This document provides information on parenteral nutrition including: - Parenteral nutrition involves infusing complete nutrient solutions directly into the bloodstream via a central or peripheral vein to meet nutritional needs. - It can be delivered through either total parenteral nutrition (TPN) using a central line, or peripheral parenteral nutrition (PPN) using a peripheral vein or peripherally inserted central catheter (PICC) line. - PPN has limitations as the peripheral sites are more prone to inflammation/infection and the catheter may need repeated insertion, while TPN is preferred for long-term nutrition support. - Indications for parenteral nutrition include when the gastrointestinal tract is non-functioning or unable to meet

1. Parenteral Nutrition

2. Parenteral nutrition is defined as the infusion of complete nutrient solutions into the bloodstream via a peripheral vein or, more commonly, by central venous access to meet nutritional needsDefinition

3. Fluid Requirements

4. Conditions requiring nutrition

5. Central access—TPN both long- and short-term placementPeripheral or PPN—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis <2000 kcal required or <10 daysRoutes of Parenteral Nutrition

6. Venous access site

7. Utilization of peripheral veins for the administration of nutrientsA. Indications for use: PN necessary but no access to central vein2. Malnourished patients with frequent NPO for procedures/tests Peripheral Parenteral Nutrition (PPN)

8. B. Contraindications:Patient can be fed enterallyPt. has weak peripheral veinsC. LimitationsPeripheral site more prone to inflammation/infectionCatheter may need to be repeatedly inserted Poor choice for long-term nutritionPeripheral Parenteral Nutrition (PPN)

9. Peripherally inserted central catheterBenefitsAccess to central veinCan accommodate hypertonic fluidsLower risk of phlebitis than PPNEasier to insert than central linePICC Line

10. Provides nutrients when less than 2 to 3 feet of small intestine remainsAllows nutrition support when GI intolerance prevents oral or enteral supportAdvantages- Parenteral Nutrition

11. CostlyLong term risk of liver dysfunction, kidney and bone disease, and nutrient deficienciesDisadvantages

12. GI non functioningNBM >5 daysGI fistulaAcute pancreatitisShort bowel syndromeMalnutrition with >10% to 15 % weight lossNutritional needs not met; patient refuses foodIndications for Total Parenteral Nutrition

13. Working GI tractTerminally illOnly needed briefly (<14 days)Contraindications

14. Avoid excess kcal (> 40 kcal/kg) Adults kcal/kg BW Obese—use desired BMI range or an adjusted factorCalculating Nutrient Needs

15. Carbohydrate glucose or dextrose monohydrate 3.4 kcal/gAmino acids 3, 3.5, 5, 7, 8.5, 10% solutionsFat 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/mlParenteral Components

16. 1.2 to 1.5 g protein/kg IBW mild or moderate stress2.5 g protein/kg IBW burns or severe traumaProtein Requirements

17. Max. 0.36 g/kg BW/hrExcess glucose causes: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumptionLipogenesis and liver problemsCarbohydrate Requirements

18. 4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acidUsual range 25% to 35% max. 60% of kcal or 2.5 g fat/kgLipid Requirements

19. Fluid—30 to 50 ml/kgElectrolytes Use acetate or chloride forms to manage acidosis or alkalosisVitaminsTrace elementsOther Requirements

20. 1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L3. Fat is isotonic and does not contribute to osmolarity.4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/LCalculating the Osmolarity of a Parenteral Nutrition Solution

21. Total nutrient admixture of amino acids, glucose, additives3-in-1 solution of lipid, amino acids, glucose, additivesCompounding Methods

22. Intralipid(separately by syringe pump via a 3-way connector)Aminoven+5% Dextrose50% Dextrose +MVI +Heparin (0.5 - 1unit/ml)+Add. electrolytes, as reqdCompounds

23. Start slowly(1 L 1st day; 2 L 2nd day)Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)Cyclic give 12 to 18 hours per dayAdministration

24. InfectionHemodynamic stabilityCatheter careRefeeding syndromeMonitoring and Complications

25. HypophosphatemiaHyperglycemiaFluid retentionCardiac arrest Refeeding Syndrome

26. Weight(daily)BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUNCa+, P Plasma transaminasesMonitor

27. BloodTwice/week Ammonia Mg Plasma transaminasesWeeklyHgbProthrombin time Zn Cu TriglyceridesMonitor—cont’d

28. Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)Monitor—cont’d

29. PPNSite irritationTPN1. Catheter sepsis2. Placement problems3. MetabolicProblems

30. Type of feeding formula and tubeMethod (bolus, drip, pump)Rate and water flushIntake energy and proteinTolerance, complications, and corrective actions Patient educationDocument in Chart

31. Thankyou