Total Parenteral Nutrition : A Review

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Mrs. Rupali A. Patil

Mrs. Rupali A. Patil

"Parenteral" means administered any other way except by the mouth.
"Nutrition" means feeding.
"Parenteral nutrition" means feeding someone via their blood stream, "intravenously".
"Total parenteral nutrition" ("TPN"), means feeding a patient solely rather than partly intravenously .

Total parenteral nutrition (TPN), also called hyperalimentation, is the practice of feeding a person without using the gut. It is normally used during surgicalrecoveries. It has been used for patients in coma, although enteric (tube) feeding is usually adequate, and less prone to complications. Chronic TPN is occasionally used treat people suffering the extended consequences of an accident or surgery. Most controversially, TPN has extended the life of a small number of children born with nonexistent or severely birth-deformed guts. The oldest were eight years old in 2003.In TPN's simplest form, a bag of nutrients is added to a patient's intravenous drip.

The preferred method of performing TPN is with a medical infusion pump. A sterile bag of nutrient solution, between 500ml and 4l is provided. The pump infuses a small amount (0.1 to 10ml/hr) continuously in order to keep the vein open. Feeding schedules vary, but one common regimen ramps up the nutrition over a few hours, levels off the rate for a few hours, and then ramps it down over a few more hours, in order to simulate a normal set of meal times . 

TPN might be necessary if:

  •  a patient is severely undernourished, and needs to have surgery, radiotherapy or chemotherapy;
  •  a patient suffers from chronic diarrhoea and vomiting;
  •  a baby's gut is too immature;
  •  a patient's (their "gastrointestinal tract") is paralysed, for example after major surgery.

TPN is used for patients who cannot or should not get their nutrition through eating. Your TPN may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elements. Your solution may contain all or some of these substances, depending on your condition.

TPN will drip through a needle or catheter placed in vein for 10-12 hours, once a day or five times a week.

Electrolytes include sodium, potassium, chloride, phosphate, calcium, and magnesium. Trace elements include zinc, copper, manganese, and chromium. Electrolytes are important for maintaining almost every organ in your body. They help your heart, muscles, and nerves to work properly and keep you from becoming dehydrated.1

What does the procedure involve?

  • A local anaesthetic is used to numb the area.
  • A tube or "catheter" is normally inserted into a large vein, such as the one situated under your collarbone.
  • A nutritious solution is fed through the catheter into your veins.

How long does the procedure take?

Placing the catheter in to vein takes very little time. The feeding each day will take several hours. The process of feeding in this way, can last for a long time, until the patient is more strong and capable of eating normally again.

Nutrients for Standard TPN

For adults, standard TPN formulation contains 4.25% AA, 15% Dextrose + 20% Fat Emulsion- plus electrolytes, trace elements, vitamins, and additives. Caloric Distribution is 20% protein, 60% CHO and 20% fat. Concentrations may have to be increased with decreased rate and volume. 

For pediatric patients of age < 10 years, 3% AA and 20% Fat Emulsion are used. Dextrose % is calculated based on patient's weight. If weight is less than 10kg, 7.5% Dextrose is used, otherwise %Dextrose=4.45+0.27 x Weight.
Detroxe is increased from about 6mg/kg/min over 5 days, as tolerated, to about 12mg/kg/min. Fat is started at 0.5g/kg/day and increased over 5 days to a maximum of 4g/kg/day, as tolerated.

* For pediatric patient age < 10, fat emulsion is started at 1/4 the amount required to meet complete caloric requirement, with increases as tolerated by serum triglycerides < 150mg

Total Parenteral Nutrition In Cancer Patients

Adjunctive Nutrition Support During Antineoplastic Treatment

Indications for TPN may arise from antineoplastic treatments that include perioperative, chemotherapy, radiotherapy, or bone marrow transplantation. Most cancer patients remain in normal nutrition status up to the time of initial diagnosis, and even during early periods of therapy. The majority of advanced cancer patients with a solid tumor of the abdomen become malnourished in association with cancer therapies involving multiple operations, palliative radiation, and repeated courses of chemotherapy particularly with high doses and combinations of toxic drugs. The use of nutritional therapy in the cancer patient is tailored to complement the primary treatment. The purpose is to improve fitness, metabolic status, and body composition - all of which will improve quality of life. Properly administered nutrition support using tailored prescription of macronutrients and micronutrients, such as in Table 1, can prevent most symptoms of malnutrition.

Table 1: Patient-Specific Feeding for Cancer Patients with Standard Stock Solutions Using a Single Source in 2000ml or Less

  Nutritional Goals Met¹

Weight (kg)

Amino acids
[conc./
vol (ml)]

Dextrose
[conc./
vol (ml)]

Lipids
[conc./
vol (ml)]

Final volume
[(ml)]

Protein or
amino acids
/kg/day

kcal/kg
/day

% of lipid calories²

40

5.5%/1000

40%/500

10%/250

1750

1.4

28

20¹

50

15%/500

30%/1000

10%/250

1750

1.5

31

15

60

8.5%/1000

70%/500

20%/250

1750

1.4

33

23

70

10%/1000

70%/500

20%/250

1750

1.4

29

22

80

11.4%/1000

70%/500

20%/250

1750

1.4

25

18

90

11.4%/1000

70%/500

20%/100
20%/250

1850

1.3

25

28

100

15%/1000

70%/500

10%/250
20%/250

2000

1.5

25

27

1) Nutritional Goals: 1.2-1.5 g protein/kg/day; 25-35kcal/kg (inc. protein); 15-30% kcal as lipids.
2) Does not include glycerol calories contained in lipid emulsion.

Total Parenteral Nutrition Support during Chemotherapy

In malnourished patients receiving chemotherapy, TPN induces improvements in body weight which is important for successful treatment at the optimal schedule although TPN can improve some nutritional parameters, the final outcome on mortality and morbidity when given in conjunction with effective chemotherapy is inconclusive. In reviewing eight prospective randomized clinical trials involving the use of TPN in patients undergoing chemotherapy, the majority showed no advantage in overall survival in those receiving nutritional support. However, the combination of drugs used for chemotherapy were ineffective. Only one study showed an increased survival of squamous cell lung cancer patients who were receiving parenteral nutrition support. Two additional meta-analyses showed TPN provides no added benefit in survival, tumor response, or chemotherapy toxicity in cancer patients undergoing chemotherapy. In summary, the provision of TPN during chemotherapy should be reserved for those patients with hypoalbuminemia or weight loss of greater than 10% who are responsive to prescribed dose and schedule of chemotherapy.

Total Parenteral Nutrition Support during Allogenic Bone Marrow Transplantation

Bone marrow transplantation requires intensive chemotherapy and often radiation leading to esophagitis and enteritis, resulting in severe malnutrition. It produced negative nitrogen balances and a greater loss of lean body mass than body weight or fat mass. Weisdorf reported increased survival and decreased relapse in those patients who received TPN compared to control subjects. These results suggest that among patients receiving bone marrow transplants, those who cannot eat for a prolonged period, particularly if they are severely malnourished, may benefit from TPN. A prospective randomized study by Szeluga showed no differences in survival between TPN and enteral nutrition support in bone marrow transplant recipients.

Precautions

Before administering total parenteral nutrition,

  • tell your doctor and pharmacist if you are allergic to any drugs.
  • tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially dexamathasone (Decadron); medications for diabetes, high blood pressure, or heart disease; prednisone; tetracycline; and vitamins.
  • tell your doctor if you have or have ever had diabetes or heart, kidney, liver, lung, or Addison's disease.
  • tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding, so that the risks and benefits of receiving TPN can be discussed. If you continue to receive TPN while you are pregnant or breast-feeding, your doctor may change the combination of sugar, protein, fat, and other elements. 1

Side effects

Although side effects from total parenteral nutrition are not common, they can occur. Tell your health care provider if any of these symptoms are severe or do not go away:

mouth sores, poor night vision, skin changes, fever or chills, stomach pain, difficulty breathing, rapid weight gain or loss, increased urination, upset stomach, vomiting, confusion,or memory loss,muscle weakness, twitching, or cramps, swelling of the hands, feet, or legs, thirst ,fatigue ,changes in heartbeat ,tingling in the hands or feet ,jumpy reflexes ,convulsions or seizures.

Signs of infection

The symptoms of a catheter-related infection (an infection where the needle enters vein or skin:

Tenderness, warmth ,irritation ,drainage ,redness ,swelling ,pain

Metabolic complications of TPN

Several complications of TPN are common and relate to the constituents used and duration of therapy. Excessive carbohydrate administration may contribute to hepatic steatosis. Adults receiving TPN can have periportal fat infiltration, canalicular plugging, and centrilobular cholestasis. Elevated gamma-glutamyltransferase (GGT), alkaline phosphatase, and hyperbilirubinemia may reflect cholestasis, and less commonly cholelithiasis or cholecystitis. Hepatic dysfunction, which manifests initially as cholestasis, appears to be more common in children. The incidence is highest in premature infants (23%-50%) and in children with a surgical abdomen or peritonitis. The severity of hepatic dysfunction may range from mild elevations in transaminases and bilirubin to frank hepatic failure. Clearly, the duration of TPN is a major factor. Uncomplicated TPN-related cholestasis usually resolves within 1 to 4 months after the cessation of TPN and the institution of EN. TPN associated liver disease is usually a relatively minor problem in the acute management of critically ill infants and children, but can be an issue with long term patients. The use of cholecystokinin to improve bile flow may offer some benefit prior to the development of end-stage liver disease . 

REFERENCES

www.doctoronline.nhs.uk

2.  www.worldhistory.com/wiki/T/Total-parenteral-nutrition.htm

3 .www.medlineplus/druginformation/totalparenteralnutrition.htm

4.Hodes JE. Hepatic failure in infants on total parenteral nutrition (TPN): clinical and histopathologic observations. J. Pediatr Surg 1982;17:463-8.

5. Sinatra FR. Cholestasis in infancy and childhood. Curr Probl Pediatr. 1982;12:1-54.

6. Teitelbaum DH. Treatment of parenteral nutrition-associated cholestasis with cholecystokinin-octapeptide. J Pediatr Surg 1995;30:1082-5.

7.Rintala RJ. Total parenteral nutrition-associated cholestasis in surgical neonates may be reversed by intravenous cholecystokinin: a preliminary report. J Pediatr Surg 1995;30:827-30.

8. Samuel Chan,George L. Blackburn, Nutrition Support Service, Department of Surgery,Beth Israel Deaconess Medical Center/Harvard Medical School Boston, Massachusetts

9. Blackburn, G.L., and Giardiello, F.M. (1995). Developing strategies for intervention/prevention trials of individuals at risk of hereditary colon cancer. JNCI Monogr. 17, 107-110.

10. Maliakkal, R.J., Blackburn, G.L., Willcutts, H.D. et al. (1992). Optimal design of clinical outcome studies in nutrition and cancer: Future directions. JPEN, J.Parenter.Enteral.Nutr. 16, 112S-116S.

11. Driscoll, D.F., and Blackburn, G.L. (1990). Total parenteral nutrition. A review of its current status in hospitalized patients, and the need for patient-specific feeding. Drugs 40, 346-363

12. Weisdorf, S.A., Lysne, J., Wind, D. et al. (1987). Positive effect of prophylactic total parenteral nutrition on long-term outcome of bone marrow transplantation. Transplantation 43, 833-838.

13. Szeluga, D.J., Stuart, R.K., Brookmeyer, R., Utermoblen, V., and Santos, G.W. (1987). Nutritional support of bone marrow transplant recipients: A prospective, randomized clinical trial comparing total parenteral nutrition to an enteral feeding program. Cancer Res. 47, 3309-3316.

14. www.worldhistory.com/wiki/T/Total-parenteral-nutrition.htm

About Authors

Mrs. Rupali A. Patil

Corresponding Author Mrs. Rupali A. Patil is working as Lecturer in Pharmacology at MAEER’S Maharashtra Institute of Pharmacy, Pune-411038. Her email address is ruupalipatil@rediffmail.com

Dr. Parakh S.R

Dr. Parakh S.R. is Principal and Prof. In Pharmaceutics at MAEER’S Maharashtra Institute of Pharmacy, Pune-411038.


Jagdale Swati C
Jagdale Swati C. is working as Assistant Professor in Pharmaceutics at MAEER’S Maharashtra Institute of Pharmacy, Pune-411038.

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Chetan Patil's picture

Chetan Patil
M.Pharm.(Q.A.)

Chetan Patil
M.Pharm.(Q.A.)