Indications for PPN and TPN
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Transcript Indications for PPN and TPN
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