This document discusses total parenteral nutrition (TPN), which is the intravenous administration of nutrients like glucose, lipids, amino acids, electrolytes, vitamins and minerals directly into the bloodstream. TPN is indicated for patients who are unable to receive adequate nutrition through the gastrointestinal tract due to conditions like intestinal obstruction or severe diarrhea. There are two main methods of TPN - total nutrient admixture into a central vein for patients requiring nutrition for over 7 days, and peripheral parenteral nutrition for less than 7 days. Proper supplies, monitoring of lab values and glucose levels, and weaning off TPN are discussed to safely provide nutrients and avoid complications.

1. Moderator: Dr Sanjay Sir
Presented by: Dr. Vishal Vaishnavi (JR1, General
Surgery)
Total parenteral
nutrition

2. Intravenous administration of varying
combinations of hypertonic or isotonic
glucose, lipids, amino acid, electrolytes,
vitamins and trace elements through a
venous access device (VAD) directly into
the intravascular fluid to provide nutrients
for patients who are unable to receive
adequate nutrition through gastrointestinal
tract.
Total Parenteral nutrition

3. ● To provide nutrients required for the
normal metabolism, tissue
maintenance, repair and energy
demands.
● To bypass the GI tract for patients who
are unable to take food orally.
Purposes

4. Indications
Patient who cannot tolerate enteral
nutrition because of
● Paralytic ileus
● Intestinal obstruction
● Acute pancreatitis
● Inflammatory bowel disease
● Gastro intestinal fistula
● Severe diarrhea
● Persistent vomiting
● Malabsorption
Hypermetabolic states for which
enteral therapy either not possible
or inadequate
● Severe burns
● NPO for more than 5 days
● Acute renal failure
● Multiple fractures
● Tumor in GI tract
Patient at risk for malnutrition of
● Gross underweight
● Metastatic cancer

5. Methods of parenteral nutrition

6. Methods of parenteral nutrition
Total nutrient admixture into a
central vein (TNA)
● It is indicated for patients requiring
parenteral feeding for seven or more
days. Given through a central vein
often into the superior venacava.
● Parenteral formula combines
○ CHO in the form of a concentrated 20-70%
dextrose solution
○ Proteins as amino acids
○ Lipids in the form of an emulsion (10-20%)
including triglycerides, phospholipids and
glycerol.
○ Water
○ Vitamins and minerals
Peripheral parenteral
nutrition
● This parenteral formula
combines carbohydrates a
lesser concentrated glucose
solution with amino acids,
vitamins, minerals
● Given through peripheral vein
● Indicated for patients requiring
nutrition for fewer less than 7
days

7. Supplies
● Central venous access devices: long term VAD
such as thick man, Broviac or Groshung
catheters or peripherally inserted central
catheter (PICC line) or peripheral IV access
● Volume control infuser
● Filters 0.22 micron for TPN (without fat
emulsion)3.2 micron filter for TNA or fat emulsion

8. Supplies
Central venous access
devices:
Central venous access
devices: long term VAD such
as thick man, Broviac or
Groshung catheters or
peripherally inserted central
catheter (PICC line) or
peripheral IV access.
Volume control infuser
Filters
0.22 micron for TPN (without
fat emulsion)3.2 micron filter
for TNA or fat emulsion
03
01 02

9. Supplies
Bag of parenteral
nutrition
luer-lock connections
Hypoallergic tape
Facemask
Sterile gloves
05
01
02 03
04

10. Laboratory Daily
Finger-stick glucose Three times daily until stable
Blood glucose, Na, K, Cl,
HCO3, BUN
Daily until stable and fully
advanced, then twice weekly
Serum creatinine, albumin,
PO4, Ca, Mg, Hb/Hct, WBC
Baseline, then twice weekly
INR
Baseline, then weekly
Micronutrient tests
As indicated

11. Discontinuation of TPN
● Discontinuation of TPN should take place when the
patient can satisfy 75% of his or her caloric and protein
needs with oral intake or enteral feeding.
● To discontinue TPN, the infusion rate should be
halved for 1 hour, halved again the next hour, and then
discontinued.
● Tapering in this manner prevents rebound
hypoglycemia from hyperinsulinemia.
● It is not necessary to taper the rate if the
patient demonstrates glycemic stability.

12. Complications
Complication Causes Interventions
Sepsis ● High glucose content
of fluid
● Venous access
device contamination
● Monitor temperature , WBC count, and insertion site for signs and
symptoms of infection
● Maintain strict surgical asepsis when changing dressing and tubing
● Consider decreasing glucose content of fluid
● Consider removal of venous access device with replacement in alternate
site
● If blood culture is positive consider antibiotic therapy
Electrolyte
imbalance
● Iatrogenic
● Effects of underlying
diseases, ie. Fistula,
diarrhea, vomiting
● Monitor for signs and symptoms of electrolyte imbalances
● Treat underlying cause
● Change concentration of electrolytes in TNA as necessary
Hyperglycemia ● High glucose content
of fluid
● Insufficient insulin
secretion
● Monitor blood glucose frequently
● Decrease glucose content of fluid if possible
● Administer insulin

13. Complications
Complication Causes Interventions
Hypoglycemia ● Abrupt discontinuation of
TNA
● Administration through a
central vein
● After discontinuation of centrally administered TNA, start 10%
dextrose at the same rate
Hypervolemia ● Iatrogenic
● Underlying heart diseases
such as congestive heart
failure and renal failure
● Monitor intake & output, daily weight,CVP, breath sounds and
peripheral edema
● Consider administering more concentrated TNA solution
Hepatic
dysfunction
● High concentration of
CHO, fats relative to
protein
● Monitor liver function test, triglyceride levels, and presence of
jaundice
● Consider alternation in formula
Hypercarbia ● High carbohydrate content
of fluid
● Consider changing formula to increase the proportion of fat relative to
carbohydrate

14. Thank You !