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total parenteral (intravenous) nutrition (TPN)

Indications: - cannot use the gastrointestinal tract - GI illness, GI rest indicated, intestinal obstruction ( partial or complete) - underlying condition preventing enteral nutrition expected to last 3-7 days [5] Contraindications: - do not add to enteral nutrition [3] Procedure: Delay parenteral nutrition for 1 week in adults & children [2] Central venous access to avoid phlebitis & thrombophlebitis: 1) peripherally-inserted central catheter (PICC) 2) central venous catheter (subclavian, jugular, femoral) 3) tunneled central catheter with subcutaneous port Daily parenteral requirements: Nutrient Quantity essential fatty acids 2-4% of total calories calcium 0.2-0.4 g phosphorous 0.4-0.8 g potassium 3-4 g sodium 1-3 g chloride 3-4 g magnesium 0.3 g iron 1-2 mg zinc 3-12 mg copper 0.3-0.5 mg iodine 0.15 mg manganese 2-5 mg chromium 15-30 ug molybdenum 20-120 ug selenium 50-100 ug ascorbate 100 mg thiamine 3.0 mg riboflavin 3.6 mg niacin 40 mg biotin 60 ug pantothenate 15 mg pyridoxine 4.0 mg folate 400 ug cobalamin 5 ug vitamin A 1000 ug vitamin D 5-10 ug vitamin E 10-15 mg vitamin K 200 ug Laboratory: 1) plasma glucose 4 times daily until patient is stable 2) chem 7 daily until glucose infusion stable, then twice weekly 3) baseline labs, then weekly a) albumin, transferrin or TIBC b) liver function tests - mild elevations in serum ALT & serum alkaline phosphatase c) Ca+2, phosphate, Mg+2 d) complete blood count (CBC) 4) baseline labs, then weekly a) prothrombin time (PT) b) activated partial thromboplastin time (aPTT) Complications: 1) mechanical - complications associated with the central venous access 2) metabolic a) 1st 48 hours - fluid overload - hyperglycemia - hypophosphatemia - hypokalemia b) 1st 2 weeks - cardiopulmonary failure - hyperosmolar, nonketotic hyperglycemic coma - acid-base imbalance - electrolyte imbalance - mild elevations in serum ALT & serum alkaline phosphatase due to steatosis with subsequent cholestasis c) after 3 months - fatty acid deficiency - copper, zinc, chromium, selenium, molybdenum deficiency - iron deficiency - vitamin deficiency - TPN metabolic bone disease - TPN liver disease 3) infectious a) catheter-induced sepsis b) exit site infection c) tunnel infections (generally > 3 months) 4) intestinal mucosal atrophy - translocation of intestinal flora to the bloodstream Management: - - parenteral nutrition should not be added to enteral feeding [3]

Related

lipid injectable emulsion (Clinolipid)

General

nutrition

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 477-78
  2. Fivez T, Kerklaan D, Mesotten D et al. Early versus late parenteral nutrition in critically ill children. N Engl J Med 2016 Mar 24; 374:1111. PMID: 26975590 - Mehta NM. Parenteral nutrition in critically ill children. N Engl J Med 2016 Mar 24; 374:1190 PMID: 26975731
  3. Medical Knowledge Self Assessment Program (MKSAP) 18, 19 American College of Physicians, Philadelphia 2018, 2022
  4. Taylor BE, McClave SA, Martindale RG et al Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438. PMID: 26771786
  5. NEJM Knowledge+ Endocrinology
  6. Pironi L, Boeykens K, Bozzetti F et al ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020 Jun;39(6):1645-1666. PMID: 32359933 Review.