How is parenteral nutrition administered

Patients who should not receive glutamine complementation above what may be present in basal TPN, as referenced by Heyland et al. Total parenteral nutrition administration is through a central venous catheter.

A central venous catheter is an access device that terminates in the superior vena cava or the right atrium and is used to administer nutrition, medication, chemotherapy, etc. Establishing this access could be through a peripheral inserted central catheter PICC , central venous catheter, or an implanted port.

PICC line insertion can be through the basilic, cephalic, brachial, or median cubital vein of the arm. The basilic vein is preferable due to its larger size and superficial location.

The catheter courses through the basilic into the axillary vein, to the subclavian vein, to settle in the superior vena cava. The insertion of central venous catheters can be through one of the large three central veins: femoral vein, subclavian vein, and internal jugular vein. Central venous catheters are used when administering TPN for several months to years.

An implanted port is a device that is implanted under the skin in the chest with an attached catheter inserted into the superior vena cava. Implantable ports are used when administering TPN for years. Total parenteral nutrition is not administered through a peripheral intravenous catheter Peripheral Parenteral Nutrition, PPN because it has high osmolarity.

PPN osmolarity needs to be less than mOsm. The lower concentration necessitates larger volume feedings, and high-fat content is necessary. High osmolarity irritates peripheral veins; hence TPN is given through central venous access. PPN is used to provide additional nutrition to patients with functional gut and enteral feedings.

The main adverse effects can be due to metabolic abnormalities, infection risk, or venous access associated. According to Maudar , TPN is generally contraindicated in the following conditions:.

Per Maudar , several variables require monitoring while on TPN [5] :. Generally, the toxicity of TPN is related to the individual toxicity of its components. Increased caloric amounts due to TPN glucose and lipid excess can lead to hepatic toxicity; this risk can decrease by using decreased glucose content and greater lipid content.

Parenteral nutrition supplementation rather than total parenteral nutrition is harmful to pediatric patients in the pediatric intensive care unit PICU. Parenteral nutrition supplementation should be withheld in the first week in the PICU independent of age or nutritional status; this is because amino acids in the PN suppress the autophagy process needed for cellular damage removal.

Excess amino acids a shuttled to urea production. Increased urea levels can pose harm to the kidney and liver. Long term usage of TPN ranging from weeks to months can be associated with the rare complication of manganese toxicity. Manganese exposure via TPN is characterized by high bioavailability due to bypassing the GI tract regulatory mechanisms.

This high concentration of manganese over time leads to its deposition in the liver, brain, and bone. However, the brain is most likely to be affected as manganese will deposit and affect the globus pallidus and striatum of the basal ganglia. Manganese preferentially affects dopaminergic neurons in the basal ganglia resulting in extrapyramidal symptoms that present in a similar way to Parkinson disease. Idiopathic Parkinson disease can be differentiated based on the location of neurons affected, i.

Managing the administration of TPN need s a well-coordinated health care team with an interprofessional approach. The clinician determines the treatment and the form of needed nutrition. The clinician coordinates care with the patient's primary health care team. The pharmacist provides sterile parenteral nutrition. The dietician assesses the nutritional status of the patient, calculates the daily requirement, and designs the feeding regiment.

Parenteral nutrition PN , the provision of nutrients via the intravenous IV route, is in some cases a life-saving therapy in patients who are unable to tolerate oral or tube feedings for prolonged periods. The development of a bedside technique for accessing a large vein e. Indications PN is commonly used in such conditions as severe pancreatitis, short-bowel syndrome, inflammatory bowel disease exacerbations, and gastrointestinal GI fistulae, as well as in critically ill patients, infants with very low birth weight, and patients with cancer receiving hematopoietic cell transplantation.

Both PN and EN should be delayed until patients are hemodynamically stable i. Few data support improved outcomes in patients receiving short-duration PN. Current guidelines from the American Society for Parenteral and Enteral Nutrition state that SNS, with a preference for EN, should be initiated when oral intake has been or is expected to be inadequate for seven to 14 days. Access Devices For short-term CPN in the hospital, a temporary central venous catheter is placed percutaneously into the subclavian vein by a physician at the bedside, with the catheter tip at the superior vena cava adjacent to the right atrium.

With more permanent devices, such as the Hickman catheter or Port-a-Cath, the injection port may be external or completely beneath the skin, respectively. A peripherally inserted central catheter PICC is another central venous access device that can be placed by specially trained nurses at the bedside. The device is usually inserted into the basilic vein on the inside of the elbow and threaded so that the tip of the catheter rests at the superior vena cava.

A midline catheter i. A patient's fluid load must also be considered when PN is administered. Protein is provided as crystalline amino acid solutions. These manufacturers also provide amino acid formulations that are specially designed for young children TABLE 1. Although the amounts of EAA and NEAA in standard products vary slightly between manufacturers, the differences are generally not clinically significant. However, clinically significant differences may exist in the endogenous electrolyte content of various products, most notably in the phosphorus, acetate, and chloride content.

When switching products due to shortages or contract changes, a brief study of electrolyte differences is prudent. Amino acid products are supplied in concentrations from 3. Amino acid formulations are available with or without added electrolytes. Added electrolyte solutions may be useful in institutions where PN use is minimal, as they minimize the number of admixtures necessary.

However, fixed electrolyte content may not be appropriate for many patients, especially those who are critically ill. Products without added electrolytes still contain some electrolytes. Pediatric formulations are commonly used in very young children. Specialty products designed for patients with renal failure, hepatic failure, and high stress are not widely used because they have little proven clinical benefit.

Most experienced nutrition support clinicians prefer to use less expensive standard formulations in these populations. Dextrose is the most common carbohydrate used in PN solutions. Dextrose for IV use provides 3. Manufacturers cannot supply dextrose and amino acid premixed because these products react when heat sterilized.

This product is used as PPN in some institutions. Caloric density of glycerol is 4. Although glycerol may be useful in controlling blood glucose, especially in patients with diabetes, the low concentrations of glycerol and amino acid in ProcalAmine limit its usefulness. Another method used by manufacturers to facilitate the mixture of dextrose and amino acid solutions is provision in dual-chamber bags. To combine dextrose and amino acids, a septum between two chambers is broken and contents are mixed.

There is room to add fat emulsion if desired. These products are supplied with and without added electrolytes. Lipid is supplied in the U. These soybean oil or safflower plus soybean oil—based emulsions primarily contain the long-chain fatty acids linoleic and linolenic acid. These products contain egg yolk phospholipids as emulsifiers and glycerol for tonicity. IV lipid provides 1.

Due to concerns that long-chain triglyceride emulsions used in the U. Micronutrient components of PN solutions include electrolytes, vitamins, and trace minerals. The electrolytes usually present include sodium, potassium, magnesium, calcium, phosphorus, chloride, and acetate. Since these electrolytes are primarily excreted by the kidneys, infused amounts required may be lower in patients with renal insufficiency.

Monitoring for serum electrolytes is useful for guiding the amount of electrolyte placed in PN. It is noteworthy that serum sodium is often not reflective of total body sodium stores, although serial values can be useful for monitoring fluid status. Patients with metabolic alkalosis may benefit from increasing chloride and decreasing acetate in the PN, whereas patients with metabolic acidosis may benefit from the opposite profile of these electrolytes.

Sodium bicarbonate should not be added to PN solutions as an alkalinizing agent because it can interact with calcium to form insoluble calcium carbonate; sodium acetate or potassium acetate should be used instead.

Vitamins are usually added using parenteral multivitamin preparations, which contain 12 or 13 essential vitamins. The number of vitamins in most commercial preparations has recently been reformulated based on FDA guidelines. The mcg amount of phylloquinone in a daily supply is relatively little and should not clinically affect warfarin anticoagulation when administered consistently.

Nevertheless, the international normalized ratio should be monitored closely in patients receiving warfarin in whom PN is being started or discontinued. Shortages of parenteral multivitamins have occurred in recent years; in such instances, the addition of individual vitamin ingredients such as thiamine and folic acid may be important to avoid complications. Zinc, chromium, manganese, and copper are the four trace elements most commonly added to PN solutions.

Selenium is also added, although not as universally for short-term PN patients. Commercially available products containing a combination of trace elements are frequently used.

Some institutions add zinc in quantities beyond those found in commercial mixtures for certain surgical patients. Copper and manganese undergo biliary excretion and can accumulate in patients with severe hepatic disease; they should be omitted in patients with significantly elevated total bilirubin. Aluminum is a contaminant of parenteral additives that can add up to potentially unsafe amounts in neonates and in patients with renal failure.

This has prompted the FDA to require disclosure of aluminum content of many of the parenteral products used in compounding PN. Although iron is not routinely added to PN, the mineral may be added to PN solutions containing dextrose and amino acids, but not to solutions containing lipid emulsion due to stability issues.

Iron dextran is the form of iron most commonly added to PN. Fluid requirements for patients receiving PN should be monitored. Daily weights are useful in hospitalized patients; weight change of more than 0. Other risks include:. Many people experience some improvement in their condition after parenteral nutrition.

You may not be rid of your symptoms, but your body may be able to heal more quickly. This can help you do more in spite of the effects of your condition. A physician or dietitian will reassess your nutritional needs after several weeks of this nutrition program to see if any adjustments need to be made in the dosage.

The results of parenteral nutrition are maintained health and energy levels in your body. You may need this treatment only temporarily. Or you may need to use it for the rest of your life. Your nutritional needs may change with time.

Women over the age of 50 have increased needs for several vitamins and minerals. Here are the 10 best multivitamins for women over Taking certain dietary supplements may be beneficial for lung health. See which vitamins our registered dietitian recommends as the best for…. TPN is also highly common among children and teenagers.

Children who are on TPN may have short bowel syndrome, which results from the malfunctioning of the small intestine and other intestinal diseases like microvillus inclusion disease.

TPN is not only used for young children but is also commonly used for teenagers. However, being on TPN may be most difficult mentally for teenagers since they are highly concerned about their body image.

Hence, it may be especially helpful for teens to get in contact with other teens who are also on TPN by joining support groups. For instance, teenagers and their caregivers can join The Oley Foundation , a national, non-profit organization that provides information, services, and emotional support for people on TPN, their families, and caregivers.

First, TPN is administered through a needle or catheter that is placed in a large vein that goes directly to the heart called a central venous catheter. Since the central venous catheter needs to remain in place to prevent further complications, TPN must be administered in a clean and sterile environment.

For instance, external tubing should be changed every day and dressings should be kept sterile with replacement every two days. TPN is usually used for 10 to 12 hours a day, five to seven times a week. Most TPN patients administer the TPN infusion on a pump during the night for hours so that they are free of administering pumps during the day.

TPN can also be used in both the hospital or at home. However, if TPN is given at home, it is crucial for patients to be given a qualified home nurse in order to better recognize various symptoms of an infection and be taught the correct steps of administering the nutrition.

For example, patients must store their prescribed liquid in a refrigerator and remove each dose from the fridge about five minutes before use. It is also important that progress be followed and monitored by an interdisciplinary nutrition team. In particular, plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Also, other measurements including liver function tests and full nutritional assessments including BMI calculation and Anthropometric measurements should be repeated at 2 weeks intervals.

TPN is beneficial because it provides nutrients that are vital in maintaining high energy, hydration and strength levels. Also, it will allow patients to heal more quickly and feel more energized.

It is especially beneficial for children and teenagers because if these two groups do not get all of the nutrients they need, then they may have developmental or growth delays. However, there are also many risks associated with receiving TPN. The most common risk includes catheter infection with the most serious form resulting in sepsis. Others include blood cots resulting from the line moving out of place. Also, long-term use of TPN may lead to liver disease and bone disease.

Hence, it is crucial for patients receiving TPN to be closely monitored for complications by their health care team.