ful maintenance of 10 dogs for up to 1 month using to-tal parenteral nutrition (TPN).
Since that time, theuse of parenteral nutrition in ill animals has expanded.Initially, parenteral nutrition was provided through alarge central vein (e.g., subclavian vein in humans, jugular vein in dogs and cats).The risks associated withcentral venous catheters (e.g., sepsis, complications dur-ing placement) may delay initiation of TPN support orprevent its use completely. Therefore, techniques thatsimplify initiation and administration of parenteral nu-trition and reduce the risk of complications make itsuse more feasible. One way of achieving these goals isby administering parenteral nutrition peripherally, which has become possible because of the developmentof new nutritional products and changing ideas of thegoals of parenteral nutrition.
GOALS OF PARENTERAL NUTRITION
The goals of parenteral nutrition are no differentthan those of any other type of nutritional support
toprevent nutritional deficiencies by providing adequateenergy substrates, protein, and micronutrients. Duringthe hypercatabolic state in ill animals, there is accelerat-ed loss of lean body mass; ongoing protein catabolismand wasting of lean body mass cannot be abolished with nutritional support.
The goal of nutritional sup-port in these patients, therefore, is to support the pa-tient and minimize ongoing destruction of body tissueuntil the animal recovers. This requires the provision of adequate calories and protein. It is now accepted thatproviding excessive levels of calories and protein willnot improve a patient
s condition and is likely to causecomplications. Another goal of nutritional support is to prevent vita-min and trace-element deficiencies. Currently availablesolutions for parenteral nutrition are designed for hu-mans and do not meet all the amino acid, vitamin, ortrace-element requirements for dogs or cats, promptingsome veterinary nutritionists to avoid the term
parenteral nutrition. Nonetheless, parenteral nutritionhas successfully supported dogs and cats for monthsand is thus usually sufficient for our purposes.
Par-enteral nutrition solutions that meet the specific re-quirements of our patients, however, will require fur-ther research and development.Ideas regarding the nutritional requirements of pa-tients have changed over the past decade. Not only must basic nutritional requirements be met, but certainnutrients called conditionally essential nutrients (e.g.,the amino acid glutamine) may be required in higherthan normal amounts in ill or traumatized patients. Inaddition, some nutrients may have benefits when pro-vided at concentrations higher than those needed forknown nutritional requirements. This higher concen-tration is meant to improve immunity, diminish thechance of gut-derived sepsis, or hasten wound healing.
Using nutrients in this manner is known as
. Examples of nutrients that have beenused experimentally include arginine, zinc, and
-3polyunsaturated fatty acids. In the future, our knowl-edge may be sufficiently sophisticated to formulate anutritional protocol not only based on a patient
s ca-loric, protein, and micronutrient requirements but alsoaimed at modulating the deleterious effects of the dis-ease itself.
Nutritional support is indicated in patients that aremalnourished; unlikely to eat for more than 3 days; orat risk of developing malnutrition because of profound,ongoing protein losses. The enteral route still should bethe first choice for providing nutritional support andshould be used when possible. Enteral feeding is a safer,more economical, and more convenient method of pro-viding nutrition. In addition, providing nutrition by theenteral route has specific benefits to the gastrointestinaltract by preventing mucosal atrophy, maintaining localimmunocompetence, and preserving normal flora.
Despite these advantages, there are situations in which the parenteral route should be chosen. Parenteralnutrition should be selected when enteral nutritioncannot be tolerated, such as in patients with vomitingor regurgitation, those with severe malabsorption orgastrointestinal obstruction, and potentiallyin patientsthat cannot protect their airway. Parenteral nutritioncan also be used to supplement enteral feedings in pa-tients that cannot tolerate receiving all nutritional re-quirements enterally. Theoretically, providing even asmall amount of nutrition enterally in conjunction with parenteral nutrition could help improve patientoutcome by protecting mucosal integrity and minimiz-ing the potential for bacterial translocation and sepsis.Parenteral nutrition can be provided via a large centralvein or a peripheral vein and can provide either 100% of requirements or partial-energy requirements. There iscurrently much controversy regarding the nomenclatureof parenteral nutrition in both the veterinary and humanliterature. We define TPN as a parenteral solution formu-lated to provide 100% of energy requirements and ad-ministered as a hyperosmolar solution via a central vein.Peripheral parenteral nutrition (PPN), sometimes alsocalled partial parenteral nutrition, is defined here as a par-enteral solution formulated to provide 50% of energy re-quirements and administered via a peripheral vein. TPNis a combination of dextrose and amino acids with or
June 199920TH ANNIVERSARYSmall Animal/Exotics
TOTAL PARENTERAL NUTRITION
CONDITIONALLY ESSENTIAL NUTRIENTS