Post on 26-Feb-2018
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Parenteral Nutrition
Graphic source: http://www.rxkinetics.com/tpntutorial/1_4.html
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Parenteral Nutrition (Definition)
omponents are in elemental or !pre"
#i$este#% form
&Protein as amino aci#s
&' as #extrose
&at as lipi# emulsion
&*lectrol+tes, -itamins an# minerals
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Parenteral Nutrition (PN) Definition
Deli-er+ of nutrients intra-enousl+, e.$. -iathe loo#stream.
&entral Parenteral Nutrition: often calle# otal
Parenteral Nutrition (PN)0 #eli-ere# into a
central -ein
&Peripheral Parenteral Nutrition (PPN):
#eli-ere# into a smaller or peripheral -ein
.2.P.*.N. Nutrition 2upport Practice 3anual, n# e#ition,
556, p. 78
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9n#ications for PN (2P*N)
hen 2peciali;e# Nutrition 2upport (2N2)is in#icate#, *N shoul# $enerall+ e use# inpreference to PN. (
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*N -s PN in ritical are (*B)
C.1. 9f the criticall+ ill 9 patient ishemo#+namicall+ stale with a functional
G9 tract, then *N is recommen#e# o-er PN.
Patients who recei-e# *N experience# lessseptic mori#it+ an# fewer infectious
complications than patients who recei-e#
PN.2tron$, on#itional
D *-i#ence nal+sis Birar+, accesse# A/58
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*N -s PN in ritical are (*B)
9n the criticall+ ill patient, *N is associate#
with si$nificant cost sa-in$s when
compare# to PN. here is insufficient
e-i#ence to #raw conclusions aout the
impact of *N or PN on B2 an# mortalit+.
2tron$, on#itional
D *-i#ence nal+sis Birar+, accesse# A/58
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ommon 9n#ications for PN
Patient has faile# *N with appropriate tueplacement
2e-ere acute pancreatitis
2e-ere short owel s+n#rome 3esenteric ischemia
Paral+tic ileus
2mall owel ostruction
G9 fistula unless enteral access can e place# #istalto the fistula or where -olume of output warrantstrial of *N
#apte# from 3irtallo in 2P*N, he 2cience an# Practice of Nutrition 2upport: ase"
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ontrain#ications
unctional an# accessile G9 tract
Patient is takin$ oral #iet
Pro$nosis #oes not warrant a$$ressi-enutrition support (terminall+ ill)
Cisk excee#s enefit
Patient expecte# to meet nee#s within 14#a+s
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PN entral ccess
3a+ e #eli-ere# -ia femoral lines, internalEu$ular lines, an# sucla-ian -ein cathetersin the hospital settin$
Peripherall+ inserte# central catheters(P9) are inserte# -ia the cephalic an#asilic -eins
entral access re=uire# for infusions thatare toxic to small -eins #ue to me#icationp', osmolarit+, an# -olume
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Fenous 2ites for ccess to the
2uperior Fena a-a
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P9 Bines (peripherall+ inserte#
central catheter)P9 lines ma+ e use# in amulator+
settin$s or for lon$ term therap+
se# for #eli-er+ of me#ication as well as
PN
9nserte# in the cephalic, asilic, me#ianasilic, or me#ian cephalic -eins an#
threa#e# into the superior -ena ca-aan remain in place for up to 1 +ear with
proper maintenance an# withoutcomplications
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PN: Peripheral ccess
PN ma+ e a#ministere# -ia peripheral access
when
herap+ is expecte# to e short term (15"14
#a+s)
*ner$+ an# protein nee#s are mo#erate
ormulation osmolarit+ is @55"755msm/B
lui# restriction is not necessar+
.2.P.*.N. Nutrition 2upport Practice 3anual, 5560 p.74
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Parenteral Nutrition
3acronutrients H
3icronutrients
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3acronutrients: aroh+#rate
2ource: 3onoh+#rous #extrose
Properties: Nitro$en sparin$*ner$+ source
I.4 Jcal/$
'+perosmolar
Cecommen#e# intake:
& 6 m$/k$/min
65"@6K of total calories
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3acronutrients: aroh+#rate
Potential Adverse Effects:
9ncrease# minute -entilation
9ncrease# pro#uction 9ncrease# CL
9ncrease# consumption
Bipo$enesis an# li-er prolems'+per$l+cemia
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3acronutrients: mino ci#s
2ource: r+stalline amino aci#sMstan#ar# or specialt+
Properties: 4.5 Jcal/$
* 45&65K N* 65" @5K
Glutamine / +steine
Cecommen#e# intake:
5.A".5 $/k$/#a+
16"5K of total calories
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3acronutrients: mino ci#s
Potential Adverse
Effects:
9ncrease# renal solute
loa#
;otemia
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3acronutrients: mino ci#s
2peciali;e# mino ci# 2olutions
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3acronutrients: Bipi# 2ource: 2afflower an#/or so+ean oil
Properties: Bon$ chain tri$l+ceri#es
9sotonic or h+potonic
2taili;e# emulsions
15 Jcals/$
Pre-ents essential fatt+ aci#
#eficienc+
Cecommen#e# intake:5.6 & 1.6 $/k$/#a+ (not > $/k$)
1 & 4 hour infusion rate
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3acronutrients: Bipi#s
Ce=uirements
4K to 15K kcals $i-en as lipi# meets *
re=uirements0 or K to 4K kcals $i-en as linoleic
aci#
Generall+ 655 mB of 15K fat emulsion $i-en two
times weekl+ or 655 mB of 5K lipi#s $i-en once
weekl+ will pre-ent *D sual ran$e 6K to I6K of total kcals
3ax. @5K of kcal or $ fat/k$
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3acronutrients: Bipi#s
Potential Adverse Effects:
*$$ aller$+
'+pertri$l+ceri#emiaDecrease# cell"me#iate# immunit+ (limit to
1 $/k$/#a+ in criticall+ ill
immunosuppresse# patients)normal Bs
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Parenteral
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ther Ce=uirements
lui#MI5 to 65 ml/k$ (1.6 to IB/#a+)
& 2terile water is a##e# to PN a#mixtureto meet flui# re=uirements
*lectrol+tes
& se acetate or chlori#e forms to
mana$e metaolic aci#osis or alkalosis Fitamins: multi-itamin formulations
race elements
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*lectrol+tes/Fitamins/race
*lements
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#ult Parenteral 3ulti-itamins
New D re=uirements pulishe# in 555replacin$ NG"3 $ui#elines
9ncrease#
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Parenteral Nutrition Fitamin
Gui#elinesFitamin DGui#elinesO
9 II55 9
D 9 55 9
* 9 15 9
Jmc$ 165 mc$
m$ 55
olate mc$ @55
Niacin m$ 45
Fitamin DGui#elinesO
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Dail+ race *lement
2upplementation for #ult PN
C* *B*3*N 9NJ*
hromium 15"16 mc$
opper 5.I"5.6 m$
3an$anese @5"155 mc$
inc .6"6.5 m$
2P*N: 2afe practices for parenteral nutrition formulations. ?P*N () 47, 177A
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Dail+ *lectrol+te Ce=uirements
#ult PN*lectrol+te PN *=ui-
CD2tan#ar# 9ntake
alcium 15 m*= 15"16 m*=
3a$nesium 15 m*= A"5 m*=
Phosphate I5 mmol 5"45 mmol
2o#ium N/ 1" m*=/k$ Q replacement
Potassium N/ 1" m*=/k$
cetate N/ s nee#e# for aci#"ase
hlori#e N/ s nee#e# for aci#"ase
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PN ontaminants
omponents of PN formulations ha-e eenfoun# to e contaminate# with traceelements
3ost common contaminants are aluminuman# man$anese
luminum toxicit+ a prolem in pts with
renal compromise on lon$"term PN an# ininfants an# neonates
an cause osteopenia in lon$ term a#ult PNpatients
2P*N Nutrition 2upport Practice 3anual 5560 p. 157
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PN ontaminants
D re=uires #isclosure of aluminum
content of PN components
2afe intake of aluminum in PN is set at 6
mc$/k$/#a+
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PN ontaminants
3an$anese toxicit+ has een reporte# inlon$ term home PN patients
3a+ lea# to neurolo$ical s+mptoms
3an$anese concentrations of A to mc$/#ail+ -olume ha-e een reporte# in
formulations with no a##e# man$anese
3a+ nee# to switch to sin$le"unit traceelements that #onRt inclu#e man$anese
2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"
77
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alculatin$ Nutrient Nee#s
Pro-i#e a#e=uate calories so protein is
not use# as an ener$+ source
-oi# excess kcal (>I6 kcal/k$)
Determine ener$+ an# protein nee#s
usin$ usual metho#s (kcals/k$, 9reton"
?ones 177, 'arris"
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Protein Ce=uirements
1. to 1.6 $ protein/k$
9
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Peripheral Parenteral Nutrition
'+perosmolar solutions causethromophleitis in peripheral -eins
Bimite# to A55 to 755 msm/k$ (3'2uses 1165 msm/k$ w/ lipi# in thesolution)
Dextrose limite# to 6"15K finalconcentration an# amino aci#s IK final
concentration *lectrol+tes ma+ also e limite#
se lipi# to protect -eins an# increase
calories
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Peripheral Parenteral Nutrition
New catheters allow lon$er support -ia
this metho#
9n a#ults, re=uires lar$e flui# -olumes to #eli-er
a#e=uate nutrition support (.6"IB) 3a+ e appropriate in mil# to mo#erate
malnutrition (555 kcal re=uire# or 14 #a+s)
3ore commonl+ use# in infants an# chil#ren ontro-ersial
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ontrain#ications to Peripheral
Parenteral Nutrition2i$nificant malnutrition2e-ere metaolic stress
Bar$e nutrition or electrol+te nee#s(potassium is a stron$ -ascular irritant)
lui# restriction
Nee# for prolon$e# PN (> weeks)Cenal or li-er compromise
rom 3irtallo. 9n 2P*N, he 2cience an# Practice of Nutrition 2upport: ase"
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ompoun#in$ 3etho#s
otal nutrient a#mixture (N) or I"in"1&Dextrose, amino aci#s, lipi#, a##iti-es are
mixe# to$ether in one container
&Bipi# is pro-i#e# as part of the PN mixture on a#ail+ asis an# ecomes an important ener$+sustrate
"in"1 solution of #extrose, amino aci#s,
a##iti-es&+picall+ compoun#e# in 1"liter a$s
&Bipi# is #eli-ere# as pi$$+ack #ail+ or
intermittentl+ as a source of *
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#-anta$es of N
Decrease# nursin$ time
Decrease# risk of touch contamination
Decrease# pharmac+ prep time
ost sa-in$s
*asier a#ministration in home PN
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Disa#-anta$es of N
Diminishe# stailit+ an# compatiilit+
9F* (9F fat emulsions) limits the amount
of nutrients that can e compoun#e#
Bimite# -isual inspection of N0 re#uce#
ailit+ to #etect precipitates
2P*N Nutrition 2upport Practice 3anual 5560 p.
7A"77
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wo"in"ne PN
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PN ompoun#in$ 3achines:
utomix
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PN ompoun#in$ 3achines:
3icromix
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PN 2olution omponentsa
entral Peripheral
"""2olutions""" 2olutions
Bipi#" Dextrose"
ase# ase#
Dextrose 14.6K I6.5K 15.5K
mino ci#s 6.6K 6.5K 4.6K
at 6.5K 65 ml/ I.5 " A.5K 5K fat =
3,haK inal oncentration ourtes+ of 3arian, 3?.
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9nitiation of PN
#ults shoul# e hemo#+namicall+ stale,ale to tolerate the flui# -olume necessar+to #eli-er si$nificant support, an# ha-e
central -enous access 9f central access is not a-ailale, PPN
shoul# e consi#ere# (more commonl+ use#in neonatal an# pe#s population)
2tart slowl+(1 B 1st #a+0 B n# #a+)
2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"77
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9nitiation of PN: formulation
s protein associate# with few metaolicsi#e effects, maximum amount of proteincan e $i-en on the first #a+, up to @5"85$rams/liter
3aximum ' $i-en first #a+ 165"55$/#a+ or a 16"5K final #extroseconcentration
9n pts with $lucose intolerance, 155"165 $#extrose or 15"16K $lucose concentrationma+ e $i-en initiall+
2P*N Nutrition 2upport Practice 3anual 5560 p. 7A"77
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9nitiation of PN: ormulation
Generall+ ener$+ an# protein nee#s can e
met in a#ults + #a+ or I
9n neonates an# pe#s, time to reach full
support relates in-ersel+ to a$e, ma+ e I"6
#a+s
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9nitiation of PN: ormulation
Dextrose content of PN can e increase# if
capillar+ loo# $lucose le-els are
consistentl+ 1A5 m$/#B
9F* in PN can e increase# if tri$l+ceri#es
are 455 m$/#B
2P*N Nutrition 2upport Practice 3anual 5560 p. 157
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PN #ministration:ransition to
*nteral ee#in$s in #ultsontro-ersial
9n a#ults recei-in$ oral or enteral nutrition
sufficient to maintain loo# $lucose, no
nee# to taper PN
Ce#uce rate + half e-er+ 1 to hrs
or switch to 15K #extrose 9F) ma+ pre-ent
reoun# h+po$l+cemia (not necessar+ inPPN)
3onitor loo# $lucose le-els I5"@5 minutes
after cessation
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PN #ministration:ransition to
*nteral ee#in$s in Pe#iatricsGenerall+ tapere# more slowl+ than in
a#ults as oral or enteral fee#in$s are
intro#uce# an# a#-ance#
Generall+ PN is continue# until 86"A5K of
ener$+ nee#s are met enterall+
2P*N Nutrition 2upport Practice 3anual 5560 p. 157
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3e#ications hat 3a+
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Parenteral Nutrition
9nfusion 2che#ules
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9nfusion 2che#ules
ontinuous PN
Non"interrupte# infusion of a PN solution o-er 4
hours -ia a central or peripheral -enous access
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ontinuous PN
#-anta$es
ell tolerate# + most patients
Ce=uires less manipulationecrease# nursin$ time
ecrease# potential for !touch% contamination
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ontinuous PN
Disa#-anta$es
Persistent anaolic state
&altere# insulin : $luca$on ratios
&increase# lipi# stora$e + the li-er
Ce#uces moilit+ in amulator+ patients
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9nfusion 2che#ules
+clic PN&he intermittent a#ministration of PN -ia a
central or peripheral -enous access, usuall+
o-er a perio# of 1 & 1A hours
&Patients on continuous therap+ ma+ e
con-erte# to c+clic PN o-er 4"4A hours
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+clic PN
#-anta$es
&pproximates normal ph+siolo$+ of
intermittent fee#in$
&3aintains:S Nitro$en alance
S Fisceral proteins
&9#eal for amulator+ patientsS llows normal acti-it+
S 9mpro-es =ualit+ of life
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+clic PN
Disa#-anta$es
&9ncorporation of N4into muscle stores ma+ e
suoptimal
S Nutrients a#ministere# when patient is less acti-e
&Not tolerate# + criticall+ ill patients
&Ce=uires more nursin$ manipulation
S 9ncrease# potential for touch contaminationS 9ncrease# nursin$ time
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Parenteral Nutrition
'ome PN
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'ome PN
2afet+ an# efficac+
depend on:
&Proper selection of patients
e=uate #ischar$e plannin$/e#ucation
&'ome monitorin$ protocols
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'ome PN
Patient selection
&Ceasonale life expectanc+
&Demonstrates moti-ation, competence,
compliance
&'ome en-ironment con#uci-e to sterile
techni=ue
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'ome PN: Dischar$e Plannin$
Determination whether patient meets pa+er
criteria for PN0 completion of 3N forms
9#entification of home care pro-i#er an#
D3* supplier
9#entification of monitorin$ team for home
on-ersion of 4"hour infusion sche#ule to
c+clic infusion with monitorin$ of patient
response
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'ome PN
ost effecti-e
&Luicker #ischar$e from hospital
&9mpro-e# rehailitation in the home&Ce#uce# hospital rea#missions
9 #i i f PN i
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ommon 9n#ications for PN in
Pe#s2ur$ical G9 #isor#ers
9ntractale #iarrhea of infanc+
2hort owel s+n#rome
9nflammator+ owel #isease
9ntractale ch+lothorax
9ntensi-e cancer treatment
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Pe#iatric *ner$+ Nee#s in PN
No consensus exists as to how to #etermineener$+ nee#s of hospitali;e# chil#ren
CDs are inten#e# for health+ chil#ren ut
can use for health+/acutel+ ill chil#ren an#monitor response
an estimate C** usin$ ' e=uation an#
a## stress factors, monitor clinical course 9n#irect calorimetr+ recommen#e# in
#ifficult cases
CDs for *ner$+ an# Protein
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CDs for *ner$+ an# Protein
ate$or+ $e (+r) *ner$+
(kcal/k$/#)
Protein
($/k$/#)
9nfants 5.5"5.6 15A .
hil#ren 1"I 15 1.
4"@ 75 1.18"15 85 1.5
emales 11"14 48 1.5
16"1A 45 5.A3ales 11"14 44 1.5
16"1A 46 5.7
Cecommen#e# Dietar+ llowances, 15
th
e#. 17A7. National ca#em+ Press,ashin$ton, D
' * ti t #i t C**
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' *=uations to pre#ict C**
from o#+ wei$ht
2ex/$e Can$e (+ears) *=uation to Deri-e C**(kcal/#)
3ales 5"I (@5.5 x wt) & 643ales I"15 (.8 x wt) Q 476
3ales 15"1A (18.6 x wt) Q @61
emales 5"I (@.1 x wt) & 61
emales I"15 (.6 x wt) Q 477
emales 15"1A (1. x wt) Q 84@
9 ' C** t
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9ncrease ' C** + stress
factorse-er 9ncrease 1IK per #e$ree
ar#iac ailure 16"6K
raumatic 9nEur+ 5"I5K
2e-ere respirator+#istress or roncho"
pulmonar+ #+splasia
6"I5K
2e-ere sepsis 46"65
lson, D. Pe#iatric Parenteral Nutrition. 9n 2harpenin$ +our skills as a nutrition support
#ietitian. DN2, 55I.
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rauma/riticall+ 9ll Pe#s
$e in +ears Jcals/k$ G/pro/k$
5"1 75"15 .5"I.6
1"@ 86"75 1.A"I.5
8"1 65"86 1.6".6
1I"1A I5"@5 1.5".5
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Pe#iatric PN: lui#s
2tan#ar# calculation:
&155 kcal/k$ for infant I"15 k$
&1555 kcal Q 65 kcal/k$ for e-er+ k$ o-er 15 k$
for a chil# 15"5 k$
&1655 kcal Q 5 kcal/k$ for e-er+ k$ o-er 5 k$
for a chil# o-er 5 k$
&1 mB flui#/kcal/# Q a#Eustments for fe-er,#iarrhea, stress, etc.
2P*N
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Pe#iatric PN: aroh+#rate
aroh+#rate shoul# comprise 46"65K of
caloric intake in infants an# chil#ren ()
or neonates, ' #eli-er+ in PN shoul#
e$in at @"A m$/k$/minute of #extrose an#
a#-ance# to 15"14 m$/k$/minute. (
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Pe#iatric PN: Bipi#
Preterm: start at .6 $/k$/#a+ an# increase + .6$/k$= #a+
9nfants: 2tart at 1 $/k$ an# increase + .6 $/k$/#a+
until the maximum or #esire# #ose is reache#0nee# 5.6 to 1 $/k$/#a+ for * nee#s
3aximum is I $/k$ for 4 months ol# an#.6$/k$ for 4 months an# ol#er
Dail+ *lectrol+te an# 3ineral
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Dail+ *lectrol+te an# 3ineral
Ce=uirements for Pe#s PtsElectrolyte Infants/Children Adolescents
2o#ium "@ m*=/k$ 9n#i-i#uali;e#
hlori#e "6 m*=/k$ 9n#i-i#uali;e#
Potassium "I m*=/k$ 9n#i-i#uali;e#
alcium 1".6 m*=/k$ 15"5 m*=
Phosphorus 5.6"1 mmol/k$ 15"45 mmol
3a$nesium 5.I"5.6 m*=/k$ 15"I5 m*=
National #-isor+ Group. 2afe practices for parenteral nutrition formulations ?P*N 177A0:47"@@
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Document in hart
+pe of fee#in$ formula an# tue
3etho# (olus, #rip, pump)
Cate an# water flush 9ntake ener$+ an# protein
olerance, complications, an#
correcti-e actionsPatient e#ucation