Peripheral parenteral nutrition in postoperative care

Know more about the postoperative care in peripheral parenteral nutrition

Postoperative catabolism puts patients at need of tailored nutritional support

Like all significant injuries, major surgeries are severe stress situations for the body. Important organ and regulatory systems such as the cardiovascular system, the immune system, and the neuronal hormones switch to survival-mode in order to protect the most critical organs, creating a metabolic state called catabolism. This state is characterized by the breakdown of energy stores including glycogen and fat as well as muscle protein, releasing glucose, free fatty acids and amino acids for healing and immune response.[1] The resulting loss of muscle mass is a significant long-term burden for the recovery of functional status. Therefore, it is of key importance to avoid long periods of perioperative fasting and the associated accumulation of energy and protein deficits.1

Following major surgery, enteral nutrition is the preferred route of providing nutrients if oral feeding is not possible. If enteral nutrition is contraindicated (e.g. in case of intestinal obstruction) or insufficient (e.g. due to gastrointestinal intolerance) the use of parenteral nutrition (PN) is recommended, alone or in addition to enteral feeding, to bridge the nutritional gap.

Peripheral PN should be considered as a straightforward alternative to central venous feeding

Patients who have difficulty with enteral access or a delay in central venous access, and are at risk of developing a nutritional deficit can be considered for peripheral PN. The insertion of a peripheral intravenous catheter does not require a surgeon or an x-ray for control of the correct placement of the catheter tip, and is the quickest and simplest way of establishing intravenous access. It may well bridge the time until central venous access or adequate enteral feeding can be established.[2]

If a central venous catheter is in place after surgery, PN is usually administered via this route. However, the supply is regularly interrupted during therapeutic or diagnostic procedures and whenever medication is administered via the same route. Experts call for a diligent documentation of delivered amounts of nutrition, commonly failing to reach the prescribed supply.[3]

Patients suitable for peripheral PN have peripheral veins available for cannulation and can handle large amounts of fluid. Sterile working procedures and careful surveillance of the insertion side for the development of thrombophlebitis should be monitored.[4]

Formulas for peripheral PN facilitate safe application

The choice of the peripheral PN solution will contribute to the success of the nutrition therapy:

  • PN solutions specifically composed for peripheral PN to minimise the risk of thrombophlebitis through a low osmolarity and a pH between 5 and 9.[5]
  • Lipids as the main energy source and moderate concentrations of osmotically active glucose and protein allow for an osmolarity below 850 mOsm/L.5, [6]
  • Intravenous lipid emulsions may have a protective effect on the vein.5
  • All-in-one solutions are safe in terms of sterility and stability of the solution.6
  • Fish oil-containing parenteral nutrition (PN) is associated with statistically and clinically significant positive effects on clinical outcomes, such as lower relative risk of infection and sepsis rates, and shorter length of intensive care unit (ICU) and hospital stay.[7]
References
  • 1Weimann A, Braga M, Carli F, et al. (2017) ESPEN guideline: Clinical nutrition in surgery. Clinical nutrition (Edinburgh, Scotland) 36:623-650
  • 2Gura KM, (2009) Is there still a role for peripheral parenteral nutrition? Nutr Clin Pract. 24:709-17.
  • 3Berger MM, Reintam-Blaser A, Calder PC et al., (2019) Monitoring nutrition in the ICU. Clin Nutr. 38:584-593
  • 4Pertkiewicz M, Dudrick SJ (2009) Basics in clinical nutrition: Parenteral nutrition, ways of delivering parenteral nutrition and peripheral parenteral nutrition (PPN). E-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4:e125-e127
  • 5Pittiruti M, Hamilton H, Biffi R et al. (2009) ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr.28:365-77.
  • 6Culebras JM, Martin-Peña G, Garcia-de-Lorenzo A et al., (2004) Practical aspects of peripheral parenteral nutrition. Curr Opin Clin Nutr Metab Care.7:303-7.
  • 7Pradelli L, Mayer K, Klek S et al. (2020) ω‐3 Fatty‐Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta‐Analysis and Trial Sequential Analysis. JPEN J Parenter Enteral Nutr. 44:44-57.

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