Nutrition, Parenteral

Source: Mattox TW and Crill CM. Parenteral Nutrition. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8012448. Accessed July 28, 2012.

Provision of macro- and micronutrients by central or peripheral venous access to meet specific nutritional requirements

Consider parenteral nutrition (PN) when nutritional requirements cannot be met through use of gastrointestinal (GI) tract (Table 1).
Consider after suboptimal nutritional intake for:
- 1 day in preterm infants
- 2–3 days in term infants
- 3–5 days in critically injured children
- 5–7 days in other children
- 7–14 days in older children and adults
Route and type of PN depend on patient’s clinical state and expected length of PN therapy (Figure 1).

Table 1. Indications for Adult Parenteral Nutrition

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Table 1. Indications for Adult Parenteral Nutrition...

1. Inability to absorb nutrients via GI tract because of one or more of the following:

a. Massive small bowel resection: usually patients with <100 cm (39 in) of small bowel distal to ligament of Treitz without colon, or <50 cm (20 in) of small bowel with intact colon

b. Intractable vomiting when adequate EN not expected for 7–14 days

c. Severe diarrhea

d. Bowel obstruction

e. GI fistulas: PN indicated in patients with prolonged inadequate nutritional intake longer than 5–7 days who are not candidates for EN.

2. Cancer: antineoplastic therapy, radiation therapy, or HSCT

a. PN may be used in moderately to severely malnourished patients receiving active anticancer treatment who are not candidates for EN.

b. PN not routinely indicated for well-nourished or mildly malnourished patients undergoing surgery, chemotherapy, or radiation therapy.

c. PN unlikely to benefit patients with advanced cancer whose malignancy is unresponsive to treatment. However, use may be appropriate for carefully selected patients who have failed trials of less-invasive medical therapies and have good performance status, estimated life expectancy of longer than 40–60 days, and strong social and financial support.

d. PN appropriate for patients undergoing HSCT who are malnourished and anticipated to be unable to ingest and/or absorb adequate nutrients for 7–14 days. PN should be discontinued as soon as toxicities have resolved after stem-cell engraftment.

3. Pancreatitis: PN may be used in patients with severe pancreatitis with prolonged inadequate nutritional intake longer than 5–7 days who are not candidates for EN. PN should be used when EN exacerbates abdominal pain, ascites, or fistula output.

4. Critical care

a. PN should be used in patients in whom EN contraindicated or unlikely to provide adequate nutritional requirements within 5–10 days.

b. Organ failure (liver, renal, or respiratory): PN should be used in patients with moderate to severe catabolism when EN contraindicated.

c. Burns: PN should be used in patients in whom EN contraindicated or unlikely to provide adequate nutritional requirements within 4–5 days.

5. Perioperative PN

a. Preoperative: for 7–14 days for patients with moderate to severe malnutrition who are undergoing major GI surgery, if the operation can be safely postponed

b. Postoperative: PN should be used in patients in whom EN is contraindicated or unlikely to provide adequate nutritional requirements within 7–10 days.

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