Parenteral nutrition initiation

Adjunctive therapy with fluid and electrolyte replacement should be initiated. Nutritional support with enteral or parenteral nutrition may be indicated for patients unable to eat for more than 5 to 7 days.2 Some evidence suggests that enteral nutrition provides anti-inflammatory effects in patients with active CD.40,41... 

Nutritional support with enteral or parenteral nutrition should be initiated if it is anticipated that oral nutrition will be withheld for more than 1 week. 

Peroxide formation has also been observed in multivitamin solutions for parenteral nutrition. Lavoie and co-workers [30] have studied the action of light, air, and composition on the stability of multivitamin formulations, and also total parenteral nutrition (TPN) admixtures containing and not containing vitamins and fatty acids. They analyzed the generation of peroxide in multivitamin solutions and in TPN for adults and neonates. The analysis of multivitamin solutions for enteral use revealed the presence of peroxides at the initial opening of the bottle. The levels were higher in Poly-Vi-Sol (vitamin A, Vitamin D, and vitamin C, vitamin Bb riboflavin, and... 

Hyperammonemia has occurred during parenteral nutrition as a component of therapy for renal insufficiency (905). The hyperammonemia presented as a change in mental status, developing about 3 weeks after initiation of parenteral nutrition therapy in most cases the episodes are of increasing duration and paroxysmal. In three of the patients, serum amino acid analysis in the acute phase showed reduced concentrations of ornithine and citrulline (the respective substrate and product of condensation with carbamyl phosphate at its entry into the urea cycle). Concentrations of arginine, the precursor to ornithine, were raised. 

A major complication of intravenous infusion is thrombophlebitis, which is a principle limitation of peripheral parenteral nutrition. Its precise pathogenesis is unclear, but venospasm has been proposed as the most likely cause. However, in a study with ultrasound techniques to monitor vein caliber, there was no evidence to support this hypothesis, although thrombophlebitis was observed (10). The author suggested that the initiating event may be venous endothelial trauma, caused by the venepuncture itself, abrasion at the catheter tip, or the delivery of the feeding solution. 

Why is it important to monitor for hyperglycemia when initiating parenteral nutrition support therapy The pancreas may not have time to adjust to the hypertonic dextrose solution, which is high in glucose. Hyperglycemia is usually temporary and dissipates once the pancreas adjusts. 

The candidates for home nutrition support should be clinically stable patients that require enteral or parenteral nutrition for a long term. Before initiation of home nutrition support, a nutrition assessment and a care plan should be performed and after initiation nutrition status should be monitored on a regular basis. 

Patients with mild AP can begin oral feeding within several days of the onset of pain. In severe disease, nutritional deficits develop rapidly and are complicated by tissue necrosis, organ failure, and surgery. Enteral or parenteral nutrition should be initiated if it is anticipated that oral nutrition will be withheld for more than 1 week, as nutritional depletion can impair recovery and increase the risk of complications. Although total parenteral nutrition is very effective in critically ill... 

Total parenteral nutrition is reserved for the initial management... 

Further clinical experience and research fostered development of protocols that promoted better patient care and resulted in a decline in complications associated with parenteral nutrition (PN) therapy. The scope of practice for nutrition support clinicians has broadened as a result of increasing knowledge regarding the metabolic consequences associated with acute injury and chronic disease states. The pharmacist s role in providing safe and effective nutrition-support care requires knowledge of the principles of patient selection, initial therapy design, preparation and dispensing of the nutritional formu-... 

Krzyda EA, Andris DA, Whipple JK, et al. Glucose response to abrupt initiation and discontinuation of total parenteral nutrition. J Parenter Enter Nutr 1993 17 64-67. 

As small bowel adaptation occurs, some short bowel syndrome patients receiving parenteral nutrition can be transitioned successfully to enteral nutrition. Early initiation of enteral intake affects adaptation because intraluminal nutrients are a stimulus for this process. 

Only one study (Ibrahim et ai, 2003) has reported iodine balances in a cohort of extreme preterm infants who were (initially) parenterally fed. Iodine intakes and urinary iodine outputs were determined for 13 infants over four separate 24h periods at postnatal day 1, 6, 13 and 27. The types and volumes of all enteral and parenteral nutrition fluids used for each infant were accurately recorded. 

All infants, on admission to the neonatal intensive care unit, were established on parenteral fluids within the first hour of day 1 at 80 ml/kg/day with a solution of electrolytes, dextrose 10%, amino acids (Vaminolact, Fresenius Kabi, Cheshire, UK) and a phosphate supplement (Addiphos, Fresenius Kabi, Cheshire, UK). Fluid intakes were thereafter managed on the basis of clinical requirements. On day 2 of life, and thereafter, the solution was further supplemented with water-soluble vitamins (Solvito N, Fresenius Kabi, Cheshire, UK) and trace elements (Peditrace, Fresenius Kabi, Cheshire, UK), to the levels recommended by the manufacmrer. In tandem, a fat emulsion solution (Intralipid 20%, Fresenius Kabi, Cheshire, UK) with added fat-soluble vitamins (Vitfipid, Fresenius Kabi, Cheshire, UK) was infused, initially at 8ml/kg/ day, increasing maximally to 18 ml/kg/day by posma-tal day 5. Enteral feeds were started, when the condition of the infant was stable, as hourly boluses of 0.5—1 ml/h. Thereafter enteral feed volumes were gradually increased as determined by the infants clinical condition, with reciprocal reductions in the volume of parenteral nutrition infused. No infant progressed beyond hourly bolus feeds for the duration of the study. 

The use of L-amino acids constitutes part of the therapeutic measure of parenteral nutrition, which also includes fat emulsions and carbohydrates, i.e., sugars. Only with mixtures of amino acids is it possible to provide physiologic intravenous protein feeding. The modern use of intravenous amino acid nutrition was initiated by Elman (1937), following studies on casein hydrolyzates. 

In summary Because of the short time required to develop biochemical evidence of a deficiency of many water soluble vitamins, it would appear that these nutrients should be included from the initiation of any complete parenteral nutrition program. If MVI (USV Pharm.) is used, care should be taken to insure that the patient does not receive excessive amounts of the fat soluble vitamins. Ideally there should be separate preparations of the water and fat soluble vitamins. Unless these solutions are made available for study, the actual requirement for each vitamin will remain difficult to assess. In this regard, it is quite disturbing that recently the FDA, with disregard for the needs of the patients whose lives may be saved by total parenteral nutrition, has placed severe restrictions on the use of intravenous vitamin preparations. 

Since one could not exclude the possibility that the findings in this teenager were not related to the mild focal abnormalities often seen in granulomatous ileocolitis, two subsequent patients (M.P. and I.W.) with this latter disease and in whom this treatment modality appeared indicated were subjected to a percutaneous liver biopsy prior to the initiation of parenteral nutrition. In both instances abnormal hepatic parenchyma was appreciated. Fig. 3a demonstrates the focal inflammatory cell response in M.P. Repeat biopsies of both patients after several weeks of parenteral nutrition revealed a more severe degree of these same findings. (Fig. 3b). 

Mineral metabolism Refeeding hypophosphatemia is a risk during parenteral nutrition. In 70 patients with refeeding hypophosphatemia who were matched with controls the independent susceptibility factors were significant malnutrition a dose of less than 12 mmol of total phosphate during the first day and an initial rate of infusion of more than 70% of calculated requirements [62. Increasing amounts of non-lipid phosphate in the first day s regimen were protective. 

---