What are the criteria for the use of Total Parenteral Nutrition (TPN)?

Criteria for Use of Total Parenteral Nutrition (TPN)

Total Parenteral Nutrition (TPN) should be initiated when patients cannot meet their nutritional requirements through oral or enteral routes, specifically when oral/enteral intake is anticipated to be inadequate (<60% of estimated energy expenditure) for more than 10 days or impossible for more than 7 days.1

Primary Indications for TPN

• TPN is indicated in patients who cannot meet their nutritional requirements via the enteral route due to intestinal failure or when enteral nutrition is contraindicated or poorly tolerated 1
• TPN should be initiated in patients facing starvation for more than 3 days when oral or enteral nutrition is impossible 1
• TPN is recommended for patients with severe mucositis or severe radiation enteritis that prevents adequate enteral intake 1
• TPN is indicated when less than 50% of caloric requirements can be met enterally for 7 or more days 1

Patient-Specific Indications

Surgical Patients

• Perioperative TPN is recommended for malnourished patients when enteral nutrition is not possible 1
• TPN should not be used routinely in well-nourished surgical patients 1
• Patients with postoperative complications such as anastomotic leakage, paralytic ileus, or fistulas may require TPN as "rescue nutrition" 1

Oncology Patients

• TPN is indicated for cancer patients with severe mucositis, ileus, or intractable vomiting 1
• In hematopoietic stem cell transplantation patients, TPN should be reserved for those with severe mucositis, ileus, or intractable vomiting 1
• Long-term TPN should be offered to incurable cancer patients with intestinal failure when: enteral nutrition is insufficient, expected survival is longer than 2-3 months, TPN is expected to improve quality of life, and the patient desires this support 1

Liver Disease Patients

• TPN improves nutritional state and liver function in malnourished patients with alcoholic steatohepatitis 1
• TPN is safe and improves mental state in patients with cirrhosis and severe hepatic encephalopathy 1

Renal Failure Patients

• TPN may benefit maintenance hemodialysis patients who meet all three criteria: evidence of protein/energy malnutrition, inadequate dietary intake, and inability to administer or tolerate adequate oral/enteral nutrition 1

Contraindications for TPN

• TPN should not be used in non-aphagic oncological patients who have no gastrointestinal reason for intestinal failure 1
• TPN is not recommended if oral/enteral nutrient intake is adequate 1
• Routine use of TPN during chemotherapy, radiotherapy, or combined therapy is not recommended unless patients are malnourished or facing prolonged starvation 1
• TPN should not be administered if the patient requires pharmacological sedation or physical restraint solely to make TPN possible 1

Nutritional Requirements for TPN

• Energy requirements: Approximately 25-30 kcal/kg ideal body weight per day, adjusted based on disease severity, inflammation level, and physical activity 1
• Protein requirements: 1.2-1.5 g/kg/day for most patients, with potentially higher needs (up to 1.5 g/kg/day) in malnourished elderly patients 1
• Glucose should cover 50-60% of non-protein energy requirements 1
• Lipid emulsions with lower content of n-6 unsaturated fatty acids than traditional soybean oil emulsions are preferred 1
• Water-soluble vitamins and trace elements should be administered daily from the first day of TPN 1

Special Considerations

Home Parenteral Nutrition (HPN)

• HPN can be considered when patients meet criteria for TPN and are:
  • Sufficiently metabolically stable outside the acute hospital setting 1
  • Have an adequate home environment to safely deliver the therapy 1
  • Patient and/or caregiver can understand and perform required procedures 1
  • Patient and/or caregiver has been trained by a nutrition support team 1

Refeeding Syndrome Prevention

• For severely malnourished patients, the caloric load delivered by TPN should be gradually increased over approximately 3 days according to individual needs 1
• Administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy 1

Monitoring and Complication Prevention

• Patients on TPN should be monitored by a specialized nutrition support team to reduce complications 2
• Catheter care protocols should be implemented to minimize thrombophlebitis and catheter-related infections 1
• Regular monitoring of metabolic parameters, including glucose levels, electrolytes, and liver function tests is essential 3
• For peripheral parenteral nutrition (PPN), close monitoring of the insertion site is needed to detect early signs of thrombophlebitis 1

Transitioning from TPN

• TPN withdrawal should be considered when patients are able to tolerate approximately 50% of their requirements enterally 1
• Gradual transition from TPN to enteral nutrition is recommended to avoid metabolic complications 3