Total Parenteral Nutrition

Aka: Total Parenteral Nutrition, TPN

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II. Types

  1. Peripheral Parenteral Nutrition
    1. Delivered via peripheral Intravenous Access
    2. May be used up to 7-10 days in patients not requiring fluid restriction
  2. Central Parenteral Nutrition
    1. Delivered via central venous access
    2. Indicated in longer term pareteral nutrition needs >7-10 days
    3. Also indicated in higher concentration formulations (>900 mOsm/L) that allow for fluid restriction

III. Indications

  1. See Nutrition in the Intensive Care Unit
  2. Bowel Obstruction
  3. Enteral feeding not possible or failed trial
  4. Short bowel syndrome
  5. Mesenteric Ischemia
  6. High output gastrointestinal fistula
  7. Gut failure or Malabsorption
  8. Transitional-Supplemental
  9. Perioperatively
    1. Start TPN 7-10 days before surgery to make difference

IV. Complications: Parenteral Nutrition

  1. See Refeeding Syndrome
  2. Biliary disease
  3. Osteoporosis (and Osteopenia)
  4. Catheter-related infection
  5. Central Line Placement related complications (e.g. Pneumothorax)
  6. Electrolyte disorders
  7. Hyperglycemia
  8. Hyperlipidemia
  9. Hepatic Steatosis (adults)
  10. Thrombosis
  11. Cholestasis (children)
  12. End-stage liver disease (50% of adults and children on lon-term parenteral nutrition)
    1. Chan (1999) Surgery 126(1): 28-34 [PubMed]

V. Evaluation: Adult Energy Requirements

  1. See Specialized Nutrition Support
  2. Lean body wt (LBW)
    1. Male: 110 + 5 x(number of inches> 60) lbs
    2. Female: 100 + 5 x(number of inches> 60) lbs
  3. IF Obese (>130% LBW) then use adjusted weight
    1. (Actual-LBW) x 0.25 + LBW
  4. Basal Energy Expenditure (BEE) per 24 hours
    1. M: BEE=66 + (13.7xWt) + (5xHt) - (6.8xAge) = KCal
    2. F: BEE=655 + (9.6xWt) + (1.7xHt) - (4.7xAge) = KCal
    3. Adjust for depletion or disease
      1. 120-130% BEE is Maintenance
      2. 150% for stress and depletion
  5. Calorie requirement (per kg/day)
    1. Usually 30-35 KCal/kg/day
    2. Range = 20-40 Kcal/kg/day
  6. Adult Protein
    1. RDA = 0.8 g/kg/day
    2. Stress Adjustment
      1. 0.7-0.8 g/kg/d Maintenance, healthy, no stress
      2. 1.0-1.2 g/kg/d Mild stress
      3. 1.3-1.5 g/kg/d Moderate stress, repletion
      4. 1.5-2.0 g/kg/d Severe stress, burns
  7. Essential Fatty Acid Requirement
    1. Estimate 4-10% (2-4% linoleic) of daily calorie need
  8. Intravenous Electrolyte Requirements
    1. Electrolytes
      1. Sodium: 60-100 meq per 24 hours
      2. Potassium: 60-100 meq per 24 hours
      3. Calcium 10-15 meq per 24 hours
      4. Phosphorus 20-45 mMol per 24 hours
      5. Magnesium 10-20 mEq per 24 hours

VI. Preparations: Types

  1. Two in one mixtures (most common)
    1. Dextrose and Amino acids
    2. Separate infusion of fat Emulsion
  2. Three in one mixtures
    1. Dextrose, amino acids and fat emulsion in same preparation

VII. Preparations: Adult 2-in-1 Parenteral Nutrition

  1. Dextrose 5 to 7 mg/kg/min (<4 mg/kg/min in the critically ill)
    1. Provides 70-85% of total daily non-protein energy
    2. Keep Dextrose concentration <10% in peripheral parenteral nutrition
  2. Amino acids
    1. See See Specialized Nutrition Support for protein recommendations based on comorbidity
    2. Amino acid concentrations vary 3 to 30%
    3. Avoid high protein loads (high renal metabolic load)
      1. Monitor Renal Function
  3. Sodium: 1-2 meq/kg
  4. Potassium: 1-2 meq/kg
  5. Calcium: 10-15 mEq
  6. Magnesium: 8-20 meq
  7. Phosphorus: 20-40 mmol
  8. Chloride: Adjusted per acid-base status
  9. Acetate: Adjusted per acid-base status
  10. Trace elements not routinely added (e.g. zinc, copper, Selenium, chromium, iron, manganese)
  11. Multivitamin 12: 10 ml (Vitamins A, B1, B2, B3, B6, B9, B12, C, D, E, K, Biotin, Pantothenic Acid)
  12. Fat emulsions 250 ml, 5x/week
  13. Regular Insulin as needed

VIII. Preparations: Child 2-in-1 Parenteral Nutrition (up to 50 kg or 110 pounds, then use adult dosing)

  1. Sodium: 2-5 meq/kg
  2. Potassium: 2-4 meq/kg
  3. Calcium: 2-4 mEq/kg for preterm newborns, 0.5 to 4 meq/kg for infants and children
  4. Magnesium: 0.3-0.5 meq/kg
  5. Phosphorus: 1-2 mmol/kg for preterm newborns, 0.5 -2.0 mmol/kg for infants and children
  6. Chloride: Adjusted per acid-base status
  7. Acetate: Adjusted per acid-base status
  8. Trace elements not routinely added (e.g. zinc, copper, Selenium, chromium, iron)
  9. Children's Multivitamin formulation (1.5 ml for <1kg, 3.25 ml for 1-3 kg, 5 ml for >3 kg)
  10. Fat emulsions: Start 1 g/kg; increase every 1-2 days in increments of 0.5 to 1 g/kg/day
  11. Regular Insulin as needed

IX. Preparations: Lipid Emulsion

  1. See Intralipid
  2. Intravenous fat emulsion (Intralipid) available in 10% (1.1 kcals/ml), 20% (2 kcals/ml) or 30% (3 kcals/ml)
  3. Smoflipid is an alternative fatty emulsion (fish oil, olive oil, long and medium chain Triglycerides)
  4. Provided as long chain Triglycerides
  5. Prevents essential Fatty Acid deficiency

X. Labs

  1. Baseline
    1. Complete Blood Count
    2. Glucose
    3. Electrolytes including Magnesium, phosphate, Calcium
    4. Renal Function tests
    5. Liver Function Tests including albumin
    6. Serum Iron
    7. Vitamin B12
    8. Vitamin D
    9. Zinc
    10. Copper
    11. Serum Folate
    12. INR
    13. Body weight
  2. Monitoring: Initially daily and may transition to weekly checks when stable
    1. Complete Blood Count
    2. Glucose (several times daily)
    3. Electrolytes including Magnesium, phosphate, Calcium
    4. Renal Function tests
    5. Liver Function Tests including albumin
      1. Expect 2-3 fold over baseline with 10-14 days TPN
    6. Body Weight
  3. Monitoring: periodic recheck when on longterm parenteral nutrition
    1. Vitamin B12
    2. Vitamin D
    3. Zinc
    4. Copper
    5. Serum Folate
    6. Triglycerides weekly

XI. Drug Interactions

  1. Multiple Drug Interactions with parenteral nutrition (consult pharmacy)

XII. References

  1. Bristrian (2006) Crit Care Med 34(5): 1525-31 [PubMed]
  2. Kulick (2011) Am Fam Physician 83(2): 173-83 [PubMed]
  3. Lesser (2021) Am Fam Physician 104(6): 580-8 [PubMed]

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Related Studies

Ontology: Parenteral Nutrition, Total (C0030548)

Definition (NCI) Total parenteral nutrition formulated for intravenous administration in patients who cannot eat or cannot get enough nutrients from the foods they eat. It is a liquid mixture of proteins, carbohydrates, fats, vitamins, minerals and other nutrients.
Definition (NCI_NCI-GLOSS) A form of nutrition that is delivered into a vein. Total parenteral nutrition does not use the digestive system. It may be given to people who are unable to absorb nutrients through the intestinal tract because of vomiting that won't stop, severe diarrhea, or intestinal disease. It may also be given to those undergoing high-dose chemotherapy or radiation and bone marrow transplantation. It is possible to give all of the protein, calories, vitamins and minerals a person needs using total parenteral nutrition.
Definition (MSH) The delivery of nutrients for assimilation and utilization by a patient whose sole source of nutrients is via solutions administered intravenously, subcutaneously, or by some other non-alimentary route. The basic components of TPN solutions are protein hydrolysates or free amino acid mixtures, monosaccharides, and electrolytes. Components are selected for their ability to reverse catabolism, promote anabolism, and build structural proteins.
Definition (NIC) Preparation and delivery of nutrients intravenously and monitoring of patient responsiveness
Concepts Therapeutic or Preventive Procedure (T061)
MSH D010289
ICD9 99.15
SnomedCT 414435008, 225372007, 54884006
LNC LP29730-6, MTHU014331, LA12418-2
English TPN, Hyperalimentation, Parenteral, Nutrition, Total Parenteral, Parenteral Hyperalimentation, Parenteral Nutrition, Total, Total Parenteral Nutrition, Total Parenteral Nutrition (TPN) Administration, TPN-Total parenteral nutrition, Parent infus nutrit sub, total parenteral nutrition (TPN), parenteral alimentation, parenteral nutrition, total parenteral nutrition, hyperalimentation, Total parenteral nutrition, TPN procedure, TPN - Total parenteral nutrition, Total parenteral nutrition (regime/therapy), Total parenteral nutrition administration, Total parenteral nutrition (procedure), Hyperalimentation, Central hyperalimentation, Parenteral hyperalimentation, Superalimentation, Suralimentation, hyperalimentation therapy, Parenteral infusion of concentrated nutritional substances, TPN (total parenteral nutrition)
Dutch TPN, totale parenterale voeding, Hyperalimentatie, parenterale, Nutritie, totale parenterale, Voeding, totale parenterale
German TPN, vollstaendige parenterale Ernaehrung, Hyperalimentation, parenterale, Parenterale Hyperalimentation, Ernährung, ausschließlich parenterale, Parenterale Ernährung, totale, Totale parenterale Ernährung
Portuguese Nutrição parentérica total, Hiperalimentação Endovenosa, Hiperalimentação Parenteral, Nutrição Parenteral Total
Spanish Nutrición parenteral total, NPT, Hiperalimentación Parenteral, procedimiento de NPT, nutrición parenteral total, alimentación parenteral total, alimentación parental total (procedimiento), alimentación parental total (régimen/tratamiento), alimentación parental total, Nutrición Parenteral Total
French Nutrition parentérale totale, Alimentation parentérale totale, Alimentation parentérale exclusive, Hyperalimentation parentérale, NPT (Nutrition Parentérale Totale), NPT (nutrition parentérale totale)
Japanese 非経口完全栄養, ＴＰＮ, TPN, ﾋｹｲｺｳｶﾝｾﾞﾝｴｲﾖｳ, 完全中心静脈栄養, 高カロリー輸液法, 完全非経口栄養, 完全非経口高栄養法, 高カロリー輸液, 完全静脈栄養, 非経腸完全栄養法, 完全中心静脈栄養法, 中心静脈栄養法, 非経口全栄養, 完全経静脈高栄養法, 経静脈高栄養法, 非経口栄養-完全, 栄養補給法-完全非経口, 中心静脈栄養
Swedish Parenteral näring, total
Czech parenterální výživa úplná, Totální parenterální výživa, TPV
Finnish Täydellinen parenteraalinen ravitsemus
Italian Iperalimentazione parenterale, Nutrizione parenterale totale, Alimentazione parenterale totale
Russian PITANIE PARENTERAL'NOE POLNOE, VNUTRIVENNAIA GIPERALIMENTATSIIA, GIPERALIMENTATSIIA PARENTERAL'NAIA, POLNOE PARENTERAL'NOE PITANIE, PITANIE PARENTERAL'NOE TOTAL'NOE, PITANIE ISKLIUCHITEL'NO PARENTERAL'NOE, ВНУТРИВЕННАЯ ГИПЕРАЛИМЕНТАЦИЯ, ГИПЕРАЛИМЕНТАЦИЯ ПАРЕНТЕРАЛЬНАЯ, ПИТАНИЕ ИСКЛЮЧИТЕЛЬНО ПАРЕНТЕРАЛЬНОЕ, ПИТАНИЕ ПАРЕНТЕРАЛЬНОЕ ПОЛНОЕ, ПИТАНИЕ ПАРЕНТЕРАЛЬНОЕ ТОТАЛЬНОЕ, ПОЛНОЕ ПАРЕНТЕРАЛЬНОЕ ПИТАНИЕ
Polish TPN, Żywienie pozajelitowe całkowite, Hiperalimentacja pozajelitowa
Hungarian Teljes parenteralis táplálás
Norwegian Total parenteral ernæring, Parenteral hyperalimentasjon
Derived from the NIH UMLS (Unified Medical Language System)

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