Rationale for Parenteral Nutrition

The principal indication for parenteral nutrition is when use of the gastrointestinal tract for feedings is not possible. In some instances, intravenous nutrition may be used to supplement inadequate oral intake. The safe and successful use of parenteral nutrition requires proper selection of patients with specific nutritional needs, experience with the technique, and an awareness of the associated complications. As with enteral nutrition, the fundamental goals are to provide sufficient calories and nitrogen substrate to promote tissue repair and to maintain the integrity or growth of lean tissue mass. The following are cases in which parenteral nutrition has been used in an effort to achieve these goals:

1. Newborn infants with catastrophic gastrointestinal anomalies, such as tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia

2. Infants who fail to thrive from gastrointestinal insufficiency associated with short bowel syndrome, malabsorption, enzyme deficiency, meco-nium ileus, or idiopathic diarrhea

3. Adult patients with short bowel syndrome secondary to massive small bowel resection (<100 cm without colon or ileocecal valve, or <50 cm with intact ileocecal valve and colon)

4. Enteroenteric, enterocolic, enterovesical, or highoutput enterocutaneous fistulas (>500 ml/day)

5. Surgical patients with prolonged paralytic ileus following major operations (>7-10 days), multiple injuries, or blunt or open abdominal trauma, or patients with reflex ileus complicating various medical diseases

6. Patients with normal bowel length but with malabsorption secondary to sprue, hypoproteine-mia, enzyme or pancreatic insufficiency, regional enteritis, or ulcerative colitis

7. Adult patients with functional gastrointestinal disorders such as esophageal dysmotility following cerebral vascular accident, idiopathic diarrhea, psychogenic vomiting, or anorexia nervosa

8. Patients with granulomatous colitis, ulcerative colitis, and tuberculous enteritis, in which major portions of the absorptive mucosa are diseased

9. Patients with malignancy, with or without cachexia, in whom malnutrition might jeopardize successful delivery of a therapeutic option

10. Failed attempts to provide adequate calories by enteral tube feedings or high residuals

11. Critically ill patients who are hypermetabolic for more than 5 days or when enteral nutrition is not feasible

Conditions contraindicating hyperalimentation include the following:

1. Lack of a specific goal for patient management, or where instead of extending a meaningful life, inevitable death is prolonged

2. Periods of hemodynamic instability or severe metabolic derangement (severe hyperglycemia, azotemia, encephalopathy, hyperosmolality, and fluid-electrolyte disturbances) requiring control or correction before attempting hypertonic intravenous feeding

3. Feasible gastrointestinal tract feeding (in the vast majority of instances, this is the best route by which to provide nutrition)

4. Patients in good nutritional status

5. Infants with less than 8 cm of small bowel, since virtually all have been unable to adapt sufficiently despite prolonged periods of parenteral nutrition

6. Patients who are irreversibly decerebrate

Total parenteral nutrition Also referred to as central parenteral nutrition, total parenteral nutrition requires access to a large-diameter vein to deliver the entire nutritional requirements of the individual. Dextrose content is high (15-25%) and all other macro- and micronutrients are deliverable by this route.

Peripheral parenteral nutrition The lower osmolar-ity of this solution secondary to reduced dextrose (5-10%) and proteins (3%) allows administration via peripheral veins. Some nutrients cannot be supplemented due to inability to concentrate them into small volumes. Therefore, peripheral parenteral nutrition is not appropriate for repleting patients with severe malnutrition. It can be considered if central routes are not available or if supplemental nutritional support is required. Typically, peripheral parenteral nutrition is used for less than 2 weeks. Beyond this time, total parenteral nutrition should be instituted.

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