Indication and Appropriate use of TPN

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(Totalhere for title
Parenteral Nutrition)
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Charles Posternack, MD, FACP, FRCPC

Chief Medical Officer
Boca Raton Regional Hospital
Definition of Total Parenteral Nutrition
• A method of providing nutrition to patients by infusing a
mixture of all necessary nutrients directly into the
circulatory system

• By definition this means bypassing the patient’s natural

conduit to absorb nutrients, the gastro-intestinal system

• And as we all know…being unnatural is frowned upon

today!
The most important takeaway from
today’s presentation…

FOLLOW THE GOLDEN RULE OF

NUTRITION!!!

and that is…..

 The Golden Rule for Nutrition
• The gut should always be the preferred route for
administration of nutrients!

• Whenever possible it should be used either through direct

oral or indirect enteral feedings with feeding tubes

• If TPN is to be used, indication needs to be clearly

validated and based on strict evidence based medicine
 WHY???

While TPN may well be life saving in certain ill and critically ill
patients, TPN is fraught with potentially life threatening
complications, as well as being a major cause of patient
morbidity!!!

Make certain that you make a wise clinical decision!!!

 ASPEN
American Society for Parenteral and Enteral Nutrition
• Have created guidelines for the appropriate and
ethical use of total parenteral nutrition

• Considered the defining “gold standard” for nutritional

consideration
 Cardinal Rules for the use of TPN

• Timing and duration

• Indications – absolute and relative
• Prognosis of patient (tolerance of potential risks)
• Can and enteral alternative be used?
 Timing and Duration
• TPN is never indicated when it’s use is anticipated to be
less than 72 hours!
• Whatever disease process exists, one should only
consider using TPN if the period of starvation is
expected to exceed 7 – 10 days for well-nourished
adults

• Severely malnourished patients may be considered for

earlier intervention if indicated
 What are the Physiologic Indications
for the Potential use of TPN?
• Short bowel syndrome
• Chronic malabsorption syndromes
• GI anatomic abnormalities (e.g.. Enterocutaneous Fistulas)
• Severe acute malabsorption syndromes → severe malnutrition
• S/P major GI surgery where gut cannot be used
• Prolonged small bowel obstruction
• GI Ischemia
• Hemodynamic instability preventing the ability to advance
enteral nutrition
• No enteral feeding access (T-E fistula, Gastric Outlet
Obstruction)
• Upper GI Hemorrhage
• Severe (hemorrhagic) Pancreatitis
• Severe trauma or severe burns
• High risk of aspiration and severe malnutrition
 Absolute Indications for TPN in Adults
• Permanent inability to absorb adequate nutrients via the gut
• Massive small bowel resection
• ˂ 100cm small bowel
• ˂60cm small bowel but with an IC valve and colon
• Chronic malabsorption from disease (Crohn’s Disease) or from
external anatomic damage (radiation)

• Entero – Cutaneous fistulas

• 7 days or more of bowel rest required for healing (pre and
post OP period included)
• High output EC-Fistula worsened by enteral feeding
 Relative Indications for TPM
1. Severe malnutrition (Prealbumin ˂ 10) along with:
• GI malabsorption syndrome or inability to absorb nutrients
˃ 7 – 10 days
• Major GI surgery or post-op bowel obstruction ˃7-10 days
• GI ischemia
• Mechanical SBO ˃ 7-10 days
• Hemodynamic instability precluding use of gut because of
hypotension and pressers ˃ 5 days
• Enteral feeds not possible because of mechanical issues
(oral/pharyngeal/esophageal obstruction, gastric outlet
obstruction, T-E fistula
2. Upper GI hemorrhage with no enteral access available for
5-7 days
3. Severe hemorrhagic pancreatitis requiring bowel rest ˃
7days (3 or more of early Ranson’s Signs)
 TPN not Indicated
• Terminal illness where live expectancy is less than three
months (TPN has not been shown to increase quality in
end of life situations; rather the opposite)
• Patient refuses enteral access
• TPN used ˂ 7 days (no clinical benefit)
• Poor gastric emptying alone
• Short term colonic ileus
TPN IS NOT INDICATED WHENEVER
PATIENT HAS A FUNCTIONAL GUT!!!
While TPN can be an important adjunct
to optimal patient care, particularly in
those critically ill, it has the potential to
be harmful as well…

So how is TPN administered and what

are its potential complications?
 Nutritional Requirements of TPN
• Energy
• Glucose
• Lipids
• Amino acids: nitrogen
• Fluid and electrolytes
• Vitamins
• Trace elements
 Energy Requirements
Approximate Energy
Patient Condition Basal Metabolic Rate
Requirement (kcal/kg/day)

No postoperative complications,
Normal 25-30
GIT fistula without infection

Mild peritonitis, long-bone

fracture, mild to moderate injury, 25% above normal 30-35
malnourished

Severe injury or infection 50% above normal 35-45

Burn 40 – 100% of total body Up to 100% above

45-80
surface normal
 Energy Requirements
Energy Source: Glucose
• The most common source of parenteral energy supply is
glucose, being:
• Readily metabolized in most patients
• Provides the obligatory needs of the substrate, thus
reducing gluconeogenesis and sparing endogenous
protein
• 1gm of glucose gives 4kcals
• Most stable patients tolerate rates of 4-5mg.kg/Min but
insulin resistance in critically ill patients may lead to
hyperglycemia even at these rates, so insulin should be
incorporated according to blood sugar levels
 Energy Requirements
Energy Source: Lipid
• Fat mobilization is a major response to stress and
infection
• Triacylglycerols are an important fuel source in those
conditions, even when glucose availability is adequate
• Need to be restricted in patients with
hypertriglyceridemia
• Lipids are also a source for the essential fatty acids
which are the building blocks for many of the
hormones involved in the inflammatory process as
well as the hormones regulating other body functions
• Ideally, energy from fat should not exceed 40% of the
total (usually 20-30%)
 Energy Requirements
Energy Source: Nitrogen
• protein (or amino acids, the building blocks of proteins)
is the functional and structural component of the body,
so fulfilling patient’s caloric needs with non-protein
calories (fat and glucose) is essential
• Protein requirements for most healthy individuals are
0.8g/kg/day
• With disease, poor food intake, and inactivity, body
protein is lost with the resultant weakness and muscle
mass wasting
• Critically ill patients may need as high as 1.5 – 2.5g
protein/kg/day depending on the disease process
(major trauma or burn ˃ standard)
• The amount should be reduced in patients with kidney
or liver disease
 Requirements
Nitrogen: daily protein requirements
Condition Example Requirement

Basic requirements Normal person 0.5 – 1g/kg

Post-operative, cancer,
Slightly increased requirements 1.5g/kg
inflammatory

Moderately increased requirements Sepsis, polytrauma 2g/kg

Highly increased requirements Peritonitis, burns 2.5g/kg

Renal failure, hepatic

Reduced requirements 0.6g/kg
encephalopathy
 Requirements
Fluid and Electrolytes
• 20 – 40mL/kg – daily – young adults
• 30mL/kg – daily – older adults
• Sodium, potassium, chloride, calcium, magnesium and
phosphorus (as per table)

• Daily lab tests to monitor electrolyte status

 Requirements
Fluids and Electrolytes
Nutrient Requirements

Water 20 – 40 mL

Sodium 0.5 – 1.0 mmol

Potassium 0.5 – 1.0 mmol

Magnesium 0.1 – 0.2 mmol

Calcium 0.05 – 0.15 mmol

Phosphate 0.2 – 0.5mmol

So as to maintain acid-base balance

Chloride/Acetate
(normally 0.5 mmol for CIˉ, & 0.1mEq for Acetate
 Requirements
Fluid and Electrolytes
• Normalization of acid-base balance is a priority and
constant concern in the management of critically ill
patients
• Most electrolytes can be safely added to the
parenteral amino acid/dextrose solution
• Sodium bicarbonate in high concentrations will tend to
generate carbon dioxide at the acidic pH of the amino
acid/glucose mix
 Requirements
Vitamins
• These requirements are usually met when standard
volumes of a nutrient mix are provided
• Increased amounts of vitamins are usually provided to
severely ill patients
• Vitamins are either fat soluble (A, D, E, K) or water
soluble (B, C), separate multivitamin commercial
preparations are not available for both
 Requirements
Trace Minerals
• These are essential components of the parenteral
nutrition regimen
• A multi-element solution is available commercially,
and can be supplemented with individual minerals
• May be toxic at high doses
• Iron is excluded, as it alters stability of other
ingredients; it is given by separate injection (iv or im)
• minerals excreted via the liver, such as copper and
manganese, should be used with caution in patients
with liver disease or impaired biliary function
 Requirements
Trace Minerals

Recommended Dietary allowance (RDA) Suggested Daily

Mineral
for daily oral intake (mg) Intravenous Intake (mg)

Zinc 15 2.5 – 5

Copper 2–3 0.5 – 1.5

Manganese 2.5 – 5 0.15 – 0.8

Chromium 0.05 – 0.2 0.01 – 0.015

Iron 10 (males)/18 (females) 3

 How must TPN be administered?

Central venous access is absolutely required

and TPN administration should be isolated
and infused only with an accurate pump
What are the potential complications
of TPN?
 Line Related Complications

• Traumatic Insertion - Pneumothorax

• Air embolus
• Catheter related thrombosis
• Catheter placement
• Central line associated bloodstream infections
 BRRH Experience

• 2011 – BRRH CLABSI rate 2.1/1000

• 2012 – Retrospective review on all cases
• 80% of CLABSI related to administration of TPN
• 2012 – Analyzed indications for TPN as per ASPEN criteria
• 78% did not meet criteria
• 2013 – Strict criteria put into place via MEC
• 2013 – No CLABSI for 11 consecutive months
 Metabolic Complications
• Fluid overload
• Hyperglycemia/hypoglycemia
• Hepatotoxicity(TPN related cholestasis)
• Can be fatal
• Acid base disorders
• CO₂ retention
• Electrolyte abnormalities
• Mineral imbalance
• Osteoporosis (long term TPN)
 Other Complications
• Intestinal bacterial translocation
• Normal gut flora subject to tropism, and altered gut
permeability → compromised ability of patient to
return to enteral feeds
• Additional increased risk of GI related sepsis
• GB sludge
• TPN ˃ 4 weeks
• Refeeding Syndrome
• Occurs when nutritional support is given to those
patients severely malnourished
• Catabolic state → anabolic state →insulin ↑
• Insulin increase triggers cellular reuptake of
potassium, phosphate and magnesium →
arrhythmias (slow gradual increase is best
treatment)
 Quality of Life Considerations
• Inconvenient
• Disturbed sleep
• Activity and work are secondary to feedings
• Social isolation
• Expense
• Fear/anxiety/depression
 Take-Home Messages
• TPN can be life saving in a very select patient population
• TPN should never be used when an intact gut is present and
enteral nutrition is possible
• If TPN is used, it is critical that those who manage it are
skilled at both initiating this nutritional program as well as
maintaining it safely
• TPN can be associated with life threatening complications

SO…..
TPN should never be used when an intact gut is present and
enteral nutrition is possible