except fair uses permitted under U.S.

or applicable copyright la

CHaPtER 3

pArenterAL nutrition
the Momentum
2016. Press.
publisher,

Prior to 1968, patients with nonfunctioning gastrointestinal (GI) tracts

from
Copyright

who were unable to absorb nutrients died of malnutrition. Parenteral

All rights reserved. May not be reproduced in any form without permission

nutrition (PN) was first introduced in canine subjects, then tried

experimentally in an infant with terminal bowel failure. Success
followed the survival of the infant and thus was launched a new era in
nutrition support (Mueller 2012; Skipper 2012). Access devices required
for PN are considered an invasive intervention due to the risks of
infection and embolic events. Solutions provided to patients include
macronutrients, micronutrients, electrolytes, medications, and fluids for
hydration. Both short-term and long-term PN can cause complications,
some with high morbidity, mortality, and poor outcomes.

3.1 aCCESS DEViCES

Parenteral feeding requires access to the circulatory system. The for-

mulations infused are complex hypertonic solutions that require access
devices to deliver nutrients. It is often implied that PN is a total
parenteral nutrition (TPN) solution, meaning all nutrition needs from
macro- and micronutrients are being supplied to the patient. However,
PN can also be provided in a supplemental role. An example of
supplemental use of PN would be for patients transitioning to enteral
feeding or oral diets. For all PN provisions, a central access device is
required. A summary of intravenous access devices is shown in Table
3.1. Although the origin of entry in central access devices varies, all
share the location of the tip of the catheter in the superior vena cava. This
allows the hypertonic nutrient-rich solution to be immediately dispersed
throughout the body. Peripherally inserted central catheters are most
often used in short-term PN patients. Patients who require long-term or
indefinite time frames of PN support

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 38  nUtRitiOn SUPPORt

Table 3.1. Vascular access devices

Catheter type Placement Use
Peripheral catheters Percutaneous Short-term hydration,
peripheral access medication, PPN in
(veins) few patients
Peripherally inserted Percutaneous PN for weeks to
central catheter peripheral insertion, several months,
(PICC), nontunneled access to superior widely used in both
vena cava acute and home care
settings
Implanted ports and Percutaneous Long-term PN
tunneled-cuffed subclavian, jugular support
catheters vessels (requires
surgical placement)
Nontunneled central Jugular, femoral, Critical and acute care
catheter subclavian for short-term PN
and other therapies
(replacement for
long term)

will likely have implanted ports or tunnel-cuffed catheters. Occasionally,

peripheral access devices may be used for short-term, modest peripheral
parenteral nutrition (PPN). Access to small veins in hands and arms is
very common and convenient. Although more often employed in the past
century, its current use has been very limited. Lack of positive outcome
data and frequent occurrence of phlebitis has minimized the role of PPN
in patient care (Ayers et al. 2014; Martindale et al. 2009). Hygiene and
main- tenance of the insertion site and hub with antiseptic agents or
devices and anticoagulant flushing prevent complications that jeopardize
the access for nutrition solution infusion.

3.2 PaREntERaL nUtRitiOn SOLUtiOnS

Parenteral formulations include macronutrients, micronutrients, medica-

tion, and electrolytes. Additional fluid in the sterile water or electrolyte
solutions may also be incorporated to meet patients’ fluid needs.
Macronutrients and their energy content, source, and stock solutions
are shown in Table 3.2. Macronutrients are available in what may be
referred to as stock solutions, and come in various concentrations. Stock
solutions are also referred to as the initial concentrations, and once all

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Table 3.2. Macronutrient component of PN
Stock
Nutrition Energy provided solutions
component kcal/g Form (%)
Carbohydrate 3.4* Dextrose 2.5–70
Protein 4 Crystalline amino 3–20
acids
Fat 10** Soybean and 10 or 20
safflower
oil
*Less kcal/g with hydrated form of CHO.
**Additional kcal/g from glycerol.

nutrients are mixed then they are in the final concentration. Solutions
may be compounded and administered with all three macronutrients
(carbohydrates, proteins, and lipids) in the same container; this is
referred to as a three-in-one system of delivery. If lipid is to be infused
separately, it is referred to as a two-in-one system of delivery. However,
lipids may be more prone to microbial contamination; therefore, a
maximum hang of 12 hours is recommended when infused separately.
Three-in-one systems have longer hang times as the pH is lower, which
inhibits bacterial growth (Ayers et al. 2014; Mueller 2012).

3.2.1 MACRONUTRIENTS

Carbohydrate is in a hydrated form, which decreases the energy available

by weight. Therefore, energy provided is 3.4 kcal/g. The initial dose of
carbohydrate should promote glycemic control. About 1–2 mg/kg/min
for the first day of PN is good to start with. If the blood sugars remain
within normal parameters, adding a few grams of carbohydrate to meet
needs is advised. Usually carbohydrate in the goal solution is about 50 to
60 percent of total kcal.
Protein in PN is in the most elemental form of amino acids. The
energy available is typically 4 kcal/g. An example initial dose can be
from 0.8 to 1 g/kg. In the presence of normal liver and kidney functions,
protein can be advanced to the assessed goal. Specialized solutions
higher in branched-chain amino acids have been used for renal
insufficiency, liver dysfunction, or azotemia. Currently, the use of
formulations high in branched-chain amino acids versus standard
intravenous solutions in critical care patients is not supported in the
literature or recommended in guidelines (Heyland 2015).
 Lipid is not required in initial PN solutions, and may not be advised
in septic or immunocompromised patients. In North America, lipid
sources are primarily omega-6 fatty acids in the form of soybean and
safflower oils. Although some internationally available solutions contain
omega-3 fatty acids, they are not widely available for use in most
institutions. The proinflammatory effect of omega-6 fatty acids is
deemed undesirable and may be unnecessary in well-nourished patients.
The actual energy pro- vision of intravenous lipid is 10 kcal/g, which
includes additional kcal from glycerol. As an important energy-providing
nutrient, fat should be considered when patients are stable to meet energy
goals (Ayers et al. 2014; Heyland 2015; Mueller 2012).

Example 1: Calculating PN Provision from Grams

The nutrition prescription for PN includes 100 g of protein, 200 g of
carbohydrate, and 30 g of lipid. How many kcal does the PN solution
provide per day?
100 g protein × 4 kcal/g = 400 kcal
200 g dextrose × 3.4 kcal/g = 680 kcal
30 g lipid × 10 kcal/g = 300 kcal
Total Energy provided = 1,380 kcal

3.3 PaREntERaL nUtRitiOn CaLCULatiOnS

Calculations may be based on

Example 2: Calculation of
grams, grams per liter, or volume
Grams from Volume
and final concentration. The easiest
500 mL of 10% protein =
calculation for overall energy
50 g of protein
provision is to order PN
300 mL of 70% dextrose =
macronutrients in grams. This
210 g of CHO
allows for simple calculations for
200 mL of 20% lipid =
kcal from each macronutrient, then
40 g of fat
total kcal. Often, the percentage of a
Total Energy provided =
macronutrient’s contribution to total
1,314 kcal
kcal is used to check the balance of
macronutrient provision. Example
1 shows that the calculation of percentage of kcal from carbohydrate as
680 kcal of carbohydrate divided by 1,380 total kcal which equals
approximately 50 percent. This is consistent with recommendations to
provide 50 to 60 percent of total kcal from carbohydrate. If the PN
prescription order is written in volume, one more step is involved to
calculate the provision. Stock solutions used to compound the PN are
usu- ally readily available and often provided on the order form.
Solutions may then be multiplied by the percentage of the initial
concentration. In Exam- ple 2, 500 mL of 10 percent amino acid solution
provides 50 g of protein. This is calculated by multiplying 500 mL × 0.1
to obtain the result of 50 g. Then the calculations for kcal from protein
are 50 g × 4 kcal/g = 200 kcal, or 14 percent of total kcal.
Other calculations that pertain to
PN include the amount of carbohy- Example 3: Calculate the
drate infused by the minute. This is mg/kg/min in PN
expressed as mg/kg/min. The liver has The patient weighs 55 kg
the ability to oxidize approximately and the PN solution contains
5 to 7 mg/kg/min of carbohydrate 300 g of carbohydrate. What
(Ayers et al. 2014). When infusing is the mg/kg/min?
carbohydrate in PN solutions, the 300 g carbohydrate ÷ 55 kg
grams of carbohydrate should not ÷ 1.44 min = 3.8 mg/kg/min
exceed this level. To calculate the
maximum carbohydrate for a 70 kg patient, multiply the weight (kg) × 5
mg × 1,440 min/day/1,000 (or 1.44) to obtain that 504 g of carbohydrate.
Of note, 1.44 is a factor used instead of taking the step to divide the final
number by 1,000, as the calculation is converting grams to milligrams.
The maximum amount of carbohydrate that the liver can tolerate is taken
as 504 g. In Example 3, the mg/kg/min is calculated for a PN solution
containing 300 g of carbohydrate and the patient weighs 55 kg. The solu-
tion provides 3.8 mg/kg/min, which is acceptable in most stable patients
on PN. Of course, overall energy provision, macronutrient distribution,
and glycemic control are also important to consider.
Another calculation that has been used to determine overall balance
of a PN solution is the nonprotein calories (NPC) to nitrogen ratio. The
purpose of this calculation is to determine if there is adequate energy
provision compared to the amount of protein provided. The theory is that
the body can use energy from carbohydrate and fat, not from protein.
The ideal ratio for most patients is thought to be between 100 and 150
NPC:N2. This has been a controversial theory, but may be practiced by
professionals to assess the PN formulation if there is sufficient energy to
spare protein. To calculate NPC:N2 of a PN solution, calculate the total
kcal from carbohydrate and fat, determine the grams of nitrogen by
dividing protein by 6.25, then divide the NPC by the grams of nitrogen.
The use of this method to design or assess PN formulations has been
discouraged as
it may result in overfeeding (Skipper and Tupesis 2005). Including
protein kcal in the total energy expenditure requirements has been more
widely accepted in practice.

3.3.1 PRACTICE PARENTERAL NUTRITION CALCULATION

Practice using the calculations for the example PN solution provided.

The order for PN is 750 mL of 10 percent amino acid initial stock
solution, 450 mL of a 70 percent dextrose initial stock solution, and 250
mL of a 20 percent lipid initial stock solution. The patient has a feeding
weight of 65 kg. The Registered Dietitian assessment determined that the
patient required 25 to 30 kcal/kg and 1.2 to 1.5 g/kg of protein. However,
one should consider the following: How does this PN solution compare
to energy and protein needs? How does the macronutrient distribution
com- pare to guidelines? Is the carbohydrate provision acceptable for
safe liver oxidation?

1. Calculate the total kcal from the PN solution.

750 mL × 0.1 = 75 g protein × 4 kcal/g = 300 kcal
450 mL × 0.7 = 315 g dextrose × 3.4 kcal/g = 1,071 kcal
250 mL × 0.2 = 50 g lipid × 10 kcal/g = 500 kcal
Total kcal provided by the PN = 1,871 kcal
2. Calculate the kcal/kg and protein/kg. This can be compared to the
assessment of energy and protein needs.
1,871 kcal ÷ 65 kg = 29 kcal/kg
75 g protein ÷ 65 kg = 1.2 g/kg
3. Calculate the percentage of each macronutrient.
Protein = 300 kcal ÷ 1,871 total kcal = 16%
Carbohydrate = 1,071 kcal ÷ 1,871 total kcal = 57%
Fat = 500 kcal ÷ 1,871 total kcal = 27%
4. Calculate the mg/kg/min of carbohydrate provision.
315 g of dextrose ÷ 65 kg ÷ 1.44 min (1,440 min/1,000) = 3.7
mg/kg/min of dextrose

The assessment of energy and protein needs can be compared to the

calculations of PN. It can be determined that 27 kcal/kg and 1.2 g/kg of
protein are adequate to meet those estimated or perhaps measured needs.
The distribution of kcal from each macronutrient may also be reviewed.
By convention, distribution may be 10 to 20 percent from protein, 50 to
60 percent of kcal from carbohydrate, and less than 30 percent from fat.
This PN solution appears to compare favorably to this distribution. In
addition, the carbohydrate provision of 3.7 g/kg/min is in an acceptable
range for the liver to utilize dextrose safely.

3.3.2 MICRONUTRIENTS

Micronutrients are provided in products that contain vitamins in both

water- and fat-soluble forms, and solutions that contain trace elements.
Most often an all-in-one multivitamin preparation is provided in PN
solutions, see Table 3.3 for the contents of the available commercial
product. Some micronutrients are available in a single-dose form, for
example, cyanocobalamin. Therefore, deficiencies can be addressed by
additional supplementation. A similar multivitamin preparation is
available without phylloquinone for patients with coagulopathies.
Recommended daily allowance (RDA) provided dosages may appear to
vary from oral or enteral recommended intakes because of the difference
in micronutrient bioavailability in intravenous products. The use of
antioxidants in intra- venous form, such as vitamin C, has no formal
recommendations due to insufficient data. Moreover, there are
insufficient data on vitamin D to recommend the use in critical care
patients (Heyland 2015).

Table 3.3. Adult parenteral multivitamin available

in the United States
Dose
Ascorbic acid 200 mg
Retinol 1 mg
Ergocalciferol 5 mcg
Thiamin 6 mg
Riboflavin 3.6 mg
Pyridoxine 6 mg
Niacinamine 40 mg
Dexapanthenol 15 mg
dl-alpha tocopheryl acetate 10 mg
Biotin 60 mcg
Folic acid 600 mcg
Cyanocobalamin 5 mcg
Phyllopquinone 150 mcg
Source: Package insert.
 Trace minerals are available for parenteral infusion in multiple
mineral solutions and individual doses. Common inclusions in a
commercially available solution are zinc, copper, chromium, manganese,
and selenium amounts shown in Table 3.4. Parenteral mineral
requirements are well defined, so monitoring levels is essential in long-
term PN patients. Additional parenteral selenium supplementation should
be considered in critical care. However, the use of intravenous zinc as an
antioxidant has not been supported in the literature or in critical care
guidelines (Heyland 2015). Iron dextran is provided only as a separate
infusion due to the destabilizing nature of the trivalent cation form and
possible allergic reaction in some patients (Ayers et al. 2014; Mueller
2012).
Proper fluid and electrolyte balance is essential for all patients,
especially those dependent on PN. Fluid requirements can be met with
intravenous solutions that are balanced with electrolytes in the form of
salts. Electrolyte requirements and availability are provided in Table 3.5.
Based on compatibility, the two most preferred salt forms are calcium
gluconate and magnesium sulfate (Mueller 2012).

Table 3.4. Commercial trace mineral solution:

MTE-5
Chromium 4 mcg
Copper 0.4 mg
Manganese 0.1 mg
Zinc 3 mg
Selenium 20 mcg
Source: Package insert.

Table 3.5. Electrolyte requirements and commercially available salts

Parenteral
Electrolyte requirement Salt form solution
Sodium 1–2 mEq/kg Chloride, acetate, phosphate
Potassium 1–2 mEq/kg Chloride, acetate, phosphate
Phosphate 20–40 mmol Chloride, acetate, phosphate
Chloride *Variable Sodium, potassium
Acetate *Variable Sodium, potassium
Calcium 10–15 mEq Gluconate, gluceptate, chloride
Magnesium 8–20 mEq Sulfate, chloride
*Adjusted for acid–base balance.
3.3.3 ACID–BASE BALANCE

In addition to monitoring the fluid status of PN patients, acid–base

balance should also be monitored. Serum pH is the measurement of
hydrogen ions in the blood. The pH balance is crucial to survival, as
many reactions in the body are driven by the acidity or alkalinity of the
environment. In the blood, two substances are responsible for acid–base
balance. Carbonic acid (H2CO3) and bicarbonate (HCO3) are constantly
being buffered by the kidneys and the lungs to maintain a normal
physiologic pH range of 7.35 to 7.45. The lungs may compensate most
quickly to an acid–base disorder by adjustments in breathing rate. This
controls carbon dioxide retention and expiration and influences H 2CO3
content in the body. The kidneys are slower to respond to correcting
metabolic acidosis or alkalosis. The concentration of CO 3 is regulated by
the kidney (Ayers, Dixon, and Mays 2015). For PN solutions,
electrolytes may need to be adjusted for pH levels showing acidosis or
alkalosis. For example, a measure of blood drawn showing a pH drifting
into alkaline range may require that additional chloride be added to the
PN. Acid–base balance is critical, and awareness of the many factors that
may influence pH is important.

3.3.4 OSMOLARITY

Osmolarity of solutions is important

Example of Blood Serum
to monitor, and PN is no exception.
Osmolarity calculation
Osmolarity refers to the number of
Serum osmolarity = (2 ×
millimoles of liquid or solid in a liter of
(Na + K)) + (BUN/2.8) +
solution. PN solutions are considered to
(glucose/18)
be higher osmolar solutions at >1,800
Note: lab values in mmol/L
mOsmo/L (Skipper 2012). Dextrose
and
amino acids are the largest contributors to the osmotic load of the
solution. Fat is considered to be isotonic. Electrolytes and salts usually
make minor contributions to the PN solution osmolarity. The relevance
for clinicians is to be aware of the hydration status and osmolar state.
When patients become hyperosmolar, PN may be contraindicated as it
may exacerbate the problem. Examples of hyperosmolar states are severe
dehydration, poorly controlled diabetes, or consequences of therapeutic
approaches to severe head injury. Blood serum osmolarity may be
obtained by a lab value, or calculated using glucose, blood urea
nitrogen (BUN), and sodium lab values. There are several calculations
available for determining blood serum osmolarity if a measured value is
not available. The variance between the measurement and calculated
serum osmolarity continues to
be investigated, especially in high-risk groups such as brain injury (Li,
Xu, and Zhou 2014). It is recommended to hold PN provision and correct
the hyperosmolar and hypernatremia before resuming the infusion.

3.4 COMPOUnDinG

Once all the components of PN are determined, the solution is

compounded. Compounding PN involves preparing the solution for
delivery to the patient by mixing the prescription and distributing it into
containers. Solutions are prepared in sterile environment to reduce the
incidence of contamination. There are procedures developed by the
United States Pharmocopia and the American Society of Health-System
Pharmacists to decrease microbial contamination and precipitate matter
that may occur in PN solutions. The standardized procedures outline the
environment and equipment to be used in PN preparation. There are now
automated com- pounding devices that make the process of making PN
more efficient and dosing more accurate (Mueller 2012; Skipper 2012).

3.5 PREMiXED PaREntERaL

nUtRitiOn VERSUS CUStOM
SOLUtiOnS

Prescriptions for PN can be very complex and time consuming for

health care providers, as they often require daily reordering of solutions.
Compounding PN solutions, or making the solutions, requires proper
equipment usually under difficult and capital-intensive conditions. One
trend to alleviate errors in ordering and providing cost savings is to use
standardized premixed solutions. Premixed solutions are commercially
available with preset macronutrient and micronutrient combinations.
They may or may not have predetermined electrolytes. The advantages
of pre- mixed, standardized solutions include decreased errors in
prescription and compounding, PN-associated infections, and pharmacy
costs. Moreover, it is reported that 90 percent of energy, and 70 percent
of protein needs, can be met with premixed PN solutions. The
disadvantages of using premixed PN solutions are that some patients
require more nutrient-specific pre- scriptions to meet metabolic and
nutrition needs. An example is a lower carbohydrate, higher protein
provision to address glycemic control to meet the lower energy goals of
obese patients. Adjustments in electrolytes until patients are
metabolically stable can be crucial as well. In contrast to premixed
solutions, customized solutions allow practitioners a range of
options in their patients, and therefore the ability to provide these solution
remains available in many institutions (Hall 2015; Mueller 2012).

3.6 aDDitiOnaL COnSiDERatiOnS fOR

PaREntERaL nUtRitiOn
COMPOSitiOn: GLUtaMinE anD
CaRnitinE

In certain patient populations, glutamine has been identified as a

conditionally essential amino acid. However, it is not included in
standard amino acid mixtures due to its instability and incompatibility
with PN solutions. Spontaneous degradation of ammonia occurs when
glutamine is included in these solutions. Although glutamine has been
trialed in solu- tions that are very dilute and require large volumes to
administer adequate amounts, it is not currently commercially available
in an intravenous form. There are clinical outcomes associated with
adequate glutamine provision of >0.2 g/kg/day, such as decreased
infection rates and hospital stay. Conditions that may warrant
supplementation are postsurgical con- ditions, burns, and pancreatitis
(Mueller 2012). The use of intravenous glutamine supplementation for
highly stressed patients is not advised in the current critical care
guidelines due to the possibility of worsening the illness (Heyland 2015).
Further research will hopefully provide a practical intravenous form of
glutamine in the future. Carnitine is a protein that facilitates transport of
long-chain fatty acids. Patients who may be at risk for deficiency are
malnourished, on long-term PN, or on dialysis. Carnitine may be added
for these patients, but it is not a routine component of PN (Ayers et al.
2014; Mueller 2012).

3.7 MEDiCatiOnS

Medications may be added directly to PN formulations. The central

venous access allows for administration in patients unable to take
medications by mouth. One of the most common medications provided is
insulin. To ensure good glucose control, insulin and carbohydrate needs
are calculated and adjusted often. There is some evidence of insulin
losses due to absorption into delivery systems. As many patients are not
eating and have no gastric feeding, it is common to provide histamine
receptor blockers for stress ulcer prophylaxis in PN. Heparin may also be
included in solutions to minimize catheter occlusions caused by fibrin
formation at the tip of the catheter (Skipper 2012). Other medications
may not be
compatible with PN solutions as they form precipitates or affect
emulsion of the lipid. Pharmacists can review compatibility and decide
on which medications may be administered simultaneously through a
separate port of the catheter.

3.8 initiatiOn Of Pn

Most important in the initial stage of PN is to have fluid balance and

metabolic stability. Because of the elemental form of macronutrients and
electrolytes, PN is a hypertonic solution. A hyperosmolar, dehydrated
patient is not appropriate for PN as it may exacerbate the situation. Fluid
resuscitation and normal electrolyte lab values should be achieved prior
to initiation of PN. In addition, fluid overload can make it difficult to
provide adequate nutrition with volume restrictions. Concentrated forms
of amino acids (15 percent solutions) are available to assist in meeting
estimated needs under fluid-restricted conditions. The initial bag of PN
should not be expected to meet all of the assessed fluid needs. Providing
approximately 1 L of solution and advancing as able to fluid goals is
reasonable (AND 2015).
Initial PN provision should not be expected to meet nutrition goals
in the first few days. Because hyperglycemia is associated with poor
health outcomes, it is important to achieve and maintain good glycemic
con- trol early in the course of PN. Blood glucose levels should be in
normal range when the first bag of solution is introduced. Dextrose
provision may need to be modest, and exogenous insulin provided to
achieve good control. Dextrose on the first day may range from 50 to 100
g. Protein may be provided at 0.8 to 1 g/kg, and advanced to goal in 2 to
3 days in the patient with adequate renal and liver function. Lipid is not
necessary in the initial PN. In malnourished patients, initiation of fat
should be considered as soon as possible if triglycerides are within
normal range. There is some controversy with regard to adding omega-6
fatty acid sources in severe inflammatory states, such as sepsis and
critical care. Well-nour- ished patients can be without lipid provision for
several days to allow the decrease in the inflammatory response (Ayers et
al. 2014; Skipper 2012).

3.9 SCHEDULES anD aDMiniStRatiOn

Most PN formulations are initiated on a continuous schedule, or an

hourly rate for up to 24 hours. Transition to cyclic schedules usually
occurs within 2 to 3 weeks of a PN course. In most cases, the total
volume remains
constant, and the rate increases to
Example infusion schedules
accommodate the shorter time of
PN at 90 mL/h × 24 h = 2,160
infusion. Cyclic schedules vary
mL
based on the needs of the individual,
PN at 135 mL/h × 16 h = 2,160
but may range from 8 to 18 hours a
mL
day of PN infusion. One reason for
this is
to reduce incidence of PN-associated liver disease (PNALD). The
constant infusion of nutrients to the liver can cause increased liver
enzymes and hepatitis; therefore, decreased hours on PN may help
decrease the work- load of the liver. Patients also may become more
independent, and cyclic schedules may allow for other activities,
treatments, and therapies.

3.10 MOnitORinG anD EVaLUatiOn

Patients on PN require frequent review of provision and tolerance in

the initial course of therapy. Adjustments to the formulation are often
necessary to achieve adequate fluid and electrolyte balance, glycemic
control, changes in medication, and meet the estimated or measured
nutrition requirements. As patients become more stable and transition to
home care environments, monitoring can be much less frequent. Table
3.6 reviews variables and frequency of PN monitoring. Simple and
routine measurements such as temperature and weight are important in
the acute and long-term patient. An elevated temperature (febrile) may
be consistent with infection and indicate the patient has higher energy
needs. It may be difficult to ascertain if weight gain is lean body mass,
fat mass, or fluid. Sudden fluid accumulation may be a concern if organ
failure or infection is suspected. Trending weight may also be insightful
to efficacy of nutri- tion support. Electrolytes and minerals are essential
to monitor along with fluid status, and adjustments made to the PN
accordingly. Input and out- put records can also reveal other sources of
fluids provided, as well as excretion. Knowledge of kidney and liver
function is important, and BUN, creatinine, and liver enzymes provide
vital information. Again, input and output records could validate or
clarify kidney function with urine output documentation. There are
several reasons why red and white blood cells can be altered that may not
be PN related, but are important to monitor in the overall status of the
patient. Reasons for red and white cell alter- ations include surgery,
blood loss, anemia, infection, and hydration status. Changes in clinical
status can affect nutrition and fluid provision in the PN. Patients
undergoing surgical stress may need less dextrose and adjust- ments in
volume to accommodate other fluid sources. As patients improve in
status, additional kcal may be added with expected increased activity
Table 3.6. Suggested PN monitoring
Variable Initial PN Stable PN
Weight Daily Weekly
Electrolytes Daily 1–2/week
Glucose Daily 3×/week
BUN or creatinine 3×/week Weekly
Calcium, phosphorus,
or magnesium 3×/week Weekly
Triglycerides Weekly Weekly
Liver function
enzymes 3×/week Weekly
Hemoglobin, hemato-
crit, or platelets Weekly Weekly
White blood cells PRN PRN
Clinical status Daily Daily
Skin integrity or fluid
status Daily Daily
Catheter site Daily Daily
Temperature Daily Daily
Input and output Daily Daily
Nitrogen balance
study (UUN) --- Weekly, then PRN
Source: AND (2015); Martindale et al. (2009).

needs. Monitoring an access site

Nitrogen balance = N2 in − N2 out and identification of infection
(UUN)
can expedite treatment and
N2 in = amount of protein from PN
decrease the severity of the
infused ÷ 6.25
infection. Additional and more
N2 out = UUN × 20% + 2 g of N2
frequent monitoring may be
complications are identified. required if
As nitrogen balance studies may be used in enteral nutrition (EN),
they also can be used to evaluate the adequacy of protein intake in
PN. To calculate the nitrogen balance, the amount of protein may be
assessed from the actual input of parenteral solution. The urine for a
defined 24-hour period is then collected and assessed for the amount
of urine urea nitrogen (UUN) excreted, with the assumption that 20
percent of that urine urea is from protein metabolism. An additional
2 g of nitrogen may be lost in feces, sweat, and tears, and therefore
nitrogen is added to the UUN. The difference is reflective of protein
utilization. The ultimate goal is a positive nitrogen balance of 2 to 4 g;
thus, the body has adequate protein to meet the needs. A negative
nitrogen balance may be expected in hospitalized patients and can be
trended for improvement with nutrition provision. Continued negative
balance may indicate that protein provision is inadequate. Patients in
high stress states are not good candidates for nitrogen balance studies
due to catabolism or high protein turnover, thus increased nitrogen
excretion (Mueller 2012). High output from drainage tube from wounds
or surgical sites may also drain signif- icant amounts of nitrogen.
Adequate urine output and accuracy of urine collection are crucial to
valid nitrogen balance studies. Once patients are stable in clinical
course and nutrition prescription, nitrogen balance studies may be

Example Calculation: UUN

The PN formula contains 125 g of protein. A 24-hour urine sample
contained 12 g of urea nitrogen. What is the nitrogen balance?
N2 in = 125 g ÷ 6.25 = 19.2 g N2
N2 out = 12 g × 20% + 2 g = 16.4 g N2
Nitrogen Balance = 19.2 − 16.4 = 2.8 or positive nitrogen balance.
Interpretation: It appears the protein in the PN is adequate.

helpful.

3.10.1 ORDERING PARENTERAL NUTRITION

Physicians are responsible for PN orders. Nutrition support teams,

pharmacists, and dietitians may be consulted for ordering or recommen-
dations depending on the ordering process of the facility. The order
forms should include the instructions for compounding and administering
PN solutions. Orders are part of the electronic or paper medical record. A
sample order form for a three-in-one solution is shown in Figure 3.1. The
amount of each macronutrient in grams or volume is defined. Scheduled
hours, hourly rate of infusion, osmolarity, and total volume are specified.
These are used as determinants for calculations. Additional fluid or
intravenous solutions may be ordered if the PN solution does not meet
assessed fluid needs. Standard multivitamin and mineral and trace min-
eral preparations are usually used. Medications can also be ordered, such
as insulin, if they are to be compounded into the PN solution. Important
information to include are the type of access device and directions for
site care. Some order sets may also have monitoring and frequency
directions
 Patient identification number:
Date of birth:
Name:
Feeding weight:
Macronutrients:
□ Amino acids g
Total volume of solution
□ Dextrose g
Osmolarity of solution
□ Lipid g
Micronutrients:
□ Multivitamin and mineral
□ Multivitamin and mineral without vitamin K
□ Trace minerals

□ Other
Electrolytes:
Sodium phosphate mmol
Sodium chloride mEq
Sodium acetate mEq
Potassium phosphate mmol
Potassium chloride mEq
Potassium acetate mEq
Magnesium sulfate mEq
Calcium gluconate mEq

□ Medications
Type of access device placed:
□ PICC □ Implanted port □ Tunneled or nontunneled catheter
Scheduled Method of Administration:
□ Continuous (mL/h) x 24 h.
□ Cyclic (mL/h) x h.
Monitoring:
Temperature daily
Access device site care every hours.
Intake and output records daily
Weight daily or □ every other day □ weekly
Additional Labs:
□ Prealbumin and CRP weekly □ Other:
□ Triglycerides weekly
□ UUN study weekly

Figure 3.1. Sample adult PN order form.

specified. Examples of monitoring items are temperature, labs, weights,

and input and output records.

3.10.2 PARENTERAL NUTRITION COMPLICATIONS

Complications associated with PN are categorized into mechanical,

metabolic, infectious, and GI related. Mechanical-related complications
involve problems with access devices. Infectious complications are
usually related to the site where the access device is inserted. Metabolic
difficulties can be related to fluid and electrolyte imbalance, glycemic
control, and PN-associated deficiencies. GI complications may occur from
long-term PN support.

3.10.2.1 Mechanical Complications

Mechanical complications may also be referred to as noninfectious

complications of PN catheters and infusion. The most common problem
is occlusion, specifically thrombolytic occlusion. The body has a natural
response of blood clotting when injured, and catheter placement and
infusion can stimulate that response. Dysfunction of the blood clotting
mechanism, or coagulopathy, can also cause occlusion. The result is the
inability to infuse PN through the catheter. Anticoagulant agents may be
given to rectify the problem, otherwise the access device must be
removed. Nonthrombolytic occlusions are much less common, and
usually occur with heparin and PN interactions, calcium and phosphorus
precipitate, and lipid accumulation (Mueller 2012).
Other mechanical complications include catheter misplacement,
resulting in perforation of the lung or blood vessel. Ultrasound-guided
placement is helpful in bedside catheter placement, and confirmation of
catheter tip location is vital prior to initiation of PN solution to prevent
severe consequences. Air embolism, or air bolus into the blood stream,
is rare but potentially fatal. This is usually due to a malfunction of a
connector or kinked tubing.

3.10.2.2 Infectious Complications

Catheter-related blood stream infections (CRBSIs) are most commonly

attributed to central access devices required to administer PN solutions.
The surrounding skin and hub site of the catheter are usually the primary
contamination area in blood stream infections. Daily inspection of the
access device site and monitoring of body temperature can help identify
infection. Approximately half of the infections in short- and long-term
central access devices are due to Staphylococcus epidermidis found on
the skin. Steps to prevent CRBSIs as recommended by the Centers for
Disease Control (CDC 2015) are shown in Table 3.7. These include hand
and skin hygiene, device barrier protection, appropriate site selection,
and fre- quent monitoring for the need of the access device. CRBSIs can
be treated with systemic antibiotics. If treatment is unsuccessful and
sepsis persists, catheter removal may be necessary. In many cases, PN is
unable to be infused during infection treatment and while identifying
new access sites.
 Table 3.7. Steps to prevent CRBSI
Hand hygiene
Maximal barrier precautions
Skin antisepsis
Optimal catheter site selection
Daily review of need for line (removal when
no longer needed)

3.10.2.3 Metabolic Complications

It is important to maintain fluid and electrolyte balance in the course of

PN. Assessed fluid needs must be adjusted as other sources of fluid are
added or removed. For example, in the case of a hospitalized patient,
intravenous fluids may be present for hydration or medication
administration. As these fluids are removed, inadequate fluid provision
can occur. In addition, drainage or wound losses should be included in
assessed needs. Reviewing input and output records is helpful, but
accuracy cannot always be assumed at all levels of care. Discussions
with nursing and the other health care team members can rectify
discrepancies and provide a better understanding of patients’ most
current condition. Along with fluid status, electrolytes must be monitored
to prevent abnormalities from becoming life threatening.
As discussed earlier, glycemic control is extremely important.
Hyperglycemia must be avoided to ensure the best possible outcomes.
Hypoglycemia may also be problematic if excess insulin is provided in
PN or another source. Rebound hypoglycemia, defined as a sudden drop
in blood glucose levels upon discontinuing PN too quickly, may occur in
full PN patients. Therefore, a taper of PN may be indicated. Decreasing
the PN rate by 50 percent for an hour, then completely discontinuing the
PN may help prevent hypoglycemia events. Research has shown rebound
hypoglycemia to be nonsymptomatic; therefore, checking blood sugar 30
minutes and 1 hour after discontinuation may be indicated (Skipper
2012). Lipids are important components of PN in providing energy
and essential fatty acids. However, overfeeding with intravenous lipid
can cause hyperlipidemia and impair immune response. Moreover, an
increased risk of pancreatitis may be present with triglycerides >400
mg/dL. Reducing lipid provision to less than 30 percent of total kcal or 1
g/kg/day can help reduce the risk of hyperlipidemia. Essential fatty acids
are provided in lip- id-containing PN; however, in rare cases, intravenous
lipid solutions may not be tolerated due to allergic reactions. If oral or
enteral linoleic and
alpha-linolenic fatty acids cannot be tolerated, 250 to 500 mL of 20
percent intravenous lipid can be given one to two times per week. This
should be adequate to prevent essential fatty acid deficiency (Mueller
2012).
High doses of protein are often prescribed in the most critically ill,
surgical, or wound patients on PN. In the absence of adequate fluid and
energy provision, prerenal azotemia may occur. By-products of protein
metabolism must be excreted with fluid and appropriate renal and liver
function is crucial. To prevent prerenal azotemia, monitoring BUN levels
is important. Rising levels may be an indication that there is too much
pro- tein or not enough fluid provision in the formulation (Ayers et al.
2014).
There is a high incidence of
Risk factors for metabolic
osteopenia and osteoporosis in PN-
bone disease
dependent patients. Metabolic bone
Long-term PN
disease has many risk factors that long-
Postmenopausal
term PN patients share. Nutrients that
GI disease: malabsorption,
play a role in maintaining bone
Crohn’s disease
integrity are provided in PN, such as
Malignancy
calcium, phosphorus, and vitamin D.
Endocrine disease
However, adequate calcium intake
Genetic disease
can be impaired by the delicate bal-
Immobilization (prolonged
ance that must be achieved in PN
illness)
solutions. Furthermore, increased
Medication
doses of calcium and phosphorus only
seem
to be excreted in the urine. Vitamin D is provided in the multivitamin
preparation in a maintenance dose, and additional supplementation has
been shown to increase bone resorption. Withholding vitamin D can
decrease blood serum calcium; however, this is difficult in PN patients
with all vitamins in preformulated solutions. Currently, there is not an
intrave- nous vitamin solution without vitamin D. Other nutrients that
may influ- ence bone disease in PN patients are aluminum, copper, and
magnesium. Amino acid solutions contained amounts of aluminum,
which over time became toxic. Currently, there are specific restrictions
on the amount of aluminum, solutions can contain. Magnesium and
copper deficiencies can also play a role in bone disease. Monitoring and
correction can help pre- vent onset and progression of metabolic bone
disease (Ayers et al. 2014).

3.10.2.4 Gastrointestinal Complications

The use of PN can present challenges to the GI tract, particularly the

liver. When the GI tract is bypassed, the intestinal villi may atrophy and
the mucosal tissue can be compromised. Bile secretion is also lessened,
resulting in potential cholecystitis and cholestasis even in the short-term
course of weeks on PN. Cholecystitis is an inflammation of the gallblad-
der, and may or may not be associated with gallstones. Cholestasis is
impaired bile secretion. These complications are exacerbated by the lack
of normal GI digestion. To prevent these conditions from developing,
it is recommended to initiate oral feed or EN as soon as possible. Even
small amounts of feeding can help stimulate gallbladder contraction and
minimize risk of developing gallbladder complications (Mueller 2012).
Steatosis, or fat accumulation, in the liver is also a concern in PN
patients. Fatty liver may occur with overfeeding, so accurate assessment
of nutri- tion requirements is important. It is common for PN patients to
have ele- vated liver enzymes in the initial course of treatment. However,
prolonged use of PN can result in impaired liver function. PNALD is of
concern in long-term PN patients. Although intestinal failure is a primary
risk factor for liver failure, PN can also play a role in progressive liver
dysfunction and ultimate failure. Efforts to prevent PNALD should
include adequate provision without overfeeding and GI tract stimulation
with oral or enteral feeding if at all possible. It is recommended that PN-
dependent patients have computed tomography (CT) examinations of the
liver to assess for steatosis, and routine liver enzymes and biliary lab
draws to trend liver function (Ayers et al. 2014).

3.11 SUMMaRY

PN is a lifesaving intervention for individuals with nonfunctioning GI

tracts. The use of parenteral support should be limited to those meeting
the indications for use. Access devices used to administer PN have
advanced technology and improved techniques to minimize
complications, but infections and occlusions are still a risk for patients.
Solutions may be cus- tomized or obtained in a standard formulation.
Both require a professional expertise in PN provision to assess and
monitor adequacy and tolerance. Fluid administration is vital to maintain
hydration, along with electrolyte and acid–base balance. Complications
of long-term PN use include met- abolic bone disease and PNALD
Identification and prevention of these complications is important to
minimize the impact on patients requiring life-sustaining PN support.
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