Indications for PPN and TPN

Report
TPN Indications
James S. Scolapio, M.D.
Director of Nutrition
Division of Gastroenterology and Hepatology
Mayo Clinic
Jacksonville, FL
E-mail: [email protected]
TPN Indications
Definitions

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
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
Nitrogen Balance
p<0.05
*14 days
*
% Mortality
25
20
15
10
5
0
Positive
Sitzman JV. Surg Gyn Ostet 168:31, 1989
Negative
Enteral vs. Parenteral
Nitrogen Balance
Enteral
Total Parenteral
Nitrogen balance
(mg per kg per day)
50
0
-50
-100
-150
-200
-250
-300
0
7
14
21
28
Time from start of nutritional support (days)
Kalfarentzos F. BJS 84:1665, 1997
35
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
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……
TPN Contraindications


Functioning GI system
Severe fluid overload
TPN Indications




82 RCTs
TPN did not influence mortality
TPN increased infections
No major effect on length of hospital
stay
Enteral vs.TPN
Patient’s Preference
N = 200
91% - Parenteral
9% - Nasogastric
JPEN 26; 248-250, 2002
Enteral vs Parenteral
Acute “Severe” Pancreatitis
Septic complications
Hyperglycemia
Peripancreatic necrosis
Cost
Enteral
Parenteral
(n=18)
(n=20)
6
4
1
Less
15
9
4
More
* “NJ” Semi-elemental; 30-35 kcal/kg; 48 hours of admit; all gallstone
Kalfarentzos F. BJS 84:1665, 1997
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
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”
Competency

ASPEN
– Clinical guidelines - JPEN 26; 2002

CME
– AGA
– ASPEN
– Mayo
– Harvard

NBNSC

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