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Parenteral

Nutrition:

A Basic Overview

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor,

professor of academic medicine, and

medical author. He graduated from Ross

University School of Medicine and has completed his clinical clerkship training in

various teaching hospitals throughout New York, including King’s County Hospital

Center and Brookdale Medical Center, among others. Dr. Jouria has passed all

USMLE medical board exams, and has served as a test prep tutor and instructor for

Kaplan. He has developed several medical courses and curricula for a variety of

educational institutions. Dr. Jouria has also served on multiple levels in the academic

field including faculty member and Department Chair. Dr. Jouria continues to serves

as a Subject Matter Expert for several continuing education organizations covering

multiple basic medical sciences. He has also developed several continuing medical

education courses covering various topics in clinical medicine. Recently, Dr. Jouria

has been contracted by the University of Miami/Jackson Memorial Hospital’s

Department of Surgery to develop an e-module training series for trauma patient

management. Dr. Jouria is currently authoring an academic textbook on Human

Anatomy & Physiology.

Abstract

All individuals need food to sustain life, but sometimes nutrients

cannot be absorbed through the stomach or bowel, or food digested

due to illness or injury. When this occurs with patients, the standard

method of eating is replaced by parenteral nutrition, which is a

lifesaving measure that involves placing an intravenous catheter in a

large vein and supplying proteins, carbohydrates, fats, vitamins, and

minerals through the intravenous solution directly to the blood supply.

Mechanical pumps are typically used to dispense the solution at

specified intervals. If needed, parenteral nutrition can be a lifelong

treatment.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity.

Statement of Learning Need

Parenteral nutrition delivers essential basic nutrients and trace

elements and is provided generally through a central intravenous

route. It is a lifesaving method to provide nutrition for patients unable

to obtain nutrients by ingesting food.

Course Purpose

To provide nursing professionals with basic knowledge of parenteral

nutrition when it is indicated, and of its benefits and risks.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 3/24/2018

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


1. A patient is administered nutrition through a feeding tube.

Which type of nutrition does this indicate? A. parenteral

B. enteral C. total parenteral nutrition

D. total enteral nutrition

2. Parenteral nutrition solution contains all of the following

EXCEPT? A. proteins

B. carbohydrates C. vitamins

D. fiber

3. For short term parenteral nutrition therapy of less than two weeks, which one of the following methods are

typically used: A. tunneled VADs

B. subclavian vein access C. PICCs

D. None of the above

4. A patient in need of parenteral nutrition therapy has a

high gastric output. This patient will need additional quantities of which electrolyte:

A. Magnesium B. potassium

C. phosphorus

D. chloride

5. All of the following are preventive measures concerning

the potential for infection related to parenteral nutrition therapy, EXCEPT:

A. thorough hand hygiene measures B. use of PICC lines

C. proper catheter care D. use of implanted ports


Introduction

When a patient cannot digest food due to illness, nutrients may need

to be provided by other means. One method, known as parenteral

nutrition, involves feeding the patient intravenously, bypassing the

usual process of eating and digestion.1 The concept of parenteral

nutrition was initially practiced in the 17th century when practitioners

infused, wine, ale, and opiates into the veins of dogs.2 It was not until

the 1960s that parenteral nutrition was developed as a bedside

technique for hypertonic fluids to be administered through large veins

as a source of full nutritional needs for patients.3

Normal digestion occurs when food is broken down in the bowel and

stomach. This absorbed food in the bowel is then carried to other parts

of the body by the blood. Parenteral nutrition bypasses digestion in the

bowel and stomach through insertion of a food mixture into the blood

by an intravenous (IV) catheter.1 This mixture contains carbohydrates,

proteins, as well as other vitamins and minerals.4 The IV catheter can

stay in place as long as needed to supply nutrition to the patient.

Initiation and monitoring of parenteral nutrition is usually undertaken

by a multidisciplinary team of physicians, dietitians, nurses, and

pharmacists.5

Routes of administration for parenteral nutrition can be done centrally

or peripherally, depending on factors, such as duration of treatment

and indication. Regardless of the chosen route of administration,

clinicians should rely on strict aseptic technique along with a lumen

dedicated exclusively for parenteral nutrition administration.2


Parenteral Versus Enteral Nutrition

The term parenteral nutrition has long been synonymous with “total

parenteral nutrition.” However, total parenteral nutrition can be a

misleading term, because many patients who receive nutrition by vein

also concomitantly receive nutrition through the mouth by enteral

(tube) feedings. This concept of intravenous and enteral nutrition

includes almost 90% of surgical patients and 100% of anaesthetized

patients, who receive intravenous fluids perioperatively.3

Enteral nutrition also relies on a special food mixture of carbohydrates,

proteins, fats, as well as vitamins and minerals, which are fed to the

patient through a tube inserted into the stomach or bowel.1 There are

various types of tubes that are employed in enteral nutrition. One type

of tube placed through the nose is known as a nasoenteral or

nasogastric feeding tube. Another type of procedure, known as a

gastrostomy or jejunostomy utilizes a tube inserted directly into the

stomach or bowel through the skin.1

There is a strong belief among nutritionists that enteral nutrition is

preferable to parenteral nutrition; however, several factors, such as

specific indication or duration play a role on which method to use.6

The literature has been mixed concerning the comparison of these two

types of nutritional delivery. Proponents of parenteral nutrition state

that it delivers more reliable calories than enteral nutrition.

Conversely, proponents of enteral nutrition cite that enteral nutrition

has showed consistently better outcomes in patients compared to

those who receive parenteral nutrition.6,7,8 Regardless of whether the

clinician chooses parenteral or enteral nutrition, careful attention must


be rendered on issues, such as safety, indications, delivery methods,

and calorie calculations.9

Candidates for Parenteral Nutrition

Parenteral nutrition is used in a variety of situations. When a patient’s

gastrointestinal tract is nonfunctional, a variety of factors may play a

role.3 These include:10,11

Severe pancreatitis

Short-bowel syndrome

Inflammatory bowel disease

Gastrointestinal fistulae

Bowel obstruction

Acute cardiovascular collapse

Selected oncology patients

To help determine whether a patient has a functioning gastrointestinal

tract, clinicians must gather specific information through a health

history, which focuses on nutrition. Questions should be catered

toward dietary intake, along with any difficulties with swallowing,

chewing, digestion, and elimination.10,11 Physical examination should

include measurements for body weight and height, as well as a careful

inspection of the oral cavity, abdomen, rectal area, neck, and head.

Endoscopic and radiological testing of the gastrointestinal tract may

also be warranted along with laboratory values for glucose, lipid levels,

serum electrolytes, proteins, along with renal and liver function.10,11


IV Access

After all signs have indicated that parenteral nutrition is a viable option

for the patient, the caregiver must determine, where parenteral

nutrition therapy should be administered, and for how long.

Determining how long the therapy should be (short term versus long

term), assists the caregiver in deciding which type of vascular access

device to use. To avoid needless catheterizations, medical staff should

take into account certain considerations prior to intravenous access.

These considerations include the following:4

Activity level

Patient and/or caregiver ability to care for the vascular access

device

Body image concerns

Additional therapies needed

Previous history of vascular access devices

The type of application and correct placement is an important

component to parenteral nutrition. Common intravenous access sites

for parenteral nutrition include:

Parenteral Nutrition IV Access Sites

Trans-lumbar/trans-hepatic venous access

Peripherally inserted central catheter

Tunneled central venous catheter

Internal jugular vein

Subclavian vein

Subcutaneous port

Cephalic vein

Cephalic venous access

Basilic vein


Choices for vascular access include tunneled VADs with an anchoring

cuff, implantable ports, and peripherally inserted central catheters

(PICC).4,12 For short term parenteral nutrition therapy of less than a

couple of weeks, PICC lines are typically used.12 Advantages of PICC

lines are decreased risk of catheter compilations, cost-effectiveness,

and ease of removal. Potential disadvantages are that the patient may

be less dependent due to the fact that the dressing must remain dry. A

greater risk of thrombosis may also be present with PICCs.4,13

For long-term parenteral nutrition therapy, tunneled catheters remain

the first line option. Advantages include ease of self-care and a lower

risk of thrombosis.4,13 Implanted ports placed under the skin are

another viable option for long-term parenteral nutrition. The chief

advantage of this option is minimal alteration to the patient’s body

image, as well as no concern for accidental pulling of the device.

Parenteral Nutrition Solutions

There are standard solutions that are used for parenteral solution as

well as solutions that are formulated specific to the patient. Solutions

are prepared in the pharmacy using aseptic technique under a

laminar-flow filtered air hood.4,5 The solutions are usually made in liter

batches. The solutions can also be quite complex containing up to 40

different additives. The two main components in parenteral nutrition

solutions are amino acids and dextrose. Other additives include

electrolytes, fats, vitamins, minerals, and trace elements.14


Amino Acids

Amino acids are used in parenteral nutrition formulas as a source of

protein. Standard solutions contain approximately 40% essential and

60% nonessential amino acids.14 More concentrated amino acid

preparations are useful on patients with renal failure. For patients with

end-stage liver disease, solutions with more branch-chained amino

acids may be warranted.15 Some solutions also contain phosphate,

which helps in compatibility when dosing with electrolytes.4

Studies have also shown that about 80% of patients who rely on

parenteral nutrition for their full source of nutrients have been found

to have low levels of choline in the blood.4 Choline is a nonessential

amino acid that is found in many foods; thus, explaining why

deficiencies are so common. However, it is not commonly added to

parenteral nutrition formulations because it can be synthesized

endogenously. Nevertheless, current studies have suggested that

choline supplementation may be warranted in patients receiving

parenteral nutrition, due too the fact that pathways allowing for

synthezation may be altered during parenteral nutrition therapy.4

Dextrose

During perenteral nutrition therapy, carbohydrates are the primary

source of calories and are supplied in the form of dextrose. Dextrose is

a readily available, inexpensive energy source that can be

administered with commercial solutions. Concentrations range from

5% to 70%.4 As the concentration of dextrose increases, the tonicity

of the parenteral nutrition solution also increases.


Electrolytes

Requirements for electrolytes, such as magnesium, phosphorus, and

potassium are influenced by the amount of carbohydrates present in

the parenteral nutrition solution. In other words, as the amount of

carbohydrates increase, so does the need for electrolytes.16 Typical

solutions contain electrolytes, such as chloride, calcium, potassium,

phosphorus, and magnesium. The types and amounts of electrolytes

added to the solution also depend on the specific patient’s diagnosis

and metabolic requirements. For example, patients with high gastric

output may require additional chloride. Conversely, patients with renal

problems may require reduction in certain electrolytes, such as

magnesium, phosphorus, and potassium, due to the fact that they

may be difficult to secrete.4

Fats

Fat is available in parenteral nutrition solutions as an oil-in-water

emulsion. These IV fat emulsions contain a mixture of egg

phospholipids as an emulsifier, water, and safflower or soybean oil as

a source of polyunsaturated fatty acids.4 Glycerol is also added to the

solution. The goal of this lipid emulsion supplementation is to prevent

fatty acid deficiency. When used properly, relatively few complications

are seen with lipid emulsions. However, caution must be used for

patients who may have allergies to eggs.17

Vitamins

Parenteral nutrition solutions typically contain approximately 12 to 13

essential vitamins.15 The amount of vitamins added to the solution is

based on the current U.S. Food and Drug Administration (FDA)


guidelines. During times of multivitamin shortages, the American

Society for Parenteral and Enteral Nutrition recommends IV vitamin

supplementation to be administered three times weekly.4 The specific

amount of required vitamins may also be dependant on the condition

of the patient. For example, parenteral nutrition solutions for pregnant

women may include additional amounts of folic acid.

Trace Elements

Trace elements are routinely added to parenteral nutrition solutions.

Examples include copper, zinc, chromium, and selenium.4,15 These

trace elements can be delivered individually or in various combinations

depending on the specific needs of the patient. Patients with iron

deficiencies may also require additional iron supplementation.

Monitoring Patients With Parenteral Therapy

There are no current professional society guidelines for monitoring

patients receiving parenteral nutrition therapy. This is, in part, due to

a lack of controlled trials along with a lack of evidence-based

guidelines for monitoring and treating potential complications

associated with parenteral nutrition.4 However, due to several known

potential complications, practitioners routinely conduct clinical

monitoring as well as several additional tests for patients receiving

therapy. In addition to clinical monitoring of the parenteral nutrition

solution, patients will also require routine blood tests.3 This is

particularly important at the beginning of therapy to assess for

conditions such as hyperglycemia or significant shifts in electrolytes.3

Trace elements should also be measured, and patients on long-term


parenteral nutrition therapy should have three to six month checks on

vitamin levels.

Assessing the quantitave needs concerning micronutrients and

macronutrients can help reduce the likelihood of complications

associated with parenteral nutrition. At the initiation of therapy,

glucose should be monitored several times a day until stable.

Laboratory tests also include levels, such as electrolytes, phosphate,

magnesium, plasma urea, and blood gases.4 Liver function tests,

plasma and urine osmolality, and plasma proteins should also be

measured routinely.4

Complications

Complications associated with parenteral nutrition therapy are either

metabolic due to the nutritional formula or nonmetabolic due to faulty

delivery technique. Metabolic complications include alteration in serum

electrolytes and hyperglycemia. Patients who receive more than 10%

concentrations of dextrose are at a greater risk for developing

hyperglycemia.14 Overfeeding is also a common cause of

hyperglycemia in patients receiving parenteral nutrition. Incorrect

placement of the central line may result in an air embolism,

hematoma, or pneumothorax. For this reason, a chest x-ray must be

used to confirm proper placement of the central line catheter tip prior

to infusion.14

Thrombosis can occur at the catheter tip from the formation of a fibrin

sheath on the outside of the catheter. A thrombolytic agent can be

useful in clearing a catheter occlusion caused by a fibrin sheath. Some

patients with permanent central catheters may also be administered


low-dose warfarin to help prevent thrombosis.15 Additionally, as in

most procedures, infection is always a cause for concern. Preventive

measures include thorough hand hygiene measures and proper

catheter care techniques.14 Tunneled catheters or implanted ports with

the fewest lumens necessary should be the primary choice due to the

fact that they have the lowest incidence of infection.4

Catheter-Related Infections

Catheter-related infections are one of the most common causes of

concern in parenteral nutrition therapy. Common organisms found in

catheter-related sepsis include:

Staphylococcus aureus

Candida sepsis

Klebsiella pneumoniae

Pseudomonas aeruginosa

S. albus

Enterobacter sepsis

Central venous catheter-related infections greatly increase morbidity,

mortality, and length of hospital stay. Research has also shown that

they also are a significant contributor to expenses related to

healthcare. According to recent literature, the healthcare expenses

range from $33,000 to $65,000 per occurrence.4

Typical signs of catheter-related infections include fever, elevated

temperature, and chills. Fever during parenteral nutrition therapy

should always be investigated. If temperature remains elevated for

more than 24 hours, the central catheter infusion should be

stopped.14,18 Laboratory findings that may indicate infection include


increased white blood cell count, positive blood cultures, and elevated

liver enzymes.19

Blood Clots

Patients who are administered long-term parenteral nutrition therapy

are at increased risk for blood clots. This is due to the fact that long-

term intravenous access may result in the accumulation of a foreign

body within the vascular system.20 Routine heparin flushes can help

prevent clots. Catheters should also be flushed before and after each

use and all parenteral nutrition solutions should be inspected for

formation of precipitant inside the bag. Experts also recommend using

IV filters, and always consulting with the pharmacist prior to adding

anything to the solution.20

Liver Disease

Another potential complication of long-term administration of

parenteral nutrition is liver disease. Recent research published in the

Journal of Parenteral and Enteral Nutrition reported that liver disease

has been found in 26% of patients who were administered parenteral

nutrition for two years and the incidence climbed to 50% in those who

received parenteral nutrition therapy for more than three years.4

When laboratory results indicate elevated liver enzymes, clinicians

should investigate the cause paying close attention to any

hepatobilliary complications.4 These abnormalities are typically

classified into two categories – hepatic steatosis and cholestasis.21

Hepatic steatosis is essentially the accumulation of excess fat in the

liver due to increased amounts of alanine aminotransferase and


aspirate aminotransferase.15,21 Hepatic steatosis is reversible following

reduction in calories.21

Cholestasis occurs when bile becomes blocked and cannot flow from

the liver to the duodenum. Research has proven that many patients on

long-term parenteral nutrition therapy develop some cholestasis.15

This is due to the absence of enteral intake, which can cause failure of

the gallbladder to become stimulated. When this happens, it does not

empty and bile becomes thick and can eventually result in billiary

obstruction.15 The best preventive method to avoid cholestasis is to

occasionally substitute parenteral nutrition with enteral feedings if

possible.15

Metabolic Bone Disease

Metabolic bone disease is another potential complication of long-term

parenteral nutrition therapy.4,15 This condition encompasses

abnormalities related to bone density, metabolism, and strength,

which ultimately results in conditions, such as osteoporosis and

osteomalacia.4

Current studies suggest that metabolic bone disease results in

osteoporosis in approximately 67% of patients who receive long term

parenteral nutrition. This same research also reports that osteopenia

results in about 84% of long-term parenteral nutrition patients.4

Although the cause of metabolic bone disease is uncertain, several

preventive strategies do exist, such as careful attention to the

amounts of magnesium, calcium, Vitamin D, and phosphorus that are

provided in parenteral nutrition solutions.15


Refeeding Syndrome

Refeeding syndrome occurs when significant shifts in fluids and

electrolytes occur. Significant shifts in fluids and electrolytes occur

when malnourished patients are introduced to normal nutrition

parenterally or enterally.22 When the body is malnourished over time,

and then suddenly flooded with nutrients, a hypermetabolic state

ensues. Glucose use pushes magnesium, potassium, and phosphorus

rapidly into the starved cells of the malnourished patient. This drastic

movement of electrolytes results in a drop in the patients’ magnesium,

serum potassium, and phosphorus levels.22

This potentially lethal metabolic complication can result in muscle

weakness, immune dysfunction, peripheral edema, hyperglycemia,

decreased gastric motility, ketoacidosis, ventricular dysrhythmias, and

cardiac failure.22 Patients who are most at risk include those who have

been without significant nutrition for a week or longer. These patients

should have a parenteral nutrition program slowly introduced and

should also be carefully monitored.

Weaning from Parenteral Nutrition

Prior to completely stopping parenteral nutrition, other alternative

methods should be established. Parenteral nutrition should never be

stopped abruptly due to the fact that hypoglycemia can occur.2 Once

the patient has reached the nutritional requirements, infusion

schedules may be slowly reduced. When the infusion schedules

change, laboratory studies are assessed to evaluate fluid and

electrolyte stability.4 After the solutions are reduced to a minimum of

three days weekly, the patient’s parenteral nutrition therapy is stopped


for one week. The patient’s weight and enteral intake is carefully

monitored. Laboratory studies are also checked again. If they are

found to be normal, the parenteral nutrition can be formally

discontinued.4

Quality of Life

There are several support groups that provide educational resources

for patients. One such example is the Oley Foundation, which is a

nonprofit organization that assists patients who receive parenteral

nutrition. It provides patient-focused newsletters aimed at increasing

the quality of life. It also provides annual conferences along with

networking and peer support groups for patients.4

Summary

Parenteral nutrition is an important part of maintaining nutrition for

patients who are unable to properly digest food. In some cases, this

lifesaving therapy can be combined with intake through enteral

nutrition to help nourish patients. Parenteral nutrition is used in a

variety of situations, such as when a patient’s gastrointestinal tract is

nonfunctional. A variety of factors can affect gastrointestinal tract

functioning, including severe pancreatitis, short-bowel syndrome,

inflammatory bowel disease, gastrointestinal fistulae, bowel

obstruction, acute cardiovascular collapse, and selected oncology

patients.

During parenteral therapy, a multidisciplinary team approach is utilized

to ensure that correct solutions are administered concerning each


patient’s unique set of needs. Additionally, initiation and monitoring of

parenteral nutrition requires a multidisciplinary team, which includes

physicians, dietitians, nurses, and pharmacists. Routes of

administration for parenteral nutrition can be done centrally or

peripherally, depending on factors, such as duration of treatment and

indication. Careful attention and thorough monitoring is crucial to

reduce the likelihood of complications associated with parenteral

nutrition therapy. Nurses are an integral part of the nutritional support

team and must have the necessary clinical and communication skills

required for working collaboratively with all team members to ensure

that patient’s receive safe and appropriate parenteral therapy for

nutritional support.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the

self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.


1. A patient is administered nutrition through a feeding tube.

Which type of nutrition does this indicate?

A. parenteral

B. enteral

C. total parenteral nutrition

D. total enteral nutrition

2. Parenteral nutrition solution contains all of the following

EXCEPT?

A. proteins

B. carbohydrates

C. vitamins

D. fiber

3. For short term parenteral nutrition therapy of less than

two weeks, which one of the following methods are

typically used:

A. tunneled VADs

B. subclavian vein access

C. PICCs

D. None of the above

4. A patient in need of parenteral nutrition therapy has a

high gastric output. This patient will need additional

quantities of which electrolyte:

A. magnesium

B. potassium

C. phosphorus

D. chloride


5. All of the following are preventive measures concerning

the potential for infection related to parenteral nutrition

therapy, EXCEPT:

A. thorough hand hygiene measures

B. use of PICC lines

C. proper catheter care

D. use of implanted ports

6. To determine whether a patient has a functioning

gastrointestinal tract condition, clinicians must gather

specific information through:

A. a health history that focuses on nutrition.

B. a physical examination, including measurements for body

weight and height.

C. an endoscopic and radiological.

D. All of the above. *

7. Glucose use pushes _________________________

rapidly into the starved cells of the malnourished patient.

A. magnesium, potassium, and phosphorus *

B. sodium, chloride, and potassium

C. protein and albumin

D. None of the above.

8. True or False. Research has proven that many patients on

long-term parenteral nutrition therapy develop some

cholestasis.

A. True *

B. False


9. The goal of lipid emulsion supplementation is to prevent

____________________ deficiency.

A. fatty acid *

B. protein

C. carbohydrate

D. Answers B and C above

10. Common organisms found in catheter-related sepsis include

all of the following EXCEPT:

A. Staphylococcus aureus

B. Treponema pallidum *

C. Candida sepsis

D. Klebsiella pneumoniae

Correct Answers:

1. B

2. D

3. C

4. D

5. B

6. D

7. A

8. A

9. A

10. B


References Section

The reference section of in-text citations include published works

intended as helpful material for further reading. Unpublished works

and personal communications are not included in this section, although

may appear within the study text.

1. American Society for Parenteral & Enteral Nutrition. What is

Parenteral Nutrition?

http://www.nutritioncare.org/About_ASPEN/About_A_S_P_E_N_/

Accessed on March 1, 2014

2. Ghosh D, Neild P. Parenteral Nutrition. Clin Med. 2011; 10(6):

620-623

3. Cano NJ, Aparicio G, Carrero B, et al. Guidelines for adult

parenteral nutrition. Clin Nutr. 2009; 28: 359-479

4. Kirby D, Corrigan M, Speerhas R, Emery D. Home parenteral

nutrition tutorial. J Parenter Enteral Nutr. 2012; 36(6): 632-644

5. Speerhas R, Rhoda K, In: Couglin KL, DeChicco R, Hamilton C,

eds. Cleveland Clinic Nutrition Support Team Manual. Cleveland,

OH: Cleveland Clinic; 2011: 81-98

6. Seres D, Valcarcel M, Guillaume A. Advantages of enteral nutrition

over parenteral nutrition. Therap Adv Gastroenterol. 2013; 6(2):

157-167

7. Akashi Y, Hiki N, Nunobe S, Jiang X, Yamaguchi T. Safe

management of anastomotic leakage after gastric cancer surgery

with enteral nutrition via a nasointestinal tube. Langenbecks Arch

Surg. 397: 737-744

http://www.nutritioncare.org/About_ASPEN/About_A_S_P_E_N_/%20Accessed%20on%20March

http://www.nutritioncare.org/About_ASPEN/About_A_S_P_E_N_/%20Accessed%20on%20March


8. Al-Omran M, Albalawi Z, Tashkandi M, Al-Ansary L. Enteral versus

parenteral nutrition for acute pancreatitis. Cochrane Database

Syst Rev (1): CD002837

9. Boulatta J, Guenter P, Mirtallo J. A parenteral nutrition use survey

gap analysis. J Parenter Enteral Nutr. 2012; 33: 67-75

10. McClave SA, Martindale RG, vanek VE, et al. Guidelines for the

provision and assessment of nutrition support therapy in the adult

critically ill patient. J Parenter Enteral Nutr. 2009; 33(3): 277-316

11. Singer P, Berger NM, Van den Berghe G, et al. ESPEN guidelines

of parenteral nutrition: intensive care. Clin Nutr. 2009; 28: 387-

400

12. Emery M, Stafford J, Pearson A, Steiger E. Venous access and

catheter care. In: Coughlin KL, DeChicco R, Hamilton C, eds.

Cleveland Clinic Nutrition Support Team Manuel. Cleveland, OH:

Cleveland Clinic; 2011: 121-143

13. Paauw JD, Borders H, Ingalls N, et al. The incidence of PICC line-

associated thrombosis with and without the use of prophylactic

anticoagulants. J Parenter Enteral Nutr. 2008; 32: 443-447

14. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the

prevention of intravascular catheter related infections. Am J Infect

Control. 2011; 39: S1-S34

15. Miller S. Parenteral Nutrition, U.S. Pharm. 2006; 7: HS-10-HS-20

16. Holcombie BJ, Gervasio JM. Adult Parenteral Nutrition. In: Koda-

Kimble MA, Young LY, Kradjan WA, et al. eds. Applied

Therapeutics: The Clinical Use of Drugs. 8th ed. Philadelphia, PA:

Lippincott Williams & Wilkins: 2005; 1-37


17. Yarandi SS, Zhao VM, Hebbar G, Ziegler TR. Amino acid

composition in parenteral nutrition: what is the evidence? Curr

Opin Clin Nutr Metab Care. 2011; 14(1): 75-82

18. Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks

in reducing central venous catheter infections in pediatric patients

with intestinal failure, J Ped Surg. 2010; 45: 1287-1293

19. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for

the diagnosis and management of intravascular catheter-related

infection: 2009 update by the Infectious Diseases Society of

America. Clin Infect Dis. 2009; 49: 1-45

20. Scgulmeister L. Management of non-infectious central venous

access device complications. Semin Oncol Nurs. 2010; 26(2):

132-141

21. Kelly D. Preventing parenteral nutrition liver disease. Early Human

Development. 2010; 86: 683-687

22. Adkins SM. Recognizing and preventing refeeding syndrome.

Dimens Crit Care Nurse. 2009; 28(2): 53-60

The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com. The information

is designed to assist healthcare professionals, including nurses, in addressing issues

associated with healthcare.

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