1. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company CHAPTER 12 Parenteral Nutrition

2. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Concepts of Parenteral Nutrition  Nutritional deficiencies  Energy for essential metabolic processes  “Malnutrition is defined as an acute, sub-acute or chronic state of nutrition, in which a combination of varying degrees of over- nutrition or under-nutrition with or without inflammatory activity had led a change in body composition and diminished function” (ASPEN, 2012).  Malnutrition  Marasmus  Kwashiorkor  Mixed malnutrition

3. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Nutrition Screening  Assessment  Anthropometric measurements  Biochemical assessment  Energy requirements  Physical examination  Other indices

4. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Nutritional Requirements: Adults  Protein/amino acids  Carbohydrates  Fats/lipids  Electrolytes  Vitamins  Trace elements

5. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Delivery of Parenteral Nutrition  Parenteral nutrition candidates  Patients with gastrointestinal disturbances affecting absorption of nutrients  Cardiac patients  Pediatric patients  Patients with anorexia (variety of reasons)  Patients with cancer  Trauma patients (burns)

6. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Modalities for Delivery of Parenteral Nutrition  Enteral nutrition  Peripheral parenteral nutrition (PPN)  Total parenteral nutrition (2 in 1)  Total nutrient admixtures (3 in 1)  Cyclic therapy  Specialized parenteral formulas

7. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Peripheral Parenteral Nutrition  Used to nourish patients who either are already malnourished or have the potential for developing malnutrition and who are not candidates for enteral nutrition (Source: ASPEN, 2002 )  “Nitrogen-sparing” therapy  Osmolarity <600 mOsm/L  Dextrose must be 10% final concentration

8. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Peripheral Parenteral Nutrition (continued)  Advantages  Avoids insertion and maintenance of a central line  Delivers less hypertonic solutions  Reduces the chance of metabolic complications  Increases calorie source, along with fat emulsions  Disadvantages  Cannot be used in severely nutritionally depleted patients  Cannot be used in volume- restricted patients  Does not usually increase a patient’s weight  Risk for phlebitis

9. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Parenteral Nutrition  Two-in-one admixtures: dextrose and amino acids  Must have central venous access  Reverses starvation and adequately achieves tissue synthesis, repair, and growth  High mOsm/kg can be administered

10. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Total Parenteral Nutrition  Advantages  Dextrose solution of 20% to 70% can be administered  Beneficial for long-term use  Useful for patients with large caloric and nutrient needs  Provides calories; restores nitrogen balance; replaces essential vitamins, electrolytes, and minerals  Promotes tissue synthesis  Allows bowel to rest and heal  Improves tolerance to surgery  Disadvantages  May require a minor surgical procedure for insertion of central line  May cause metabolic complications  Risk for pneumothorax during insertion  Radiographic verification of tip placement of central line needed  Full barrier precautions when inserting catheter

11. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Total Nutrient Admixture (TNA)  Three-in-one solutions of dextrose, amino acids, and fat emulsions in one bag  Infuses over 24 hours, then change bag  Pharmacy admixing  Administer through 1.2-μm filter because of fat emulsion  Risk for catheter occlusions from fat deposits

12. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company TNA (continued)  Advantages  Same as for t otal parenteral nutrition ( TPN)  Cost effective  Nursing time saved  Disadvantages  Same as for TPN  Increased risk for bacterial and Candida infections because of lipid emulsions  Must use 1.2-μm filter  Catheter occlusion

13. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Cyclic Parenteral Nutrition  Cyclic parenteral nutrition is usually infused over a 12- to 18-hour period versus 24 continuous hours  Often infused while patient is sleeping  Risk for sepsis-associated central line increases because of increased manipulation of line

14. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Cyclic Total Parenteral Nutrition (C-TPN)  Advantages  Prevents or treats hepatoxicity induced by continuous TPN  Prevents or treats essential fatty acid deficiency  Improves quality of life by encouraging normal daytime routines  Disadvantages  Must observe for symptoms of hypoglycemia and dehydration  Sepsis associated with central line manipulation  Hyperglycemia during peak C-TPN flow rate

15. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Key Points in Parenteral Nutrition Administration  Thorough assessments before initiation of parenteral nutrition (PN)  Ascertain correct placement of central line with radiographic verification  Strict attention to sterile technique  Use appropriate hand hygiene  Maintain central line patency and dressing per agency protocols  Check the peripheral PN (PPN) or PN solution to ensure correct nutrients are included as ordered  Maintain sterile technique when manipulating solution or administration set  Check vital signs every 6 hours  Monitor blood sugar every 6 hours  Maintain strict intake and outtake  Daily serial weights  Keep infusion within 10% of prescribed rate

16. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Key Points in Parenteral Nutrition Administration (continued)  Initially, PN should be started slowly, increasing at a rate of 25-mL/hr increments until desired rate of infusion is achieved.  Container of PN must not infuse beyond a 24-hour period.  Use electronic infusion device for delivery of PN.  Change administration sets every 72 hours for two-in-one admixtures, every 24 hours for TNA.  Avoid rapidly replacing lagged PN solutions.  Administer insulin as ordered to maintain serum glucose in the designated range.  Report to physician abnormal signs and symptoms associated with therapy.  Use central line bundle for insertion and maintenance of central venous catheter.

17. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Key Points in Parenteral Nutrition Administration (continued)  Use of a 0.22-μm filter inline for PN, 1.2 μm whenever fat emulsions are delivered  Sterile dressing should be done every 48 to 72 hours if nontransparent occlusive dressing is used; every 4 to 7 days with transparent dressing  Observe for signs and symptoms of hypophosphatemia, hypokalemia, hypomagnesemia, and hypernatremia

18. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Specialized Parenteral Formulas  Renal formulas  Hepatic formulas  Stress formulas

19. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Nutritional Complications  Mechanical or technical complications (catheter related)  Infectious and septic complications  Catheter-related sepsis

20. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Complications (continued)  Metabolic complications  Altered glucose metabolism: rebound hypoglycemia  Altered glucose metabolism: hyperglycemia  Essential fatty acid deficiency  Hyperammonemia  Electrolyte imbalances

21. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Complications (continued)  Nutrition altered  Refeeding syndrome  Essential fatty acid deficiency  Altered vitamin and trace element balance

22. Manual of I.V. Therapeutics, 6 th Edition Copyright F.A. Davis Company Copyright © 2014. F.A. Davis Company Discontinuation of Parenteral Nutrition  Before discontinuation of parenteral (PN) or enteral nutritional support, one of the following criteria should be applicable:  PN should not be discontinued until nutrient requirements can be met by enteral or oral nutrients.  Enteral nutrition should not be discontinued until nutrient requirements can be met by oral nutrients.  PN or enteral nutrition support should be discontinued whenever the patient’s medical condition indicates.  Parenteral or central nutrition support should be terminated when the physician judges that the patient no longer benefits from therapy. Note: Decision to stop PN must be made according to accepted community standards of medical care and in compliance with applicable law.