What's in Parenteral Nutrition?

What's in Parenteral Nutrition?



hey everyone welcome back to dietitians in nutrition support today we're kicking off our parenteral nutrition series talking about what you might find in your typical bag of prendre nutrition we'll discuss all three of the macronutrients micronutrients and other considerations you may have to take when you start recommending parenteral nutrition for your patients let's go ahead and get started as a nutrition support dietitian or a future one you'll be working closely with IV nutrition otherwise known as parenteral nutrition or p-n understanding PN and all of its complexities can take some time but having this background will allow for you to provide the best care possible to your pn patients and these skills are often associated with higher-level practice leadership opportunities and independence in your work so let's start off this conversation talking about what's in parental nutrition when we're talking about parental and nutrition there's a few different options the first option we're going to discuss is custom parenteral nutrition within this category you have the opportunity to customize all three of the macronutrients as well as the micronutrients found in the parenteral nutrition solution there's a few primary options for custom PN the first choice is called a two-in-one solution meaning there's two macronutrients in one solution within a two-in-one solution you'll see the two macronutrients included are amino acids and dextrose these will provide the protein and carbohydrates needed to your patients now you may think where's our third macronutrient lipids well with a two in one solution you can only provide amino acids and dextrose but you may see what's called a lipid piggyback added to your patients parenteral nutrition recommendation this will allow for them to get those customized lipids just given separately from the two-in-one solution you should note that a two in one solution is typically clear a lipid piggyback is oftentimes a cloudy white color it's important to know what parenteral nutrition typically looks like so you can spot any abnormalities as they arise the second kind of custom parenteral nutrition we'll see is a three-in-one solution meaning all three macronutrients within one solution this will include the amino acids the dextrose and the lipids within this solution you still have the ability to customize all three of the macronutrients and the micronutrients but it'll be a little different than the two and one in the separate lipid piggyback being that they're all combined together and we'll have a cloudy appearance the second variety of parenteral nutrition often seen in hospitals is standard parenteral nutrition within this category we're looking at pre-formulated bags of parenteral nutrition they often come in different varieties offering different amounts of calories as well as macronutrients oftentimes with a standard level of micronutrients within the standard parenteral nutrition category you'll still see a two in one option that provides amino acids and dextrose all of which can be accompanied by that lipid piggyback that we previously talked about in custom parenteral nutrition and you'll also see the three-in-one parenteral nutrition that will provide amino acids in dextrose and lipids both custom and parenteral nutrition can provide your patient with a nutrition they need for the 24 hour period that a parenteral nutrition bag will typically hang for institutions will often determine whether or not they want custom parenteral nutrition or standard parenteral nutrition but some facilities will offer both for facilities that create custom parenteral nutrition they will have to have a sterile environment for all of the custom parenteral nutrition to be compounded together into the parenteral nutrition formula this solution is typically made in the pharmacy if your institution has custom parental nutrition that's compounded within the facility and you're interested in seeing how that works I encourage you to ask the pharmacist if you might be able to observe the process whether or not your hospital has custom or standard parenteral nutrition will be based on what they've selected to provide to their patients sometimes you'll see just custom or just standard parenteral nutrition available and at other hospitals you'll see both make sure to take some time to get to know what your institution has available so that you can make those recommendations for your patients who may be in need of parenteral nutrition so let's start chatting about what macronutrients we're going to see within our parenteral nutrition and what they can provide to our patients the first one we're starting with is protein also known as amino acids within parenteral nutrition their protein provided to our patients will be given as amino acids and thankfully for us it is concocted to be the perfect balance of all essential amino acids to ensure that your patients get just what they need similarly to an oral or an enteral recommendation you'll see that the amino acids provided through parenteral nutrition are also for kcals per gram of protein this allows you to make a pretty easy calculation just as you normally would for your patients protein recommendations all those standard bags do not allow you as much opportunity to customize the amount of protein provided to your patient you will be able to see a total number of protein grams within the solution that you'll be providing within custom parenteral nutrition you'll see that there's an opportunity to select a Verret from a variety of solutions that each contain a different amount of protein in grams based on their concentration for example of this you might see a 25% amino acid solution which actually equals 250 grams of protein per one liter of solution so you can make your own recommendations of concentration as well as volume to ensure that your patient gets the right amount of amino acids in their parenteral nutrition alright let's move on to carbohydrates when we're talking about carbohydrates provided and parenteral nutrition they're a little bit different than the carbohydrates you might consume orally or entirly within this solution specifically we'll be using dextrose now while dextrose can provide carbohydrates to your patient just know that the calculations are a touch different because dextrose is not the typical 4 K Cal's per gram of carbohydrate but it's actually 3.4 K Cal's per gram of dextrose just remember this one when you start to calculate because it's often forgotten similar to protein you'll see that the amount of dextrose you can provide in a carbohydrate solution can differ so you can offer different concentrations which would allow for different amounts of grams of dextrose depending on the volume that you provided for example we might see a 10% dextrose solution that would equal 100 grams of dextrose per one liter of solution so working with your math there to try and figure out how many grams of dextrose they need you can determine an appropriate concentration of solution and then in turn an appropriate volume to provide to your patients our third macronutrient is obviously lipids when we're talking about lipids we may be considering the lipids within a three in one solution or potentially even as a lipid piggyback but it's important for us to know that there's often two primary concentrations that people will be talking about when they're discussing intravenous lipid emulsions the first of our two varieties of lipids is the 10% lipid solution at this percentage we'll see 1.1 kcals per milliliter or a total of 100 grams of lipid per one liter of solution so you can make your calculations based on the amount of grams of lipid you need or you can make it based on the amount of calories you need from lipid similarly we'll see a 20% lipid solution within this solution you'll see that it's to cake house per milliliter or you'll also see it written as 200 grams of lipid per one liter of solution depending on your institution they will be the ones to help you determine whether or not you need to write this recommendation in the amount of kcals or in the amount of grams of lipid you'd like to provide also you may see some institutions choose to only provide either the 10 percent or the 20 percent lipid so make sure you're familiar with the offerings at your institution one thing to know about intravenous lipid emulsions is that they actually contain ten kcals per gram of lipid so it's a touch higher than you would typically see in an oral or an enteral diet and this is due to extra glycerol that's added to the formula so make sure you take that into consideration when you're making calculations for your patients now that we finished up our macronutrients let's talk a little bit about micronutrients multivitamin and mineral solutions added into parenteral nutrition is very common within custom parenteral nutrition you will likely just check the box to say yes please add the standard multivitamin / mineral solution into my parenteral nutrition so I can prevent any deficiencies and micronutrients for my patient within a standard bag you may likely see it already mixed into the solution as the bag is likely ready to hang so we're all good there some caution is necessary with patients who might have special concerns due to irregularly high or irregularly low micronutrient needs for example an individual who's an alcoholic might require additional thiamine supplementation that can be added into their parenteral nutrition while you can add additional micronutrients into the pn bag it doesn't always suit the needs of the patient and isn't always the best solution so you may see a separate hanging solution of a specific group or a single micronutrient that will be infusing externally from the pn bag don't be alarmed by this but just know that this is a treatment option should there be something saying that the extra micronutrient should not be added to the parenteral nutrition or maybe you've already just hung the parenteral nutrition bag and you don't have time to add the micronutrient anymore so know there are multiple options when approaching micronutrients in parental nutrition alright let's chat about electrolytes whether or not an RD will manage electrolytes are just lights for short is based on hospital policy and protocol are the skillset and comfort with making recommendations and choice of parenteral nutrition used in-house whether it's a standard or a custom bag with a competent RD managing lights for a custom parenteral nutrition bag they will make daily recommendations for what the lights they'd like to see added into the parenteral nutrition for the patient's best management this is based on labs that are typically taken in the morning time that will allow for the dietitian to view what kind of electrolytes are currently in the person system and then try and provide the amount of electrolytes needed to maintain appropriate balance within normal limits primarily custom PN bags are meant to hang for 24 hours a day meaning that you need to plan accordingly when you make lights recommendations for the entire next 24 hours should hospital policy states though or if the Rd does not feel comfortable a pharmacist can also determine what lights will go into the bag of prendre nutrition with a standard bag of parenteral nutrition lights are often already added at a standard level and the bag should be ready to hang based on the hospital policy for hang time with no need to make extra considerations for electrolytes well we've made it to our last section other additives most of the time in this category we're talking about medications medications can sometimes be added to parenteral nutrition not every medication is appropriate to be added into this IV solution but if the doctors on the team and the pharmacists on the team have determined that it would be appropriate to add the medication in you may see them infusing within the parenteral nutrition when we're talking about concerns with medications were oftentimes looking for something called a precipitate the precipitate itself can be from any strange interaction between certain chemicals in the premise real nutrition solution and they could happen from the medication or they could happen from other things in solution so make sure to kind of keep this in mind just as you continue to provide parenteral nutrition support to your patients this can be anything from a cloudiness to kind of a greediness or sediment type thing at the bottom of a parenteral nutrition bag so if you see anything that seems strange particularly within the clear two-in-one bags you may want to bring it up to your care team it's a little more difficult to see a precipitate within a three in one solution being that the lipids are particularly kind of cloudy in themselves so if you see any concerns it's likely to happen in a two and one but we'll keep our eyes open for issues so three and one solutions as well overall of course this is the entire care team's responsibility to make sure our patient is getting the best care possible including their parenteral nutrition and any medications that could be provided through it so keeping an extra eye out for what it looks like and making sure it's infusing appropriately is always important I hope this video has been helpful for you as we have introduced what you might see in a bag of parenteral nutrition if you have any comments or questions please don't forget to leave them in the boxes below and if you like what you saw please don't forget to like our video and subscribe to our channel for more updates on parenteral nutrition including case studies coming in the future take care and we'll see you next time

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