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Parenteral Nutrition: Principles Indications and Complications

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All the human races, animals and other living things need food in their day to day survival. Unfortunately, with plenty quantities of food, some cannot take their share of it. This could be as a result of the failure of the gut to an extent that certainly prevents tolerable gastrointestinal absorption of nutrients, consequent and persistent intestinal failure for several (more than five in this matter) days, or one may have had a surgery to remove the part or all of the stomach and bowel. When this occurs, nutrition is supplied in a different one, being parenteral nutrition. Parenteral nutrition refers to the administration of nutrients through the intravenous route. In humans, parenteral nutrition applies to all ages through a vein in either the chest or arm. It could be as a result of Diabetes Mellitus, Azotemia, Electrolyte disorders, Congestive heart failure or Pulmonary disease.

Principles

Various types of parenteral nutrition have varying principles. Parenteral nutrition is divided into the two categories, namely: partial parenteral nutrition and total parenteral nutrition. Partial parenteral nutrition (PPN) is normally prescribed to those patients who can tolerate some feeding habits, but have a problem with ingesting enough amounts of foods to meet their nutritional requirements. It’s normally administered through a peripheral intravenous catheter. Total parenteral nutrition is offered to a patient when there is a need for an intensive nutritional support.  It is more often than not administered through a central venous catheter, using fusion pump. Unlike the partial parenteral nutrition, its TPN solutions usually contain high concentrations of proteins and dextrose.

There are many considerations that need to be made, in order to arrive at a decision of giving a parenteral nutrition care. The general principles of parenteral nutrition, according to (Foster et al.,2010) include:

  • Patients who are incapable of devouring “sufficient” nutrients for a “lengthened” period of time by means of oral or enteral routes need parenteral nutrition treatment to thwart the undesirable effects of malnutrition.
  • The decision to use parenteral nutrition can be difficult, since the precise definition of “sufficient” and “lengthened” is not clear and depends on the patient’s body fat, lean tissue mass, preexisting medical illnesses, and level of metabolic stress.
  • Parenteral nutrition should be considered, if the intake has been or is to be anticipated to be inadequate (that is below fifty percent of the daily requirements) for more than seven to ten days, and enteral feeding is not feasible. It has not yet been given clinical test.
  • Routine use of immediate postoperative TPN does not appear to improve the outcomes in unselected patients.

Indications

The decision to administer parenteral nutrition therapy to a patient is based on the patient’s medical assessment and the nutrition needs. Generally, parenteral nutrition is indicated for patients who do not have functioning gastrointestinal tracks, and those who are malnourished or are likely to become so. The therapy, though important, may be an implication of damage to one’s life though the severe damage of the tissues and intestinal tracks. The indications for the parenteral nutrition also depend on the category. However, there are other common indications. Other considerations include the age and maturity of the patient being assisted. The common indications are as discussed in the next paragraphs.

Firstly, in some situations the patient could be failing enteral nutrition with appropriate tube placement.  This is attributed to the failure in the tubes or wrong placement techniques used. The complications, therefore, would demand an alternative.

The second indication is a severe acute pancreatic. This stipulation is associated with the development of acute and impulsive inflammation of the pancreas. It can have severe complications and high mortality, if not diagnosed and treated early. Its initiation into the body is associated with the excessive consumption of alcohol, gallstones, some infections (such as Clonorchis, mumps among others), malignancy, drug abuse and abdominal trauma among others. It’s highly associated with the parenteral nutrition indications.

Another indication is severe short bowel syndrome, a malabsorption disorder that is majorly caused by the surgical amputation of the small intestine or on the odd occasion, due to the dysfunction of a large segment of the bowel. It’s majorly acquired even though some children are born with the complications. Its symptoms include fatigue, diarrhea, abdominal pain, malnutrition and weight loss and fluid depletion.

 Mesenteric ischemia, an inflammatory condition of the small intestine, due to inadequate blood supply through the mesenteric arteries, is also an indication. It normally occurs when one of the blood arteries is blocked or narrowed majorly in older people above sixty years old. It can be either acute or chronic. It’s difficult to diagnose it at an early age.

 Paralytic ileus is another indication that defines the partial or complete blockage of the bowel that results into the failure of the intestinal contents to pass through. It may be as a result of mechanical reasons, ileus and pseudo-obstruction. Its causes vary from one to another, depending on the kind of activities and bad luck encountered.

The last indication to discuss is the small bowel obstruction and the Gastrointestinal (GI) fistula, unless the enteral access is placed distal to the fistula, or where the volume of output warrants trial of Enteral Nutrition (EN). It prevents the normal transit of the products of digestion and occurs at any level of distal to duodenum. It is conservatively treated for a period of over two or five days with the patient under the monitoring by the assigned physician. Depending on the level of obstruction, it may be characterized by constipation, abdominal distension, fecal vomiting, vomiting and abdominal pain.

The contraindications include: functional and accessible GI tract, patient taking the oral diet, the prognosis does not warrant an aggressive nutrition support, risk exceeds benefit, the patient expected to meet all the needs within fourteen days.

In summary, the indications of parenteral nutrition include: bowel obstruction, blood and marrow transplant, short bowel syndrome, paralytic Ileus, fistula, inflammatory bowel disease, server pancreatitis, intractable vomiting or diarrhea and severe electrolyte, mineral and glucose imbalance. Any patient diagnosed with these conditions is considered candidate for parenteral nutrition.

Complications

Patients on parenteral nutrition need a lot of care, as for any mistake may terminate one’s life. There are many factors to consider, while administering the therapy, in order for one to achieve the set goals. The patients receiving parenteral nutrition are at a risk of receiving many complications. These complications may result from the solutions administered or from the central venous catheter.

To begin with, there is a possibility of fluid overload in patients receiving blood products. The administration of blood products needs a careful monitoring, that if violated, it would lead to the patient getting excess of a certain product e.g. hemoglobin.  The nurse or other medical practitioners could be running the blood too hurriedly, in order that an emergency be overcome. This violates the flow rate of the product and medical settings, hence, putting the patient at many risks. The results of these practices are even worse.

Extreme hyperosmolarity of the solutions administered may cause the fluid shifts in the body. Hyperosmolarity in this context is caused by concentrations of amino acids and dextrose. The increase in the level of dextrose is a potential cause of hyperglycemia, which in turn causes dextrose to move into the interstitial spaces in the plasma. This in turn causes a series of events that may lead to dehydration and hypovolemic shock. The situation is even worse, when the patient’s heart or kidney is not efficiently functioning and may lead to congestive heart failure and pulmonary edema. Whenever a patient is on the solutions, he or she should be observed keenly to avoid the risks of more significant complications. The body fluid, the serum electrolyte levels should be monitored keenly for every course, and a record taken upon which the decisions are made on what to give next (Howard, 1998).

Another possible complication for the patients under the parenteral nutrition is the range of electrolyte imbalance. Daily serum electrolyte levels should be taken into account.

Another complication allied to parenteral nutrition is contagion at the site of the central venous catheter. Due to the medications through this path, it is exposed to contamination by other blood, fluids, parasites and microorganisms. This exposure is a bridge to the creation of more problems than solutions, since more complications will be introduced through it.

In general, the complications can be categorized into mechanical and metabolic related complications. The mechanical complications include: catheter infection, pneumothorax, arterial laceration, nerve injury, hydrothorax, hemothorax, sepsis, air embolism, thoracic duct injury, venous embolism and perforation and catheter embolism. The metabolic complications include: hyperglycemia characterized by sepsis, liver disease, pancreatitis and rapid initiation of infusion; hyperglycemia characterized by slowing of the infusion, endogenous overproduction of insulin and excessive insulin administration; hyperosmolar hyperglycemic nonketotic comafever; fluid overload; electrolyte abnormality; acid based imbalances; trace mineral deficiency  and liver function derangement.

Parenteral nutrition is very important in our day-to-day pediatrics practices. It helps to give a sense of life to a few individuals suffering from digestive track related complications. However, there are principles of practice guiding the considerations, when making the decision on who should be a beneficiary of the same. The indications give a clear support on how to identify them and with the complications fostered we can take great care in handling our patients. The complications alert us of the risks that we bear during the practice.

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