Tpn guide

. ..The Hitchhiker s Guide to Parenteral Nutrition Management .
.

The Hitchhiker s Guide to Parenteral Nutrition Management for Adult Patients

. ก. F
ก F ก F

(Introduction)
ก F กF F F FF ก F ก ก F Enteral
Parenteral กF F F F F ก F F
ก F F ก กF F F F F ก F
F ก (specialized nutrition support) ก ก ก F F F ก ก
F ก ก F F Parnteral Nutrition F Fก ก F
Fก F ก F Parenteral nutrition F กF F

F F F (Indication)
กก ก F (Nutrition support) Fก ก ก F F ก F F ก ก
F F F F ก ก F infusion F F F ก
1
F Fก F กF F F ก ก F กF F F F F F
F ก ก F ก F กF
1. ก F F (central parenteral nutrition; PN) ก Fก ก
1,2
กF กก F central venous catheter F F thrombosis ก F
2. ก F F (peripheral parenteral nutrition ; PPN)
F F F (Indication) F F F (Contraindications) ก F
1

ก F (Patient assessment)
ก F กF ก F PN F ก F ก ก F
ก ก metabolic change F ก F F F F ก ก F
F 2 ก ก F F ก ก F

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1 Indications, Relative Indications Contraindications ก F
(Parenteral Nutrition)
F F F ก F Parenteral Nutrition
o F F F F กF
- Massive small-bowel resection/short bowel syndrome ( F F ก)
- Radiation enteritis
- Severe diarrhea
- Untreatable steatorrhea/malabsorption ( F F ก ก F , small bowel
bacterial overgrowth celiac disease)
o ก F F pseudo-obstruction
o Severe catabolism F F F 5-7
malnutrition F F Fก F
o F Enteral F
o F ก F F F Enteral F F
o ก (Pacreatitis) F ก F F (abdominal pain ) กก F F
jejunum
o ก F F (Persistent GI hemorrhage)
o F (Acute abdomen/ileus)
o กก F F
o Enterocutaneous fistula output ก ก F 500 ml F F F enteral F F F
fistula F
o F F F ก F ก
Relative Indications ก F Parenteral Nutrition
o Enterocutaneous fistula
o Inflammatory bowel disease F Fก ก F ก F
o ก กก ก F ก F F กก F 5-7 F F
Enteral F
o Partial small bowel obstruction
o F F F / severe mucositis
o Major surgery/stress F F FF ก F Enteral nutrition 7-10
o ก F ก F F Enteral nutrition F F F jejunum F
o F (chyle) F ก (Chylous ascites) chylothorax ก

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F enteral nutrition F ก F ก F F ก ก ก F
F
Contraindications ก F Parenteral Nutrition
o F F ก
o F F F F severe malnutrition F F ก ก Fก 5
o F F F (venous access) F
o ก ก F F F F F F aggressive nutrition support
o ก F F risk ก F PN กก F benefit

2 F F FF F Parenteral Nutrition
o F ก ก ก F (Anthropometric Data) F กF
- ก ก
- F ก
o F F ก (Lab values) F กF
- F F ก ก ก metabolic panel (Comprehensive metabolic panel)
- ก ก (Serum magnesium level
- ก (Serum phosphorus)
- triglycerides ก (Serum triglycerides) 18
o ก F ก F (Medical/Surgical History)
- ก F F F (ostomies)
- ก ก ก F (resections)
- Pre-existing conditions F F F
o ก ก F (Diet/Medication History)
- ก F F
- ก F
- Special diets
- /
- F F ก F F F F

ก F ก F ก F Physical stress, F F
F ก F F F F F F ก ก ก ก F F ก

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F ก F ก F F F ก F ก
F ก กF F F F ก F กF F ก Fก กF F
3,4
F F ก F ก F stress, fever seizures ก
F F ก ก F ก gold standard ก
F ก F ก F indirect calorimetry ก ก F ก F
F ก ก F ก F F F ก F ก -
F FF ก F ก ก F ก
F ก F
F F F ก ก F ก F ก F Fก FF F
F ก 3 F Guidelines ก ก
F , F ก F ก F F
F F nutrition support
5-8
3 guideline ก ก F F F F

(Nutrient) ก ก ก ก ก ก
(Acute Care ) (Critical Care)
(Energy) 25 30 total kcals/kg/d 25 total kcals/kg/d
- Refeeding 15 25 kcal/kg/d 15 25 kcal/kg/d
- Obesity (≥ 130% IBW) 15 20 kcal/kg/d adjusted weight * 15 20 kcal/kg/d adjusted
weight *
(Protein)
0.8 1.0 g/kg/d maintenance 1.5 2.2 g/kg/d
1.2 2.0 g/kg/d catabolism
Dextrose <7 g/kg/d <5 g/kg/d
(Lipid) ** <2.5 g/kg/d 0.4 0.75 g/kg/d
*Adjusted weight F ก F 50% correction factor ([usual weight ideal body weight] x 0.50)
**ก F F PN กก F 3 F, F F 2% 4% F F ก IV fat emulsion
(IVFE) F F F linoleic acid ก ก ก essential fatty acid deficiency (EFAD)

ก F F (Venous access)
Line F F กF F , F F F F F
ก F ก F F ก 4 F F ก
F ก F Parenteral nutrition support ก F F ก F ก ก F ก
ก F

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ก F F (Peripheral parenteral nutrition support;PPN)
ก F F F F F ก F ( F กF 2
F) กก F ก F F ก F F ก ก F ก
F PPN F ก , , , ก F F F (infusion
rates) กก F 150 mL/hr F F ก ก thrombophlebitis F F F
12,14
osmolarity F ก F 600 900 mOsm/L ก osmolarity parenteral solutions F 5
6 osmolarity 600 900 mOsm Hypertonic F F poor
peripheral access F F PPN ก F ก F F
F กF ก FF F Central PN ก F peripheral protein-sparing IV fluids
ก F 5% dextrose F ก F parenteral support F F F
F enteral nutrition ก F F ก F F F IV fluids F
F F F ก F PPN ก F F F parenteral support ก peripheral access
2-3 48 ก F F standard IV fluids F F F F F PPN
ก ก ก heparin hydrocortisone PPN ( F F ก nitroglycerin patch F Fก
)F catheter site F ก F ก F peripheral catheters F
16-18
( 7)
4 Access Devices F ก F Nutritional Support10-13

Line type F F
Peripheral Lines
Peripheral Short - - F F ก line F , ก
-ก F F กF phlebitis vein damage F
- Fก ก catheter F - F F ก ก
- กF F F ก nutrition ก ก ก ก F
support F F (<1 week) - Lumen ก 1 lumen
- F ก 48-72 - F ก osmolality 600 900
mOsm/L pH F 5-9

Peripheral Midline - F F ก F peripheral - F F F pH
catheters guideline ก peripheral lines
-ก F F ก F central lines - F F central line
- F F F F F

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4 Access Devices F ก F Nutritional Support ( F )
Line type F F
Central Lines
Peripherally Inserted - - ก F F ก F Central Lines
Central Catheters osmolality >900 mOsm/L F
PICC lines - trained RN F - ก Fก F F
- ก anticubital position
- F line F ก -ก ก F F F ก
Multiple lumens* F - ก F F F กF
- Fก CT contrast injection F - F ก F ก F
- ก F กก F
Hickman® - - F ก ก F ก Broviac®
osmolality >900 mOsm/L F F
- F Nutrition support IV route - F ก
F F F
- F line F ก ML* F -ก ก F กก F
- F F -ก F F line F ก
- locked F normal saline F F F F F
Femoral Lines - F IV access กF F F - Fก
ก F
Multiple Lumen acute - ก - Fก
care catheters trained RN F - F ก acute care F F F
- F F F F ก F F
Radiology F
Port -ก F - ก F line ก F ก
Fก F กF ก F F F ก F
- F F F F - F ก access port F Huber -
- ideal intermittent access needle Fก

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5 ก Osmolarity IV Admixtures
ก Osmolarity IV Admixtures
o ก , mEq mL F F mOsm/Unit 6
o F F F F ก ก F F total mOsm Admixtures
o formulation F F F
o total mOsm F the total volume (Liters) F F mOsm/L formulation

6 Milliosmoles F F TPN formula15
F (Additive) mOsm/Unit
Sterile Water 0.00
Dextrose Options (3.4 cal/g)
Dextrose 5, 10, 30, 50, 70% ~5 mOsm/g
Amino Acid Options (4 cal/g)
Amino Acid 8.5, 10, 15% ~10 mOsm/g
Intravenous Fat Emulsion (IVFE) Options
10% (1.1 cal/mL)
20% (2.0 cal/mL) ~0.280 mOsm/mL
30% (3.0 cal/mL)
Micronutrients
Calcium Gluconate 0.662 mOsm/mEq
Magnesium Sulfate 1 mOsm/mEq
Multi-trace Elements (MTE-5) 0.36 mOsm/ml
MVI infusion Concentrate (MVI-12) 41.1 mOsm/dose
Potassium Acetate 2 mOsm/mEq
Potassium Chloride 2 mOsm/mEq
Potassium Phosphate 2.47 mOsm/mM
Sodium Acetate 2 mOsm/mEq
Sodium Chloride 2 mOsm/mEq
Sodium Phosphate 4.0 mOsm/mM

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7 Vein Protector ก F Peripheral Parenteral Nutrition
Vein Protector ก F Peripheral Parenteral Nutrition F กF
o Hydrocortisone 15 mg
o Heparin 1500 units
o F ก transdermal nitroglycerin (NTG) patch 0.1 mg/hour

Peripheral lines ก 48-72 F F ก ก ก
13
thrombophlebitis Fก F PPN F F central venous access F F F
F ก F Nutrition support criteria F 8 F F F
intravenous nutrition support F ก criteria ก F PPN F F F Nutrition support
central PN
8 criteria F ก F Peripheral Parenteral Nutrition
criteria F ก F Peripheral Parenteral Nutrition F กF
o F ก F ก F 1800 kcals F
o F F ก F intravenous nutrition support F ก 10-14
o F ( peripheral veins) ก F
o F ก F 1 intravenous line F ก ก intravenous fat emulsion (IVFE) F
piggyback infusion
o F F F ก

ก ก F Fixed concentration PPN product F ก F
ก F ก F ก F dextrose F F F
F F กF 5% 10% 3% glycerol amino acids F F F 3% - 4.25%
F F electrolytes F ก F F PPN formulations F F intravenous
fat emulsions (IVFE) electrolytes F F F F ก F
F F F ก IVFE F F F IVFE F F 10% 20% F F piggyback F IVFE
F isotonic osmolarity ก F osmolarity F F F
F F ก กก F 70 % F F F ก F F
ก F 1 gm/kg/day ก Fก ก immune function Fก ก F infusion long
chain triglycerides19 ก ก ก Fat Overload Syndrome F F IVFE ก / ก ก
ก ก F F กF hypertriglyceridemia, ,F clotting disorders, hepatosplenomegaly variable end organ

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dysfunction F ก ก ก ก F F ก F F ก F IVFE ก
ก 20,21 F ก F F ก ก ก F ก F anesthesia sedation
propofol 10% IVFE F

ก F F F ก (Central nutrition support)
ก F Central venous catheters F F F F ก F 2 6 L/min
ก ก F F nutrition formulations
osmolarities กก F 900 mOsm/L (~1500 2800 mOsm/L) F ก F F ก Central venous access F กF
Groshong®, Hickman®, Hohn®, multiple lumen catheters, peripherally inserted central catheter (PICC) lines
implanted intravenous port devices ก central catheters multiple lumens single lumen
ก F F PN F 22 distal lumen ก lumen F ก F F ก
ก blood transfusions ก ก F (blood sampling) Central catheters route of choice
F F ก ก F F congestive heart failure (CHF) F renal failure F , F
peripheral venous access F ก F F F PN กก F 10-14

ก ก ก F TPN (Designing the formulation)
Macronutrients
F (Carbohydrate)
F F ก F 60 % กF F ก F F ก ก F
F ก ก F กF F dextrose
F F F ก 7.2 g/kg/day (5 mg/kg/minute) ก
23
ก fatty liver hyperglycemia F ก F F ก F F FF ก ก
F กก F F F F F F dextrose
กก F 5 mg/kg/minute F F F ก F ก maintenance ก ก ก

(Protein)
(Amino acids) F F F 1.5 g protein/kg/day Fก
stress catabolism ก F F F ก (Critical care), F F F ก
F (post-surgical), F Burn, F F dialysis F ก ก
F ก F 1.2 2 g/kg/day F F severe catabolic states F ก ก
2 2.5 g/kg/day24 F Acute renal failure ก F ก 1.5 1.6 g/kg/day ก
25
ก ก F glomeruli กก dialysis ก F renal insufficiency
renal failure F F F ก ก F F urea nitrogen ก ก

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.

26
F F 0.8 gm/kg F ก ก ก กF กก ก F
F ก F F ก ก protein utilization F glucose
F F , ก ก endogenous protein (lean body mass) F Fก F กก F ก F
F ก F Nitrogen F 25% ก ก 1.3
g/kg/day 1 g/kg/day F ก 75 ก ก F F F 22 g/day GI
bleeding, hyperglycemia trauma/sepsis Fก ก กF 22 g/day F F
standard practice ก ก F liver failure F ก F ก F F ก Fก
ก F Fก กF F F FF ก ก ก ก hepatic Encephalopathic F
F ก F ก ก ก ก ก F F F F กF
27 28 9 ก ก F amino acid ก F
F F

ก F (To Count, or Not to Count Protein as Calories?)
F (Total calories) ก F F ก ก F ก F F F
tube feeding ก ก ก ก F PN protein non-protein calories F F F ก29,30
ก F nonprotein calories ก ก F ก ก ก protein utilization F
F Amino acid กF F catabolic (catabolic patient) F ก ก ก oxidation
amino acid กก F Fก ก infusion amino acid ก F amino acid ก F ก pathways
ก ก utilization substrate F F F ก F 1 pathway Mixed fuel utilization ก
ก F F relative amounts F substrate ก ก

(Fat)
Intravenous fat emulsions (IVFE) กF กก F lipid emulsions ก F F กF F
F F 20-30 F F F F F ก F F F ก กF
กก F F กF ก F hypertrigly-ceridemia ก F F infusions propofol
(vehicle propofol 10% IVFE F essential fatty Acids, (1.1 cal/mL infused) vitamin K)31 F
10 lipid emulsions ก F F ก K
F ก F F ก F K F F Fก F
F F lipid emulsion F F ก safflower oil K F กF F F
ก soybean oil ก ก F F F lipid emulsion ก F F F
K F F F K F F F lipid emulsion
32-34
ก 10% 20% F

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9 Crystalline Amino Acid ก F

ก F / F F F F F
Aminosyn II™ Standard 3.5%, 4.25%, 5%, 7%, 8.5%, 10%
Travasol™ Standard 3.5%, 4.25%, 5.5%, 8.5%, 10%
Aminosyn II™ Standard/fluid restriction 15%
Clinisol™ Standard/fluid restriction 15%
Novamine™ Standard/fluid restriction 15%
Prosol™ Standard/fluid restrictions 20%
Hepatamine™ Hepatic failure 8%
Hepatasol™ Hepatic failure 8%
Aminosyn HBC™ Metabolic stress 7%
Freamine HBC™ Metabolic stress 6.9%
Branchamin™ ( F ก F Metabolic stress 4%
leucine, isoleucine valine F
ก Standard amino acid base)
Amino PF™ Pediatric 7%, 10%
Trophamine™ Pediatric 6%, 10%
*
Aminess™ (EAA + histidine) Renal 5.2%
Aminosyn RF™ (EAA+ arginine) Renal 5.2%
Nephramine™ (EAA+ histidine) Renal 5.4%
Renamin™ (EAA non-EAA
) Renal 6.5%
*
EAA= Essential amino acids
ก Barber JR, Miller SJ, Sacks GS. Parenteral feeding formulations. In: Gottschlich MM, Ed. The Science and
Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.;2001: 251
268 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
A.S.P.E.N. does not endorse the use of this material in any form other than its entirety.

Micronutrients
ก ก F PN Fก F ก F , ก metabolism
กก F F F F F F 11 F ก F

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ก FF F parenteral ก ก F ก ก , กก ก GI suction, กก
surgical drains, F ( ), (emesis), F (diarrhea) F F F ก
PN IV Solutions 12 ก F
F ก F F ก
32-35
10 K Intravenous fat emulsions (IVFE) F
Lipid Emulsion F Soybean Oil Safflower Oil K
(Kcals/mL*) (g/L) (g/L) (mcg/dL)
Intralipid 10% 1.1 100 0 30.8
Intralipid 20% 2 200 0 67.5
Intralipid 30% 3 300 0 93
Liposyn II 10% 1.1 50 50 13.2
Liposyn II 20% 2 100 100 26
Liposyn III 10% 1.1 100 0 31
Liposyn III 20% 2 200 0 62
Liposyn III 30% 2.9 300 0 93
* F ก F ก ก lipid
F glycerol F ก IVFE

11 F ก F ก ก , ก ก F ก F Parenteral Enteral36-
38

Electrolyte Normal Serum Range* Parenteral Intake Range Adult Enteral Requirements
Sodium 135 145 mM/L 0 200 mEq/L 100 150 mEq/day
Chloride As needed to maintain acid-base balance
Potassium 3.5 5.1 mM/L 0 240 mEq/day 60 120 mEq/day
Acetate** As needed to maintain acid-base balance
Phosphate 2.3 4.7 mg/dl 0 60 mM/day 15 30 mM/day
Magnesium 1.7 2.5 mEq/L 0 48 mEq/day 8 24 mEq/day
Calcium 9.2 11.0 mg/dl (ionized calcium
0.8 1.2 mEq/L) 0 25 mEq/day 9 22 mEq/day
*Note: F ก ก F ก ก F ก ก F F ก F ก
**Acetate ก bicarbonate

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36
12 ก F F ก F Body fluids F ก

F/ F (mL/d) ก F (mEq/L)
Na K HCO3 Cl
500 2000 2 10 20 30 30 8 18
ก 2000 2500
pH<4 60 10 90
pH>4 100 10 100
F 1000 140 5 90 75
1500 140 5 35 100
F ก 3500 100 15 25 100
F ก 60 30 75
1000 4000 60 30 45 45
1500 40 0 20
1500 50 5 55
Reprinted from Matarese LE. Metabolic complications of parenteral nutrition therapy. In: Gottschlich MM, Ed. The
Science and Practice of Nutrition Support: A Case-Based Core Curriculum. 2001;269-286, with permission from the
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material
in any form other than its entirety.

F F ก ก ก Prepared multivitamin trace metal ก F
กF cocktails F ก F ก F ก ก ก F
F F 13 F F ก ก parenteral multivitamin injections Fก
39
(FDA)
ก F Parenteral nutrition F ( F กF 1 F) F F FF F K
F ก F F Parenteral nutrition กก F 1 F 1 F FF F K
40,41
2 4 mg/ F F ก F F F ก F F Infuvite® (Baxter Healthcare Inc,
Deerfield, IL) MVI-Adult® (Mayne Pharma (USA), Paramus, NJ) F standards F FDA F
ก K F Mayne Pharma F F F K F ก (MVIAdult without
vitamin K®) Fก F F F F ก F F F F F warfarin ก F F
K F F ก ก K ก F F wafarin
F F K F ก F F F F ก F ก F anticoagulant

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42
Fก กF F กF F ( 10 ) F IVFEs ก K F ก
Fก oils F F ก , ก infusion F F lipid emulsion
10
39
13 Intravenous Vitamins F F F 1

FDA/AMA/NAG* /

Thiamin (B1) 6 mg
Riboflavin (B2) 3.6 mg
Pyridoxine (B6) 6 mg
Cyanocobalamin (B12) 5 mcg
Niacin 40 mg
Folic Acid 600 mcg
Pantothenic acid 15 mg
Biotin 60 mcg
Ascorbic acid (C) 200 mg
Vitamin A 3300 IU
Vitamin D 5 mg
Vitamin E 10 IU
Vitamin K 150 mcg
*National Advisory Group on Standards and Practice Guidelines for PN (ASPEN)

F F 1 F 14 F
manganese F F ก FF F PN F F F ก
44
ก F F ก manganese ก multivitamins
trace elements F F ก F ก F F cholestatic liver disease
F manganese copper 45, 47 F

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43
14 Intravenous Trace Minerals F 1 F F F F

F (Trace element) /

Chromium 10 15 mcg
Copper 0.3 0.5 mg
Manganese 60 100 mcg
Selenium 20-60 mcg
Zinc* 2.5 5.0 mg
*Note: zinc F F ostomy stool output lost:
12.2mg/L small bowel fluid
17.1mg/kg stool / ileostomy
Adapted from Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P; Task Force for the
Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. J Parenter Enteral Nutr, 2004;
28:S39 S70 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N.
does not endorse the use of this material in any form other than its entirety

(Medications)
PN F F F ก F กF H2-
48
antagonists F กF F F ก F F

(Insulin)
Hyperglycemia กF F F F F PN ก ก regular Insulin (RI)
PN F F F F F F FกF F
F ก RI 1 unit F 10 ก dextrose F F PN F fasting
blood glucose F F ก F PN กก F 200 mg/dL F RI F F
F F RI 1.5 2 units F 10 g dextrose F ก F sliding scale F RI กก F
1 rapid acting
insulin analogs F insulin lispro (Humalog®) insulin aspart (Novolog®) medication regimen
F F PN F ก F F F ก F ก F ก insulin
analogs F F F F F PN F PN F RI F
PN F F ก F F

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duration ก F ก ก ก F ก F F F
Fก ก FF F PN ก F F F sliding scale insulin F ก F PN กF
F ก ก F F ก Fก ก
F , F F F F กก F enteral กF F
F
F F F ก ก ก ก ก ก F
PN F ก F F F ก RI F F ก F 2 units F 10 ก
dextrose F ก Fก ก F F ก F F F ก
ก F กก ก F F ICU ก Fก ก
F ก ก F F ก F F F F 80 130 mg/dL49
ก F IV drip ก F sliding scale insulin regimen F F ก F
ก ก hypoglycemia, F FF ก PN admixture F ก ก
ก ก F IV drip ก F กF F F
PN F F กก 2/3 infusion F ก F PN กF F ก F
ก กF ก bioavailability PN ก F
ก F F Dextrose F ก ก F F
ก F Fก F F ก ก F ก F
ก ก FF F dextrose F F F IVFE
FF F ก F F ก dextrose ก F F ก
F ก F PN กF F F ก 50 F
ก ก F ก ก F F F F ก ก F
F 15 ก ก ก ก ก ก F
F ก ก ก ก F , stress activity F F ก F ก ก
F F 16 ก F ก
F

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51, 52
15 F

Fก Hyperglycemia Fก Hypoglycemia
Corticosteroids Flouroquinolones
Diuretics - Gatifloxacin
Adrenergic agents Insulin
Cyclosporin Alcohol
Tacrolimus Sulfonylureas
Sandostatin Methandrostenolone
Phenytoin Clofibrate
Phenobarbital Cypionate
Lithium B-blockers
Calcitonin Monoamine Oxidase Inhibitors (MAOI)
Rifampin

16 ก ก
ก ก F กF
o F FF F ก ก
o F ก ก dextrose TPN F F ก 150 mg/ day
o ก IV dextrose F F F ก CVVHD,
กก peritoneal dialysis, กก antibiotic drips F ก dextrose
F F F
o unit ก F sliding scale
o ก ก ก ( ก 4-6 )
o drips
o ก F TPN กF F 24 F F กF
F

ก F H2-antagonists
F F F ก ก ก ก Gastrointestinal stress ulcer ก F ก F H2-
antagonists PN F famotidine F F F 72
53
3-in-1 admixtures F ก F F 20 mg ก 12

17
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.

40 mg PN 24-hour bag F ก Famotidine
ก ก F clearance F ก F 50 mg/min 50%
ก ก famotidine F ranitidine ก PN F F ก
54
3-in-1 admixtures F 24 F F ก กก F F 10 F 48
ranitidine F F F F 200 300 mg F F Fก 400 mg
50 mg F F F creatinine clearance F ก F 50 mg/min55 ก F F ก F proton
pump inhibitor F F F F F F F ก F H2-antagonist ก

ก (Iron)
Chronic home PN patients F F F F Iron supplement F F F ก ก
ก F F 6 ก ก ก ก กก ก F F PN F F
56
ก supplement ก F 2 ก F Iron dextran 2-in-1 PN formulations 10 75
57,58
mg/day F F Fก ก F F F F ก F ก ก ก ก ก
F Fก ก Iron dextran 3-in-1 PN admixtures58 ก ก F Anaphylaxis
ก F F ก ก ก ก F supplement กF ก
PN F F ก F F Ferrlecit® (Na ferric gluconate complex) Schein
Venofer® (iron sucrose iron saccharate complex) American Regent ก F ก Fก F
supplement ก ก F ก ก PN F ก F PN formulations F F
ก ก F F F PN F F F ก ก ก ก compatibility F ก F
PN ก F F F ก F ก ก

F F ก F PN (Frequently asked questions in the clinical setting)

F PN ? F (How Should PN Be Initiated?)
FF ก F Infusion PN ก F ก F Fก F F F
F F F Fก ก refeeding F F F PN F
F กก F F ก F F ก F ก F ก F ก F
F ก ก F F ก ก F F ก F PN F F
PN ก F F F PN F ก F F F F ก
ก ก ก F metabolism F F F F overfed F
Hyperglycemia ก ก ก utilization F
ก PN formulation ก ก F Overfeeding กF F FF F F F F ก
dextrose macronutrient F F ก ก F PN F ก F ก

18
………………………………………………………………………………………………………......

.

ก F dextrose F F F F F F F
ก F ก ก F F ก PN ก F ก refeeding
hyperglycemia ก F F F F ก ก ก F PN ก F PN F F
F ก ก F F F reformulation ก F Fก F
F ก F ก F Fก F F กF F F

F F PN ? (When Should PN Be Discontinued?)
F F F ก ก F enteral nutrition ก
F F
PN F F ก F F กก F enteral feeding F ก F PN F F F
F F F enteral feedings กก F F 50 F F กก
F F enteral กก ก F F Fก F F ก ก F F
F F กก F PN F ก กF F Fก F F enteral ก
F F F กก F ก F (enteral ก ) F ก F F 50
F F
ก FF ก F PN F ก 2-3 ก ก ก F ก F PN
F ก F F กF F F F ก กF F F F ก F
hyperglycemia ก ก ก F PN F F F F
FFก F PN therapy ก glucose tolerance test กF F

PN F ? (How Should PN Be Tapered?)
F ก F ก F F ก PN formulations กF ก FF ก F
PN ก F PN FF ก hypoglycemia F F Rebound
hypoglycemia ก F F Fก ก ก ก F 59-61 F F PN
Fก ก hypoglycemia F ก Fก F ก F F ก
ก ก ก hypoglycemia F F F ก ก ก
F ก F PN ก ก
F drips F half-life Regular Insulin 5 ( F ) ก
F PN F F F ก F F ก F F F F
F กF F F ก hypoglycemia F ก F PN F
1-2 กF F ก ก ก hypoglycemia ก F

F ก ก Refeeding? (When Should I Be on the Lookout for Refeeding?)
F ก ก ก ก ก F กก
F ก ก F F PN F F F ก F ก F ก ก ก

19
………………………………………………………………………………………………………......

.

refeeding refeeding ก F Refeeding syndrome ก ก F
, ก / ก ก กก ก F F ก
ก F FF ก F ก ก F ก / ก
refeeding syndrome F กF ก Fก F F
ก F F ก / ก กF F F F กF
F F F ก ก F supplement ก F F
62
F F Stable F F F F PN F F F

ก F F PN ก ก ? (What Happens If the Patient is Overfed?)
ก F ก F F F ก ก ก F ก (hyperalimen- tation) F
parenteral F ก F catabolic (catabolic patients) ก F
ก ก (overfeeding) F ก F ก กF F
Fก F กก F Fก F F ก F F ก F ก obligatory
hypercatabolism F Fก กF F F ก F feeding63 ก FF ก F F ก
64,65
ก (overfeeding) F F ก F , F ก F
ก F PN F ก F F F F F ก ก ก F 30 35 kcal/kg F ก F
indirect calorimetry ก F F F ก F F ก
ก F F F ก ก F F F ก
66
ก (overfeeding)

F 3-in-1 ก 2-in-1 formulation F ก F ก ? (Which is Best? 3-in-1 versus 2-in-1)
F F ก กก F Traditional 2- in-1 PN admixtures 3-in-1 admixture 3-
in-1 admixture ก IVFE amino acid/dextrose ก IVFE ก F F ก ก F
F F ก F F ก F ก ก 17

Hang Time IVFE (Intravenous Fat Emulsion Hang Time)
CDC F F F F F 3-in-1 solutions F ก infusion F กF F F ก 24
ก F ก ก ก ก IVFE F F ก F 2-in-1
solutions F IVFE F F F ก 12

20
………………………………………………………………………………………………………......

.

17 F F Total Nutrient Admixture (3-in-1) System
F Total Nutrient Admixture (3-in-1) System F กF
o F ก ก F ก ก F ก
o ก ก ก F ก ก F F ก

o F ก ก ก F
o Fก F
o F nursing time 1 bag/day F F F piggyback
o F ก F F FF F F F pump IV tubing
o ก ก ก ก F Fก ก home care settings
o Glucose venous access tolerance ก F ก F
o F ก F
F F ก ก
o cost-effective ก F
F Total Nutrient Admixture (3-in-1) System F กF
o ก particle lipid emulsion F F F F F ก 0.22- (ก
bacteria-eliminating) F F F ก pore size ก F 1.2
F
o ก lipid emulsion F F F ก ก ก F ก ก
F
o F F ก Fก F ก ก F ก F
o Fก ก ก F ก F ก
o ก ก incompatibility F ( F ก admixture F ) ก F lipid emulsion
o ก ก Catheter F F
o F ก ก F pediatric settings ก ก ก ก pH compatibility

Reprinted from Barber JR, Miller SJ, Sacks GS. Parenteral feeding formulations. In: Gottschlich MM, Ed. The
Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing
Co.; 2001: 251 268 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
A.S.P.E.N. does not endorse the use of this material in any form other than its entirety

Series Editor s Note: . . 1982 The Centers for Disease Control and Prevention F F FF
69
ก Infusion lipid emulsions F 12 ก F F
70
ก ก . . 1996 CDC F F ก lipid 3-in-1 solution F 24

21
………………………………………………………………………………………………………......

.

71
F ก ก F IV lipid emulsions F 12 ก ก
ก ก F F ก ก F ก F lipid emulsions 3-in-1 solution ก ก
F IV lipid Emulsions 24 ก ก F F F ก F F ก ก
กF ก ก ก F F ก F F F lipid emulsion ก F 72
ก CDC F ก F กก ก invitro กก
F กF F Fก F F ก ก ก กก F F F
24 F F ก F 12 F ก ก ก
ก F line F ก ก ก ก ก ก ก F ก ก hang-time
F lipid
emulsions ก F ก F ก ก ก

ก ก F ก Serum Electrolyte (What is the Best Way to Manage Serum
Electrolyte Abnormalities?)
ก ก F ก ก ก F parenteral formulations F
ก F ก F F F , organ function, oral/enteral intake F F
F F F ก F F F ก F F F F
F F ก ก ก F F F PN F ก ก F
serum electrolyte กก F F F Serum electrolyte กF F F
กก ก F ก ก F F ก ก
ก F PN F F F F ก ก ก ก F F F PN
ก F ก F PN F ก ก guidelines ก Fก ก F ก
F ก F 44,67,68

F F F ? (How Often Should Labs Be Checked?)
F ก ก F PN ก F ก ก ก ก ก F
กก F PN ก F ก F ก F
Fก Guidelines ก F F ก F (Guidelines for appropriate lab
monitoring) 18

ก F กก F PN (Long-term Complications)
กF กก F PN F กF fatty liver, cholestasis, metabolic bone disease,
electrolyte/ vitamin/mineral depletion electrolyte/ vitamin/mineral toxicity46 ก F F
F PN ก ก ก F กก F PN F Fก F กF

22
………………………………………………………………………………………………………......

.

ก ก longterm complications ก F PN F F ก ก F
47 19 กF ก F PN
18 F ก F F ก (Lab value) F F Parenteral Nutrition

F ก Baseline ก F F ก
F ก ก F PN F ก F ก
- CBC with differential ก F ก F
- PT, PTT ก F ก F
- Basic chemistry-Na,
K, Cl, CO2, BUN,
Creatinine ก 3 ก 1-2 F F
- ก ,
1 ก F
- Serum triglycerides 1
- Serum glucose ก ก 1-2 F F
- Capillary glucose ก6 hr 2 3 /
กF
<150 mg/dl*
- ก ก ก 2-3 F F
- Intake and output ก ก
- ALT, AST, ALP, total 1 ก F ก
- Bilirubin, Nitrogen
Balance

* F F F 80-130 mg/dl
ก Mirtallo JM. Introduction to parenteral nutrition. In: Gottschlich MM, Ed. The Science and Practice of
Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall/Hunt Publishing Co.;2001: 211 223, with
permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse
the use of this material in any form other than its entirety.

9, 36
19 กF ก F PN

23
………………………………………………………………………………………………………......

.

ก ก ก /ก ก
Fatty Liver F F F F LFTs - ก F overfeeding
F ก F ก ก F Overfee- - F F macronutrients
ding dextrose / total ก ( 3)
calories ก F overfeeding - FF F
, EFAD, ก carnitine enteral F
choline F F
- F Enteric antibiotics
- Taurine PN

Cholestasis F F F F alkaline phosphatase - ก F overfeeding
F ก
F ก ก total bilirubin - F F macronutrients
F F ก ก F ก ก ( 3)
Fก - FF F
ก F , ก F overfeeding enteral F
glucose, lipid / amino acids, F F
toxic tryptophan metabolites - F Enteric antibiotics
ก choline

GI Atrophy ก villi in vivo: enteric bac- - FF F EN F
ก enteral nutrients teremia sepsis F F

Gottschlich MM, Ed. Nutrition Support Dietetics Core Curriculum. 2nd edition. American Society of Parenteral and
Enteral Nutrition. Silver Spring, MD: 1993.

24
………………………………………………………………………………………………………......

.

F Fก F ก F ก ก (What Should You Do
When the Labs on Your PN Patient Look Like This?!!)

Fก F ก 4.00 .
Sodium 125
Potassium 6.7
Chloride 101
CO2 17
BUN 12
Creatinine 0.7
Glucose 896
Triglycerides 684
Magnesium 3.5
ก F ก F F F
o F F F (20 units SQ) sodium polystyrene resin (Kayexalate®) 30 mL enema STAT
o F F F endocrine
o fingerstick glucose กF ก F
ก ก FF F F F ก ก ก F ก F PN
ก F draws ก central line F ก ก flushing F
ก ก F Fก F PN, ก line flushing , ก initial aspirate F ก ก draw
F ก F ก F ก F PN F F F F ก F PN / ก flushing
F Fก draw ก F F ก F ก ก ก F
ก F ก ก,
potassium triglyceride F ก ก F PN ก ก F F ก
F ก ก F ก finger stick blood sugar ก F F ก
ก ก ก F F

(Conclusion)
ก F PN F F ก ก ก ก F F ก ก F
ก F F F F F F F
ก F nutrition Support กF ก F F - ก กF F
ก F F F กF F F กF unfeedable. F F ก 20
(summary guidelines) ก F PN

25
………………………………………………………………………………………………………......

.

20 (summary guidelines)
(summary guidelines) ก F PN F กF
o F indication ก ก F PN F
o F (medical/surgical history, review drug/medication profile, anthropometric data lab values)
o F F F F PN F F( (7-10 ))
o F ก , F
o 20 30 kcal/kg
o 0.8 1.5 gm/kg ( ก F F severe catabolic states)
o F กF F ก 30%
o ก F ก ก ,F F
o ก ก ก F ก PN formulation F ก F H2-antagonists

o F
o F ก ก refeeding syndrome
o Glucose intolerance ( F ก F dextrose F กF F F
กF F F ก F F F 24-
48 )
o F ก enteral F F F F F F
ก ก F

Acknowledgment
Gordon S. Sacks, Pharm.D., BCNSP, FCCP Clinical Associate Professor Schools of Medicine and Pharmacy University
of Wisconsin Madison
ก F (References)
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6. National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition. J Parent Enteral Nutr,
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