137Parenteral nutrition is the intravenous (IV) administration of nutrients via the venous system. In the past, IV nutrition was referred to as “hyperalimentation” or “total parenteral nutrition” but the current terminology is simply parenteral nutrition (PN), and in the case of home care, home PN (HPN). Administration of HPN is a well-accepted home infusion therapy. HPN may be a short-term therapy for some patients; for example, those who require a period of bowel rest as with pancreatitis, presence of fistulas, exacerbation of inflammatory bowel disease, or with disorders such as hyperemesis gravidarum. It may be a long or even lifetime therapy for patients with disorders such as short bowel syndrome, motility disorders (e.g., scleroderma), or malignancies. Pediatric indications for HPN are similar to adults including bowel rest, malabsorption, and motility disorders. PN is a complex infusion therapy that requires considerable patient education and patient monitoring. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), and more recently the European Society for Clinical Nutrition and Metabolism (ESPEN) provide standards and guidelines providing direction for HPN administration (e.g., Ayers et al., 2014; Boulatta et al., 2014; Durfee et al., 2014; Pironi et al., 2016).
After reading this chapter, the reader will be able to:
■ Summarize patient selection criteria
■ Describe key aspects of PN administration
■ Summarize components of comprehensive care, assessment, and monitoring
■ Prepare a plan for patient education
138UNDERSTANDING PN: AN OVERVIEW
Components of PN Solution
The PN solution is formulated based upon a formal and individualized nutritional assessment. Nutritional requirements vary based on age, nutritional status, disease, organ function, metabolic condition, and duration of PN. Due to the high-energy needs associated with growth, fluid and caloric requirements of pediatric patients are diverse within the ages of birth to 18 years.
HPN is most often administered with the fat emulsion, dextrose, amino acids, and other additives mixed in a single container. This is called “3-in-1” or “total nutrient admixture (TNA).” Infusion administration for home patients is simplified with the use of a single container. Components of PN solution include fluid, protein, carbohydrate, fat, electrolytes, vitamins and trace minerals, and medications.
Fluid
■ Basic requirements are 30 to 35 mL/kg/d.
■ Fluid needs are higher when there are significant fluid losses (e.g., diarrhea and enterocutaneous fistula).
Protein
■ It is required for tissue growth and repair and replacement of all body cells.
■ There is no storage of protein; all protein is functional.
■ It is provided in the form of synthetic amino acids, both essential and nonessential.
■ Various commercial formulations and concentrations are available.
Carbohydrate
■ Major function is as an energy-providing nutrient, sparing body protein.
■ If not immediately used, it is stored in the liver and muscle as glycogen; when glycogen storage is exhausted, excess carbohydrate is then stored as fat.
■ 139Needs are based on estimation of energy requirements; generally used to provide about 50% of calories in PN solution.
■ It provides 4 kcal/g.
Fat
■ Its primary purpose is to provide metabolic fuel and prevent essential fatty acid deficiency (EFAD); EFAD can occur in as little as 5 days without supplementation (Krzywda & Meyer, 2014).
■ It is provided in the form of lipid emulsion that contains a combination of essential and nonessential fatty acids, glycerin, and phospholipids.
■ It is more calorically dense providing 9 kcal/g.
Electrolytes
■ Standard preparations are available in premixed formulas that include sodium, potassium, magnesium, calcium, chloride, and phosphorus.
■ Additional amounts are added based on patient need determined by serum electrolyte levels.
Vitamins and Trace Elements
■ Multivitamins should be a component of all PN formulas (Durfee et al., 2014).
■ Multivitamin solution is added to the HPN solution just prior to initiating infusion because there is lack of long-term stability of vitamins in solution.
■ Vitamin K is included in the pediatric multivitamin preparation but is not included in the standard adult multivitamin solution; must be added separately.
■ Trace elements are micronutrients that are found in the body in minute amounts (Table 10.1). They include iron, iodine, zinc, copper, chromium, manganese, and selenium and molybdenum; when iron is clinically indicated, there are alternate forms available including separate infusions (Durfee et al., 2014). Iron dextran can be added to an HPN solution that does not contain fat; however, an iron dextran test is required before the initial infusion due to the risk of allergic reaction.
■ Vitamin and trace element doses are adjusted as needed (Pironi et al., 2016).
140Table 10.1
Trace Elements in PN Solutions
| Trace element | Purpose | Signs/symptoms of deficiency |
| Iron | Oxygen transport | Pallor, fatigue, exertional dyspnea, tachycardia, paresthesias, and glossitis/stomatitis |
| Iodine | Thyroid hormone synthesis | Hypothyroidism |
| Copper | Involved in the action of many oxidative enzymes | Microcytic anemia, neutropenia, osteoporosis, depigmentation of hair/skin, and skeletal demineralization |
| Chromium | Potentiates actions of insulin | Neuropathy, insulin-resistant glucose intolerance, and hyperlipidemia |
| Manganese | Involved in enzyme activation | Extrapyramidal symptoms, bony abnormalities, central nervous system dysfunction, weight loss, dermatitis, nausea, vomiting, and change in hair color |
| Selenium | A component of various enzymes; one enzyme protects cells from lipid peroxides and free radicals | Muscle dysfunction, including cardiac and myalgias |
| Zinc | Most abundant trace element; needed for RNA, DNA, and protein synthesis; plays a role in wound healing | Alopecia, scaly skin, dermatitis, diarrhea, mental depression/apathy, glucose intolerance, night blindness, impaired taste/wound healing, and T-lymphocyte dysfunction |
| Molybdenum | Cofactor for sulfite oxidase and xanthine oxidase | Headache, night blindness, irritability, lethargy, and coma |
Source: Krzywda and Meyer (2014).
PN, parenteral nutrition.
Medications
141■ The complexity of PN solutions increases the possibility of physiochemical interactions such as precipitation, loss of drug activity, or clumping or curdling of the solution between the drug and the solution (Rollins, 2012).
■ Compatible medications that may be added to the PN include insulin, histamine receptor agonists (e.g., famotidine), and heparin. Current guidelines recommend against the addition of heparin in the PN solution as it has not been shown to decrease the risk of catheter-associated thrombosis (Boullata et al., 2014).
Fast Facts in a Nutshell
Only limited additives to any PN solution should be made outside of the compounding pharmacy. Concentrated electrolyte solutions should not be added to PN in the home and no additions to the PN solution should be made after PN administration has started.
PATIENT SELECTION CONSIDERATIONS
■ The patient and family are motivated, willing, and capable of participating in self-infusion management.
PN is a complex therapy that must be integrated into the daily life of the patient and family. The patient or caregiver must participate in infusion administration and monitoring. With some exceptions, such as very short courses of HPN, the patient or caregiver is expected to learn how to administer PN independently.
Preparation for HPN varies by institution. Acute care settings with nutritional support teams provide careful patient and family evaluation and significant patient education in preparation for home care. Patients discharged from acute care settings without specialty teams may be less prepared. Home care teaching and support and the expertise of the home care clinicians become more critical.
■ The patient is clinically stable prior to going home with PN.
Weight maintained or increased as per HPN goals
Stable blood chemistry levels
142Stable nutritional laboratory indicators
No evidence of rebound hypoglycemia with discontinuation of cyclic infusions
No adverse reactions
■ The patient is stabilized on the intended home infusion regimen for PN prior to acute care discharge.
Patients may be converted from a continuous to a cyclic infusion at home but this requires increased monitoring for fluid volume (overload), glucose, and electrolyte imbalances as the IV rate is increased to deliver the infusion over a shorter period of time.
Initiating HPN without prior hospitalization is done, although infrequently. Requirements include clinical stability and capability of being educated in the home. This should be done based only on an analysis of benefits versus risks (Durfee et al., 2014). Laboratory data are obtained prior to initiation of PN. Thorough nutritional assessment and comprehensive patient and family education are required before starting HPN. Close monitoring of patient response to fluid volume continuous infusion and a decreased rate and/or concentration of infusion are also recommended.
■ A central vascular access device (CVAD) is in place.
Patients receiving HPN may have an implanted port, a tunneled catheter, or a peripherally inserted central catheter (PICC); for long-term HPN, tunneled catheters, ports are recommended over PICCs due to higher thrombosis risk and more difficulty with self-administration with PICCs (Pironi et al., 2016).
Never administer HPN via a short peripheral or midline catheter because HPN solutions are irritating formulas that contain greater than 10% dextrose and/or 5% protein. Note that peripheral parenteral nutrition (PPN) may be administered by a peripheral catheter but this type of nutritional support is uncommon in home care. PPN is characterized by lower osmolarity (≤900 mOsm) and lower dextrose concentration (<10%; Boullata et al., 2014; Gorski et al., 2016).
■ The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.
HPN and related supplies are generally delivered to patient homes on a weekly basis. The HPN bags are stored in the refrigerator. In some cases, the home infusion pharmacy may provide a small refrigerator dedicated to PN storage.
■ 143Reimbursement is verified.
Private third-party payers vary in coverage.
Certain diagnoses and HPN infusions may be covered under the durable medical equipment benefit under Part B of the Medicare program. Patients must meet criteria that include “permanence” interpreted as requiring HPN for at least 3 months.
COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING
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