PARENTERAL NUTRITION

Parenteral Nutrition=Hyperalimentation

⮚Delivery of nutrients intravenously, via the

bloodstream

• Central Parenteral Nutrition= Total Parenteral

Nutrition (TPN)-delivered into a central vein

• Peripheral Parenteral Nutrition (PPN)-

delivered into a smaller or peripheral vein
 Parenteral Nutrition Central Access

• May be delivered via internal jugular lines,

and subclavian vein catheters

• Central access are required for infusions that

are toxic to small veins due to medication pH,
osmolarity, and volume
 PICC Lines (peripherally inserted central
catheter)
• PICC lines may be used in ambulatory settings
or for long term therapy
• Used for delivery of medication as well as PN
• Inserted in the cephalic, basilic, median
basilic, or median cephalic veins and threaded
into the superior vena cava
• Can remain in place for up to 1 year with
proper maintenance and without
complications
 PN: Peripheral Access

✔Therapy is expected to be short term (10-14

days)
• Parenteral nutrition may be administered via
peripheral access when:
✔ Energy and protein needs are moderate
✔ Formulation osmolality is <600-900 mOsm/L
✔Fluid restriction is not necessary
 The Solution

• Manually mixed in hospital pharmacy or

nutrition-mixing service

• Premixed solutions

• Separate administration for every element at

one in a separate line.
 INDICATIONS

• When specialized nutritional support is

indicated, EN should generally be preference
to PN
• PN should be used when the gastrointestinal
tract is not functional or cannot be accessed
and in patients who cannot be adequately
nourished by oral diets or EN
• The anticipated duration of PN should be > 7
days
What to do before starting TPN
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
 Nutritional Assessment
• Dietary history
• Significant weight loss within last 6 months
• > 15% loss of body weight
• compare with ideal weight
• Beware in patient with ascites/ edema
• IBW
 Physical Examination
• Evidence of muscle wasting
• Depletion of subcutaneous fat
• Peripheral edema, ascites
• Features of Vitamin deficiency
eg nail and mucosal changes
• Ecchymosis and easy bruising
 COMPONENTS

• Protein as amino acid

• CHO as dextrose
• Fat as lipid emulsion
• Electrolytes, vitamins and minerals
 Indications for TPN

• Weight loss of 10%

• Little or no intake for 7 days
• Continuous weight loss despite adequate
intake
• Serum albumin < 3.5 gm/100ml
• Poor tolerance to tube feeding
• Chronic vomiting or diarrhea
 COMMON INDICATIONS

• Patients has failed EN with appropriate tube

placement
• Severe acute pancreatitis
• Severe short bowel syndrome
• Mesenteric ischemia
• Paralytic ileus
• Small bowel obstruction
 Venous Access Device

1. Multilumen Catheter

1. Implantable Port
 2 Types of TPN

• Solution with lipids ( 3-in-1 )

Calories from amino acids 20% – 25%
Calories from lipids 20%
Calories from dextrose 55% – 60%
• Solution without lipids ( 2-in-1 )
Calories from amino acids 20% – 25%
Calories from dextrose 75% - 80%
 ADVANTAGES OF (3-in-1 )

• Lower cost of preparation

• Less administration time

• Potentially reduced risk of sepsis

 DISADVANTAGES OF (3-in-1)

• Precipitants cannot be seen

• Expiration date for 2-in-1 is 21 days

• Expiration date for 3-in-1 is 7 days

✔ can remain at room temperature for 24
hours
 Infusion schedule
1. Continuous
2. Cyclic
 Infusion Schedules

• Continuous parenteral nutrition

-Non-interrupted infusion of parenteral
nutrition solution for 24 hours via a central or
peripheral venous access
 Advantages of continuous parenteral nutrition

• Well tolerated by most patients

• Requires less manipulation
• decreased nursing time
• decreased potential for “touch”
contamination
 Disadvantages of continuous parenteral
nutrition
• Persistent anabolic state
• altered insulin : glucagon ratios
• increased lipid storage by the liver
• Reduces mobility in ambulatory patients
 Infusion Schedules

Cyclic PN
• The intermittent administration of PN via a
central or peripheral venous access, usually
over a period of 12 – 18 hours
• Patients on continuous therapy may be
converted to cyclic PN over 24-48 hours
 Advantages of cyclic parenteral nutrition

• Approximates normal physiology of

intermittent feeding
• Maintains:
• Nitrogen balance
• Visceral proteins
• Ideal for ambulatory patients
• Allows normal activity
• Improves quality of life
 Disadvantages of cyclic parenteral
nutrition
• Incorporation of N2 into muscle stores may be
suboptimal
• Nutrients administered when patient is less
active
• Not tolerated by critically ill patients
• Requires more nursing manipulation
• Increased potential for touch
contamination
• Increased nursing time
 Monitoring the Client

Daily Monitoring
Weight
Intake and output
Nitrogen balance
Electrolytes
Glucose
 Monitoring the Client

• Assess calorie, protein, carbohydrate, vitamin

and mineral intake twice weekly
• Check serum potassium chloride, CO2,
phosphorous, BUN, creatinine and
triglycerides twice weekly
• Assess complete blood count, prothrombin
time, albumin, calcium, magnesium, copper,
zinc and liver function test weekly
• Obtain urinalysis weekly
 Complications
Air embolism
Pneumothorax
bleeding
Infection
Arterial puncture
Catheter displacement
Sepsis
blockage
 Complications

• Glucose abnormalities are common.

– Hyperglycemia can be avoided by
monitoring blood glucose often, adjusting
the insulin dose in the TPN solution and
giving subcutaneous insulin
– Hypoglycemia can be precipitated by
suddenly discontinuing constant
concentrated dextrose infusions.
 Complications
Abnormalities of serum electrolytes and minerals
–should be corrected by modifying subsequent infu sions
or, if correction is urgently required, by begin ning
appropriate peripheral vein infusions.
–Vitamin and mineral deficiencies are rare if solutio ns are
given correctly. E
–elevated BUN may reflect dehydration, which can be
corrected by giving free water as 5% dextrose via a
peripheral vein.
 Complications
Volume overload (suggested by > 1 kg/day weight gain)
–may occur when high daily energy requirements require large fluid vo lumes.

Metabolic bone disease, or bone demineralization (osteoporosis or ost

eomalacia),
–develops in some patients receiving TPN for > 3 mo.

–Mechanism is unknown.

–Advanced disease can cause severe periarticular, lower extremity, a nd back

pain.
–Temporarily or permanently discontinuing TPN is the only known trea
tment.
 Defense Against PN
Complications
Select appropriate patients to receive PN
Aseptic technique for insertion and site care of IV
catheters
Do not overfeed
●Maintain glycemic control <150-170 mg/dl
●Limit lipids to 1 gm/kg and monitor TG levels

●Adjust protein based on metabolic demand and organ fu

nction
Monitor fluid/electrolyte/mineral status
Provide standard vitamin and trace element preps
daily
 Stopping TPN
Stop TPN when enteral feeding can restart
Wean slowly to avoid hypoglycemia
●Give IV Dextrose 10% solution at previous
infusion rate for at least 4 to 6h
●Alternatively, wean TPN while introducing enteral
feeding and stop when enteral intak e meets TEE
 Complications
• Adverse reactions to lipid emulsions
● dyspnea, cutaneous allergic reactions, nausea, headache, ba ck
pain, sweating, dizziness
● uncommon but may occur early, particularly if lipids are given at >
1.0 kcal/ kg/h.
● Temporary hyperlipidemia may occur, particularly in patients
• with kidney or liver failure
– treatment is usually not required.
● Delayed adverse reactions to lipid emulsions include hepatom
egaly, mild elevation of liver enzymes, splenomegaly, thrombo
cytopenia, leukopenia, and, especially in premature infants wit h
respiratory distress syndrome, pulmonary function abnormal ities.
– Temporarily or permanently slowing or stopping lipid emulsion infusio n
may prevent or minimize these adverse reactions.
 Complications
Hepatic complications
–liverdysfunction
–painful hepatomegaly
–hyperammonemia.
–Transient liver dysfunction, evidenced by increased
transaminases, bilirubin, and alkaline phosphatase, is
common with the initiation of TPN.
–Delayed or persistent elevations may result from ex cess
quantities of amino acids.
 Complications
Gallbladder complications
–include cholelithiasis, gallbladder sludge, and cholecystitis.
–These complications can be caused or worsened by prolon ged
gallbladder stasis.
–Stimulating contraction by providing about 20 to 30% of cal ories
as fat and stopping glucose infusion several hours a day is helpful.
–Oral or enteral intake also helps.

–Treatment with metronidazole, ursodeoxycholic acid, phen

obarbital, or cholecystokinin helps some patients with chole stasis.
 Refeeding Syndrome
• Patients at risk are malnourished
• particularly marasmic patients
• Can occur with enteral or parenteral
nutrition
• Results from intracellular electrolyte shift
 Refeeding Syndrome
• Reduced serum levels of magnesium,
potassium, and phosphorus
• Hyperglycemia and hyperinsulinemia
Interstitial fluid retention
• Cardiac decompensation and arrest
 Refeeding Syndrome
Prevention/Treatment
• Monitor and supplement electrolytes,
vitamins and minerals prior to and during
infusion of P N until levels remain stable
• Initiate feedings with 15-20 kcal/kg or 1000
kc als/day and 1.2-1.5 g protein/kg/day
• Limit fluid to 800 ml + insensible losses
(adjus t per patient fluid tolerance and
status)
 Handling and Storage

• Refrigerate

• Protect from light

• Check for integrity

 Administration of TPN

Infusion pump

Check solution for clarity

Aseptic technique

2000ml daily = maximum infusion time = 12H

per 1000ml
 Equipment

Prescribed infusion
IV tubing with extension tubing
Filter for albumin or lipid
Alcohol sponges
Sterile dressing package
Labels
Sterile gloves
 Procedure
1.Check physician's order and check it against the listed
ingredients
2.Wash hands
3.Identify the client, provide privacy and explain the
procedure
4.Check the solution
✔ Remove the solution from the refrigerator at least 1 hour
before using it
✔ Observe the solution for cloudiness, turbidity, particles or
crack in the container
✔ If the solution has brown layer, return it to the pharmacy
because the lipid emulsion has separated from the solution
 Procedure
5.Assess the client
✔ Check potassium, phosphorous and glucose values
✔ Look for any sign of inflammation or swelling at the
infusion site
✔ Assess the client's frame of mind to erase any fear,
reassure that the procedure is not painful
6.Prepare the tubing
✔ Connect tubing, extension tubing and filter
✔ If the tubing does not have the luer-lock connection,
tape all the connections
✔ Hang bag to an IV pole ( or thread through infusion
pump)
7.Prepare the central line
✔Flush the catheter, according to facility policy,
with saline
✔Put on sterile gloves
✔Clean the catheter cap with alcohol
✔Using aseptic tecnique,insert the needle into
the injection cap
✔Unclamp the tubing
8.Regulate the flow to the desired rate
9. Do not use the single lumen central line to infuse
blood or draw blood. If possible, avoid giving an IV
medication during a parenteral nutrition. Before adding
a piggy back medication to parenteral nutrition, check
with the pharmacist to make sure it is compatible.
Never add a medication to a parenteral nutrition
solution.
10.Ensure client safety and comfort
11.Remove and dispose gloves wash hands
12.Wash hands
13.Monitor and document client’s vital signs,
laboratory values (including electrolytes),
glucose levels daily weight, urine output and
catheter site
14.Document the type of solution used, time
and date the bag was hang, the client’s
response and the amount of solution added on
the intake output sheet
 Metabolic Complications

Fluid Load

Electrolytes balance

Glucose Levels
 Catheter Related Problems

Infection (catheter site)

redness
swelling
tenderness
irritation
drainage
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