Parenteral Nutrition

Nutrition support team

DR.dr. I Wayan Suranadi,
spAnKIC
Bag. Anestesiologi Intensive
Care Managemen Nyeri

While we are terribly

hungry, its horrible
watching others eat when
we can not

 ....................but if not, dont starve

the patient cause theyll canibalize
themself that can kill them, so
how?

Put the food

intravenously

Vein systems make parenteral

nutrition possible

If not nutritionize

Dont starved anyone

What is PN
IV administration calories, nitrogen
and all other nutrients in sufficient
quantities to achieve tissue synthesis
and anabolism
Is lifesaving nutrition to provide
healing process
Peripheral Parenteral Nutrition (PPN, PVN)
Central Parenteral Nutrition

Indication
When adequate nutrition cannot be maintained via GIT, due to
non-functioning GI tracts and who are either malnourished or
likely to become so:
Short bowel syndrome
Carcinoma
Severe pancreatitis
Geriatric refuse to eat
Malabsorpsion disorders
Young anorexic patients
Intestinal obstructions or fistulas
Surgical patients who
Major trauma or burns
should not be fed orally
Critical illnesses or wasting
[NPO]
disorders
GIT motility disorder
Bone marrow transplants
Severe vomiting, when
enteral feeding cannot be Being malnourished and having a
high risk of aspiration
tolerated

Parenteral technique as
part of the nutrition
support outside of oral

When to start

PPN
In case of unable to ingest adequate calories
enterally or when central venous nutrition is not
feasible
The vein may damages by indwelling catheter
and the concentrated solution (phlebitis, etc), so
it is not for patients with this risk
Just in limited energy and protein with maximal
900 mOsm/liter
For just short term PN (7 to 10 days), with
lower nutrients needs or without fluid
restriction

The sets

Frequently in superior extremities

Complications

CPN
Using larger or deep vein with greater blood
volume and higher flow
Usually to facilitate total parenteral (TPN)
without limitation on concentration so
complete nutrients demand can be provide
Concentrated nutrients rapidly diluted, so
almost without the risk of phlebitis and lower
risk of fluid overload
For longer period of PN, that can be inserted
pheriperally or centrally

Central Venous Catheter Sites

PICC (Peripherally
inserted
Central Catheter)

Percutaneous(Subclavia
n)

Implanted Port
(single or double
lumen)
Tunnelled (Hickman)

Percutaneous (IJ-Int.
Jugular)

The sets

The solutions

Components of TPN
Dextrose and lipids to provide energy.
70%-85% of calories from dextrose

Protein for tissue synthesis and repair.

15%-30% from lipids.

Osmolarity:
PPN: Maximum of 900 milliosmoles / liter
TPN: as nutrient dense as necessary (>900
m.osmol and up as high as 3000)
Amino acids (10 m.osmol/gm), dextrose (5
m.osmol/gm) and electrolytes (2 m.osmol
/mEq) contribute most to the osmolarity, while
lipids give 1.5 m.osmol/gm.

How much to be given

Defining basal energy requirement

Estimate Basal Energy Expenditure
(BEE): Harris-Benedict equation
For women:
655.1 + (9.56 * weight in kg) + (1.86 * height
in cm) - (4.68 x age)

For men
66.67+ (13.75 x weight in kg) + (5 x height in
cm) - (6.76x age)

Total Daily Expenditure(TDE)

TDE= BEE* Activity*Stress
Activity
BED=1.2
Ambulatory=1.3

Stress:
Surgery: 1.2
Infection: 1.4-1.6
Trauma: 1.3-1.5
Burns: 1.5-2.1

In close estimation
Non-stressed (ambulatory): 30 kcal/kg
Mild stress (malnourished): 35-40
kcal/kg
Severe injury or sepsis- 45-60kcal/kg
Severe burns: up to 80kcal/kg

Energy Requirements
Patient condition

Basal
metabolic rate

Approximate energy Requirement

(kcal/kg/day)

No postoperative
complications, GIT
fistula without infection

Normal

25-30

Mild peritonitis, long-bone

fracture, mild to moderate
injury, malnourished

25% above
normal

30-35

Severe injury or infection

50% above
normal

35-45

Burn 40-100% of total body Up to 100%

surface
above normal

45-80

Individual substrate requirement

Carbohydrates
Hydrous Dextrose (glucose)
Provides

3.4 kcalg-1

L D5W =170 kcal,

1 L D25W = 850 kcal

Final dextrose concentrations

5-10% (peripheral)
35% (central)
D5W=252 mOsmL-1
D25%=1263 mOsmL-1

Lipid
Energy Sources
Triacylglycerols are an important fuel source
even when glucose availability is adequate
They are available in 10, 20 and 30%
preparations
Ideally, energy from fat should not exceed 40% of
the total (usually 20-30%)

Protein
Daily Protein requirements
Condition

Example

requirement

Basic requirements

Normal person

0.5-1g/Kg

Slightly increased
requirements

Post-operative, cancer,
inflammatory

1.5g/Kg

Moderately increased
requirements

Sepsis, polytrauma

2g/Kg

Highly increased
requirements

Peritonitis, burns,

2.5g/Kg

Reduced requirements

Renal failure, hepatic

encephalopathy

0.6g/Kg

Fluids and electrolytes

Nutrient
Water

Requirements (/Kg/day)
20-40 mL (young adult), 30 ml (older)

Sodium
Potassium
Magnesium
Calcium

0.5-1.0 mmol
0.5-1.0 mmol
0.1-0.2 mmol
0.05-0.15mmol

Phosphate
Chloride/Acetate

0.2-0.5mmol
So a to maintain acid-base balance (normally
0.5 mmol for Cl- , & 0.1mEq for Acetate)

Trace minerals
Mineral

Recommended dietary
allowance (RDA) for daily
oral intake (mg)

Suggested daily
intravenous intake
(mg)

Zinc

15

2.5-5

Copper

2-3

0.5-1.5

Manganese

2.5-5

0.15-0.8

Chromium

0.05-0.2

0.01-0.015

Iron

10 (males)-18 (females)

Vitamins
Vitamins are either fat soluble (A,D,E,K) or
water soluble (B,C) or multivitamin in soluble
preparation
Multivitamin formulations for parenteral use
for adult patients usually contain 12 vitamins
at levels estimated to provide daily
requirements

Potential complication of
parenteral nutrition
Catheter related Metabolic
Air embolism
Blood clothing at the
catheter tip
Clogging of catheter
Dislodgment of catheter
Improper placement
Infection, sepsis
Phlebitis
Tissue injury

Abnormalities in liver function

Electrolyte imbalance
Gallbladder disease
Hyperglycemia, hypoglycemia
Hypertriglyceridemia
Metabolic bone disease
Nutrient deficiencies
Refeeding syndrome

Formula preparation
Highly individualized refer to their needs
Patients medical condition
Primer illness
Related complications

Nutrition status
Hypercathabolic
Starvation

The line to be chosen

Formula preparation
TNA (3 in 1): all in one solution, where
lipid is included
2-in-1 solution: lipid is separated from
the solution
Aseptic non-pirogenic and stable
Shielded from light
Refrigerated

How to give
Aseptic principles
Start slowly and be increased gradually
Initially in rate of 25 to 50 mL/h, then increased by
25 mL/h until the predetermined final rate is
achieved (in 2-3 days periods)
Final infusion rate is delivered in proper and stable
continuous way using an infusion pump over 22-24
h/day, or in cyclic fashion overnight aroud 12-16 h

How to monitor