parenteral nutrition

1. Enteral and
Parenteral Nutrition

3. What is parenteral nutrition?
• What is parenteral nutrition?
• Parenteral nutrition, or intravenous feeding, is a method of getting
nutrition into your body through your veins. Depending on which vein is
used, this procedure is often referred to as either total parenteral nutrition
(TPN) or peripheral parenteral nutrition (PPN).
This form of nutrition is used to help people who can’t or shouldn’t get
their core nutrients from food. It’s often used for people with:
• Crohn’s disease
• cancer
• short bowel syndrome
• ischemic bowel disease

4. Enteral tube feeding
• Nutrition plays an important role in maintaining health as well as in
the prevention and management of a variety of diseases. Nutritional
support is therapy for people who cannot get enough nourishment by
eating or drinking.Enteral tube feeding is the delivery of nutrients
directly into the digestive tract via a tube. The tube is usually placed
into the stomach, duodenum or jejunum via either the nose, mouth
or the direct percutaneous route. It is used to feed patients who
cannot obtain an adequate oral intake from food and/or oral
nutritional supplements, or who cannot eat/drink safely. Enteral
feeding is used commonly in patients with dysphagia – any
impairment of eating, drinking and swallowing.3

5. TPN (Total Parenteral Nutrition)

12. Gastrostomy feeding tubes are
put in for different reasons.
• Gastrostomy feeding tubes are put in for different reasons. They may
be needed for a short period of time or permanently. This procedure
may be recommended for:
• People, potentially babies, with birth defects of the mouth,
esophagus, or stomach (for example, esophageal atresia or tracheal
esophageal fistula)
• Persons who cannot swallow correctly
• Persons who cannot take enough food by mouth to stay healthy

14. What is exclusive enteral nutrition?
• What is exclusive enteral nutrition?
• Children with inflammatory bowel disease (IBD) often have trouble
gaining weight. Intestinal inflammation often makes it difficult for
their bodies to absorb the nutrients needed to help them grow. In
addition, impaired bone growth and delayed puberty may also occur
in children managing IBD.
• Exclusive Enteral Nutrition (EEN) is the recommended first-line
therapy to treat active Crohn’s disease. The formula-based (no solid
foods) diet is designed to induce remission in patients. It is a short-
term program and may extend six to 12 weeks.

15. Total parenteral nutrition (TPN)
• Parenteral nutrition is by definition given IV.
• Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing
oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method.
• Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be used in
the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of
peripheral veins, a central venous catheter is usually required.
• Parenteral nutrition should not be used routinely in patients with an intact gastrointestinal (GI)
tract. Compared with enteral nutrition, it has the following disadvantages:
1. It causes more complications.
2. It does not preserve GI tract structure and function as well.
3. It is more expensive.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-
parenteral-nutrition

16. Indications for TPN
• Indications
• TPN may be the only feasible option for patients who do not have a
functioning GI tract or who have disorders requiring complete bowel rest,
such as the following:
• Some stages of ulcerative colitis
• Bowel obstruction
• Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged
diarrhea regardless of its cause)
• Short bowel syndrome due to surgery

17. Nutritional content
• Nutritional content
• TPN requires water (30 to 40 mL/kg/day), energy (30 to 35
kcal/kg/day, depending on energy expenditure; up to 45 kcal/kg/day
for critically ill patients), amino acids (1.0 to 2.0 g/kg/day, depending
on the degree of catabolism), essential fatty acids, vitamins, and
minerals
• Children who need TPN may have different fluid requirements and
need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5
or 3.5 g/kg/day).

18. Nutritional content
• Basic TPN solutions are prepared using sterile techniques, usually in liter
batches according to standard formulas. Normally, 2 L/day of the standard
solution is needed. Solutions may be modified based on laboratory results,
underlying disorders, hypermetabolism, or other factors.
• Most calories are supplied as carbohydrate. Typically, about 4 to 5
mg/kg/minute of dextrose is given. Standard solutions contain up to about
25% dextrose, but the amount and concentration depend on other factors,
such as metabolic needs and the proportion of caloric needs that are
supplied by lipids.
https://www.msdmanuals.com/professional/nutritional-
disorders/nutritional-support/total-parenteral-nutrition-
tpn#:~:text=TPN%20

19. Nutritional content
• Commercially available lipid emulsions are often added to supply
essential fatty acids and triglycerides; 20 to 30% of total calories are
usually supplied as lipids. However, withholding lipids and their
calories may help obese patients mobilize endogenous fat stores,
increasing insulin sensitivity.
https://www.msdmanuals.com/professional/nutritional-
disorders/nutritional-support/total-parenteral-nutrition-
tpn#:~:text=TPN%20

20. TPN Solutions
• TPN Solutions
• Many TPN solutions are commonly used. Electrolytes can be added to meet the
patient’s needs.
• TPN solutions vary depending on other disorders present and patient age, as for
the following:
• For renal insufficiency not being treated with dialysis or for liver failure: Reduced
protein content and a high percentage of essential amino acids
• For heart or kidney failure: Limited volume (liquid) intake
• For respiratory failure: A lipid emulsion that provides most of nonprotein calories
to minimize carbon dioxide production by carbohydrate metabolism
• For neonates: Lower dextrose concentrations (17 to 18%)
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-
support/total-parenteral-nutrition-tpn#:~:text=TPN%20

21. Beginning TPN administration
• Beginning TPN administration
• Because the central venous catheter needs to remain in place for a long time, strict sterile
technique must be used during insertion and maintenance of the TPN line. The TPN line should
not be used for any other purpose. External tubing should be changed every 24 hours with the
first bag of the day. In-line filters have not been shown to decrease complications. Dressings
should be kept sterile and are usually changed every 48 hours using strict sterile techniques.
• If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection,
and qualified home nursing must be arranged.
• The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make
up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The
amount of regular insulin given (added directly to the TPN solution) depends on the plasma
glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting
dose is 5 to 10 units of regular insulin/L of TPN fluid.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-
parenteral-nutrition-tpn#:~:text=TPN%20

22. Monitoring
• Monitoring
• Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary
nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes,
and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose
should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake
and output should be monitored continuously. When patients become stable, blood tests can be
done much less often.
• Liver tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-
binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and
phosphate should be measured twice/week. Changes in transthyretin and retinol-binding protein
reflect overall clinical status rather than nutritional status alone. If possible, blood tests should
not be done during glucose infusion.
• Full nutritional assessment (including BMI calculation and anthropometric measurements) should
be repeated at 2-week intervals.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-
parenteral-nutrition-tpn#:~:text=TPN%20

23. Complications
• Complications
• About 5 to 10% of patients with a TPN line have complications related to central
venous access.
• Catheter-related sepsis rates have decreased since the introduction of guidelines
that emphasize sterile techniques for catheter insertion and skin care around the
insertion site. The increasing use of dedicated teams of physicians and nurses
who specialize in various procedures including catheter insertion also has
accounted for a decrease in catheter-related infection rates.
• Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction
occurs in > 90% of patients.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-
support/total-parenteral-nutrition-tpn#:~:text=TPN%20

24. Complications
• Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often,
adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia can
be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the
degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged
hypoglycemia may require infusion of 5 or 10% dextrose for 24 hours before resuming TPN via the central
venous catheter.
• Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can
develop at any age but are most common among infants, particularly premature ones (whose liver is
immature).
• Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline
phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result from
excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive
fibrosis occasionally develops. Reducing protein delivery may help.
• Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be reduced.
• Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized
seizures. Arginine supplementation at 0.5 to 1.0 mmol/kg/day can correct it.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-
nutrition-tpn#:~:text=TPN%20

25. Complications
• If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be
necessary.
• Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent
infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions.
Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated blood urea
nitrogen may reflect dehydration, which can be corrected by giving free water as 5% dextrose via
a peripheral vein.
• Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily
energy requirements and thus require large fluid volumes.
• Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in
some patients given TPN for > 3 months. The mechanism is unknown. Advanced disease can
cause severe periarticular, lower-extremity, and back pain.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-
parenteral-nutrition-tpn#:~:text=TPN%20

26. Complications
• Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea,
headache, back pain, sweating, dizziness) are uncommon but may occur early,
particularly if lipids are given at > 1.0 kcal/kg/hour. Temporary hyperlipidemia may occur,
particularly in patients with kidney or liver failure; treatment is usually not required.
Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of
liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in
premature infants with respiratory distress syndrome, pulmonary function abnormalities.
Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or
minimize these adverse reactions.
• Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis.
These complications can be caused or worsened by prolonged gallbladder stasis.
Stimulating contraction by providing about 20 to 30% of calories as fat and stopping
glucose infusion several hours a day is helpful. Oral or enteral intake also helps.
Treatment with metronidazole, ursodeoxycholic acid, phenobarbital, or cholecystokinin
helps some patients with cholestasis.
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-
support/total-parenteral-nutrition-tpn#:~:text=TPN%20

27. Key Points
• Key Points
• Consider parenteral nutrition for patients who do not have a functioning gastrointestinal tract
or who have disorders requiring complete bowel rest.
• Calculate requirements for water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day,
depending on energy expenditure; up to 45 kcal/kg/day for critically ill patients), amino acids
(1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins,
and minerals.
• Choose a solution based on patient age and organ function status; different solutions are
required for neonates and for patients who have compromised heart, kidney, or lung function.
• Use a central venous catheter, with strict sterile technique for insertion and maintenance.
• Monitor patients closely for complications (eg, related to central venous access; abnormal
glucose, electrolyte, mineral levels; hepatic or gallbladder effects; reactions to lipid emulsions,
and volume overload or dehydration).
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-
parenteral-nutrition-tpn#:~:text=TPN%20

30. References
• https://www.healthline.com/health/parenteral-nutrition
• https://www.bostonscientific.com/en-US/patients/health-
conditions/enteral-feeding.html
• https://www.childrenshospital.org/conditions-and-
treatments/treatments/een
• https://www.msdmanuals.com/professional/nutritional-
disorders/nutritional-support/total-parenteral-nutrition-
tpn#:~:text=TPN%20

31. ACKNOWLEDGEMENT
• Allah Almighty
• My mother and my son

32. Thank you

33. Questions