310 CHAPTER 20 | Nutrition Support Intravenous Access
Intravenous access is determined by the expected length of therapy and by the individual responsible for managing the access device, such as the older adult, clinician, or family member. A variety of intravenous access devices can be used to administer PN, and they are categorized as either peripheral or central and temporary or permanent. Peripheral catheters can be used to administer peripheral PN; however, this is short-term therapy and likely will not be able to fully meet nutritional needs.22,30
It should be used in
the rare occasions when EN or PN is delayed or not available for a short period of time (< 2 weeks). Central catheters are used to administer more concentrated PN. Tunneled catheters (eg, Hickman, Broviac, and Groshong) are inserted surgically or radiologically, are tunneled subcutaneously, and have an exit site on the chest wall. Implantable devices (eg, Mediport and port-a-cath), are inserted surgi- cally, are completely under the skin, and are accessed using a special needle. A peripherally inserted cen- tral catheter (PICC) is another type of intravenous access device that can be inserted radiologically or at the bedside by a specially trained nurse. A PICC is typically used to administer intravenous antibiotics but can also be used for PN. Permanent catheters (ie, tunneled catheters, implanted devices, or PICCs) are usually required for long-term administration of PN in nursing facilities or at home.30 Regular and meticulous care of central catheters is imperative to prevent catheter-related problems such as infection or sepsis. Catheter sepsis is the most common therapy-related reason for hospital admis- sion of clients receiving PN. Catheter care protocols must be in place in any institution or home parenteral therapy program where catheters are used for nutri- tion support.
Components of Parenteral Nutrition Solutions
Macronutrients
The macronutrients used in PN solutions include dextrose, amino acids, and lipids.2
Requirements
are based on the individual’s clinical and nutritional status.2,22
Dextrose is the primary source of energy,
provides 3.4 kcal/g, and is available in concentra- tions ranging from 5% to 70%. Amino acids provide 4 kcal/g and are available in concentrations ranging from 3% to 15%. Lipids as ILEs provide essential fatty acids in addition to being a source of energy. ILE, commonly provided in a 20% concentration (although 10% is available), should be provided daily in the PN solution. ILEs differ based on the source of oil used in the
product. Newer ILEs have a mixture of oils reducing the omega-6 content, which has been shown to be more efficacious for long-term use.17
A 20% ILE con-
tains 2 kcal/mL or 10 kcal/g. The macronutrient com- position of PN solutions administered to older adults may need to be adjusted to compensate for age-related changes in body composition, nutrient metabolism, and organ function.2
Protein needs should always be
met first to ensure adequate protein intake, with ILE next as 25% to 30% of calories and the balance made up with dextrose.
Fluids
PN solutions must meet fluid requirements for individuals unable to maintain hydration enterally or orally.2
Fluid intake must be adequate to replace normal losses via urine, feces, sweat, and respiration, along with abnormal losses such as output from osto- mies, fistulas, wounds, or drainage tubes. Maintain- ing fluid homeostasis is more difficult in older adults because of age-related alterations in thirst perception and decreases in cardiovascular and kidney function. Careful monitoring and documentation of fluid input and output, weight, laboratory values, and vital signs is necessary for managing fluid status in individuals receiving PN.
Micronutrients
Electrolytes, minerals, vitamins, and trace elements are essential for normal cellular function and need to be added daily to the PN solution.2,22,31,32
Requirements
vary among individuals based on clinical status, nutri- tional status, kidney function, and medications. There are no different standards for micronutrients when provided via the intravenous route. Electrolytes are commercially available as single or multiple additives and can be added as needed to the PN solution. Most
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