Parenteral nutrition therapy

PARENTERAL
NUTRITION THERAPY
C O M P I L E D B Y : - D R J O G I N D E R S I N G H , R E S I D E N T
U N D E R G U I D A N C E : - D R A S H O K K U M A R ,
A S S O C I A T E P R O F E S S O R , S P M C B I K A N E R

2Dept of Surgery, SPMC, Bikaner

Malnutrition has a negative impact
on patient outcome: longer hospital
stays, increased medical costs &
mortality

BASIC PRINCIPLES OF NUTRITION
– Avoid malnutrition.
– If bowel works, enteral nutrition is preferred over parenteral nutrition.
– Safe and adequate administration of nutrition is more important than the
route of administration.
– Route, timing and type of nutritional formulation are more important than
the specific amount of nutrients supplied.
– Avoid overfeeding: hyperglycaemia, hepatic steatosis with hepatic
dysfunction, elevated BUN, excessive CO2 production.
– During acute stress, nutritional support is to limit protein wasting and to
supply essential and conditionally essential nutrients.
Dept of Surgery, SPMC, Bikaner 4

• Parenteral nutrition is pharmacological therapies where
nutrients, vitamins, electrolytes and medications are
delivered via the venous route to those patients whose GI
tract is not functioning and are unable to tolerate enteral
nutrition.

HOW TO PLAN PARENTERAL
NUTRITION?
• Selection of patient: Nutritional support is recommended only when potential
benefits exceed the risks.
• Calculation of nutritional requirements.
• Select and establish appropriate route of administration
• Prescribe parenteral nutrition
• Administration, monitoring and avoiding complications of parenteral nutritional
support.

Enteral nutrition Parenteral nutrition
Maintains mucosal protection
Provides gut-preferred fuels
More physiological (liver not by-passed)
Prevents cholelithiasis
Fewer serious complications
Less costly
Ensured, desired volume delivery of nutrients
Improved metabolic, electrolyte and micronutrient
management
Better acid-base manipulation
Contraindication
1. GI causes: paralytic ileus, intestinal obstruction,
severe acute pancreatitis, high output external
fistula
2. Cardiac causes: risk of GI ischemia
Contraindication
1. General: if enteral feeding meets requirements.
Patient with good nutritional status requiring short-
term support.
2. Specific: Severe liver failure, cardiac failure,
shock, blood dyscrasias

INDICATIONS OF PARENTERAL
NUTRITION
• General Indications
– Inadequate enteral nutrition for at least 7-10 days
– Pre existing severe malnutrition with inadequate enteral nutrition
• Anticipated or actual inadequate enteral intake
– Impairs absorption of nutrients
• Enterocutaneous fistula, short bowel syndrome, obstruction. Post chemo-radiation
– need for bowel rest
• Severe pancreatitis, IBD, Ischemic bowel, peritonitis, pre and post operative status,
ileus
• Significant MODS

FACTORS CONSIDERED WHILE
DETERMINING NUTRITIONAL SUPPORT
• Age and premorbid state
• Nutritional status
• Duration of starvation and degree of anticipated insult
• Underlying disease, its severity and concomitant medical therapy
• GI function and likelihood of resuming normal intake soon

NUTRITIONAL REQUIREMENTS
• Fluid requirements
– 35 ml/kg or 1500 ml for 20 kg weight + 20 ml/kg for additional weight
• Energy requirements
– Simple body weight based calculation:
• REE (kcal/day) = 25 × weight
– Harris-Benedict equation:
• REE (Man) = 66 + (13.7 × W) +(5.0 × H) – (6.7 × A)
• REE (Women) = 655 + (9.6 × W) + (1.8 × H) – (4.7 × A)
– Indirect calorimetry:
• REE (Man) = (3.9 × VO2) + (1.1 × VCO2) -61
REE= Resting energy expenditure, W= Weight in kg, H= height in cm, A= age in years

• TEE = REE × AF × DF × TF
• 50-70% Carbohydrate (1 gram dextrose = 3.4 kcal)
• 20-30% Fat (I gram lipid = 9 kcal)
• 15-20% Protein (1 gram protein = 4 kcal)
AF= Activity Factor DF=Disease Factor TF=Thermal Factor
1.2 Bed rest
1.3 Out of bed
1.25 General surgery
1.3 Sepsis
1.6 Multiorgan failure
1.7 30-50% Burns
1.8 50-70% Burns
2.0 70-90% Burns
1.1 38° C
1.2 39° C
1.3 40° C
1.4 41° C

CARBOHYDRATE
• Dextrose- primary source in PN
– Least expensive, most commonly used
– 50-70% of total energy requirement
– 1 gram dextrose = 3.4 kcal
– Commercially made formulas 5-70% concentration
– Central PN use dextrose 50-70%
– Nitrogen sparing effect
• Disadvantages
– Low calorie supply
– Increased CO2 production (high respiratory quotient)
– Thrombophlebitis
– Administration: not > 7 mg/kg/min in stable patient
– In critical patient Not > 4 mg/kg/min
– Maintain Blood sugar 120-180 mg/dl 12Dept of Surgery, SPMC, Bikaner

FAT
• Lipid emulsion provides iv source of fat including linoleic and linolenic acids.
– Contains long chain triglycerides derived from soya bean oil and sunflower oil
– Also contain egg yolk phospholipids as an emulsifying agent, glycerine to achieve isotonicity with
plasma.
• I gram lipid = 9 kcal
– 20-30% of total calories
– Lipid emulsions 10%(1.1 kcal/ml). 20%(2.0 kcal/ml), 30% (3kcal/ml)
– Osmolarity 260mosm/l
– Dose 1 gm/kg/day
• Glucose sparing effect
• Protein sparing
• Less CO2 production (RQ Fat=0.7, protein=0.8, carbohydrate=1)
• Risk: hypertriglyceridemia(>400mg/dl), sepsis, fat embolism
• C/I: S triglyceride >350mg/dl, pH<7.3, anaemia, intravascular coagulation, impaired circulation
• Not necessary in obese patients

Cont’d
• To prevent essential fatty acid deficiency 3-4 days a week
• As a calorie source given daily
• Rate not >0.7 kcal/kg/hr
• Administered slowly over 12 hours
• Modified preparations
– Mixture of long chain and medium chain triglycerides
– Medium chain acts as energy source in stress
– Advantage of more rapid elimination of plasma, carnitine & insulin independent metabolism
– Triglycerides lowering effect
– Improved nitrogen balance

PROTEIN
• Amino acids – primary source (4kcal/g)
• 6.25gm of protein contain 1 g nitrogen
• Std amino acid solution (3-15%)
– 40-50% essential amino acids (N=9)
– 50% nonessential + semi essential amino acids
• 15-20% of total energy intake
• Calorie: nitrogen::100-150:1.

CLINICAL CONDITION PROTEIN REQUIREMENTS
(G/kg ideal body wt/day)
Normal 0.8
Metabolic stress (illness/injury) 1.0-1.5
Acute renal failure (undialysed) 0.8-1.0
ARF receiving dialysis 1.2-1.5
Critically ill patients 1.5
Compensated cirrhosis 1.0-1.2
Hepatic encephalopathy <0.5
Acute sepsis 1.7

• Contraindications
– Hepatic insufficiency: Std amino acids infusion may cause metabolic alkalosis, prerenal
azotemia, increased ammonia, stupor or coma.
– Renal failure: ↑ BUN
– Metabolic or respiratory alkalosis (acetate ions)
– Nausea, vomiting, headache, flushing, chills or fever
• Nitrogen balance = Nitrogen intake – Nitrogen loss
• Nitrogen loss = {[24-urine urea nitrogen (g) + 4] × 6.25

DISEASE SPECIFIC AMINO ACIDS
• Hepatic encephalopathy
– Branched chain amino acids (BCAAs) up to 50%
– Oxidized in skeletal muscle, adipose tissue
– It competes with aromatic amino acids for the carrier
• Aromatic AA crosses BBB & contribute Hepatic encephalopathy
– BCAAs appears to reduce grade of encephalopathy & possibly improve survival in
chronic (not acute) encephalopathy.
– Costlier than standard AA infusion

• Renal failure
– Nitrogen in essential AAs is partially recycled to produce non-
essential AAs
– Amino acid infusion rich in essential amino acids (67-100%)
– Advantage over standard amino acid infusion not established
• Volume overloaded patients
– 15% concentrated amino acid solution
– Expense and lack of evidence for its efficiency

SPECIAL FORMULAS -
IMMUNOMODULATORS
• Modify inflammatory response
• Enhance resistance to infection
– ↓ gut bacterial translocation
– Enhancing gut associated lymphatic tissues
• Recent metanalysis trials of “immune enhancing” enteral diet (glutamine,
arginine, omega 3 fatty acids), was found to reduce the risk of infection,
ventilator days, hospital length of stay without influencing mortality

NUTRITION OF SPECIFIC DISEASE
• Perioperative Nutrition
– Preoperative parenteral nutrition
– Severely malnourished patients
• Weight loss > 10-15% in previous 3 monthes
• S albumin < 2.8 gm/dl
• Nutrition risk index score < 83.5
– Reduces rate of postoperative complications & improve outcome
– Effective preoperative restoration of malnutrition by PN requires at least 7-14 days
and should be continued post operatively
• PN not benefitted in mild malnutrition

• Postoperative parenteral nutrition
– Routine use of PN in immediate post-op period carried approximately 10%
increased risk of postoperative complications
– Short term (9 days or <) glucose given
• Indication of Post-operative PN
– Patient unlikely to resume oral feeds within 10 days. PN initiated usually within 3
days after surgery
– Immediate nutritional support may be appropriate in continuation of preoperative
nutritional support for malnutrition
– In previously severely malnourished patients undergoing emergency surgery
– In previously well-nourished patients who have suffered major trauma or burns

CONT’D
• Critical Illness
– Life threatening medical or surgical conditions usually requiring ICU care
– Metabolic alterations include hypermetabolism, hyperglycaemia with insulin resistance,
accelerated lipolysis, net protein catabolism
– Critically ill patient more prone to malnutrition
– Enteral nutrition is preferred route
– Early nutritional support (withing first 48 hrs) improves survival and reduces infections and
length of hospital stay
• Indications of PN
– In severe head injuries, burns and major abdominal trauma early PN is recommended for 5-7
days if enteral nutrition is not possible
– Energy expenditure 2000 Kcal/day

Critically ill patients Stable patients
Protein 1.2-1.5 g/kg/d 0.8-1.0 g/kg/d
Carbohydrate Not >4 mg/kg/min Not >7 mg/kg/min
Lipid 1 g/kg/d 1 g/kg/d
Total calories 25-30 kcal/kg/d 30-35 kcal/kg/d
Fluid Minimum needed to deliver
adequate macronutrients
30-40 ml/kg/d

CONT’D
• Pancreatitis
– About 80% of patients have mild and self limiting disease
– Patient able to take oral diet within 7 days
– About 20% patients will develop severe disease unlikely to eat within 7 days
– If these patient is provided with oral or enteral feed in duodenum, it will stimulate
pancreatic enzymes secretion causing auto digestion, inflammation, necrosis,
abdominal pain
– So, aim of enteral feeding in to jejunum distal to ligament of Treitz or PN is to
provide adequate nutrition and rest to pancreas
– PN is superior and more effective in providing rest to the pancreas as well as
providing total nutritional requirements

• When to start PN?
– Acute severe necrotizing pancreatitis (highly catabolic)
– Starting nutritional support within 48-72 hrs of hospitalization is
beneficial
– PN delayed beyond 72 hrs in these Pts, complications & mortality
rates 3-times higher

SHORT BOWEL SYNDROME
• Causes
– Crohn’s disease
– Mesenteric vascular occlusion
– Malignancy
– Volvulus
• Pathophysiology
– Massive resection of small bowel reduces area for absorption lead to large volume
diarrhoea, hypovolemia, hypokalemia, malnutrition, gastric acid hypersecretion, D-
lactic acidosis, Nephrolithiasis
• Before the advent of PN, survival in acute SBS was very poor

TREATMENT OF SBS
• After massive bowel resection, adaptation occur via bowel hyperplasia
and hypertrophy, which occur immediately after surgery and may
continue for at least first 2-years
– Immediate postoperative period
– Bowel adaptation period
– Long term treatment
• Immediate post-op: -
– Adequate IVF, electrolytes, other nutrients (Zn)
– Early PN is beneficial and decrease mortality
– H2 receptor antagonists

• Bowel adaptation period: -
– Enteral feeding is necessary, should be started asa the volume of faecal loss decreases
< 1000ml/day
– EN should be slow continuous overnight tube is recommended
– PN reduced gradually as EN increases
– Nutrient supplementation should contain glutamine, MCT for mucosal healing
• Long term treatment: -
– With colon intact, diet rich in complex carbohydrates with low fat, oxalate
– End jejunostomy, normal amount of complex carbohydrates
– Terminal ileum resected, inj vit B12 monthly
– Pt with D-lactic acidosis needs non-absorbale antibiotics

INFLAMMATORY BOWEL DISEASE
INDICATIONS OF PN
• If patient cannot tolerate oral feeds during acute exacerbation
• If patient develops paralytic ileus, mechanical bowel obstruction, distal small
bowel fistula, toxic megacolon, where more than 7 days of starvation is
anticipated
• Perioperative PN is indicated in patients who are severely malnourished and in
whom surgery may be safely postponed. Patients of IBD, who received surgical
treatment following preoperative PN for 5 days or more, had fewer
postoperative complications

GI FISTULA
• High output GI fistulas (loss >500 ml of fluid daily)
• Role of PN is supportive & should be provided with anticipated
inadequate enteral nutrition beyond 7-14 days

BURNS
• Enteral nutrition should be used in preference to PN
• PN reserved in whom EN is contraindicated or unlikely to meet
nutritional requirements within 4-5 days
• 30-35 kcal/kg/day
• 1.3-1.5 gram protein/kg/day
• At least 15% lipids

CANCER
• Role of PN
– PN should not be used routinely in patients undergoing major
cancer operations or along with chemotherapy and radiotherapy
– PN is provided only if clinical improvement with quality survival is
expected
– PN is indicated in cancer patients if chemotherapy/radiotherapy is
likely to cause GI toxicity, which will prevent oral intake for >7 days
– PN is unlikely to benefit patients with rapidly progressive malignant
diseases who fail to respond to the treatment

PULMONARY DISEASES
• “Death from starvation is death from pneumonia”
• Malnutrition induces muscle weakness
• EN is preferred, but if GI function impaired PN is indicated
• Carbohydrate: lipid::70:30
• Weaning from ventilator in these patients, 50:50 ratio can be used

ACUTE RENAL FAILURE
• Avoid PN during acute phase of ARF (within 24 hrs of trauma or surgery)
• If the Pt likely to resume oral intake withing 5 days, nutritional support is
not indicated
• EN is preferred. PN is indicated if EN is inadequate or gi dysfunction
• Avoid hyperkalaemia, hypermagnesemia, hyperphosphatemia, volume
overload
• Energy requirement: -
– 25-35 kcal/kg/day in critically ill
– Protein: 0.8-1 gm/kg/day in undialysed ; 1.2-1.5 gm/kg/day in dialysed patient

LIVER DISEASE
• Guidelines for PN in patients with liver disease are similar to other acute
& chronic illnesses
• Aggressive PN support improves survival in patients with hepatic failure
• Energy: - In stable compensated Pts 25-35 kcal/kg/day
– In cirrhotic pt with complication, 35-45 kcal/kg/day
• Protein: - in compensated cirrhosis 1 gm/kg/day
– Cirrhosis with encephalopathy 0.5 gm/kg/day (BCAAs)
• Fat & water soluble vitamin especially vit-k

ADMINISTRATION OF PARENTERAL
NUTRITION
• Selection of Macronutrients
– Only dextrose, avoid PN: If pt unable oral feed < 7 days, pt is not malnourished
& stable
• Dextrose infusions (100-150 g/day) with electrolyte, vitamins
– Amino acids + dextrose: Pt need PN, but its expected duration is only < 2 weeks
• Pt is not malnourished, stable and total caloric requirements is not high
• In Pt, lipid emulsion is contraindicated
– AA + Dextrose + Lipid (MC): PN for a prolonged period
• Lipid provides additional calories, reduces osmolarity & prevent essential fatty acid
deficiency

DELIVERING PARENTERAL NUTRITION
• Routes of nutrient delivery
– Peripheral PN vs. Central PN
• System of delivering PN
– “Multiple bottle” system vs. Three-in-one solution
• Duration of delivering PN
– Continuous infusion vs Cyclic infusion of PN

ROUTES OF NUTRIENT DELIVERY
• PPN
– Osmolarity <900 mOsm/L
– Low concentrated dextrose (5-10%) + AA + 20% Lipid emulsion
– Indications: For short period (7-10 days)
– C/I: High nutritional requirements
– Advantage: Easy & safe access
– Disadvantage: Large volume is required
– Thrombophlebitis: Add heparin (1U/ml) and hydrocortisone (5mg/ml) to PPN
• Placing glycerine trinitrate transdermal patch on tip of iv catheter
• Frequent change of infusion site

CENTRAL PARENTERAL NUTRITION
• Dextrose (50-70%) + AA (8.5-10%) + Lipid emulsion (20-30%)
• 1000-1900 mOsm/L
• Site for catheter for CPN
– Short term central access (infraclavicular approach to subclavian vein)
– Long term central access “Tunnelled” catheter placed in IJV/Subclavian
vein and implanted ports
– Percutaneous inserted central catheter (PICC): Catheter is inserted into a
vein in antecubital area of arm and threaded into subclavian vein with the
tip placed in SVC

SYSTEM OF DELIVERING PN
• Multiple Bottle System
– Pros: Flexibility & ease of adjustment
– Cons: Needs proper monitoring to avoid risk related to rapid
administration
• Higher risk of incompatibility due to improper mixing of various
nutrients
• Amino acid + dextrose with lipid emulsion separately

“THREE IN ONE” SYSTEM
• Most preferred way
• Pros: Convenience & time saving
– Better assimilation and utilization of nutrients due to slow rate of
infusion
– Lesser chances of infection
• Cons: lack of flexibility in change of its contents
– Lesser stability due to addition of lipids
– Absence of transparent colour, which impairs visual inspection for
fungal growth or precipitation

DURATION OF DELIVERING PN
• Continuous PN:
– Acute, critical & hospitalized patients
– Slow continuous infusion of PN avoids volume overload, hyperglycaemia,
triglyceridemia
• Cyclic PN:
– over 8-12 hours (overnight)
– Effective & safe for stable chronically ill patients
– C/I: glucose intolerance, fluid intolerance

DESIGNING PN FORMULA
• Calculating of daily requirements of PN
• Convert requirements into prescription
• To prepare PN solution or to select an optimal commercially
available formula

CALCULATION OF DAILY REQUIREMENTS OF PN
• 60 kg patient, who is stable, euvolemic with good urine output and moderate
stress
– Fluid requirements: approx. 35ml/kg
• 35 × 60 = 2100 ml/day
– Caloric requirements: approx. 25kcal/day
• 25 × 60 = 1500 kcal/day
– Protein requirements: for stable pt, 1 gm/kg
• 1 × 60 = 60 gm/day
• 1 gm protein provides 4 kcal, 60 × 4=240 kcal
– Fat requirements: 30% of total calories
• 30% of 1500=450 kcal
• 1 gm of fat provides 9 kcal, 450/9=50 gm of fat will be required
– Carbohydrate requirements: 1500- (240+450)=1500-690=810 kcal (202.5 gm) 46Dept of Surgery, SPMC, Bikaner

CONVERT REQUIREMENTS INTO
PRESCRIPTION
• Volume of lipid emulsion (10%)=Amt of substance (gm)/conc of
substance (%) ×100
– 50/10 ×100=500 ml of 10% fat emulsion required
• Amino Acid
– 60/10 ×100=600 ml of 10% AA solution required
• Dextrose
– In remaining 1000 ml fluid volume, 202.5 gm needs to be infused
– 1000=202.5/x ×100;
– 20.25=20% dextrose

Route Fresenius Kabi Claris Lifescience
Amino acid containing
PPN Aminoven 5% 500ml(440INR) None
CPN Aminoven 10% 500ml(686INR) Celemin-10 Plus (677INR)
Amino acid & dextrose containing
PPN Celemin-5S 500ml(350INR)
CPN Aminomix 1 1000ml (1900INR) PNA-10 1000ML(2204)
Lipid emulsion
PPN Intralipid 10% 500ml(640INR)
Intralipid 20% 500ml(700INR)
Celepid-10% 500ml (592INR)
Celepid-20% 500ml(900INR)
Three in One solutions
PPN Kabiven Peri 1440ml(2550INR),
1920ml(2699INR),
2400ml(3300INR)
TNA PERI 2000ml(3550INR),
CPN Kabiven Central 1026ml(3102INR),
2053ml(4199INR)
Celemix-G 1000ml(2059INR)
TNA 2000ml(3075INR)

Route Fresenius Kabi Claris Lifescience
Disease specific amino acids
PPN Aminosteril N Hepa 8% 500ml
(808INR)
Nephrosteril 7% 500ml
(869INR)
Celemin-Hepa 8%
500ml(698INR)
Celemin-Nephro 7%
500ml(450INR)
Immunomodulator solutions
PPN Dipeptiven 20% 50ml(1454INR),
100ml (2099INR)
Omegaven 10% 50ml(935INR)

ECONOMIC FACTOR
• 500ml of 10% Intralipid = ₹640
• 500ml of 10% Aminoven = ₹686
• 1000ml of 20% Dextrose = ₹60
• Total ₹ 1386 provides approx. 1500 kcal (2000ml)
• Kabivan (3 in one) 1400 kcal (1920ml) ₹ 2699
• So, ₹ 1313 (48%) less in multi bottle system

INITIATION OF PN
• 50% of goal on 1st day
• 75% on 2nd day
• 100% on 3rd to 4th day
– Monitor S. glucose every 6 hrly on 1st day then once a day
– Monitor electrolyte, protein levels daily on 1st week then twice a
week
– LFT, S. creatinine, Hb/Hct, WBC, Ca, Mg, PO4- Baseline, then
twice weekly
– Clotting, INR, Lipid profile baseline, then weekly

TERMINATION OF PN
• PN is temporary method of nutritional supplementation
• Transition from PN to EN should be done gradually
• Reduce infusion rate to 50% for 1-2 hours before
discontinuing PN to prevent rebound hypoglycaemia
• Once patient is able to take 60% of total energy and protein
requirements orally, PN may be stopped

COMPLICATIONS
• Hyperglycaemia
– Greatest danger in first 24 hrs
– S. glucose 120-180 mg/dl
– Add 20 units of regular insulin per litre in PN solution
– If this does control the hyperglycaemia, then insulin drip 2-5 unit/hr
• Hyponatremia

CONT’D
• Refeeding syndrome: In previously malnourished patient, carbohydrate
refeeding stimulates insulin secretion, which in turn increases cellular uptake of
electrolytes and reduces its serum concentration, if replacement is inadequate.
• Clinical manifestations:
– fluid overload, CHF
– Severe muscle weakness, hypokalemia, hypophosphatemia, risk of respiratory failure`
– Glucose intolerance with hyperglycaemia
– Cardiac arrhythmia, cardiac dysfunction, death
• Prevention: PN started gradually, only one-third of basal energy given in first 24 hrs
– Glucose <150gm/day
– Na <20 mEq/day
– Total fluid <800 ml/day
– K, Ca, Mg, P04 monitoring

CONT’D
• Hepatic abnormalities
– Most common gi complications
– Generally benign & temporary
– PN related complications includes
• Transaminases elevation in 1-2 weeks, steatosis
• Bilirubin, alkaline phosphatase elevations later 2-3 weeks
– Prevention: avoid excessive calories, 20-40% of calories as fat, cycling
the infusion
– Rule out underlying hepatic disease, sepsis, medications, essential
fatty acid deficiency, carnitine deficiency

REFERENCE
• Sanjay Pandya Practical Guidelines on Fluid Therapy 2nd edition; 12:308-
375
Dept of Surgery, SPMC, Bikaner 56

Parenteral nutrition therapy

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