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

Enteral versus parenteral nutrition

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)

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

No postoperative complications, GIT fistula without infection

Approximate energy Requirement (kcal/kg/day) 25-30

Mild peritonitis, long-bone 25% above fracture, mild to moderate normal injury, malnourished Severe injury or infection Burn 40-100% of total body surface 50% above normal Up to 100% above normal

30-35

35-45 45-80

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 Requirements (/Kg/day) 20-40 mL 0.5-1.0 mmol 0.5-1.0 mmol

Magnesium Calcium
Phosphate
Chloride/Acetat e

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 15 Copper 2-3 Manganese 2.5-5 Chromium 0.05-0.2 Iron 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 nutritionmixing 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).

Nursing Guidelines:

Administering TPN
Weigh the client daily
( A record of the clients weight assists with monitoring his or her response treatment).

Use tubing that contains a filter.

( Filters absorb air and bacteria, two potent complications associated with the use of central venous catheters).

Change TPN tubing daily

(Doing so reduces the potential for infection).

 Tape all connections in the tubing and central

catheter.
(Taping prevents accidental separation and reduces the potential for an air embolism).

Clamp the central catheter and have the

client bear down whenever separating the tubing from its catheter connection.
( This action prevents air embolism)

 Use an infusion device to administer tpn

solutions.
(An infusion device monitors and regulates precise fluid volumes.)

Infuse initial TPN solutions gradually (25-

50mL/hr).
(Gradual administration allows time for physiologic adaptation.)

Never increase the rate of infusion to make

up for an uninfused volume unless the physician has been consulted.

(Speeding up the infusion tends to increase blood glucose levels.)

 Monitor intake and especially urine output.

(High blood glucose levels can trigger diuresis (increased urine excretion), resulting in output greater than intake.)

Monitor capillary blood glucose levels.

(Blood glucose may not be ad4quately metabolized without the additional administration of insulin.)

Wean the client from TPN gradually.

(weaning prevents a sudden drop in blood glucose levels.)

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

Possible Nursing Diagnoses:

Self-care Deficit, Feeding Deficient Fluid Volume Excess Fluid Volume Risk for Impaired Oral Mucous Membrane Risk for Impaired Skin Integrity Risk for infection Deficient Knowledge

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).
Characterized by: fever, chills, drainage around the catheter entrance site, Leukocytosis, +ve cultures (blood & catheter tip). Treatment: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. treatment: 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.

General Gerontologic Considerations

Older adults are at risk for fluid and

electrolyte imbalances if they experience chronic conditions affecting the heart, kidney and intestinal absorption
older adults with cardiovascular disorder, increase the risk for fluid and electrolyte imbalances. Laxatives, enemas, antihistamines or tricyclic anti-depressants may also alter fluid and electrolyte balance.

Diuretic medications, often prescribed for

 Mobility limitations, cognitive

impairments, and impaired ability to perform activities of daily living can lead to fluid deficits in older adults who cannot maintain adequate food and fluid intake independently.
Infections, elevated temperature, or

both may alter fluid balance.

 Assessment of stool consistency is

important because water is lost through loose or very soft stools.

Older adults may need to be encouraged

to drink fluids, even at times when they do not feel thirsty, because age-related changes may diminished the sensation of thirst.

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.