THIS IS NUTRIATION SLIDE

1. PARAENTERAL NUTRITION
(PN)
GROUP 5
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2. INTRODUCTION
• Parenteral nutrition (PN) also known as Total
Parenteral Nutrition.
• Is “intravenous” administration of nutrients.
• Sends nutrients straight into the bloodstream.
• Used when Impaired GI prevents adequate Oral or
Enteral Nutrition.
• For patients who cannot eat or absorb enough food
through tube feeding formula or by mouth to
maintain good nutrition status.
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3. INTRO cont…
• Is a sterile liquid chemical formula, given directly
into the bloodstream through an intravenous
catheter (needle in the vein).
• Include administration of protein,
carbohydrate, fat, minerals and electrolytes,
vitamins and other trace elements.
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4. INDICATION OF PN
• When GI dysfunction prevents Oral/Enteral
nutrition.
• For variety of diseases or conditions that impair
food intake, nutrient digestion or absorption.
• Must primarily assess and evaluate the patient’s
nutrition status, clinical status, age, and potential
risks of initiating therapy (infection and other
metabolic abnormalities)
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5. INDICATION OF PN cont.
1. Impaired absorption or loss of nutrients via the Gl
tract because of one or more of for eg. Massive
small bowel resection or mucosal disease:
Radiation- or Chemotherapy-related enteritis.
2. Mechanical bowel obstruction.
3. Restricted oral intake or EN necessary for bowel
rest.
4. Motility disorders
5. Inability to achieve or maintain EN instability
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6. INDICATION OF PN cont.
• PN is not an emergent intervention;
• should not be initiated until the patient is
hemodynamically and metabolically stable.
• Can be used as long as needed.
• But many times, parenteral nutrition is used for a
short time.
• Lessened or discontinued when the person begins
to switch to tube feeding or eat enough by mouth.
• Taken lifelong at home or for a short period of time.
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7. DESIRED OUTCOME
• Correction patient’s: Caloric, Nitrogen, Fluid,
Electrolyte, Vitamin, and/ or Trace element
abnormalities.
• Lessen the metabolic response to injury by
minimizing oxidant stress and favorably modulating
immune response.
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8. COMPONENTS
• Should provide the optimal combination of macro- and
micronutrients to provide a patient’s specific
nutritional requirements.
• PN formulations include IV sources of protein, dextrose,
fat, water, electrolytes, vitamins, trace elements, and
other additives.
• Macronutrients include water, protein (as structural
substrates), dextrose, and fat or lipid (used for energy).
• Micronutrients include vitamins, trace elements, and
electrolytes. (for cellular homeostasis such as
enzymatic reactions, fluid balance, and regulation of
electrophysiological processes.)
• Both are necessary for maintenance of normal
metabolism
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9. COMPONENTS cont.
1. Proteins (Amino Acids)
2. Carbohydrate (Dextrose)
3. IV lipid emulsion (IVLE)
4. Vitamins
5. Trace Elements
6. Electrolytes
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10. Proteins (Amino Acids)
• In the form of crystalline amino acids (CAAs).
• When oxidized for energy yield 4cal (approx 17
kJ/g)
• Differ in protein concentration, total nitrogen, and
electrolyte content.
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11. Amino Acids cont.
Standard amino acid solutions:
• for patients with
“normal” organ
function and nutritional
requirements.
• contain a balanced
profile of essential,
semi-essential, and
nonessential L-amino
acids.
Modified amino acid solutions:
• disease-specific PN regimens:
• for patients with altered protein
requirements, i.e. hepatic
encephalopathy, kidney disease,
metabolic stress or trauma, for
neonates and pediatric patients.
• highly concentrated products
(15%-20% amino acids) for
critically ill patients who
typically require fluid restriction
but have large protein needs.
• More expensive and
controversial
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12. Amino Acids cont.
• Cysteine
• a conditionally essential amino acid for preterm and
term infants because of their enzymatic immaturity of
the trans-sulfuration pathway.
• enhances Ca and P solubility by decreasing soln pH.
• Showed: positive effects on nutritional markers,
including improved fatty acid oxidation, weight gain, and
nitrogen balance, have been documented.
• reserved for neonates expected to receive PN support
for 7 days or longer.
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13. Amino Acids cont.
• Carnitine
• quaternary amine.
• required for long-chain fatty acid transport into the
mitochondria for β-oxidation and energy production.
• Glutamine
• most abundant free amino acid in the body.
• important intermediate for many metabolic processes.
• maintain intestinal integrity, immune function, and
protein synthesis when there is metabolic stress.
• Showed:
• positive effects on nutritional markers,
• decreased length of hospitalization,
• low incidence ofinfections,
• lower GI toxicities associated with chemotherapy or radiation.
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14. Amino Acids cont.
• Dextrose
• in the form of dextrose monohydrate.
• available in concentrations ranging from 5% to 70%.
• each gram of dextrose provides 3.4 kcal (14.2 kJ) when
oxidized
• IV dextrose dose depends on the patient’s age,
estimated caloric requirements, and clinical condition
• Neonates: 6 to 8 mg/kg/min
• Infants: 14 to 18mg/kg/min
• Adults: 4 to 7 mg/kg/min
• Excessive dextrose infusion rates - may contribute to the
development of hyperglycemia and fatty infiltration of
the liver.
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15. Amino Acids cont.
• Dextrose cont.
• If dextrose infusion rate exceeds > glucose oxidation rate;
glycogen repletion and lipid synthesis are favored = increased
energy expenditure = increased oxygen consumption =
increased carbon dioxide production.
• Glycerol
• an alternate Carbohydrate sources to Dextrose
• not insulin-dependent to improve glycemic control for
patients with impaired insulin secretion or activity.
• Disadvantage; dilute amino acid and carbohydrate
concentrations.
• require up to 3 to 4 L/day together with IV lipid emulsion as a
caloric source to meet minimum energy requirements.
• Safe in Adult but no data available for infants and children.
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16. IV lipid emulsion (IVLE)
• Used as a concentrated source of calories and
essential fatty acids.
• Prepared as: combinations of
• SO and olive oil;
• SO, olive oil, medium chain triglyceride oil (MCT), and fish oil
(FO)…SMOF, or
• 100% FO
• Used as a caloric source,
• minimize complications of nutrition therapy such as
hyperglycemia, hepatotoxicity, or increased carbon
dioxide production.
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17. IV lipid emulsion (IVLE) cont.
• SO Based:
• higher linoleic and linolenic FA composition.
• important for cellular integrity, platelet function,
postnatal brain development, and wound healing.
• for treatment or prevention of essential fatty acid
deficiency
(EFAD) in both adult and pediatric patients.
• may have negative effects on immune function and
hepatic function (cholestasis: PN-associated liver disease
(PNALD))
• Adult: 100 g SO IVLE weekly… for EFAD prevention
• Neonates and infants: min 0.5 - 1 g/kg SO IVLE daily.
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18. IV lipid emulsion (IVLE) cont.
• SO-Olive oil and SMOF products:
• lower linoleic and linolenic acid content.
• inadequate provision of essential fatty acids to prevent
or treat EFAD.
• Not approved for use in pediatric patients.
• 100% FO
• relatively lower essential FA content
• not indicated for treating EFAD
• Indicated for use in pediatric patients with PN-
associated cholestasis.
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19. IV lipid emulsion (IVLE) cont.
• Caloric content:
• 10% IVLE = 1.1 kcal/mL (4.6 kJ/mL)
• 20% IVLE = 2 kcal/mL (8.4 kJ/mL) and
• 30% emulsion = 3 kcal/mL (12.6 kJ/mL)
• patients receiving their first IVLE dose should be
monitored for dyspnea, chest tightness, palpitations,
and chills. Headache, nausea, and fever also have been
reported and might be associated with a rapid infusion
rate.
• contraindicated for patients with an impaired ability to
clear fat emulsion, such as patients with pathologic
hyperlipidemia, lipoid nephrosis, and
hypertriglyceridemia associated with pancreatitis.
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20. Vitamins
• Vitamin requirements may be altered in
malnutrition and other specific
disease states or with certain drug therapies.
• Individual and combination products (as Multi-
vitamins) are available.
• Vitamin K was not included in early multivitamin
formulations due to the potential for drug-nutrient
interactions in patients receiving anticoagulants.
150 mcg/day
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21. Trace Elements
• important part of metalloenzymes and function as
cofactors in a variety of regulatory metabolic
pathways.
• deficiency syndromes in humans have been
described only for cobalt (as vitamin B12), copper,
iodine, iron, and zinc.
• available as single-trace element solutions and as
multiple-trace element combinations.
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22. Trace Elements cont.
• Single-entity injectable :
• allows for individualization of trace mineral supplementation of
chromium, copper, iodine, manganese, selenium, and zinc.
• Combination products:
• provide the daily requirements for the trace elements considered
essential by the NAG-AMA (ie, chromium, copper, manganese,
selenium, and zinc).
• higher doses of supplemental zinc likely are necessary
for patients with high-output ostomies or diarrhea because
the GI tract is the predominant excretion route for zinc
• manganese and copper are excreted through the biliary
tract, chromium, molybdenum, and selenium are excreted
renally. Hence, these trace elements should be restricted or
withheld from PN solutions for patients with cholestatic
liver disease and kidney disease, respectively.
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23. Electrolytes
• Sodium, potassium, calcium, magnesium,
phosphorus, chloride, and acetate
• Necessary PN components for the maintenance of
many cellular functions.
• Given to maintain normal serum concentrations or
to correct deficits.
• Pt with “normal” organ function and relatively
normal serum concentrations of any electrolyte =
receive “normal” maintenance electrolyte doses
when PN is initiated and daily thereafter.
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24. Electrolytes cont.
• Requirements vary according to the patient’s age,
disease state, organ function, previous and current
drug therapy, nutrition status, and extrarenal
losses.
• Available commercially as single- and multiple-
nutrient solutions
• Multiple-nutrient solutions : useful for stable
patients with normal organ function who are
receiving PN
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25. Designing the regimen
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26. • Several factors including the patient’s venous
access, fluid status, and macronutrient and
micronutrient requirements, are important
considerations when designing the PN regimen.
• PN solutions may be administered by central or
peripheral venous acess.
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27. • Parenteral nutrition formulations may be provided
as:
• a two-in-one admixture that contains dextrose, CAA, and
other necessary micronutrients or as,
• three-in one admixture or TNA that contains dextrose,
CAA, and IVLE, as well as other necessary micronutrients
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28. • Advantage of Using TNA,
• reduced inventory (infusion pumps, tubing, and other related
supplies),
• decreased time for compounding and administration,
• a potential decrease in manipulations of the infusion line
(which should correspond with a decreased risk of catheter
contamination),
• ease of delivery and storage for patients receiving home PN.
• Potential disadvantages,
• increased risk of infections and
• stability and compatibility concerns. For example, the stability
of TNA admixtures is less predictable than that of two-inone
admixtures, which makes their use less desirable in some
patient populations such as neonates and infants.
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29. Choosing the
route of
administration
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30. Peripheral venous acess
• An option for mild-to-moderately stressed patients in
whom adequate GI tract function is expected to return
within 10 to 14 days.
• May be used as a temporary source of PN, or as a
bridge therapy during transition periods.
• Potential PPN candidates should not be fluid-restricted
or require large nutrient amounts.
• Low concentration of CAA (3-5%), Dextrose (5-10%)
and micronutrients. (usually require high volume and
IVLE)
• Primary advantages of PPN include a potentially lower
risk of infectious and technical complications associated
with CVC access.
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31. • Who is more likely to be a poor candidate for PPN?
• poor venous access as the result of multiple courses of
chemotherapy
• malnutrition
• illness of long duration that has required multiple
venous accesses for fluid and medication administration
• premature infants
• elderly
• Thrombophlebitis is a commonly reported
complication for patients receiving PPN (for
solutions greater than 600 to 900 mOsm/L)
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32. Central Parenteral Nutrition
• CPN solutions are highly concentrated hypertonic
solutions that must be administered through a
large central vein. (because the high blood flow)
• CPN is the preferred route for patients requiring PN
for more than 7 to 14 days.
• Candidates for CPN
• large nutrient requirements
• poor peripheral venous access
• fluctuating fluid requirements
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33. • Disadvantage of CPN
• risks associated with catheter insertion,
• routine catheter use, and
• Care of the access site.
• Relative to peripheral venous access, CVC access is
associated
• with a greater potential for infection
• risk of more serious catheter induced trauma and
related sequelae
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34. • Choice of central venous access site depends on;
• Age and anatomy.
• CVS for short-term use for adults are commonly
inserted percutaneously into the subclavian vein and
advanced so that the tip is at the superior vena cava.
• short-term for critically ill neonates via a catheter
placed in the umbilical vein.
• When therapy is expected to last longer than 4 weeks,
the catheter usually is tunneled subcutaneously before
entering the central vessel, secured initially with
retaining sutures, and anchored in place with a felt cuff
that promotes subcutaneous fibrotic tissue growth
around the catheter.
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35. Implanted CVS vs PICC
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36. Constructing
a Parenteral
Nutrition
Regimen
After the route of delivery is chosen, the
components of the PN regimen are
determined based on the patient’s
nutritional assessment.
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37. Adult Parenteral Nutrition
Solutions
• There are two methods for ordering adult PN.
• The “standard formula approach” offers a variety of
admixtures with a fixed non-protein calorie-to-
nitrogen ratio.
• Because the nonprotein-calorie-to-nitrogen ratio is
fixed, the daily amount of nutrient delivered
depends solely on the volume infused.
• However, efficiencies associated with use of the
standard formula approach may be hindered if
there is a frequent need to modify the PN
formulation.
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38. • The “individualized formula approach” permits
compounding of patient specific admixtures.
• Compounding of the PN admixture is limited only by
the concentrations of stock solutions and stability of
the additives.
• Traditionally, adult PN formulations have been ordered
by expressing the final concentrations of each
component in the solution. For example, CAA and
dextrose are ordered commonly in final percentage,
electrolytes in milliequivalents (or millimoles) per liter,
and other additives in amount (milliliters or units) per
day.
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39. Calculation of an Adult PN Regimen
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40. Calculation of an Adult PN Regimen
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41. Calculation of an Adult PN Regimen
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42. Pediatric Parenteral Nutrition
Solutions
• Pediatric PN admixtures are typically ordered using
an individualized approach because current safe
clinical practice guidelines recommend nutrient
intakes based on the patient’s weight.
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43. Calculation of an Pediatric PN Regimen
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44. Calculation of an Pediatric PN Regimen
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45. Calculation of an Pediatric PN Regimen
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46. Administration Techniques
• PN admixtures should be administered with an
infusion pump.
• The IV administration line for CAA-dextrose
solutions should include a 0.22-micron inline filter
to remove particulate matter, air, and any
microorganisms that may be present in the
solution.
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47. Initiating and Advancing the
regimen
• For Adults
• Stable patients … okay to abruptly start and stop
• receiving intermittent subcutaneous regular insulin;
patients with severe kidney or liver disease; and patients
with other disease states that have an increased risk for
development of hyperglycemia or hypoglycemia, such as
severe diabetes or pancreatic malignancy
• Gradually increase infusion rate in 12-24hrs and decrease to ½
an hour before discontinuation OR
• Start at desired rate with hypocaloric dextrose dose
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48. • For Pediatrics;
• Pediatric PN solutions typically … maintenance fluid
requirements on the first day of therapy. Individual
nutrient substrates … generally being achieved by
day 3 of therapy.
• Protein dose should be pushed on day one.
• IV electrolytes, vitamins, and trace elements should
be initiated on the first day of therapy and
continued as a daily component of the PN solution.
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49. • The PN infusion rate should be reduced for 1 to 2
hours before stopping the infusion for neonates
and infants because of their immature counter-
regulatory mechanisms that contribute to an
increased risk for developing rebound
hypoglycemia.
• Blood glucose concentrations should be measured
within 15 to 60 minutes after the PN infusion ends
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50. EVALUATION OF THERAPEUTIC
OUTCOMES
• Ensure nutritional outcomes
• Prevent the occurrence of adverse effects or
complications.
• Routine evaluation should include the assessment
of the patient’s clinical condition with a focus on
nutritional and metabolic effects of the PN
regimen.
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51. • Serum concentrations of electrolytes, hematologic
indices, and biochemical markers for kidney and
liver function, and nutrition status.
• The frequency of blood laboratory measurements
for neonates and infants tends to be more
conservative because of their smaller blood
volumes and, in some cases, lack of central vascular
access
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53. COMPLICATIONS OF PARENTERAL
NUTRITION
• Mechanical and Technical Complications
• malfunctions in the system used for IV delivery of the solution
• CVC-related complications are potentially life-threatening.
• Pneumothorax, catheter misdirection or migration into the
wrong vein or improper positioning within the cardiac
chambers, arterial puncture, bleeding, and hematoma
formation may occur during surgical placement of the
catheter.
• CVCs occasionally occlude or break during use and if these
problems cannot be rectified easily, the catheter may need to
be surgically replaced.
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54. • Infectious Complications
• Infectious complications can be a major hazard for
patients receiving CPN because of the increased risk
associated with the presence of an indwelling CVC.
• The source of a CVC infection may be skin organisms
from the catheter insertion site, contamination of the
catheter hub, or hematogenous seeding of the catheter
from a distant site.
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55. • The risk of catheter infection is increased for those who
require multiple manipulations of the line used for PN
administration as well as those who experience failure
of in-line bacterial filter, poor catheter placement
technique, and poor CVC and insertion site care.
• Catheter-related bloodstream infections (CRBSIs),
defined as the presence of clinical manifestations of
infection (eg, fever, chills, hypotension) associated with
bacteremia or fungemia resulting from no apparent
source other than the catheter, are common sources of
systemic infection.
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56. REFERENCES
1. ASPEN | What Is Parenteral Nutrition. (n.d.).
ASPEN.
http://www.nutritioncare.org/about_clinical_nut
rition/what_is_parenteral_nutrition/
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57. THANK YOU
GROUP 5
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58. Group Members
1. Natnael Abebe
2. Natnael
3. Nebyu Daniel
4. Niyat Alem
5. Nuhamin Milion
6. Rahel
7. Habiba
HSR/3086/11
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