Transitioning from Parenteral Nutrition: Steps to Successes! - NHIA

Carol Ireton-Jones, PhD, RD, LD,
CNSC
Nutrition Therapy Specialist
Consultant
dr.cijrd@verizon.net

The attendee will be able to:
1. Identify an appropriate candidate for
transition of PN dependence to EN or oral
nutrition.
2. Understand the types of EN formulas and
oral diet considerations to use based on
disease process and GI function
3. Apply monitoring techniques for
assessing adequacy of nutrition intake -
oral, EN or PN.

Oral
Parenteral
Enteral
Parenteral

Parenteral nutrition bypasses the normal digestion in
the stomach and bowel. It is a special liquid food
mixture given into the blood through an intravenous
(IV) catheter (needle in the vein). The mixture contains
proteins, carbohydrates (sugars), fats, vitamins and
minerals (such as calcium). This special mixture may
be called parenteral nutrition and was once called total
parenteral nutrition (TPN), or hyperalimentation.
www.nutritioncare.org
Indications: Non-functioning GI tract or insufficient
absorptive capacity
• Short bowel syndrome
• Ulcerative colitis/Crohn’s disease
• Patients with high output fistulas
• Intractable vomiting or nausea
• Chronic pancreatitis
• Bowel obstruction or GI hemorrhage
• Enteral failure

Enteral nutrition or tube feeding is when
a special liquid food mixture containing
protein, carbohydrates (sugar), fats,
vitamins and minerals, is given through a
tube into the stomach or small bowel.
www.nutritioncare.org

T
I
M
I
N
g
GI Tolerance

*based on several cases and not one specific
patient case
62 y/o female
s/p gastric surgery due to
obstruction followed by
intestinal resection. Fistula
developed in hospital.
PN started in the hospital –
patient sent home on PN after
2 weeks.
Currently home on PN for 8
weeks; fistula is now closed
Now what?

Oral or enteral nutrition contraindicated?
• If yes – continue PN
• If no
GI tract functional?
• If no – continue PN
• If yes – Evaluate GI anatomy:
• Normal
• Stomach
• Small intestine
• Colon

Esophagus
• Swallowing?
• Obstruction
Stomach
• Gastrectomy?
• Obstruction?
Small intestine
• Length?
• Function?
• Ileocecal valve?
Colon
• Present?

GI anatomy -
no swallowing
disorder
SBS -
→Ready to assess
tolerance to enteral
nutrition
GI anatomy –
• Fistula closed
• Wound vac removed
• Patient is taking some
liquids by mouth
• How much SI is left?
PN continues
• Ready to wean?
YES!
• EN or oral?
*based on several cases and not one specific
patient case

Intact nutrients
Most commonly used tube feeding formula
Energy Density: 1.0 -2.0 kcal.ml
• Nutrient dense formula’s 1.5 – 2.0 kcal/ml for fluid restriction, volume
sensitive
Protein: 14% to 25% of total calories
• Very high protein formulas for increased protein needs i.e. wound
healing, anabolism, PEM
Fiber
• With/without
Low to moderate osmolality
(300 to 700 mOsm/kg water)

Peptide –based
• Malabsorption, maldigestion, Impaired gastrointestinal function and/or symptom of GI
intolerance
• Easily digested forms of carbohydrate, protein and fat
• Protein: free amino acid and peptides
• Carbohydrate: mono-, di- and oligosaccharides.
• Fat: Medium chain triglycerides
• Fiber-free, low residue, low fat
• Low-lactose
Disease Specific
• Customized to meet needs of patients with specific diseases.
• Diabetes formulas: to help manage blood glucose levels compared to standard products
• Unique carbohydrate blend including slowly digesting carbohydrates
• Renal formulas: to help minimize complications such as uremia, fluid overload, and
elevated serum electrolytes
• Energy dense ( 2.0 kcal/ml) to support fluid restrictions
• Modified electrolytes and micronutrients

Access
Enteral
Nutrition
Nasogastric
nasoduodenal tube
Gastrostomy tube
Jejunostomy tube
nasojejunal tube

Swallowing
• Typically normal digestion
Enteral formula?
Enteral access?

Swallowing
• Typically normal digestion
Enteral formula: Standard – with fiber (i.e. Jevity ® )
Enteral access: Naso-enteric or gastrostomy
(long-term or
esophageal obstruction)

Partial or full gastrectomy?
Gastroparesis?
Obstruction?
Enteral formula?
Enteral access?

Partial or full gastrectomy?
Gastroparesis?
Obstruction?
Enteral formula:
Standard – with fiber (i.e. Jevity ® ) or without fiber (i.e.
Osmolite ® )
Disease specific - (i.e. Glucerna ® or Nepro ® )
Enteral access: Naso-duodenal (by pass stomach)
or gastrostomy to small intestine (may include
venting - long-term)

Length?
Function?
Ileocecal valve?
Enteral formula?
Enteral access?

Length –
• less than 50 cm with intact colon – peptide based enteral
formula (i.e., Vital ® )naso enteric or gastrostomy access → oral
diet
• less than 100 cm with ileocecal valve and some colon present –
peptide based enteral formula – naso enteric or gastrostomy
access → oral diet
• less than 50 cm without colon – lifelong PN likely
• greater than 50 cm with intact colon – peptide based or
standard enteral formula – naso enteric or gastrostomy access
→ oral diet
Function –
• Pseudoobstruction, Crohn’s disease, malabsorption – peptide
based enteral formula – naso enteric or gastrostomy access →
oral diet

Medical Nutrition therapy
Oral supplements
High
protein
shake

Nutrition Recommendations based on:
• GI anatomy
• Absorptive capacity
• Disease process – diabetes, IBD, IBS, SBS, oncology,
etc
• Fluid tolerance
• Likes and dislikes
Carbohydrate, protein, fat, fiber, and fluid
recommendations are individualized
Call on your Registered Dietitian!

GI anatomy - no
swallowing disorder
but with SBS - ready
to assess tolerance
to nutrition
PN transition
• Diet instruction – what to eat
and how much
Steps to wean
1. Decrease 1-2 days/week of HPN
2. Evaluate for tolerance, adequacy
of oral intake
3. Decrease HPN to 4 days/week
4. Evaluate for tolerance, adequacy
Decrease HPN to 2 days/wk or D/C
OR
1. Decrease volume or daily HPN
Then , decrease days as above
Keep fluids available if needed
Pull line when transition is assured

COLON PRESENT
CHO 50-60%
PRO 20%
FAT 20-30%
Meals 5-6 daily
Avoid oxalates
Isotonic/hypoosmolar
fluids
Soluble fiber 5-10
g/day
Lactose as tolerated
COLON ABSENT
CHO 40-50%
PRO 20%
FAT 30-40%
Meals 4-6 daily
Oxalates: no restriction
Isotonic, high Na fluids
Soluble fiber 5-10
g/day
Lactose as tolerated
Byrne et al. NCP 15:306, 2000 Slide courtesy of L. Matarese,
PhD, RD

MNT –
• Follow post SBS diet recommendations
• Food logging
• Assess for adequacy
*based on several cases and not one specific
patient case
If not adequate, initiate EN
• Access/monitoring

Multi-vitamin and minerals!
• Supplied in EN and PN – for oral diet, consider
beginning an oral multivitamin plus adequate
calcium and vitamin D
Fluids!
• Calculate 30-35 ml/kg or 8 glasses of fluid per
day!
• Appropriate fluids – ORS? Water? Sugar-free
beverages? Calorie containing beverages?
Monitor….

Enteral:
• Placement of access device
• Initiate enteral feeding
• Pump – overnight feeding
• Bolus/Drip
Oral
• Diet instruction – what to eat and how much

1 – Assess ability to take enteral/oral diet
2 – Decrease PN to 75% of needs
3 – Add EN to make up 25-40% of needs
4 – PN decreases as EN/oral increases
5 - Try decreasing PN and increasing EN
by 25% increments or 50/50 PN /EN then
25% PN (or stop) and 75- 100% EN/oral.
**Don’t pull that line or tube until you are
sure!

•Body Weight - gain or
loss based on goals
•Fluid status
•Compliance
•Comprehension
• Diarrhea
• Nausea/vomiting
• Abdominal
distention/cramping
• Dehydration
• Enteral access
site/device
• Disease
progression &/or
recovery
• Lab and physical
data

Transition from PN to
EN or oral diet
Adequate intake
without
complications
Continuing progress
to goals!

The Oley Foundation – Don’t Go Home Without It!!!
www.oley.org 800-776-OLEY (6539)