Energy parenteral nutrition

The composition of body fluids remains relatively constant despite the many demands placed on the body each day. On occasion, these demands cannot be met, and electrolytes and fluids must be given in an attempt to restore equilibrium. The solutions used in the management of body fluids discussed in this chapter include blood plasma, plasma protein fractions, protein substrates, energy substrates, plasma proteins, electrolytes, and miscellaneous replacement fluids. Electrolytes are electrically charged particles (ions) that are essential for normal cell function and are involved in various metabolic activities. This chapter discusses the use of electrolytes to replace one or more electrolytes that may be lost by the body. The last section of this chapter gives a brief overview of total parenteral nutrition (TPN). 

When normal enteral feeding in not possible or is inadequate to meet an individual s nutritional needs, intravenous (IV) nutritional therapy or total parenteral nutrition (TPN) is required. Products used to meet the IV nutritional requirements of the patient include protein substrates (amino acids), energy substrates (dextrose and fat emulsions), fluids, electrolytes, and trace minerals (see the Summary Drug Table Electrolytes). 

Kamiya et al. [83] evaluated particulate contamination in 199 samples of admixed and un-admixed parenteral nutrition solution bags from 10 hospitals in Japan. Seven samples were used as controls since they had not been mixed with ampoules or vials (un-admixed samples). Size and number of particles were measured using a particle counter, and the identification of elements was carried out by scanning electron microscopy coupled to energy dispersion spectroscopy. The authors collected the residual volume of the samples (10-60 mL) after their usage. The results are presented in Table 40. 

Therapeutically, sunflower oil is used to provide energy and essential fatty acids for parenteral nutrition. Studies have shown that sunflower oil may be used in intramuscular injections without inducing tissue damage. ... 

The principal energy sources in the diet are carbohydrates and fats. Glucose provides 4 kcal/g while fat provides 9 kcal/g. The entire calorie load may be admin-stered using carbohydrates, but prescribing a mixture of carbohydrates and lipids is more physiological and serves to reduce the volume of the diet. This is imponant in tube feeding as well as in parenteral nutrition. 

Bresson JL, et al. Energy substrate utihzation in infants receiving total parenteral nutrition with different glucose to fat ratios. Pediatr Res. 1989 25(6) 645-8. 

The calculation of the energy, substrate and volume needs in parenteral nutrition is given in textbooks and guidelines [52]. The needs depend on the patient s disease and nutritional status. The first step is the specificatirMi and calculation of the necessary amounts of fluid, glucose, and amino acids (macro-nutrients). The second step includes the calculation of the electrolytes. Vitamins and trace elements are commonly added in standard amounts according to professional guidelines. 

The fluid, energy, and substrate requirements and the composition of the admixtures is stated in different guidelines [52]. Fusch et al. presented a standardised questionnaire, which takes into account partial parenteral nutrition and enteral nutrition and should be used for prescribing parenteral nutrition to neonates [53,54]. Examples for the composition of a neonatal AIO admixture can be found in the literature [53]. 

Intravenous requirements for energy, protein, amino acids, vitamins, minerals, and trace metals have not been definitely established for the newborn infant, although significant advances have been made in the past 5 years. Current estimates of intravenous requirements continue to be based on recommended oral intakes and a few nutrient balance studies. In this chapter, it is not possible to provide a detailed review on the termination of intravenous requirements for all the essential nutrients which are recommended for inclusion in TPN regimens. This topic has been the subject of several recent reviews (Jeejeebhoy, 1983 Heim et al, 1981 Zlotkin and Anderson, 1985 Winters et al, 1983). This section will deal with some of the newer issues associated with parenteral nutrition. 

More direct evidence of utilization is the favorable effect fat emulsion administration has on body weight, the shift in respiratory quotient towards fat oxidation, and a rise in the concentration of blood ketones. Absolute evidence for the metabolism of the emulsified triglyceride is given by the conversion of C-labeled fat to C02 and C-phospholipids following its intravenous injection. Finally, the fact that when fat emulsions comprise an essential part of the energy source in complete parenteral nutrition, growth and development occur, shows in a very practical manner that such emulsions are indeed utilized (Hallberg et al , 1970 and Hakansson jet al., 1967). ... 

In a few studies it has been demonstrated that taurine supplementation improves retinal development in premature babies receiving parenteral nutrition. Human data on the efficacy of taurine supplementation in so-called energy drinks are very limited. In the absence of taurine supplementation in children taurine concentrations drop, suggesting its conditional indispensability also in the postneonatal period. This has led to the addition of taurine to standard feeding formulas for infants and growing children. 

The fact that normal humans have a requirement for biotin has been clearly documented in two situations prolonged consumption of raw egg white and parenteral nutrition without biotin supplementation in patients with short bowel syndrome and other causes of malabsorption. Based on lymphocyte carboxylase activities and plasma biotin levels, some children with severe protein-energy malnutrition are biotin deficient. Investigators have speculated that the effects of biotin deficiency may be responsible for part of the clinical syndrome of protein-energy malnutrition. 

Uses Energy source for parenteral nutrition osmotic agent in injectable solutions and dialysis solutions treatment of hypoglycaemia Regulidory USP... 

PN should provide a balanced nutritional intake, including macronutrients, micronutrients, and fluid. Macronutrients, including amino acids, dextrose, and intravenous lipid emulsions, are important sources of structural and energy-yielding substrates. A balanced PN formulation includes 10% to 20% of total daily calories from amino acids, 50% to 60% of total daily calories from dextrose, and 20% to 30% of total daily calories from intravenous lipid emulsion. Micronutrients, including electrolytes, vitamins, and trace elements, are required to support essential biochemical reactions. Parenteral... 

Jequier, E. (1987). Measurement of energy expenditure in clinical nutritional assessment. /. Parenteral Enteral Nutr. 11,86S-89S. 

Frankenfield D. Energy and macrosubstrate requirements. In Gottschlich MM, ed. The Science and Practice of Nutrition Support A Case-Based Core Curriculum, America Society for Parenteral and Enteral Nutrition. Dubuque, lA, Kendall/Hunt, 2001 31-52. 

Stearic acid, a major fatty acid in cocoa butter, does not raise total, LDL, and HDL cholesterol levels compared with carbohydrates. Also, MCFA have been reported not to raise LDL and HDL cholesterol concentrations compared with carbohydrates, but data are limited. Like carbohydrates, diets containing large amounts of MCFA increase fasting triacylglycerol concentrations compared with the other saturated fatty acids. However, such diets are the sole energy source only in parenteral or enteral nutrition or in sports drinks. Other saturated fatty acids have not been reported to raise triacylglycerol concentrations compared with each other, but lower triacylglycerol concentrations compared with carbohydrates. 

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