 of 22 amino acids are essential
Essential: not produced by body
Nonessential: body can synthesize
Provide nitrogen, which aids in protein metabolism

15. Electrolytes and Minerals
Sodium: 80–100 mEq/day
Determines total body water
Potassium: 80–100 mEq/day
Aids nerve & muscle function (heart)
Regulates water balance of cells
Balances electrolytes

16. Electrolytes and Minerals (cont’d)
Chloride: 80–100 mEq/day
Regulates water balance of cells
Maintains blood volume & pressure, pH

17. Electrolytes and Minerals (cont’d)
Calcium: 15–20 mEq (0.2–0.3 mEq/kg/day)
Bone formation/maintenance
Nerve function
Muscle contraction
Blood clotting
Heart function

18. Electrolytes and Minerals (cont’d)
Magnesium: 15–25 mEq (0.25–0.35 mEq/kg/day)
Muscles & nerves
Phosphate: 20–30 mM (7–9 mM/1000 kcal)
Bone growth
Energy
Fighting infection
Proper muscle function

19. The Order Physician writes order & sends to pharmacy
Pharmacy follows protocols in compounding TPN
Types of order
Standard: basic, nonspecialized for average patient
Specialized

20. The Order (cont’d) Administration route
Central line: dextrose concentration >10%
Peripheral line: dextrose concentration ≤10%

21. Factors to Consider in Choosing Peripheral vs. Central Line
Type of medication being administered
Osmolarity & pH of solution
Duration of therapy
Diagnosis or medical condition of patient
Patient preferences
Current availability & status of veins
Patient history
Secondary risk factors

22. Infusion Rate Must be steady Large changes can cause significant
Hypoglycemia
Hyperglycemia
At beginning, rate is tapered up for several hours
When complete, rate is tapered down

23. Infusion Rate (cont’d)
During interruption, a bag of low-concentration dextrose (10%) can be infused

24. Compounding the TPN Pharmacist
Compares patient’s lab values to TPN order
Suggests clinical changes, if needed
Checks calcium gluconate & potassium phosphate levels to ensure no precipitation
Performs calculations

25. Compounding the TPN (cont’d)
Pharmacy Technician
Chooses correct size bags, syringes, & needles
Compounds base solutions (manually or auto)
Draws up additives in separate syringes
Injects additives into TPN bag (after pharmacist checks)

26. Compounding the TPN (cont’d)
Pharmacy Technician (cont’d)
Mixes the bag between each addition
Inspects solution for particulates

27. Automated Devices Automix 3+3
Automated compounder linked to a computer
Order is entered into computer
Computer calculates amount of each ingredient
Computer displays warnings if levels are off

28. Automated Devices (cont’d)
Automix 3+3 (cont’d)
Label is printed out
Tech enters patient info, hangs correct size bag
Compounder pumps fluid into IV bag

29. Automated Devices (cont’d)
Micromix
Compounds TPN additives
Can add up to 10 different additives to bag
Reduces amount of syringes to be drawn
Reduces error rate
Adds additives to TPN bag using specific gravity

30. Automated Devices (cont’d)
Micromix (cont’d)
Can pump as little as 2 mL into TPN bag
Can measure to tenths (0.1 mL)