TPN Indications

James S. Scolapio, M.D.

Director of Nutrition
Division of Gastroenterology and
Hepatology
Mayo Clinic
Jacksonville, FL
E-mail: scolapio.james@mayo.edu
 TPN Indications
Definitions
TPN - Total parenteral nutrition
Via central vein (CPN)
Dextrose > 5 %
PPN Peripheral parenteral nutrition
Via peripheral iv
No central catheter
Dextrose </= 5% & osmolarity < 900

Gastroenterology 2001; 121: 970

 When to Feed?
Nutrition Subjective Global
Assessment
A < 5% weight loss (mild)
B 5-10% weight loss (moderate)
C >10% weight loss (severe)
7-14 days for A & Bs
Disease severity
Detsky AS. JPEN 8:153, 1984
 Nitrogen Balance
p<0.05 *
*14 days
% Mortality

Sitzman JV. Surg Gyn Ostet 168:31, 1989

 Enteral vs. Parenteral
Nitrogen Balance
Nitrogen balance (mg
per kg per day)

Time from start of nutritional support (days)

Kalfarentzos F. BJS 84:1665, 1997
What to Feed?
Adults
25-30 kcal/kg
Lipids (30% of total)
Protein (1.0-1.5 g/kg)
CHO (other); < 5 mg/kg/min
Metabolic Cart
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
TPN Contraindications
Functioning GI system
Severe fluid overload
TPN Indications
82 RCTs
TPN did not influence mortality
TPN increased infections
No major effect on length of
hospital stay
 Enteral vs.TPN
Patients Preference
N = 200

91% - Parenteral
9% - Nasogastric

JPEN 26; 248-250, 2002

 Enteral vs Parenteral
Acute Severe Pancreatitis
Enteral Parenteral
(n=18) (n=20)
Septic complications 6 15
Hyperglycemia 4 9
Peripancreatic necrosis 1 4
Cost Less More

* NJ Semi-elemental; 30-35 kcal/kg; 48 hours of admit; all gallstone

Kalfarentzos F. BJS 84:1665, 1997

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
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
> 3 months, pursing active treatment)
Anticipated use 90 days or more
Competency
ASPEN
Clinical guidelines - JPEN 26; 2002
CME
AGA
ASPEN
Mayo
Harvard
NBNSC