Administering Parenteral Nutrition

Considerations for Methods of Parenteral Nutrition Delivery

In the planning of parenteral nutrition (PN), the proper route of access is crucially important. PN solutions are administered either via a central venous catheter or via peripheral venous cannulas.1

The choice of the appropriate administration route, i.e., peripheral or central venous, must be based on the following criteria1,3,4:

  • Condition of the patient (type of disease, current state of health, etc.)
  • Accessibility of the venous system
  • Composition of the infused solution and amount of energy to be administered
  • Osmolarity of PN products
  • Planned duration of PN (short-term or long-term)

 

 

Central Venous PN Route of Access

Central venous access is indicated in the majority of patients with the following conditions1,3,4:

  • Need for long-term nutritional support
  • Poor peripheral veins
  • Need for hyperosmolar solutions (osmolarity greater than 850 mOsmol/l)
  • High energy and nutrient requirements
  • Severe fluid restriction
  • Administration of solution with pH lower than five or greater than nine
  • Need for multiple lumen intravenous treatment

In the case of central venous PN, the catheter type needs to be considered as well. Different catheter types are used in response to specific patient conditions.2,3,4

Central catheters are inserted into a central vein, usually with the catheter tip being located at the junction of the superior vena cava and right atrium.2

 

 

Peripheral Venous PN Route of Access

Peripheral administration is performed via a cannula or catheter inserted into a peripheral vein, usually of the forearm.2

The decision to administer via peripheral access depends on whether the solution is hypertonic, isotonic or hypotonic. The osmolarity of the parenteral solution, which refers to the number of osmotically active particles in one liter of solution, is a crucial factor in determining the feasibility of peripheral PN (PPN). Hypertonic solutions are irritants to the veins, causing pain, phlebitis and thrombosis.2

Generally, (local) complications with the peripheral route such as peripheral vein thrombophlebitis can be prevented by4:

  • Aseptic techniques during catheter placement and care
  • Choice of the smallest gauge possible
  • Use of polyurethane and silicone catheters
  • Appropriate osmolarity of the solution
  • Administration of solutions with pH >5 and <9
  • Adequate fixation (transparent adhesive membranes or sutureless fixation devices)
  • Use of lipid-based solutions

 

The addition of lipid emulsions reduces osmolarity and appears to exert a protective effect on the vascular endothelium. For this reason, PN admixtures containing lipid emulsions are more suitable for PPN than emulsions based solely on glucose as an energy source.2

 

References
  • 1.Jauch KW, Schregel W, Stanga Z, et al. Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9. Ger Med Sci. 2009;7(19):1-18.
  • 2.Pertkiewicz M, Dudrick SJ. Parenteral nutrition. Methods of delivering parenteral nutrition. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011:348-369.
  • 3.National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guidelines, No. 32 London 2006.
  • 4.Pittiruti M, Hamilton H, Biffi R, et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications). Clin Nutr, 2009;28:365-77.

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