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Nutrition
Margel Camille Luy-Galagar
Parenteral nutrition is administered outside the
digestive tract, intravenously. This is in contrast to
enteral nutrition, which encompasses oral and
tube feedings into the digestive tract.
The general rule of thumb for deciding whether to
use parenteral or enteral feeding, is "if the gut
works, use it". The GI tract should be used if
possible because it tends to atrophy when not
used. Gut bacteria can translocate to the
circulatory system through an atrophied GI tract
and increase the risk of infection.
Peripheral Parenteral
Nutrition
With peripheral parenteral nutrition (PPN)
nutrients are supplied via a peripheral
vein, usually a vein in the arm. Another
term for PPN is peripheral venous
nutrition (PVN)
Hypertonic Solutions
Peripheral parenteral nutrition feedings usually
supplement enteral feedings. Large amounts of
nutrients cannot be supplied via a peripheral
vein, because these relatively small veins
cannot tolerate the rush of fluid into the vein
that occurs when a hypertonic solution is
introduced into the circulatory system.
Body fluids have an osmolarity of about 300
mOsm. The introduction of a hypertonic
solution into a body compartment will cause an
osmotic gradient, resulting in a fluid shift.
Hypertonic- having a higher osmolality
than the comparison solution.
osmotic gradient- solutions on either side
of a semipermeable membrane.
Osmolarity- The osmolarity of a PPN
solution is an important consideration in
PN solutions. Osmolarity is the number of
dissolved molecules and ions per liter of a
solution.
It may be easier to think of osmolarity as the
number of particles per liter of water.
Hypertonic Solutions
When a hypertonic solution is introduced into a
small vein with a low blood flow, fluid from the
surrounding tissue moves into the vein due to
osmosis. The area can become inflamed, and
thrombosis can occur.
A hypertonic PN solution results in an osmotic
gradient that causes water to enter the blood
vessel, as is illustrated in the picture, where
high concentrations of glucose (green) and
amino acids (yellow) draw water (blue) into a
blood vessel (red).
Osmolarity of
Solutions
Protein and carbohydrate both contribute
to hypertonicity. Fat is isotonic, and can
therefore be administered peripherally.
However, if the patient has delayed lipid
clearance, the use of lipids is
contraindicated.
Infusion of Peripheral
Nutrition
In peripheral PN, the catheter is inserted
into the arm vein of the patient. Up to
1800-2500 kcal and 90g protein can be
supplied via peripheral parenteral
nutrition. However, this relatively high
kcalorie/protein amount can be
supported peripherally only for a short
period of time.
Recommended Rates
IBW Infusion rate (cc/hr)
40 60-80
50 75-100
70 100-140
80 120-160
90 130-170
Total Parenteral
Nutrition
Total parenteral nutrition (TPN) is
sometimes called central parenteral
nutrition (CPN) or "hyperal"
(hyperalimentation).
Hypertonic Solutions
Large amounts of nutrients in a hypertonic
solution can be supplied via TPN. The catheter
is surgically placed into the superior vena cava.
The reason that larger amounts of nutrients in
a hypertonic solution can be supplied via the
superior vena cava than with peripheral
parenteral nutrition is that the superior vena
cava has a much larger diameter and a higher
blood flow rate, both of which serve to quickly
dilute the TPN solution.
Amino Acid Solutions
Protein is provided as a crystalline amino acid
solution. 500 ml bottles are standard.
Solutions vary in amino acid concentration and
amino acid composition. The patient's protein
needs determine the protein concentration to
use, and the underlying disease state
determines the composition of amino acids to
use.
Amino acid (AA) % solution AA content
solutions are (g/100ml)
generally available in 3.0% 3.0
the following
concentrations: 3.5% 3.5
5.0% 5.0
7.0% 7.0
8.5% 8.5
10.0% 10.0
Uses of Amino Acids
0.36 x 60 kg x 24 hr
= 518 grams per day
Practice Calculation:
70 kg=_______g
80 kg=_______g
90 kg=_______g
100 kg=______g
Lipid Emulsions
Lipids in parenteral nutrition are used as a
source of essential fatty acids (EFA) and
energy. Lipid emulsions are composed of
soybean and/or safflower oil, glycerol, and egg
phospholipid.
Approximately 4% of total kcaloric intake
should be EFAs to prevent EFA deficiency.
Since IV lipids are isotonic and calorically
dense, they are a good source of
kcalories for hypermetabolic patients, or
patients with volume or carbohydrate
restrictions. Lipids can provide up to 60%
of non-protein calories.
Essential Fatty Acids
2.5g/kg x 60 kg
= 150g lipid per day maximum
Practice for 70-100 kg
Evaluation of Lipid
Tolerance
There are three methods that can be
used for evaluation of a patient's lipid
tolerance:
Test dose
Serum triglycerides
Plasma Turbidity
Test Dose Method
Element Dose
Zinc 2.5 - 4.0mg
Copper 0.5 - 1.5 mg
Iron 1.0 mg
Chromium 10 - 15 mcg
Manganese 0.15 - 1.8 mg
Iodine 1 - 2 mcg
Selenium 20 - 40 mcg
Vitamins
Commercial vitamin preparations for TPN are
available. The vitamin requirements for TPN
patients are different from non-TPN patients
because absorption is not a factor with TPN.
When needs are increased for certain disease
states, single vitamin supplements can be
added to the solution. Serum vitamin levels can
be monitored and dosage adjusted
accordingly.
Vitamin preparations should be added to
the TPN solution just prior to
administration to avoid losses from light
exposure.
Water/Fat Soluble
Vitamins
Water soluble vitamins are provided at
levels greater than the RDA since rapid
administration exceeds renal threshold
and therefore increases urinary losses.
Fat soluble vitamins can become toxic,
and are provided in amounts equal to the
RDA, except for Vitamin K.
Vitamin K is not provided because it may
interfere with anticoagulant medications.
Vitamin K must be given parenterally or
intramuscularly, at a dose of 2-4 mg/wk,
depending on prothrombin time. A long
prothrombin time indicates an increased
vitamin K need.
Other Components of
PN Solutions
Other components commonly added to
parenteral solutions include:
Albumin
Can be added if serum albumin levels are very low.
Heparin
An anticoagulant used to prevent blood clots from
forming on the IV catheter.
Insulin
Used if needed to regulate blood glucose levels.
Ordering and Mixing
PN Solutions
The physician writes the order for the TPN
prescription. Often a form is used.
The pharmacist mixes the TPN solution using
aseptic technique. Prescriptions are
compounded by mixing the solutions at a 1:1
dextrose-to-amino acid ratio and placing in 1-L
bags. Alternatively, lipids can be mixed with the
dextrose/amino acid solution, referred to as the
3-in-1 total nutrient admixture (TNA).
Calculation of protein
needs:
Protein requirements vary with the
patient's disease state. Protein needs
can be estimated by multiplying
kilograms of body weight by a factor, or
by making a nitrogen balance study.
Gram/kg Method for
Determining Protein Needs
The simplest, but least precise, method to
estimate protein needs is by multiplying IBW in
kilograms by a factor appropriate for the
patient's condition.
If this method is used, the patient must be
monitored for protein status to determine if
adjustment in the protein prescription is
necessary.
Example Gram/kg Calculation
IBW: 120lb; 54.5 kg (120/2.2)
2250 kcals/d
550 kcal 10% lipid (50% EFA) 550 kcal x 50% = 275
kcal EFA
Nutrient Needs:
Kcals: 1800 Protein: 88 g Fluid: 2000 cc