TPN IndicationsTPN Indications

James S. Scolapio, M.D.James S. Scolapio, M.D.

Director of NutritionDirector of Nutrition

Division of Gastroenterology and Division of Gastroenterology and HepatologyHepatology

Mayo ClinicMayo Clinic

Jacksonville, FLJacksonville, FLE-mail: scolapio.james@mayo.eduE-mail: scolapio.james@mayo.edu

TPN IndicationsTPN IndicationsDefinitionsDefinitions TPN - Total parenteral nutritionTPN - Total parenteral nutrition

– Via central vein (CPN)Via central vein (CPN)– Dextrose > 5 %Dextrose > 5 %

PPN – Peripheral parenteral nutritionPPN – Peripheral parenteral nutrition– Via peripheral ivVia peripheral iv– No central catheterNo central catheter– Dextrose </= 5% & osmolarity < 900Dextrose </= 5% & osmolarity < 900

Gastroenterology 2001; 121: 970Gastroenterology 2001; 121: 970

When to Feed?When to Feed?

Nutrition Subjective Global Nutrition Subjective Global AssessmentAssessment– A < 5% weight loss (mild)A < 5% weight loss (mild)– B 5-10% weight loss (moderate)B 5-10% weight loss (moderate)– C >10% weight loss (severe)C >10% weight loss (severe)

7-14 days for A & B’s7-14 days for A & B’s

Disease severity Disease severity

Detsky AS. JPEN 8:153, 1984

Nitrogen BalanceNitrogen Balance

0

5

10

15

20

25

Positive Negative

Sitzman JV. Surg Gyn Ostet 168:31, 1989

% M

orta

lity

p<0.05*14 days

*

Enteral vs. ParenteralEnteral vs. ParenteralNitrogen BalanceNitrogen Balance

-300

-250

-200

-150

-100

-50

0

50

0 7 14 21 28 35

Enteral Total Parenteral

Nitr

ogen

bal

ance

(m

g pe

r kg

per

day

)

Time from start of nutritional support (days)Kalfarentzos F. BJS 84:1665, 1997

What to Feed?What to Feed?AdultsAdults

25-30 kcal/kg25-30 kcal/kg– Lipids (30% of total) Lipids (30% of total) – Protein (1.0-1.5 g/kg) Protein (1.0-1.5 g/kg) – CHO (other); < 5 mg/kg/minCHO (other); < 5 mg/kg/min

Metabolic CartMetabolic Cart

TPN IndicationsTPN Indications

Preexisting nutrition deprivationPreexisting nutrition deprivation Anticipated or actual inadequate energy Anticipated or actual inadequate energy

intake by mouthintake by mouth Significant multi organ system diseaseSignificant multi organ system disease Non functioning gastrointestinal systemNon functioning gastrointestinal system

– Obstruction Obstruction – Distal fistulaDistal fistula– Severe motility disorder Severe motility disorder – Severe absorptive disease Severe absorptive disease

Short bowel, radiation enteritis, PLE…… Short bowel, radiation enteritis, PLE……

TPN ContraindicationsTPN Contraindications

Functioning GI systemFunctioning GI system Severe fluid overload Severe fluid overload

TPN IndicationsTPN Indications

82 RCTs82 RCTs TPN did not influence mortalityTPN did not influence mortality TPN increased infectionsTPN increased infections No major effect on length of No major effect on length of

hospital stayhospital stay

Enteral vs.TPNEnteral vs.TPNPatient’s PreferencePatient’s Preference

N = 200N = 200

91% - Parenteral91% - Parenteral

9% - Nasogastric9% - Nasogastric

JPEN 26; 248-250, 2002

Enteral vs ParenteralEnteral vs ParenteralAcute “Severe” PancreatitisAcute “Severe” Pancreatitis

Septic complicationsSeptic complications

HyperglycemiaHyperglycemia

Peripancreatic necrosisPeripancreatic necrosis

CostCost

66 1515

44 99

1 1 44

LessLess More More

Kalfarentzos F. BJS 84:1665, 1997

Enteral(n=18)

Parenteral(n=20)

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

MonitoringMonitoring

Chem 7 twice weeklyChem 7 twice weekly TG q weekTG q week I do not follow albumin or I do not follow albumin or

prealbuminprealbumin– T-1/2 albumin 21 days; fluid & stressT-1/2 albumin 21 days; fluid & stress– T-1/2 prealbumin 3 daysT-1/2 prealbumin 3 days

Weights and I/O’sWeights and I/O’s Calorie countsCalorie counts

HPN IndicationsHPN Indications

Unable to take p.o. or tube feeds for Unable to take p.o. or tube feeds for prolong period of time.prolong period of time.– Short bowel syndromeShort bowel syndrome– Prolonged malabsorptive stateProlonged malabsorptive state

Documentation 72 fecal fatDocumentation 72 fecal fat

– Severe motility disorderSevere motility disorder Most document with motility testingMost document with motility testing

– Non terminal “obstructive” cancer Non terminal “obstructive” cancer (survival > 3 months, pursing active (survival > 3 months, pursing active treatment)treatment)

– Anticipated use “90 days or more”Anticipated use “90 days or more”

CompetencyCompetency

ASPENASPEN– Clinical guidelines - Clinical guidelines - JPEN 26; 2002JPEN 26; 2002

CMECME– AGAAGA– ASPENASPEN– MayoMayo– HarvardHarvard

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