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ÐSigns of abnormal gut function (complete intestinal obstruction, mesenteric ischemia, bowel Þstula).
ÐPatients cannot consume adequate amounts of nutrients by enteral feeding.
ÐThey are not expected to be able to eat orally by 3Ð7 days and are malnourished.
Step 12: Select the route of total parenteral nutrition (TPN)
TPN can be provided by peripheral or central route:
¥Peripheral (partial or supplemental) parenteral nutrition:
ÐMinimizes cost and complications of the central catheter
ÐCan provide supplemental calories and protein not met by enteral route
ÐPhlebitis, requires frequent site rotations and ßuid overload
¥TPN by central route:
ÐPreferably a multilumen catheter with a single lumen dedicated to TPN.
ÐTPN being delivered as an Òall-in-oneÓ solution as a commercially available standard solution, or made-to-order solution from a pharmacist-based mixing center.
ÐSupplementing parenteral glutamine to the TPN formula is known to reduce infectious complication, length of ICU stay, and mortality in burn and trauma patients.
Step 13: Monitor patients on parenteral nutrition
¥This consists of clinical examination, ßuid balance, catheter care, and blood glucose monitoring.
¥Renal, liver, and lipid proÞles should be measured weekly.
Step 14: Look for complications of TPN
¥Mechanical complications:
ÐRelated to vascular access technique
ÐVenous thrombosis
ÐCatheter occlusion
¥Metabolic complications:
ÐHyper-/hypoglycemia
ÐElectrolyte abnormalities
ÐAcidÐbase disorders
ÐHyperlipidemia
ÐSteatosis
¥Infectious complications
Suggested Reading
1.McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G, A.S.P.E.N. Board of Directors, American College of Critical Care Medicine, Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine
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(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr. 2009;33(3):277Ð316.
2.Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, GrifÞths R, Kreyman G, Leverve X, Pichard C, et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009;28(4):387Ð400.
Recent comprehensive guidelines on parenteral nutrition
3.Kreymann KG, Berger MM, Deutz NE, et al. ESPEN Guidelines on Enteral Nutrition: intensive care. Clin Nutr. 2006;25:210Ð23.
Recent comprehensive guidelines on enteral nutrition
4.Heyland DK, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr. 2003;27(5):355Ð73.
Part V
Renal System
Raj Kumar Mani and Arghya Majumdar