Parenteral nutrition

Parenteral nutrition is the provision of nutrients intravenously. It is used in patients who cannot
meet their nutritional goals by the oral or enteral route. When the gut is not working, PN is also
used for long-term nutrition support in the home setting. The principle forms of PN are peripheral
and central (TPN).

PN should only be initiated in patients who are hemodynamically stable and who are able to
tolerate the fluid volume, protein, carbohydrate, and lipid doses necessary to provide adequate
nutrients.

Conditions warranting cautious use of PN:

• Azotemia
• Congestive heart failure
• Diabetes Mellitus
• Electrolyte disorders
• Pulmonary disease

Central PN (TPN) is a concentrated formula which is hyperosmolar and must be delivered into a
central vein. TPN provides:

• Carbohydrates in the form of glucose.

• Protein in the form of amino acids.
• Lipids in the form of triglycerides.
• Electrolytes.
• Vitamins and trace minerals.

Peripheral PN has similar nutrient components as TPN but in a lower concentration so it may be
delivered by peripheral vein. Large fluid volumes must be administered to provide comparable
nutrients. PPN is typically used for short periods (up to two weeks) because of limited tolerance.
 EN Indications Advantages Disadvantages
administration
 routes

Nasogastric • Intact gag reflex • Easy tube • Highest risk of

• No esophageal insertion pulmonary
reflux aspiration
• Normal gastric • Larger reservoir
emptying capacity in • Patient self-
stomach conscious due to
• Stomach appearance of
uninvolved with nasogastric tube
primary disease
Nasoduodenal • Gastroparesis or • Reduced • Potential GI
impaired gastric aspiration risk intolerance
emptying compared to (bloating,
NG cramping,
• Esophageal diarrhea) to goal
reflux TF infusion rate
• May require
endoscopic
placement of
nasoenteric tube
• Patient self-
conscious due to
appearance of
nasoenteric tube

• Tube
displacement
and potential
aspiration
Nasojejunal • Gastroparesis or • TF may be • Potential GI
impaired gastric initiated intolerance to
emptying immediately goal TF infusion
• Esophageal after injury rate
reflux • May require
• Reduced endoscopic
• Gastric aspiration risk placement of
dysfunction due compared to tube
to trama or NG • Patient self-
surgery conscious due to
appearance of
nasoenteric tube

• Tube
 displacement
and potential
aspiration
Gastrostomy • Long-term • Placed • Potential risk of
feeding; normal adjunctly with aspiration
gastric GI surgery • Stoma care
emptying • No surgery needed; potential
• Swallowing needed for infection at
dysfunction and percutaneous stoma site
subsequent endoscopic • Potential skin
impairment of gastronomy excoriation from
ability to (PEG) leakages of
consume an oral • PEG less costly digestive
diet than surgical secretions at
• Nasoenteric gastronomy stoma site
route • Large bore tube • Potential fistula
unavailable provides after tube
• Intact gag decreased risk removed
reflex; no of tube
esophageal occlusion • Surgery needed
reflux for surgical
• Larger reservior gastrostomies
• Stomach capacity in
uninvolved with stomach
primary disease
• Potential GI intolerance to goal TF infusion rate Jejunostomy
• Stoma care needed; potential infection at stoma site
• Potential skin excoriation from leakages of digestive secretions at stoma site
• Potential fistula after tube removed
• Tube occlusion with small bore tube or needle catheter

• Surgery needed for surgical jejunostomies

• Reduced
risk of
aspiratio
n Long-
term
feeding
• Placed
adjunctl
y with
GI
surgery
• No
surgery
needed
for
percutan
eous
endosco
pic
jejunosto
my
(PEJ)
• PEJ less
costly
than
surgical
jejunosto
my

• TF may
be
initiated
immedia
tely after
injury
• High
risk of
aspiratio
n
• Esophag
eal
reflux
• Inability
to access
upper GI
tract
• Gastropa
resis or
impaired
gastric
emptyin
g

• Gastric
dysfunct
ion due
to trama
or
surgery