TOTAL PARENTERAL NUTRITION (TPN)

Partial parenteral nutrition Supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method.

Total parenteral nutrition (TPN) Supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required. Parenteral nutrition should not be used routinely in patients with an intact GI tract. Compared with enteral nutrition, it causes more complications, does not preserve GI tract structure and function as well, and is more expensive.

Indications: TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following:

Some stages of Crohn's disease or ulcerative colitis Bowel obstruction Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless of its cause)

Short bowel syndrome due to surgery

Nutritional content: TPN requires water (30 to 40 mL/kg/day), energy (30 to 60 kcal/kg/day, depending on energy expenditure), amino acids (1 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals. Children who need TPN may have different fluid requirements and need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day). Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors. Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/min of dextrose is given. Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids. Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories may help obese patients mobilize endogenous fat stores, increasing sensitivity.

Solutions: Many solutions are commonly used. Electrolytes can be added to meet the patient's needs. Solutions vary depending on other disorders present and patient age, as for the following: For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein content and a high percentage of essential amino acids For heart or kidney failure: Limited volume (liquid) intake

 For respiratory failure: A lipid emulsion that provides most of nonprotein calories to minimize CO2 production by carbohydrate metabolism For neonates: Lower dextrose concentrations (17 to 18%)

Beginning TPN administration: Because the central venous catheter needs to remain in place for a long time, strict sterile technique must be used during insertion and maintenance. The TPN line should not be used for any other purpose. External tubing should be changed every 24 h with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 h using strict sterile techniques. If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged. The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular insulin/L of TPN fluid.

Monitoring: Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.

Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and Ca, Mg, and phosphate should be measured twice/wk. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion. Full nutritional assessment (including BMI calculation and anthropometric measurements see Under nutrition: Physical examination and see Obesity and the Metabolic Syndrome: Body composition analysis) should be repeated at 2-wk intervals.

Complications: About 5 to 10% of patients have complications related to central venous access. Catheter-related sepsis occurs in about 50% of patients. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients. Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often, adjusting the insulin dose in the TPN solution and giving subcutaneous insulin as needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged hypoglycemia may require infusion of 5 or 10% dextrose for 24 h before resuming TPN via the central venous catheter. Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any age but are most common among infants, particularly premature ones (whose liver is immature).

 Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result from excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive fibrosis occasionally develops. Reducing protein delivery may help. Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be reduced. Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized seizures. Arginine supplementation at 0.5 to 1.0 mmol/kg/day can correct it. If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be necessary. Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated BUN may reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein. Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy requirements and thus require large fluid volumes. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients given TPN for > 3 mo. The mechanism is unknown. Advanced disease can cause severe periarticular, lower-extremity, and back pain. Temporarily or permanently stopping TPN is the only known treatment. Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/kg/h. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure;

treatment is usually not required. Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions. Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These complications can be caused or worsened by prolonged gallbladder stasis. Stimulating contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is helpful. Oral or enteral intake also helps. Treatment with metronidazole ursodeoxycholic acid, phenobarbital or cholecystokinin helps some patients with cholestasis.

Basic Adult Daily Requirements for Total Parenteral Nutrition Nutrient Water (/kg body wt/day) Amount 3040 mL 30 kcal 3045 kcal 4560 kcal 1.0 g 2.0 g 3.0 g

Energy* (/kg body wt/day)

Medical patient Postoperative patient Hypercatabolic patient Medical patient Postoperative patient Hypercatabolic patient

Amino acids (/kg body wt/day)

Minerals

Acetate/gluconate Calcium Chloride Chromium Copper Iodine Magnesium Manganese Phosphorus Potassium Selenium Sodium Zinc

90 mEq 15 mEq 130 mEq 15 g 1.5 mg 120 g 20 mEq 2 mg 300 mg 100 mEq 100 g 100 mEq 5 mg 100 mg 60 g 5 g 400 g 40 mg 15 mg 4 mg 3.6 mg 3 mg

Vitamins
Ascorbic acid Biotin Cobalamin Folate (folic acid) Niacin Pantothenic acid Pyridoxine Riboflavin Thiamin

Vitamin A Vitamin D Vitamin E

4000 IU 400 IU 15 mg

Vitamin K 200 g *Requirements for energy increase by 12% per 1 C of fever.

TOTAL PARENTERAL NUTRITION (TPN)