How Is Parenteral Nutrition Applied? | Clinical Nutrition LAM Initiative

How Is Parenteral Nutrition Applied?

Parenteral Nutrition Application Systems and Modes of Delivery

Parenteral nutrition (PN) admixtures contain a broad range of components in varying amounts and combinations. There are a number of application systems available to meet various patient needs, including:

  • Single-bottle systems
  • All-in-one systems

Single-Bottle Systems

With single-bottle systems, amino acids, glucose, lipids and electrolytes are administered in parallel from separate bottles by combining multiple connectors that feed into a common IV catheter. Vitamins and trace elements are usually added to PN from concentrated preparations.1,2

Graphic of a single-bottle system

The single-bottle system is associated with various disadvantages1,2 rendering its use inconvenient in clinical practice:

  • Need for a connector and multiple administration sets
  • Requiring frequent bottle changes
  • Necessity to set up different, irregular flow rates and make many additions
  • Increased probability of administration errors
  • Time consuming

However, if handled correctly, single-bottle systems offer wide flexibility when it comes to dosage and enabling highly specific PN therapy, adjusting to various patients’ needs.1,2

All-In-One Systems

All-in-One (AiO) systems combine all components of PN, macronutrients, water, electrolytes, vitamins and trace elements, in one container to be administered via a single infusion line.2

The clinical advantages of AiO admixtures include:

  • Simultaneous supply of all nutrients3,4,5
    • Improved utilization and nitrogen balance3,4,5
    • Less metabolic complications1,2
  • Fewer manipulations
    • Reduced risk of infections5,6

AiO systems come in three forms:

  • Compounding PN
  • Automated compounding
  • Multi-chamber bags

Compounding PN: Ready-To-Use Admixtures

As in the AiO system, compounding enables the provision of ready-to-use admixtures that can be adjusted to the energy, volume and substrate needs of the majority of patients. Customized admixtures are often mandatory in patients with rapidly changing metabolic requirements (e.g. critical care patients, and patients with metabolic disorders or fluid restriction). The simultaneous administration of all substrates reduces the risk for metabolic complications.1

Compounded bags are aseptically manufactured from various sterile components, usually in hospital pharmacies, and are designed for immediate intravenous administration with no mixing or admixing of further ingredients required. Due to physicochemical instability, compounded bags require short-term production according to strict aseptic techniques by pharmaceutical experts. Proper storage of compounded bags should be in a temperature range of two to eight °C.1,2

The use of compounded bags does have several limitations, including:

  • High expenditure of time, material, and facility
  • High staff costs
  • Higher risk of prescription errors versus multi-chamber bags7
  • More blood stream infections versus multi-chamber bags8
  • Higher cost versus multi-chamber bags9

Under specific clinical conditions, nutritional therapy needs to be adapted accordingly. Specific clinical conditions include:10

  • Patients with heart failure (need for low volume/more concentrated PN)
  • Patients with chronic renal failure and oliguria (require a Na/K-restricted, low volume PN-therapy)
  • Patients with hepatic failure (benefits of branched-chain amino acid BCAA-enriched PN)
  • Patients with gut failure or high output fistulas (increased requirements for electrolytes, vitamins and trace elements)
  • By using stress factors, the requirements can be further defined.

Automated Compounding

In many large hospital centers, compounding of PN is performed using automated compounding devices. Compared to manual manufacturing, using such devices can lower the risk of human errors, improve the accuracy of compounding and reduce personnel time.11,12

Multi-Chamber Bags

Two-Chamber Bags

Two-chamber bags are standard AiO bags with two chambers containing glucose and amino acids to be mixed together immediately prior to intravenous infusion by breaking the separation seals between the bag chambers. The lipid emulsion is admixed with a transfer set shortly prior to administration. Vitamins, trace elements and additional electrolytes are either added to the lipid emulsion or infused by a separate intravenous line. When not mixed together, these bags have a shelf life of 12 to 24 months.1

Image of a two-chamber bag

Three-Chamber Bags

Three-chamber bag (3CBs) systems are standard AiO bags that allow delivery of macronutrients, with or without electrolytes, provided in three separate compartments that are divided by seals which can easily be opened prior to administration by rolling up the bag. Micronutrients (vitamins and trace elements) can be added to the reconstituted mixture as needed.

Image of a three-chamber bag

Image of the use of a three-chamber bag

Compared to other application systems, 3CBs possess a number of key advantages:

  • Sustained convenience in parenteral nutrition
  • Save costs and time13,14,15
  • Flexible and adaptable therapy covering the needs of the majority of patients14
  • Increase safety of mixtures regarding stability and sterility as well as safety and efficacy of therapy2,3,4,16,17,18,19

Modes of Delivery

PN may be delivered using a pump for intravenous feeding or by gravity. Criteria for the choice of the appropriate mode of delivery include:

  • Infusion rate
  • Duration of infusion
  • Required precision
  • Therapeutic aims

Infusion by gravity relies on hydrostatic pressure without the assist of an infusion pump. The infusion rate is regulated by a passive flow controller and calculated basing on the drip rate. The flow controller can be a roller clamp interacting with the tube directly or a specific flow rate controller. The latter achieves a higher accuracy and stability of the flow rate. Gravity infusion is recommended if demands for infusion rate and precision are comparatively low.

Pump-assisted infusion is performed by means of a volumetric pump working in combination with infusion systems or by means of syringe devices controlling flow with a motor-driven piston. This approach is appropriate for low-volume infusions. Pump-assisted infusion ensures high precision with constant infusion rates and enables programmable rate cycling.

  • 1. a. b. c. d. e. f. g. Mühlebach S, Franken C, Stanga Z et al. Practical handling of AIO admixtures – Guidelines on Parenteral Nutrition, Chapter 10. Ger Med Sci 2009;7(18).
  • 2. a. b. c. d. e. f. g. Pertkiewicz M, Dudrick SJ. Different systems for parenteral nutrition (AIO vs. MB). In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011;370-372.
  • 3. a. b. c. Sandström R, Hyltander A, Körner U et al. The effect of energy and nitrogen metabolism by continuous bolus, or sequential infusion of a defined total parenteral nutrition formulation in patients after major surgical procedures. JPEN1995;19:333-340.
  • 4. a. b. c. Meguid MM. Clinical applications and cost-effectiveness of All in One. Nutrition 1989;5(5):343-344.
  • 5. a. b. c. Pertkiewicz M, Dudrick SJ. Basics in clinical nutrition: Systems for parenteral nutrition, different systems for parenteral nutrition (AIO vs. MB). e-SPEN 2009;4:e123-e124.
  • 6. Barnett MI, Pertkiewicz M, Gosslett AG et al. Basics in clinical nutrition: Parenteral nutrition admixtures, how to prepare parenteral nutrition (PN) admixtures. e-SPEN 2009;4:e114-e116.
  • 7. Valentin A, Capuzzo M, Guidet B et al. Errors in administration of parenteral drugs in intensive care units: Multinational prospective study. BMJ 2009;338:b814.
  • 8. Turpin RS, Canada T, Rosenthal V et al. Bloodstream infections associated with parenteral nutrition preparation methods in the United States: A retrospective, large database analysis. JPEN 2012;36:169-176.
  • 9. Turpin RS, Canada T, Liu FX et al. Nutrition therapy cost analysis in the US: Pre-mixed multi chamber bag. Appl Health Econ Health Policy 2011;9:281-292.
  • 10. Braga M, Ljungqvist O, Soeters P et al. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr 2009;28:378-386.
  • 11. Crill CM, Hak EB, Helms RA. Accuracy of parenteral nutrition solutions compounded with automated systems and by hand. Am J Health Syst Pharm 2005;62(22):2345,2348.
  • 12. Dickson LB, Somani SM, Herrmann G et al. Automated compounder for adding ingredients to parenteral nutrition base solutions. Am J Hosp Pharm 1993;50:678-682.
  • 13. Pichard C, Schwarz G, Frei A et al. Economic investigation of the use of three-compartment total parenteral nutrition bag: Prospective randomized unblinded controlled study. Clin Nutr 2000;19:245-251.
  • 14. a. b. Raper S, Milanov S, Park GR. The cost of multi-compartment ‘big bag’ total parenteral nutrition in an ICU. Anesthesia 2002;57(1):96-97.
  • 15. Menne R, Adolph M, Brock E et al. Cost analysis of parenteral nutrition regimens in the intensive care unit: Three-compartment bag system vs multi-bottle system. JPEN J Parenter Enteral Nutr 2008;32(6):606-612.
  • 16. Carter DM, Wheatley C, Payne-James JJ et al. Home nutrition survey in the UK: the patient’s perspective. Clin Nutr 1993;12:208-212.
  • 17. Rollins CJ, Elsberry VA, Pollack KA et al. Three-in-one parenteral nutrition: A safe and economical method of nutritional support for infants. JPEN 1990;14:290-294.
  • 18. Mitchell KA, Jones EA, Meguid MM et al. Standardized TPN order form reduces staff time and potential for error. Nutrition 1990;6:457-460.
  • 19. Flynn EA, Pearson RE, Barker KN. Observational study of accuracy in compounding I.V. admixtures at five hospitals. Am J Health Syst Pharm 1997;54:904-912.

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