TPN Indications

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TPN Indications

• James S. Scolapio, M.D.
• Director of Nutrition
• Division of Gastroenterology and Hepatology
• Mayo Clinic
• Jacksonville, FL
• E-mail scolapio.james_at_mayo.edu

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TPN IndicationsDefinitions

• TPN - Total parenteral nutrition
• Via central vein (CPN)
• Dextrose gt 5
• PPN Peripheral parenteral nutrition
• Via peripheral iv
• No central catheter
• Dextrose lt/ 5 osmolarity lt 900

Gastroenterology 2001 121 970
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When to Feed?

• Nutrition Subjective Global Assessment
• A lt 5 weight loss (mild)
• B 5-10 weight loss (moderate)
• C gt10 weight loss (severe)
• 7-14 days for A Bs
• Disease severity

Detsky AS. JPEN 8153, 1984
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Nitrogen Balance
plt0.0514 days

Mortality
Sitzman JV. Surg Gyn Ostet 16831, 1989
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Enteral vs. ParenteralNitrogen Balance
Nitrogen balance (mg per kg per day)
Time from start of nutritional support (days)
Kalfarentzos F. BJS 841665, 1997
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What to Feed?Adults

• 25-30 kcal/kg
• Lipids (30 of total)
• Protein (1.0-1.5 g/kg)
• CHO (other) lt 5 mg/kg/min
• Metabolic Cart

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TPN Indications

• Preexisting nutrition deprivation
• Anticipated or actual inadequate energy intake by
  mouth
• Significant multi organ system disease
• Non functioning gastrointestinal system
• Obstruction
• Distal fistula
• Severe motility disorder
• Severe absorptive disease
• Short bowel, radiation enteritis, PLE

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TPN Contraindications

• Functioning GI system
• Severe fluid overload

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TPN Indications

• 82 RCTs
• TPN did not influence mortality
• TPN increased infections
• No major effect on length of hospital stay

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Enteral vs.TPNPatients Preference

• N 200
• 91 - Parenteral
• 9 - Nasogastric

JPEN 26 248-250, 2002
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Enteral vs ParenteralAcute Severe Pancreatitis
Enteral (n18)
Parenteral (n20)

• Septic complications
• Hyperglycemia
• Peripancreatic necrosis
• Cost

• 6 15
• 4 9
• 1 4
• Less More

NJ Semi-elemental 30-35 kcal/kg 48 hours of
admit all gallstone
Kalfarentzos F. BJS 841665, 1997
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Monitoring

• Chem 7 twice weekly
• TG q week
• I do not follow albumin or prealbumin
• T-1/2 albumin 21 days fluid stress
• T-1/2 prealbumin 3 days
• Weights and I/Os
• Calorie counts

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HPN Indications

• Unable to take p.o. or tube feeds for prolong
  period of time.
• Short bowel syndrome
• Prolonged malabsorptive state
• Documentation 72 fecal fat
• Severe motility disorder
• Most document with motility testing
• Non terminal obstructive cancer (survival gt 3
  months, pursing active treatment)
• Anticipated use 90 days or more

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Competency

• ASPEN
• Clinical guidelines - JPEN 26 2002
• CME
• AGA
• ASPEN
• Mayo
• Harvard
• NBNSC