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Parenteral nutrition: Uses, indications, and compounding

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 An In-Depth Look:
PARENTERAL NUTRITION
CE Article #1

Parenteral Nutrition: Uses,

Indications, and Compounding*
Elizabeth Thomovsky, DVMa
Alisa Reniker, DVM, DACVECCb
Robert Backus, DVM, PhD, DACVN
F. A. Mann, DVM, MS, DACVS, DACVECC
John R. Dodam, DVM, MS, PhD, DACVA
University of Missouri-Columbia

ABSTRACT: Decreased caloric and other nutrient intake can complicate the course of both mild
and serious illness.With proper case selection, providing parenteral nutrition (PN) can improve
clinical outcome, reduce hospitalization time, and reduce the cost of patient care. Many pharmacy
facilities can compound PN formulations; with proper staff training and patient monitoring resources,
PN can be administered in many veterinary practices.This article discusses the components of PN
formulations as well as the criteria for rational selection of patients to receive PN.

A
common problem in veterinary medi- successfully in human medicine since 1966.3
cine is maintenance of the nutrient and Although the first published veterinary study
caloric requirements of patients that are demonstrating the provision of complete intra-
malnourished, anorectic, or otherwise unable to venous nutrition to dogs was in 1977,4 PN has
use enteral nutrition. Although the goal is to become progressively more widely used in ani-
discover and resolve the underlying condition, mals since the 1990s. PN is classified as either
allowing the patient to go without food until the total parenteral nutrition (TPN) or peripheral
condition is resolved may contribute to morbid- (partial) parenteral nutrition (PPN).
ity and prolong therapy. In most if not all cases,
providing nutrition is believed to be beneficial to TOTAL PARENTERAL NUTRITION
patients and, based on human study findings, In human medicine, the strict definition of
may improve clinical outcome, shorten hospital TPN refers to intravenous provision of the total
stay, and reduce the cost of care.1 nutrient needs of the patient. As practiced in
Parenteral nutrition (PN) is one potential veterinary medicine, TPN may not supply all
modality of providing nutrition to animals for nutrient needs because the specific requirements
which enteral feeding is not indicated. PN typi- of critically ill dogs and cats have not been as
cally involves intravenous thoroughly investigated as they have in humans.
administration of nutritional Thus it is controversial whether veterinary TPN
products2 and has been used formulations are appropriately supplemented
• Take CE tests
*A companion article on parenteral nutrition formulations, monitoring, and complications
• See full-text articles begins on p. 88.
aDr. Thomovsky is conducting research funded by the Waltham Foundation.
CompendiumVet.com bDr. Reniker is now affiliated with First Regional Animal Hospital, Chandler, Arizona.

COMPENDIUM 76 February 2007

 Parenteral Nutrition: Uses, Indications, and Compounding CE
AN IN-DEPTH LOOK
Table 1. A Comparison of Veterinary Total and Partial Parenteral Nutrition
Total Parenteral Nutrition
• Marked hypertonicity (850–2,000 mOsm/L)
• Supplies total patient energy needs
• Central venous administration required
• May be deficient in total vitamin and mineral needs,
depending on the formulation
with the vitamins, macrominerals, and trace elements
required for long-term nutritional maintenance.5,6 How-
ever, veterinary TPN typically does attempt to supply all
the energy and protein needs of patients. Veterinary
TPN has classically been administered through a central
vein because of the high osmolarity of TPN solutions.
PERIPHERAL VERSUS PARTIAL
PARENTERAL NUTRITION
The abbreviation PPN refers to either partial or
peripheral PN. PPN solutions are less hyperosmolar than
TPN solutions and, therefore, are safely administered
into peripheral veins. PPN can be formulated to provide
all daily energy, protein, vitamin, and mineral require-
ments; these solutions are referred to as peripheral PN
solutions because they are supplied through a peripheral
vein. However, in many cases, the volume of PPN
required per day to meet the full energy needs of patients
is excessive because PPN has a greatly reduced osmolar-
ity versus that of TPN. Thus veterinary PPN is not com-
monly formulated to fully supply either the daily energy
and protein requirements or vitamin and mineral
requirements but rather seeks to provide a portion of the
total energy requirements (i.e., commonly 50% of total
daily energy requirements). Therefore, these solutions
provide partial PN5,6 (Table 1).
FEEDING PATIENTS
Metabolic Changes When Food
Intake Is Decreased
Patients requiring nutritional support are experiencing
either uncomplicated or stressed starvation.5,7 Uncom-
plicated starvation results when an animal is deprived of
food sources but is not injured or ill. To decrease the
nutrient needs of starving animals, their metabolic rates
slow down, resulting in less protein use by the body and
down-regulation of the release of catecholamines and
other stress hormones.5 These animals have decreased
February 2007
77
Partial Parenteral Nutrition
• Mild hypertonicity (500–600 mOsm/L)
• Does not usually supply all patient energy needs
• Peripheral venous administration possible
• Typically deficient in vitamin and mineral needs
insulin secretion and rely on gluconeogenesis and
hepatic glycogenolysis to supply glucose to their tissues.
Fatty acids are broken down to provide ketone bodies
for skeletal muscle energy as well as gluconeogenesis,
and body proteins are broken down to amino acids that
in turn are used for gluconeogenesis. In cases of short-
term uncomplicated starvation, providing food reverses
the metabolic changes, allowing patients to shift back to
a normal metabolic rate and begin to preferentially use
carbohydrates for energy. In cases of prolonged uncom-
plicated starvation, reintroduction of food requires close
patient monitoring. A possible side effect is a syndrome
of hypophosphatemia, hypokalemia, and hypomagne-
semia induced by the introduction of food. This “refeed-
ing syndrome” is thoroughly discussed in the companion
article beginning on p. 88.
Stressed starvation occurs when ill or injured animals
do not have adequate food intake. 5,6 Many of these
patients have elevated resting metabolic rates and an
increase in protein catabolism proportional to the extent
of disease.5 The production of catecholamines and other
stress hormones is up-regulated, leading to increased
cardiac output and systemic vascular resistance, insulin
resistance, proliferation of inflammatory mediators, and
rapid onset of malnutrition.5
Feeding patients with stressed starvation is challeng-
ing for multiple reasons.5,7 These animals have relative
insulin resistance and do not use exogenous carbohy-
drate sources as efficiently as normal animals. It is also
important to provide affected patients with sources of
amino acids to help reverse protein catabolism. More-
over, it is difficult to determine the actual energy
requirements for these animals because they may have
increased resting metabolic rates associated with stress
and disease. However, it is equally difficult to determine
the exact degree of increase of the metabolic rate. In
addition, as discussed more thoroughly later in this arti-
cle, the underlying reason for a patient’s stressed state
COMPENDIUM
78 CE Parenteral Nutrition: Uses, Indications, and Compounding
Guidelines for Initiating Nutritional
Support a
• Acute weight loss of 5%, or chronic weight loss of
10% or more
• Anorexia or inappetence for 3 or more days,
especially in patients already receiving intravenous
fluidsb
• Indications of decreased protein intake, such as
cachexia, poor body condition, overall weakness, and
nonhealing wound(s)
aJackson MW, Vail DM: Nutritional management of cats with
infectious disease. Vet Clin North Am Small Anim Pract
23:155–170, 1993.
bAs discussed in the text, it is appropriate to initiate nutritional
support sooner than 3 days, especially if other physical exami-
nation or historical parameters indicate the need to do so.
can be important in determining how the patient will
respond to supplemental nutrition.
Enteral Versus Parenteral Nutrition
When clinicians are deciding whether to provide nutri-
tional support to a patient, enteral nutritional support
(i.e., orally or through feeding tubes placed directly in the
gastrointestinal [GI] tract) is preferable to PN when
enteral feeding is tolerable and not contraindicated.
Enteral nutrition (EN) is more physiologic than PN and
reduces GI tract atrophy that may otherwise develop
from disuse. Histologic examination of liver and small
intestine samples from normal cats before and after 2
weeks of complete nutritional support by TPN revealed
swelling and vacuolization of hepatocytes and mild to
moderate small intestinal villous atrophy.8 All changes
were reversed 3 weeks after the animals resumed normal
enteral feeding. There is also evidence of decreased mus-
cular contraction of the gallbladder, stomach, and duode-
num during TPN administration. 8 In addition to
contributing to gallbladder sludging, gut stasis may lead
to bacterial overgrowth and predispose patients to bacter-
ial translocation and sepsis.9,10
Because PN administration is not without risk, it
should be reserved for malnourished patients or patients
unable to use the GI tract for prolonged periods. When
patients are in good nutritional status before clinical
presentation and interruption of feeding is anticipated
to be brief, it is rational to delay the start of nutritional
support for 3 to 5 days.11 It is important to take histori-
cal information into account when determining the
need for nutritional support because many animals may
COMPENDIUM
AN IN-DEPTH LOOK
have been anorectic or undernourished for 1 day or
longer before admission to the veterinary hospital. On
the other hand, if the patient was already undernour-
ished before its current illness, immediate initiation of
nutritional supplementation is important, regardless of
the number of days of complete anorexia (see box on
this page). For help in determining the best choice for a
patient’s nutrient needs (i.e., PPN or TPN), specific
indications for administering PPN and TPN are found
in the box on p. 80.12
COMPONENTS OF PARENTERAL
NUTRITION
Veterinary PN solutions are primarily composed of
carbohydrates, amino acids, electrolytes, and possibly a
lipid substrate. Some formulations also include vitamins
and minerals. The carbohydrate source used in most
TPN formulations is 50% dextrose, which contributes to
most of the osmolarity of the solution. PPN solutions
contain a lesser concentration (i.e., typically 5%) of dex-
trose and thus have a greatly reduced osmolarity. Most
PN solutions also contain synthetic amino acid formula-
tions that may not contain electrolytes. The lipid com-
ponent is supplied as a commercial lipid formulation
made primarily of long-chain triglycerides derived from
soybean and/or safflower sources.
Carbohydrates
A goal of using dextrose and lipid-based formulations
is to provide nonprotein energy sources to patients.
Dextrose is normally a readily usable energy source that
can be transported from the bloodstream directly into
the cells through the actions of insulin. Once in the
cells, dextrose is readily converted into needed substrates
and ATP by glycolytic oxidative metabolism.
However, in practice, there are limitations to dextrose
use in PN.11 The proportion of dextrose in a PN admix-
ture must be limited to prevent excessive osmolarity.
High osmolarity may lead to thrombophlebitis, espe-
cially when solutions are administered through periph-
eral veins. Many animals with stressed starvation are
insulin resistant and cannot completely use administered
dextrose. In addition, malnourished patients commonly
have protein malnutrition, which is not corrected by
dextrose administration.
Lipids
Lipids are an efficient form of energy and a source of
essential fatty acids that are often incorporated into PN
February 2007
80 CE Parenteral Nutrition: Uses, Indications, and Compounding
Indications for Nutritional Support
PPN11
• Short-term nutritional support in nondebilitated
patients (no signs of malnutrition)
• Patients in which central venous catheterization is
contraindicated or impossible
• A supplement to enteral feeding to provide complete
nutrition
TPN12
• Patients unable to enterally absorb sufficient nutrients
for more than 3–5 days, especially with apparent signs
of malnutrition (e.g., massive small intestinal resections,
chronic or intractable vomiting, severe diarrhea)
• Severe prolonged pancreatitis when enteral feeding
tubes (especially jejunostomy tubes) are not an option
• Severe malnutrition with a nonfunctional GI tract
• Intolerance to enteral tube placement (including
anesthesia required for feeding-tube placement) or
force feeding
solutions. Lipid emulsions have several beneficial char-
acteristics: they are isosmolar, provide energy through
gluconeogenesis or ketone body production, and are the
building blocks of cellular membranes. The addition of
lipid substrates to the PN admixture reduces the volume
of dextrose required to meet an animal’s energy require-
ments and thus reduces the solution’s osmolarity.
However, controversy exists regarding the inclusion of
lipids in PN, especially PN administered to critically ill
animals. Recent research 13 suggests that concurrent
administration of dextrose and lipids may result in ineffi-
cient lipid use when dextrose stimulates insulin release.
However, research14 in healthy dogs indicates that despite
an increase in insulin concentrations, PN solutions with
lipids as the main source of energy do provide adequate
energy. It is unknown whether these findings apply to
patients with an altered metabolism during illness.
There is also concern that in conditions of widespread
inflammation (i.e., sepsis), parenterally administered
lipids may amplify the inflammatory response.13 Most
commercial lipid preparations have a predominance of
omega-6 fatty acids, including linoleic acid. Although
linoleic acid is a nutritionally essential fatty acid, it is
also a precursor of arachidonic acid in dogs, which in
turn is a precursor of many proinflammatory mediators,
such as thromboxanes, leukotrienes, and prostaglan-
dins.15,16 The results of recent studies 13,15,16 in species
other than dogs and cats indicate that exogenous lipid
COMPENDIUM
AN IN-DEPTH LOOK
administration could lead to deleterious effects in
patients with medical conditions perpetuated by inflam-
mation, such as sepsis.
One study15 has compared omega-6 fatty acids with
omega-3 fatty acid preparations in humans with sepsis.
The study demonstrated that omega-6 fatty acids (e.g.,
linoleic acid) up-regulated endotoxin-induced monocyte
cytokine production during sepsis, worsening inflamma-
tion. Interestingly, patients who received omega-3 fatty
acids showed suppression of proinflammatory cytokine
production by monocytes, suggesting the possible value
of lipid substrates rich in omega-3 fatty acids in the for-
mulation of future PN solutions.15,16
In addition, a retrospective human study 17 showed
that patients receiving parenteral lipids had decreased
platelet-activating factor (PAF) acetylhydrolase versus
patients who did not receive lipids parenterally. This
enzyme normally inactivates PAF, which is another
proinflammatory mediator that may be active in criti-
cally ill or stressed patients.17 Therefore, patients who
receive parenteral lipid solutions may have an increased
inflammatory response as a result of higher PAF activ-
ity. Despite this, lipids are still considered a useful com-
ponent of PN, and further studies are needed to
determine the clinical significance of these findings.
Amino Acids
Amino acids are added to PN solutions to slow mus-
cle breakdown, help in the function of the immune sys-
tem, play a role in wound healing, and aid in the
function of many organs.7,18 Simply providing nonpro-
tein energy in the form of glucose or lipids spares pro-
tein catabolism to an extent, but some form of protein
or amino acid supplementation is also required.18,19 A
study 19 comparing nitrogen balance in healthy dogs
administered electrolytes, dextrose-containing solutions,
or amino acid–containing solutions demonstrated a neg-
ative nitrogen balance in all patients except those receiv-
ing amino acid supplementation.
Other Components
Electrolytes, vitamins, and trace minerals are added to
PN solutions to provide nonenergy daily nutritional
requirements. The Nutrition Advisory Group of the
Department of Foods and Nutrition has published
guidelines for vitamin, electrolyte, and trace element
supplementation in humans receiving PN. Unfortu-
nately, similar guidelines are unavailable to direct veteri-
nary PN composition, making vitamin and mineral
February 2007
 Parenteral Nutrition: Uses, Indications, and Compounding CE
AN IN-DEPTH LOOK
supplementation of veterinary PN solutions variable.
Components commonly added to veterinary PN solu-
tions include B vitamins as well as vitamins D and A;
these are often found as multivitamin supplements.
Human formulations may also include iron, magnesium,
or selenium,2 whereas veterinary PN mineral supple-
mentation is less standardized.
Although long-term PN has been administered on an
experimental basis to dogs, most clinical veterinary
patients receive PN for only a short duration compared
with humans. This minimizes the development of signs
of mineral or vitamin deficiencies, which humans on
long-term supplementation are more at risk of develop-
ing.2 Also, veterinary patients are typically placed on EN
as soon as possible (usually within 7 days); EN is ade-
quately supplemented with vitamins and minerals.4,5
It is important that veterinary patients receive appro-
priate electrolyte supplementation while receiving PN.
Very few long-term studies investigating the clinical merits of parenteral nutrition administration
exist in veterinary medicine; extrapolations from the human literature indicate that patients
experience measurable improvement when administered parenteral nutrition.
In some cases, amino acid solutions contain electrolytes
such as sodium, chloride, magnesium, and potassium
that typically supply the patient’s needs. In other cases,
amino acid solutions are not combined with electrolytes;
in this situation, patients should receive electrolyte-con-
taining fluids through a separate intravenous catheter or
a different port on the central line.6 As discussed in the
companion article beginning on p. 88, any patient
receiving PN should have at least daily electrolyte panels
conducted to ensure that the patient’s electrolyte needs
have been appropriately supplied.
COMPOUNDING PARENTERAL
NUTRITION SOLUTIONS
Asepsis is extremely important in the formulation and
administration of PN solutions. Lipid-containing
admixtures (e.g., dextrose, amino acids, lipids) are sig-
nificantly more supportive of bacterial and fungal
growth compared with dextrose or amino acid solutions
alone.20 However, with the advent of sterile formulations
of lipids and sterile technique used by pharmacists when
compounding PN solutions, contamination can be min-
February 2007
81
imized in today’s formulations.21–23 To ensure the safety
of PN formulations, human and veterinary pharmacies
must adhere to comprehensive guidelines regarding PN
compounding and formulation.24
Other concerns about the stability of PN formulations
are minimized when PN is formulated by a pharmacist.
The stability of the PN formulation depends on the
techniques and order in which the components are
added. The Maillard (browning) reaction refers to the
negative interaction between amino acids (e.g., glycine)
and carbohydrates.2,24 The brown color of the resulting
solution is due to decomposition of carbohydrates. The
pharmacist must separately prepare and combine amino
acids and carbohydrates to avoid this reaction. Amino
acid stability is also negatively affected by light; there-
fore, amino acid solutions must be carefully handled to
avoid exposure to light during formulation of PN solu-
tions.2,24 This includes keeping amino acid solutions
covered both before and after they are added to the PN
solution as well as when PN is administered to the
patient. However, if properly prepared and stored, dex-
trose and amino acid solutions are stable for several
months.2,24
Precipitation of PN components can occur. The most
commonly reported precipitation reaction is between
calcium and phosphorus.2,24,25 Although calcium is not
routinely used in veterinary PN solutions, calcium glu-
conate is used when needed because it is the least reac-
tive formulation of calcium available. When calcium
and phosphorus are needed, pharmacists add them sepa-
rately in the compounding regimen to allow maximal
dilution of the two nutrients in the PN solution, mini-
mizing the chance of precipitation reactions.2,24,25 In vet-
erinary medicine, the compositions of PN formulations
vary widely and may not contain readily precipitant
components, such as calcium and phosphorus.
A third compatibility issue is the stability of lipid par-
ticles.2,24–27 Over time, lipid particles begin to associate
together, forming a layer at the surface of the admixture.
This phenomenon is known as creaming and can be
COMPENDIUM
82 CE Parenteral Nutrition: Uses, Indications, and Compounding
AN IN-DEPTH LOOK

Technical Guidelines for Administering

Parenteral Nutrition
• Place intravenous lines (central or peripheral) in
aseptic fashion:
— Clean and prepare skin as for surgery.
— Wear sterile gloves when placing and handling
intravenous catheter, intravenous line, PN bag, etc.
— Maintain sterility of catheter, intravenous tubing,
and PN bag.
• Cover all connections between intravenous catheter,
intravenous lines, and PN bag with sterile dressing to
prevent bacterial or fungal contamination.
• Do not disconnect the patient from the PN bag
unless attaching a new bag; transport the patient at
all times (including outdoors) with the intravenous
lines and PN bag attached.
• Do not use the intravenous catheter through which
PN is being administered for any other solution (e.g.,
no drugs or fluids should be administered through
the PN tubing or intravenous ports).
• Minimize handling of the PN system.
Figure 1. Supplies for administering parenteral
nutrition: PN bag (1), sterile gloves (2), extension set
(3), intravenous tubing (4), sterile packets of povidone–
reversed by agitating the admixture. Creaming occurs iodine dressing (5), sterile bandaging material for tubing
almost immediately after the lipid-containing admixture connections (6), and nonsterile tape to cover the sterile
is compounded. If particle association is unimpeded, dressings (7).
lipid particles in the cream layer will begin to associate
in aggregates (i.e., flocculation), eventually leading to
coalescence of lipid particles into larger particles. meable to air. Air trapped in the bag during compound-
In human medicine, it is accepted that when lipid ing or diffusion of air into the bag can result in air bub-
particles greater than 5 µm make up more than 0.4% of bles that oxidize PN components as well as trigger alarms
a PN solution, embolization of pulmonary capillaries in the intravenous pumps used to administer PN.25,28,30
can occur.2,25,27 The exact time point of flocculation and Ethylene vinyl acetate is also less likely to bind to compo-
coalescence varies, depending on the temperature of the nents of PN (e.g., vitamins and lipids), which helps to
solution, the components of the solution, the hang time protect the components of PN from oxidation reac-
of the PN bag, and whether the bag has been agitated. tions.25,28 In addition, bags not made of ethylene vinyl
However, it is believed that unacceptable levels of coa- acetate may release carcinogens into the PN solution.25
lescence do not occur until the PN solution has been
kept at room temperature for at least 24 hours. OBTAINING AND ADMINISTERING
Lipid particulate association is increased with decreas- PARENTERAL NUTRITION
ing pH and when admixtures contain more cations than Veterinary PN can be compounded at most pharma-
anions.2,24–29 Increased cation concentration neutralizes cies that prepare human PN solutions because all com-
the negative charge on lipid particles, decreases electro- ponents are the same. Some large veterinary referral
static repulsion between lipids, and increases the likeli- institutions formulate and ship PN to private practices,
hood of coalescence. Appropriate formulation of PN as do commercial pharmacies. PN solutions can be for-
solutions by a pharmacist is the best way to minimize mulated and stored for days or weeks at refrigerated
the chance of these reactions. temperatures (35.6˚F to 46.4˚F [2˚C to 8˚C]).2,23,25–28,31,32
PN should be compounded only in specialized bags. However, once the PN formulation warms to room
PN bags are composed of several layers of ethylene vinyl temperature, most institutions recommend changing
acetate and other components to make them poorly per- PN bags daily as per FDA recommendations to avoid

COMPENDIUM February 2007

 Parenteral Nutrition: Uses, Indications, and Compounding CE 83
AN IN-DEPTH LOOK

contamination and lipid particle destabiliza-

tion. 28 There is some debate regarding the
longest amount of time that a PN bag can be
administered at room temperature, with some
institutions administering a single bag of PN
for 48 hours or more. However, there are little
published data to support the safety of this
deviation from FDA guidelines.33
PN solutions in veterinary medicine have
traditionally been administered continuously
over 24 hours largely because of their use at
referral institutions where 24-hour care is avail-
able. However, the calculated daily energy
Figure 2. Attaching a parenteral nutrition bag to intravenous tubing.
requirements can safely be administered over
A: The connection is performed aseptically.
shorter periods of time without adverse B: The connection is covered with sterile povidone–iodine ointment (not
effects.20,34,35 One investigation34 demonstrated shown) and a sterile bandage (arrow).
complete daily nutrient infusion over 10 hours C: The connection is then covered with bandaging tape (arrow).
in healthy dogs. The shorter administration
time improves convenience of administration
when 24-hour monitoring is not readily available. A
case study36 described the accidental administration of
1,800 ml of TPN solution within 2 hours to a German
shepherd (the calculated rate for this patient was 50
ml/hr), resulting in transient hyperglycemia, hyperlipi-
demia, and osmotic diuresis, which were reversed with
aggressive intravenous fluid therapy. Obviously, this
infusion rate exceeds recommendations, but this case
study demonstrates that TPN can be given without last-
ing negative effects at faster rates than those during a
24-hour continuous-rate infusion.
As already mentioned, veterinary TPN should be
administered through a central vein because of the high
osmolarity of the solution. TPN solutions are always
hyperosmolar compared with plasma. Normal plasma
osmolarity is approximately 300 mOsm/L, whereas that Figure 3. Aseptic attachment of an intravenous drip set
to the extension set using sterile gloves.
of TPN solutions is typically at least 850 mOsm/L and
A: Connections are covered with sterile povidone–iodine
commonly 1,500 to 2,000 mOsm/L. Hyperosmolar ointment (arrow) and a sterile bandage.
solutions can directly damage the tunica intima of blood B: The sterile connection is then covered with bandaging tape.
vessels. Also, erythrocytes and other cells can lyse when C: The final prepared bag of parenteral nutrition with all
they are exposed to a hyperosmolar environment in the connections aseptically prepared is ready for attachment to the
bloodstream. Therefore, TPN solutions must be admin- patient’s intravenous catheter in similar aseptic fashion.
istered through a central venous catheter (typically
placed into or terminating in the jugular vein) to allow
dilution to an isosmolar solution. This dilution occurs isotonicity within 1.5 to 2.5 cm from the point of infu-
when TPN quickly mixes with a relatively large volume sion into the central vein.
of blood in a central vein. Early studies 3 in beagles Another significant issue in PN administration is
proved the safety of administering hyperosmolar solu- catheter-related infection introduced by catheter placement
tions through a central vein; hyperosmolar solutions up or improper handling of intravenous tubing or ports.
to 2,400 mOsm/L were diluted by the bloodstream to Human medicine adheres to strict guidelines to prevent

February 2007 COMPENDIUM

84 CE Parenteral Nutrition: Uses, Indications, and Compounding
such complications, and most of these guidelines have been
adapted to veterinary medicine37 (see box on p. 82). Figures
1 through 3 demonstrate the sterility and technique
needed when handling and administering PN solutions.
Minimizing manipulation of and contact with the
intravenous catheter, the administration set, and the PN
bag itself, including routine line changes, can lower the
risk for catheter-related infections. Human studies38 of
24- versus 72-hour PN line changes revealed a signifi-
cant decrease in the incidence of nosocomial septicemia
when changes were prolonged to 72 hours. The authors
of the study speculated that decreased septicemia was
due to the fact that most of the contamination was
introduced through the open catheter hub during intra-
venous line changes. In the case of patients receiving
PN through a central catheter, multilumen central
catheters do not have an increased risk for infection ver-
sus single-lumen catheters as long as the lumen dedi-
cated to PN is kept sterile as outlined in the box on p.
82 and is dedicated solely to PN.37,39,40
CONCLUSION
PN is a viable nutritional choice for small animal
patients that cannot receive nutrition enterally. It is pos-
sible to both obtain and administer PN in a private prac-
tice setting. PN formulations should be obtained from a
pharmacy where appropriate protocols are followed to
safely compound the solution. However, once the PN
has been formulated, special equipment—other than an
aseptically placed and maintained catheter dedicated
specifically to PN—is not required for administration.
See p. 74 for a Veterinary Therapeutics abstract
related to this topic.
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AN IN-DEPTH LOOK
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2005.
14. Zentek J, Stephan I, Kramer S, et al: Parenteral nutrition in healthy dogs:
Comparison of fat versus glucose as main energy sources. J Anim Physiol
Anim Nutr 80:67–69, 1998.
15. Mayer K, Gokorsch S, Fegbeutel C, et al: Parenteral nutrition with fish oil
modulates cytokine response in patients with sepsis. Am J Respir Crit Care
Med 167:1321–1328, 2003.
16. Calder PC: Long chain omega-3 fatty acids and inflammation: Potential appli-
cation in surgical and trauma patients. Braz J Med Biol Res 36:433–446, 2003.
17. Claus RA, Russwurm S, Dohrn B, et al: Plasma platelet-activating factor acetyl-
hydrolase activity in critically ill patients. Crit Care Med 33:1416–1419, 2005.
18. Mauldin GE, Reynolds AJ, Mauldin NG, et al: Nitrogen balance in clinically
normal dogs receiving parenteral nutrition solutions. Am J Vet Res 62:912–
920, 2001.
19. Chandler ML, Guilford WG, Maxwell A, et al: A pilot study of protein spar-
ing in healthy dogs using peripheral parenteral nutrition. Res Vet Sci 69:
47–52, 2001.
20. D’Angio RG, Quercia RA, Treiber NK, et al: The growth of microorganisms in
total parenteral nutrition admixtures. JPEN J Parenter Enteral Nutr 11:394–
397, 1987.
21. Vasilakis A, Apelgren KN: Answering the fat emulsion contamination ques-
tion: Three in one admixture versus conventional total parenteral nutrition in
a clinical setting. JPEN J Parenter Enteral Nutr 12:356–359, 1988.
22. D’Angio RG, Riechers KC, Gilsdorf RB, et al: Effect of the mode of lipid
administration on parenteral nutrition–related infections. Ann Pharmacother
26:14–17, 1992.
23. Didier ME, Fischer S, Maki DG: Total parenteral nutrient admixtures
appear safer than lipid emulsion alone as regards microbial contamination:
Growth properties of microbial pathogens at room temperature. JPEN J Par-
enter Enteral Nutr 22:291–296, 1998.
24. National advisory group on standards and practice guidelines for parenteral
nutrition: Safe practices for parenteral nutrition formulations. JPEN J Par-
enter Enteral Nutr 22:49–66, 1998.
25. Driscoll DF: Compounding TPN admixtures: Then and now. JPEN J Par-
enter Enteral Nutr 27:43–48, 2003.
26. Brown R, Quercia RA, Sigman R: Total nutrient admixture: A review. JPEN
J Parenter Enteral Nutr 10:650–658, 1986.
27. Driscoll DF: Clinical issues regarding the use of total nutrient admixtures.
DICP Ann Pharmacother 24:296–303, 1990.
28. Driscoll DF, Baptista RJ, Bistrian BR, et al: Practical considerations regard-
ing the use of total nutrient admixtures. Am J Hosp Pharm 43:416–419, 1986.
29. Rollins CJ: Total nutrient admixtures: Stability issues and their impact on
nursing practice. J IV Nurs 20:299–304, 1997.
30. Wormleighton CV, Catling TB: Stability issues in home parenteral nutrition.
Clin Nutr 17:199–203, 1998.
31. Sayeed FA, Tripp MG, Sukumaran KB, et al: Stability of total nutrient
admixtures using various intravenous fat emulsions. Am J Hosp Pharm
44:2271–2280, 1987.
32. Desport JC, Hoedt B, Pelagatti V, et al: Twenty-nine day study of stability for
six different parenteral nutrition mixtures. Crit Care 1:41–44, 1997.
33. Macintire DK, Drobatz KJ, Haskins SC, et al: Manual of Small Animal Emer-
gency and Critical Care Medicine. Philadelphia, Lippincott Williams &
Wilkins, 2005.
34. Zentek J, Stephan I, Kramer S, et al: Response of dogs to short term infu-
sions of carbohydrate- or lipid-based parenteral nutrition. J Vet Med A Physiol
Pathol Clin Med 50:313–321, 2003.
February 2007
 Parenteral Nutrition: Uses, Indications, and Compounding CE 85
AN IN-DEPTH LOOK

35. Caprile KA, Spears KE: Long-term cyclic total parenteral nutrition in the 4. EN is _____ PN.
growing canine. Proc 5th Vet Med Forum:906, 1987.
a. less physiologic than c. as physiologic as
36. Moens NMM, Remedios AM: Hyperosmolar hyperglycemic syndrome in a
dog resulting from parenteral nutrition overload. J Small Anim Pract
b. more physiologic than d. none of the above
38:417–420, 1997.
37. Pearson ML: Hospital Infection Control Practices Advisory Committee: 5. Patients should begin receiving PN
Guideline for prevention of intravascular-device-related infections. Infect a. immediately if they were undernourished before
Control Hosp Epidemiol 17:438–473, 1996.
their current illness.
38. Robathan GR, Woodger S, Merante D: A prospective study evaluating the
effects of extending TPN nutrition line changes to 72 hours. J IV Nurs b. after 3 to 5 days of decreased or absent nutritional
18:84–87, 1995. intake if they were appropriately nourished before
39. Johnson BH, Rypins EB: Single-lumen versus double-lumen catheters for their current illness.
total parenteral nutrition. Arch Surg 125:990–992, 1990. c. after more than 7 days of decreased or absent nutri-
40. Savage AP, Picard M, Hopkins CC, et al: Complications and survival of mul-
tilumen central venous catheters used for total parenteral nutrition. Br J Surg
tional intake.
80:1287–1290, 1993. d. all of the above

ARTICLE #1 CE TEST 6. Which patient would be the best candidate for

This article qualifies for 2 contact hours of continuing CE
PN?
education credit from the Auburn University College a. a cat with hepatic lipidosis that has not been vomiting
of Veterinary Medicine. Subscribers may purchase b. a patient after GI resection and anastomosis
individual CE tests or sign up for our annual c. a patient with prolonged pancreatitis
CE program. Those who wish to apply this credit to d. an anorectic patient that has undergone exploratory
fulfill state relicensure requirements should consult their abdominal surgery for biopsies
respective state authorities regarding the applicability
of this program. CE subscribers can take CE tests online 7. Which component of parenteral solutions con-
and get real-time scores at CompendiumVet.com. tributes the most to the osmolarity of the solu-
tion?
1. Which statement is most correct? a. dextrose c. lipids
a. The purpose of veterinary TPN is to supply every b. amino acids d. vitamin additives
nutrient needed by patients.
b. Because of hyperosmolarity, veterinary PPN solutions 8. Which is not a possible negative consequence of
are typically provided through a central vein. lipid administration?
c. Veterinary PPN solutions are typically partial PN. a. inhibition of lipolysis in the presence of insulin
d. a and b b. proinflammatory effects
c. provision of energy via gluconeogenesis
2. Veterinary TPN solutions are d. There are no negative consequences of lipid adminis-
a. hyperosmolar to plasma and to PPN solutions. tration.
b. hyperosmolar to plasma and hypoosmolar to PPN
solutions. 9. Which is(are) a possible sequela(e) of the formu-
c. hypoosmolar to plasma and hyperosmolar to PPN lation of PN?
solutions. a. the Maillard reaction
d. hypoosmolar to plasma and to PPN solutions. b. precipitation of calcium and phosphorus
c. lipid particle coalescence
3. Which statement regarding starvation is correct? d. all of the above
a. Animals experiencing stressed starvation have insulin
resistance, whereas animals experiencing uncompli- 10. Which is an important procedure for PN admin-
cated starvation have decreased insulin secretion. istration?
b. Animals experiencing stressed starvation have de- a. Clean and aseptically prepare the skin before intra-
creased insulin secretion, whereas animals experienc- venous catheterization.
ing uncomplicated starvation have increased insulin b. Change the intravenous lines every 12 hours.
resistance. c. Disconnect the intravenous lines when the patient is
c. Simply feeding animals experiencing stressed starva- removed from the cage.
tion allows them to regain their normal metabolism. d. Mix all intravenous drugs in the PN solution before
d. none of the above administration.

February 2007 COMPENDIUM

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