ADULT 
                         PARENTERAL 
                           NUTRITION 
                         CURRICULUM 
                       Nassau University Medical Center 
     Revised 5-2019 by Lisa Musillo MS, RDN, CNSC 
     Formatting & Citations by Fariha Azad, MPH, MS, RDN 
      Table of Contents 
      Objectives ................................................................................................................................................................................................................... 3 
      Introduction ............................................................................................................................................................................................................... 3 
                                2 3
      Indications for Parenteral Nutrition    ........................................................................................................................................................... 4 
        Contraindications for Parenteral Nutrition ............................................................................................................................................. 4 
      Vascular Access ........................................................................................................................................................................................................ 4 
        Peripheral Venous Access ............................................................................................................................................................................... 5 
        Central Venous Access ...................................................................................................................................................................................... 5 
        Peripherally Inserted Central Catheter (PICC or PIC line) ................................................................................................................ 5 
      PN Formulation Components ............................................................................................................................................................................. 6 
        Energy Substrates .............................................................................................................................................................................................. 6 
          Carbohydrates ................................................................................................................................................................................................. 6 
        Lipid Injectable Emulsion ............................................................................................................................................................................... 9 
          Amino Acids ................................................................................................................................................................................................... 11 
          Electrolytes..................................................................................................................................................................................................... 12 
        Vitamins................................................................................................................................................................................................................ 13 
        Trace Elements .................................................................................................................................................................................................. 14 
      Parenteral Nutrient Preparations .................................................................................................................................................................. 15 
      Stability and Compatibility of PN .................................................................................................................................................................... 16 
        Lipid Emulsion ................................................................................................................................................................................................... 16 
        Calcium and Phosphate .................................................................................................................................................................................. 17 
        Vitamins and Trace Elements ...................................................................................................................................................................... 18 
        Drugs and PN ...................................................................................................................................................................................................... 18 
      Filters ......................................................................................................................................................................................................................... 18 
      Prescribing Parenteral Nutrition .................................................................................................................................................................... 19 
        PN Osmolarity .................................................................................................................................................................................................... 19 
        Parenteral Nutrition Order Writing .......................................................................................................................................................... 21 
        Premixed PN – Clinimix ................................................................................................................................................................................. 24 
        Initiation of PN ................................................................................................................................................................................................... 25 
        Monitoring Patients on PN ........................................................................................................................................................................... 25 
        Storage and Handling ...................................................................................................................................................................................... 25 
        Discontinuation of PN ..................................................................................................................................................................................... 26 
      Parenteral Nutrition Safety ............................................................................................................................................................................... 27 
      Complications ......................................................................................................................................................................................................... 29 
        Infections ............................................................................................................................................................................................................. 29 
        Mechanical Complications ............................................................................................................................................................................ 29 
        Metabolic Complications ............................................................................................................................................................................... 30 
          Macronutrient Related Complications ................................................................................................................................................ 30 
      Revised 5-2019                                                                      1 
             Micronutrient Related Complications ................................................................................................................................................. 31 
                           8,20
               Electrolytes    .......................................................................................................................................................................................... 32 
               Vitamins ...................................................................................................................................................................................................... 33 
               Trace Elements ........................................................................................................................................................................................ 33 
             Refeeding Syndrome .................................................................................................................................................................................. 34 
             Hepatobiliary Complications .................................................................................................................................................................. 36 
             Metabolic Bone Disease ............................................................................................................................................................................ 37 
             Allergy/Hypersensitivity to components of PN .............................................................................................................................. 39 
        PN Ordering on Sunrise ...................................................................................................................................................................................... 39 
        References ................................................................................................................................................................................................................ 40 
        Glossary of Terms/Abbreviations .................................................................................................................................................................. 44 
        Appendix: Sample order forms and processes .......................................................................................................................................... 45 
        Revised 5-2019                                                                                                     2 
              Objectives   
               
              The participant will be able to: 
                     1.  Identify appropriate patients who will benefit from parenteral nutrition (PN).  
                     2.   State the best PN route based on the patient’s nutritional, metabolic, and clinical status. 
                     3.  List the basic components typically incorporated into a PN formulation. 
                     4.  Formulate a basic PN solution, including the appropriate dosing of macronutrients and 
                            micronutrients. 
                     5.  Adjust the PN solution daily based upon laboratory data and physical assessment. 
                     6.  Describe the clinical and laboratory monitoring required for the use of PN. 
                     7.  Identify the potential complications associated with PN. 
                     8.  Transition to enteral nutrition (EN) therapy while maintaining adequate nutrition support. 
                     9.  Discontinue PN therapy. 
              Introduction  
               
              Parenteral nutrition (PN) is a life-saving method of nutrition support when enteral nutrition (EN) 
              support is not an option. This therapy has been in use for over 50 years, however its history dates back 
              more than 350 years.  PN is the provision of nutrients intravenously. A complete, balanced formulation 
              includes dextrose as the carbohydrate source; amino acids; fat emulsions (lipids) in addition to a variety 
              of electrolytes such as potassium, magnesium, and phosphorus; vitamins; and multiple trace minerals 
              (zinc, copper, manganese, chromium, selenium). It can also be used as a vehicle to provide certain 
              medications. The principal forms of PN are central and peripheral—which describes the venous route of 
              delivery. 
              Central parenteral nutrition (CPN) is often referred to as “total parenteral nutrition” (TPN), since the 
              entire nutrient needs of the patient may be delivered by this route. TPN is not a preferred acronym since 
              total nutrition can be provided peripherally if a larger volume is prescribed.  CPN has higher glucose 
              content (usually greater than 12% final concentration) and, along with amino acids (AA) and electrolytes, 
              provides a hyperosmolar (1300-1800mOsm/L) formulation that must be delivered into a large-diameter 
              vein, usually the superior vena cava. Central venous access can be maintained for prolonged periods 
              (weeks to years). 1 
               Peripheral parenteral nutrition (PPN) can have similar nutrient composition as CPN but with a larger 
              volume and lower osmolarity.  It contains a lower concentration of dextrose (usually ≤10% final 
              concentration) and amino acids (≤4.25% final concentration) so it may be delivered via the peripheral 
              vein. PPN may be used for patients to provide partial or complete nutrition support when they are unable 
              to receive it orally or enterally. PPN therapy is typically used in patients who can tolerate a higher fluid 
              load.  
              PN is a nutrition option not without risk and should be ordered for the appropriate patients. Risks 
              include those related to infection, access, electrolyte and glycemic management, and vitamin and trace 
              element deficiencies or excesses. A skilled and knowledgeable clinician should be responsible for the 
              management of PN therapy.                                                                                                                                                                                  3 
              Revised 5-2019