What Is Parenteral

Nutrition
All people need food to live. Sometimes a person cannot eat any or
enough food because of an illness. The stomach or bowel may not be
working normally, or a person may have had surgery to remove part or all
of these organs. When this occurs, and you are unable to eat, nutrition
must be supplied in a different way. One method is parenteral
nutrition (intravenous nutrition). Below are some basic facts about
parenteral nutrition.

Who Receives Parenteral Nutrition?

People of all ages have received parenteral nutrition. It may be given to
infants and children as well as to adults. People can live very well on
parenteral nutrition for as long as it is needed. Many times, parenteral
nutrition is used for a short time; then it is removed when the person can
begin to eat normally again.
Normal digestion occurs when food is broken down in the stomach and
bowel, then absorbed in the bowel. These absorbed products are carried
by the blood to all parts of the body.
Parenteral nutrition bypasses the normal digestion in the stomach and
bowel. It is a special liquid food mixture given into the blood through an
intravenous (IV) catheter (needle in the vein). The mixture contains
proteins, carbohydrates (sugars), fats, vitamins and minerals (such as
calcium). This special mixture may be called parenteral nutrition and was
once called total parenteral nutrition (TPN), or hyperalimentation.

How Is Parenteral Nutrition Supplied?

A special intravenous (IV) catheter is placed in a large vein in the chest or
arm. It can stay in place for as long as needed. The nurse cares for the
catheter. Proper care is required to avoid infection and clotting. Different
kinds of catheters may be used. Common names of these catheters
are Hickman, Broviac, PICC, triple lumen, double lumen or single
lumen catheters, and ports. Nutrition is given through this large vein.
Your health care team (doctors, nurses, dietitians and pharmacists) can
talk with you about the different types.

http://www.nutritioncare.org/about_clinical_nutrition/what_is_parenteral_nutrition/

Total Parenteral Nutrition

(TPN)
By David R. Thomas, MD

CLICK HERE FOR

Patient Education

NOTE: This is the Professional Version. CONSUMERS: Click here

for the Consumer Version

Nutritional Support

Overview of Nutritional Support

Enteral Tube Nutrition
Total Parenteral Nutrition (TPN)
Nutritional Support for Dying or Severely Demented Patients

Parenteral nutrition is by definition given IV.

Partial parenteral nutrition supplies only part of daily nutritional requirements,
supplementing oral intake. Many hospitalized patients are given dextrose or amino acid
solutions by this method.
Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be
used in the hospital or at home. Because TPN solutions are concentrated and can cause
thrombosis of peripheral veins, a central venous catheter is usually required.
Parenteral nutrition should not be used routinely in patients with an intact GI tract. Compared
with enteral nutrition, it causes more complications, does not preserve GI tract structure and
function as well, and is more expensive.

Indications

TPN may be the only feasible option for patients who do not have a functioning GI tract or who have
disorders requiring complete bowel rest, such as the following:

Some stages of ulcerative colitis

Bowel obstruction

Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless of its
cause)

Short bowel syndrome due to surgery

Nutritional content
TPN requires water (30 to 40 mL/kg/day), energy (30 to 45 kcal/kg/day, depending on energy
expenditure), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty
acids, vitamins, and minerals (see Table: Basic Adult Daily Requirements for Total Parenteral Nutrition).
Children who need TPN may have different fluid requirements and need more energy (up to 120
kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).

Basic Adult Daily Requirements for Total Parenteral Nutrition

Nutrient

Amount

Water (/kg body wt/day)

3040 mL

Energy* (/kg body wt/day)

Medical patient

30 kcal

Postoperative patient

3045 kcal

Hypercatabolic patient

45 kcal

Amino acids (/kg body wt/day)

Medical patient

1.0 g

Nutrient

Amount

Postoperative patient

2.0 g

Hypercatabolic patient

3.0 g

Minerals

Acetate/gluconate

90 mEq

Calcium

15 mEq

Chloride

130 mEq

Chromium

15 mcg

Copper

1.5 mg

Iodine

120 mcg

Magnesium

20 mEq

Manganese

2 mg

Phosphorus

300 mg

Potassium

100 mEq

Selenium

100 mcg

Nutrient

Amount

Sodium

100 mEq

Zinc

5 mg

Vitamins

Ascorbic acid

100 mg

Biotin

60 mcg

Cobalamin

5 mcg

Folate (folic acid)

400 mcg

Niacin

40 mg

Pantothenic acid

15 mg

Pyridoxine

4 mg

Riboflavin

3.6 mg

Thiamin

3 mg

Vitamin A

4000 IU

Vitamin D

400 IU

Nutrient

Amount

Vitamin E

15 mg

Vitamin K

200 mcg

*Requirements for energy increase by 12% per 1 C of fever.

Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard
formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on
laboratory results, underlying disorders, hypermetabolism, or other factors.
Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/min of dextrose is given.
Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other
factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids.
Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20
to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories may
help obese patients mobilize endogenous fat stores, increasing insulin sensitivity.

Solutions
Many solutions are commonly used. Electrolytes can be added to meet the patients needs.
Solutions vary depending on other disorders present and patient age, as for the following:

For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein content
and a high percentage of essential amino acids

For heart or kidney failure: Limited volume (liquid) intake

For respiratory failure: A lipid emulsion that provides most of nonprotein calories to minimize
CO2 production by carbohydrate metabolism

For neonates: Lower dextrose concentrations (17 to 18%)

Beginning TPN administration

Because the central venous catheter needs to remain in place for a long time, strict sterile technique must
be used during insertion and maintenance. The TPN line should not be used for any other purpose. External
tubing should be changed every 24 h with the first bag of the day. In-line filters have not been shown to

decrease complications. Dressings should be kept sterile and are usually changed every 48 h using strict
sterile techniques.
If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and
qualified home nursing must be arranged.
The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the
balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular
insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is
normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular
insulin/L of TPN fluid.

Monitoring
Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should
monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients).
Plasma glucose should be monitored every 6 h until patients and glucose levels become stable. Fluid intake
and output should be monitored continuously. When patients become stable, blood tests can be done much
less often.
Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinolbinding protein), prothrombin time, plasma and urine osmolality, and Ca, Mg, and phosphate should be
measured twice/wk. Changes in transthyretin and retinol-binding protein reflect overall clinical status
rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion.
Full nutritional assessment (including BMI calculation and anthropometric measurementssee Overview
of Undernutrition : Physical examination and Obesity : Body composition analysis) should be repeated at
2-wk intervals.
Clinical Calculator: Body Mass Index (Quetelet's index)

Complications
About 5 to 10% of patients have Professional. complications related to central venous access.
Catheter-related sepsis occurs in probably 50% of patients.
Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients.
Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often,
adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia
can be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on
the degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more
prolonged hypoglycemia may require infusion of 5 or 10% dextrose for 24 h before resuming TPN via the
central venous catheter.
Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can
develop at any age but are most common among infants, particularly premature ones (whose liver is
immature).

Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline
phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result
from excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may
contribute. Progressive fibrosis occasionally develops. Reducing protein delivery may help.

Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be reduced.

Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized

seizures. Argininesupplementation at 0.5 to 1.0 mmol/kg/day can correct it.

If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be necessary.
Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent
infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin
and mineral deficiencies are rare when solutions are given correctly. Elevated BUN may reflect
dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein.
Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy
requirements and thus require large fluid volumes.
Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some
patients given TPN for > 3 mo. The mechanism is unknown. Advanced disease can cause severe
periarticular, lower-extremity, and back pain.
Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back
pain, sweating, dizziness) are 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 hepatomegaly, mild
elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature
infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently
slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions.
Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These
complications can be caused or worsened by prolonged gallbladder stasis. Stimulating contraction by
providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is helpful.
Oral or enteral intake also helps. Treatment with metronidazole, ursodeoxycholic acid, phenobarbital, or
cholecystokinin helps some patients with cholestasis.

Key Points

Consider parenteral nutrition for patients who do not have a functioning GI tract or who have
disorders requiring complete bowel rest.

Calculate requirements for water (30 to 40 mL/kg/day), energy (30 to 45 kcal/kg/day, depending
on energy expenditure), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism),
essential fatty acids, vitamins, and minerals.

Choose a solution based on patient age and organ function status; different solutions are required
for neonates and for patients who have compromised heart, kidney, or lung function.

Use a central venous catheter, with strict sterile technique for insertion and maintenance.

Monitor patients closely for complications (eg, related to central venous access, glucose levels,
electrolyte and mineral levels, hepatic or gallbladder effects, volume, or lipid emulsions).

https://www.merckmanuals.com/professional/nutritional-disorders/nutritionalsupport/total-parenteral-nutrition-tpn
Enteral Nutrition versus Parenteral Nutrition

Reviewed and revised 21 May 2013

OVERVIEW

controversial issue

at present best recommendations are to optimize oral/enteral nutrition, avoid forced

starvation if at all possible, and judiciously use supplemental parenteral nutrition.

data somewhat unclear on empirical outcomes

feed the malnourished and plan to feed those that will be soon

tendency to enterally feed first

use simple goals based on patient size (25kcal/kg/day + 1.5g protein/kg/day)

if EN delivery fails use TPN to complement or replace

control glucose with insulin

give glutamine

ENTERAL NUTRITION

via NGT

some risk may be minimised with PEG, post pyloric feeding or feeding jejunostomy

Advantages

cheaper

simpler

fewer complications

for efficient use of nutrients

stimulates intestinal blood flow

maintain GI mucosal barrier (prevents bacterial translocation and portal

endotoxaemia)

reduced gut associated lymphatoid system (GALT) -> becomes a source of activated
cells and proinflammatory stimulants

prevents disuse atrophy

reduces septic complications compared with TPN

avoids CVL complications

avoids TPN induced immunsuppression (lipid load)

improves healing

improved weaning and recovery

reduced muscle catabolism

Disadvantages

independent risk factor for VAP (microaspiration, decreased with post-pyloric feeding)

sinusitis (N/G)

misplacement into trachea -> aspiration

perforation of oesophagus, pharynx, stomach or bowel

PEG use associated with high 30 day mortality (site infection -> abdominal wall
infection, bowel obstruction)

diarrhoea

metabolic derangement: electrolytes, hyperglycaemia, re-feeding syndrome

intolerance: vomiting, excessive aspirates (200-500mL), abdominal distension,

constipation or diarrhoea

PARENTERAL NUTRITION
Advantages

can be started early

simple

no delay in caloric intake

does not rely of gastric/intestinal function

less need for interruptions

safe and less need for mechanical ventilation and better muscle mass if used early
when relative CI to enteral nutrition (Doig et al 2013 ANZICS trial)

Disadvantages

catheter related: sepsis, occlusion, insertion

hyperglycaemia

hypercholesterolaemia
use fat emulsions with low phospholipid to TG ratio, stop fat infusion, use IV
heparin to increase plasma lipolytic activity, use insulin to increase lipase activity in
adipose tissue

refeeding syndrome

abnormalities in LFTs
?mechanism, may develop steatosis, cholecystitis

hyperchloraemic metabolic acidosis

amino acids have a high Cl- content

low bone mass ?unknown cause

decreased GFR ?unknown cause

http://lifeinthefastlane.com/ccc/enteral-nutrition-versus-parenteral-nutrition/