Parenteral nutrition

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Home TPN formula

Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process
ofeating and digestion. The person receives nutritional formulae that contain nutrients such
asglucose, amino acids, lipids and added vitamins and dietary minerals. It is called total parenteral
nutrition (TPN) or total nutrient admixture (TNA) when no significant nutrition is obtained by other
routes. It may be called total peripheral nutrition (also TPN) when administered through vein access
in a limb, rather than through a central port in body.

Contents
[hide]

 1 Mechanism

 2 Indications

o 2.1 Gastrointestinal disorders

o 2.2 Use in cancer

 3 Duration

 4 Complications

o 4.1 Infection

o 4.2 Blood clots

o 4.3 Fatty liver and liver failure

o 4.4 Other complications

 5 Solutions

 6 Emulsifier

 7 Total parenteral nutrition

 8 Individual components

 9 See also

 10 References

 11 External links

[edit]Mechanism

A mechanical pump under computer control is used to dispense the TPN fluid. Pumps are available
that allow TPN administration at home, usually with the preparation and attachment by a family
member. These pumps operate on an external dispensing line, part of a single-use dispensing
cassette. Connection of the dispensing line to the patient is via a valve on a semi-permanent attached
venous port whose closure is displaced by a connection on the dispensing line. Preparation,
attachment, and valve replacement require care in sanitation and sterile techniques at specific
locations. The use of a rechargeable battery and a portable component pack allows a convenient
household mobility for many patients during administration periods, these being typically from twelve
to sixteen hours a day.

[edit]Indications

Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is nonfunctional because of
an interruption in its continuity (it is blocked, or has a leak - a fistula) or because its absorptive
capacity is impaired.[1] It has been used for comatose patients, althoughenteral feeding is usually
preferable, and less prone to complications. Parenteral nutrition is used to prevent malnutrition in
patients who are unable to obtain adequate nutrients by oral or enteral routes.[2]

[edit]Gastrointestinal disorders
TPN may be the only feasible option for providing nutrition to patients who do not have a functioning
gastrointestinal tract or who have disorders requiring complete bowel rest, including bowel
obstruction, short bowel syndrome, Gastroschisis, prolonged diarrhea regardless of its cause, high-
output fistula, very severe Crohn's disease or ulcerative colitis, and certain pediatric GI disorders
including congenital GI anomalies.[3]

[edit]Use in cancer
The benefit of TPN to cancer patients is largely debated, and studies to date have generally showed
minimal long term benefit. There is no evidence to support the idea that intravenous nutrition 'feeds
the cancer, not the patient', but weight loss with advanced disease is significantly more complicated
than simply replacing calories as cancer produces a multitude of chemicals that also lead to weight
loss, and giving extra nutrition does not prevent this.

[edit]Duration

Short-term PN may be used if a person's digestive system has shut down (for instance by peritonitis),
and they are at a low enough weight to cause concerns about nutrition during an extended hospital
stay. Long-term PN is occasionally used to treat people suffering the extended consequences of an
accident, surgery, or digestive disorder. PN has extended the life of children born with nonexistent or
severely deformed organs.

[edit]Complications

TPN is an artificial method of feeding, fully by-passing the GI tract. This unnatural way of feeding the
body is far from perfect and comes with several significant complications

[edit]Infection

TPN requires a chronic IV access for the solution to run through, and the most common complication
is infection of this catheter. Infection is a common cause of death in these patients, with a mortality
rate of approximately 15% per infection, and death usually results from septic shock.[4] Contrary to
common belief, evidence suggests that moderate amounts of intravenous lipid rich in linoleic acid are
not associated with an increased incidence of bacterial or fungal infections in immunosuppressed
patients receiving total parenteral nutrition.[5]

[edit]Blood clots
Chronic IV access leaves a foreign body in the vascular system, and blood clots on this IV line are
common.[6] Death can result frompulmonary embolism wherein a clot that starts on the IV line but
breaks off and goes into the lungs.[7]

Micrograph of periportal fatty liver as may arise due to TPN. Trichrome stain.

Patients under long-term TPN will typically receive a periodic heparin flush to dissolve such clots
before they become dangerous.

[edit]Fatty liver and liver failure

Fatty liver is usually a more long term complication of TPN, though over a long enough course it is
fairly common. The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of
soybean oil) as a major source of calories.[8] [9]

[edit]Other complications
Total parenteral nutrition increases the risk of acute cholecystitis[10] due to complete disuse of
gastrointestinal tract, which may result in bile stasis in the gallbladder. Other potential hepatobiliary
dysfunctions include steatosis,[11]steatohepatitis, cholestasis, and cholelithiasis.[12] Six percent of
patients on TPN longer than 3 weeks and 100% of patients on TPN longer than 13 weeks develop
biliary sludge. The formation of sludge is the result of stasis due to lack of enteric stimulation and is
not due to changes in bile composition. Gallbladder sludge disappears after 4 weeks of normal oral
diet. Administration of exogenous cholecystokinin (CCK) or stimulation of endogenous CCK by
periodic pulse of large amounts of amino acids have been shown to help prevent sludge formation.
These therapies are not routinely recommended.[13] Such complications are suggested to be the main
reason for mortality in people requiring long-term total parenteral nutrition, such as in short bowel
syndrome.[14] In newborn infants with short bowel syndrome with less than 10% of expected intestinal
length, thereby being dependent upon total parenteral nutrition, 5 year survival is approximately
20%.[15]

Complications are either related to catheter insertion, or metabolic, including refeeding syndrome.
Catheter complications include pneumothorax, accidental arterial puncture, and catheter-related
sepsis. The complication rate at the time of insertion should be less than 5%.[16] Catheter-related
infections may be minimised by appropriate choice of catheter and insertion technique. [17] Metabolic
complications include the refeeding syndrome characterised
by hypokalemia, hypophosphatemia and hypomagnesemia. Hyperglycemiais common at the start of
therapy, but can be treated with insulin added to the TPN solution. Hypoglycaemia is likely to occur
with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and
to fatty infiltration (demonstrated by elevated transaminases). Severe hepatic dysfunction is a rare
complication.[18] Overall, patients receiving TPN have a higher rate of infectious complications. This
can be related to hyperglycemia.[19] TPN was consid-ered to be a dangerous form of therapy. Critical
review of the data suggests that, in humans, TPN does not cause mucosal atro-phy or increase
bacterial translocation. Increased sepsis with TPN can be ascribed to overfeeding; the dangers of
TPN-induced complications have been exaggerated. TPN is an equally effec-tive alternative to EN
when a risk of malnutrition is present and EN is not tolerated or when gut failure is present.[20]

[edit]Solutions

The nutrient solution consists of water and electrolytes; glucose, amino acids, and lipids;
essential vitamins, minerals and trace elements are added or given separately. Previously lipid
emulsions were given separately but it is becoming more common for a "three-in-one" solution of
glucose, proteins, and lipids to be administered.[21][22]

[edit]Emulsifier

Only a limited number of emulsifiers is commonly regarded as safe to use for parenteral
administration, of which the most important isLecithin. Compared with its synthetic
alternatives, Lecithin can be totally biodegraded and metabolised, since it is an integral part of
biological membranes, making it virtually non-toxic. Other emulsifiers can only be excreted via the
kidneys, creating a toxic load. The emulsifier of choice for most fat emulsions used for Parenteral
nutrition is a highly purified Egg Lecithin[23] such as Lipova-E120 from VAV Life Sciences due to its
low toxicity and complete integration with cell membranes.[24]

[edit]Total parenteral nutrition

Prescription lipid parenteral nutrition formulation

Solutions for total parenteral nutrition may be customized to individual patient requirements, or
standardized solutions may be used. The use of standardized parenteral nutrition solutions is cost
effective and may provide better control of serum electrolytes.[25] Ideally each patient is assessed
individually before commencing on parenteral nutrition, and a team consisting of specialised doctors,
nurses, clinical pharmacists and Registered Dietitians evaluate the patient's individual data and
decide what PN formula to use and at what infusion rate.
For energy only, intravenous sugar solutions with dextrose or glucose are generally used. This is not
considered to be parenteral nutrition as it does not prevent malnutrition when used on its own.
Standardized solutions may also differ between developers. Following are some examples of what
compositions they may have. The solution for normal patients may be given both centrally and
peripherally.

Examples of total parenteral nutrition solutions[25]

Substance Normal patient High stress Fluid-restricted

Amino acids 85 g 128 g 75 g

Dextrose 250 g 350 g 250 g

Lipids 100 g 100 g 50 g

Na+ 150 mEq 155 mEq 80 mEq

K+ 80 mEq 80 mEq 40 mEq

Ca2+ 360 mg 360 mg 180 mg

Mg2+ 240 mg 240 mg 120 mg

Acetate 72 mEq 226 mEq 134 mEq

Cl- 143 mEq 145 mEq 70 mEq

P 310 mg 465 mg 233 mg

MVI-12 10 mL 10 mL 10 mL

Trace elements 5 mL 5 mL 5 mL

[edit]Individual components
Individual nutrient components may be added to more precisely adjust the body contents of it. That
individual nutrient may, if possible, be infused individually, or it may be injected into a bag of nutrient
solution or intravenous fluids (volume expander solution) that is given to the patient.

Administration of individual components may be more hazardous than administration of pre-mixed

solutions such as those used in total parenteral nutrition, because the latter are generally already
balanced in regard to e.g. osmolarity and ability to infuse peripherally. For example, incorrect IV
administration of concentrated potassium can be lethal, but this is not a danger if the potassium is
mixed in TPN solution and diluted.[26]

Vitamins may be added to a bulk premixed nutrient immediately before administration, typically in two
doses, one fat soluble, the other water soluble, this since the additional vitamins can promote
spoilage of stored product.

[edit]See also

 Feeding tube
 Intravenous therapy
 Hickman line
[edit]References

1. ^ Kozier, B., & Erb, G., & Berman, A.J., & Burke, K., & Bouchal, S. R., & Hirst, S. P.. (2004).

Fundamentals of Nursing: The Nature of Nursing Practice in Canada. Canadian Edition. Prentice Hall
Health: Toronto.

2. ^ American Gastroenterological Association medical position statement: parenteral nutrition

3. ^ The Merck Manual, 2008

4. ^ Deshpande, KS (2003 Jul). "Total parenteral nutrition and infections associated with use of central

venous catheters.".American journal of critical care : an official publication, American Association of

Critical-Care Nurses 12 (4): 326–7, 380.PMID 12882062.

5. ^ Lenssen, P; Bruemmer, BA; Bowden, RA; Gooley, T; Aker, SN; Mattson, D (1998). "Intravenous lipid

dose and incidence of bacteremia and fungemia in patients undergoing bone marrow
transplantation". The American journal of clinical nutrition 67(5): 927–33. PMID 9583851.

6. ^ Mollitt, DL; Golladay ES. (1983 Aug). "Complications of TPN catheter-induced vena caval thrombosis

in children less than one year of age". Journal of pediatric surgery 18 (4): 462–7.doi:10.1016/S0022-

3468(83)80201-2. PMID 6413671.

7. ^ Mailloux, RJ; DeLegge, MH; Kirby, DF (1993 Nov-Dec). "Pulmonary embolism as a complication of

long-term total parenteral nutrition". JPEN. Journal of parenteral and enteral nutrition 17 (6): 578–

82. doi:10.1177/0148607193017006578.PMID 8301814.

8. ^ Evaluation of OMEGAVEN 10%® (n-3 EFA Lipid Emulsion) in Home Parenteral Nutrition-associated

Liver Disease (MEGANORM). Retrieved 15 April 2013.

9. ^ Piper, SN; Rohm KD (Dec 2009). "Hepatocellular integrity after parenteral nutrition: comparison of a

fish-oil-containing lipid emulsion with an olive-soybean oil-based lipid emulsion". Eur J

Anaesthesiol. 26 (12): 1076–82.doi:10.1097/EJA.0b013e32832e08e0. PMID 19916246.

10. ^ Tucker, RA; Jenkins, HL (1984). "Acalculous cholecystitis and fever related to total parenteral
nutrition". Drug intelligence & clinical pharmacy 18 (11): 897–9. PMID 6437783.

11. ^ Wang, H; Khaoustov, VI; Krishnan, B; Cai, W; Stoll, B; Burrin, DG; Yoffe, B (2006 Oct). "Total

parenteral nutrition induces liver steatosis and apoptosis in neonatal piglets". The Journal of
nutrition 136 (10): 2547–52. PMID 16988124.

12. ^ Quigley EM, Marsh MN, Shaffer JL, Markin RS (January 1993). "Hepatobiliary complications of total
parenteral nutrition".Gastroenterology 104 (1): 286–301. PMID 8419252.

13. ^ http://www.bcm.edu/gastro/VGICC/GI-M0054/09-DISC.HTM

14. ^ Vanderhoof JA, Langnas AN (1997). "Short-bowel syndrome in children and

adults". Gastroenterology 113 (5): 1767–78.doi:10.1053/gast.1997.v113.pm9352883. PMID 9352883.

15. ^ Spencer AU, Neaga A, West B, et al. (September 2005)."Pediatric short bowel syndrome: redefining
predictors of success". Ann. Surg. 242 (3): 403–9; discussion 409–

12.doi:10.1097/01.sla.0000179647.24046.03. PMC 1357748.PMID 16135926. (mean follow-up time

was 5.1 years)

16. microbial contamination: growth properties of microbial pathogens at room temperature". JPEN
J Parenter Enteral Nutr22 (5): 291–6. doi:10.1177/0148607198022005291.PMID 9739032.

17. ^ Rollins CJ, Elsberry VA, Pollack KA, Pollack PF, Udall JN (1990). "Three-in-one parenteral

nutrition: a safe and economical method of nutritional support for infants". JPEN J Parenter
Enteral Nutr 14 (3): 290–4.doi:10.1177/0148607190014003290. PMID 2112645.

18. ^ Lecithin - An Emulsifier for Parenteral Use: TORVS Research Team

19. ^ Lipid Emulsions as Drug Delivery Systems: Jack Stevens, Pam Mims and Neil Coles

20. ^ a b Hayes, EM; Cohen KR, Pinard BE,Lauletta J, Ruggiero R. (2000). "Standardized

versusindividually customized parenteral nutrition solutions: a comparison ofserum electrolyte

values".P&T 25 (2): 78–80, 83, 87.

21. ^ Intravenous Potassium Guidelines (ADULTS) From RNSH Pharmacy Department.

Authorised by: Margaret Duguid. Last Modified: June 2006