Parenteral Nutrition

1
Parenteral Nutrition
2
Objectives

• To define Parenteral Nutrition Therapy
• To explain parenteral nutrition components
• To describe monitoring parameters of parenteral
  nutrition

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Definition

• Parenteral nutrition is partial or total
  nutrition administered intravenously. A
  peripheral or central vein is used for access.

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Indications Parenteral Nutrition

• Non-functional gastrointestinal tract
• Inability to use the gastrointestinal tract
• intestinal obstruction
• peritonitis
• intractable vomiting
• severe diarrhea
• high-output enterocutaneous fistula
• short bowel syndrome
• severe malabsorption.
• Need for bowel rest

Palliative use in terminal patients is
controversial.
ASPEN Board of Directors. JPEN 2002 26 Suppl 1
83SA
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Contraindications Parenteral Nutrition

• Ability to consume and absorb adequate nutrients
  orally or by enteral tube feeding
• Hemodynamic instability

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Formulas Parenteral Nutrition

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Central Parenteral Nutrition

• Selection depends on caloric requirements, volume
  to be administered and patient condition, as well
  as final concentration of components
• Amino acids gt 5
• Dextrose gt 20
• Lipids
• Includes vitamins, minerals, and trace elements
• Osmolality gt 700 mOsm/kg H2O

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Formulas Parenteral Nutrition

• Dextrose
• Provides 3.4 kcal/g
• Can be the only source of energy
• Dextrose infusion rate should not exceed 5
  mg/kg/min
• Closely related to solution osmolality

Hill GL, et al. Br J Surg 1984711
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Formulas Parenteral Nutrition

• Amino Acids
• Standard concentrations can vary between 5 and
  15
• Energy value of amino acids (4 kcal/g)
• Nitrogen (g) protein (g) / 6.25

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Sources of Protein Parenteral Nutrition

• Customize this slide for your situation. Indicate
  the available parenteral protein solutions for
  your country i.e., standard and specialized
  solutions

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Formulas Parenteral Nutrition

• Lipids
• Prevent essential fatty acid deficiency
• Non-protein source of kcal. Recommended dose1
  g/kg/day
• Available in 10, 20 and 30 concentrations
• Included as LCT or a mix of MCT/LCT at 10 and
  20
• Added to basic parenteral nutrition solutions or
  administered individually

Trimbo SL, et al. Nutr Supp Serv 1986618
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Formulas Parenteral Nutrition

• Lipids
• Less hyperglycemia
• Lower concentrations of serum insulin
• Less risk of hepatic damage
• High doses can interfere with immune functions
• High infusion rates can affect respiratory
  functions
• Should be used with care in
• Hyperlipidemia
• Symptomatic atherosclerosis
• Acute pancreatitis with hypertriglyceridemia

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Formulas Parenteral Nutrition

• Electrolytes
• Calcium, magnesium, phosphorus, chloride,
  potassium, sodium, and acetate
• Forms and amounts are titrated based on metabolic
  status and fluid/electrolyte balance
• Must consider calcium-phosphate solubility

Alpers DH, et al., eds. In Manual of
Nutritional Therapeutics. Little, Brown and
Company 1995
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Formulas Parenteral Nutrition

• Vitamins and Minerals
• In general, amounts below daily recommended
  intake for healthy people, but nonetheless
  sufficient to cover requirements, are added to
  oral or enteral formulas
• Added daily to parenteral nutrition
• Acute illness, infection, preexisting
  malnutrition, and excessive fluid loss increase
  vitamin requirements

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Formulas Parenteral Nutrition

• Trace Elements
• Include daily zinc, copper, chromium, and
  manganese for patients with kidney or liver
  failure
• Different requirements dictated by patient and
  pathology
• Patients under extended parenteral nutrition
  require the addition of iron and selenium

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Peripheral Parenteral Nutrition

• Selection of peripheral access depends on
  clinical situation, requirements, tolerance to
  volume, and final formula concentration
• Osmolality lt 700 mOsm/kg
• Total kcal limited by concentration and ratio to
  volume being administered
• Include ½ of the recommended electrolytes for PN

Torosian MH, ed. In Nutrition for the
Hospitalized Patient. Marcel Dekker Inc. 1995
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PN Types of Infusion

• Continuous Total volume of formula is
  administered over a 24 hour period
• Cyclic Volume is administered in one period,
  with infusion adjustments and a period of rest
• Selection of infusion type depends on patients
  condition
• Use a parenteral infusion pump

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Monitoring Patient on Parenteral Nutrition

• Assessment
• Body weight
• Nitrogen balance
• Plasma protein
• Creatinine/height index

• Metabolic
• Glucose
• Fluid and electrolyte balance
• Renal and hepatic function
• Triglycerides and cholesterol

Campbell SM, Bowers DF. Parenteral Nutrition. In
Handbook of Clinical Dietetics. Yale University
Press, 1992
19
Summary

• Parenteral nutrition supplies partial or total
  nutrition by venous access
• Total parenteral nutrition components supply all
  required nutrients
• Metabolic monitoring and changes in solution
  components are needed to maintain adequate
  metabolic balance