Parenteral Nutrition

Definition A method of feeding patients by infusing a mixture of all necessary nutrients into the circulatory system, thus bypassing the GIT.
Also referred to as: intravenous nutrition, parenteral alimentation, and artificial nutrition.

The gut should always be the preferred route for nutrient administration.
Therefore, parenteral nutrition is indicated generally when there is severe gastrointestinal dysfunction (patients who cannot take sufficient food or feeding formulas by the enteral route) .

Categories of PN
If enteral feeding is completely stopped or ineffective, Total Parenteral Nutrition is used (TPN). If enteral feeding is just not enough , supplementation with Partial Parenteral Nutrition (PPN) is indicated.

INDICATIONS
In well-nourished adults, 7 - 10 days of starvation with conventional intravenous support (using 5% dextrose solutions) is generally accepted. If the period of starvation is to extend beyond this time, or the patient is not well-nourished, Total Parenteral Nutrition (TPN) is necessary to prevent the potential complications of malnutrition.

Indications for TPN

Short-term use
Bowel injury, surgery, major trauma or burns Bowel disease (e.g. obstructions, fistulas) Severe malnutrition Nutritional preparation prior to surgery. Malabsorption - bowel cancer Severe pancreatitis

Malnourished patients who have high risk of aspiration Long-term use (HOME PN)
Prolonged Intestinal Failure Crohns Disease Bowel resection

Partial Parenteral Nutrition:

PPN can be used to supplement Ordinary or Tube feeding esp. in malnourished patients. Indications: Short bowel syndrome Malabsorption disorders Critical illness or wasting disorders

 As far as gastrointestinal failure is concerned, long term parenteral nutrition is a life-saving procedure. Enteral nutrition has the advantage over parenteral nutrition of lower % of infectious complications. Parenteral nutrition has been shown to lead to changes in intestinal morphology and function and an increase in permeability (with higher % of bacterial translocation)

Enteral versus parenteral nutrition

Nutritional Requirements
Energy: Glucose Lipid Amino acids (Nitrogen) Water and electrolytes Vitamins Trace elements

Requirements:
Energy
Basal energy requirements are a function of the individual's weight, age, gender, activity level and the disease process. The estimation of energy requirements for parenteral nutrition relies on predictive equations. Hospitalized adults require approximately 25-30 kcal/ kgBW/day. However, these requirements may be greater in patients with injury or infection.

Energy Requirements
Patient condition Basal metabolic rate Normal Approximate energy Requirement (kcal/kg/day) 25-30

No postoperative complications, GIT fistula without infection Mild peritonitis, long-bone fracture, mild to moderate injury, malnourished Severe injury or infection

25% above normal 50% above normal

30-35

35-45

Burn 40-100% of total body Up to 100% 45-80 surface above normal

Requirements:
Energy Sources: Glucose
The most common source of parenteral energy supply is glucose, being: Readily metabolized in most patients, provides the obligatory needs of the substrate , thus reducing gluconeogenesis and sparing endogenous protein. 1 gm of glucose gives 4 Kcals.

Most stable patients tolerate rates of 4-5 mg.kg-1.Min-1,

but insulin resistance in critically ill patients may lead to hyperglycemia even at these rates, so insulin should be incorporated acc. to blood sugar levels.

Requirements:
Energy Sources: Glucose
Route

Glucose in 5% solution can be safely administered via a peripheral vein, but higher concentrations require a central venous line.

20, 25, or even 50 % solutions are needed to administer meaningful amounts of energy to most patients for proper volume administration.

Requirements:
Energy Sources: Lipid
Fat mobilization is a major response to stress and infection.
Triacylglycerols are an important fuel source in those conditions, even when glucose availability is adequate.

Need to be restricted in patients with

hypertriglyceridemia.

Requirements:
Energy Sources: Lipid
Lipids are also a source for the essential fatty acids which are the building blocks for many of the hormones involved in the inflammatory process as well as the hormones regulating other body functions.
Ideally, energy from fat should not exceed 40% of the total (usually 20-30%).

Requirements:
Energy Sources: Lipid
Fat emulsions can be safely administered via peripheral veins, provide essential fatty acids, and are concentrated energy sources for fluid-restricted patients.
They are available in 10, 20 and 30% preparations. Though lipids have a calorific value of 9Kcal/g, the value in lipid emulsions is 10Kcal/g due to the contents of glycerol and phospholipids.

Requirements:
Nitrogen Protein (or amino acids, the building blocks of proteins) is the functional and structural component of the body, so fulfilling patients caloric needs with non-protein calories (fat and glucose) is essential. Protein requirements for most healthy individuals are 0.8 g/kg/day.

Requirements:
Nitrogen
With disease, poor food intake, and inactivity, body protein is lost with the resultant weakness and muscle mass wasting.

Critically ill patients may need as high as 1.5-2.5 g protein/kg/day depending on the disease process: (major trauma or burn > infection or after surgery > standard)
The amount should be reduced in patients with kidney or liver disease.

Requirements:
Nitrogen Daily Protein requirements
Condition Basic requirements Example Normal person requirement 0.5-1g/Kg

Slightly increased requirements Moderately increased requirements Highly increased requirements Reduced requirements

Post-operative, cancer, inflammatory Sepsis, polytrauma Peritonitis, burns,

Renal failure, hepatic encephalopathy

1.5g/Kg 2g/Kg 2.5g/Kg

0.6g/Kg

Requirements:
Nitrogen Nitrogen Balance =
Protein intake in grams 6.25 UUN (in grams) + 3
The nitrogen lost in urine derives primarily from amino acids released by protein breakdown in response to catabolic mediators that include stress hormones (corticosteroids, catecholamines) and cytokines.

It is a way to assess the sufficiency of protein intake for the patient.

Requirements:
Nitrogen
Parenteral amino acid solutions provide all known essential amino acids.

Available a.a. preparations are 3.5 - 15 % (ie contains 3.5-15 gms of protein or a.a.s/100 mL solution).
1gm of protein = 0.16 gm of N2.

Requirements:
Nitrogen
Special a.a. solutions are also available containing higher levels of certain a.a.s, most commonly the branched-chain ones (valine, leucine and isoleucine), aimed at the management of liver diseases, sepsis and other stress conditions. Conversely, solutions containing fewer a.a.s (primarily the essential ones) are available for patients with renal failure.

Requirements:
Nitrogen Arginine was added to enteral formulae claiming positive effects on immune function and length of hospital stay.

In some clinical trials, glutamine-enriched solutions improved nitrogen balance and gut morphology.

Requirements:
Fluids and electrolytes 2040 mL/kg - daily young adults 30 mL/kg daily older adults Sodium, potassium, chloride, calcium, magnesium, and phosphorus ( as per the table) Daily lab tests to monitor electrolyte status

Requirements:
Fluids and electrolytes
Nutrient Water Sodium Potassium Magnesium Calcium Phosphate
Chloride/Acetate

Requirements (/Kg/day) 20-40 mL 0.5-1.0 mmol 0.5-1.0 mmol 0.1-0.2 mmol 0.05-0.15mmol 0.2-0.5mmol So a to maintain acid-base balance
(normally 0.5 mmol for Cl- , & 0.1mEq for Acetate)

Requirements:
Fluids and electrolytes
Normalization of acid-base balance is a priority and constant concern in the management of critically ill patients.

Most electrolytes can be safely added to the parenteral amino acid/dextrose solution.
Sodium bicarbonate in high concentrations will tend to generate carbon dioxide at the acidic pH of the amino acid/glucose mix.

Requirements:
Vitamins
These requirements are usually met when standard volumes of a nutrient mix are provided. Increased amounts of vits are usually provided to severely ill patients. Vitamins are either fat soluble (A,D,E,K) or water soluble (B,C). Separate multivitamin commercial preparations are now available for both.

Requirements:
Vitamins
Multivitamin formulations for parenteral use for adult patients usually contain 12 vitamins at levels estimated to provide daily requirements.

Additional amounts can be provided separately when indicated. Most adult vitamin formulae do not contain vitamin K, which is added according to the patients coagulation status.

Requirements:
Trace minerals
These are essential component of the parenteral nutrition regimen.
A multi-element solution is available commercially, and can be supplemented with individual minerals.

may be toxic at high doses. Iron is excluded, as it alters stability of other ingredients. So it is given by separate injection (iv or im).

Requirements:
Trace minerals
minerals excreted via the liver, such as copper and manganese, should be used with caution in patients with liver disease or impaired biliary function.
Mineral Recommended dietary allowance (RDA) for daily oral intake (mg) Suggested daily intravenous intake (mg)

Zinc Copper Manganese Chromium Iron

15 2-3 2.5-5 0.05-0.2 10 (males)-18 (females)

2.5-5 0.5-1.5 0.15-0.8 0.01-0.015 3

Osmolarity:
PPN: Maximum of 900 milliosmoles / liter

TPN: as nutrient dense as necessary (>900 m.osmol and up as high as 3000).

Amino acids (10 m.osmol/gm), dextrose (5 m.osmol/gm) and electrolytes (2 m.osmol /mEq) contribute most to the osmolarity, while lipids give 1.5 m.osmol/gm.

Application:
The Solution Manually mixed in hospital pharmacy or nutrition-mixing service, premixed solutions,

Separate administration for every element alone in a separate line.

Application:
Venous access
PPN: (<900 m.osmol/L): a peripheral line can be enough. TPN: Central venous access is fundamental, Ideally, the venous line should he used exclusively for parenteral nutrition. Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of the high rate of associated infection), or a long catheter placed in an arm vein and threaded into the central venous system (a peripherally inserted central catheter line) Once the correct position of the catheter has been established (usually by X ray), the infusion can begin.

Application:
Initiation of Therapy
TPN infusion is usually initiated at a rate of 25 to 50 mL/h. This rate is then increased by 25 mL/h until the predetermined final rate is achieved.

Administration
To ensure that the solution is administered at a continuous rate, an infusion pump is utilized to administer the solution. In hospitalized patients, infusion usually occurs over 22-24 h/day. In ambulatory home patients, administration usually occurs overnight (12-16 h).

Monitoring
Policy: to monitor: 1- Effecacy: electrolytes (S. Na, K, Ca, Mg, Cl, Ph), acid-base, Bl. Sugar, body weight, Hb. 2- Complications: ALT, AST, Bil, BUN, total proteins and fractions. 3- General: Input- Output chart. 4- Detection of infection: Clinical (activity, temp, symptoms) WBC count (total & differential) Cultures

Monitoring

Monitoring

Complications of TPN
Sepsis Pneumothorax Air embolism Clotted catheter line Catheter displacement Fluid overload Hyperglycemia Rebound Hypoglycemia

Complications of TPN
Catheter-related complications
o Catheter sepsis: which can be localized or systemic (skin portal, malnutrion, poor immunity). ccc by: fever, chills, drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip).

ttt:1- exclusion of other causes of fever 2- short course of anti-bacterial and antifungal therapy (acc. to C&S) 3- Catheter removal may be required

Complications of TPN
Catheter sepsis (Cont.): Prevention: a rigorous program of catheter care: Only i.v. nutrition solutions are administered through the catheter, no blood may be withdrawn from the catheter. Catheter disinfection and redressing 2 to 3 times weekly. The entrance site is inspected for signs of infection and if present, culture is taken or the catheter is removed.
Other catheter-related complications: Thromboembolism, pneumothorax, vein or artery perforation, and superior vena cava thrombosis

Complications of TPN
Metabolic Complications o Hyperglycemia (an elevated blood sugar): Associated with the infusion of excess glucose in the feeding solution or the diabetic-like state in the patient associated with many critical illnesses. It can result in an osmotic diuresis (abnormal loss of fluid via the kidney), dehydration, and hyperosmolar coma. ttt: decrease the amount of infused glucose (to<4 mg/kg/min) OR insulin can be administered (either S.C. inj. or incorporation in the infusion bag).

Complications of TPN
Metabolic Complications
o Hypertriglyceridemia (High S. Triglycerides) Associated with excess infusion of fat emulsion. N.B. Infusion of both glucose and fat emulsion in excess may result in pulmonary insufficiency. Excess glucose infusion > excess carbon dioxide (CO2) production a result of glucose metabolism. Excess lipid infusion --> the lipid particles may accumulate in the lungs and reduce the diffusion capacity of respiratory gases.

Complications of TPN
Metabolic Complications
o liver toxicity (also know as parenteral nutrition cholestasis): It causes severe cholestatic jaundice, elevation of transaminases, and may lead to irreversible liver damage and cirrhosis. Multiple causes have been proposed, including high infusion rates of aromatic amino acids, high proportion of energy intake from glucose, e.t.c.. There is no specific treatment, other than anticholestatic therapy.

Complications of TPN
Metabolic Complications
o Intestinal bacterial translocation: The lack of direct provision of nutrients to the intestinal epithelia during total parenteral nutrition Trophism and altered permeability of the GI mucosa, thus compromising any potential recovery of the patients ability for enteral feeding, and allowing bacterial entery to blood stream sepsis
Prevention is to provide a minimal enteral nutrition supply to avoid or minimize this risk.

Complications of TPN
Metabolic Complications
o Other metabolic complications: Electrolyte imbalance, mineral imbalance, acid-base imbalance, toxicity of contaminants of the parenteral solution.

Complications of TPN
Mechanical Complications
Catheters and tubing may become clotted or twist and obstruct. Pumps may also fail or operate improperly.

HOME PARENTERAL NUTRITION

Patients who are unable to eat and absorb adequate nutrients for maintenance over the long term may be candidates for home parenteral nutrition e.g. extensive Crohn's disease, mesenteric infarction, or severe abdominal trauma. patients must be able to master the techniques associated with this support system, be motivated, and have adequate social support at home.

HOME PARENTERAL NUTRITION

A patient who is judged to be a candidate for home parenteral nutrition requires an indwelling Silastic catheter designed for long-term permanent use. The nutrient solutions are prepared weekly and delivered to the patient's home. The patient sets up the infusion system and attaches the catheter to the delivery tubing in the evening for infusion over the next 12-16 h. The intravenous nutrition is terminated by the patient the next morning.