Parenteral Formulas

Clinical Nutrition
Chapter 21

Parenteral Nutrition
1.
2.
3.
4.
5.

Costly
Liver dysfunction
Progressive kidney problems
Bone disorders
Many nutrient deficiencies

Indications for Parenteral

Support
Patients with:
Short bowel syndrome
Severe pancreatitis
Malabsorption disorders
Intestinal obstructions or fistulas
Major trauma or burns
Critical illness or wasting disorders

Indications for Parenteral

Support
Patients:
Who have undergone bone marrow
transplants
Who are malnourished and have high risk
of aspiration

Indications for Parenteral

Support
Peripheral parenteral nutrition (PPN)
Osmolarity - limited to 900 milliosmoles per
liter
Used for short-term nutrition support
(7-10 days) and for clients who do not have
high nutrient needs or fluid restrictions

Indications for Parenteral

Support
Total Parenteral Nutrition (TPN)
Uses larger, central veins
Volume is greater and nutrient concentrations
are not limited

Accessing Central Veins for

Total Parenteral Nutrition

Parenteral Nutrients
Amino acids
3.5 15%
4 kcalories per gram
A 10% amino acid solution 10 grams amino
acids per 100 mL
Disease specific solutions for patients with:
liver disease, kidney failure and metabolic
stress

Parenteral Nutrients
Carbohydrate
2.5 70%
3.4 kcalories per gram
Concentrations > 10% - administered through
central lines

Parenteral Nutrients
Lipids
Often contain triglycerides from soybean oil
and safflower oil, phospholipids
Lipid emulsions available in 10, 20, 30%
solutions
Often provided daily
May provide 20-30% of total kcalories

Parenteral Nutrients
Lipids
As an energy source, reduces the need for
energy from dextrose.
Lowers the risk of hyperglycemia in glucoseintolerant patients.
Need to be restricted in patients with
hypertriglyceridemia.
Concern about excessive linoleic content may
suppress immune response.

Parenteral Nutrients
Fluids and electrolytes
3040 mL/kg - daily young adults
30 mL/kg daily older adults
Sodium, potassium, chloride, calcium,
magnesium, and phosphorus
Daily lab tests to monitor electrolyte status

Parenteral Nutrients
Vitamins and trace minerals
Multivitamin and trace minerals added
Vitamin K often omitted added separately
Iron excluded alters stability of other
ingredients given by injection

Parenteral Nutrients
Osmolarity
PPN 900 milliosmoles / liter
TPN as nutrient dense as necessary
Amino acids, dextrose and electrolytes
contribute most to the osmolarity

Medications
May be added directly or by piggyback insulin,
heparin

Formula Preparation
Depends on patients:
Medical condition
Nutritional status
PPN or TPN

Total nutrient admixture

3-in-one, all-in-one
Dextrose, amino acids, lipids

Formula Preparation
2-in-one solution
Dextrose, amino acids

Careful attention to solution preparation and

handling
Prepared in pharmacy under aseptic conditions
Shielded from light
Refrigerated

Administering
Parenteral
Nutrition
Nutrition
support
team

Insertion and Care of

Intravenous Catheters
Catheter problems include:
Improper positioning
Dislodgement after placement
Phlebitis in peripheral veins
Clogging
Blood clot
Scar tissue around catheter tip

Insertion and Care of

Intravenous Catheters
Catheters are a leading cause of infection
insertion, at placement site or from
contaminated solutions
Redness or swelling around catheter site
Unexplained fever

Administration of Parenteral
Solutions
Start at a slow rate
Gradually increase over a two- to three
day period
1 liter on first day
Increase by one liter per day until goal
reached

Administration of Parenteral
Solutions
May begin full volume of diluted solution
on first day
Chance of hypoglycemia

Continuous parenteral nutrition

Cyclic parenteral nutrition

Managing Metabolic
Complications
Hyperglycemia
Occurs in patients who are glucose-intolerant
Occurs in in patients who are undergoing
stress
Prevented by providing insulin
Limiting dextrose content of solutions
Premature infants at risk pancreas and liver
not fully functioning

Managing Metabolic
Complications
Hypoglycemia
Occurs when feedings are interrupted or
discontinued
Young infants at risk taper feedings off
over several hours

Managing Metabolic
Complications
Hypertriglyceridemia
May occur in critically ill patients
May result from excessive carbohydrate
feedings or severe infection
If blood triglyceride levels exceed 350 to 400
milligrams/deciliter lipid infusion is reduced or
stopped

Managing Metabolic
Complications
Refeeding syndrome
Occurs when severely malnourished patients are fed
aggressively
Characterized by electrolyte and fluid imbalances and
hyperglycemia
Promotes anabolic processes that quickly remove
phosphate, potassium and magnesium
Leads to fluid retention and changes in organ systems

Prevented by starting feedings slowly and monitoring

electrolyte levels

Managing Metabolic
Complications
Abnormalities in liver function
Fatty liver often results
Monitor serum levels of liver enzymes
Usually readily reversed when parenteral feedings
discontinued
May become chronic irreversible liver disease when
parenteral nutrition is continued long-term - lead to
liver failure

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Managing Metabolic
Complications
Gallbladder disease
Sludge often builds up in gallbladder if
parenteral nutrition >4 weeks
May eventually lead to gallstones
May be given chlecystokinin injections or
have gallbladder removed surgically

Managing Metabolic
Complications
Metabolic bone disease
Decrease bone density and mineralization
May alter calcium, phosphorus, and Vitamin D
metabolism
May alter function of parathyroid gland
causing disruptions in bone metabolism

Discontinuing intravenous
feedings
Transitional feedings
Taper off parenteral feedings as tube feedings
or oral feedings are begun
Small enteral feedings given at first to assess
tolerance
If nausea, vomiting, bloating or diarrhea
develop give enteral feedings more slowly

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Discontinuing intravenous
feedings
Transitional feedings
May use progression diet, see Chapter 18.
Patients appetite may be suppressed for
several weeks after termination of parenteral
feedings
Patients may have better appetites during the
day if they are given nocturnal cyclic feedings
before beginning oral intakes

Quality of Life Issues

Lifestyle adjustments required
Economic impact of nutrition support
Demands of home feedings
Time-consuming
Inconvenient

Disturbed sleep
Social issues
Health practitioners should be ready to
recommend support groups or counseling
resources to help patients cope with ongoing
stresses.

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