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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