How Is Parenteral Nutrition Applied?

Parenteral Nutrition Application Systems and Modes of Delivery

Parenteral nutrition (PN) admixtures contain a broad range of components in varying amounts and combinations. There are several application systems available to meet various patient needs, including:

Single-Bottle Systems

With single-bottle systems, amino acids, glucose, lipids and electrolytes are administered in parallel from separate bottles by combining multiple connectors that feed into a common IV catheter. Vitamins and trace elements are usually added to PN from concentrated preparations.1,2

 

In figure: The single-bottle system 3

 

The single-bottle system is associated with various disadvantages2rendering its use inconvenient in clinical practice:

However, if handled correctly, single-bottle systems offer wide flexibility when it comes to dosage and enabling highly specific PN therapy, adjusting to various patient needs.1,2

 

All-In-One Systems

All-in-One (AiO) systems combine all components of PN, macronutrients, water, electrolytes, vitamins and trace elements, in one container to be administered via a single infusion line.2

The clinical advantages of AiO admixtures include:

AiO systems come in three forms:

 

Compounding PN: Ready-To-Use Admixtures

As in the AiO system, compounding enables the provision of ready-to-use admixtures that can be adjusted to the energy, volume and substrate needs of the majority of patients. Customized admixtures are often mandatory in patients with rapidly changing metabolic requirements (e.g. critical care patients, and patients with metabolic disorders or fluid restriction). The simultaneous administration of all substrates reduces the risk for metabolic complications.1

Compounded bags are aseptically manufactured from various sterile components, usually in hospital pharmacies, and are designed for immediate intravenous administration with no mixing or admixing of further ingredients required. Due to physicochemical instability, compounded bags require short-term production according to strict aseptic techniques by pharmaceutical experts. Proper storage of compounded bags should be in a temperature range of two to eight °C.1

The use of compounded bags does have several limitations, including:

Under specific clinical conditions, nutritional therapy needs to be adapted accordingly. Specific clinical conditions include10:

 

 

Automated Compounding

In many large hospital centers, compounding of PN is performed using automated compounding devices. Compared to manual manufacturing, using such devices can lower the risk of human errors, improve the accuracy of compounding and reduce personnel workload.11,12

 

Multi-Chamber Bags

Two-Chamber Bags

Two-Chamber Bags are standard AiO bags with two chambers containing glucose and amino acids to be mixed together immediately prior to intravenous infusion by breaking the separation seals between the bag chambers. The lipid emulsion is admixed with a transfer set shortly prior to administration. Vitamins, trace elements and additional electrolytes are either added to the lipid emulsion or infused by a separate intravenous line. When not mixed together, these bags have a shelf life of more than 12 months.1

In photo: A 2-chamber bag before mixing of components. 3

 

Three-Chamber Bags

Three-Chamber Bags (3CBs) systems are standard AiO bags that allow delivery of macronutrients, with or without electrolytes, provided in three separate compartments that are divided by seals which can easily be opened prior to administration by rolling up the bag. Micronutrients (vitamins and trace elements) can be added to the reconstituted mixture as needed.

In photo: A 3-chamber bag before mixing of components. 3

 

 

In photo: Mixing of the 3-chamber bag 3

 

Compared to other application systems, 3CBs possess a number of key advantages:

Modes of Delivery3

PN may be delivered using a pump for intravenous feeding or by gravity. Criteria for the choice of the appropriate mode of delivery include:

Infusion by gravity relies on hydrostatic pressure without the assistance of an infusion pump. The infusion rate is regulated by a passive flow controller and calculated basing on the drip rate. The flow controller can be a roller clamp interacting with the tube directly or a specific flow rate controller. The latter achieves a higher accuracy and stability of flow rate. Gravity infusion is recommended if demands for infusion rate and precision are comparatively low.

Pump-assisted infusion is performed by means of a volumetric pump working in combination with infusion systems or by means of syringe devices controlling flow with a motor-driven piston. This approach is appropriate for low-volume infusions. Pump-assisted infusion ensures high precision with constant infusion rates and enables programmable rate cycling.

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