Reflection – Total Parenteral Nutrition

I really enjoyed this rotation at SPH and learned so much from Linda and the rest of the team on how to manage total parenteral nutrition. During this week, the team also had a new gastroenterology fellow and dietitian intern starting and it was a nice experience to be learning and working together with them!

With the help of Linda, I was able to build on a systematic approach to working up and assessing patients for TPN:

  1. Identify if there is an indication to TPN
    1. Surgery progress notes/reports (e.g. length of bowel resected) and imaging often provide the indication for TPN (e.g. anastomotic leak)
      1. Generally don’t give “pre-operative TPN”, but there are exceptions to this (e.g. had a patient who lost ~20kg over the last yr and surgery wanted pre-op TPN for malnutrition)
    2. This will also help you identify how to assess when your patient should be off TPN!
      1. Generally ideally would like to see pts tolerate solid foods for 24 hours prior to coming off TPN…generally TPN → PO intake and if can’t tolerate PO → EN (unless in ICU, generally don’t go from TPN → EN)
  2. If TPN indicated, assess the risk for refeeding syndrome and nutrition status
  3. Information gathering:
    1. current weight (assess fluid status → is this a dry or wet weight?)
      1. Calculate BMI, IBW and do adjBW if overweight
    2. usual weight at home
    3. weight change
    4. nutrition status
      1. intake during hospital admission
      2. intake prior to hospital admission
      3. signs of muscle wasting
    5. PMHx
      1. hx of organ failure (kidney, liver, cardiac)
      2. diabetes
    6. IV maintenance fluids and replacement fluids
      1. Provides you an idea of their volume status, tolerance to fluids and need for electrolyte replacements
      2. Check how long they have been on it and whether they have been any recent rate changes
    7. IV access
    8. Inputs and outputs
      1. Consider what patient is losing (e.g. diarrhea, vomiting, NG suction output, stoma output, urine output) + insensible losses
      2. Diarrhea → lose bicarb, sodium, chloride
      3. Vomiting → lose chloride
    9. Electrolytes → should get a baseline Mg and PO4 prior to starting TPN
  4. Order any electrolyte replacement orders
    1. TPN changes and starts tonight (reach the wards from VGH at 1830h)
    2. Electrolyte replacements would be given prior to TPN start

General monitoring parameters:

  • Main Labs: Na, K, Ca, Phos, Mg, urea, sCr, glucose
    • Other labs: bicarb, Cl, alb, prealbumin, LFTs
  • Weights today and then q Mon + Th
  • Ins and outs
    • Can choose to order strict ins and outs – good to specify if want to record PO intake even if you specify “strict”
    • If no ins and outs → checking with patient to get a sense of that (e.g. frequency and volume of diarrhea, vomiting, etc.)
  • Calorie counts if progressing with diet
  • Plan with diet (decided by surgery)
  • Plan with surgery
  • s/s associated with indication for TPN → e.g. vomiting, presence of gas, abdominal discomfort, tolerance to PO intake

Practical pearls:

  • when changing orders, write delta signs to any change (helps pharmacy identify if there are any unintended mistakes)
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