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INTRODUCTION: WHAT IS PARENTERAL

NUTRITION?

Parenteral nutrition (PN), often called Total Parenteral Nutrition, is the feeding of nutritional

products to a person intravenously(IV nutrition) without undergoing the usual process of

eating and digestion. According to Jane Anne Yaworski, MSN, RN, a Clinical Nurse

Specialist in the Nutrition Support Service and Intestinal Care Center, "parenteral" actually

means to eat (-enteral) through an IV (par-). This method applies when a person is unfit to

feed by mouth. In other words, PN is observed when there is impaired gastrointestinal

function and contraindications to enteral nutrition( a way of delivering food directly into the

stomach or small intestine through the mouth. This is also known as tube feeding). A person

may need PN for a short time over weeks, months, or life. It depends on the condition that

causes the need for PN.

The patient receives a nutritional mix according to a formula including glucose, salts, amino

acids, lipids, vitamins and dietary minerals. Parenteral nutrition is a medication used to

manage and treat malnourishment and is under the class of drugs in nutrition. The catheter(IV

tube) and the skin where the catheter enters the body need to be kept clean.

What are the two types of parenteral nutrition? They are, Partial or Total.

➢ Partial parenteral nutrition (PPN): partial parenteral nutrition is often given

temporarily to people who need an immediate boost of calories before transitioning to

a longer-term solution — either enteral feeding or gradually resuming mouth feeding.

PPN is also commonly given to long-term hospital patients having general

malnutrition for different reasons. Sometimes parenteral nutrition is classified by the

type of vein used to deliver the nutrients.

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➢ Total parenteral nutrition (TPN): complete nutrition delivered intravenously to

people unable to use their digestive system to the last degree. TPN might be required

when certain conditions impair your ability to process food and absorb nutrients

through your digestive tract or when you need to avoid using your digestive system

for a while so it can heal.

Sometimes parenteral nutrition is classified by the type of vein used to deliver the nutrients.

➢ Central parenteral nutrition (CPN): is delivered through a main vein — usually,

the superior vena cava located under your collarbone, which goes directly to your

heart. The large main vein allows a larger catheter to deliver a higher dose of nutrition

with higher calories. For this reason, CPN implements total parenteral nutrition.

➢ Peripheral parenteral nutrition (PPN): delivers through a small peripheral vein,

perhaps in your neck or in one of your limbs. PPN provides partial parenteral nutrition

temporarily, using quicker and easier access to the peripheral vein.

WHAT DOES PARENTERAL NUTRITION CONTAIN?

Parenteral nutrition is a chemical formula with standard variations and can be customized to a

patient’s specific nutritional requirements. It may include different amounts of any of the six

essential nutrients that your body requires (water, carbohydrates, proteins, fats, vitamins and

minerals). Even when you receive total parenteral nutrition, your formula will be tailored to

you based on lab results. Parenteral nutrition is complete enough to replace mouth feeding for

as long as necessary — even for life.

HOW IS THE PARENTERAL NUTRITION IV INSTALLED?

Placing the IV catheter on the body will require two points of penetration through your skin.

Your healthcare provider will offer you anaesthesia to numb the pain and help you relax and
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carefully clean and sterilize the two points. They’ll begin by inserting a needle threaded with

a guidewire through the skin into your vein. Then they’ll remove the needle, place the

catheter tube over the guidewire and remove that. They might use a small ultrasound device

to guide the placement of the catheter or an X-ray to confirm the correct placement

afterwards.

Three types of catheters they might use:

➢ External “tunnelled” catheters. The external catheter tunnels under your skin and

out a separate exit point were chosen for your comfort. The exit point requires a small

incision for the catheter to come out, and temporary stitches to hold it in place for four

to six weeks.

➢ Fully implanted catheter. An implanted catheter remains completely under your

skin, with a needle insertion port attached at the end. The port is attached to the end of

the catheter under the skin through a separate small incision at the site.

➢ A peripherally inserted central catheter (PICC). A PICC catheter is inserted into a

vein in your upper arm and threaded into your superior vena cava. The needle port

remains outside of your body. PICC is used when parenteral nutrition is required for

less than six weeks.

CLINICAL INDICATIONS OF PARENTERAL NUTRITION.

➢ Chronic intestinal obstruction as in intestinal cancer.

➢ Bowel pseudo-obstruction with food intolerance.

➢ Abdominal surgery.

➢ Chemotherapy.

➢ Intestinal ischemia.
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➢ Small or large intestinal obstructions.

➢ Intestinal pseudo-obstruction.

➢ Prolonged ileus.

➢ Gastrointestinal bleeding.

➢ Radiation enteritis.

➢ Extremely premature birth.

➢ Necrotizing enterocolitis.

➢ Prolonged diarrhoea.

➢ Inflammatory bowel diseases.

➢ Short bowel syndrome.

➢ Persistent chyle leak.

➢ Graft-versus-host disease of the gut.

APPLICATIONS

➢ Cancer. Cancer of the digestive tract may obstruct the bowels, preventing adequate

food intake. Cancer treatment, such as chemotherapy, may cause your body to poorly

absorb nutrients.

➢ Crohn's disease. Crohn's disease is an inflammatory disease of the bowel that may

cause pain, bowel narrowing and other symptoms that affect food intake, digestion

and absorption.

➢ Short bowel syndrome. In this condition, which can be present at birth or occur as

the result of surgery that has removed a significant amount of small intestine, you do

not have enough bowel to absorb the nutrients you eat.

➢ Ischemic bowel disease. Causes difficulties resulting from reduced blood flow to

the bowel.
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➢ Abnormal bowel function: causes the food you eat to have trouble moving

through your intestines, resulting in different symptoms that prevent enough food

intake. Abnormal bowel function can occur due to surgical adhesions or abnormalities

in bowel motility. These may occur by radiation enteritis, neurological disorders etc.

HOW WILL I BE MONITORED DURING PARENTERAL

NUTRITION?

Healthcare providers will repeatedly monitor your fluid intake and output and periodically

weigh and measure you. They will also take regular blood tests to ascertain you have the right

balance of essential nutrients and adjust your formula accordingly. Some of the things they

will monitor include:

➢ Electrolytes and blood urea nitrogen/creatinine — to prevent dehydration or

overhydration.

➢ Blood glucose — to prevent hyperglycemia or hypoglycemia.

➢ Mineral levels — to screen for deficiencies.

➢ Liver function indicators — including aminotransferases and bilirubin.

BENEFITS OF PARENTERAL NUTRITION

The primary advantage of parenteral nutrition is to give your gastrointestinal system a chance

to heal from severe illness or surgery. For long-term hospital patients, especially geriatric

patients who have trouble sustaining their nutritional needs through eating or with enteral

nutrition, partial parenteral nutrition can provide an important boost to help their bodies

manage their other difficulties. For people with permanently impaired gastrointestinal
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function or extremely premature and sick infants who have not yet developed the ability to

feed normally, total parenteral nutrition is life-saving.

SIDE EFFECTS OF PARENTERAL NUTRITION

The common side effects of parenteral nutrition are mouth sores, poor night vision, and skin

changes. Other less common side effects include

➢ Changes in heartbeat

➢ Confusion

➢ Convulsions Or Seizures

➢ Difficulty Breathing

➢ Fast Weight Gain Or Weight Loss

➢ Fatigue

➢ Fever Or Chills

➢ Increased Urination

➢ Jumpy Reflexes

➢ Memory Loss

➢ Muscle Twitching, Weakness, Or Cramps

➢ Stomach Pain

➢ Swelling Of Your Hands, Feet, Or Legs

➢ Thirst

➢ Tingling In Your Hands Or Feet

➢ Vomiting
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RISKS/COMPLICATIONS OF PARENTERAL NUTRITION

This is considered less ideal than enteral feeding because of the higher risk of complications

involved. The primary concerns are infection of the bloodstream from the IV catheter and

atrophy of the digestive tract when it is not being used. There are other risks, however.

The most common complications include

➢ Infection. Bacteria from the IV catheter can infect your bloodstream. If the infection

spreads throughout your body, it can lead to sepsis, a life-threatening complication.

➢ Blood clots forms where the catheter meets the vein.

➢ GI atrophy can begin to occur after about two weeks. GI function usually returns

gradually.

➢ Glucose imbalances (hyperglycemia or hypoglycemia) are common and are treated

with insulin and dextrose adjustments.

➢ Transient liver reactions to the nutritional formula can occur. Healthcare providers

manage these by adjusting the formula.

➢ Parenteral nutrition-associated liver disease (PNALD) is a complication of long-

term parenteral nutrition. Liver disease affects up to 50% of patients after five to

seven years. We don’t know exactly why. In premature infants, it may be because

their liver is not fully developed. In adults, it might be related to the diminished gut

bacteria that results when your gut is not being used.

➢ Gallbladder problems can result when the lack of stimulation from the digestive

system causes bile to accumulate without being released normally into the small

intestine. Your healthcare providers may be able to stimulate gallbladder contractions

by varying your formula and encouraging at least a small amount of oral feeding
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➢ Bone demineralization (osteoporosis or osteomalacia) develops in people who

receive long-term parenteral nutrition, possibly due to vitamin and mineral

deficiencies (calcium, magnesium and vitamin D).

Other possible complications include

➢ Injury during the insertion of the catheter.

➢ Fluid overload.

➢ Reactions to lipid emulsions in the formula due to food allergies.

➢ Hunger pangs.
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REFERENCES

https://www.mayoclinic.org/tests-procedures/total-parenteral-nutrition/about/pac-20385081

https://my.clevelandclinic.org/health/treatments/22802-parenteral-nutrition

https://www.researchgate.net/publication/347274252_Total_Parenteral_Nutrition

https://www.healthline.com/health/parenteral-nutrition#side-effects