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Total Parenteral Nutrition: Review
Total Parenteral Nutrition: Review
Col KK MAUDAR
ABSTRACT
Total parenteral nutrition has been used in clinical practice for over a quarter of a century. It has
revolutionized the management of potentially fatal condition like the short bowel syndrome in infants
as well as adults. Refinements in techniques have led to development of sophisticated catheters and
delivery systems. Better understanding of human nutrition and metabolic processes has lead to formu›
lation of scientific parenteral solutions to suit specific situations. This article addresses the role oftotal
parenteral nutrition in modern surgical practice.
MJAFI 1995; 51 : 122-126
KEY WORDS: Parenteral nutrition total.
T
otal parenteral nutrition (TPN) was in› more important indications of TPN are listed
troduced in clinical practice over 25 below [4].
years ago by Dudrick et al who demon›
1. Newborns with gastrointestinal anoma›
strated the beneficial effects oflong-term TPN
lies such as tracheoesophageal fistula,
on the growth and development in children
massive intestinal atresia, complicated
[1]. Since then it has come a long way, and it
meconium ileus, massive diaphragmatic
is now a standard tool in the armamentarium
hernia, gastroschisis, omphalocele or
ofthe physicians in their quest for delivery of
cloacal exostrophy, and neglected pyloric
comprehensive health care to patients. The
stenosis.
indications of TPN are now fairly well de›
fined, as is the knowledge about its limita› 2. Failure to thrive in infants with short
tions, side effects, and complications. bowel syndrome, malabsorption, inflam›
Advances in technology have now made it matory bowel disease, enzyme deficien›
possible for TPN to be delivered at the pa› cies and chronic idiopathic diarrhea.
tients own residence, thus reducing hospital 3. Other paediatric indications include ne›
costs [2]. New areas of research include the crotizing enterocolitis, intestinal fistulae,
possible use of TPN in arresting and possibly severe trauma, burns, postoperative in›
reversing atherosclerotic disease processes fections and malignancies.
[3]. This review article discusses the place of 4. Adults with short bowel syndrome secon›
TPN in modern surgical practice. dary to massive small-bowel resection or
Indications internal or external enteric fistulae.
The principal indication for TPN is a seri› 5. Malnutrition secondary to high intestinal
ously ill patient where enteral feeding is not obstruction for example achalasia, oeso›
possible. It may also be used to supplement phageal strictures and neoplasms, pyloric
inadequate oral intake. The successful use of obstruction and gastric neoplasms.
TPN requires proper selection of patients, 6. Prolonged ileus due to medical or surgi›
adequate experience with the technique, and cal causes (for example post-operative,
Professor and Head, Dept of Surgery, Armed Forces Medical College, Pune 411040.
MIAFI, 51 : 2, APRIL 1995 Total Parenteral Nutrition 123
is associated with a mortality of 33% [8]. weight for the first 10 kg, 50 mLlkg for next
10 kg and 20 mLlkg for each additional kg of
Nutritional Requirements and Delivery of body weight. Compensations should be made
TPN for additional losses e.g., from a fistula.
The delivery of TPN is via a large bore Calories : Glucose is the major carbohy›
central venous catheter placed in the superior drate which supplies calories, and this is
vena cava through the subclavian or the inter› administered in the form of 25% or 50%
nal jugular vein. This can be done by a "cut› solution. Total energy requirement may vary
down", but it is much better to use one of the considerably between 2000 to 4500 or more
modem percutaneous catheter-systems, as calories daily. ,
the incidence of infection is much lower by
Fats: In order to avoid essential fatty acid
the use of the latter technique. Strict asepsis
deficiency at least 4% of calories should be
is to be observed during the placement of the
supplied as fats.
catheter. A chest radiograph should be taken
prior to the commencement offeeding to con› Proteins: Protein requirement varies from
firm the position of the catheter-tip and to 1.5 to 2.5 g/kg of body weight per day. The-.
exclude traumatic pneumothorax, the com› ratio of nitrogen to calories should be 1 :
monest complication related to catheter 100-150. Branched-chain amino acids have
placement. The catheter should be flushed been recommended as an integral part of
with dilute heparin daily, to avoid catheter TPN. However their benefits have so far not
thrombosis. With proper care, a central cathe› been conclusively proved.
ter can be maintained for several days or even Electrolytes : Daily maintenance require›
weeks for the delivery of TPN. ments of sodium are 1-1.5 mEq/kg; potassium
While energy requirements can be calcu› 1 mEq/kg; chloride 1.5 - 2 mEq/kg; calcium
lated by the Harris-Benedict equation or the 0.2 mEq/kg and magnesium 0.35 - 0.45
Long’s modification of the same [9], in prac› mEq/kg.
tice the institution of TPN is riot so compli› Micronutrients : Trace elements are an im›
cated. The therapy is now well standardized, portant component ofTPN. Zinc 5 mg, copper
yet it allows a fair deal of freedom to the 1 mg, chromium 10 mcg, manganese 0.5 mg
treating physician" However, certain basic and iron 1-2 mg are required daily.
principles must be adhered to. The ratio of Vitamins: Vit K-l 10 mg and folic acid 5
calories to nitrogen must be adequate (at least mg should be administered intramuscularly
100 to 150 kcal/g nitrogen) and the two mate› once a week. Vit B-12 1 mg is given once a
rials must be infused simultaneously as there month. Water soluble vitamins should be
is significant decrease in nitrogen utilization given daily.
if they are infused at different times. The Nutritional monitoring : It is recom›
entire TPN requirement for the day should be mended that the following parameters be
constituted in the hospital pharmacy under measured daily during TPN : Body weight
strict aseptic conditions. The basic solution estimation; 12-hourly intake-output chart; B-
should contain 20% to 25% dextrose and 3% hourly urine-sugar estimation; serum so›
to 5% crystalline amino acids from the com› dium, potassium, bicarbonate, calcium and
mercially available kits/solutions. Lipid chloride; blood urea and serum creatinine.
emulsions are not only an important source Liver function tests and serum proteins
of energy, but also prevent development of should be measured twice daily.
essential fatty acid deficiency. While there
are several special formulations available for Complications
specific clinical situations, an outline of basic TPN is a highly sophisticated technique
TPN solution is given below [10J. and is not free from complications. These
Fluid requirements : 100. mLlkg body relate to the use of a central venous catheter
MJAFI, 51 : 2, APRIL 1995 Total Parenteral Nutrition 125