Nutrition
Total Parenteral Nutrition
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Total Parenteral Nutrition
, TPN
Indications
Bowel Obstruction
Enteral feeding not possible or failed trial
Short bowel syndrome
Mesenteric Ischemia
High output gastrointestinal fistula
Gut failure or Malabsorption
Transitional-Supplemental
Perioperatively
Start TPN 7-10 days before surgery to make difference
Complications
Parenteral Nutrition
Biliary disease
Osteoporosis
(and
Osteopenia
)
Catheter-related infection
Central Line Placement
related complications (e.g.
Pneumothorax
)
Electrolyte
disorders
Hyperglycemia
Hyperlipidemia
Hepatic
Steatosis
(adults)
Thrombosis
Cholestasis (children)
End-stage liver disease (50% of adults and children on lon-term parenteral nutrition)
Chan (1999) Surgery 126(1): 28-34 [PubMed]
Evaluation
Adult Energy Requirements
Lean body wt (LBW)
Male: 110 + 5 x(number of inches> 60) lbs
Female: 100 + 5 x(number of inches> 60) lbs
IF Obese (>130% LBW) then use adjusted weight
(Actual-LBW) x 0.25 + LBW
Basal Energy Expenditure (BEE) per 24 hours
M: BEE=66 + (13.7xWt) + (5xHt) - (6.8xAge) = KCal
F: BEE=655 + (9.6xWt) + (1.7xHt) - (4.7xAge) = KCal
Adjust for depletion or disease
120-130% BEE is Maintenance
150% for stress and depletion
Calorie requirement (per kg/day)
Usually 30-35 KCal/kg/day
Range = 20-40 Kcal/kg/day
Adult Protein
RDA = 0.8 g/kg/day
Stress Adjustment
0.7-0.8 g/kg/d Maintenance, healthy, no stress
1.0-1.2 g/kg/d Mild stress
1.3-1.5 g/kg/d Moderate stress, repletion
1.5-2.0 g/kg/d Severe stress, burns
Essential
Fatty Acid
Requirement
Estimate 4-10% (2-4% linoleic) of daily calorie need
Intravenous
Electrolyte
Requirements
Electrolyte
s
Sodium
: 60-100 meq per 24 hours
Potassium
: 60-100 meq per 24 hours
Calcium 10-15 meq per 24 hours
Phosphorus 20-45 mMol per 24 hours
Magnesium
10-20 mEq per 24 hours
Preparation
Adult 2-in-1 Parenteral Nutrition
Sodium
: 1-2 meq/kg
Potassium
: 1-2 meq/kg
Calcium: 10-15 mEq
Magnesium
: 8-20 meq
Phosphorus: 20-40 mmol
Chloride: Adjusted per acid-base status
Acetate: Adjusted per acid-base status
Trace elements not routinely added (e.g. zinc, copper,
Selenium
, chromium, iron)
Multivitamin
12: 10 ml
Fat emulsions 250 ml, 5x/week
Regular Insulin
as needed
Preparation
Child 2-in-1 Parenteral Nutrition (up to 50 kg or 110 pounds, then use adult dosing)
Sodium
: 2-5 meq/kg
Potassium
: 2-4 meq/kg
Calcium: 2-4 mEq/kg for preterm newborns, 0.5 to 4 meq/kg for infants and children
Magnesium
: 0.3-0.5 meq/kg
Phosphorus: 1-2 mmol/kg for preterm newborns, 0.5 -2.0 mmol/kg for infants and children
Chloride: Adjusted per acid-base status
Acetate: Adjusted per acid-base status
Trace elements not routinely added (e.g. zinc, copper,
Selenium
, chromium, iron)
Children's
Multivitamin
formulation (1.5 ml for <1kg, 3.25 ml for 1-3 kg, 5 ml for >3 kg)
Fat emulsions: Start 1 g/kg; increase every 1-2 days in increments of 0.5 to 1 g/kg/day
Regular Insulin
as needed
Labs
Baseline
Complete Blood Count
Glucose
Electrolyte
s including
Magnesium
, phosphate, calcium
Renal Function
tests
Liver Function Test
s including albumin
Serum Iron
Vitamin
B12
Vitamin D
Zinc
Copper
Serum Folate
INR
Monitoring: Initially daily and may transition to weekly checks when stable
Complete Blood Count
Glucose
(several times daily)
Electrolyte
s including
Magnesium
, phosphate, calcium
Renal Function
tests
Liver Function Test
s including albumin
Expect 2-3 fold over baseline with 10-14 days TPN
Monitoring: periodic recheck when on longterm parenteral nutrition
Vitamin
B12
Vitamin D
Zinc
Copper
Serum Folate
References
Bristrian (2006) Crit Care Med 34(5): 1525-31 [PubMed]
Kulick (2011) Am Fam Physician 83(2): 173-83 [PubMed]
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