Peripheral parenteral nutrition

TPN may be administered through a peripheral vein or through a central venous catheter. Peripheral TPN is used for patients requiring parenteral nutrition for relatively short periods of time (no more than 5-14 days) and when the central venous route is not possible or necessary. Peripheral TPN is used when the patient s caloric needs are minimal and can be partially met by normal... 

PPN, peripheral parenteral nutrition TNA, total nutrient admixture. 

Parenteral nutrition (PN) provides macro- and micronutrients by central or peripheral venous access to meet specific nutritional requirements of the patient, promote positive clinical outcomes, and improve quality of life. PN is also referred to as total parenteral nutrition or hyperalimentation. 

Peripheral PN (PPN) is a relatively safe and simple method of nutritional support. PPN candidates do not have large nutritional requirements, are not fluid restricted, and are expected to begin enteral intake within lOto 14days. Thrombophlebitis is a common complication this risk is greater with solution osmolarities greater than 600 to 900 mOsm/L (Table 60-2). Solutions for PPN have lower final concentrations of amino acid (3% to 5%), dextrose (5% to 10%) and micronutrients as compared to central parenteral nutrition (CPN). 

Simon, D., Galambos, XT. A randomized controlled study of peripheral parenteral nutrition in moderate and severe alcoholic hepatitis. J. Hepatol. 1988 7 200 - 207... 

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. 

Because copper is excreted primarily in the bile, some experts advocate reducing or curtailing copper supplementation in patients with chronic hyperbUrrubinemia. The earliest signs of copper deficiency are peripheral blood cytopenias (typically anemia and neutropenia) and occasionally thrombocytopenia, caused by reduced bone marrow production. The authors recommended that serum copper should be monitored quarterly and that copper should be included in the parenteral nutrition mixture three times a week, adjusting the frequency in response to serum copper concentrations. 

Precipitates can develop in parenteral nutrition admixtures because of a number of factors such as the concentration, pH, and phosphate content of the amino acid solutions, the calcium and phosphorus additives, the order of mixing, or the mixing process. The consequences can be serious. In one cohort study of hospitalized patients who received peripheral parenteral nutrition, a subgroup developed unexplained chest pain, dyspnea, cardiopulmonary arrest, or new interstitial infiltrates on chest radiograph. A change in the amino acid source of a parenteral nutrition mixture was associated with respiratory adverse events that ranged from interstitial infiltrates to sudden death. The events apparently resulted from infusion of calcium phosphate precipitate in an opaque admixture, and the deposition of the crystals in the pulmonary microvasculature (147). 

A filter should be used when infusing either central or peripheral parenteral nutrition admixtures. Data are not available to determine which size filter is most effective in trapping precipitates. 

Kane KF, Lowes JR. Peripheral parenteral nutrition and venous thrombophlebitis. Nutrition 1997 13(6) 577-8. 

May J, Murchan P, MacFie J, Sedman P, Donat R, Pahner D, Mitchell CJ. Prospective study of the aetiology of infusion phlebitis and line failure during peripheral parenteral nutrition. Br J Surg 1996 83(8) 1091. ... 

Kerin MJ, Pickford IR, Jaeger H, Couse NF, et al. A prospective and randomised study comparing the incidence of infusion phlebitis during continuous and cyclic peripheral parenteral nutrition. Chn Nutr 1991 10 315. 

Sawada M, Tsurumi H, Kara T, Goto H, Yamada T, Oyama M, Moriwaki H. Graft failure of autologous peripheral blood stem cell transplantation due to acute metabohc acidosis associated with total parenteral nutrition in a patient with relapsed breast cancer. Acta Haematol 2000 102(3) 157-9. 

Shay DK, Fann LM, Jarvis WR. Respiratory distress and sudden death associated with receipt of a peripheral parenteral nutrition admixture. Infect Control Hosp Epidemiol 1997 18(12) 814-17. 

Parenteral nutrition support therapy is used for disorders of the GI track, bums, and debilitating disease. Parenteral nutrition support therapy is administered through a central venous line (subclavian or internal jugular veins) to prevent irritation to the peripheral veins. 

Records of enteric nutrition, peripheral parenteral nutrition, and central parenteral nutrition. 

A decrease in PaC02 occurs when ventilatory excretion exceeds metabolic production. Because endogenous production of CO2 is relatively constant, negative CO2 balance is primarily caused by an increase in ventilatory excretion of CO2 (hyperventilation). The metabolic production of CO2, however, may be increased during periods of stress or with excess carbohydrate administration (e.g., parenteral nutrition). Hyperventilation may develop from an increase in neurochemical stimulation via either central or peripheral mechanisms, or be the result of voluntary or mechanical (iatrogenic) hyperventilation. 

Parenteral nutrition (PN) solutions may be appropriately formulated for administration by peripheral or central venous access. 

NPC N nonprotein-calorie nitrogen ratio PN parenteral nutrition PPN peripheral parenteral nutrition PUPA polyunsaturated fatty acid RDA recommended daily allowance RS refeeding syndrome TNA total nutrient admixture TPN total parenteral nutrition USP United States Pharmacopeia... 

Miller SJ. Peripheral parenteral nutrition Theory and practice. Hosp Pharm 1991 26 796-801. 

Anderson ADG, Palmer D, MacFie J. Peripheral parenteral nutrition. Br J Surg 2003 90 1048-1054. 

Chromium is a trace metal that helps maintain normal glucose metabolism and peripheral nerve function. It is used as a supplement to IV solutions given for total parenteral nutrition (TPN) to prevent depletion of endogenous stores and subsequent deficiency symptoms. 

Chromium deficiency symptoms have been clearly identified in patients receiving total parenteral nutrition (TPN) without chromium. One patient who had received TPN for 31/2 years developed symptoms of hyperglycemia, weight loss, ataxia and peripheral neuropathy. When chromium... 

G. Grotte. S. Jacobsen, and A. Wretlind, Lipid emul.sions and technique of peripheral administration in parenteral nutrition, pp. 335-362. in Ref. 42. 

Respiratory Chylous pleural effusions have been reported in two adults who received parenteral nutrition delivered via peripherally inserted central catheters [19 ]. 

Johnson TJ, Jamous EG, Kooistra A, Zawada ET. Iatrogenic chylothorax due to pleural cavity extravasation of total parenteral nutrition in two adults receiving nutrition through a peripherally inserted central catheter. Hosp Pract (Minneap) 2010 38 (1) 50-2. 

Osmolarity of the nutrient admixtures and thereby the infusion route is determined by the type and amount of the components mixed. In general the admixtures are hyperosmolar and to be administered via a central venous catheter in a big vein (vena cava superior or vena subclavia). Only admixtures with a maximum osmolarity of900 mOsm/ L can be administered via a peripheral vein and only for a limited period of time [69]. Lmig term parenteral nutrition can be also administered via a port (see Sect. 13.10.3) especially when patients are treated at home. Because of the high probability of incompatibilities nutrition admixtures should always be administered via a separate line and Y-site infusion should be avoided. 

---