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1. Indication for prarnteral nutrition
Adult Parenteral Nutrition
Done by :
Raniya.Khalid
@Rania1997301
Reference:
Murdaugh, L. (2015). Competence assessment tools for health-system
pharmacies (5th ed., p. Chapter 37). Jack Bruggeman.

2. Indications for Parenteral Nutrition
nutrition may need to be delivered intravenously, which is referred to as parenteral nutrition (PN).
Patients who are unable to absorb enough nutrients from the GIT to meet nutrition requirements with enteral nutrition
(EN)—These patients are malnourished, or have the potential of becoming malnourished, and generally will not resume
adequate EN within 7 days. Common conditions requiring PN include the following:ͷ Massive small bowel resectionͷ
Intractable vomitingͷ Severe diarrheaͷ Bowel obstructionͷ GIT fistulae
Cancer therapy (e.g., radiation, antineoplastic medications, or bone marrow
transplantation)
Pancreatitis
Critical care
Hyperemesis during pregnancy
Eating disorder
Failure when patient attempted a trial of EN
Preoperatively in moderately-to-severely malnourished patients
undergoing major GIT surgery when the surgery can be postponed for 7 to
14 days
Raniya.Khaled
@Rania1997301

3. One gram of protein yields 4 kilocalories (kcal).
There are two basic types of solutions:
1.Standard solutions:
These solutions are for patients with normal
organ function and nutritional requirements
2. Specialized solutions:
These solutions are for patients with altered
protein requirements due to conditions such as
hepatic encephalopathy, renal failure, and
metabolic stress from disease, trauma, injury, or
surgery.
Formulations containing increased amounts of
branched-chain amino acids (BCAA) and
decreased amounts of aromatic amino acids (AAA)
and methionine :
can be used in patients with hepatic
encephalopathy. Preparations containing
increased amounts of BCAA and proportional
amounts of AAA can be used in patients under
metabolic stress (e.g., sepsis or multiple trauma).
Amino Acids
Macronutrients
Composition of Parenteral nutrition formulations
Carbohydrates
Intravenous Fat Emulsion
Fat emulsions provide a
concentrated source of
calories and essential fatty
acids.
Essential fatty acids are
needed by the body for many
important functions, such as
platelet function and wound
healing. Fat emulsions can be
especially useful as a daily
source of calories in patients
with diabetes, metabolic stress,
and certain respiratory
conditions.
The major source of
energy in PN formulations
is carbo- hydrate, usually
in the form of dextrose.
One gram of dextrose
yields 3.4 kcal.
Raniya.Khaled
@Rania1997301

4. Composition of Parenteral nutrition formulations
Electrolytes
Micronutrients
Support metabolic activities such as enzymatic reactions, fluid balance, and nerve conduction processes
Vitamins
The principal electrolytes in
PN formulations are sodium,
potassium, calcium, magnesium,
phosphorus, chloride, and
acetate.
Electrolytes are essential for
many cellular functions, such as
acid–base balance and nerve
conduction.
Trace Elements
Vitamins are needed to
preserve metabolism and
cellular functions.
They are also needed to
properly utilize the
macronutrients in PN
formulations.
Trace elements are minerals
needed in small amounts for
certain body functions, including
enzyme function and other
metabolic pathways.
Multiple-mineral preparations
include zinc, copper, chromium,
manganese, and selenium. Some
preparations also contain iodide
or molybdenum.
Raniya.Khaled
@Rania1997301

5. Assessment of Nutritional Status
To determine a patient’s nutritional needs and monitor the effectiveness of nutrition support,
the patient’s nutritional status must be assessed.
Nutrition assessment includes evaluation of several parameters:
1-Medical/dietary history—Useful in the initial assessment of the patient’s nutritional status.
2-Physical examination
3-Anthropometric measurements
4-Immune function
5-Biochemical assessment :
Three common proteins monitored are albumin, prealbumin, and transferrin
Raniya.Khaled
@Rania1997301

6. Assessment of Nutritional Status cont..
5-Biochemical assessment :
Three common proteins monitored are albumin, prealbumin, and transferrin
Albumin Prealbumin Transferrin
Albumin is useful in the initial
assessment of a patient’s
nutritional status. Normal
serum concentrations are 3.5
to 5.4 g/dL. Because it has a
long half-life (18 to 21 days),
use of albumin is limited in
evaluating the short-term
improvements from PN
Prealbumin (transthyretin
protein) is a more sensitive
indicator of the adequacy of
nutrition support. The short
half-life (2 to 3 days) makes
prealbumin useful as an early
indicator of nutritional
repletion. Normal serum
concentrations are 15 to 40
mg/dL.
Transferrin is another clinically
useful indicator of nutritional
status, but it is not as sensitive
or specific as prealbumin. It has
an intermediate half-life (7 to
10 days), allowing weekly
monitoring. Normal serum
concentrations are 200 to
400 mg/dL
Raniya.Khaled
@Rania1997301

7. Assessment of Nutrition Requirements
CALORIE REQUIREMENTS PROTEIN REQUIREMENTS FLUID REQUIREMENTS
The RMR
(Resting metabolic rate )
is calculated as follows
Females
RMR (kcal/day) = [10 × Wt (kg)] + [6.25 ×
Ht (cm)] – [5 × Age (yr)] – 161
Males:
RMR (kcal/day) = [10 × Wt (kg)] + [6.25 ×
Ht (cm)] – [5 × Age (yr)] + 5
Calorie requirements increase with physical
activity and the presence of stress (e.g.,
fever, sepsis, major surgery, trauma, burns,
chronic disease). Calorie requirements may
decrease in obesity.
For the
healthy adult patient with normal organ function,
the
protein requirement is decreased for patients
with organ dysfunction, such as liver and kidney
disease that alter protein breakdown and
elimination from the body. Protein requirements
may be increased in surgical patients or those
with critical illness.
Another method used to determine protein
requirements is to calculate the nitrogen balance
The goal is to provide enough protein to the
patient to equal or exceed losses
Nitrogen balance (NB) can be calculated using
the following formula9:
NB (g/day) = [protein intake (g/day)/6.25] –
[UUN(g/day) + 4]
A simple method for estimating a
patient’s fluid needs is to use 20 to
40 mL/kg/day. A more accurate
method is to use 1,500 mL for the
first 20 kg of body weight plus 20
mL/kg for actual weight above the
first 20 kg. Fluid requirements are
dependent on many variables,
including renal and hepatic function,
presence of fever, or gastrointestinal
loss (e.g., vomiting, diarrhea, or
gastrointestinal suction),
concomitant diseases, and nutritional
status. All non-nutrition fluid
sources must also be taken into
account (e.g., fluid volume of IV
medications).
Raniya.Khaled
@Rania1997301

8. Selection of Parenteral Nutrition Formulations
Selection of Parenteral Nutrition Formulations
Nutritional status
Organ function
Disease states
Medication therapy
Patient-specific factors to consider when selecting the ingredients of a PN nutrition
formulation include the following:
Miscellaneous factors such as
nasogastric suction, fistulas, diarrhea,
and vomiting
Metabolic stress from sepsis, burns,
surgery, and other trauma
Fluid and electrolyte balance
Raniya.Khaled
@Rania1997301

9. Preparation and Storage of Parenteral Nutrition
Formulations
There are
two types of
PN bases
Amino acid/dextrose admixtures
Amino acids and dextrose are
prepared in the same container.
Micronutrients are added as
required by the patient’s
nutritional needs.
The admixture is administered
with or without IV fat emulsion
piggybacked into the PN line.
Total nutrient admixture (TNA)
Amino acids, dextrose, and IV
fat emulsion are prepared in the
same container.
This type of preparation is also
known as a 3-in-1 admixture.
Micronutrients are added as
required by the patient’s
nutritional needs.
Raniya.Khaled
@Rania1997301

10. Preparation and Storage of Parenteral Nutrition
Formulations
TNA
Preparation
Advantages of TNA
preparations:
Disadvantages of TNA
preparations:
•Increased clearance and utilization of IV
fat emulsion
•Decreased compounding and
administration time
•Decreased amount of administration
supplies such as tubing
•Potential decrease in the risk of
catheter contamination due to
manipulation of the infusion line
•Easy delivery and storage for patients
receiving PN at home
•Difficulty in visually inspecting the
preparation for precipitates and
other particulate matter due to
opaque appearance
•Inability to be filtered with a
bacteria-retentive filter
•Concerns regarding stability of the
preparation, compatibility of the
ingredients, and the risk of bacterial
and fungal contamination and growth
Raniya.Khaled
@Rania1997301

11. Testing of formulations during and after the compounding process to ensure
correct concentrations of ingredients, including
Gravimetric analysis Chemical analysis
Refractometric analysis
Indirect assessment of the
accuracy of amounts of
ingredients by measuring
their weight
Direct measurement of the
final concentrations of the
ingredients
Indirect determination of
the final concentrations of
the ingredients by
measuring refractive index
(this method cannot be used
with formulations containing
IV fat emulsion)
Preparation and Storage of Parenteral Nutrition
Formulations
It is recommended that PN admixtures be refrigerated if not administered immediately
after compounding. Refrigerated admixtures should be used within 24 to 48 hours.
Raniya.Khaled
@Rania1997301

12. Stability and Compatibility
PN admixtures are prone to problems with stability and
compatibility of components. Factors influencing stability
and compatibility include temperature, pH,
concentrations of ingredients, order of admixture of
ingredients, and the length of time between compounding
and administration.
The most common compatibility problem is the precipitation of
calcium and phosphorus, which can be life-threatening.
The risk of this interaction is increased by the following factors:
• High concentrations of calcium and phosphorus salts
• Decreased amino acid concentrations (amino acids act as a
buffer to retard precipitation)
• Increased temperature of the admixture
• Use of the chloride salt of calcium
• Increased pH of the admixture
• Improper mixing sequence of calcium and phosphorus salts
• Presence of other additives
To prevent precipitate formation, calcium and
phosphorus salts should be added separately to the
admixture. In general, phosphate should be added first,
and calcium should be added near the end of the
compounding procedure.
Sodium bicarbonate can also cause compatibility problems.
The addition of bicarbonate to acidic admixtures may cause
formation of carbon dioxide gas and precipitation of calcium and
magnesium salts.
The use of acetate salts (which convert to bicarbonate in the
body) is a safer alternative.
The stability of vitamins may be adversely affected by pH
changes, storage time, temperature, light, and other additives. It
is recommended that vitamins be added to the PN admixture
close to the administration time, if possible, and not remain in the
admixture more than 24 hours.
Raniya.Khaled
@Rania1997301

13. Administration of Parenteral Nutrition Formulations
PN may be administered through central or
peripheral venous access.
Patients considered candidates for peripheral
administration must meet two criteria:
They must have good peripheral venous
access.
They must be able to tolerate large volumes of
fluid (2.5 to 3 L).
They also should require at least 5 days but
not
more than 14 days of therapy.
Contraindications to peripheral PN include
the following:
Significant malnutrition
Severe metabolic stress
Large electrolyte needs
Large nutrient needs
Fluid restriction
Greater than 2 weeks of PN required
Renal dysfunction
Liver compromise
It is recommended that a 0.22-micron filter
be used when infusing amino acid–dextrose
formulations to remove air, particulate
matter, and microorganisms that may be
present.
TNA formulations and IV fat emulsions
administered separately should be infused
through a 1.2-micron filter because the fat
droplets are too large to pass through a
0.22-micron filter.
A filter clog during administration of PN
should be investigated by a healthcare
practitioner.
An occluded filter should never be removed
to allow a PN formulation to infuse freely as
this increases the risk of infusion of
particulates and microprecipitates
Raniya.Khaled
@Rania1997301

14. Administration of Parenteral Nutrition Formulations
Vascular Access Devices
Catheter Type Placement Advantages Disadvantages
Central access
Percutaneous
nontunneled central
catheter
• Jugular
• Femoral
• Subclavian
Economical
Easily removable
Can be replaced over guidewire
Useful in acute care and short duration
therapies
Catheter breakage not repairable
Patient self-care difficult
Requires sutures to prevent dislodgment
High risk for catheter- related infection
Not recommended for home care
Tunneled cuffed catheters
Percutaneous placement via
subclavian or jugular vessel
Cephalic
Jugular vein cutdown
Long-term usage
Home care
Dressings and sutures can be removed
after 1 mo
Self-care easy
Repair kit available
Operating room or specialized room for placement
Requires small procedure for removal
Peripherally inserted
central catheter (PICC)
nontunneled
• Percutaneous placement via
a peripheral vein
Used in acute and home care for
therapies ranging from several weeks to
months
Low risk of placement complications
Placement occurs anywhere from
radiology suite to patient bedside
Self-care may be difficult with antecubital
placement because dressing changes require both
hands
Extended home care repair kits may not be
available
Implanted ports
• Percutaneous venous
placement via subclavian,
jugular, or peripheral vessels
Used for long-term therapies
Site care only when accessed
Monthly heparin flush
Body image intact
No external segment for breakage
Needle access required
Needle dislodgement can result in infiltration
Placement in operating room or specialized room
Surgical procedure for removal
Raniya.Khaled
@Rania1997301

15. Administration of Parenteral Nutrition Formulations
Vascular Access Devices
Catheter Type Placement Advantages Disadvantages
peripheral access
Peripheral catheters • Percutaneous peripheral
insertion
Least expensive
Least risk for catheter- related infections
No special placement room
Clinicians are easily trained in placement
Requires site rotation q 48–72 hr
Not appropriate to infuse solutions >400–600
mOsm/L, concentrated antibiotics, and vesicants
Midline catheters
• Percutaneous peripheral
insertion
• Used for therapies lasting 2–4 wk
• Not appropriate for infusions requiring central
access including PN with >900 mOsm/L
Midclavicular catheters • Percutaneous peripheral
insertion
• Used for therapies 2–3 mo
• Not appropriate for infusions requiring central
access including PN with >900 mOsm/L
Raniya.Khaled
@Rania1997301

16. Complications of Parenteral Nutrition Therapy
Metabolic Complications
Complications can be divided into three categories: 1. Mechanical 2. Infectious 3. Metabolic
Category Type of Complication Possible Cause Management
Mechanical
• Pneumothorax
• Incorrect position of central venous
catheter
• Radiologic verification of catheter placement
• Catheter occlusion • Precipitation of PN ingredients or
other medications
• Replacement of catheter, identification and correction of
incompatibilities
of formulation ingredients or with other medications infused
through the catheter
• Venous thrombosis • Platelet aggregation around catheter
• Anticoagulant therapy
• Phlebitis
• Admixture too hypertonic for
peripheral infusion
• Decrease dextrose concentration or amino acid concentration,
administer IV fat emulsion, or increase volume
Infectious
• Bacterial or fungal
growth at catheter site
• Poor care of catheter site
• Proper care of catheter site
• Multiple manipulations of catheter
including administration of medications
• Minimize manipulations, strict adherence to aseptic technique
when administering lipids and medications through the catheter
• Sepsis • Contaminated PN admixtures, infected
catheter site
• Strict adherence to aseptic technique when preparing and
administering PN, quality assurance procedures, hang time not to
exceed 24 hr, proper care of catheter site
Raniya.Khaled
@Rania1997301

17. Complications of Parenteral Nutrition Therapy
Metabolic Complications
Complications can be divided into three categories:
1. Mechanical 2. Infectious 3. Metabolic
Metabolic Complications
There are numerous potential metabolic complications
associated with PN :
• Inadequate or excessive intake of nutrients
• Diseases (e.g., diabetes and cancer)
• Major organ dysfunction, especially renal and hepatic
• Nutrient losses from diarrhea, vomiting, GIT suction, dialysis,
fistulae
• Drugs that alter the disposition of nutrients (e.g.,
corticosteroids, diuretics, and insulin)
• Stress (e.g., infection, malnutrition, major surgery, burns, or
trauma)
Refeeding Syndrome
Refeeding syndrome is a potentially life-threatening
condition that occurs from rapid refeeding of malnutrition
patients using high-calorie, high-carbohydrate
formulations.
It causes an intracellular shift of phosphorus resulting in
severe hypophosphatemia (serum phosphorus less than 1
mg/dL).
Hypokalemia, hypomagnesemia, and alterations in serum
glucose also occur.
The patient exhibits progressive symptoms of irritability,
weakness, paresthesias , confusion, seizures, and coma.
Raniya.Khaled
@Rania1997301

18. Complications of Parenteral Nutrition Therapy
Metabolic Complications
Complications can be divided into three categories:
1. Mechanical 2. Infectious 3. Metabolic
Metabolic Complications
There are numerous potential metabolic complications associated with PN :
• Inadequate or excessive intake of nutrients
• Diseases (e.g., diabetes and cancer)
• Major organ dysfunction, especially renal and hepatic
• Nutrient losses from diarrhea, vomiting, GIT suction, dialysis, fistulae
• Drugs that alter the disposition of nutrients (e.g., corticosteroids, diuretics, and insulin)
• Stress (e.g., infection, malnutrition, major surgery, burns, or trauma)
Type of Complication
Management
Type of Complication Management
Hyperglycemia
• Administer insulin
• Decrease infusion rate
• Decrease dextrose concentration
Metabolic acidosis
• Treat underlying causes
• Increase acetate intake
• Decrease chloride and amino acid intake
Hypoglycemia • Increase dextrose intake
• Decrease administration of insulin
Metabolic alkalosis
• Treat underlying causes
• Increase chloride intake
• Decrease acetate intake
Elevated cholesterol or
triglycerides
• Decrease or discontinue IV fat emulsion
Trace element deficiencies
or toxicity
• Adjust trace element intake
Abnormal liver function tests
• Decrease dextrose intake
• Decrease total calories
• Adjust IV fat emulsion or cycle solution with 4 hr off
Vitamin deficiencies or
toxicity
• Adjust vitamin intake
Excess carbon dioxide
production
• Decrease dextrose intake
• Adjust balance of dextrose and IV fat emulsion
Essential fatty acid
deficiency
• Initiate IV fat emulsion
Fluid imbalance
• Adjust fluid intake
• Administer diuretics if excessive fluid load is present
Decreased immune function • Decrease IV fat emulsion intake
Electrolyte imbalance
• Adjust intake of specific electrolytes
• Discontinue phosphate binding antacids in hypophosphatemia
Raniya.Khaled
@Rania1997301

19. Medication Administration in Adults Receiving
Parenteral Nutrition
Patients receiving PN often receive IV medications
as well. These medications are usually given
piggyback
into the PN line
There are several advantages to using PN as a
vehicle for medication delivery
• Decreased compounding and administration time
• Decreased fluid volume infused in fluid-restricted
patients
• Decreased venous catheter manipulations
• Improved therapeutic effectiveness for some
medications (e.g., H2 antagonists)
• However, some disadvantages exist21,22:
• Possible toxicity or therapeutic failure resulting
from changes in the rate of infusion and loss of peak
and trough levels
• Potential for waste with dose changes
• Stability and compatibility concerns
Medications can also affect the disposition of
nutrients in the body.
Possible effects of medications on nutrient utilization
include the following:
Alteration of the patient’s nutrition needs
Alteration of the body’s response to nutrients
Potentiation of medication-related problems that
impede the patient’s nutritional progress
Patients receiving PN should be monitored for drug–
nutrient interactions.
Some examples of common interactions between
medications and PN include the following:
Altered excretion of electrolytes induced by diuretics
Hyperglycemia induced by furosemide,
corticosteroids, or phenytoin
Impaired utilization of nutrients for protein synthesis
induced by antineoplastic agents
• Depletion of vitamin B12 by H2 antagonists and
proton pump inhibitors
• Impaired protein metabolism by corticosteroids
Raniya.Khaled
@Rania1997301