fbpx
AmeriPharma’s premier pharmacy services are available in multiple states throughout the US.

Related Posts

What is Parenteral‌ ‌Nutrition‌ (PN) & TPN?

Home  /  IVIg   /  What is Parenteral‌ ‌Nutrition‌ (PN) & TPN?
TPN

What is Parenteral‌ ‌Nutrition‌ (PN) & TPN?

What is Parenteral‌ ‌Nutrition‌ (PN)?

PN is the medical abbreviation for parenteral nutrition, also known as intravenous nutrition. Nutrition is delivered directly to the body through the veins when a person is unable to obtain adequate nutrition through the digestive tract. When properly managed, this can be safely done at home. There are two subtypes of PN: total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN).

 

Total Parenteral Nutrition (TPN)

Those who cannot obtain nutrition through oral consumption may be prescribed TPN. TPN is typically composed of some or all of the following ingredients: carbohydrates, proteins, lipids, electrolytes, trace elements, and insulin. It often contains electrolytes such as sodium, potassium, chloride, phosphate, calcium citrate, bicarbonate, acetate, and magnesium. Trace elements (copper, manganese, zinc, chromium, and selenium), as well as multivitamins, may also be added for further nutritional supplementation.

Common conditions that TPN is used to treat are:

➢   Ischemic bowel disease

➢   Short bowel syndrome

➢   Cancer

➢   Crohn’s disease

Basically, patients who have conditions that do not allow for a normally functioning digestive tract may benefit from TPN therapy. This includes those who have poor blood flow to their bowels as well. TPN is usually formulated to meet and replace complete daily nutritional needs. Because solutions can be very concentrated to deliver enough nutrients, a central line, which is an intravenous catheter that accesses one of the largest veins in the body, is typically needed for administration.

 

Peripheral Parenteral Nutrition (PPN)

PPN is PN that is administered through a peripheral intravenous line, also known as a hep-lock. Because it is administered through smaller veins, PPN solutions are formulated to be much more dilute than TPN solutions to prevent vein thrombosis. As a result, PPN solutions generally provide significantly less calories than TPN solutions. PPN is prescribed for short-term nutritional support, generally 2 weeks or less.

 

TPN versus PPN

Both TPN and PPN serve the same general purpose, which is to provide nutrition to the body through alternative means. The key differences between the two are associated with calorie content and treatment duration:

PPN is reserved for short-term when the expected duration of treatment is no greater than 2 weeks, usually during or after an acute event. Solutions are much more dilute and often meant to supplement nutritional needs rather than replacing the daily requirements.

TPN, on the other hand, is much more comprehensive. Each formula is much more calorie-dense and may replace the daily needs completely. It is often prescribed over PPN when the condition being treated is expected to be chronic with no definite time table of recovery. Also, when PPN treatment extends beyond 2 weeks, it is often converted to TPN.

 

Composition and Protocols

Total parenteral nutrition comprises many separate components, including:

➢   Minerals

➢   Electrolytes

➢   amino acids

➢   Dextrose

➢   lipid emulsions

➢   trace elements

TPN nutrition composition should be personalized to meet the specific needs of each patient. Lipid emulsions, amino acids, and dextrose are the three major macronutrients that provide the daily calorie needs.

 

Micronutrients: Electrolytes, Vitamins, and Trace Elements

➢   Daily essential vitamins are provided as an additive to the TPN, commonly known as Infu-Vite, which is a multivitamin solution made for intravenous administration.

➢   Trace elements (zinc, copper, manganese, selenium, and sometimes chromium) are added based on daily needs.

➢   In most cases, each daily TPN bag will contain the following amounts of electrolytes per liter of solution:

○     Sodium (Na): 1 – 2 mEq/kg/day

○     Potassium (K): 1 – 2 mEq/kg/day

○     Phosphorus (Phos): 15 – 30 mM/day

○     Magnesium (Mg): 8 – 20 mEq/day

○     Calcium (Ca): 5 – 15 mEq/day

Note: Exact amounts will vary from patient to patient based on laboratory response.

 

Carbohydrate:

➢   Dextrose content in a TPN solution may be anywhere from 10 to 25% (wt/vol). It is often the largest calorie contribution source.

➢   For most patients, the body’s maximum rate of glucose utilization is between 4 and 6 mg/kg/min. Dextrose infusion rate is best maintained less than or within this range.

➢   Over-administration carbohydrates can cause dangerous blood sugar and lipid imbalances.

➢   Long-term rapid administration of carbohydrates may lead to the development of fatty liver.

 

Proteins:

➢   A solution of amino acids, except arginine and glutamine, contains both essential and non-essential amino acids.

➢   A healthy adult usually requires between 0.8 and 1 gm of protein per kilogram of body weight per day.

➢   Patients with acute hepatic encephalopathy require a temporary protein restriction of 0.8 gm/kg/day. Patients with critical illnesses may sometimes require up to 2 gm/kg/day. Hemodialysis patients need 1.2-1.3 gm/kg/day.

 

The current amino acid mixture for TPN contains only 19 amino acids. TPN’s amino acid profile was completed by adding glutamine (Glutamine 8 to 10 percent in PN is a compliment). Upon admission, glutamine levels in critical surgical patients are lower than in the general population. According to Tsuji, a glutamine level above 700 nmol/mL or below 400 nmol/l increased mortality in the ICU. Supra healthy glutamine doses should be used in conjunction with total parenteral nutrition. According to Heyland et al, glutamate supplementation is not recommended for septic shock, hemodynamic instability, or renal failure.

 

Lipid Emulsions

➢   Lipids provide calories and essential fatty acids. Without them, deficiencies can occur after three weeks of fat-free TPN nutrition.

➢   Cholesterol and lipids usually account for 20 to 30 percent of total calories consumed.

To summarize, the calorie source in TPN comes from the three macronutrients, amino acids, dextrose, and lipids.

➢   Intravenous lipid emulsions with water, vitamins, trace elements, and electrolytes. The 2-in-1 TPN solution, a parenteral solution containing only dextrose and amino acids, has also been used to treat patients. TNA is the gold standard of care for adults with TPN nutrition.

 

 

TPN Solutions for Specific Populations

TPN solutions come in a variety of formulations. The solution can be supplemented with electrolytes to meet the patient’s requirements.

TPN solutions vary according to the presence of other disorders and the patient’s age, as demonstrated by the following:

➢   TPN in neonates: Lower dextrose concentrations (17 to 18%)

➢   TPN in respiratory failure: To mitigate carbon dioxide production during carbohydrate metabolism, a lipid emulsion containing most nonprotein calories are used.

➢   TPN in kidney or heart failure: Consumption of a small volume (liquid)

➢   Suppose you have renal insufficiency that is not being treated with dialysis or liver failure. In that case, Protein content has been reduced, while the proportion of essential amino acids has increased.

 

 

Administration

Total parenteral nutrition is usually administered via a central venous catheter (CVC). Common types of CVC are peripherally inserted central catheter (PICC line), tunneled CVC, and implanted port. These are used to access the central circulatory system where more concentrated solutes can be infused.

 

PICC lines can be placed in the median cubital veins (brachial, cephalic, or basilic), depending on size and desired location. The catheter is inserted peripherally, guided by radiographic imaging until the tip is placed near the superior vena cava of the heart. PICC lines can be used for TPN infusion, up to 6 months as long as the catheter and the site of insertion remain stable and infection-free. After 6 months, these catheters will need to be replaced with a new one. Upon completion of treatment, PICC lines can safely be removed by a trained nurse in almost any setting.

 

Tunneled CVCs are surgically placed to enter the central circulatory system via the internal jugular veins, subclavian, or femoral vein. These function the same way as PICC lines, except that they are sutured into the skin. For removal, the patient must be referred back to interventional radiology.

 

An implanted port, commonly known as medi-port or port-a-cath, is the most permanent type of central venous catheter. It is also surgically placed, but the entry point is placed under the skin. Each access will require a special type of needle called a Huber needle, which comes in various sizes and types depending on preference and how the port was placed. TPN has long been delivered via implantable ports, especially to patients who require chronic IV nutrition. Ports may stay placed indefinitely as long as the catheter remains stable and infection-free. Removing ports also require a referral to interventional radiology.

 

TPN may not be administered via peripheral intravenous catheter due to high osmolarity. For peripheral administration (PPN), PN solutions must be formulated below 900 mOsm. This provides much less flexibility on how many calories to add into each bag, and therefore, PPN often will not provide enough to meet daily nutritional requirements. PPN is often reserved for nutritional support, rather than nutritional replacement. It is given short-term when the expected need does not exceed 2 weeks. Also, because peripheral catheters access the circulatory system through smaller veins, these devices cannot remain stable for very long after access.

 

 

Definite Indications

TPN therapy is considered when a patient’s gastrointestinal function is inadequate and enteral nutrition is contraindicated. Enteral diets are preferable to parenteral diets because they are less expensive and have fewer complications such as infection and blood clots. However, it is only possible if the patient has a functional gastrointestinal system. TPN indications include the following:

➢   Cancer of the digestive tract: Tumors can obstruct the bowels, which make compromises the consumption of enough calories. Chemotherapy and other cancer treatments may also cause your body to have difficulty absorbing nutrients.

➢   Food intolerance combined with pseudo-obstruction of the bowel.

➢   GI fistulas with high flow: TPN nutrition can be used to rest the bowel and replace fluids lost from drains.

➢   Pediatrics: When an infant is born, if the digestive system is immature or has a congenital gastrointestinal malformation.

➢   Any time there is a leak from a postoperative bowel anastomosis.

➢   Severe vomiting or diarrhea preventing adequate nutritional intake

➢   Small bowel obstruction.

➢   Hypercatabolic states such as sepsis, polytrauma, and major fractures.

➢   Exacerbations of inflammatory bowel disease

➢   Critically ill patients 

➢   Any other conditions with expected NPO time longer than seven days.

 

Possible Indications

One of the following conditions may necessitate the use of total parenteral therapy:

➢   Crohn’s disease: Crohn’s disease is an inflammatory bowel disease that may manifest as abdominal pain, bowel narrowing, and other symptoms that impair food intake, digestion, and absorption.

➢   Short bowel syndrome: A person may be born with this condition or develop it due to surgery involving the removal of a significant portion of the small intestine. Patients with this condition do not have excellent bowels to absorb enough nutrients from oral consumption.

➢   Ischemic bowel disease: Decreased blood flow to the bowel may lead to

➢   Abnormal bowel function: The food you eat will have difficulty moving through your intestines due to this, and you will experience a variety of symptoms that will prevent you from eating enough food. Abnormal bowel function can occur as a result of surgical adhesions or bowel motility abnormalities. These can be caused by various conditions such as radiation enteritis, neurological disorders, and many others.

 

Complications

TPN therapy does not come without risks. Some of the more severe adverse events to consider are:

➢   Chemically-induced metabolic abnormalities

➢   Infection

➢   Vascular injury

➢   Venous thrombosis

➢   Bleeding

➢   Air embolism

➢   Pneumothorax

 

Catheter-Related Infections:

Unfortunately, PN solutions also encourage growth of other unwanted organisms such as bacteria and fungi. Patients on chronic TPN therapy are at higher risk of the following complications associated with intravenous catheters:

➢   Infection of the skin at the site of catheter insertion

➢   Bacteremia / sepsis, which is a bloodstream infection

With proper aseptic and sterilization techniques, these risks can be significantly minimized. Be sure to consult your nurse on how to best care for intravenous catheters.

Metabolic Abnormalities:

Because nutrition and electrolytes are administered directly into the veins, TPN patients are more susceptible to metabolic fluctuations, especially when solutions are administered too quickly. Common metabolic complications with TPN therapy include:

➢   Refeeding syndrome: The greatest concern with this is at the beginning of TPN therapy, especially with patients with severe malnutrition. The risk is minimized with slow titration of calories to the desired goal.

➢   Wernicke’s encephalopathy

➢   Hyperglycemia

➢   Hypoglycemia:  This risk is increased with abrupt. Hypoglycemia is often corrected by infusing 50% dextrose in water solutions.

➢   Electrolyte abnormalities

➢   Cholestasis

 

 

Contraindications

According to Maudar (2017), total parenteral nutrition is generally contraindicated in the following circumstances:

➢   Infants with a small bowel that is less than 8 cm in length.

➢   Patients who are irreversibly decerebrate.

➢   Patients who are suffering from severe cardiovascular instability or metabolic instabilities. Before initiating parenteral nutrition, it is necessary to correct any instabilities.

➢   Patient’s digestive tract is functional and usable.

➢   Patient’s nutritional status is favorable with only short-term expected benefit from TPN.

➢   Patient’s death is unavoidable regardless of nutritional status. Total parenteral nutrition should not be used to prolong life in such situations.

 

 

PN In Infants

The use of PN therapy can be beneficial in certain infants with nutritional challenges.. While it is always preferable for nutrition to be delivered through the GI tract, the UCSF Children’s Hospital recommends that when this is not possible, PN nutrition should be initiated. Nutritional requirements for sick or premature newborns are frequently higher than for healthy newborns. This is due to a variety of factors, including:

➢   An insufficient amount of time spent in the womb, resulting in an infant not receiving the entire supply of nutrients required for healthy growth and development.

➢   Stunted kidney growth, preventing it from functioning normally

➢   Dehydration

➢   Diarrhea

 

 

ASPEN PN Recommendations for Infants

The American Society of Parenteral and Enteral Nutrition (ASPEN) states that parenteral nutrition can save the lives of underweight or sick infants who can’t process food taken orally or via gastric tubes. Parenteral nutrition is more effective than water-based IV feedings in meeting these babies’ nutritional needs.

Several studies published in the medical journal, Mayo Clinic Proceedings, suggest that parenteral nutrition may help nursing infants. Premature infants with birth-related medical conditions, diarrhea, and surgical complications have benefited from PN therapy.. A study of 20 patients found that administration of PN helped infants resume regular weight gain and growth. Also, according to the medical journal Archives of Disease in Childhood, the effectiveness of parenteral nutrition versus milk was studied in 34 infants with extremely low birth weights. The TPN group consumed more protein and carbohydrates than the milk group.

Parenteral nutrition, if administered and appropriately managed, could be an effective treatment for premature infants. On the other hand, these studies were conducted during the early years of its use. In follow-up research, it was determined that PN therapy carries several high risks of complications, and therefore, it is not routinely recommended for low birth weight infants capable of receiving nutrition through the gastrointestinal tract.

 

 

Parenteral‌ ‌Nutrition‌ PN Administration in Infants

For infants, PN is administered into a vein in the baby’s hand, foot, scalp, or navel. These routes are considered “peripheral” because they involve the use of smaller veins. 

This is the most common indication for PPN, which is intended to provide short-term nutritional support. When an infant requires continuous PN feedings, a placement of a central line is then considered. Like in adults, central lines can provide higher nutrient contents to infants due to the larger diameters of the veins that they access.

 

 

TPN in Infants: Risk Summary

While parenteral nutrition can save the lives of infants who are unable to feed themselves, it is not without risks. According to the Merck Manual, between 5% and 10% of patients of all ages will experience complications such as:

➢   Sepsis: a potentially fatal immune response to bacteria or other germs.

➢   Imbalances of electrolyte levels, blood sugars, and lipid profile

➢   Liver problems such as fatty liver and/or transaminitis

According to the Merck Manual, chronic excess fat intake parenterally can cause chronic lung disease or high blood pressure. Also, TPN-induced liver disease occurs at any age, but premature infants are the most commonly affected. This is because their livers have not yet reached full maturity.

Liver problems most commonly occur when TPN nutrition is first started. It is possible to limit this risk by slowly titrating the dextrose and lipid contents to the determined goals.

Healthcare providers often order blood and urine tests on infants to determine their nutritional requirements. The results are also used to evaluate whether or not the nutritional components of PN need to be adjusted.

For the first week of PICU hospitalization, regardless of age or nutritional status, parenteral nutrition should be avoided because amino acids inhibit autophagy, which is required to remove cellular damage. Also, increased urea levels from metabolism of amino acids can harm the kidneys and the liver.

 

 

What is the Prognosis for Those on TPN?

According to ASPEN’s Parenteral Nutrition Fact Sheet, children and adults can thrive on parenteral nutrition when no complications arise. While parenteral nutrition is typically discontinued once the patient can eat by mouth again, it may be continued for as long as necessary in certain cases.

 

 

Parenteral‌ ‌Nutrition‌ PN in Pregnancy

Nausea and vomiting are widespread side effects of pregnancy, and they can significantly affect activities of daily living, including nutrition. Approximately 85% of pregnant women will experience nausea and vomiting during the first three months of pregnancy, and 20% of those may experience nausea and vomiting for the remainder of the pregnancy.

Approximately 2% of pregnant women suffer from hyperemesis gravidarum, a severe form of nausea and vomiting that can last for several days and sometimes weeks. High-risk pregnancy complications such as ketonuria, dehydration, and catabolism may necessitate hospitalization for pregnant women with hyperemesis gravidarum. It has also been demonstrated that severe dietary malnutrition during pregnancy can impair fetal growth and development

According to the American College of Obstetricians and Gynecologists (ACOG), parenteral or enteral nutrition should be considered in patients with hyperemesis gravidarum who experience a decrease of 10% or more of their pre-pregnancy body weight. Antiemetics may also be prescribed together to help tolerate oral liquids as well as to improve quality of life.Following the publication of several case reports, parenteral nutrition is a viable option for severely malnourished patients with hyperemesis gravidarum to maintain adequate nutrition and ensure continued fetal growth.

 

 

American College of Obstetricians and Gynecologists Recommendation for TPN in Pregnancy

ACOG recommends parenteral or enteral nutrition for patients with hyperemesis gravidarum who continue to lose weight and have difficulty tolerating oral intake despite antiemetic therapy. In these patients, when vomiting is present, vitamins such as thiamine should be included with the parenteral nutrition. ACOG recommends against insertion of a PICC line to avoid complications associated with a central catheter.

 

 

TPN Monitoring Guidelines

According to Maudar 2017, several variables must be monitored while on TPN nutrition, especially during the acute phase when hospitalized:

➢   Liver function tests twice daily

➢   Serum protein levels twice daily

➢   Blood urea and Serum creatinine daily values

➢   Serum electrolytes: daily chloride, sodium, calcium, bicarbonate, and potassium values

➢   Every eight hours, urine sugar levels are estimated.

➢   Consumption and output Charts for the 12 hours

The following are some recommendations from the American Society for Parenteral and Enteral Nutrition (ASPEN):

➢   A week without any formulation changes should be monitored every 1–4 weeks when clinical stabilization occurs.

➢   Patients who have been in stable hospital conditions for one week and have not had any formulation changes should be checked every 2 to 7 days.

➢   Patients who are unstable or critically ill should be monitored daily until they are stabilized.

➢   At TPN initiation, patients should be monitored closely for signs or symptoms of refeeding syndrome, which manifests as severe electrolyte instabilities, mainly with potassium, magnesium, and phosphate. The risk is greatest with severely malnourished and cachectic individuals.

Patients experiencing refeeding syndrome may also present with respiratory distress, acute kidney injury, and even rhabdomyolysis. A slow initial TPN infusion and titration, especially with dextrose and lipids, will help prevent refeeding syndrome.

 

 

TPN-Induced Liver Toxicity

Excess caloric intake with glucose and lipids can lead to hepatic steatosis.For most patients, a glucose infusion rate of more than 5 mg/kg/min is the most common cause of this. High blood glucose and insulin levels trigger hepatic lipogenesis. To avoid this effect, dextrose dose should be reduced to less than 5 g/kg per day with an infusion rate of less than 5 mg/kg min. Cyclic PNtime may be reduced to 8 hours to reduce hyperinsulinemia. If needed, lipids can supplement 30% of dextrose energy to help meet and maintain caloric needs.

 

Long-Term Use of TPN and Manganese Toxicity

Long-term TPN use (several weeks to months) has been linked to manganese toxicity. Because TPN nutrition bypasses the GI tract’s protective mechanisms, manganese is highly bioavailable. Manganese accumulates in the liver, brain, and bones over time.

Manganese will deposit in and affect the globus pallidus and striatum of the basal ganglia, both located in the cerebral cortex. Extrapyramidal symptoms similar to Parkinson’s disease have been linked to manganese’s preferential effect on dopaminergic neurons in the basal ganglia. The affected neurons in substantia nigra differentiate idiopathic Parkinson’s disease from other forms of the disease.

 

Central Venous Access Complications

Central venous access complications occur in approximately 5% to 10% of patients who receive TPN through a central line.

Guidelines emphasizing sterile catheter insertion techniques and proper skincare around the catheter insertion site have reduced the incidences of catheter-associated sepsis. 

Catheter-related infections have decreased due to the increased use of dedicated teams of physicians and nurses specializing in specific procedures like catheter insertion.

Glucose Abnormalities

Anomalies of glucose are common during TPN therapy, especially with diabetic patients. Ensuring proper insulin dose in TPN solution and subcutaneous insulin administration can help prevent hyperglycemia. Tapering infusions can help reduce the incidences of hypoglycemia associated with TPN. Hypoglycemia can be treated intravenously with 50% dextrose; however, In severe hypoglycemia, a 24-hour infusion of 5-10% dextrose is required before restarting TPN infusion.

Other Hepatic Complications

Liver disease can cause hepatomegaly and hyperammonemia. While they can occur at any age, they are most common in premature infants (whose liver is immature).

➢   Liver dysfunction: 

Symptoms such as elevated transaminases, bilirubin, and alkaline phosphatase may indicate transient liver dysfunction; this is most common when TPN nutrition is first initiated. Excess calories may cause elevations to occur slowly or persistently. However, cholestasis and inflammation are thought to play a role in the development of the disease. On rare occasions, progressive fibrosis develops.

➢   Painful hepatomegaly: 

Fat accumulation is suspected in the presence of painful hepatomegaly; carbohydrate delivery should be reduced.

➢   Hyperammonemia: 

Hyperammonemia can develop in infants, resulting in symptoms such as lethargy, twitching, and generalized seizures. It can be corrected by administering arginine at 0.5–1.0 mmol/kg/day.

If an infant develops a hepatic complication of any kind, amino acid intake may need to be restricted to 1.0 g/kg/day.

 

Abnormalities of Serum Electrolytes and Minerals

Abnormalities in minerals and serum electrolytes can be corrected either by modifying subsequent TPN infusions or, in the case of an emergency, by initiating the appropriate peripheral vein infusions. Deficits in vitamins and minerals are rare when the correct solutions are administered. High blood urea nitrogen (BUN) in the bloodstream may indicate dehydration, which can be remedied by administering free water as dextrose 5% in water (D5W) or normal saline (NS).

 

Volume Overload

Patients who require a large amount of calories often also require a large volume of fluids. In these cases, they are at risk of volume overload, which is indicated by a weight gain of more than 1 kg/day.

 

Metabolic Bone Disease

Some patients who have been on TPN nutrition for more than three months develop metabolic bone disease, also known as bone demineralization (osteoporosis or osteomalacia). The cause of this is not well defined. Advanced forms of this disease can cause severe back, lower-extremity, and periarticular pain as well as swelling and inflammation.

 

Adverse Reactions to Lipid Emulsions

Acute adverse reactions to lipid-emulsion include::

➢   Dizziness

➢   Sweating

➢   Back pain

➢   Nausea

➢   Cutaneous allergic reactions

➢   Dyspnea

 

These reactions are uncommon, but they can still occur in the course of treatment, mainly when high-calorie lipids are administered at a rate greater than 1.0 kcal/kg/hour. The risk is greater with patients with liver or kidney failure. In these patients, untreated acute hyperlipidemia may lead to hepatosplenomegaly and increases in liver enzyme levels. 

Additional delayed and more serious side effects to lipid emulsions include the following:

➢   Thrombocytopenia

➢   Leukopenia

➢   Pulmonary function abnormalities (particularly prevalent in premature infants with RDS [respiratory distress syndrome])

Lipid emulsions can be slowed, reduced, or stopped to help reduce and even prevent such reactions.

 

Gallbladder Complications

Cholelithiasis, gallbladder sludge, and cholecystitis are all conditions that can affect the gallbladder. Gallbladder stasis for an extended period can lead to these complications. 

To stimulate contraction, approximately 20 to 30% of calories should be provided as fat, and infusions should be cyclic to stop glucose infusions for several hours a day. Stimulation of the digestive tract by oral intake is also beneficial. 

Some patients with cholestasis respond well to treatment with cholecystokinin, phenobarbital, ursodeoxycholic acid, or metronidazole.

 

TPN Price

If you purchase 500 milliliters of TPN Electrolytes intravenous solution (Electrolytes/Nutrilyte II/Lypholyte II), the cost is approximately $176, depending on the pharmacy you choose to purchase it from. Price quotes are available only to customers who pay in cash and are not valid with insurance plans.

QuantityPer unit Price
500 (25 x 20 milliliters) $0.35 $176.33

 

TPN Healthcare Team Outcomes

A well-coordinated health care team using an interprofessional approach is required to manage TPN therapy.

Teams usually include:

➢   Infusion nurse (RN)

➢   Prescriber (MD, DO, NP, or PA)

➢   Dietician (RD)

➢   Pharmacist (PharmD/RPh)

The prescriber decides on the appropriate course of treatment and the type of nutrition. Collaborating with the patient’s primary health care team, the clinician ensures that care is coordinated appropriately.

The pharmacist provides sterile parenteral nutrition. Consult a pharmacist about the compound’s stability and any possible drug/nutrient interactions. Under the direction of the prescriber, pharmacists may also make reasonable adjustments to the TPN formula based on clinical assessments and laboratory results.

The dietician assesses the patient’s nutritional status, calculates the daily requirements, and designs an appropriate feeding regimen.

The TPN nursing specialist oversees catheter and TPN tube care. They educate and train the patient and the caregiver on adequately managing the TPN tubes in their homes.

The extended team of professionals may also include wound management nurses, occupational therapists, and social workers.

 

Frequently Asked Questions

 

Who is TPN given to and why?

TPN is prescribed for patients who cannot obtain adequate nutrition through their digestive tract for various medical reasons. It could be the result of a clog or a leak in the digestive system. Certain patients also have difficulties with absorption, possibly as a result of short bowel syndrome. In general, when the digestive tract is compromised, TPN is required to ensure that patients receive adequate nutrition.

How long can you survive on TPN?

The prognosis for patients receiving total parenteral nutrition varies depending on the cause of the gastrointestinal failure. TPN-dependent patients have a three-year survival rate of 65-80%. Patients who do not respond well to transfusion-related perfusion can be considered for intestinal transplantation.

What is the most common complication with TPN?

The most common complication of TPN is infection (catheter-induced sepsis) due to the chronic use of a central catheter. There are various recommended aseptic and sterilization techniques to help minimize this risk. Be sure to consult your infusion nurse on how to stay infection-free.

Can you eat while receiving TPN?

Depending on the condition and the reason for receiving TPN, you can consume food and beverages while on TPN therapy. If it is a possibility, oral intake is often encouraged to help expedite discontinuation. However, this should still be done cautiously under the direction of the prescriber and/or dietician because early oral intake may sometimes exacerbate the condition in question.

 

References

  1. Braunschweig C, Liang H, Sheean P. Indications for administration of parenteral nutrition in adults. Nutr Clin Pract. 2004 Jun;19(3):255-62. doi: 10.1177/0115426504019003255. PMID: 16215113.
  2. Chowdary KV, Reddy PN. Parenteral nutrition: Revisited. Indian J Anaesth. 2010 Mar;54(2):95-103. doi: 10.4103/0019-5049.63637. PMID: 20661345; PMCID: PMC2900762.
  3. Weimann A, Ebener Ch, Holland-Cunz S, Jauch KW, Hausser L, Kemen M, Kraehenbuehl L, Kuse ER, Laengle F; Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Surgery and transplantation – Guidelines on Parenteral Nutrition, Chapter 18. Ger Med Sci. 2009 Nov 18;7:Doc10. doi: 10.3205/000069. PMID: 20049072; PMCID: PMC2795372.
  4. Messing B. Nutrition parentérale: indications et techniques [Parenteral nutrition: indications and techniques]. Ann Med Interne (Paris). 2000 Dec;151(8):652-8. French. PMID: 11173709.
  5. Maudar KK. TOTAL PARENTERAL NUTRITION. Med J Armed Forces India. 1995 Apr;51(2):122-126. doi: 10.1016/S0377-1237(17)30942-5. Epub 2017 Jun 26. PMID: 28769264; PMCID: PMC5529889.
  6. Gotthardt DN, Gauss A, Zech U, Mehrabi A, Weiss KH, Sauer P, Stremmel W, Büchler MW, Schemmer P. Indications for intestinal transplantation: recognizing the scope and limits of total parenteral nutrition. Clin Transplant. 2013 Jul-Aug;27 Suppl 25:49-55. doi: 10.1111/ctr.12161. PMID: 23909502.
  7. Slattery E, Rumore MM, Douglas JS, Seres DS. 3-in-1 vs 2-in-1 parenteral nutrition in adults: a review. Nutr Clin Pract. 2014 Oct;29(5):631-5. doi: 10.1177/0884533614533611. PMID: 25606645.
  8. Mohandas KM, Shastri YM, Shirodkar M. Total parenteral nutrition. Natl Med J India. 2003 Jan-Feb;16(1):29-33. PMID: 12715955.
  9. Wischmeyer PE. The glutamine debate in surgery and critical care. Curr Opin Crit Care. 2019 Aug;25(4):322-328. doi: 10.1097/MCC.0000000000000633. PMID: 31247630.
  10. Tsujimoto T, Shimizu K, Hata N, Takagi T, Uejima E, Ogura H, Wasa M, Shimazu T. Both high and low plasma glutamine levels predict mortality in critically ill patients. Surg Today. 2017 Nov;47(11):1331-1338. doi: 10.1007/s00595-017-1511-0. Epub 2017 Apr 3. PMID: 28374265.
  11. Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, Elke G, Berger MM, Day AG; Canadian Critical Care Trials Group. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013 Apr 18;368(16):1489-97. doi: 10.1056/NEJMoa1212722. Erratum in: N Engl J Med. 2013 May 9;368(19):1853. Dosage error in article text. PMID: 23594003.
  12. Kovacevich DS, Corrigan M, Ross VM, McKeever L, Hall AM, Braunschweig C. American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration. JPEN J Parenter Enteral Nutr. 2019 Jan;43(1):15-31. doi: 10.1002/jpen.1455. Epub 2018 Oct 19. PMID: 30339287.
  13. Gonzalez R, Cassaro S. Percutaneous Central Catheter. 2020 Sep 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083596.
  14. Leib AD, England BS, Kiel J. Central Line. 2020 Jul 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30137796.
  15. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, Marqué S, Thuong M, Pottier V, Ramakers M, Savary B, Seguin A, Valette X, Terzi N, Sauneuf B, Cattoir V, Mermel LA, du Cheyron D; 3SITES Study Group. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. doi: 10.1056/NEJMoa1500964. PMID: 26398070.
  16. Mattioli S, Miglioli M, Montagna P, Lerro MF, Pilotti V, Gozzetti G. Wernicke’s encephalopathy during total parenteral nutrition: observation in one case. JPEN J Parenter Enteral Nutr. 1988 Nov-Dec;12(6):626-7. doi: 10.1177/0148607188012006626. PMID: 3148047.
  17. Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, Marshall N, Neal A, Sacks G, Seres DS, Worthington P; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr;38(3):296-333. doi: 10.1177/0148607113511992. Epub 2013 Nov 26. PMID: 24280129.
  18. Lakananurak N, Gramlich L. The Role of Preoperative Parenteral Nutrition. Nutrients. 2020 May 6;12(5):1320. doi: 10.3390/nu12051320. PMID: 32384662; PMCID: PMC7285090.
  19. Guglielmi FW, Boggio-Bertinet D, Federico A, Forte GB, Guglielmi A, Loguercio C, Mazzuoli S, Merli M, Palmo A, Panella C, Pironi L, Francavilla A. Total parenteral nutrition-related gastroenterological complications. Dig Liver Dis. 2006 Sep;38(9):623-42. doi: 10.1016/j.dld.2006.04.002. Epub 2006 Jun 12. PMID: 16766237.
  20. Jacobs A, Verlinden I, Vanhorebeek I, Van den Berghe G. Early Supplemental Parenteral Nutrition in Critically Ill Children: An Update. J Clin Med. 2019 Jun 11;8(6):830. doi: 10.3390/jcm8060830. PMID: 31212639; PMCID: PMC6616588.
  21. Khan A, Hingre J, Dhamoon AS. Manganese Neurotoxicity as a Complication of Chronic Total Parenteral Nutrition. Case Rep Neurol Med. 2020 Apr 23;2020:9484028. doi: 10.1155/2020/9484028. PMID: 32373376; PMCID: PMC7196137.
  22. Nightingale J. Nutrition support teams: how they work, are set up and maintained. Frontline Gastroenterol. 2010 Oct;1(3):171-177. doi: 10.1136/fg.2009.000224. Epub 2010 Aug 5. PMID: 28839571; PMCID: PMC5517177.
  23. Russo-Stieglitz KE, Levine AB, Wagner BA, Armenti VT. Pregnancy outcome in patients requiring parenteral nutrition. J Matern Fetal Med. 1999 Jul-Aug;8(4):164-7. doi: 10.1002/(SICI)1520-6661(199907/08)8:4<164::AID-MFM5>3.0.CO;2-Z. PMID: 10406299.
  24. Zibell-Frisk D, Jen KL, Rick J. Use of parenteral nutrition to maintain adequate nutritional status in hyperemesis gravidarum. J Perinatol. 1990 Dec;10(4):390-5. PMID: 2126033.
  25. Peled Y, Melamed N, Hiersch L, Hadar E, Wiznitzer A, Yogev Y. Pregnancy outcome in hyperemesis gravidarum–the role of fetal gender. J Matern Fetal Neonatal Med. 2013 Nov;26(17):1753-7. doi: 10.3109/14767058.2013.798293. Epub 2013 May 24. PMID: 23611752.
  26. American College of Obstetrics and Gynecology. ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstet Gynecol. 2004 Apr;103(4):803-14. PMID: 15051578.
  27. Tamay AG, Kuşçu NK. Hyperemesis gravidarum: current aspect. J Obstet Gynaecol. 2011 Nov;31(8):708-12. doi: 10.3109/01443615.2011.611918. PMID: 22085059.
  28. Madjunkova S, Maltepe C, Koren G. The Leading Concerns of American Women with Nausea and Vomiting of Pregnancy Calling Motherisk NVP Helpline. Obstet Gynecol Int. 2013;2013:752980. doi: 10.1155/2013/752980. Epub 2013 Apr 15. PMID: 23690784; PMCID: PMC3649700.
  29. Feliciano DV, Telander RL. Total parenteral nutrition in infants and children. Mayo Clin Proc. 1976 Oct;51(10):647-54. PMID: 823382.
  30. Yu VY, James B, Hendry P, MacMahon RA. Total parenteral nutrition in very low birthweight infants: a controlled trial. Arch Dis Child. 1979 Sep;54(9):653-61. doi: 10.1136/adc.54.9.653. PMID: 117755; PMCID: PMC1545805.
  31. Herbert WN, Seeds JW, Bowes WA, Sweeney CA. Fetal growth response to total parenteral nutrition in pregnancy. A case report. The Journal of Reproductive Medicine. 1986 Apr;31(4):263-266. PMID: 3086545.