V 20TH ANNIVERSARY Vol. 21, No.

6 June 1999

CE Refereed Peer Review

Peripheral
FOCAL POINT Parenteral Nutrition
★Peripheral parenteral nutrition Tufts University
(PPN) is a safe, simple technique
that can be used as an alternative Erika Zsombor-Murray, DVM
to total parenteral nutrition (TPN) Lisa M. Freeman, DVM, PhD
in selected patients.
ABSTRACT: Many clients now expect appropriate nutritional support to be provided to their
hospitalized pets. In many veterinary clinics, enteral nutrition via feeding tubes is perceived to
KEY FACTS be the only viable option. Although enteral nutrition is usually the preferred method, parenteral
nutrition is the method of choice when the enteral route is contraindicated. Advances in the
■ Abolishing protein catabolism formulation of parenteral nutritional solutions, intravenous catheters, and administration tech-
is impossible in many ill or niques make its use more amenable to veterinary clinics. Parenteral nutrition administered
traumatized patients, but through a peripheral vein can be used as an alternative to total parenteral nutrition in appropri-
nutritional support helps ate patients.
minimize losses and supports

M
the patient until recovery. etabolic alterations put ill and traumatized patients at risk for malnu-
trition and its deleterious effects on immune function, wound healing,
■ Administering PPN is a simpler and overall survival.1 The benefits of nutritional support in preventing
method of providing nutritional malnutrition are well accepted, but the optimal use of parenteral or intravenous
support compared with TPN and nutrition is controversial. In the past, parenteral nutrition was recommended
usually is associated with fewer only when enteral nutrition was contraindicated; parenteral nutrition was some-
complications. times considered a technique that should be avoided at all costs because of its
potential complications. Administering parenteral nutrition has also been pre-
■ Although combination parenteral sented as a complicated prospect for nutritional support. Thus, its use in veteri-
products are commercially nary medicine has been primarily limited to universities and a few referral hospi-
available, compounded PPN tals. However, parenteral nutrition is now more accepted, safer, and easier than it
formulas are superior because once was, and its use is becoming more feasible for all veterinarians. Much of the
they provide more balanced initial resistance to parenteral nutrition was the result of its potential complica-
nutrition and can be tailored to tions, some of which can be overcome or minimized by using the peripheral
meet individual patients’ needs. route of administration.

■ Strict adherence to administration, HISTORY OF PARENTERAL NUTRITION

monitoring, and aseptic technique The use of parenteral nutrition in companion animals is not new. In 1656, a
protocols in patients receiving pig’s bladder attached to a goose quill was used to infuse wine into a dog’s vein.2
PPN will reduce the risk of In the 1930s, increased study and awareness of the dangers of malnutrition pro-
complications. vided the impetus behind the development of better methods to prevent it. Par-
enteral nutrition began to be used in the late 1930s to prevent and treat malnu-
trition in humans; however, its regular use in humans did not occur until the
late 1960s, at which time Dudrick and coworkers reported normal growth and
development in dogs fed parenterally.3 The use of parenteral nutrition in dogs
was first reported in the veterinary literature in 1977 in an article on the success-
Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

ful maintenance of 10 dogs for up to 1 month using to- known nutritional requirements. This higher concen-
tal parenteral nutrition (TPN).4 Since that time, the tration is meant to improve immunity, diminish the
use of parenteral nutrition in ill animals has expanded. chance of gut-derived sepsis, or hasten wound healing.6
Initially, parenteral nutrition was provided through a Using nutrients in this manner is known as nutritional
large central vein (e.g., subclavian vein in humans, pharmacology. Examples of nutrients that have been
jugular vein in dogs and cats). The risks associated with used experimentally include arginine, zinc, and n-3
central venous catheters (e.g., sepsis, complications dur- polyunsaturated fatty acids. In the future, our knowl-
ing placement) may delay initiation of TPN support or edge may be sufficiently sophisticated to formulate a
prevent its use completely. Therefore, techniques that nutritional protocol not only based on a patient’s ca-
simplify initiation and administration of parenteral nu- loric, protein, and micronutrient requirements but also
trition and reduce the risk of complications make its aimed at modulating the deleterious effects of the dis-
use more feasible. One way of achieving these goals is ease itself.
by administering parenteral nutrition peripherally,
which has become possible because of the development INDICATIONS
of new nutritional products and changing ideas of the Parenteral Nutrition
goals of parenteral nutrition. Nutritional support is indicated in patients that are
malnourished; unlikely to eat for more than 3 days; or
GOALS OF PARENTERAL NUTRITION at risk of developing malnutrition because of profound,
The goals of parenteral nutrition are no different ongoing protein losses. The enteral route still should be
than those of any other type of nutritional support—to the first choice for providing nutritional support and
prevent nutritional deficiencies by providing adequate should be used when possible. Enteral feeding is a safer,
energy substrates, protein, and micronutrients. During more economical, and more convenient method of pro-
the hypercatabolic state in ill animals, there is accelerat- viding nutrition. In addition, providing nutrition by the
ed loss of lean body mass; ongoing protein catabolism enteral route has specific benefits to the gastrointestinal
and wasting of lean body mass cannot be abolished tract by preventing mucosal atrophy, maintaining local
with nutritional support.5 The goal of nutritional sup- immunocompetence, and preserving normal flora.7
port in these patients, therefore, is to support the pa- Despite these advantages, there are situations in
tient and minimize ongoing destruction of body tissue which the parenteral route should be chosen. Parenteral
until the animal recovers. This requires the provision of nutrition should be selected when enteral nutrition
adequate calories and protein. It is now accepted that cannot be tolerated, such as in patients with vomiting
providing excessive levels of calories and protein will or regurgitation, those with severe malabsorption or
not improve a patient’s condition and is likely to cause gastrointestinal obstruction, and potentially in patients
complications. that cannot protect their airway. Parenteral nutrition
Another goal of nutritional support is to prevent vita- can also be used to supplement enteral feedings in pa-
min and trace-element deficiencies. Currently available tients that cannot tolerate receiving all nutritional re-
solutions for parenteral nutrition are designed for hu- quirements enterally. Theoretically, providing even a
mans and do not meet all the amino acid, vitamin, or small amount of nutrition enterally in conjunction
trace-element requirements for dogs or cats, prompting with parenteral nutrition could help improve patient
some veterinary nutritionists to avoid the term “total” outcome by protecting mucosal integrity and minimiz-
parenteral nutrition. Nonetheless, parenteral nutrition ing the potential for bacterial translocation and sepsis.
has successfully supported dogs and cats for months Parenteral nutrition can be provided via a large central
and is thus usually sufficient for our purposes.3,4 Par- vein or a peripheral vein and can provide either 100% of
enteral nutrition solutions that meet the specific re- requirements or partial-energy requirements. There is
quirements of our patients, however, will require fur- currently much controversy regarding the nomenclature
ther research and development. of parenteral nutrition in both the veterinary and human
Ideas regarding the nutritional requirements of pa- literature. We define TPN as a parenteral solution formu-
tients have changed over the past decade. Not only lated to provide 100% of energy requirements and ad-
must basic nutritional requirements be met, but certain ministered as a hyperosmolar solution via a central vein.
nutrients called conditionally essential nutrients (e.g., Peripheral parenteral nutrition (PPN), sometimes also
the amino acid glutamine) may be required in higher called partial parenteral nutrition, is defined here as a par-
than normal amounts in ill or traumatized patients. In enteral solution formulated to provide 50% of energy re-
addition, some nutrients may have benefits when pro- quirements and administered via a peripheral vein. TPN
vided at concentrations higher than those needed for is a combination of dextrose and amino acids with or

TOTAL PARENTERAL NUTRITION ■ CONDITIONALLY ESSENTIAL NUTRIENTS ■ NUTRITIONAL PHARMACOLOGY

Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

without a lipid source, vita- volumes can be adminis-

mins, and trace elements. tered. In addition, solutions
The use of TPN has been re- available in the past were
viewed. 8–10 Because of the too high in osmolarity to be
technical requirements of TPN administered peripherally. It
administration and potential was not until the develop-
complications, however, its ment of safe fat emulsions
use is not always feasible. that PPN became a reality.
Nevertheless, there are many Fats are a more concentrated
animals that can benefit from energy source than is glu-
parenteral nutrition, and thus cose and reduce the osmo-
PPN may be a practical alter- larity of PPN solutions.11
native. Providing parenteral nutri-
Peripheral parenteral nu- Figure 1—In certain patients, parenteral nutrition adminis- tion via a peripheral catheter
trition is an option that may tered through a peripheral vein can be an effective and simple offers several advantages over
alternative to total parenteral nutrition.
be easier to implement than using a central catheter (see
is TPN (Figure 1). The for- Advantages of Peripheral Par-
mula presented in this article provides a solution with a enteral Nutrition). The first is the ease of peripheral
lower osmolarity than that of TPN that can still pro- catheter placement compared with placing jugular
vide 50% of caloric needs. There are other methods of catheters. In many hospitals, technicians do not routinely
formulating PPN solutions that allow up to 100% of place jugular catheters and TPN is therefore not an op-
caloric requirements to be met, but calculating and ad- tion. Another advantage is that PPN is less likely than is
ministering these formulas can be more chal-
lenging. The formula for PPN presented in
this article is easy to administer and results in
Candidates for Peripheral Parenteral Nutrition
few complications when specified protocols are
followed, thus requiring less intensive monitor- ■ Patients in which the support (i.e., fewer than 5
ing than that required for TPN. gastrointestinal tract to 7 days)
cannot be used (e.g., ■ Patients in which a jugular
Peripheral Parenteral Nutrition due to obstruction, catheter cannot be placed
Peripheral parenteral nutrition has a number severe malabsorption, ■ Patients that cannot
of advantages over TPN. It should not, howev-
pancreatitis, or risk tolerate their full nutritional
er, be viewed as a replacement for TPN but as
an alternative that may be appropriate in se- of aspiration) requirements enterally
lected patients (see Candidates for Peripheral ■ Nondebilitated patients (use peripheral parenteral
Parenteral Nutrition). Because PPN will not ■ Patients likely to require nutrition to supplement
provide all of an animal’s energy requirements, only short-term oral or tube feeding [low-
it should not be used in patients that are debil- intravenous nutritional dose enteral nutrition])
itated (i.e., those that already have signs of
malnutrition), have large protein losses, or will
require nutritional support for long periods.

ADVANTAGES AND DISADVANTAGES OF Advantages of Peripheral Parenteral Nutritiona

PERIPHERAL PARENTERAL NUTRITION
■ Easier catheter ■ Nutritional support may
It is only within the past decade that PPN
has been considered a reasonable route of ad- placement be initiated earlier
ministration for parenteral nutrition. Previous- ■ Less likely to cause ■ Can be as effective as
ly, parenteral nutrition was administered only metabolic complications total parenteral nutrition
via a large central vein because relatively large ■ Less intensive monitoring in appropriately selected
volumes of parenteral nutrition were given to is required patients
most patients to meet perceived energy re-
quirements. Estimates of energy requirements a
Versus total parenteral nutrition.
are now much more conservative; thus smaller

INDICATIONS FOR PPN ■ ENERGY REQUIREMENTS ■ FAT EMULSIONS

Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

TPN to cause metabolic anced nutrition and are prob-

Reducing Thrombophlebitis Risk in
complications because of its lematic when used alone (e.g.,
lower energy content. This Patients Receiving Peripheral 50% dextrose is too hyperos-
means that clinicians may be Parenteral Nutrition (PPN)14–16 molar and 5% dextrose is
more likely to initiate nutri- too low in calories to be ben-
tional support earlier, result- ■ Use the largest vein and smallest catheter eficial when administered
ing in a shorter delay to the possible. alone via a peripheral vein;
onset of therapy. In addition, ■ Use a catheter material of the lowest Table I). For example, ad-
less intensive monitoring is thrombogenicity (polyurethane or silicone is ministering 5% dextrose to a
required. Finally, in appropri- ideal; tetrafluoroethylene is acceptable; avoid 25-lb dog at a maintenance
ately selected patients, PPN fluid rate would provide only
polyvinyl chloride and polyethylene).
can be as effective as TPN. 128 kcal (less than 25% of
Human studies show similar ■ Keep the osmolarity of the solution below 750 energy requirements and no
muscle and respiratory func- mOsm/L. protein). Administering lipid
tion with TPN and PPN in ■ Use three-in-one solutions containing lipid to as a single agent can suppress
postoperative patients.12 Sim- reduce osmolarity. the immune system and, like
ilarly, nondebilitated dogs ■ Keep the pH of the solution neutral. dextrose, provides no pro-
and cats with pancreatitis tein. The osmolarity of amino
■ Administer PPN through a 1.2-µm inline filter.
maintained body weight acids (Table I) makes this so-
while receiving PPN.13 ■ Follow protocols for compounding and lution too irritating to the
The primary disadvantage administering solutions and monitoring patients vascular endothelium to be
of PPN is the limited num- receiving PPN. administered peripherally,
ber of calories that can be ■ At the first signs of thrombophlebitis, remove the and amino acids are not a
provided peripherally. Thus, catheter and place a new one at a different site. balanced or efficient means
an animal receiving PPN of providing calories. Thus,
can still become malnour- the use of these agents indi-
ished. If the patient’s underlying condition does not vidually as a means of nutritional support should be
improve after 3 to 5 days of PPN, other methods of avoided.
nutritional support should be used (i.e., a combina-
tion of enteral nutrition and PPN; TPN if the animal Commercial Combination Products
cannot tolerate enteral feeding). Although PPN will Until recently, there were no commercially available
help to maintain nutritional status, it will not im- dextrose–amino acid solutions because such solutions
prove nutritional status in an already debilitated pa- were difficult to sterilize. When heat-sterilized together,
tient; therefore, its use should be restricted to nonde- amino acids and dextrose undergo the Maillard brown-
bilitated animals. ing reaction, which adversely affects the quality of the
In humans, thrombophlebitis continues to be the most individual ingredients. Thus, manufacturers had to de-
common problem associated with PPN administration. vise alternate methods for this process.
The incidence of thrombophlebitis in human patients There are two approaches to this problem. Dextrose
ranges from 2.3% to 70%, depending on the study14; the and amino acids can be sterilized in a dual-chamber
incidence in dogs and cats has not been reported but bag in which the two components are connected but
anecdotally appears to be lower than that in humans. separated (Figure 2). Just before administration, the seal
Nonetheless, many factors increase the risk of throm- between the two compartments is broken by squeezing
bophlebitis, including properties of the veins, catheter, the bag and the solutions are mixed. Products that use
and solution as well as infusion rates, all of which must this approach are Clinimix™ and Quick Mix® (both
be considered to maintain a low incidence of this prob- manufactured by Clintec Nutrition Co., Deerfield, IL;
lem (see Reducing Thrombophlebitis Risk in Patients Table I). In another product (ProcalAmine®; McGaw,
14–16
Receiving Peripheral Parenteral Nutrition ). Inc., Irvine, CA), glycerin or glycerol, which can safely
be sterilized with amino acids, is used as a calorie
PERIPHERAL PARENTERAL NUTRITION source. Glycerol can be a substrate for glycolysis and is
SOLUTION CHOICES thus an effective substitute for glucose. In addition, less
Single Agents exogenous insulin is required in humans to maintain
Although single agents are available and have been glucose homeostasis with a glycerol-containing solution
used clinically by veterinarians, they do not provide bal- compared with an isocaloric, isonitrogenous dextrose–

THROMBOPHLEBITIS ■ DEXTROSE–AMINO ACID SOLUTIONS ■ GLYCEROL

Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

TABLE I
Commercially Available Components Versus Combination Solutions for Peripheral Parenteral Nutritiona
Trade Osmolarity Na+ Cl + K+ Mg ++ Ca ++ PO4 – – Calories (kcal/L)
Name (mOsm/L) pH (mEq/L) (mEq/L) (mEq/L) (mEq/L) (mmol/L) (kcal/L) Nonprotein Protein
Components
5% dextrose –– 252 4.0 –– –– –– –– –– ––- 170 ––

10% dextrose –– 505 4.0 — — — — — — 340 —

50% dextrose — 2525 4.2 — — — — — — 1700 —

8.5% amino acids Travasol® 890 6.0 — 34 — — — — — 340

8.5% amino acids Travasol® 1144 6.0 70 70 60 10 — 30 — 340

with electrolytes

20% lipid Intralipid® 260 8.0 — — — — — 15 2000 —

10% lipid Intralipid® 260 8.0 — — — — — 15 1000 —

Combination Products
2.75% amino Clinimix™ 665 6.0 35 39 30 5 4.5 15 170 110
b
acids/5% dextrose (2 L)
2.75% amino Quick Mix® 670 6.0 35 35 30 5 — 15 170 110
acids/5% dextroseb (1 L)
3% amino acids/3% ProcalAmine® 735 6.8 35 41 24 5 3 3.5 130 116
glycerin (1 L)
aRepresentativeproducts are listed; see text for manufacturer information. Similar available products may have different properties.
b Productswithout electrolytes are also available.
Ca = calcium; Cl = chloride; K = potassium; Mg = magnesium; Na = sodium; PO4 = phosphate.

amino acid combination.17 The number of calories pro- quirements. We currently administer these products at
vided is less than that in the dextrose–amino acid prod- a maintenance fluid rate (cats, 50 ml/kg/day; dogs, 66
ucts (Table I). ml/kg/day) by continuous-rate infusion unless this rate
The major advantages of using these products are is contraindicated (e.g., in cardiac disease). At this rate,
their commercial availability and the fact that no prepa- these products provide the majority of protein require-
ration is required. This makes them useful in clinics ments (dogs, 100%; cats, 50% to 60%) but only 20%
that are not yet equipped to mix PPN solutions. These to 40% of an animal’s energy requirements and should
products vary in their osmolarity, protein content, be used only in nondebilitated patients.
caloric density, pH, and electrolyte concentration Benefits of these commercial solutions are attributed
(Table I), and thus it is important to determine which to the concept of “protein-sparing,” which is the idea
is most appropriate for an individual patient. Potassium that administering the products will decrease the use of
content in these products ranges from 24 to 30 mEq/L; endogenous protein. In some studies, using combina-
therefore, additional potassium supplementation is usu- tion products improved nitrogen balance compared
ally not required unless a patient is severely hy- with amino acids or dextrose alone, although the bene-
pokalemic. Additional sodium and chloride supple- fits of protein-sparing are still controversial.18 Some ad-
mentation may be required if ongoing losses or vocate the use of lipid solutions in conjunction with
preexisting imbalances are present. It also is important these commercial products to supplement caloric intake.
to realize that the amino acid profiles are designed for Lipids can be administered through a Y-type adminis-
humans and do not necessarily meet canine or feline re- tration set, although this increases the risk of sepsis.

SODIUM AND CHLORIDE SUPPLEMENTATION ■ AMINO ACID PROFILES ■ PROTEIN-SPARING

Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

Most animals tolerate the adminis- Lipids

tration of combination products well, Although dextrose and amino acid
although some with moderate to severe solutions supply readily usable sources
hepatic or renal failure may not tolerate of calories and protein, respectively,
their administration at the usual rate; they have the disadvantage of signifi-
these animals may require more cau- cantly increasing the tonicity of the so-
tious administration or different nutri- lution as their concentrations rise and
tional support techniques. Care should are thus more thrombogenic. Providing
be taken when administering these so- PPN with only dextrose and amino
lutions to cardiac patients because of acids therefore carries a high risk of
their sodium content and the potential thrombophlebitis (if 50% dextrose is
for fluid overload. Thrombophlebitis used) or provides negligible calories (if
can occur because of the relatively high 5% or 10% dextrose is used). Thus, it
osmolarity. Although these commercial was only after safe lipid emulsions were
products are superior to any single developed for commercial use that
agent for nutritional support, they are PPN became practical.
not a replacement for other types of Lipids are an ideal nonprotein calo-
parenteral nutrition and are used only rie source because of their much high-
for interim support in our hospital. er energy content (9 kcal/g for lipids
Figure 2—One type of commercially
compared with 4 kcal/g for protein or
Three-in-One Formula available combination product for pe-
carbohydrate), low osmolarity, and
ripheral parenteral nutrition adminis-
The preferred method for supplying tration combines dextrose and amino neutral pH. Intralipid® (Clintec Nutri-
PPN is to compound a mixture specif- acids in a dual-chamber bag. tion Co.) is currently the most com-
ically tailored to the patient’s individu- monly used lipid source in the United
al needs using amino acids, dextrose, States. It is available in a 10% or 20%
and lipid. The formulation should have an osmolarity solution (Table I); a maximum infusion rate of 2
that is less than 750 mOsm/L. g/kg/day should be observed. Intralipid® contains fat
from soybean oil and egg yolk phospholipid in combi-
Amino Acids nation with glycerol to create an isotonic solution. Us-
A variety of amino acid solutions are available, in- ing lipids in compounded PPN solutions allows the
cluding standard preparations and specialized solu- formulation of peripheral solutions that provide a rea-
tions designed for humans with various diseases (e.g., sonable number of calories without increasing the risk
formulas for hepatic or renal disease). The safety and of thrombophlebitis.11 The diminished incidence of
efficacy of these specialized solutions have not been thrombophlebitis in humans who are given lipid-con-
tested in dogs or cats, and their cost usually makes taining solutions may also be attributed to a “coating”
them unrealistic for veterinary use. Therefore, this ar- effect of lipid emulsions.19
ticle discusses only standard amino acid preparations. Several precautions must be undertaken when using
The most commonly used amino acid preparation lipid solutions. Because lipid solutions may react with
(Travasol®; Clintec Nutrition Co.) consists of 8.5% other PPN ingredients, careful observation for discol-
amino acids in sterile water and provides 340 kcal/L oration or precipitation during mixing is necessary. In
and essential amino acids for humans (Table I). addition, fat precipitates can form and cause fat em-
Amino acids are available with or without elec- bolization in animals. Side effects to lipid solutions are
trolytes, and the appropriate selection depends on the rare, but chills, fever, and headaches occasionally occur
status of the individual patient. All compounded in humans.11 Anecdotal reports in dogs and cats suggest
PPN solutions should contain amino acids as a pro- that allergic reactions, such as rashes, can develop from
tein source. repeated lipid infusion. Propofol has the same base as
lipid solutions; thus allergic reactions could theoretical-
Dextrose ly develop in animals that have received propofol. High
Dextrose is used as a caloric source for PPN. Three dosages or rapid infusion of lipid solutions suppress the
preparations (50%, 10%, and 5%) are available, but reticuloendothelial system and can therefore impair im-
only the 5% or 10% preparations should be used for mune function.20 Finally, lipid solutions are normally
peripheral administration because of their osmolarity quickly cleared from the serum, but patients with cer-
(see Table I for comparison). tain diseases (e.g., hypothyroidism, idiopathic hyper-

PROTEIN SOURCE ■ CALORIC SOURCE ■ LIPID PRECAUTIONS

Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

lipidemia, pancreatitis) have abnormalities in lipid RER = 30 × Body weight (kg) + 70

clearance and may not tolerate the use of lipid in
The second step for determining energy requirements
PPN.11 Lipids should not be used in animals with pre-
is to calculate the illness energy requirement (IER),
existing hypertriglyceridemia or should at least be used
which is an estimate of the number of calories needed
at reduced concentrations and with caution.
to sustain an ill or injured patient. This is calculated by
multiplying the RER by an illness factor, which is a
Vitamins and Trace Minerals
subjective assessment of a patient’s needs above those
In our hospital, vitamins are routinely added to com-
required for RER. Illness factors for dogs and cats have
pounded PPN solutions. Although there has been a na-
been extrapolated from research in human patients and
tionwide shortage of parenteral vitamins for both humans
are selected based on activity level and underlying dis-
and companion animals, one company currently has an
ease.10 Until recently, illness factors as high as 2.0 were
available parenteral multivitamin preparation (Cernevit™;
used in human and veterinary patients to calculate IER,
Clintec Nutrition Co.) that contains vitamins A, D, E, C,
but these values were too high and often led to over-
and B; biotin; and folate. Our hospital uses a dose of 0.5
feeding. Current recommendations in both humans
ml reconstituted product/5 kg body weight (maximum, 5
and animals are therefore more conservative, and illness
ml/animal). An alternative is to use a standard parenteral
factors lower than 1.5 should be used for nearly all pa-
B-vitamin complex solution for animals (2 ml/L of PPN).
tients. Therefore, the IER is calculated as follows:
Trace elements (zinc, copper, manganese, and chromium)
can also be administered, although we consider these to IER = RER × Illness factor (i.e., 1.0 to 1.5)
be optional in most patients receiving PPN because they
Next, the partial energy requirement (PER) is calcu-
should already be well nourished. When used, trace ele-
lated. Because only 50% of the animal’s IER can be
ments (Abbott Laboratories, North Chicago, IL) are ad-
provided by three-in-one PPN, the IER is multiplied
ministered at a dose of 0.5 ml/5 kg body weight (maxi-
by 50%. Depending on the size of the animal, different
mum, 5 ml/animal).
percentages of the PER are supplied by dextrose, amino
acids, and lipid. These are standard formulas, and per-
CALCULATING REQUIREMENTS AND A
centages may need to be adjusted depending on the an-
PERIPHERAL PARENTERAL NUTRITION FORMULA
imal’s underlying disease. For example, if the animal
In our hospital, commercial PPN solutions are used
has preexisting hypertriglyceridemia, reduction or elim-
as an interim means of nutritional support (i.e., for 1 to
ination of the lipid is necessary.
2 days) and are administered at a maintenance fluid
Commercial parenteral multivitamins for humans are
rate (cats, 50 ml/kg/day; dogs, 66 ml/kg/day). Veteri-
routinely added to PPN in our hospital, although a
nary nutritionists use a variety of methods for formu-
standard parenteral B-vitamin complex can also be
lating three-in-one PPN, and each has its advantages
used. Trace elements also can be administered if de-
and disadvantages. This article presents the technique
sired. Vitamin K is administered subcutaneously once
used in our hospital (see Worksheet for Calculating
on day 1 of PPN and then once weekly. If amino acids
Three-in-One Compounded Peripheral Parenteral Nu-
with electrolytes are used, this formulation will approx-
trition), although it is important to note that this is not
imate maintenance amounts of potassium. Additional
the only method possible and that it provides only 50%
potassium supplementation may be required if hy-
of energy requirements (plus 100% and 50% to 60%
pokalemia is present.21 Other supplements, including
of protein requirements in dogs and cats, respectively).
drugs, may or may not be compatible with the PPN.
The method is designed to approximate a maintenance
Check with the manufacturer of the supplement before
fluid rate and has been used successfully in more than
adding anything to the PPN. Any additives should be
200 dogs and cats in our hospital.
introduced in a sterile fashion at the time of mixing.
First, the animal’s energy requirements are calculated.
The resting energy requirement (RER) is the number
SOURCES OF PERIPHERAL PARENTERAL
of calories required for maintaining homeostasis while
NUTRITION COMPOUNDING
an animal sits quietly. The most accurate formula for
Some clinics have the facilities and technical staff to
calculating RER is:
compound their own PPN. This requires a clean area,
RER = 70 × Body weight0.75 (kg) adequate supplies, and trained personnel. Commercial
sets are available for compounding PPN (i.e., sterile bags
For animals that weigh between 2 and 35 kg, the fol-
with three-lead transfer sets [All-in-One Containers;
lowing linear formula gives a good approximation of
Clintec Nutrition Co.]; Figure 3) that can be connected
energy needs:

RESTING ENERGY REQUIREMENT ■ ILLNESS ENERGY REQUIREMENT ■ PARTIAL ENERGY REQUIREMENT

Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

Worksheet for Calculating Three-in-One Compounded Peripheral Parenteral Nutrition (PPN)

Resting Energy Requirement (RER)
RER (kcal/day) = 70 × Body weight0.75 (kg)
or, for animals weighing between 2 and 35 kg:
RER = 30 × Body weight (kg) + 70 = kcal/day RER = _____ kcal/day

Illness Energy Requirement (IER)

IER = RER × Illness factor IER = _____ kcal/day

Partial Energy Requirement (PER)

To supply 50% of the animal’s IER
PER = IER × 0.50 PER = _____ kcal/day

Nutrient Requirements
(Note: This will supply fluids at greater than maintenance rate for animals <3 kg)
Cats and dogs <10 kg: Dogs 10 to 25 kg:
PER × 0.25 = _____ kcal/day from dextrose PER × 0.33 = _____ kcal/day from dextrose
PER × 0.25 = _____ kcal/day from amino acids PER × 0.33 = _____ kcal/day from amino acids
PER × 0.50 = _____ kcal/day from lipid PER × 0.33 = _____ kcal/day from lipid
Dogs >25 kg:
PER × 0.50 = _____ kcal/day from dextrose
PER × 0.25 = _____ kcal/day from amino acids
PER × 0.25 = _____ kcal/day from lipid

Nutrient Solution Volume Requirements

5% dextrose = 0.17 kcal/ml _____ kcal/day from dextrose ÷ 0.17 kcal/ml = _____ ml/day

8.5% amino acids with electrolytes = 0.34 kcal/ml _____ kcal/day from amino acids ÷ 0.34 kcal/ml = _____ ml/day

20% lipid solution = 2.00 kcal/ml _____ kcal/day from lipid ÷ 2.00 kcal/ml = _____ ml/day
Micronutrient Requirements
Multivitamins (Cernevit™; Clintec Nutrition Co., Deerfield, IL)
Add 0.5 ml reconstituted product/5 kg of body weight (up to 5 ml/day) = ______ ml/day
Standard parenteral B-vitamin complex (2 ml/L) can also be used.
Trace elements (Abbott Laboratories, North Chicago, IL)—Optional
Add 0.5 ml/5 kg (up to 5 ml/day) = ______ ml/day
Vitamin K
Administer 0.5 mg/kg subcutaneously once on day 1 of PPN and then once weekly
For animals <25 kg, this formulation will approximate maintenance amounts of potassium. For animals >25 kg, additional potassium
supplementation may be required, depending on serum potassium concentrations.

Total Requirements
_____ ml 5% dextrose
_____ ml 8.5% amino acids with electrolytes
_____ ml 20% lipid solution
_____ ml multivitamin solution
+ _____ ml trace-element solution
_______________________________________
= _____ ml total volume of PPN solution

Administration Rate
Total volume of PPN solution ____ ml ÷ 24 hr = _____ ml/hr
This formulation approximates a maintenance fluid rate. Check that this rate is appropriate for the patient and that other fluids are adjusted
accordingly.
Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

to dextrose, amino acids, and lipid more likely to result in metabolic

for transfer to a special mixing bag. complications (see Complications
After mixing, the bag is clamped off and Monitoring section).
and the solution is administered to Using the calculations in this arti-
the animal. cle, PPN can be started at the full cal-
For many clinics, however, com- culated rate (i.e., there is no need to
pounding PPN in-house is not feasi- gradually increase the PPN rate). Bags
ble. In this situation, there are now a of PPN should be refrigerated until
number of alternatives. Many phar- used and hung at room temperature
macies in human hospitals are willing for no longer than 24 hours. A bag of
to make arrangements with veterinar- PPN should not be administered to
ians to compound PPN. Typically, more than one animal. An animal’s
they require the calculations to be tolerance of oral feeding and its con-
made by the veterinarian, and either dition should be assessed daily. If the
one or several days’ worth of PPN is animal’s condition does not start to
compounded (it is often more cost resolve after 3 to 5 days of PPN ad-
efficient to make enough for several ministration, either TPN or PPN
days at a time). Alternatively, some combined with enteral nutrition should
universities and referral veterinary be considered. When the animal is
clinics will compound PPN and ship able to acquire at least half of its ener-
it to veterinarians. The advent of hu- gy requirements orally, PPN can be
man home health care in many cities Figure 3— A sterile bag with a three-lead discontinued (tapering PPN is not re-
has recently expanded the availability transfer set allows veterinary clinics to com- quired).
of TPN and PPN for veterinarians. pound a three-in-one peripheral parenteral Inline filters (1.2 µm) should al-
Many home health care companies nutrition in a sterile fashion. ways be used as part of the admin-
compound and deliver TPN to hu- istration set to filter particulate mat-
man patients on a daily basis and are ter from the solution and to prevent
willing to make arrangements with air from entering the vascular sys-
veterinarians for this service. Using tem. Solutions should be adminis-
the method of calculation described tered with an infusion pump to
in this article, PPN can now be avail- avoid giving a bolus of the PPN so-
able to most veterinary clinics. lution. A nonthrombogenic catheter
should be placed; we use 8- to 12-
PERIPHERAL PARENTERAL inch, 19- to 22-gauge, tetrafluo-
NUTRITION ADMINISTRATION roethylene Intracath ® catheters
Regardless of the type of PPN (Becton Dickinson, Sandy, UT).
chosen, there are certain rules of ad- Maintaining the sterility of PPN
ministration that apply. Dehydrated solutions, lines, and catheters is ab-
patients should be rehydrated be- solutely critical to prevent sepsis
fore commencing PPN administra- because the solution is an ideal
tion. Ongoing fluid losses should be growth medium for bacteria.
corrected with concurrent adminis- The patient’s PPN catheter
tration of a crystalloid fluid. Thus if Figure 4—Catheters and lines used for pe- should be a dedicated line and
ongoing fluid losses are miscalculat- ripheral parenteral nutrition administration should therefore not be used to ad-
ed or change daily, adjustments to must be handled aseptically to reduce the minister medications or additional
risk of infection.
the crystalloid fluid therapy can be fluids, take blood samples, or mea-
performed without altering the PPN sure central venous pressure. The
solution or rate of administration. The PPN solution line should not be disconnected, except to change PPN
itself is calculated to approximate maintenance fluid re- bags. When the bag is empty (which should occur every
quirements. Ideally, PPN should be administered over 24 hours), the bag, line, and catheter bandage should be
24 hours as opposed to cyclically. In certain conditions, changed. Sterile technique should be used when han-
such as a hospital without 24-hour care, it may be ac- dling the catheter or the line and when changing bags
ceptable to administer PPN over 12 hours, but this is (Figure 4). The catheter site should be evaluated for

COMPOUNDING PPN ■ INLINE FILTERS ■ BAGS AND CATHETERS

Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

signs of swelling, redness, or irritation. If there is irrita- failure resulting from volume overload, especially when
tion at the site or any question of the catheter’s patency, intravenous fluids are given in addition to the PPN.
the catheter should be removed and a new one placed in Metabolic complications are not always the direct result
a different vein. The catheter should be carefully of the PPN but may be caused by the underlying disease.
rewrapped. The bandage also should be changed if it be- Septic complications are the most serious potential
comes soiled with urine, feces, or vomit. problem of PPN but can be minimized by adhering to
strict protocols for mixing and handling solutions and
COMPLICATIONS AND MONITORING monitoring animals. If fever or other signs of potential
Although complications are much less common with sepsis occur and other causes (e.g., peritonitis, urinary
PPN than with TPN, patient monitoring is still one of tract infection, pneumonia) are ruled out, cultures of
the most important aspects of providing nutritional the blood and PPN catheter should be performed.
support. Potential complications can be mechanical, The complication rate is quite low, however, if strict
metabolic, or septic. protocols for mixing and administering PPN are ob-
MPENDIU The most common com- served. In a study conducted in our hospital of dogs and
M’

20th

CO

plications of PPN are me- cats with pancreatitis receiving three-in-one compound-
S

1 9 7
9 - 1
9 9 9
chanical, including catheter ed PPN, the only complications noted were metabolic
ANNIVERSARY
occlusion or premature re- (e.g., hyperammonemia, hypercholesterolemia, and hy-
moval, line disconnection pertriglyceridemia) in 1 of 12 patients.13 No cases of
A LookBack or breakage, and throm-
bophlebitis. Catheter and
thrombophlebitis or sepsis occurred.13 In a recently com-
pleted study of dogs and cats receiving a commercial
The importance of providing line problems can be mini- PPN solution, 2 of 30 patients developed transient mild
nutrition to ill veterinary mized by careful attention hyperglycemia and 2 developed phlebitis; sepsis was not
patients has become increasingly
to catheter care and moni- noted.22
toring of animals (e.g., us- Other important parameters to monitor include
clear over the past two decades,
ing an Elizabethan collar to body weight and signs of malnutrition. PPN is intend-
and nutritional support is now prevent animals from chew- ed for animals that are not already debilitated, do not
commonplace. Although total ing the line or catheter). have large protein losses, and are expected to eat within
parenteral nutrition is now Thrombophlebitis is not an 4 to 5 days. If the situation changes (e.g., the animal
more widely accepted, safer, indication for termination has increased vomiting or diarrhea or significant
and easier than it once was, its of therapy but does require drainage from wounds or the condition persists for
use is still not feasible for many relocation of the catheter. more than few days) or the animal begins to exhibit
practices. Advances in the
Metabolic complications weight loss or decreasing serum albumin concentra-
are much less common tions, it is important to change to TPN or a combina-
formulation of parenteral
with PPN formulated using tion of PPN and low-dose enteral nutrition.
nutrition solutions, intravenous the calculations in this arti-
catheters, and administration cle than with TPN. The SUMMARY
techniques as well as more most common problem is Many of the problems associated with TPN can be
conservative calculation of hyperglycemia, which, if se- overcome by using PPN, but PPN should not be
nutritional requirements have vere, can be managed with viewed as a replacement for TPN. Although it does not
facilitated the use of peripheral exogenous insulin. Hyper- provide all nutritional requirements, PPN can be bene-
parenteral nutrition (PPN).
ammonemia or hypertrigly- ficial in appropriately selected patients. In addition,
ceridemia are uncommon PPN reduces the risk of complications compared with
Simplified administration and
but can occur and usually TPN. Like TPN, however, PPN does have potential to
fewer complications make PPN require reformulation of the cause major problems and thus should be administered
a convenient and practical solution with reduced pro- with care; protocols for mixing and administering solu-
method of nutritional support tein or reduced lipid levels, tions as well as monitoring patients should be devised
in carefully selected patients. respectively. Refeeding syn- and strictly followed. The ease of use of PPN has made
drome (characterized by the benefits of parenteral nutrition more widely avail-
hypokalemia, hypophos- able to veterinarians and their patients.
phatemia, and hypomag-
nesemia) also can occur but REFERENCES
is unlikely. Another possible 1. Thatcher CD: Nutritional needs of critically ill patients.
problem is congestive heart Compend Contin Educ Pract Vet 18(12):1303–1313, 1996.

MECHANICAL COMPLICATIONS ■ HYPERGLYCEMIA ■ SEPTIC COMPLICATIONS

Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

2. Rhoads JE, Dudrick ST: History of intravenous nutrition, in 17:468–478, 1993.

Rombeau JL, Caldwell MD (eds): Clinical Nutrition: Par- 15. Kane KF, Cologiovanni L, McKiernan J, et al: High osmo-
enteral Nutrition, ed 2. Philadelphia, WB Saunders Co, lality feedings do not increase the incidence of throm-
1993, pp 1–10. bophlebitis during peripheral IV nutrition. J Parenter Enter-
3. Dudrick ST, Wilmore DW, Vars HM, Rhoads JL: Long- al Nutr 20:194–197, 1996.
term total parenteral nutrition with growth, development, 16. Bodoky A: Parenteral nutrition by peripheral vein, portal
and positive nitrogen balance. Surgery 64:134–142, 1968. vein, or central venous catheter? World J Surg 10:47–52,
4. Carter JM, Freedman A: Total intravenous feeding in the 1986.
dog. JAVMA 171:71–76, 1977. 17. Lev-Ran A, Johnson M, Hwang DL, et al: Double-blind
5. Nordenstrom J: Peripheral parenteral nutrition: Changing study of glycerol vs glucose in parenteral nutrition of post-
trends in intravenous feeding. Nutrition 8:440–441, 1992. surgical insulin-treated diabetic patients. J Parenter Enteral
6. Barton RG: Immune-enhancing enteral formulas: Are they Nutr 11:271–274, 1987.
beneficial in critically ill patients? Nutr Clin Pract 12:51–62, 18. Fairfull-Smith R, Stoski D, Freeman JB: Use of glycerol in
1987. peripheral parenteral nutrition. Surgery 92:728–732, 1982.
7. Mainous MR, Block EFJ, Deitch EA: Nutritional support of 19. Kehoe JE, Mihranian MH, Masser EL, et al: Use of 20% fat
the gut: How and why. New Horizons 2:193–201, 1994. emulsion in peripheral parenteral nutrition. J Parenter Enter-
8. Davenport DJ: Enteral and parenteral nutritional support, in al Nutr 8:647–651, 1984.
Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Inter- 20. Carpentier YA, Van Gossum A, Dubois DY, Deckelbaum
nal Medicine, ed 4. Philadelphia, WB Saunders Co, 1995, RJ: Lipid metabolism in parenteral nutrition, in Rombeau
pp 244–252. JL, Caldwell MD (eds): Clinical Nutrition: Parenteral Nutri-
9. Lippert AC, Armstrong PJ: Parenteral nutritional support, in tion, ed 2. Philadelphia, WB Saunders Co, 1993, pp 35–74.
Kirk RW (ed): Current Veterinary Therapy X: Small Animal 21. Dibartola SP, Autran de Morais HS: Disorders of potassium:
Practice. Philadelphia, WB Saunders Co, 1989, pp 25–30. Hypokalemia and hyperkalemia, in DiBartola SP (ed): Fluid
10. Remillard RL, Thatcher CD: Parenteral nutritional support Therapy in Small Animal Practice. Philadelphia, WB Saun-
in small animal patients. Vet Clin North Am Small Anim ders Co, 1992, pp 89–115.
Pract 19:1287–1306, 1989. 22. Freeman LM, Rush JE, Rozanski EA, et al: Nutritional sup-
11. Dickerson RN, Brown RO, White KG: Parenteral nutrition port using a commercial glycerin/amino acid solution. Proc
solutions, in Rombeau JL, Caldwell MD (eds): Clinical Nu- Int Vet Emer Crit Care Soc Meet:827, 1998.
trition: Parenteral Nutrition, ed 2. Philadelphia, WB Saun-
ders Co, 1993, pp 310–333.
12. Stokes MA, Hill GL: Peripheral parenteral nutrition: A pre- About the Authors
liminary report on its efficacy and safety. J Parenter Enteral
Drs. Zsombor-Murray and Freeman are affiliated with the
Nutr 17:145–147, 1993.
13. Freeman LM, Labato MA, Rush JE, Murtaugh RJ: A retro- Department of Clinical Sciences, School of Veterinary
spective evaluation of peripheral parenteral nutrition (PPN) Medicine, Tufts University, North Grafton, Massachusetts.
in small animal patients with pancreatitis. Proc Int Vet Emer Dr. Freeman is a Diplomate of the American College of
Crit Care Soc Meet:881, 1996. Veterinary Nutrition.
14. Payne-James JJ, Khawaja HT: First choice for total parenter-
al nutrition: The peripheral route. J Parenter Enteral Nutr