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MSD  MANUAL
MSD

Professional Version
Professional / Nutritional Disorders / Nutritional Support

Total Parenteral Nutrition

(TPN)
By David R. Thomas, MD, Professor Emeritus, St. Louis University
School of Medicine

Parenteral nutrition is by definition given IV.

Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing
oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this
method.

Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be used in
the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of
peripheral veins, a central venous catheter is usually required.

Parenteral nutrition should not be used routinely in patients with an intact GI tract. Compared
with enteral nutrition, it has the following disadvantages:

It causes more complications.

It does not preserve GI tract structure and function as well.

It is more expensive.

(See also Overview of Nutritional Support.)

Indications

TPN may be the only feasible option for patients who do not have a functioning GI tract or who
have disorders requiring complete bowel rest, such as the following:
 Some stages of ulcerative colitis

Bowel obstruction

Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless

of its cause)

Short bowel syndrome due to surgery

Nutritional content

TPN requires water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day, depending on energy
expenditure; up to 45 kcal/kg/day for critically ill patients), amino acids (1.0 to 2.0 g/kg/day,
depending on the degree of catabolism), essential fatty acids, vitamins, and minerals (see table
Basic Adult Daily Requirements for Total Parenteral Nutrition).

Children who need TPN may have different fluid requirements and need more energy (up to 120
kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).

Basic Adult Daily Requirements for Total Parenteral Nutrition

Nutrient Amount

Water (/kg body wt/day) 30–40 mL

Energy* (/kg body wt/day)

Medical patient 30-35 kcal

Postoperative patient 30–45 kcal

Hypercatabolic patient 45 kcal

Amino acids (/kg body wt/day)

Medical patient 1.0 g

Postoperative patient 2.0 g

Hypercatabolic patient 3.0 g

*Requirements for energy increase by 12% per 1° C of fever.

Nutrient Amount

Minerals

Acetate/gluconate 90 mEq

Calcium 15 mEq

Chloride 130 mEq

Chromium 15 mcg

Copper 1.5 mg

Iodine 120 mcg

Magnesium 20 mEq

Manganese 2 mg

Phosphorus 300 mg

Potassium 100 mEq

Selenium 100 mcg

Sodium 100 mEq

Zinc 5 mg

Vitamins

Ascorbic acid 100 mg

Biotin 60 mcg

Cobalamin 5 mcg

*Requirements for energy increase by 12% per 1° C of fever.

Nutrient Amount

Folate (folic acid) 400 mcg

Niacin 40 mg

Pantothenic acid 15 mg

Pyridoxine 4 mg

Riboflavin 3.6 mg

Thiamin 3 mg

Vitamin A 4000 IU

Vitamin D 400 IU

Vitamin E 15 mg

Vitamin K 200 mcg

*Requirements for energy increase by 12% per 1° C of fever.

Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to
standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be
modified based on laboratory results, underlying disorders, hypermetabolism, or other factors.

Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/min of dextrose is

given. Standard solutions contain up to about 25% dextrose, but the amount and concentration
depend on other factors, such as metabolic needs and the proportion of caloric needs that are
supplied by lipids.

Commercially available lipid emulsions are often added to supply essential fatty acids and
triglycerides; 20 to 30% of total calories are usually supplied as lipids. However, withholding lipids
and their calories may help obese patients mobilize endogenous fat stores, increasing insulin
sensitivity.

TPN Solutions

Many TPN solutions are commonly used. Electrolytes can be added to meet the patient’s needs.
TPN solutions vary depending on other disorders present and patient age, as for the following:

For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein
content and a high percentage of essential amino acids

For heart or kidney failure: Limited volume (liquid) intake

For respiratory failure: A lipid emulsion that provides most of nonprotein calories to
minimize carbon dioxide production by carbohydrate metabolism

For neonates: Lower dextrose concentrations (17 to 18%)

Beginning TPN administration

Because the central venous catheter needs to remain in place for a long time, strict sterile
technique must be used during insertion and maintenance of the TPN line. The TPN line should
not be used for any other purpose. External tubing should be changed every 24 h with the first
bag of the day. In-line filters have not been shown to decrease complications. Dressings should
be kept sterile and are usually changed every 48 h using strict sterile techniques.

If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection,
and qualified home nursing must be arranged.

The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make
up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The
amount of regular insulin given (added directly to the TPN solution) depends on the plasma
glucose level; if the level is normal and the final solution contains 25% dextrose, the usual
starting dose is 5 to 10 units of regular insulin/L of TPN fluid.

Monitoring

Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary

nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should
be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 h until
patients and glucose levels become stable. Fluid intake and output should be monitored
continuously. When patients become stable, blood tests can be done much less often.

Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin
or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium,
magnesium, and phosphate should be measured twice/wk. Changes in transthyretin and retinol-
binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood
tests should not be done during glucose infusion.

Full nutritional assessment (including BMI calculation and anthropometric measurements)

should be repeated at 2-wk intervals.

Clinical Calculator: Body Mass Index (Quetelet's index)

Complications

About 5 to 10% of patients with a TPN line have complications related to central venous access.

Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize
sterile techniques for catheter insertion and skin care around the insertion site. The increasing
use of dedicated teams of physicians and nurses who specialize in various procedures including
catheter insertion also has accounted for a decrease in catheter-related infection rates.

Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of

patients.

Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma

glucose often, adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as
needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose
infusions. Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be
reversed with 50% dextrose IV; more prolonged hypoglycemia may require infusion of 5 or 10%
dextrose for 24 h before resuming TPN via the central venous catheter.

Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia.

They can develop at any age but are most common among infants, particularly premature ones
(whose liver is immature).

Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and

alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent
elevations may result from excess amino acids. Pathogenesis is unknown, but cholestasis
and inflammation may contribute. Progressive fibrosis occasionally develops. Reducing
protein delivery may help.

Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be

reduced.

Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized

seizures. Arginine supplementation at 0.5 to 1.0 mmol/kg/day can correct it.

If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be
necessary.

Abnormalities of serum electrolytes and minerals should be corrected by modifying

subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral
vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly.
Elevated BUN may reflect dehydration, which can be corrected by giving free water as 5%
dextrose via a peripheral vein.

Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily
energy requirements and thus require large fluid volumes.
Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in
some patients given TPN for > 3 mo. The mechanism is unknown. Advanced disease can cause
severe periarticular, lower-extremity, and back pain.

Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea,
headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if
lipids are given at > 1.0 kcal/kg/h. Temporary hyperlipidemia may occur, particularly in patients
with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid
emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly,
thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress
syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping
lipid emulsion infusion may prevent or minimize these adverse reactions.

Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These

complications can be caused or worsened by prolonged gallbladder stasis. Stimulating
contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several
hours a day is helpful. Oral or enteral intake also helps. Treatment with metronidazole,
ursodeoxycholic acid, phenobarbital, or cholecystokinin helps some patients with cholestasis.

Key Points
Consider parenteral nutrition for patients who do not have a functioning GI tract or who
have disorders requiring complete bowel rest.

Calculate requirements for water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day,

depending on energy expenditure; up to 45 kcal/kg/day for critically ill patients), amino
acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids,
vitamins, and minerals.

Choose a solution based on patient age and organ function status; different solutions are
required for neonates and for patients who have compromised heart, kidney, or lung
function.

Use a central venous catheter, with strict sterile technique for insertion and maintenance.

Monitor patients closely for complications (eg, related to central venous access; abnormal
glucose, electrolyte, mineral levels; hepatic or gallbladder effects; reactions to lipid
emulsions, and volume overload or dehydration).

Last full review/revision November 2018 by David R. Thomas, MD

© 2019 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA