Total Parenteral Nutrition (TPN)

The delivery of calories and protein together with trace elements and vitamines is
essential for critical patients. The goals of nutrition therapy include prevention of
infectious morbidity, preservation of muscle mass, and prevention of metabolic
complications. Choosing the appropriate route, timing and dose of nutrition is crucial
to achieving these goals.
Critically ill/injured patients are at risk for calorie-protein malnutrition. The response to
critical illness/injury includes increased energy expenditure, increased secretion of
hormones like glucagon, glucocorticoids, catecholamines, vasopressin, and increase
in inflammatory mediators.
Increased glycogenolysis, gluconeogenesis, and insulin resistance result in
hyperglycemia. Skeletal muscle protein is catabolized for gluconeogenesis, resulting
in protein depletion.
Resting energy expenditure remains elevated, and catabolism can continue up to 3
weeks after the initial insult despite adequate nutrition support.
Pre-existing conditions such as chronic disease, malnutrition and alcohol abuse
increase the patient’s risk for protein-calorie malnutrition. The severity of the current
illness, including the presence of fever, burns, sepsis or trauma, is associated with
varying degrees of hypermetabolism and increased nutritional requirements.
Indication for TPN: For all critically ill patients who need aggressive nutritional
support but cannot tolerate EN for at least 3-5-7 days. Common reasons for TPN
include extensive bowel surgery, prolonged ileus, and entero-cutaneous fistula
Indications for supplementary PN: for all critically ill patients who cannot receive
sufficient nutrition via EN to meet their caloric/protein needs for an extended period of
time (3-5 days).
Components of TPN:
1. Dextrose is the major source of non-protein calories (3.4kcal/g dextrose).maximum
daily administration is 5-7g/kg bw./day. Exceeding this maximum may lead to lipid
synthesis with CO2 accumulation and liver steatosis.
2. Lipid emulsion is another source of non-protein calories (9 kcal/g fat). It also
provides essential fatty acids. Dosage 0.7-1.5 g/kg bw/d. Non-nutritional lipid sources
such as Propofol must be included.
3. Amino acids (essential and non-essential): Dosage: 1.2-1.5 g/kg bw. AA are
needed to build muscles and keep a positive nitrogen balance, but are also a source
of calories (4 kcal/g).
4. Water: 25-30 ml/kg/day
5. Electrolytes: daily maintenance doses according to the patient’s need have to be
added.
6. Trace elements including zinc, copper, selenium, and Vitamins including Vit.C, A,
B, D, E, K.
Access: TPN can be provided either through peripheral or central access. Peripheral
venous access should only be used for short term therapy (-5days). Only fluids with
osmolality ≤ 900 mosmol/l should be given through peripheral access, e.g. Dextrose
10%, AA 3%.Lipids 10%. Primary advantages of peripheral TPN are fewer infections
and easy access when adequate veins are present. Primary complication of
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peripheral venous access is thrombophlebitis of the peripheral vein. It occurs in a
high percentage. The inflammation results in venous thrombosis and possible
occlusion. It leads to skin changes and edema, erythema, pain, and often a palpable
venous cord. Blood and medications, should be given via a separated venous
access.
There is a marked increase in the incidence of thrombophlebitis after 48h of infusion.
It is therefore recommended to change the site latest after 72h.The lowest rate of
thrombophlebitis occurs when solution osmolality ≤ 450 mosmol/l. If thrombophlebitis
occurs, the cannula/catheter should be removed rapidly and replacement should be
preferably at an alternative limb. Central venous access is indicated when TPN is
longer needed than 7 days. Complication rate is about 10% with over half associated
with the initial placement of the CVC (pneumothorax, bleeding, hydrothorax,
cheilothorax, air embolism). Cardiac arrhythmias often result from the wire (Seldinger
technique) tickling the heart. The wire passed through into the atrium (ectopics) or
into the ventricle (tachycardia/fibrillation). Immediate withdrawing of the wire is
mandatory. Note: No CVC should be inserted without ECG monitoring! Chest X-
ray after CVC insertion is mandatory before the catheter is used!
Late complications Infection is the most common complication of CVC. Infections
include catheter colonization and central line associated blood stream infections.
Infections result from either transition or deposition of microorganisms during
insertion, migration along the catheter from the insertion site, contamination from
infusion or access site. Diagnosis from cultures (blood from the catheter and
peripheral). Skin insertion site infections are local infections manifesting as
tenderness, erythema, induration and pus. Treatment consists of local wound care
and removal of the catheter. Prevention of line sepsis is most important. Sterile
technique during insertion, appropriate line care, strict aseptic technique of infusion
preparation are mandatory.
Catheter dislodgement and Catheter occlusion and thrombosis: occlusion is the
second most common complication.
Administration of TPN: the daily requirements are infused continuously over 24 h.
Energy is provided by a combination of carbohydrates (dextrose) and lipid. 30-40% of
non-protein energy are commonly given as lipid. It is also possible to provide almost
all energy with dextrose with lipid only infused once or twice per week to provide
essential fatty acids. Many patients need insulin because of the high amount of
dextrose delivered. But persistent hyperglycemia is better treated by reducing the
dextrose infusion rate than by large doses of insulin .Protein is given as amino-acids
1.2-2 (2.5) g/kg /day. They should not be counted as energy donors. Vitamins, trace
elements and electrolytes have to be added according to the patient’s needs. TPN
admixture should be administered as a complete all-in-one bag.
It is recommended, not to use nutritional modifications for special diseased
conditions like renal or liver failure, pancreatitis or respiratory failure. Overfeeding
has to be avoided (increased CO2, hyperglycemia, fatty liver).
Complications of TPN The major complications can be divided into catheter
complications and metabolic complications. Catheter associated complications occur
in 1-4%. (see above).
Metabolic complications Hyperglycemia is common in patients receiving TPN due to
the glucose loads, systemic inflammation, postop. changes, and disease induced
insulin resistance. BS level should be kept 6-8mmol/l. Rebound hypoglycemia (rare)
may occur when TPN is suddenly discontinued. Hyperlipidemia can be induced by
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the lipid and caloric content of PN.. Underfeeding leads to ketogenesis and may also
ultimately result in hyperlipidemia. TPN related hyperlipidemia is generally benign
and self-limited, when lipid infusions are stopped. However severe elevations (≥
1000mg/dl) may be associated with pancreatitis.
Elevated lipid infusion rates (greater than 1g/kg/day) may lead to cholestasis
resulting in hepatic dysfunction.
Hepato-biliary complications: About 15-30% of patients on TPN have hepatic
complications. Causes are excess protein administration, hyperglycemia, and
elevated lipid intake. Cholestasis is thought to develop from lack of enteral
stimulation. Lack of enteral stimulation may also lead to bacterial overgrowth. Hepatic
steatosis is more often seen in patients on long term TPN. Gastro-intestinal
complications Lack of intestinal stimulation leads to mucosal atrophy. Marked
pancreas atrophy due to lack of trophic substances also develops and exocrine
function decreases. Electrolyte abnormalities include hypophosphatemia,
hypomagnesia, and hypokalemia.
Refeeding syndrome may arise when normal intake is resumed after a period of
starvation. It is associated with profound hypophosphatemia, hypomagnesemia and
hypokalemia. Symptoms include respiratory and cardiac failure, sometimes
paraesthesiae and seizures.
Monitoring during TPN: V/S, temperature, fluid balance, BS 4h. Daily: urea,
electrolytes and creatinine. At least weekly: triglycerides (patients who receive lipid
infusions). If above 500mg/dl, reduce the infusion rate (risk of pancreatitis).also
weekly FBC, LFT, magnesium, calcium and phosphate. Weight if possible.

Enteral (EN) versus parenteral nutrition (PN)

Advantages of EN: is physiological, less invasive, cheaper, easier to start (NGT),
and important for sustaining physiological gut mucosa (maintains gastro-intestinal
integrity, protecting it from atrophy, and also supports gut immune function). Can be
started earlier that deficits in protein and energy levels are at least minimized.
Improves systemic immune function. Enteral feed is easier to prepare since sterility is
not an issue.
Advantages of TPN Keeps patients alive when EN is contraindicated (impossible).
More exact calculation of the amount of energy and protein to cover the patient’s
needs.
Disadvantages of EN: complications from NGT insertion, absorption from the gut
cannot be relied on, vomiting, diarrhea, risk of aspiration. EN may have to be
frequently stopped for short surgical interventions (burns)
Disadvantages of PN: catheter related complications.
GI mucosa atrophies if it is not regularly exposed to food which may lead to gastric
ulceration and malabsorption. PN may cause more infections because it is a very
effective culture medium. Other disadvantages include fat overload, fatty liver,
immune dysfunction, hyperglycemia, hyperchloremic acidosis.
The influence of enteral versus parenteral nutrition on ICU outcomes: there is
no evidence for any mortality difference between EN and PN. It seems that early and
sufficient nutrition in general improves mortality of critically ill patients.