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Parenteral Nutrition

Parenteral nutrition (Para: other; Enteral: gastro-intestinal tract) is a concept of providing nutritional support without using gastro-intestinal tract. Indications of PN Parenteral nutritional supported is indicated in case of people who do not have functional GI tract or other bowel disorders. Some of the conditions where PN preferred in adults include the following: Severely malnourished- marked weight loss and muscle wasting Gastro-intestinal failure- GI fistula, inflammatory bowel disorder, Pancreatis etc.

Incase of neonates and paediatrics PN if provided due to intestinal failure so as to establish and maintain good nutritional state. PN indicated in children depending upon the duration of disease condition i.e. either short term or long term which are detailed as follows: Short term Major intestinal surgery Post chemotherapy Acute pancreatic Prematurity Multi-organ failure, Trauma and burns Route of administration Parenteral nutrition is provided by two main route i.e. peripheral parenteral nutrition and central parenteral nutrition depending on the duration of therapy and formulation. Peripheral route is preferred when nutritional support is required for short period of time and also glucose concentration less than 12.5%. Central route is preferred when the duration of therapy is longer and peripheral venous access is unavailable and high caloric density solution. Nutritional requirements Nutritional requirements are similar in adults and children but vary in the required quantities. Nutrition requirements are categorised as follows: 1) Macro nutrients Water, Amino acid solution, carbohydrate and fat 2) Micronutrients- Vitamins (water soluble and fat soluble), Trace elements 3) Electrolytes- Sodium, Potassium, Magnesium, calcium and phosphate. Long term Enteropathy Pseudo-obstruction Short gut

1.1 Carbohydrate: Carbohydrate is main source of energy and glucose is used as the main source of carbohydrates in PN formulation. 1.2 Amino acid Different types of amino acid solution are available which suites in using for neonates, paediatrics and adult formulation. Aminoacid Vaminolact Vamin 9 glucose Aminoven Vamin 18EF Used in Children<15kg Children >15kg Adults Adults Profile Breast milk amino acid Egg protein amino acid Fluid restricted Fluid restricted

Amino acid is used as main source of protein in PN formulation. 1.3 Lipid Lipids provide essential fatty acids to the body. Various standard lipid formulations are available which contain different sources of lipids. Various standard lipid formulations available includes Lipid formulation Intralipid SMOF Omegaven Lipofundin Clinoleic Contents Purified Soya-bean oil and Purified Egg phospholipids Soya-Bean oil, MCT, Olive oil and Fish oil Highly refined fish oil (EPA and DHA) Structured lipids(MCT/LCT) Olive oil 80%+Soya-bean oil 20%

2.1 Vitamins
Wide range of water and fat soluble vitamins are provided depending on the individual needs and some of the products containing vitamins include the following: Source Cernevit Solvito Vitlipid Adult or Vitlipid Infant Vitamins Contain water and fat soluble vitamins except Vitamin K Water soluble vitamins Fats soluble vitamins

Water soluble Vitamins: Vitamin C and Vitamin B complex [B1 (Thiamine); B2 (riboflavin); B6 (pyridoxine)] Fat soluble vitamins: Vitamin A, D, E, and K

2.2 Trace elements Some of the products that contains various trace elements are as follows Product Peditrace Additrace Decan Trace elements Zinc, Copper, selenium, Manganese Ferrous, zinc, Copper, Selenium, Manganese Ferrous, Zinc, Copper, Selenium, Manganese.

3.1 Electrolytes
Sodium, Potassium, Magnesium, Calcium and phosphate are the electrolytes provided in wide ranges depending on the patients condition and blood results. Complications: Complications can be described into mechanical, metabolic as well as due to overfeeding and inadequate feeding which are as follows: Mechanical Septicaemia Catheter Occlusion Thromboemboli Metabolic Liver diseases: Cholestasis, Cirrhosis Electrolyte and trace elements disturbances

Problems of overfeeding: Glucose: Hyperglycaemia; Liver Problems. Lipid: Hyperlipidaemia; Immunosupression.

Nitrogen: Fluid loss to excrete unwanted nitrogen, Increases Mortality in animal models. Fluid and salts: Delayed recovery in gut function, delayed wound healing, Effects in Electrolyte balance Problems of inadequate feeding: Electrolytes: Might not be given at all; be given down the IV lumen. Micronutrients: Clinical deficiency: Scurvy, Retinal Problems, Osteomalacia. Impaired function: Wound healing, Immunity.

Regimen Choice: Triple chamber bags: Less time consuming, Long expiry pre-use, and will probably needs to make electrolyte and micronutrient additions. Ex: Kabiven, Oliclinomel and Nutriflex ranges. Bespoke Regimen: More accurately suits the patients needs, but needs more time to arrange and expensive. Stability Issues: Chemical Instability Electrolytes: Na, K are monovalent inorganic ions which posses few stability problems. Ca and Mg are divalent ions which forms precipitation reaction with phosphate.

Vitamins: Undergoes degradation in presence of light Vitamin C undergoes oxidation reaction in presence of Oxygen. pH: As the pH in solution increases favours binding of dibasic phosphate to bind with free calcium. Temperature: As the Temp increases there is more calcium ions available to form complex with phosphate. Aminoacid: Increase in aminoacid concentration causes drop in pH, which causes more solubility of calcium and phosphate thus giving stability.

Physical Instability Trace element Precipitation: Aminoacid containing sulphur and cysteine reacts with Zinc and copper ions causes crystallisation which causes defiency. Iron undergoes precipitation with phosphate as iron phosphate in presence of synthamin. Calcium Phosphate Precipitation.

Lipid emulsions: Lipid globules tend to aggregate together which leads to instability like aggregation, creaming and cracking. Depends on many factors like temp, pH, Electrolyte etc.