Total parenteral nutrition (TPN)

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Total parenteral nutrition (TPN)

• Intern ???

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Definition

• Provision of all nutritions through other than
  the alimentary tract

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Indications

• Those who do not eat anorexia nervosa,
• Those who can not eat esophageal stenosis,
  prolong ileus,
• Those who are not allowed to eat
  gastrointestinal fistula, inflammatory bowel
  disease, radiation enteritis, GI chemotoxicity,
  pancreatitis

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Indications

• Those who are not eating enough short bowel
  syndrome, burn, sepsis
• Those who can manage what they eat hepatic
  failure
• Others renal failure, operation

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Perioperative parenteral nutrition

• Predicted weigh loss gt 15
• Albumin lt 3 g per 100 ml
• Duration 810 days
• Mortality not changed, Sandstrom

VATPN study, Buzby, NEJM, 1991
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Complications -- mechanical

• Catheter infection
• Pneumothorax
• Arterial laceration
• Hemothorax
• Hydrothorax
• Nerve injury brachial plexus or its branches,
  phrenic nerve, recurrent laryngeal

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Complications -- mechanical

• Air embolism
• Catheter embolism
• Thoracic duct injury
• Venous embolism, perforation
• Sepsis

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Complications -- metabolic

• Hyperglycemia
• Rapid initiation of the infusion
• Pancreatic insufficiency (more common in elderly)
• Pancreatitis
• Liver disease
• Sepsis

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Complications -- metabolic

• Hypoglycemia
• Slowing of the infusion
• Excessive insulin administration
• Endogenous overproduction of insulin
• Hyperosmolar hyperglycemic nonketotic comafever
  dizziness, osmotic diuresis, blood sugar of
  7001400 mg/dl

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Complications -- metabolic

• Fluid overload
• Electrolytes abnormality
• Acid-base imbalances
• Trace mineral deficiency

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Complications -- metabolic

• Liver function derangement
• Elevated AST, ALT levels
• Hyperbilirubinemia rare, related to sepsis
• Hepatic steatosis almost all components of
  parenteral nutrition
• Excessive glucose adminstration, translocation of
  bacteria and their products such as endotoxin

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Complications

• First 48 hrs catheter insertion
• First 2 weeks Thrombosis
• 3 months Fractures or tears in catheter,
  catheter embedded in vein wall

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Complications

• First 48 hrs Fluid overload, hyperglycemia
• First 2 weeks Cardiopulmonary failure, HHNK,
  electrolyte imbalabce
• 3 months TPN liver disease, Zinc, copper,
  chromium, selenium, molybdenum, deficiency

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Postabsorptive state

• Interprandial

Liver
Skeletal Muscle
Serum amino acid
Visceral organ
Moore et al.
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Bypass theory

• Decreased first pass clearance of amino acid,
  glucose, and insulin
• Increased de novo lipogenesis of liver

Buchman et al.
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Cyclic TPN

• Mobility
• Establish a more metabolic and hormonal profile
  insulin, glucagon, GH, thyroid hormone
• Miani et al. change of hormonal profile
  decreased at 23 weeks, similar sepsis rate
• Lerebours et al. similar nitrogen balance after
  1 week

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• Thanks !!