Total Parenteral Nutrition

Peripheral Parenteral Nutrition
1. Delivered via peripheral Intravenous Access
2. May be used up to 7-10 days in patients not requiring fluid restriction
Central Parenteral Nutrition
1. Delivered via central venous access
2. Indicated in longer term pareteral nutrition needs >7-10 days
3. Also indicated in higher concentration formulations (>900 mOsm/L) that allow for fluid restriction

See Refeeding Syndrome
Biliary disease
Osteoporosis (and Osteopenia)
Catheter-related infection
Central Line Placement related complications (e.g. Pneumothorax)
Electrolyte disorders
Hyperglycemia
Hyperlipidemia
Hepatic Steatosis (adults)
Thrombosis
Cholestasis (children)
End-stage liver disease (50% of adults and children on lon-term parenteral nutrition)
1. Chan (1999) Surgery 126(1): 28-34 [PubMed]

See Specialized Nutrition Support
Lean body wt (LBW)
1. Male: 110 + 5 x(number of inches> 60) lbs
2. Female: 100 + 5 x(number of inches> 60) lbs
IF Obese (>130% LBW) then use adjusted weight
1. (Actual-LBW) x 0.25 + LBW
Basal Energy Expenditure (BEE) per 24 hours
1. M: BEE=66 + (13.7xWt) + (5xHt) - (6.8xAge) = KCal
2. F: BEE=655 + (9.6xWt) + (1.7xHt) - (4.7xAge) = KCal
3. Adjust for depletion or disease
  1. 120-130% BEE is Maintenance
  2. 150% for stress and depletion
Calorie requirement (per kg/day)
1. Usually 30-35 KCal/kg/day
2. Range = 20-40 Kcal/kg/day
Adult Protein
1. RDA = 0.8 g/kg/day
2. Stress Adjustment
  1. 0.7-0.8 g/kg/d Maintenance, healthy, no stress
  2. 1.0-1.2 g/kg/d Mild stress
  3. 1.3-1.5 g/kg/d Moderate stress, repletion
  4. 1.5-2.0 g/kg/d Severe stress, burns
Essential Fatty Acid Requirement
1. Estimate 4-10% (2-4% linoleic) of daily calorie need
Intravenous Electrolyte Requirements
1. Electrolytes
  1. Sodium: 60-100 meq per 24 hours
  2. Potassium: 60-100 meq per 24 hours
  3. Calcium 10-15 meq per 24 hours
  4. Phosphorus 20-45 mMol per 24 hours
  5. Magnesium 10-20 mEq per 24 hours

Two in one mixtures (most common)
1. Dextrose and Amino Acids
2. Separate infusion of fat Emulsion
Three in one mixtures
1. Dextrose, Amino Acids and fat emulsion in same preparation

Dextrose 5 to 7 mg/kg/min (<4 mg/kg/min in the critically ill)
1. Provides 70-85% of total daily non-Protein energy
2. Keep Dextrose concentration <10% in peripheral parenteral nutrition
Amino Acids
1. See See Specialized Nutrition Support for Protein recommendations based on comorbidity
2. Amino Acid concentrations vary 3 to 30%
3. Avoid high Protein loads (high renal metabolic load)
  1. Monitor Renal Function
Sodium: 1-2 meq/kg
Potassium: 1-2 meq/kg
Calcium: 10-15 mEq
Magnesium: 8-20 meq
Phosphorus: 20-40 mmol
Chloride: Adjusted per acid-base status
Acetate: Adjusted per acid-base status
Trace elements not routinely added (e.g. zinc, copper, Selenium, chromium, iron, manganese)
Multivitamin 12: 10 ml (Vitamins A, B1, B2, B3, B6, B9, B12, C, D, E, K, Biotin, Pantothenic Acid)
Fat emulsions 250 ml, 5x/week
Regular Insulin as needed

Preparations
Child 2-in-1 Parenteral Nutrition (up to 50 kg or 110 pounds, then use adult dosing)

Sodium: 2-5 meq/kg
Potassium: 2-4 meq/kg
Calcium: 2-4 mEq/kg for preterm newborns, 0.5 to 4 meq/kg for infants and children
Magnesium: 0.3-0.5 meq/kg
Phosphorus: 1-2 mmol/kg for preterm newborns, 0.5 -2.0 mmol/kg for infants and children
Chloride: Adjusted per acid-base status
Acetate: Adjusted per acid-base status
Trace elements not routinely added (e.g. zinc, copper, Selenium, chromium, iron)
Children's Multivitamin formulation (1.5 ml for <1kg, 3.25 ml for 1-3 kg, 5 ml for >3 kg)
Fat emulsions: Start 1 g/kg; increase every 1-2 days in increments of 0.5 to 1 g/kg/day
Regular Insulin as needed

See Intralipid
Intravenous fat emulsion (Intralipid) available in 10% (1.1 kcals/ml), 20% (2 kcals/ml) or 30% (3 kcals/ml)
Smoflipid is an alternative fatty emulsion (fish oil, olive oil, long and medium chain Triglycerides)
Provided as long chain Triglycerides
Prevents Essential Fatty Acid deficiency