Nutrition

TOTAL parenteral nutrition is the aseptic
Amultidisciplinary delivery of nutrients into the circulatory
approach to the system via a central venous catheter or the
peripheral veins.TPN is used when the gut
management of is not functioning and there are several
indications that may suggest its use fsee
patients receiving TPN Table 1).
Access routes and duration
is recommended to Establishing and maintaining suitable
reduce complications, access to the circulation is essential for the
successful management of TPN. The route
writes Deirdre used is dependent on the anticipated
duration of feeding and the osmolarity of
McCormack the solution.
Central vein cannulation is the most
commonly used route, however peripheral
feeding is an acceptable alternative for
short-term feeding. A single dedicated
Table 1
lumen should be used for administration
ofTPN.
Nutritional assessment
Prior to commencement of TPN the
patient's nutritional requirements are
assessed. Energy and nitrogen require-
ments can vary, depending on age, sex,
body composition, clinical status and
activity.
A baseline biochemical assessment
should identify any abnormal plasma
electrolyte levels, liver function tests, renal
function tests, glucose levels or lipid
screen.
Nutritional requirements
Fluid
TPN may be the sole source of fluid or
used in combination with other sources

Indications for totai parenteral nutrition

I Inadequate absorption resulting from short bowel syndrome
I Gastrointestinal fistula
I Bowel obstruction
I Prolonged bowel rest
I Severe malnutrition, signiticant weight loss and/or hypoproteinaemia when enteral
therapy is not possible
I Other disease states or conditions in which oral or enteral feeding are not an option

The world of Irish Nursing June 2004

 Nutrition

Table 2

Monitoring patients receiving TPN - fluid overload/dehydration

I Fluid balance - Monitor daily - electrolyte imbalance
I Glucose tolerance - Initially levels checked every 4-6 hours; daily when stahle - hyperglycaemia/hypoglycaemia
-overfeeding
I Weight - Daily weights can show fluid changes
- re-feeding syndrome
- Long term trends determine changes in tissue mass - nutrient deficiency
I Venous access - Venous access site regularly checked for signs of infection, phlehitis - hepatobiliary dysfunction.
I Routine biochemistry - Serum Na, K, urea and creatinine checked daily initially Standard versus tailored regimens
- Ca, Mg and P checked at least twice a week initially TPN can be provided by a standard or
patient specific prescription. Many factors
- Trace elements - zinc, copper, selenium checked monthly
influence this decision such as frequency
- Vitamins - B12, Folate. Vitamin A, Vitamin E checked monthly of use, patient types, local compounding
I Urinaiysis - Urinary levels of electrolytes useful when determining clinical facilities and cost.
significance of plasma levels Patients on TPN that are metabolically
stable can tolerate slight under or over
such as iv fluids, Jv antibiotics and blood in parenteral nutrition is provided In the provision of nutrients, fluid or electrolytes
products. The fluid balance chart is an form of an amino acid solution. with no complications.
informative summary of determining Electrolytes It is the careful assessment that will
adequacy of input versus output. The normal daily electrolyte require- identify those patients who are likely to be
Acute changes in fluid can also be ments are: substrate intolerant and require frequent
determined by monitoring acute changes o Sodium 1 -1.5 mmol/kg manipulations or specifically tailored regi-
in biochemical parameters such as o Potassium l-1.5mmol/kg mens.
albumin, haemoglobin, mean cell volume, • Calcium 0.1 -0.15mmol/kg Albumin
urea and sodium.To maintain fluid levels, • Magnesium 0.1-0.2 mmol/kg A low plasma albumin level is
the following is required; • Phosphate 0.5-0.7mmol/kg. occasionally used as a reason for nutrition
• 18-60 years old - 35ml/kg/day Vitatriins and trace elements support. Albumin is a negative acute
• > 60 years old - 30ml/kg/day • Water soluble (Pabrinex), fat soluble phase protein, levels dropping within six
Plus replacement of ongoing fluid (Vitlipid) and combined preparations hours of an acute injury, decreasing by up
losses, eg. pyrexia, urine, drains, excess (Cernevit Multibionta) of vitamins are to 50% in severe cases.This is due to the
wound exudates, stomas and high Gl available. increased transcapillary escape rate and a
losses. • Additrace contains trace elements, eg. reduced return via the lymphatic system.
Energy iron, zinc, manganese, copper,chromium, Albumin is not a useful indicator of
Energy requirements are most commonly selenium, molybdenum, fluoride and nutritional status, but is a useful
estimated using predictive equations.' iodine. prognostic marker.
These are based on population data, tak- Monitoring Novel substrates
ing into account activity and stress factors. Regular monitoring is essential to The principal novel substrate with the
It is imperative that these equations are detect and minimise complications and most clinical evidence is glutamine. tt
not used in isolation and that monitoring determine response to nutritional should be reserved for critically ill and
of the patient occurs to assess efficacy. support. surgical patients with anticipated
Indirect calorimetry may be used. Patients receiving TPN should have their prolonged length of stay.
However, this is not practical in the acute nutritional requirements reviewed regu- After injury/hypercatabolic conditions,
setting. larly, taking into account clinical condition, profound intracellular glutamine
Nutritional requirements are also treatments (eg. dialysis), drug therapy, depletion has been found, thus is
affected by medical conditions, thus alter- nutritional status, response to TPN and regarded as a 'conditionally' essential
nate evidence based predictive equations supporting laboratory data. amino acid. Studies have shown
exist for certain conditions such as liver Clinical assessment of the patient can improvements in the clinical outcome of
disease, renal failure and the critically ill reveal ascites, oedema, impaired wound hypermetabolic patients.
obese. healing or loss of muscle mass that may Optimal management
Nitrogen not be evident from monitoring weight Parenteral nutrition is the most complex
Patients do not have a requirement for and biochemical indices fseerab/e2J. and expensive form of artificial nutrition
nitrogen per se, but for amino acids, which Complications support. A muitidisciplinary approach to
are the substrates needed for protein Mechanical, infectious and nutritional the management of these patients can
synthesis (lg nitrogen = 6.25g protein). complications can arise, including: optimise this therapy and reduce compli-
The aim of nutritional support is to • Mechanical - pneumothorax, malposi- cations.
achieve a state of nitrogen balance using tion, embolism Delrdre McCormack It a clmlcat nutritionist at
nitrogen balance data where available or • Infectious - sepsis, thrombophlebitis St James's Hospital Dublin
general recommendations.^ The nitrogen • Nutritional complications including - References on request

The World of Irish Nursing June2004