Parental Nutrition

Therapy
By
Ms. Teba Abdul Lateef
 Definition
Parenteral nutrition is the
provision of nutrients directly
into the bloodstream
intravenously. It bypasses the
normal digestion in the stomach
and bowel through IV catheter
(needle in the vein).
 Indications
 Non functioning GI tract
 Inability to use the GI tract
 Complete intestinal obstruction
 Peritonitis
 Intractable vomiting
 Patient requiring additional nutritional
support (trauma, burns, malignant
disease, chemotherapy) and enteral
nutrition is not well tolerated.
 Indications
 Severe catabolism w/wo malnutrition
when GI tract is not usable within 5-7
days.
 Inability to obtain enteral access.
 Persistent GI bleed.
 NPO status for several days w GI
compromised.
 Inability to provide sufficient nutrients.
 Severe diarrhea.
 Contraindications

 Functioning GI tract.
 Treatment anticipated for less than 5
days in pts w/o severe malnutrition.
 Inability to obtain venous access.
 When the risks of PN are judged to
exceed the potential benefits.
 Nutrition Assessment

 Anthropometric data:
 Recent weight changes.
 Current height and weight.
 Lab Values:
 Comprehensive metabolic panel.
 Serum TGs.
 Serum phosphorous & magnesium.
 Nutrition Assessment

 Medical History:
 Anatomy (resections)/ostomies
 Pre-existing conditions such as diabetes, renal failure,
liver disease etc
 Diet/Medication History:
 Food/drug allergies.
 Diet intake prior to admission.
 Home & current medications.
 Prescription

 Parenteral nutrition is a mixture of solutions

that contain dextrose, AAs, electrolytes,
vitamins, minerals and trace elements. Lipid
emulsion may be infused separately or added
to the mixture.
 Before using most parenteral nutrition
products, macronutrients and trace elements
should be added and additional electrolytes
and other nutrients may also be needed.
 Additions should be made under appropriate
pharmaceutically controlled environment.
 How to initiate PN?

 In order to initiate parenteral nutrition,

appropriate access must be obtained and
the prescription (i.e, composition and
infusion rate) needs to be determined.
 Hospitalized patients requiring PN can be
started at the goal rate for the volume to
be provided; assuming measures have
been taken to minimize metabolic
response. (i.e. patient not overfed).
 Delivery Modes
PN is administrated through either a peripheral or a
central vein. The decision to use central venous or
peripheral PN depends on:
 Patient’s nutritional needs
 Expected length of PN therapy
 Vein accessibility
 Risk of Infections
 Osmolarity & pH of solution
 Vein Access

 While planning parenteral

nutrition (PN), the proper
choice, insertion and venous
access are important.
 Central
 PICC
 Peripheral
 Central & Peripheral Access

 Central access refers to catheter tip

placement in a large, high-blood-flow
vein such as the superior vena cava; this
is central parenteral nutrition (CPN).
 Peripheral access refers to catheter tip
placement in a small vein typically in the
arm.
 Central Access

 It refers to catheter tip placement in a

large, high-blood flow vein such as the
superior vena cava; this is central
parenteral nutrition.
 Veins for Central access are:
 Subclavian veins
 Internal & External jugular veins.
 Cephalic & Basilic veins.
 Femoral veins (least preferred b/c of
increase chances of infections)
 Central Access

 Advantages:
 Route of choice for pts with fluid
management.
 Pts with poor peripheral venous access.
 Those requiring PN> 10-14 days.
 Osmolarity >900 mOsm/l
 Better able to meet energy needs.
 Disadvantages:
 Greater risk of infection as compared to
other peripheral lines.
 Peripheral Access

 Itrefers to catheter tip placement

in a small vein typically in the arm.
 Advantages:
 Least expensive.
 Easily placed & removed.
 Lowest risk for catheter related
infections.
 Beneficial for short duration (<1
week).
 Peripheral Access

 Disadvantages:
 Veindamage because of nutrition
support.
 Kcaloriesusually limited due to
volume restriction.
 Limits
infusion osmolality to 900
mOsm/l.
 Need to change frequently. (48-72
hrs).
 PICC Line

 It is inserted into a vein in the arm and

threaded into the subclavian vein with the
tip placed in the superior vena cava.
 Advantages:
 Able to infuse solutions >900 mOsm/l.
 Decreased rate of infection when
compared to other central lines.
 Disadvantages:
 Blood sampling not always possible.
 Comparison

Central venous PNT Peripheral PNT

 Infused via central  Infused via peripheral
line. vein
 Therapy > 10 days  Therapy ≤ 10 days
 Adequate calories  Inadequate calories
 PN Solution Components

The principal component of PN

solutions are
 Fluid

 Macronutrients

 Micronutrients
 Fluid

 PN is a significant source of fluid

 Patients who require fluid restriction
should have their PN solution concentrated
to the minimum volume possible.
 PN should not be used to correct acute
fluid losses.
Estimated Daily Maintenance
Fluid Requirement

Weight (Kgs) Fluid Requirement

1-10 100 ml/kg/d
10-20 1000 ml + 50 ml for each kg >
10 kg
>20 1500 ml + 20 ml for each kg >
10 kg
 Macronutrients
They are the energy yielding components of PN:
 amino acids
 dextrose &
 lipid emulsions

Macronutrients can be prescribed in percentage,

gram or specific volume of each components .
 Amino acids

 Provide about 10%-20% of the daily caloric

needs .
 Amino acids are source of energy (4 kcal/g).
 Building blocks of protein .
 Standard concentrations range from 5%- 10%.
Non-protein kcal to nitrogen
ratio (NPC:N)
 Example:
 A person with weight of 55 kg.
 12.5% Dextrose Water 1300 ml 552.5 kcal
 10% Amino Acids 500ml 200 kcal
 20% Lipids 400ml 800 kcal
 Step 1:
 Calculate grams of nitrogen supplied per day (1gN = 6.25 g
protein) 50/6.25 = 8 (N)
 Step 2:
 Divide total non-protein kcal by gms of nitrogen.
 (552.5 +800) / 8 = 169.0
 NON-Protein to Nitrogen
Ratio Ranges
80-100 Highly severely
stressed patients.
101-130 Severely
stressed patients
131-180 Unstressed
patients.
 Dextrose

 Provides 50%-60% of daily caloric

needs .
 Provides 3.4 kcal/g.
 In peripheral PN the final dextrose
concentration is limited to 12.5%
 Example

A person with weight of 55 kg

getting 1552 kcal, 50 gm protein
and 80 gm of fat from 2200 ml
volume of PN solution administered
via peripheral line.
 12.5 % Dextrose Water 1300ml
 10% Amino Acids 500ml
 20% Lipids 400ml
 Example

 Calculating gm of CHO:
 12.5/100 x 1300 = 162.5gms
 Convert gm to mg : 162.5 x 1000 = 162500 mg
 Calculating CHO calories:
 162.5 x 3.4 = 552.5 kcal (35%)
 Final Concentration: 162.5/2200 x 100= 7.4%
 Calculating Glucose Infusion Rate:
 Mg CHO/wt in kg/minutes of the day
 162500/55/1440
 2.05 mg/kg/min
 CHO

 Excess of CHO leads to :

 Fatty Liver
 Hypercapnia
 Difficultyin weaning from
ventilator in ICU pt.
 PN induced hyperglycemia.
 Lipid Emulsions

 Lipids should not exceed more

than 60% of daily calories.
 9.5-10 kcal/gm.
 Used to prevent essential fatty
acid deficiency.
 Calculating Lipids Calories

 Example:
A person with weight of 55 kg.
 12.5 % Dextrose Water 1300 ml
 10% Amino Acids 500ml
 20% Lipids 400ml
 20/100 x 400 = 80gms
 80 x 10* = 800 kcal (51%)
* lipid emulsions provide 10 kcal
 Special Considerations -
Lipids
 Higher ratio of fat requires in:
 Volume restricted pts like kidney
disease or congestive heart disease.
 Pts with hypercapnia
 Hyperglycemia
 Long term PPN
 Contraindications for Lipids

 It includes:
 Egg allergy
 Hyperlipidemia
 Severe Liver disease
 Acute pancreatitis with
hyperlipidemia
 Severe pulmonary disease
 Thrombocytopenia
 Micronutrients

The micronutrients included in PN

solutions are
 Multivitamins.

 Trace elements
 Electrolytes.
 PN Additives
Additives Functions
Sodium Helps control water distribution & maintain a normal fluid
balance.
Potassium Needed for cellular activity & tissue synthesis.

Magnesium Helps absorb CHO & protein.

Calcium Needed for bone & teeth development & aids in clotting.

Phosphate Minimizes the threat of peripheral parasthesis.

Chlorides Regulates acid-base equilibrium & maintains osmotic

pressure.
Acetate Added to prevent metabolic acidosis.
 PN Additives
Ascorbic Helps in wound healing.
Acid
Vitamin A Assists in maintaining skin and vision.

Vitamin D Essential for bone and serum Ca++ levels.

Vit B Comp Absorption of CHO & protein

Folic Acid Necessary for DNA formation

Vit K Helps prevent bleeding disorders

Trace Help in wound healing & RBC synthesis

elements
 OSMOLARITY IN PN

 When a hypertonic solution is

introduced into a small vein with a
low blood flow, fluid from the
surrounding tissue moves into the
vein due to osmosis. The area can
become inflamed and thrombosis
can occur.
 OSMOLARITY IN PN

 Osmolarity, or mOsm/mL is used to

calculate IV fluids rather than
osmolality which is used for body
fluids.
 Calculation of the osmolarity of a
parenteral solution is important to
ensure venous tolerance
 PN Complications

Infection & Sepsis:

• Catheter entrance site
• Contamination during insertion
• Long-term catheter placement
• Solution contamination
 PN Complications
Metabolic Complications:
 Hypoglycemia on sudden ending of PN in patient with
unstable glucose levels
 Hypomagnesemia
 Hypocalcemia/Hypercalcemia
 Hyper/Hypophosphatemia
 Electrolyte imbalance
 Trace mineral deficiencies
 Essential fatty acid deficiency
 Hyperlipidemia
 Monitoring

 Routine monitoring includes:

 Measurement of fluid intake &
output
 Serum electrolytes
 Glucose,Ca++, Magnesium &
Phosphate.
 Liver
profile, TGs at least once a
week.
 Dsicontinuation of PN

 Parenteral nutrition can be withdrawn

once adequate oral or enteral nutrition is
tolerated and nutritional status is stable
with a daily review of the patient’s
progress.
 PN can be restarted in 2-3 days if the pt
does not continue to tolerate enteral or
PO or if intake is <50 % of estimated
requirements.
Thankyou