Nutrition support in critically ill patients: Parenteral nutrition
- David Seres, MD
David Seres, MD
- Director of Medical Nutrition
- Associate Professor of Medicine in the Institute for Human Nutrition
- Columbia University College of Physicians and Surgeons
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
Parenteral nutrition (PN) support refers to the provision of calories, amino acids, electrolytes, vitamins, minerals, trace elements, and fluids via a parenteral route. Access, prescribing, monitoring, and complications of parenteral nutrition are reviewed here.
The goals, outcomes, indications, contraindications, and nutritional requirements for parenteral nutrition are discussed separately. (See "Nutrition support in critically ill patients: An overview".)
The American Society of Parenteral and Enteral Nutrition recommendations for managing shortages relevant to components of parenteral nutrition can be accessed at the following site: http://www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update/.
INDICATIONS AND CONTRAINDICATIONS
The indications and contraindications for parenteral nutrition are described elsewhere. (See "Nutrition support in critically ill patients: An overview", section on 'Patient selection'.)
In order to initiate parenteral nutrition, appropriate access must be obtained and the prescription (ie, composition and infusion rate) must be determined. Guidelines suggest that when tolerance to enteral nutrition is evident, parenteral nutrition should be weaned and discontinued when >60 percent of the patients' needs are met enterally, although there are no data to support this practice .
- McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159.
- Kuwahara T, Asanami S, Tamura T, Kaneda S. Effects of pH and osmolality on phlebitic potential of infusion solutions for peripheral parenteral nutrition. J Toxicol Sci 1998; 23:77.
- Kuwahara T, Asanami S, Tamura T, Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: an experimental study in rabbits. Nutrition 1998; 14:186.
- Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81:466.
- DeLegge MH, Borak G, Moore N. Central venous access in the home parenteral nutrition population-you PICC. JPEN J Parenter Enteral Nutr 2005; 29:425.
- O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51:1.
- Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr 2004; 28:S39.
- Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28:251.
- Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr 2014; 38:296.
- Branched chain amino acids. http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 11, 2009).
- Type of lipids. http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 11, 2009).
- Manzanares W, Dhaliwal R, Jurewitsch B, et al. Parenteral fish oil lipid emulsions in the critically ill: a systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2014; 38:20.
- Edmunds CE, Brody RA, Parrott JS, et al. The effects of different IV fat emulsions on clinical outcomes in critically ill patients. Crit Care Med 2014; 42:1168.
- Hall TC, Bilku DK, Al-Leswas D, et al. A randomized controlled trial investigating the effects of parenteral fish oil on survival outcomes in critically ill patients with sepsis: a pilot study. JPEN J Parenter Enteral Nutr 2015; 39:301.
- Combined vitamins and trace elements http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 11, 2009).
- Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27:355.
- Composition of PN: Glutamine. http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on March 11, 2009).
- Grau T, Bonet A, Miñambres E, et al. The effect of L-alanyl-L-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients. Crit Care Med 2011; 39:1263.
- Jones JS, Tidwell B, Travis J, et al. Nutritional support of the hospitalized patient: a team approach. J Miss State Med Assoc 1995; 36:91.
- Kritchevsky SB, Braun BI, Kusek L, et al. The impact of hospital practice on central venous catheter associated bloodstream infection rates at the patient and unit level: a multicenter study. Am J Med Qual 2008; 23:24.
- Yilmaz G, Koksal I, Aydin K, et al. Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization. JPEN J Parenter Enteral Nutr 2007; 31:284.
- Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome. Nutr Clin Pract 2005; 20:625.
- Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008; 336:1495.
- Mattioli S, Miglioli M, Montagna P, et al. Wernicke's encephalopathy during total parenteral nutrition: observation in one case. JPEN J Parenter Enteral Nutr 1988; 12:626.
- Petrov MS, Zagainov VE. Influence of enteral versus parenteral nutrition on blood glucose control in acute pancreatitis: a systematic review. Clin Nutr 2007; 26:514.
- INDICATIONS AND CONTRAINDICATIONS
- - Dextrose
- - Amino acids and electrolytes
- - Lipids
- - Vitamins and trace elements
- - Glutamine
- Bloodstream infection
- Metabolic effects
- Venous access
- PERIPHERAL PARENTERAL NUTRITION
- SUMMARY AND RECOMMENDATIONS