total parenteral (intravenous) nutrition (TPN)
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Indications
- cannot use the gastrointestinal tract
- GI illness, GI rest indicated, intestinal obstruction ( partial or complete)
- underlying condition preventing enteral nutrition expected to last 3-7 days[5]
Contraindications
- do not add to enteral nutrition[3]
Laboratory
- plasma glucose 4 times daily until patient is stable
- chem 7 daily until glucose infusion stable, then twice weekly
- baseline labs, then weekly
- albumin, transferrin or TIBC
- liver function tests
- mild elevations in serum ALT & serum alkaline phosphatase
- Ca+2, phosphate, Mg+2
- complete blood count (CBC)
- baseline labs, then weekly
Procedure
Delay parenteral nutrition for 1 week in adults & children[2]
Central venous access to avoid phlebitis & thrombophlebitis:
- peripherally-inserted central catheter (PICC)
- central venous catheter (subclavian, jugular, femoral)
- tunneled central catheter with subcutaneous port
Daily parenteral requirements:
| Nutrient | Quantity |
|---|---|
| essential fatty acids | 2-4% of total calories |
| calcium | 0.2-0.4 g |
| phosphorous | 0.4-0.8 g |
| potassium | 3-4 g |
| sodium | 1-3 g |
| chloride | 3-4 g |
| magnesium | 0.3 g |
| iron | 1-2 mg |
| zinc | 3-12 mg |
| copper | 0.3-0.5 mg |
| iodine | 0.15 mg |
| manganese | 2-5 mg |
| chromium | 15-30 ug |
| molybdenum | 20-120 ug |
| selenium | 50-100 ug |
| ascorbate | 100 mg |
| thiamine | 3.0 mg |
| riboflavin | 3.6 mg |
| niacin | 40 mg |
| biotin | 60 ug |
| pantothenate | 15 mg |
| pyridoxine | 4.0 mg |
| folate | 400 ug |
| cobalamin | 5 ug |
| vitamin A | 1000 ug |
| vitamin D | 5-10 ug |
| vitamin E | 10-15 mg |
| vitamin K | 200 ug |
Complications
- mechanical
- complications associated with the central venous access
- metabolic
- 1st 48 hours
- 1st 2 weeks
- cardiopulmonary failure
- hyperosmolar, nonketotic hyperglycemic coma
- acid-base imbalance
- electrolyte imbalance
- mild elevations in serum ALT & serum alkaline phosphatase due to steatosis with subsequent cholestasis
- after 3 months
- fatty acid deficiency
- copper, zinc, chromium, selenium, molybdenum deficiency
- iron deficiency
- vitamin deficiency
- TPN metabolic bone disease
- TPN liver disease
- infectious
- intestinal mucosal atrophy
- translocation of intestinal flora to the bloodstream
Management
- - parenteral nutrition should not be added to enteral feeding[3]
More general terms
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 477-78
- ↑ 2.0 2.1 Fivez T, Kerklaan D, Mesotten D et al. Early versus late parenteral nutrition in critically ill children. N Engl J Med 2016 Mar 24; 374:1111. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26975590
Mehta NM. Parenteral nutrition in critically ill children. N Engl J Med 2016 Mar 24; 374:1190 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26975731 - ↑ 3.0 3.1 3.2 Medical Knowledge Self Assessment Program (MKSAP) 18, 19 American College of Physicians, Philadelphia 2018, 2022
- ↑ Taylor BE, McClave SA, Martindale RG et al Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26771786
- ↑ 5.0 5.1 NEJM Knowledge+ Endocrinology
- ↑ Pironi L, Boeykens K, Bozzetti F et al ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020 Jun;39(6):1645-1666. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32359933 Review.