From the Guidelines
Initiation of Total Parenteral Nutrition (TPN) after a Stroke
Total parenteral nutrition (TPN) should be initiated in patients who are unable to meet their nutritional needs through oral or enteral routes within 7-10 days of hospital admission following a cerebrovascular accident (stroke) 1.
Key Considerations
- TPN should be considered in patients with a severe stroke, indicated by a National Institutes of Health Stroke Scale (NIHSS) score ≥ 10, or in those with a decreased level of consciousness, dysphagia, or other conditions that preclude adequate oral intake.
- The recommended caloric intake is 20-25 kcal/kg/day, with a protein dose of 1.2-1.5 g/kg/day.
- TPN should be started with a gradual increase in infusion rate over 24-48 hours to prevent refeeding syndrome, with close monitoring of electrolytes, glucose, and liver function.
Enteral vs. Parenteral Nutrition
- Enteral nutrition is preferred over parenteral nutrition whenever possible, as it is associated with fewer complications and better outcomes 1.
- However, in patients who are unable to tolerate enteral nutrition, TPN may be necessary to ensure adequate nutrition and prevent malnutrition.
Monitoring and Adjustment
- Patients receiving TPN should be closely monitored for signs of refeeding syndrome, electrolyte imbalances, and other complications.
- The TPN regimen should be adjusted as needed to ensure that the patient's nutritional needs are being met, and to minimize the risk of complications.
- A nutrition specialist, such as a dietitian or nutritionist with experience in stroke, should be involved in the development and monitoring of the individual nutrition care plan 1.
From the Research
Initiation of Total Parenteral Nutrition (TPN) following a Cerebrovascular Accident (Stroke)
- The decision to initiate TPN in stroke patients depends on various factors, including the patient's nutritional status, presence of dysphagia, and level of consciousness 2.
- In patients with severe dysphagia or decreased level of consciousness, enteral nutrition is recommended, and TPN may be considered if enteral nutrition is not feasible 2.
- A study found that starting enteral nutrition too early is not nutritionally beneficial, and TPN with 20% glucose fed through a tube is recommended as adequate nutrition for comatose acute stroke patients 3.
- However, TPN should not be employed for longer than 10 days, as switching to enteral nutrition after this period contributes to better nutritional recovery than continuing TPN 3.
- The optimal timing for initiating TPN in stroke patients is not well established, but it is generally recommended to start nutritional support within 3 days after admission 3.
- Patients at high risk of refeeding syndrome should receive lower initial calories and close monitoring of electrolyte levels when starting TPN 4.
- Local food-based enteral nutrition supplementation may improve the nutritional status of post-stroke patients, but more research is needed to determine the optimal nutritional approach 5.
- The use of parenteral nutrition in critically ill patients, including those with stroke, should be individualized and based on the patient's nutritional status, phase of illness, and other factors 6.