When is tpn appropriate for use in a surgery patient

Studies published in or earlier and studies with a lower methods score were associated with a significant reduction in complication rates and a trend to a reduction in death rate when compared with studies published after and studies with a higher methods score. There was no difference in studies that provided lipids as a component of TPN when compared with studies that did not. Studies that initiated TPN preoperatively demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies that initiated TPN postoperatively.

Conclusions: TPN does not influence the death rate of surgical patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by methodologic quality and year of publication.

In addition, a deeper understanding of the physiologic derangements in surgical nutritionally deficient patients allows the current clinical practitioners to identify patients preoperatively at risk for nutritionally related complications. Improvements in techniques and equipments as well as formulations have made parenteral nutrition safer and effective. The enteral route however, continues to be the optimal approach to aggressive supplemental nutrition in those patients capable of this mode of administration.

The current recommendation by the ESPN is to employ EN in all patients without contraindications who require nutritional support. The surgical patient with established malnutrition should begin aggressive nutrition at least 7—10 days prior to surgery.

Many patients may benefit from newer enteral formulations, such as those designed to enhance immune function Immunonutrition , as well as other disease-specific formulations, such as pulmonary insufficiency and renal dysfunction. National Center for Biotechnology Information , U.

Journal List Nutrients v. Published online Feb Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC.

Abstract Nutritional support of surgical and critically ill patients has undergone significant advances since when Studley demonstrated a direct relationship between pre-operative weight loss and operative mortality. Keywords: total parenteral nutrition, enteral nutrition, perioperative, immunonutrition.

Introduction Nutritional support of surgical and critically ill patients has undergone significant advances since when Studley demonstrated a direct relationship between preoperative weight loss and operative mortality [ 1 , 2 ].

Nutritional Assessment and Population at Risk for Perioperative Malnutrition Nutritional support is critical at a time of severe stress as the synthesis of acute phase proteins, white cells, fibroblasts, collagen, and other tissue components are required for proper wound healing and recovery [ 3 , 18 , 19 , 20 ]. Open in a separate window. Figure 1. Has the patient lost weight within the last 3 months?

Has the patient reduced dietary intake in the last week? Is the patient severely ill e. If the patient, e. Figure 2. Benefits Total parenteral nutrition has been shown to significantly affect postoperative outcomes in the severely malnourished patient group [ 1 , 43 ]. Table 2 The daily vitamin and trace element requirements for an adult receiving artificial nutrition. Table 3 Complications associated with total parenteral nutrition. Preoperative TPN Use If a patient is clinically deemed to be malnourished, then a 7—10 day course of preoperative nutrition is recommended [ 1 , 33 ].

Postoperative TPN Use It is expected that oral food consumption will resume promptly after surgical intervention [ 3 ]. Enteral Nutrition TPN has been the favored route of artificial nutrition until the early nineties; when the benefits of enteral nutrition EN became increasingly recognized [ 42 ].

Benefits Specific benefits to perioperative EN include a reduction in the incidence of postoperative infections and complications, as well as improved wound healing [ 1 , 6 , 18 , 51 , 52 ]. Risks and Complications of EN Generally complications of EN can be divided into gastrointestinal, mechanical, and metabolic complications.

Table 4 Complications associated with enteral nutrition. Preoperative Use As previously mentioned, patients found to be clinically malnourished, may require a 7—10 day course of preoperative nutrition [ 1 , 33 ]. Postoperative Use According to Woods et al. TPN vs. EN Overall, EN is associated with fewer complications, a decrease in the length of hospital stay, and a favorable cost-benefit analysis, compared to TPN [ 1 , 3 , 56 ].

Immunonutrition Immunonutrition IN is a conceptual framework which enhances enteral nutrition with arginine, omega 3 polyunsaturated fatty acids, glutamine or ribonucleic acid thought to enhance the immune fucntion [ 44 , 54 , 61 , 62 ].

Conclusion Since the first randomized trials comparing TPN to the then standard of care which was intravenous normal saline infusion, much progress in nutritional support has been made. Conflict of Interest The authors declare no conflict of interest. References 1. Ward N. Nutrition support to patients undergoing gastrointestinal surgery. Studley H. Percentage of weight loss: A basic indicator of surgical risk in patients with chronic peptic ulcer.

Braga M. Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Care Med. Palesty J. Cachexia, malnutrition, the refeeding syndrome, and lessons from Goldilocks. North Am. Bozzetti F. Nutritional support in oncologic patients: Where we are and where we are going. Perioperative nutritional management. Beattie A. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients.

Fujita T. Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer. Van Der Hulst R. Gut permeability, intestinal morphology, and nutritional depletion. Visser M. Rationale and design of a proof-of-concept trial investigating the effect of uninterrupted perioperative par enteral nutrition on amino acid profile, cardiomyocytes structure, and cardiac perfusion and metabolism of patients undergoing coronary artery bypass grafting.

Brady M. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst. Lennard T. The influence of surgical operations on components of the human immune system. Thorell A. Insulin resistance: A marker of surgical stress. Hausel J. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients.

Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Noblett S. Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial.

Colorectal Dis. Gustafsson U. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol. Braunschweig C. Enteral compared with parenteral nutrition: A meta-analysis. Hulsewe K. Liver protein and glutamine metabolism during cachexia.

Bollschweiler E. Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the oesophagus. Butters M. Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters. Correia M. Risk factors for malnutrition in patients undergoing gastroenterological and hernia surgery: An analysis of patients. Durkin M. Vascular surgical society of great britain and ireland: Contribution of malnutrition to postoperative morbidity in vascular surgical patients.

Haugen M. Assessment of nutritional status in patients with rheumatoid arthritis and osteoarthritis undergoing joint replacement surgery. Arthritis Care Res. Lumbers M. Nutritional status in elderly female hip fracture patients: Comparison with an age-matched home living group attending day centres.

Padillo F. Factors predicting nutritional derangements in patients with obstructive jaundice: Multivariate analysis. World J. Takagi K. Preoperative immunosuppression: Its relationship with high morbidity and mortality in patients receiving thoracic esophagectomy.

Kudsk K. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. JPEN J. Enteral Nutr. Kondrup J. ESPEN guidelines for nutrition screening Soeters P. Advances in understanding and assessing malnutrition. Giner M. In a correlation between malnutrition and poor outcome in critically ill patients still exists. Perioperative nutritional management in digestive tract surgery.

Torosian M. Perioperative nutrition support for patients undergoing gastrointestinal surgery: Critical analysis and recommendations. Jie B. Notify health care provider of any signs and symptoms of infection. Pneumothorax A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse.

Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia.

Interventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion. Air embolism An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open or removed without being clamped.

Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure. Interventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed.

Hyperglycemia Related to sudden increase in glucose after recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis again caused by insulin stimulation. This may cause fatty liver, increased CO 2 production, hypercapnea, and respiratory failure.

Interventions: Monitor blood sugar frequently QID four times per day , then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Refeeding syndrome Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts decreased phosphate, magnesium, and potassium in serum levels that may lead to widespread cellular dysfunction.

Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk.

The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia. Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly and titrated up for four to seven days.

Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment. Fluid excess or pulmonary edema Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia decreased O 2 sats. Interventions: Notify primary health care provider regarding change in condition. Patient may require IV medication, such as Lasix to remove excess fluids.

A decrease or discontinuation of IV fluids may also occur. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.

Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work. Common blood work includes CBC complete blood count , electrolytes with special attention to magnesium, potassium, and phosphate , liver enzymes total and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin , and renal function tests creatinine and urea.

Dextrose in TPN increases risk of infection. Assess for signs and symptoms of infections at site redness, tenderness, discharge and systemically fever, increased WBC, malaise. Dressing should be dry and intact. Daily or biweekly weights Monitor for evidence of edema or fluid overload.

Capillary or serum blood glucose levels QID 4 times a day capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult. Monitor intake and output Monitor and record every eight hours or as per agency policy. Monitor for signs and symptoms of fluid overload excessive weight gain by completing a cardiovascular and respiratory assessment.

Daily to weekly blood work Review lab values for increases and decreases out of normal range. Lab values include CBC, electrolytes, calcium, magnesium, phosphorus, potassium, glucose, albumin, BUN blood urea nitrogen , creatinine, triglycerides, and transferrin.

Mouth care Most patients will be NPO.