Parenteral nutrition (PN) involves administering nutrients intravenously and is considered when a patient is unable to meet nutritional needs enterally. PN can be partial (PPN), containing less than 10% dextrose, or total (TPN), containing greater amounts. PN provides proteins, carbohydrates, lipids, vitamins, minerals, electrolytes and water to meet nutritional needs. Close monitoring is required to prevent deficiencies or complications from excess levels.

1.  
Continuing Education

2.  Parenteral Nutrition must be considered when the patient
is malnourished and unable to obtain nutrients through
the gastrointestinal tract, either orally or through enteral
feedings.
 Golden Rule of Nutrition is: “If the gut works, use it”.
 Parenteral nutrition is a mixture of proteins and
carbohydrates, along with vitamins, minerals and
electrolytes that are administered IV to provide complete
nutrition.
o Parenteral nutrition is sometimes referred to as a 2-in-1 solution.
A fat emulsion (lipids) is often given with parenteral nutrition to
prevent the occurrence of essential fatty acid deficiency.
o When the lipids are added directly to the solution, it is called a 3-
in-1 solution.

3.  Parenteral Nutrition can be divided into two
types
o PPN (Partial Parental Nutrition)
o TPN (Total Parental Nutrition)

4.  Contains less than 10 % final concentration of dextrose
 Solution tonicity (concentration) is less than 500 mOsm/
liter
 May be administered through a larger peripheral vein
 Often given if a patient can tolerate enteral nutrition but
nutritional needs exceed what he/she can ingest through
the gut

5.  Contains 10% or greater concentration of Dextrose and
greater than 5% protein.
 Solution tonicity is 500 mOsm/ liter or greater
 Must be administered through a central line (tip
placement confirmed in the SVC)
 Designed to totally replace enteral intake
 Lipids may be administered separately via piggy back at
the hub or mixed directly into the solution (referred to as
a 3-in-1 formula)

6.  Universal principles that define the indications for nutritional
support include the following based on recommendations of
ASPEN guidelines.
o When specialized nutritional support is required, enteral
nutrition should generally be used in preference to PN
o PN should be used when the GI tract is not functional or
cannot be accessed and in patients who cannot be
adequately nourished by oral diets or enteral nutrition.
o Specialized nutrition support should be initiated in patients
with inadequate oral intake for 7-10 days. Or in those patients
in whom inadequate oral intake is expected over a 7-14 day
period.

7.  GI trauma
 Ileus
 Bowel obstruction
 Short bowel syndrome
 Severe mal-absorption
 Pancreatitis
 Inflammatory bowel disease requiring bowel rest
 Entercutaneous fistula
 Malignancy of the GI tract

8.  A functioning GI tract
 Inability to obtain appropriate IV access
 An unstable clinical condition or terminal disease for
which complication risk outweighs favorable response
 Allergies: Important to determine if patient has any
allergy to Amino acid or fat emulsions, corn or corn
products, eggs, soybeans and any drug allergies.
 Liver disease, kidney or heart failure
 Pregnancy
 Diabetes
 Unsafe environment or caregiver ability.

9. Protein
 Protein is considered the premiere macronutrient in PN solution.
 Protein is provided in PN solutions by the addition of crystalline
amino acids.
 The human body contains an estimated 10,000 to 50,000 different
types of proteins, all with a special function.
 Proteins are essential to cell function and structure.
 Proteins act as building blocks for muscles, tendons, enzymes,
hormones, and antibodies.
 A patient’s estimated protein requirement depends on age, level of
activity, nutritional status, renal function, hepatic function, and
presence or absence of hypermetabolism or stress.
 The daily protein requirement in healthy adults is 0.8g/Kg.
 During periods of stress , injury or infection, patients require an
increased amount of protein in the PN.

10. Amino Acids
Amino acids are classified either as essential or
nonessential amino acids.
Essential amino acids: Histidine, Isoleucine, Leucine,
Lysine, Methionine, Phenylalanine, Threonine, Valine
Nonessential amino acids: Alanine, Arginine, Asparagine,
Aspartic acid, Cysteine, Glumatic acid, Glutamine, Glycine,
Proline, Serine, Tyrosine

11. Carbohydrates
 Carbohydrates serve as the prime energy source and
provide 45% to 65% of daily energy needs.
 Nearly all dietary carbs are broken down into glucose
and oxidized for energy.
 They are classified as either simple or complex.
 The basic unit of carbohydrate metabolism in humans is
glucose.
 Each gram of carbohydrate provides 4 kcal of energy.

12. Lipids
 Fat emulsions are needed to prevent essential fatty acid
deficiency.
 Fat is the most calorically dense nutrient in PN
(approximately 9 kcal per gram) providing more than
twice the caloric density of carbohydrate and protein.
 They are composed of triglycerides, sterols, and
phospholipids.
 Their functions include insulation and support of organs;
precursors for steroid hormones, prostaglandin and
thromboxane; and carriers of essential nutrients such as
fat-soluable vitamins.
 Lipids may be ordered daily or on certain days of the
week in quantities sufficient to prevent essential fatty
acid deficiency.

13. Water
 The body consists of 50% to 60% water.
 The average healthy adult requires 2 to 3 L of fluid per day.
 Individual fluid requirements vary greatly and can fluctuate daily,
therefore accurate patient I&O records and weights are invaluable
in determining fluid requirements.
 Fluids are lost through the kidneys, lungs, bowel and skin.
 It is important to consider the patient’s cardiac, respiratory, and
renal status. Critically ill patients can easily become fluid
overloaded.
 Estimates of fluid maintenance requirements can be obtained
from body surface area (BSA).
 Continual assessment of the patient’s hydration status must be
taken during PN therapy.
 Monitoring hydration includes measuring daily I & O; assessing
for signs of cardiac, respiratory, and renal compromise; observing
for rapid weight changes; evaluating peripheral edema; and

14. Electrolytes
 Electrolytes play a critical role in almost all of the body’s
physiological functions.
 Electrolytes commonly used in a PN formula include
sodium, potassium, calcium, magnesium, chloride and
phosphorous.
 Electrolytes are included in the formula to meet daily
requirements and to correct any deficits.
 The management of electrolytes for patients can be one
of the most time-consuming aspects of monitoring and
managing nutritional support.
 It is very important to recognize the signs and smptoms
of deficiency.

15.  Vitamin A (retinol)
 Vitamin D
 Vitamin E (tocopherol)
 Vitamin K
*vitamins are only stable
at room temperature for
24 hours so they are
added to the PN solution
at the time of infusion.
 Vitamin B1 (thiamine)
 Vitamin B2 (riboflavin)
 Pantothenic acid
 Vitamin B6 (pyridoxine)
 Vitamin B12
(cyanocobalamin)
 Biotin, Niacin, Folic
acid, and
 Vitamin C (ascorbic
acid)
Fat Soluble
Vitamins
Water Soluble Vitamins

16. Trace Elements
 Copper
 Chromium
 Manganese
 Selenium
 Zinc
 Trace element requirements vary by age
 Some trace elements are added at the time of the
infusion due to stability

17. Additives to TPN
 Some medications are added to the PN solution at time
of administration due to decreased stability.
 Examples of common additives include, but are not
limited to:
 Insulin
 Famotadine
 Carnatine
 Vitamins
 Trace Elements
Plus any other additives deemed necessary by the
Physician or Pharmacist according to the patient’s
condition.

18.  Solutions should be compounded in a pharmacy using a
laminar flow hood to ensure sterility.
 Solutions should be refrigerated and removed 60
minutes before administration to minimize patient
discomfort from administration of chilled solution.
 Solutions must be infused or discarded within 24 hours
after hanging to minimize the risk of bacterial
contamination.