From the Guidelines
Total Parenteral Nutrition (TPN) should be used with caution due to its significant risks, including catheter-related complications, metabolic complications, and gut mucosal atrophy, and should only be initiated when enteral nutrition is impossible or insufficient, with careful patient selection and monitoring. The primary risks associated with TPN include catheter-related complications such as infection, thrombosis, pneumothorax during insertion, and mechanical problems like occlusion or displacement, as well as metabolic complications including hyperglycemia, electrolyte imbalances (particularly potassium, phosphate, and magnesium), refeeding syndrome in malnourished patients, and liver dysfunction that may progress to cholestasis or steatosis with prolonged use 1.
To minimize these risks, TPN should be initiated with careful consideration of the patient's nutritional needs and underlying health conditions. Regular laboratory testing is essential, including daily glucose checks initially, and frequent electrolyte, liver function, and triglyceride monitoring 1. Strict aseptic technique during catheter care is crucial to prevent infections. Gradual initiation of TPN (starting at 50-75% of goal rate) helps prevent refeeding syndrome, particularly in severely malnourished patients who require additional phosphate, potassium, and magnesium supplementation 1.
Some key considerations for TPN administration include:
- Providing 25 non-protein kcal/kg per day, increasing to no more than 30 kcal/kg per day, with reductions for patients with systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS) 1
- Monitoring for signs of overfeeding, such as hyperglycemia, hyperlipidemia, and hepatic dysfunction, and adjusting the TPN regimen accordingly 1
- Maintaining some enteral nutrition alongside TPN, whenever possible, to preserve gut integrity and facilitate transition to enteral feeding as soon as feasible 1
- Paying close attention to fluid and electrolyte balance, particularly in patients with acute pancreatitis or other conditions that may affect these parameters 1
By carefully weighing the risks and benefits of TPN and taking steps to minimize its complications, healthcare providers can optimize patient outcomes and improve quality of life for those requiring this form of nutrition support.
From the Research
Risks of Total Parenteral Nutrition (TPN)
- TPN is a life-saving modality, but it also carries risks for potentially life-threatening complications, including central line-associated bloodstream infections (CLABSIs) 2, 3, 4.
- The risk of CLABSIs is particularly high in patients receiving TPN, with studies showing that TPN is an independent risk factor for developing CLABSIs 3, 4.
- Other risk factors for CLABSIs in patients receiving TPN include intensive care unit stay, renal disease, and immunodeficiency 4.
- Overfeeding, defined as greater than 30 kcal/kg/day, is also associated with an increased risk of CLABSIs in patients receiving TPN 5.
- Proper administration techniques, including careful selection of candidates, individualizing formulas, and monitoring response to therapy, are crucial to minimizing complications associated with TPN 2, 6.
Considerations for Using TPN
- Comprehensive management of patients receiving TPN is essential to promote optimal outcomes and minimize complications 2.
- A collaborative, multidisciplinary approach to TPN therapy is recommended, involving nurses, physicians, and other healthcare professionals 2, 6.
- Electronic medical records can be useful in identifying risk factors for CLABSIs and assessing the association between CLABSI and TPN administration, but may have limitations due to free-text data entry 4.
- Further research is needed to identify effective strategies to reduce rates of CLABSIs among patients receiving TPN 3, 5.