Intravenous nutrition

9.3 Intravenous nutrition

When adequate feeding through the alimentary tract is not possible, nutrients may be given by intravenous infusion. This may be in addition to ordinary oral or tube feeding—supplemental parenteral nutrition, or may be the sole source of nutrition—total parenteral nutrition (TPN). Indications for this method include preparation of undernourished patients for surgery, chemotherapy, or radiation therapy; severe or pro- longed disorders of the gastro-intestinal tract; major surgery, trauma, or burns; prolonged coma or refusal to eat; and some patients with renal or hepatic failure. The composition of proprietary preparations available is given in the table Proprietary Infusion Fluids for Par- enteral Feeding, p. 527.

Parenteral nutrition requires the use of a solution con- taining amino acids, glucose, fat, electrolytes, trace ele- ments, and vitamins. This is now commonly provided by the pharmacy in the form of a 3-litre bag. A single dose of vitamin B , as hydroxocobalamin, is given by intramus- cular injection; regular vitamin B injections are not usually required unless total parenteral nutrition con- tinues for many months. Folic acid is given in a dose of

15 mg once or twice each week, usually in the nutrition solution. Other vitamins are usually given daily; they are generally introduced in the parenteral nutrition solution. Alternatively, if the patient is able to take small amounts by mouth, vitamins may be given orally.

The nutrition solution is infused through a central venous catheter inserted under full surgical precautions. Alternatively infusion through a peripheral vein may be used for supplementary as well as total parenteral nutrition for periods of up to a month, depending on the availability of peripheral veins; factors prolonging cannula life and preventing thrombophlebitis include the use of soft polyurethane paediatric cannulas and use of feeds of low osmolality and neutral pH. Only nutritional fluids should be given by the dedicated intra- venous line.

Before starting, the patient should be well oxygenated with a near normal circulating blood volume and atten- tion should be given to renal function and acid-base status. Appropriate biochemical tests should have been carried out beforehand and serious deficits corrected. Nutritional and electrolyte status must be monitored throughout treatment.

Complications of long-term parenteral nutrition include gall bladder sludging, gall stones, cholestasis and abnor- mal liver function tests. For details of the prevention and management of parenteral nutrition complications, spe- cialist literature should be consulted.

Protein is given as mixtures of essential and non-essen- tial synthetic L -amino acids. Ideally, all essential amino acids should be included with a wide variety of non- essential ones to provide sufficient nitrogen together with electrolytes (see also section 9.2.2). Solutions vary in their composition of amino acids; they often contain an energy source (usually glucose) and electrolytes.

Energy is provided in a ratio of 0.6 to 1.1 megajoules (150–250 kcals) per gram of protein nitrogen. Energy requirements must be met if amino acids are to be utilised for tissue maintenance. A mixture of carbohy- drate and fat energy sources (usually 30–50% as fat) gives better utilisation of amino acids than glucose alone.

526

9.3 Intravenous nutrition BNF 57

Nutritio

and

bl

ood

BNF 57

9.3 Intravenous nutrition 527

Proprietary Infusion Fluids for Parenteral Feeding

Electrolytes mmol/litre Other components/litre Preparation

Cl Aminoplasmal 5% E (Braun)

g/litre

kJ/litre

8 25 2.6 43 59 29 dihydrogen phosphate Net price 500 mL = £9.02

9 mmol, malic acid 1.01 g Aminoplasmal 10% (Braun)

16 57 Net price 500 mL = £17.06

Aminoven 25 (Fresenius Kabi) 25.7 Net price 500 mL = £23.20

Clinimix N9G20E (Baxter)

30 2.5 35 50 40 Ca 2.25 mmol, phosphate Net price (dual compartment bag

15 mmol, anhydrous glu- of amino acids with electrolytes

cose 100 g 1000 mL and glucose 20% with calcium 1000 mL) = £29.00

Clinimix N14G30E (Baxter)

30 2.5 35 70 40 Ca 2.25 mmol, phosphate Net price (dual compartment bag

15 mmol, anhydrous glu- of amino acids with electrolytes

cose 150 g 1000 mL and glucose 30% with calcium 1000 mL) = £33.00

ClinOleic 20% (Baxter)

purified olive and soya oil Net price 100 mL = £6.28; 250 mL

200 g, glycerol 22.5 g, egg = £10.08; 500 mL = £13.88

phosphatides 12 g Glamin (Fresenius Kabi)

Net price 250 mL = £14.58; 500 mL = £27.20

Hyperamine 30 (Braun)

Net price 500 mL = £23.67 Intralipid 10% (Fresenius Kabi)

soya oil 100 g, glycerol 22 g, Net price 100 mL = £4.70; 500 mL

purified egg phospholipids = £10.30

12 g, phosphate 15 mmol Intralipid 20% (Fresenius Kabi)

soya oil 200 g, glycerol 22 g, Net price 100 mL = £7.05; 250 mL

purified egg phospholipids = £11.60; 500 mL = £15.45

12 g, phosphate 15 mmol Intralipid 30% (Fresenius Kabi)

soya oil 300 g, glycerol Net price 333 mL = £17.30

16.7 g, purified egg phos- pholipids 12 g, phosphate

15 mmol Kabiven (Fresenius Kabi)

Nutrition

23 4 31 38 45 Ca 2 mmol, phosphate

Net price (triple compartment bag 9.7 mmol, anhydrous glu- of amino acids and electrolytes

cose 97 g, soya oil 39 g 300 mL, 450 mL, 600 mL, or 750 mL; glucose 526 mL, 790 mL, 1053 mL, or 1316 mL; lipid emul-

and

sion 200 mL, 300 mL, 400 mL, or 500 mL) 1026 mL = £35.00,

blood

1540 mL = £50.00, 2053 mL = £67.00, 2566 mL = £70.00

Kabiven Peripheral (Fresenius

17 2.8 22 27 33 Ca 1.4 mmol, phosphate Kabi)

7.5 mmol, anhydrous glu- Net price (triple compartment bag

cose 67.5 g, soya oil 35.4 g of amino acids and electrolytes 300 mL, 400 mL, or 500 mL; glu- cose 885 mL, 1180 mL, or 1475 mL; lipid emulsion 255 mL, 340 mL, or 425 mL) 1440 mL = £35.00, 1920 mL = £50.00, 2400 mL = £64.00

Lipidem (Braun)

omega-3-acid triglycerides Net price 100 mL = £18.00; 250 mL

20 g, soya oil 80 g, medium- = £30.00; 500 mL = £38.00

chain triglycerides 100 g Lipofundin MCT/LCT 10% (Braun)

soya oil 50 g, medium-chain Net price 100 mL = £7.70; 500 mL

triglycerides 50 g = £12.90

1. Note. 1000 kcal = 4200 kJ; 1000 kJ = 238.8 kcal. All entries are A 2. Excludes protein- or amino acid-derived energy

9.3 Intravenous nutrition BNF 57

Preparation 1;2 Nitrogen Energy Electrolytes mmol/litre Other components/litre

Acet Cl Lipofundin MCT/LCT 20% (Braun)

g/litre

kJ/litre

Mg

Na +

soya oil 100 g, medium- Net price 100 mL = £12.51; 250 mL

chain triglycerides 100 g = £11.30; 500 mL = £19.18

Nutriflex basal (Braun)

50 Ca 3.6 mmol, acid phos- Net price (dual compartment bag

phate 12.8 mmol, anhy- of amino acids 400 mL or 800 mL;

drous glucose 125 g glucose 600 mL or 1200 mL) 1000 mL = £24.99, 2000 mL = £27.50

Nutriflex peri (Braun)

15 4 27 19.5 31.6 Ca 2.5 mmol, acid phos- Net price (dual compartment bag

phate 5.7 mmol, anhydrous of amino acids 400 mL or 800 mL;

glucose 80 g glucose 600 mL or 1200 mL) 1000 mL = £26.00, 2000 mL = £28.70

Nutriflex plus (Braun)

25 5.7 37.2 22.9 35.5 Ca 3.6 mmol, acid phos- Net price (dual compartment bag

phate 20 mmol, anhydrous of amino acids 400 mL or 800 mL;

glucose 150 g glucose 600 mL or 1200 mL) 1000 mL = £27.15, 2000 mL = £31.10

Nutriflex special (Braun)

49.5 Ca 4.1 mmol, acid phos- Net price (dual compartment bag

phate 14.7 mmol, anhy- of amino acids 500 mL or 750 mL;

drous glucose 240 g glucose 500 mL or 750 mL) 1000 mL = £28.65, 1500 mL = £31.26

NuTRIflex Lipid peri (Braun)

24 2.4 40 32 38.4 Ca 2.4 mmol, Zn Net price (triple compartment bag

24 micromol, phosphate of amino acids 500 mL or 1000 mL;

6 mmol, anhydrous glucose

ood

glucose 500 mL or 1000 mL; lipid 64 g, soya oil 20 g, medium-

bl

emulsion 20% 250 mL or 500 mL) chain triglycerides 20 g 1250 mL = £43.38, 2500 mL =

and

NuTRIflex Lipid plus (Braun)

28 3.2 40 36 36 Ca 3.2 mmol, Zn Net price (triple compartment bag

24 micromol, phosphate of amino acids 500 mL, 750 mL or

12 mmol, anhydrous glu- 1000 mL; glucose 500 mL, 750 mL

Nutritio cose 120 g, soya oil 20 g,

or 1000 mL; lipid emulsion 20% medium-chain triglycerides

9 250 mL, 375 mL or 500 mL)

1250 mL = £47.17, 1875 mL = 20 g £60.23, 2500 mL = £69.27

anhydrous glucose 120 g, trolytes (Braun)

NuTRIflex Lipid plus without Elec- 5.44 3600

soya oil 20 g, medium-chain Net price (triple compartment bag

triglycerides 20 g of amino acids 500 mL, 750 mL or 1000 mL; glucose 500 mL, 750 mL or 1000 mL; lipid emulsion 20% 250 mL, 375 mL or 500 mL) 1250 mL = £47.17, 1875 mL = £60.23, 2500 mL = £69.27

NuTRIflex Lipid special (Braun)

48 Ca 4.24 mmol, Zn Net price (triple compartment bag

32 micromol, phosphate of amino acids 500 mL, 750 mL or

16 mmol, anhydrous glu- 1000 mL; glucose 500 mL, 750 mL

cose 144 g, soya oil 20 g, or 1000 mL; lipid emulsion 20%

medium-chain triglycerides 250 mL, 375 mL or 500 mL)

20 g 1250 mL = £57.69, 1875 mL = £75.58, 2500 mL = £89.21

NuTRIflex Lipid special without

anhydrous glucose 144 g, Electrolytes (Braun)

soya oil 20 g, medium-chain Net price (triple compartment bag

triglycerides 20 g of amino acids 500 mL, 750 mL or 1000 mL; glucose 500 mL, 750 mL or 1000 mL; lipid emulsion 20% 250 mL, 375 mL or 500 mL) 1250 mL = £57.69, 1875 mL = £75.58, 2500 mL = £89.21

1. Note. 1000 kcal = 4200 kJ; 1000 kJ = 238.8 kcal. All entries are A 2. Excludes protein- or amino acid-derived energy

BNF 57

9.3 Intravenous nutrition 529

Nitrogen Preparation 1;2 Energy Electrolytes mmol/litre Other components/litre g/litre

Cl OliClinomel N4-550E (Baxter)

kJ/litre

16 2.2 21 30 33 Ca 2 mmol, phosphate Net price (triple compartment bag

8.5 mmol, refined olive and of amino acids with electrolytes

soya oil 20 g, anhydrous 1000 mL; glucose 20% 1000 mL;

glucose 80 g lipid emulsion 10% 500 mL) 2500 mL = £69.30

OliClinomel N4-720E (Baxter)

24 2 28 40 40 Ca 1.8 mmol, phosphate Net price (triple compartment bag

8 mmol, refined olive and of amino acids with electrolytes

soya oil 40 g, anhydrous 1000 mL; glucose 20% 1000 mL;

glucose 80 g lipid emulsion 20% 500 mL) 2500 mL = £69.30

OliClinomel N5-800E (Baxter)

24 2.2 32 49 44 Ca 2 mmol, phosphate Net price (triple compartment bag

10 mmol, refined olive and of amino acids with electrolytes

soya oil 40 g, anhydrous 800 mL or 1000 mL; glucose 25%

glucose 100 g 800 mL or 1000 mL; lipid emulsion 20% 400 mL or 500 mL) 2000 mL = £60.39, 2500 mL = £65.34

OliClinomel N6-900E (Baxter)

24 2.2 32 53 46 Ca 2 mmol, phosphate Net price (triple compartment bag

10 mmol, refined olive and of amino acids with electrolytes

soya oil 40 g, anhydrous 800 mL or 1000 mL; glucose 30%

glucose 120 g 800 mL or 1000 mL; lipid emulsion 20% 400 mL or 500 mL) 2000 mL = £70.40, 2500 mL = £75.90

OliClinomel N7-1000 (Baxter)

37 16 phosphate 3 mmol, refined Net price (triple compartment bag

olive and soya oil 40 g, of amino acids 600 mL; glucose

anhydrous glucose 160 g 40% 600 mL; lipid emulsion 20% 300 mL) 1500 mL = £43.70

OliClinomel N7-1000E (Baxter)

24 2.2 32 57 48 Ca 2 mmol, phosphate Net price (triple compartment bag

10 mmol, refined olive and of amino acids with electrolytes

soya oil 40 g, anhydrous 800 mL; glucose 40% 800 mL; lipid

glucose 160 g emulsion 20% 400 mL) 2000 mL = £66.33

OliClinomel N8-800 (Baxter)

42.5 20 phosphate 2.25 mmol, Net price (triple compartment bag

refined olive and soya oil of amino acids 800 mL; glucose

30 g, anhydrous glucose 31.25% 800 mL; lipid emulsion

125 g

15% 400 mL) 2000 mL = £77.10 Omegaven (Fresenius Kabi)

highly refined fish oil 100 g,

Nutrition

Net price 100 mL = £22.50 glycerol 25 g, egg phospha- tide 12 g

Plasma-Lyte 148 (water) (Baxter)

98 gluconate 23 mmol Net price 1000 mL = £1.59

and

Plasma-Lyte 148 (dextrose 5%)

98 gluconate 23 mmol, anhy- (Baxter)

blood

drous glucose 50 g

Net price 1000 mL = £1.59 Plasma-Lyte M (dextrose 5%)

16 1.5 40 12 40 Ca 2.5 mmol, lactate (Baxter)

12 mmol, anhydrous glu- Net price 1000 mL = £1.33

cose 50 g 3 Primene 10% (Baxter)

15 19 Net price 100 mL = £5.78, 250 mL

= £7.92 SMOFlipid (Fresenius Kabi)

fish oil 30 g, olive oil 50 g, Net price 500 mL = £20.50

soya oil 60 g, medium-chain triglycerides 60 g

1. Note. 1000 kcal = 4200 kJ; 1000 kJ = 238.8 kcal. All entries are A 2. Excludes protein- or amino acid-derived energy 3. For use in neonates and children only

9.3 Intravenous nutrition BNF 57

Preparation 1;2 Nitrogen Energy Electrolytes mmol/litre Other components/litre

Acet Cl StructoKabiven Electrolyte Free

g/litre

kJ/litre

Mg

Na +

74.5 phosphate 2.8 mmol, anhy- (Fresenius Kabi)

drous glucose 127 g, glyce- Net price (triple compartment bag

rol 4.23 g, egg phospholi- of amino acids 500 mL, 750 mL or

pids 4.56 g, purified 1000 mL; glucose 42% 298 mL,

structured triglyceride 446 mL or 595 mL; lipid emulsion 188 mL, 281 mL or 375 mL)

38.5 g (contains coconut oil, 986 mL = £66.50, 1477 mL =

palm kernel oil and soya oil £69.00, 1970 mL = £74.00

trigylcerides) Structolipid 20% (Fresenius Kabi)

purified structured triglycer- Net price 500 mL = £16.09

ide 200 g (contains coconut oil, palm kernel oil, and soya oil triglycerides)

Synthamin 9 (Baxter) 9.1 60 5 70 100 70 acid phosphate 30 mmol Net price 500 mL = £6.66; 1000 mL

= £12.34 Synthamin 9 EF (electrolyte-free) 9.1 44 22

(Baxter) Net price 500 mL = £6.66; 1000 mL

= £12.34 Synthamin 14 (Baxter)

14 60 5 70 140 70 acid phosphate 30 mmol Net price 500 mL = £9.64; 1000 mL

= £17.13; 3000 mL = £48.98 Synthamin 14 EF (electrolyte–

14 68 34 free) (Baxter) Net price 500 mL = £9.87; 1000 mL = £17.51

Synthamin 17 (Baxter) 16.5 60 5 70 150 70 acid phosphate 30 mmol Net price 500 mL = £12.66;

ood

1000 mL = £23.00

bl

Synthamin 17 EF (electrolyte– 16.5 82 40

and free) (Baxter) n Net price 500 mL = £12.66;

1000 mL = £23.00

20 1.5 50 50 Ca 2.5 mmol, anhydrous Net price 100 mL = £3.80; 500 mL

Vamin 9 Glucose (Fresenius Kabi) 9.4 1700

glucose 100 g

Nutritio

= £7.70; 1000 mL = £13.40

9 Vamin 14 (Fresenius Kabi)

13.5 50 8 100 135 100 Ca 5 mmol, SO 8 mmol Net price 500 mL = £10.80;

1000 mL = £14.67 Vamin 14 (Electrolyte-Free)

(Fresenius Kabi) Net price 500 mL = £10.80;

1000 mL = £18.30 Vamin 18 (Electrolyte-Free)

18 110 (Fresenius Kabi) Net price 500 mL = £13.70; 1000 mL = £26.70

Vaminolact (Fresenius Kabi)

Net price 100 mL = £4.35; 500 mL = £10.00

1. Note. 1000 kcal = 4200 kJ; 1000 kJ = 238.8 kcal. All entries are A 2. Excludes protein- or amino acid-derived energy

BNF 57

9.3 Intravenous nutrition 531

Glucose is the preferred source of carbohydrate, but if pantothenic acid (as dexpanthenol) 17.25 mg, pyrid- more than 180 g is given per day frequent monitoring of

oxine hydrochloride 5.5 mg, retinol (as palmitate) blood glucose is required, and insulin may be necessary.

3500 units, riboflavin (as dihydrated sodium phos- Glucose in various strengths from 10 to 50% must be

phate) 4.14 mg, thiamine (as cocarboxylase tetrahy- infused through a central venous catheter to avoid

drate) 3.51 mg. Dissolve in 5 mL water for injections. thrombosis.

Net price per vial = £3.32 In parenteral nutrition regimens, it is necessary to

provide adequate phosphate in order to allow phos- phorylation of glucose and to prevent hypophosphatae-

Decan c (Baxter) A

, trace elements for addition to infusion mia; between 20 and 30 mmol of phosphate is required

Solution solutions, Fe , Zn , Cu , Mn , F , Co , I , Se ,

daily. Mo , Cr . For adults and children over 40 kg. Net Fructose and sorbitol have been used in an attempt to

price 40-mL vial = £2.00 avoid the problem of hyperosmolar hyperglycaemic

non-ketotic acidosis but other metabolic problems may occur, as with xylitol and ethanol which are now c Dipeptiven (Fresenius Kabi) A rarely used.

Solution , N(2)- L -alanyl- L -glutamine 200 mg/mL (providing L -alanine 82 mg, L -glutamine 134.6 mg).

Fat emulsions have the advantages of a high energy to For addition to infusion solutions containing amino fluid volume ratio, neutral pH, and iso-osmolarity with

acids. Net price 50 mL = £16.40, 100 mL = £30.50 plasma, and provide essential fatty acids. Several days

Dose amino acid supplement for hypercatabolic or hypermeta- of adaptation may be required to attain maximal utilisa-

bolic states, 300–400 mg/kg daily; max. 400 mg/kg daily, dose not tion. Reactions include occasional febrile episodes

to exceed 20% of total amino acid intake (usually only with 20% emulsions) and rare anaphylactic

responses. Interference with biochemical measure- ments such as those for blood gases and calcium may

Glycophos c Sterile Concentrate (Fresenius Kabi) A , sterile, phosphate 20 mmol, Na +

40 mmol/ occur if samples are taken before fat has been cleared.

Solution

20 mL. For addition to Vamin c and Vaminolact c Daily checks are necessary to ensure complete clear-

solutions, and glucose intravenous infusions. Net ance from the plasma in conditions where fat metab-

price 20-mL vial = £4.60 olism may be disturbed. Additives may only be mixed

with fat emulsions where compatibility is known. Peditrace c (Fresenius Kabi) A

Administration Solution , trace elements for addition to Vaminolact c , Because of the complex requirements relating to

Vamin c 14 Electrolyte-Free solutions and glucose parenteral nutrition full details relating to adminis-

intravenous infusions, traces of Zn , Cu , Mn , tration have been omitted. In all cases product litera-

Se , F , I . For use in neonates (when kidney function ture and other specialist literature should be consulted .

established, usually second day of life), infants, and children. Net price 10-mL vial = £4.18 Cautions reduced biliary excretion especially in cholestatic liver disease or in markedly reduced urinary excretion (careful bio-

chemical monitoring required); total parenteral nutrition exceed- ing 1 month (measure serum manganese concentration and check

Nutrition

liver function before commencing treatment and regularly during treatment)—discontinue if manganese concentration raised or if cholestasis develops

Supplementary preparations and

Solivito N c (Fresenius Kabi) A Compatibility with the infusion solution must be

blood

Solution , powder for reconstitution, biotin 60 micr-

ascertained before adding supplementary prepara- ograms, cyanocobalamin 5 micrograms, folic acid tions.

400 micrograms, glycine 300 mg, nicotinamide 40 mg, pyridoxine hydrochloride 4.9 mg, riboflavin sodium Addiphos c (Fresenius Kabi) A phosphate 4.9 mg, sodium ascorbate 113 mg, sodium

pantothenate 16.5 mg, thiamine mononitrate 3.1 mg. Na

Solution , sterile, phosphate 40 mmol, K + +

30 mmol/20 mL. For addition to Vamin solu- Dissolve in water for injections or glucose intravenous tions and glucose intravenous infusions. Net price 20-

c 30 mmol,

infusion for adding to glucose intravenous infusion or mL vial = £1.53

Intralipid c ; dissolve in Vitlipid N c or Intralipid c for adding to Intralipid c only. Net price per vial = £2.32

Additrace c (Fresenius Kabi) A

solutions and glucose intravenous infusions, traces of Vitlipid N (Fresenius Kabi) A Fe , Zn , Mn , Cu , Cr , Se , Mo , F , I . For

Solution , trace elements for addition to Vamin c c

Emulsion, adult , vitamin A 330 units, ergocalciferol adults and children over 40 kg. Net price 10-mL amp

20 units, dl-alpha tocopherol 1 unit, phytomenadione

15 micrograms/mL. For addition to Intralipid = £2.31 c . For

adults and children over 11 years. Net price 10-mL Cernevit c (Baxter) A amp = £2.32

Solution , dl-alpha tocopherol 11.2 units, ascorbic acid Emulsion, infant , vitamin A 230 units, ergocalciferol 125 mg, biotin 69 micrograms, colecalciferol

40 units, dl-alpha tocopherol 0.7 unit, phytomena- 220 units, cyanocobalamin 6 micrograms, folic acid

dione 20 micrograms/mL. For addition to Intralipid c . 414 micrograms, glycine 250 mg, nicotinamide 46 mg,

Net price 10-mL amp = £2.32

9.4 Oral nutrition BNF 57

9.4 form and relative contribution of carbohydrate and fat to Oral nutrition

the energy requirements. There are a number of nutritionally complete foods

9.4.1 Foods for special diets

available and their use reduces an otherwise heavy

9.4.2 Enteral nutrition

workload in hospital or in the home. Most contain protein derived from milk or soya. Some contain protein hydrolysates or free amino acids and are only appro- priate for patients who have diminished ability to break

9.4.1 Foods for special diets

down protein, as may be the case in inflammatory bowel disease or pancreatic insufficiency.

These are preparations that have been modified to Even when nutritionally complete feeds are being given eliminate a particular constituent from a food or are

it may be important to monitor water and electrolyte nutrient mixtures formulated as substitutes for the food.

balance. Extra minerals (e.g. magnesium and zinc) may They are for patients who either cannot tolerate or

be needed in patients where gastro-intestinal secretions cannot metabolise certain common constituents of

are being lost. Additional vitamins may also be needed. food.

Regular haematological and biochemical tests may be needed particularly in the unstable patient.