Parenteral Nutrition sequesters fluid in the interstitial and intracellular

spaces and in a third-body space (such as the

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
Parenteral nutrition delivers nutrients such as sugar,
carbohydrates, proteins, lipids, electrolytes, and trace
elements to the body. These nutrients are vital in
maintaining high energy, hydration, and strength
levels. Some people only need to get certain types of
nutrients intravenously.
intestinal lumen) where it doesn't support circulation.
TPN can be categorized as a vesicant, which is a
hyperosmolar, acidic, and polar solution with a high
concentration of ionic substances
Some minerals are needed in larger amounts than
others, e.g. calcium, phosphorus, magnesium, sodium,
potassium and chloride.
Others are required in smaller quantities and are
sometimes called trace minerals, e.g. iron, zinc,
iodine, fluoride, selenium and copper.
General indications
TPN therapy is indicated for patients:
● Requiring long-term (>10 days) supplemental
nutrition because they are unable to receive all
daily requirements through oral or enteral
feedings.
● Requiring total nutrition because of severe gut
dysfunction or inability to tolerate enteral
feedings.

When the number of protein molecules in plasma is

low, such as in proteinuria seen with uncontrolled
diabetes or protein-calorie malnutrition known as
kwashiorkor, fluid moves into and stays in the
interstitial spaces, where it's unavailable to meet the
body's hydration needs. This is a type of third-space
fluid shift, also called third-spacing. This condition
Specific indications
TPN therapy is part of routine care in:
● Patients who cannot eat or absorb nutrients
through the GI tract because of:
o Massive bowel resection
o Diseases of the small bowel
o Radiation enteritis
● Malnourished patients undergoing high-dose
chemotherapy or radiation therapy.
● Patients with severe necrotizing pancreatitis
when enteral feeding is not possible.
● Patients with severe malnutrition and
nonfunctional gut.
● Malnourished patients with AIDS who have
intractable diarrhea.
● Severely catabolic patients whose gut cannot be
used within 5 to 7 days.
When enteral feeding cannot be established, TPN is
usually helpful:
● After major surgery.
● In patients with enterocutaneous fistulas, both
high and low.
● In patients with inflammatory bowel disease.
● In patients with hyperemesis gravidarum.
● In patients with small bowel obstruction
secondary to adhesions.
Diabetes
Diabetes is neither a relative nor an absolute
contraindication to TPN, but careful monitoring of
therapy to avoid hyperglycemia is obligatory. In both
diabetic and nondiabetic patients, any benefit of TPN is
compromised significantly by persistent
hyperglycemia.
As with any other patient, in diabetic patients, vital
energy substrates and protein should be administered
in accordance with immediate metabolic needs. Insulin
may be added to the parenteral admixture and
combined with sliding-scale insulin administration to
achieve an appropriate blood glucose level.
Reasonable glucose control should ensure a blood
glucose level greater than 100 mg/dL (to minimize the
risk of hypoglycemia) and less than 220 mg/dL (to
reduce the harmful effects of hyperglycemia on
metabolism, immunocompetence, and fluid balance).
This guideline is applicable to any patient receiving
TPN.
Acute renal failure
Patients with acute renal failure are hypercatabolic,
hypermetabolic, and frequently afflicted by coexisting
multiple-system organ failure. Therefore, nutritional
substrates should be administered in accordance with
metabolic needs.
Protein intake should not be limited arbitrarily. The
presumption of impaired removal of nitrogenous waste
does not mean that the patient has a reduced daily
need for protein. Underfeeding of critically ill patients
with renal failure perpetuates catabolism and
exacerbates an already difficult, unstable situation.
Patients with acute renal failure must be assessed
carefully for signs of fluid overload and electrolyte
abnormalities, particularly hyperkalemia,
hyperphosphatemia, and hypermagnesemia. TPN
volume and composition may require modification.
Protein is provided at approximately 1- 1.2 g/kg/day,
and dialysis is used as indicated to control uremia.
Limitations should be guided by data gathered from
careful assessment of nitrogen losses in urine,
dialysate, and other sources.
Specialized formulations of amino acids (e.g.,
branched chain, essential and nonessential, and
mixtures) are widely available. However, no reduction
of mortality rates is seen with either mixtures or
essential amino acids alone. Branched-chain amino
acids (BCAAs; e.g., leucine, isoleucine, valine) may be
combined with other amino acids to improve protein
use.
Pulmonary disease
Patients with significant pulmonary dysfunction, and
those who require ventilator support present
therapeutic challenges for nutrition support. Increased
catabolic needs, if unmet by feeding, pose threats to
the pulmonary musculature and the ability to fuel the
work of breathing. Overfeeding may increase CO2
production, complicate respiratory function, and
impede weaning from ventilator support.
The amount of carbohydrate administered to patients
with pulmonary disease should be carefully controlled.
Carbohydrate metabolism is associated with a
relatively greater production of CO2 than metabolism
of other substrates. The delivery of excess
carbohydrate energy also stimulates lipogenesis, which
further increases CO2 production and may contribute
to hypercapnia, increased work of breathing, and
ongoing degradation of respiratory function.
The goal of nutritional therapy in these patients is to
provide adequate carbohydrate calories to meet
energy needs and (with fat) promote protein sparing,
but not to produce unacceptably high levels of CO2.
An acceptable strategy is to increase the proportion of
calories supplied by fat and to restrict the
administration of carbohydrate to 4 mg/kg/min.
Protein needs should be estimated at 1.5 g/kg/day.
Hepatic disease
The liver performs a central role in metabolism, and
impairment of this organ has profound consequences
for nutrition support. Cirrhosis and alcoholism are
associated with significant pre-existing malnutrition.
This malnutrition is exacerbated by critical illness,
surgery, and other stressors.
Lipid, carbohydrate, protein, and vitamin metabolism
is sharply altered in patients with hepatic failure. Lipid
clearance is defective, with decreased lipolytic activity,
increased triglyceridemia, and decreased removal of
free fatty acids. Glucose intolerance and insulin
resistance, which are prevalent in this patient
population, may occur in approximately 80% of
patients with cirrhosis. Despite this background of
broad dysfunction, intolerance to protein presents the
greatest challenge to nutritional management.
Many patients with liver failure have fluid overload
that may require restriction of TPN volume. Protein
needs in patients with liver failure and mild or no
encephalopathy should be calculated at 1.5 g/kg/day.
These patients usually can tolerate a conventional
parenteral amino acid formula with a full complement
of essential amino acids.
Protein needs in patients with significant
encephalopathy are reduced to 1.0 g/kg/day. BCAAs
are useful sources of protein energy because they do
not require hepatic metabolism. Their effect on the
mortality rate is unclear; however, patients with
pronounced encephalopathy should be given a
modified amino acid formula containing a high
percentage of BCAAs.
Cardiac disease
In addition to prolonged malnutrition, patients with
long-standing cardiac disease are vulnerable to a
typical wasting (cardiac cachexia). Impaired baseline
cardiac function and pre-existing malnutrition, in
conjunction with acute illness and other stressors,
demand that patients with cardiac disease receive
careful adjustment of TPN solutions and strict
monitoring of infusions.
Calories should be provided to satisfy, not exceed,
daily energy needs. The total volume of TPN solution is
generally restricted to 1000 to 1500 mL/day in
patients with severe congestive heart failure
secondary to valvular dysfunction, coronary

Complications of Total Parenteral Nutrition
Although TPN is a good method in providing nutrition
to those that are ill and unable to eat normally, there
are many complications that may occur alongside it.
Mechanical Complications
Mechanical complications are often associated with the
improper placement of a central venous catheter.
When the catheter isn't placed properly, it may cause
pneumothorax (the collapsing of lungs due to air
escaping it), vascular injury with hemothorax (the
accumulation of blood in the pleural cavity, brachial
plexus injury or cardiac arrhythmia.
The two most common problems that occur after
central venous access is established are venous
thrombosis and infection.
Venous thrombosis is the formation of a blood clot in
the vein, and is at higher risk if the patient has or has
had the following: dehydration, a presence of
malignancies, prolonged bed rest, venous stasis,
sepsis, or hypercoagulation. Other risk factors include
morbid obesity, smoking, or ongoing estrogen
therapy. This is due to the nature of circulation.
Infectious Complications
During the insertion of the catheter the client is prone
to the introduction of bacterial or fungal organisms,
which may cause infection to the client. IV breeches
the body’s barrier system, which is why aseptic
techniques must be strictly followed with any
procedure involving IV.
Primary preventive measures include the following:
1. Routinely changing the dressing, or when it
becomes soiled, wet or loose. Additionally,
masks and gloves should be worn.
2. Applying antimicrobial solution at least 1 inch
beyond the final dressing.
3. Placing a sterile sponge between the catheter
and occlusive dressing.
4. Constantly inspecting the IV site for tenderness,
erythema, edema, loose sutures, or drainage.
Metabolic Complications
Metabolic complications fall into two broad categories:
early and late complications. Early metabolic
complications can be avoided by monitoring and
adjustment of intake. late metabolic complications are
slightly harder to predict, and may be caused by
preexisting abnormalities, unexpected long-term
requirements, inadequate solution composition, or
failure to monitor adequately.
Fluid and Electrolyte Complications
Electrolyte management is one of the most difficult to
control, as they easily fall outside of normal range due
to underlying causes. Because of this, incremental
dose adjustments are made until the patient’s results
fall under the correct amount.
Refeeding Syndrome
Patients who are severely malnourished and given
refeeding may accrue refeeding syndrome, which is
the metabolic disturbance due to fatal shifts in fluids
and electrolytes such as potassium, magnesium, and
phosphate. As this is more of a circulatory problem, it
would affect nearly every organ system.

This is primarily caused by the shift from stored body

fat to carbohydrates as the client’s primary fuel
source. Serum insulin levels rise due to the use of
carbohydrates, causing the intracellular movement of
electrolytes for use in metabolism.

The most reliable method in avoiding this is to start

slow and adjust little by little in initiating nutritional
support. You may additionally do the following:

1. Recognize patients at risk

a. Anorexia nervosa
b. Classic kwashiorkor or marasmus
c. Chronic malnutrition
d. Chronic alcoholism
e. Prolonged fasting
f. Prolonged IV hydration
g. Significant stress and depletion
2. Correct electrolyte abnormalities BEFORE
initiating nutritional support
3. Administer volume and energy slowly
4. Monitor pulse, input and output, and
electrolytes closely
5. Provide appropriate vitamin supplementation
6. Avoid overfeeding