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Peripheral Parental Nutrition

Peripheral Parental Nutrition

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20TH ANNIVERSARYVol. 21, No. 6June 1999
Refereed Peer Review
Peripheral parenteral nutrition(PPN) is a safe, simple techniquethat can be used as an alternativeto total parenteral nutrition (TPN)in selected patients.
PeripheralParenteral Nutrition
Tufts University 
Erika Zsombor-Murray, DVMLisa M. Freeman, DVM, PhD
Many clients now expect appropriate nutritional support to be provided to theirhospitalized pets. In many veterinary clinics, enteral nutrition via feeding tubes is perceived tobe the only viable option. Although enteral nutrition is usually the preferred method, parenteralnutrition is the method of choice when the enteral route is contraindicated. Advances in theformulation of parenteral nutritional solutions, intravenous catheters, and administration tech-niques make its use more amenable to veterinary clinics. Parenteral nutrition administeredthrough a peripheral vein can be used as an alternative to total parenteral nutrition in appropri-ate patients.
etabolic alterations put ill and traumatized patients at risk for malnu-trition and its deleterious effects on immune function, wound healing,and overall survival.
The benefits of nutritional support in preventingmalnutrition are well accepted, but the optimal use of parenteral or intravenousnutrition is controversial. In the past, parenteral nutrition was recommendedonly when enteral nutrition was contraindicated; parenteral nutrition was some-times considered a technique that should be avoided at all costs because of itspotential complications. Administering parenteral nutrition has also been pre-sented as a complicated prospect for nutritional support. Thus, its use in veteri-nary medicine has been primarily limited to universities and a few referral hospi-tals. However, parenteral nutrition is now more accepted, safer, and easier than itonce was, and its use is becoming more feasible for all veterinarians. Much of theinitial resistance to parenteral nutrition was the result of its potential complica-tions, some of which can be overcome or minimized by using the peripheralroute of administration.
The use of parenteral nutrition in companion animals is not new. In 1656, apig’s bladder attached to a goose quill was used to infuse wine into a dog’s vein.
In the 1930s, increased study and awareness of the dangers of malnutrition pro-vided the impetus behind the development of better methods to prevent it. Par-enteral nutrition began to be used in the late 1930s to prevent and treat malnu-trition in humans; however, its regular use in humans did not occur until thelate 1960s, at which time Dudrick and coworkers reported normal growth anddevelopment in dogs fed parenterally.
The use of parenteral nutrition in dogs was first reported in the veterinary literature in 1977 in an article on the success-
Abolishing protein catabolismis impossible in many ill ortraumatized patients, butnutritional support helpsminimize losses and supportsthe patient until recovery.
Administering PPN is a simplermethod of providing nutritionalsupport compared with TPN andusually is associated with fewercomplications.
Although combination parenteralproducts are commerciallyavailable, compounded PPNformulas are superior becausethey provide more balancednutrition and can be tailored tomeet individual patients’ needs.
Strict adherence to administration,monitoring, and aseptic techniqueprotocols in patients receivingPPN will reduce the risk ofcomplications.
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.
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
nutritional  pharmacology 
. 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.
INDICATIONSParenteral Nutrition
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
 without a lipid source, vita-mins, and trace elements.The use of TPN has been re-viewed.
Because of thetechnical requirements of TPNadministration and potentialcomplications, however, itsuse is not always feasible.Nevertheless, there are many animals that can benefit fromparenteral nutrition, and thusPPN may be a practical alter-native.Peripheral parenteral nu-trition is an option that may be easier to implement thanis TPN (Figure 1). The for-mula presented in this article provides a solution with alower osmolarity than that of TPN that can still pro-vide 50% of caloric needs. There are other methods of formulating PPN solutions that allow up to 100% of caloric requirements to be met, but calculating and ad-ministering these formulas can be more chal-lenging. The formula for PPN presented inthis article is easy to administer and results infew complications when specified protocols arefollowed, thus requiring less intensive monitor-ing than that required for TPN.
Peripheral Parenteral Nutrition
Peripheral parenteral nutrition has a numberof advantages over TPN. It should not, howev-er, be viewed as a replacement for TPN but asan alternative that may be appropriate in se-lected patients (see Candidates for PeripheralParenteral Nutrition). Because PPN will notprovide all of an animal
s energy requirements,it should not be used in patients that are debil-itated (i.e., those that already have signs of malnutrition), have large protein losses, or willrequire nutritional support for long periods.
It is only within the past decade that PPNhas been considered a reasonable route of ad-ministration for parenteral nutrition. Previous-ly, parenteral nutrition was administered only via a large central vein because relatively largevolumes of parenteral nutrition were given tomost patients to meet perceived energy re-quirements. Estimates of energy requirementsare now much more conservative; thus smallervolumes can be adminis-tered. In addition, solutionsavailable in the past weretoo high in osmolarity to beadministered peripherally. It was not until the develop-ment of safe fat emulsionsthat PPN became a reality.Fats are a more concentratedenergy source than is glu-cose and reduce the osmo-larity of PPN solutions.
Providing parenteral nutri-tion via a peripheral catheteroffers several advantages overusing a central catheter (see Advantages of Peripheral Par-enteral Nutrition). The first is the ease of peripheralcatheter placement compared with placing jugularcatheters. In many hospitals, technicians do not routinely place jugular catheters and TPN is therefore not an op-tion. Another advantage is that PPN is less likely than is
Small Animal/Exotics20TH ANNIVERSARY
June 1999
Figure 1—
In certain patients, parenteral nutrition adminis-tered through a peripheral vein can be an effective and simplealternative to total parenteral nutrition.
Patients in which thegastrointestinal tractcannot be used (e.g.,due to obstruction,severe malabsorption,pancreatitis, or riskof aspiration)
Nondebilitated patients
Patients likely to requireonly short-termintravenous nutritionalsupport (i.e., fewer than 5to 7 days)
Patients in which a jugularcatheter cannot be placed
Patients that cannottolerate their full nutritionalrequirements enterally(use peripheral parenteralnutrition to supplementoral or tube feeding [low-dose enteral nutrition])
Candidates for Peripheral Parenteral Nutrition
Easier catheterplacement
Less likely to causemetabolic complications
Less intensive monitoringis required
Nutritional support maybe initiated earlier
Can be as effective astotal parenteral nutritionin appropriately selectedpatients
Advantages of Peripheral Parenteral Nutrition
Versus total parenteral nutrition.

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