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TPN Indications

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 %

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TPN Indications

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  1. 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

  2. TPN IndicationsDefinitions • 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

  3. 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 & B’s • Disease severity Detsky AS. JPEN 8:153, 1984

  4. Nitrogen Balance p<0.05*14 days * % Mortality Sitzman JV. Surg Gyn Ostet 168:31, 1989

  5. Enteral vs. ParenteralNitrogen Balance Nitrogen balance (mg per kg per day) Time from start of nutritional support (days) Kalfarentzos F. BJS 84:1665, 1997

  6. 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

  7. 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……

  8. TPN Contraindications • Functioning GI system • Severe fluid overload

  9. TPN Indications • 82 RCTs • TPN did not influence mortality • TPN increased infections • No major effect on length of hospital stay

  10. Enteral vs.TPNPatient’s Preference N = 200 91% - Parenteral 9% - Nasogastric JPEN 26; 248-250, 2002

  11. Septic complications Hyperglycemia Peripancreatic necrosis Cost 6 15 4 9 1 4 Less More Enteral vs ParenteralAcute “Severe” Pancreatitis Enteral (n=18) Parenteral (n=20) * “NJ” Semi-elemental; 30-35 kcal/kg; 48 hours of admit; all gallstone Kalfarentzos F. BJS 84:1665, 1997

  12. 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/O’s • Calorie counts

  13. 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”

  14. Competency • ASPEN • Clinical guidelines - JPEN 26; 2002 • CME • AGA • ASPEN • Mayo • Harvard • NBNSC

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