Basic Principles of Critical Care

1. PARENTERAL FEEDING
Gradian Health Systems
Basic Principles of Critical Care
NUTRITIONAL SUPPORT

2. Disclaimer
Basic Principles of Critical Care Training I Parenteral Feeding
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 4
Gradian Health Systems
Basics Principles of Critical Care
Nutritional Support

4. Module 4: Nutritional Support
MODULE OVERVIEW
Lesson 1 I Enteral Feeding
Lesson 2 I Parenteral Feeding
Basic Principles of Critical Care Training I Parenteral Feeding

5. Components of the Gradian CCV SystemLesson 2: Parenteral Feeding
Lesson Objectives
• Describe aspects of parenteral feeding
• Outline the types of parenteral feeding tubes
• Identify patient conditions requiring parenteral feeding
Basic Principles of Critical Care Training I Parenteral Feeding

6. Components of the Gradian CCV SystemLesson 2: Parenteral Feeding
Key Concepts
• Indications for parenteral reeds
• Complications of parenteral feeding
• Monitoring for parenteral feeds
Basic Principles of Critical Care Training I Parenteral Feeding

7. Components of the Gradian CCV SystemParenteral Feeding
What is Parenteral Feeding?
This is nutrition given directly into systemic circulation (intravenously) bypassing
the GIT and the first circulation through the liver. The aim is to maintain or
improve the nutritional and metabolic status of patients who have temporary or
permanent intestinal failure. Parenteral nutrition can either be:
• Partial parenteral nutrition (PPN)
• Total parenteral nutrition (TPN)
Basic Principles of Critical Care Training I Parenteral Feeding

8. Components of the Gradian CCV SystemParenteral Feeding
Partial Parenteral Nutrition (PPN)
• Supplies only part of the daily nutritional requirements
• Supplements other oral or enteral routes
• Glucose concentration of 5-10%
Total Parenteral Nutrition (TPN)
• Supplies all the daily nutritional requirements
• Involves administration of highly concentrated dextrose (25-70%), providing a
rich source of calories
• Solutions are hyperosmolar, as much as 1800mOsm/L, and therefore must
be delivered through a central line
Basic Principles of Critical Care Training I Parenteral Feeding

9. Components of the Gradian CCV SystemParenteral Feeding
Indications for Parenteral Feeds
• Bowel obstruction
• Congenital anomalies
• Short bowel syndrome
• Patients getting less than needed on enteral feeds
• Patients with hyperbolic states (e.g. burns, sepsis, trauma)
Patients in ICU should be fed because starvation leads to increased morbidity
and mortality. Patients who are not likely to start enteral feeding in 2-3 days
should be started on PN.
Basic Principles of Critical Care Training I Parenteral Feeding

10. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feed Types
• Prepared under sterile techniques
• Carbohydrates, lipids, amino acids, micronutrients and water all mixed in one
bag
• Preferably administered in a central vein because of their high osmolarity
• Usually administered into a large-diameter vessel, normally the superior vena
cava or right atrium, accessed via the jugular or subclavian vein
• For longer-term ICU use, a tunneled-catheter or implanted chamber is
occasionally used as alternatives to a standard central venous access device
• Peripherally inserted central catheters (PICC) can also be used
• Low osmolarity (<850mOsmol/L) feeds can be given into a peripheral line
Basic Principles of Critical Care Training I Parenteral Feeding

11. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feed Monitoring
• Daily blood sugar and electrolytes
• Weekly liver function tests
Points to Consider
• Do not mix TPN with other infusions
• Regulate infusion rate
• Label TPN port
• Keep fluid chart
• Do not abruptly stop TPN (patient may get hypoglycemia)
• Use dextrose 5% while awaiting TPN, if not available
• Do not obtain blood samples from the same line
Basic Principles of Critical Care Training I Parenteral Feeding

12. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feed Initiation and Discontinuation
• Start infusion slowly and then gradually increase volume to ensure patient
tolerance to liquid emulsion, dextrose concentration, and total volume
• Monitor vital signs daily, including temperature, BP, RR, RBS, electrolytes,
CVP, and BUN
• Gradually discontinue parenteral feeding to avoid hypoglycemia
• Use standard IV infusion for a while as enteral nutrition is introduced
Basic Principles of Critical Care Training I Parenteral Feeding

13. Components of the Gradian CCV SystemParenteral Feeding
Nursing Care for Parenteral Feeding
• Administer PN through a filter to prevent precipitant from entering blood
• Take X-ray to confirm position of central line before use
• Document intake and output accurately
• Maintain aseptic technique
• Maintain high standards of hygiene
• Weigh the patient daily
• Monitor fluid and electrolyte imbalances, blood, and chemistry
• Monitor for early signs of infection
• Monitor blood glucose levels every 6 hours
• Monitor blood triglycerides, LFTS
• Change all tubing every 24 hours
Basic Principles of Critical Care Training I Parenteral Feeding

14. Components of the Gradian CCV SystemParenteral Feeding
Nursing Care for Parenteral Feeding
• Label the tubing (i.e. date of insertion)
• Change dressing covering the catheter daily, or as per institution’s protocol
• Do not take blood samples or give drugs through IV line used for PN infusion
• Use infusion pump to regulate infusion rates
• Give individualized care as per the patient’s needs
Basic Principles of Critical Care Training I Parenteral Feeding

15. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feeding – Catheter-related Complications
• Central venous thrombosis
• Catheter blockage (type, diameter, period of use)
• Catheter-related infections and sepsis
• Skin or systemic circulation
• Strict adherence to aseptic technique at insertion, care and maintenance
• Frequently assess CVC site for redness, tenderness or pus
• Air embolism
• Ensure all connections are clamped and closed
• Use an air filter
Basic Principles of Critical Care Training I Parenteral Feeding

16. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feeding – Metabolic Complications
• Fluid and electrolyte imbalance
• Fluid overload
• Deficiencies
• Hyperglycemia
• Abnormal liver function
• Deranged liver enzymes
• Painful hepatomegaly
• Metabolic bone disease
• Demineralization (osteoporosis, osteomalacia)
Basic Principles of Critical Care Training I Parenteral Feeding

17. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feeding – Metabolic Complications
• Refeeding syndrome
• Potentially fatal shifts in fluids and electrolytes that may occur in
malnourished patients receiving artificial refeeding (whether enterally or
parenterally)
• Hypophosphatemia  hallmark biochemical feature
• Usually follows a prolonged period of starvation
Basic Principles of Critical Care Training I Parenteral Feeding

18. Components of the Gradian CCV SystemParenteral Feeding
Parenteral Feeding – Adverse Reactions to Lipid Emulsion
• Allergies
• Sweating
• Dizziness
Parenteral Feeding – Gallbladder Complications
• Cholelithiasis
• Cholecystitis
Basic Principles of Critical Care Training I Parenteral Feeding