INTRAVENOUS NUTRIENT SOLUTIONS

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 Parenteral nutrition is the continuous

infusion of a hyperosmolar solution containing carbohydrates, proteins, fat, and other necessary nutrients through an intravenous route Parenteral nutrition is used when the enteral route is unable to provide or sustain sufficient caloric intake.

Goals of Nutrition Support

and To optimize immune responses

PN Summary Guidelines
1. Determine if PN is truly indicated 2. Assess the patient (medical history, medication profile, anthropometric data & lab values) 3. Determine need for long-term vs. short term
<710 days

4. Confirm or establish adequate IV access

5. Determine estimated kcal, protein and lipid needs

6. Determine initial electrolyte, vitamin and trace element requirements; consider ongoing losses 7. Consider any additional additives to PN formulation including insulin and H2-receptor antagonists

8. Monitor for:
Risk of refeeding syndrome Glucose intolerance Start low & advance slowly if labs stable over 24-48 hours Fluid, electrolyte, metabolic, macro- and micro-nutrient changes Complications sepsis, thrombosis, abuse

9. Initiate trophic feedings or convert patient to PO or enteral feeding when feasible

Dextrose Solutions
the standard nutritional support regimen uses

carbohydrates to supply approximately 70% of the daily (nonprotein) calorie requirements. These are provided by dextrose (glucose) solutions, which are available in various strengths. As dextrose is not a potent metabolic fuel, the solutions must be concentrated to provide enough calories to satisfy daily requirements. As a result, the dextrose solutions used for TPN are hyperosmolar and should be infused through large central veins

Intravenous Dextrose Solutions

Amino acid solutions

the dextrose solutions to provide the daily protein requirements. A variety of amino acid solutions are available for specific clinical settings. The standard amino acid solutions contain approximately 50% essential amino acids and 50% nonessential + semiessential amino acids

Amino acid cont

partially recycled for the production of nonessential amino acids So metabolism of essential amino acids produces less of a rise in the blood urea nitrogen concentration than metabolism of nonessential amino acids amino acid solutions designed for use in renal failure are rich in essential amino acids

Standard and Specialty Amino Acid Solutions

Glutamine
Glutamine is the principle metabolic fuel for

intestinal epithelial cells, Glutamine-supplemented TPN has an important role in maintaining the functional integrity of the bowel mucosa and preventing bacterial translocation. Glutamine is formed when glutamic acid combines with ammonia in the presence of the enzyme glutamine synthetase. Glutamic acid is given as exogenous source of glutamine.

Amino Acid Solutions with Glutamic Acid

Lipid Emulsions
Intravenous lipid emulsions consist of

submicron droplets (=0.45 mm) of cholesterol and phospholipids surrounding a core of longchain triglycerides The triglycerides are derived from vegetable oils (safflower or soybean oils) and are rich in linoleic acid, an essential polyunsaturated fatty acid lipid emulsions are available in 10% and 20% strengths (the percentage refers to grams of triglyceride per 100 mL of solution). The 10% emulsionsprovide approximately 1 kcal/mL, and the 20% emulsions provide 2 kcal/mL

 Unlike the hypertonic dextrose solutions, lipid

emulsions are roughly isotonic to plasma Can be infused through peripheral veins. The lipid emulsions are available in unit volumes of 50 to 500 mL They can be infused separately (at a maximum rate of 50 mL/hour) or added to the dextroseamino acid mixtures. The triglycerides introduced into the bloodstream are not cleared for 8 to 10 hours, and lipid infusions often produce a transient, lipemic-appearing (whitish) plasma.

Intravenous Lipid Emulsions

Lipid Restriction
Lipids are used to provide up to 30% of the

daily (nonprotein) calorie requirements. Dietary lipids are oxidation-prone and can promote oxidant-induced cell injury Use of lipids in critically ill patients (who often have high oxidation rates) should be restricted. Minimal amounts (4% of calorie) of lipid infusion is necessary to prevent essential fatty acid deficiency (cardiomyopathy, skeletal muscle myopathy)

Additives
Electrolytes
Most electrolyte mixtures contain sodium,

chloride, potassium, and magnesium; they also may contain calcium and phosphorous. The daily requirement for specific electrolyte can be specified in the TPN orders. If no electrolyte requirements are specified, the electrolytes are added to replace normal daily electrolyte losses.

Normal Serum Electrolytes

 Vitamins
Aqueous multivitamin preparations are added to the

dextroseamino acid mixtures. One unit vial of a standard multivitamin preparation will provide the normal daily requirements for most vitamins Enhanced vitamin requirements in hypermetabolic patients in the ICU may not be satisfied. Some vitamins are degraded before they are delivered. Some examples are riboflavin and pyridoxine (which are degraded by light) and thiamine (which is degraded by sulfites used as preservatives for amino acid solutions)

Vitamins
Vitamin Thiamine (B1) Riboflavin (B2) Pyridoxine (B6) Cyanocobalamin (B12) Niacin Folic acid Pantothenic acid Biotin Ascorbic acid (C) Vitamin A Vitamin D Vitamin E Vitamin K RDI (FDA/AMA/NAG) 6 mg 3.6 mg 6 mg 5 mcg 40 mg 600 mcg 15 mg 60 mcg 200 mg 3300 IU 5 mg 10 IU 150 mcg

 Trace Elements
A variety of trace element additives are available Most trace element mixtures contain chromium,

copper, manganese, and zinc, but they do not contain iron and iodine. Some mixtures contain selenium, which has a role in proctection against oxidation injury Routine administration of iron is not recommended in critically ill patients because of the pro-oxidant actions of iron

Trace Element Preparations and Daily Requirements

Monitoring PN Patients Clinical Status

Weight Fluid requirements Patient complaints Physical exam Overall clinical status

Monitoring PN Patients Metabolic and Biochemical Aspe

Renal function: Lytes, Mg, Ca, Phos, BUN, Cr Hematologic: CBC (Hgb, WBC, Plt), INR Liver function: Alk Phos, AST/ALT, Bilirubin Glucose/lipid tolerance: Glucose, Triglycerides Iron status: Iron, TIBC, Ferritin Serum proteins: Albumin

Insulin coverage

DEXA

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