TOTAL

Parenteral Nutrition
Achieving the right nutritional intake in a timely manner can help combat complications and
be an important part of a patient’s recovery. Parenteral nutrition is sometimes called Total
Parenteral Nutrition (TPN).

The goal of nutrition management in neonates, especially very low birth weight (VLBW)
infants is the achievement of postnatal growth at a rate that approximates the intrauterine
growth of a normal fetus at the same postmenstrual age. Although, this is best achieved with
optimal enteral nutrition, early enteral feeding is commonly limited by immaturity of
gastrointestinal motor function, manifested principally as delayed stomach emptying, gastro-
esophageal reflux, abdominal distension, and infrequent stooling. Likewise, establishing an
alternative source of nutrition becomes a life-sustaining intervention in surgical neonates with
congenital or acquired disease causing gastrointestinal failure.

DEFINITION:
Parenteral nutrition (PN) is intravenous administration of nutrition, which may include
protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements
for patients who cannot eat or absorb enough food through tube feeding formula or by
mouth to maintain good nutrition status.

INDICATIONS:
Parenteral nutrition (PN) should be considered in neonates who are not on significant enteral
feeds for more than 3-5 days or are anticipated to be receiving less than 50% of total energy
requirement by day 7 of life

 Birth weight less than 1000 g

 Birth weight 1000-1500 g and anticipated to be not on significant feeds for 3 or
more days
 Birth weight more than 1500 g and anticipated to be not on significant feeds for 5
or more days
 Surgical conditions in neonates: Necrotizing enterocolitis, Gastroschisis,
Omphalocele, Tracheo-esophageal fistula, Intestinal atresia, Mal-rotation, Short
bowel syndrome, and Meconium ileus

C0MPONENTS:
1. Energy

A daily energy intake of 110-120 kcal/kg is needed to meet the metabolic demands of a
healthy premature neonate and to allow for growth rate comparable to intrauterine
growth rate. Energy requirement of term neonate is 90-100 kcal/kg/day. Energy intake
of sick neonates (e.g. acute respiratory illness, chronic lung disease, necrotizing
enterocolitis) is not exactly known but is likely to be near upper limits of the energy
requirement of preterm infant.

10% dextrose solution provides 0.34 kcal/ml. 10% lipid solution provides 0.9 Kcal/ml
and 20% lipid solution provides 1.1 Kcal/ml. If sufficient amount of non-protein energy
is not provided, amino acids are catabolized for energy production. Adequate balance
between nitrogen and non-protein energy sources (Protein/Energy ratio: 3-4 g/100
kcal) is needed to promote protein accretion. Balance between carbohydrates and fat
is needed to prevent excessive fat deposition and excessive production of CO2. The
ideal distribution of calories should be 50-55% carbohydrate, 10-15% proteins and 30-
35% fats.

2. Amino acids

PN should provide 3.0-3.5 g/kg/day of AA. An optimal AA solution should contain

essential (valine, leucine, isoleucine, methionine, phenylalanine, threonine, lysine and
histidine) and conditionally essential (cysteine, tyrosine, glutamine, arginine, proline,
glycine and taurine) AAs, should not have excess of glycine and methionine and should
not contain sorbitol. Depending on practical feasibility, AA infusion should be started
on the first day of birth preferably soon after birth. To avoid negative protein balance,
one should start with at least 1.5 g/kg/d and then increase by 1 g/kg/d to maximum of
3.5 g/kg/d.

AA solutions are available as 10% and 20% preparations.

3. Carbohydrates
Carbohydrates are the main energy substrate for the neonates receiving PN. The
amount of carbohydrate delivered in the form of dextrose is commonly initiated at the
endogenous hepatic glucose production and utilization rate of 4 to 6 mg/kg/min. This
provides energy intake of 40-50 kcal/kg/d and preserves carbohydrate stores. Once the
GIR supports acceptable serum glucose values, it is advanced in a gradual, stepwise
fashion (2 mg/kg/min/day) to a suggested maximum glucose oxidative rate for
neonates of 12-13 mg/kg/min to support growth and maintained there unless serum
glucose values change significantly. Insulin infusion should not be used to increase the
GIR. However, if infant is developing high glucose levels despite glucose infusion rate
of 4-6 mg/kg/minute, insulin infusion can be started.

Glucose is available as 5%, 10%, 25% and 50% solutions.

4. Lipids

Lipids can be started on first day at dose of 1.0 g/kg/d and then increased gradually in
stepwise fashion to 3.0 g/kg/d. In preterm neonates with hyperbilirubinemia in range
of exchange transfusion threshold, lipids may be restricted to minimum amounts (1
g/kg/d) that will provide only the essential fatty acids.

IVL emulsions are available in two strengths: 10% and 20%. Use of 20% lipid emulsion
is preferable to a 10% solution to decrease the risk of hypertriglyceridemia,
hypercholesterolemia, and hyperphospholipidemia. When lipids are exposed to light,
they form potentially toxic lipid hydroperoxides. Hence lipid syringes and tubing should
be covered by wrapping it in aluminum foil.

5. Minerals

Sodium, potassium, chloride, calcium, magnesium and phosphorus need to be

provided in PN solution as per their daily needs. Except phosphate, all these minerals
are easily available in India. Sodium, potassium, and chloride are essential to life and
requirements are dependent on obligatory losses, abnormal losses, and amounts
necessary for growth. Calcium, phosphorus, and magnesium are the most abundant
minerals in the body. They are closely interrelated to each other in metabolism, the
formation of tissue structure, and function. Estimated and advisable intakes are based
on accretion studies and urinary and fecal losses from balance studies.
Table: Daily requirement of minerals

Mineral Requirement

Sodium 0-3 meq/kg/d (1st week of life)

2-3 meq/kg/d (beyond 1st week in term neonates)

3-5 meq/kg/d (beyond 1st week in preterm neonates)

Potassium 0-2 meq/kg/d (1st week of life) 1-3 meq/kg/d (beyond 1st week)

Chloride 2-3 meq/kg/d

Calcium 150-200 mg/kg/day

Magnesium 15-25 mg/d

Phosphate 20-40 mg/kg/d

6. Vitamins

Vitamins are added in PN solution to meet the daily requirement. Separate

preparations of fat-soluble and water-soluble vitamins suitable for neonates are not
available in India. Multivitamin injection (MVI), when added in a dose of 1.5 mL/kg to
lipid solution meets the need of vitamin A and most other vitamin. Furthermore,
intravenous vitamin delivery may be less due to photo-degradation of vitamins A, D, E,
K, B2, B6, B12, C, and folic acid and adsorption of vitamins A, D, and E into the vinyl
delivery bags and tubing. Vitamin K needs to be given separately as weekly
intramuscular injections. Although vitamin B12 is not present in MVI, its deficiency is
not manifested unless the neonate is on long-term PN.

Table: Recommended vitamin intake

Vitamin Term (daily dose) Preterm (dose/kg/day)

Vitamin A (IU) 2300 1640

 Vitamin D (IU) 400 160

Vitamin E (IU) 7 2.8

Vitamin K (μg) 200 80

Vitamin B6 (μg) 1000 180

Vitamin B12 (μg) 1 0.3

Vitamin C (mg) 80 25

Biotin (μg) 20 6

Folic acid (μg) 140 56

Niacin (mg) 17 6.8

Pantothenic acid (mg) 5 2

Riboflavin (μg) 1400 150

Thiamine (μg) 1200 350

7. Trace elements

Trace elements like zinc, copper, manganese, selenium, fluorine and iodine should be
provided in PN solutions. Zinc is universally recommended from day one of TPN, whereas
the other trace minerals are generally provided after 2 weeks of TPN without any
appreciable enteral feeding. Copper, selenium, molybdenum, and iron can be delivered
separately also. Dosage of zinc to be provided is 150-400 microgram/kg/d even with short-
term PN, but a suitable preparation is difficult to find in Indian market.

8. Fluids

Intravenous fluid is the carrying medium for PN. It is started at 60-80 mL/kg/d and advanced
by 15-20 mL/kg/d to maximum of 150 mL/kg/d by end of first week of life. Fluid therapy is
regulated by monitoring hydration status of the infant (weight gain/loss, serum sodium,
urinary specific gravity, urine output and osmolality of plasma and urine).
Table: Recommendations for parenteral nutrition
Component Recommendations
Fluids Day 1: 60-80 mL/kg/d.
Postnatal weight loss up to 3% per day to a maximum of 10 to 15% is
acceptable. This is achieved by progressively increasing the fluid
intake to 120-150 mL/kg/d by one week of age.
Energy An intake of 50 kcal/kg/d is sufficient to match ongoing expenditure,
but it does not meet additional requirements of growth. The goal
energy intake is 100-120 kcal/kg/d (higher in infants with chronic lung
disease)
Proteins Optimal parenteral amino acid intake is 3.5 g/kg/d. Parenteral amino
acids can begin from day 1 at 1-1.5 gm/kg/d
Carbohydrates From day one, 6 mg/kg/min can be infused, increased by 2 mg/kg/min/d
to 12-14 mg/kg/min and adjusted to maintain euglycemia.
Insulin is only used in infants who continue to have hyperglycemia
associated with glycosuria and osmotic dieresis even after the glucose
intake has been reduced to 4 to 6 mg/kg/min. Insulin is given as a
continuous infusion commencing at a rate of 0.05 units/kg/h, increasing
as required for persistent hyperglycemia.
Fats Intravenous fat, 1 g/kg/d can be started from day 1, at the same time as when
intravenous amino acids are started. This is increased to 2 g/kg/d and
3 g/kg/d over the next two days. It is delivered as a continuous infusion
of 20% intravenous fat via a syringe pump, separate from the infusate
containing the amino acids and glucose. The syringe and infusion line
should be shielded from ambient light.
Minerals & Trace Minerals should include: sodium, chloride, potassium, calcium,
Elements phosphorus, magnesium. Trace elements should include: zinc, copper,
selenium, manganese, iodine, chromium, and molybdenum.
Vitamins Vitamins must be added to the fat emulsion to minimize loss during
administration due to adherence to tubing and photo-degradation.

DISPENSING PN SOLUTION:
In developed countries PN solution is prepared by central pharmacy and delivered ready to
be used. But this facility is usually not available in most of Indian hospitals and physicians
and nurses have to chart and prepare PN. Steps for calculation and preparing PN are as
follows (a PN chart is provided in appendix):
1. Determine total fluid requirement for the day
2. Subtract amount of fluid to be used for medications (e.g. diluting and infusing
antibiotics) and enteral feeds
3. Plan AA, IVL and glucose to be given over 24 h
4. Take IVL suspension in one syringe and add MVI in to it.
5. In second syringe mix AA, dextrose, electrolytes and trace elements
6. IVL+MVI suspension is infused separately from AA-glucose-minerals solution,
although they can be mixed at the site of infusion using a three-way adapter.
7. For calculating amount of each PN component, use following formula:

For example, for a baby weighing 1.5 kg to be given 3 mEq/kg of sodium, amount of
3% NaCl to be used is:

All PN solutions should be administered with accurate flow control. The infusion
system should undergo regular visual inspection. Peripheral infusions should be
checked frequently for signs of extravasation. The pump should have free flow
prevention if opened during use, and have lockable settings.

ROUTE OF ADMINISTRATION:

PN can be delivered through peripheral or central venous lines. Short-term PN can be

given through peripheral venous line. Peripheral access offers the advantage of a
lower risk of infection due to the greater distance of the catheter from the central
circulation as well as a smaller risk of mechanical complications. However, nutrition
delivery is limited with peripheral lines due to constraints created by a solution's
osmolarity. The limiting factor in deciding route of delivery is osmolarity of the AA-
glucose solution which is dependent on dextrose concentration. A dextrose
concentration greater than 12.5% has an acidic pH and can be irritating to the
peripheral veins. In addition to dextrose, electrolytes and minerals added to the
solution increase the osmolarity of the solution. Hypertonic solution need to be
administered through central venous line.
Increasing use of peripherally inserted central catheters (PICC) has facilitated
administration of PN while avoiding many potential complications of surgically
inserted central lines. Another attractive option in neonates is central line inserted
through umbilical vein. Umbilical venous catheter can be used for up to 14 days after
which risk of complications increases
Position of central line should be confirmed by X-ray before starting infusion through
it. To avoid risk of pericardial tamponade, tip of the central catheter should lie
outside the pericardial sac (on the chest x-ray is at least 0.5 cm outside the cardiac
outline). In comparison to catheters made of stiffer material (polyvinylchloride,
polypropylene, polyethylene), softer catheters (silicone and polyurethane) are less
thrombogenic and less traumatic, and are, therefore, preferable for long-term use.
The venous access used for PN should not be interrupted for giving antibiotics or
other medications. For this a separate intravenous line should be established.

ARTICLES REQUIRED:
 Central venous access devices: long term VAD such as thick man, Broviac or
Groshung catheters or peripherally inserted central catheter (PICC line) or
peripheral IV access
 Volume control infuser
 Filters 0.22 micron for TPN (without fat emulsion)3.2 micron filter for TNA or
fat emulsion
 Bag of parenteral nutrition
 Administration tubing with luer-lock connections
 Hypoallergic tape
 Face mask
 Sterile gloves
PROCEDURE:
S.n NURSING ACTION RATIONALE
1 Perform Nutritional assessment Provides baseline data
2 Check physician’s order Parenteral therapy must be ordered
by physician
3 Explain the procedure
4 Obtain informed consent
5 Collect needed equipment for the
procedure
6 Remove the bag of parenteral Decreases the incidence of
nutrition from refrigerator at least hypothermia, pain &vaso spasm
1hr before procedure (if refrigerated)
7 Inspect fluid for presence of Indicates fluid separation TPN
creaming or any change in solution should be clear with out
constitution clouding
8 Wash hands and done cap, mask, Follow strict aseptic precautions
gown and sterile gloves
9 Using strict aseptic technique , Prevents chances of developing air
attach tubing (with filter)to TNA bag embolus
purge out air
10 Close all clamps on new tubing
and insert tubing into volume
control infuses
11 Place the patient in supine Supine position with head turned
position and turn head away from one side opens the angle b/w
VAD insertion site clavicle and first rib
12 Clean the insertion site with alcohol
and providone-odine solution
13 Assist physician while inserting
VAD
14 After insertion of VAD connect
tubing to hub of VAD using sterile
technique and make sure that the
connection is secured using luerlock
connection
15 Open all clamps and regulate flow
through volume control infuser
16 Monitor administration hourly,
assessing for integrity of fluid and
administration system and patient
tolerance
17 Record the procedure

MONITORING:
Meticulous monitoring is needed in a neonate receiving PN. Monitoring should be
more frequent in the initial stages. Once a steady metabolic stage has been achieved,
monitoring can be reduced to once a week.
Table: Monitoring schedule for a neonate on parenteral nutrition

Parameter Frequency

Blood sugar 2-3 times a day while increasing glucose infusing rate Once a day
while on stable glucose infusion rate

Urine sugar once per nursing shift

Serum electrolytes Twice a week initially, then weekly

Blood urea Twice a week initially, then weekly

Calcium, magnesium and

Weekly
phosphorous
Serum albumin Weekly

Packed cell volume Weekly

Liver function tests Weekly

Serum triglycerides Weekly

Anthropometry

Weight Daily at the same time

Head circumference Weekly
Length Weekly

Nutrient intake Energy in kcal per kg day

calculation Proteins in grams per kg per day

Data Monitored Daily:

• General sense of well-being

• Strength as evidenced in getting out of bed, walking, resistance exercise as
appropriate
• Vital signs including temperature, blood pressure, pulse, and respiratory rate
 • Fluid balance: weight at least several times weekly, fluid intake (parenteral and
enteral) vs. fluid output (urine, stool, gastric drainage, wound, ostomy)
• Parenteral nutrition delivery equipment: tubing, pump, filter, catheter, Dressing
• Nutrient solution composition

COMPLICATIONS:
Complications of PN can be nutrient-related or venous access-related.

Nutrient related complications:

 Hypoglycemia (plasma sugar < 54 mg%) and hyperglycemia (plasma sugar > 150
mg/dL) (glucose-related)
 Azotemia and metabolic acidosis (protein-related)
 Hypertriglyceridemia (triglyceride >200 mg/dL) (lipid-related)
 Cholestasis and trace element deficiency.
 PN-related cholestasis is usually complication of long-term PN and can be
avoided by provision of at least minimal-enteral nutrition

Most of these complications can be avoided by proper monitoring and provision of

nutrients.

Venous access-related:

 Occlusion
 Dislodgement
 Infection

Prevention of infection:

Hospital-acquired infection (HAI) is a major complication of PN. All efforts should be

made to avoid HAI.

 Aseptic precautions during preparation of PN

 Use of laminar flow
 No compromise on disposables
 Trained staff
 No reuse of the PN solutions
  No interruption of the venous line carrying PN
 Use of bacterial filter

DISCONTINUATION OF TPN: