The Value of TPN in Preoperative
Malnourished Patients
Benjamin Lou, MD
4/6/11
Introduction
• TPN (total parenteral nutrition)
– First practiced in Europe during 1946-54 French-Vietnam
War. (1)
– Described by Wilmore and Dudrick in 1968 in a infant with
intestinal atresia. (2)
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Acceptance as safe, life-saving intervention
Risks/Disadvantages
Previously accepted use of TPN questioned
Current literature favors enteral nutrition
Goal of nutritional therapy: preserve lean body mass,
maintain immune function, avert metabolic
complications (6)
Malnutrition
• May be present on admission, or develop during
hospitalization
• 50% of hospitalized patients: moderate malnutrition
(3-5)
• 5-10% severely malnourished (3-5)
• Rapid weight loss of >10% of normal body weight:
– Higher infectious complications (60% septic complications)
– Increased length of hospital stay
– Increased mortality
• Albumin <3.0 or poor nutritional status by Subjective
Global Assessment
– 3.5 to 4 fold higher postop complication rate (7)
Subjective Global Assessment
Nutritional Risk Index
• Screening tool to assess risk of complications
• Useful in pts undergoing noncardiac, abdominal
surgery.
• NRI= (1.519 x albumin) + (41.7 x present wt/usual wt)
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NRI
NRI
NRI
NRI
>100
97.5-100
83.5-97.5
<83.5
normal
mild malnutrition
moderate
severe
• Disadavantage: relies on weight (affected by volume
retention in cardiac, renal, hepatic dysfunction)
Identifying those at risk
• Lab markers:
– Serum Albumin < 3.0 g/dL
– Serum Transferrin <220 mg/dL
– Prealbumin/retinol binding protein
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Recent weight loss over 3 months of > 10% normal body weight.
Nitrogen balance determination
Indirect calorimetry
Midarm muscle circumference
Delayed hypersensitivity reactions to injected antigens
Functional impairment of ventilatory effort or muscle response by
electrical stimulation
• Various indices and equations for stratifying risk of
complications/mortality (PNI)
– Rely on heavily on Albumin
• #1: Physician history and physical examination (8)
Enteral vs TPN
• Enteral feedings preferred if tolerated.
– Lower risk
• Lower septic morbidity (burn/trauma)
• Lower intraabdominal abscess/pneumonia rates
– Prevents gut mucosal atrophy
– Maintains barrier function
– Normal gut flora/immmunocompetence
– Hepatic protein synthesis
– Lower cost (including complications)
TPN indications
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Nonfunctional GI tract
Gastrointestinal cutaneous fistulas
Congenital GI disorders
Short bowel syndrome
Acute radiation enteritis
Chronic obstruction/pseudoobstruction
Intractable diarrhea/emesis
Acute pancreatitis (severe, when intolerant of enteral)
Prolonged ileus
Motility disorders
Acute chemotherapy toxicity
Weight loss preliminary to major surgery
Perioperative Total Parenteral Nutrition in Surgical Patients
The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group*
N Engl J Med 1991; 325:525-532August 22, 1991
NEJM
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VA TPN cooperative study group
P= 395 malnourished patients
M
Laparotomy or noncardiac thoracotomy
Groups:
– TPN 7-15 days preoperatively + 3 days postop
– No TPN
• Monitored patients for 90 days postop
NEJM Results
• 30 day major complication rate similar. (25.5
vs 24.6%)
• 90 day mortality rate (13.4 vs 10.5%)
• Higher infectious complication rate in TPN
– 14.1 vs 6.4%
– For those with borderline or mild malnourishment
• Severely malnourished w/TPN (NRI <83.5)
– Lower noninfectious complications (5 v 43%)
– No increase in infectious complications
Indications for Periop Support (1)
• Emergent operation: no indication
– If anticipated NPO status >7 days: nutritional
support indicated immediately postop
– If suspected during OR: enteral access
considered, ie. Jejunostomy
• Elective operation:
– Unable to eat, operation delayed >5 days: TPN
– No delay, mild to mod malnourished: no TPN
– Severe malnourished, 5-10 d TPN preop
SCCM/ASPEN guidelines
• Guidelines by panel of Society of Critical Care Medicine
and American Society for Parenteral and Enteral Nutrition:
– offer basic recs supported by current review and analysis of
literature.
– Range from large randomized trials to case series/expert
opinion.
• Meant for adult medical and surgical critically ill patient
populations.
• Enteral nutrition is the preferred route.
– Well documented in numerous RCT: crit ill, trauma, burns, head
injury, major surg, acute pancreatitis.
– Reduced infectious morbidity
• Focus today will be their guidelines for Preop TPN use.
Indications for TPN
• No preop malnutrition, if enteral route not
available, NPO >7days
– Meta analysis Braunschwieg et al. (7 studies)
• No nutritional support: reduced infectious/overall
complications vs TPN in first 7-10 days.
– Sandstrom et al.
• NPO >14 days: higher mortality and extended LOS vs
TPN
• START TPN after 7 days (level IV/V evidence)
Inidications for TPN
• Preop malnutrition, enteral route not
available
– Recent weight loss >10-15% or <90% ideal body
weight
– Heyland et al. Fewer overall complications vs no
nutrition
– Braunschweig et al. Higher mortality and infection
rate in pts with no nutrition vs TPN
• Start TPN without delay (level II)
TPN indications
• Major upper GI surgery (esophagectomy,
gastrectomy, pancreatectomy, reoperative
abdominal surgery), enteral route unavailable
• Malnourished
– TPN start 5-7 days preoperatively and continue postop
• Postop
– If enteral route still unavailable after 5-7 days: start
TPN.
– TPN beneficial if duration of therapy >7 days
TPN in major upper GI surgery
• Critically ill pts: increased mortality and
complications with TPN vs no nutrition
• Surgical pts: no difference in mortality and
decreased complications with TPN
– Klein et al. (13 studies)
• Benefits with preop TPN x 7-10 days and postop.
• 10% decrease in infectious complications
– Postop TPN only: lose benefit
• Level I
Transitioning from TPN to Enteral
• Periodic repeated efforts: start enteral
nutrition.
• Tolerance of enteral nutrition: >60% caloric
requirements reached
– TPN may be stopped.
• Level V
References
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1)
Archer SB, Burnett RJ, Fischer JE. Current Uses and Abuses of Total Parenteral Nutrition.
Advances in Surgery Vol. 29: 165-189. 1996
2)
Wilmore DW, Dudrick SJ: Growth and development of an infant receiving all nutrients
exclusively by vein. JAMA 203:860-864, 1968.
3)
Bistrian BR, Blackburn GL, Hallowell E, et al: Protein status of general surgical patients.
JAMA 230: 858-860, 1974.
4)
Bistrian BR, Blackburn GL, Vitale J, et al: Prevalance of malnutrition in general medical
patients. JAMA 235: 1567-1570, 1976.
5)
Coats, KG, Morgan SL, Bartolucci AA, et al: Hospital-associated malnutrition: A reevaluation
12 years later. J Am Diet Assoc 93: 27-33, 1989.
6)
Buzby, et al. Perioperative Total Parenteral Nutrition in Surgical Patients. The Veterans
Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 1991; 325: 525-532.
7)
Detsky AS, Baker JP, Mendelson RA, et al. Evaluating the accuracy of nutritional assessment
techniques applied to hospitalized patients: Methodology and comparisions. JPEN J Parenter
Enteral Nutr 8: 153-159, 1984.
8)
Jeejeebhoy KN, Baker JP, Wolman SL, et al. Critical evaluation of the role of clinical
assessment and body composition studies in patients with malnutrition and after parenteral
nutrition. Am J Clin Nutrition 35: 1117-1127, 1982.