1. TPN Indications James S. Scolapio, M.D. Director of Nutrition Division of Gastroenterology and Hepatology Mayo Clinic Jacksonville, FL E-mail: scolapio.james@mayo.edu

2. TPN Indications Definitions TPN - Total parenteral nutrition TPN - Total parenteral nutrition –Via central vein (CPN) –Dextrose > 5 % PPN – Peripheral parenteral nutrition PPN – Peripheral parenteral nutrition –Via peripheral iv –No central catheter –Dextrose </= 5% & osmolarity < 900 Gastroenterology 2001; 121: 970

3. When to Feed? Nutrition Subjective Global Assessment 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 7-14 days for A & B’s Disease severity Disease severity Detsky AS. JPEN 8:153, 1984

4. Nitrogen Balance Sitzman JV. Surg Gyn Ostet 168:31, 1989 % Mortality p<0.05 *14 days *

5. Enteral vs. Parenteral Nitrogen Balance Nitrogen balance (mg per kg per day) Time from start of nutritional support (days) Kalfarentzos F. BJS 84:1665, 1997

6. What to Feed? Adults 25-30 kcal/kg 25-30 kcal/kg –Lipids (30% of total) –Protein (1.0-1.5 g/kg) –CHO (other); < 5 mg/kg/min Metabolic Cart Metabolic Cart

7. TPN Indications Preexisting nutrition deprivation Preexisting nutrition deprivation Anticipated or actual inadequate energy intake by mouth Anticipated or actual inadequate energy intake by mouth Significant multi organ system disease Significant multi organ system disease Non functioning gastrointestinal system Non functioning gastrointestinal system –Obstruction –Distal fistula –Severe motility disorder –Severe absorptive disease Short bowel, radiation enteritis, PLE…… Short bowel, radiation enteritis, PLE……

8. TPN Contraindications Functioning GI system Functioning GI system Severe fluid overload Severe fluid overload

9. TPN Indications 82 RCTs 82 RCTs TPN did not influence mortality TPN did not influence mortality TPN increased infections TPN increased infections No major effect on length of hospital stay No major effect on length of hospital stay

10. Enteral vs.TPN Patient’s Preference N = 200 91% - Parenteral 9% - Nasogastric 9% - Nasogastric JPEN 26; 248-250, 2002

12. Enteral vs Parenteral Acute “Severe” Pancreatitis Septic complications Hyperglycemia Peripancreatic necrosis Cost 615 4 9 1 4 LessMore Kalfarentzos F. BJS 84:1665, 1997 Enteral (n=18) Parenteral (n=20) * “NJ” Semi-elemental; 30-35 kcal/kg; 48 hours of admit; all gallstone

13. Monitoring Chem 7 twice weekly Chem 7 twice weekly TG q week TG q week I do not follow albumin or prealbumin 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 Weights and I/O’s Calorie counts Calorie counts

14. HPN Indications Unable to take p.o. or tube feeds for prolong period of time. Unable to take p.o. or tube feeds for prolong period of time. –Short bowel syndrome –Prolonged malabsorptive state Documentation 72 fecal fat Documentation 72 fecal fat –Severe motility disorder Most document with motility testing Most document with motility testing –Non terminal “obstructive” cancer (survival > 3 months, pursing active treatment) –Anticipated use “90 days or more”

15. Competency ASPEN ASPEN –Clinical guidelines - JPEN 26; 2002 CME CME –AGA –ASPEN –Mayo –Harvard NBNSC NBNSC