Indications
Gut not functional/accessible = complete bowl rest |
Cannot meet needs orally |
PN duration longer than 5 days |
E.g. bowel obstruction, gut ischemia, ileus/GI stasis, fistula, radiation damage, intractable vomiting, persistent severe diarrhoea, short-bowl, Crohn’s, trauma, critically ill, malnourished, SBS, burns |
Routes
Central - TPN |
Into superior vena cava, hypertonic solution. Larger vein. |
Peripheral line – PPN |
~Short-term. Into arm//legs/hands. Lower osmolarity. Only when central line is not available. |
Formulas
NO micronuts & trace elements - Come in separate vials (Soluvit, Vitalipid, Cernevit) – added to bag when administered or an injection |
SCHU: Administered with 100mL saline over 24 hours. |
CHO (as dextrose) |
max total: 2g/kg. Max rate: 4-5mg/min/kg |
P (as free AA & electrolytes) |
1g N = 6.25g protein. N usually in name - “SuperPH 24” = 24 g N. |
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Standard solutions = 1.0-1.2g/kg. Standard bag (3-in-1): 10-15%. Standard bag (2-in-1): 15-25%. |
F (as lipid emulsion) |
Minimum 0.5 mg LCT/kg/d to prevent EFA deficiency. Standard bag (3-in-1): 30-45%, Standard bag (2-in-1): 0%. |
Energy |
0.6-1.2 kcal/mL |
Regimes
Continuous |
40-150 ml/hour for 24 hours. Don’t need to start lower rate (unless risk of refeeding or if hyperglycaemic). Refeeding = 50% of reqs, ↑ when biochem stable. |
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SCUH policy: start rate = ½ goal for the first 12 hours. |
Intermittent/cyclic |
100-300ml/hour. Eg. only at night or on specific days of the week |
Dual Feeding |
PN & EN – helps maintain gut function – gut integrity & gut microbiome |
Guidelines & References
DA Parenteral feeding manual and guidelines |
ASPEN refeeding consensus recommendations (2020) |
ESPEN guideline on home parenteral nutrition |
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Nut Reqs
Simple ratio – same as EN |
Consider any fluid restrictions – NO FLUSHING IN PN |
All additional fluids = IV |
Bag volume = fluid (not like EN) |
GI Losses: ↑ reqs zinc, copper & selenium |
Long-term PN: Gradual depletion of stores: trace elements & fat-sol vits. Greater risk of micronutrient deficiencies |
Transitional feeding – PN to EN
Step 1: Start EN 30-40mL to establish GI tolerance. |
Step 2: PN rate can be slowly reduced to keep nutrient levels at the same prescribed amount |
Step 3: Continue increasing EN rate and decreasing PN rate until full requirements are met by EN |
Transitional feeding – PN to oral
Pts w/ unstable BG or ↓ glycogen: Taper infusion to 50% for an hour, review insulin dosage & cease insulin infusion, OR replace PN with 10% dextrose at same rate as PN for an hour |
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Monitoring
Concerns: ↓ gut microbiome biodiversity, ↑ inflammation |
Strategies to ↑ oral intake – ONS/EN/oral intake |
Biochem – refeeding, hypo/hyperglycaemic |
If reqs aren’t met (due to fluid restrictions): consult w/ med team. Reduce IV? |
Weight = daily-weekly |
Fluid balance = hourly. Totalled daily |
BGL: every 6 hours-daily |
Troubleshooting
Nausea or vomiting |
anti-nausea meds, swap to cyclic, reduce rate & run continuously, 2-in-1 instead (no fat) |
Too hungry |
Swap to cyclic & ↑ rate. |
Too full |
slow rate & run continuous. |
Constipation |
Medication. Ensure adequate fluid. |
Overfeeding |
↑ BGL, serum triglycerides, AST & ALT. Glucose: higher than 5mg/min/kg is unlikely to be tolerate. |
Hyperglycaemia |
Swap to a higher lipid, lower glucose formula |
Dehydration |
supplemented with IV fluids. ↑ rate ≠ ↑ hydration |
Fluid overload |
Consider other fluid sources – IV, medications, line flushing. Change to a more concentrated formula. |
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