Indications for total parenteral nutrition in the hospitalized patient: A prospective review of evolving practice

The indications for initiating total parenteral nutrition (TPN) were prospe ctively evaluated in 100 consecutive patients at a tertiary referral hospit al with a long-standing Nutritional Support Service to illustrate the reaso ns why the parenteral route was chosen at this unique institution in terms of patient population. Sixty male and 40 female patients, average age 59 +/ - 17 years (range 22-86 years), were classified a priori as to the underlyi ng reasons for initiation of TPN. The study was conducted by a Nutrition Su pport Service at this hospital without pediatric, trauma, or burn services, specializing in the care of patients with diabetes mellitus. Of the 100 pat ients, 63% were from the surgical service; 24% had diabetes mellitus. Their mean weight (118 +/- 29% of ideal), body mass index (25 +/- 6 kg/m(2)), an d serum albumin (2.8 +/- 0.7 g/dL) indicated a reasonable body composition with a moderate systemic inflammatory response. Six patients received preop erative TPN for an average of 5 +/- 3 days with a variety of diagnoses incl uding malignancy, Crohn's disease, bowel obstruction, and gastrointestinal bleeding. The underlying reasons for initiating nutritional support were re lated to three factors that largely determine the need for involuntary feed ing: preexisting protein calorie malnutrition, actual or anticipated semist arvation for a prolonged period, and the presence of a systemic inflammator y response. The choice of TPN was based on anticipated or proven intoleranc e to full enteral feeding. The duration of time time before initiation of T PN postoperatively was 6 +/- 5 days, which reflects our policy that initial ly well-nourished patients who are experiencing a systemic inflammatory res ponse should not undergo more than 5 to 7 days of inadequate feeding. The d uration of TPN overall was 11 +/- 10 days, which primarily illustrates the dramatic reduction in length of hospital stay that has occurred throughout the health care system and the willingness to provide TPN in alternative se ttings including transitional care units, rehabilitation hospitals, and for short-tel-m care, the patient's home. The most common specific reasons ide ntified for initiating TPN rather than enteral nutrition were ileus (25%), an underlying acid-base or electrolyte/mineral disorder (13%) requiring cor rection and the convenience of TPN because a central venous catheter was in place (12%). The usual indication for nutritional support at this tertiary referral and specialty hospital was actual or impending protein calorie ma lnutrition. TPN was chosen for a variety of reasons related to actual or an ticipated tolerance to enteral feeding. This audit demonstrates that our TP N practice has evolved in relation to lime of initiation and duration of fe eding, which reflect a clearer appreciation of the risks and benefits of TP N. (J. Nutr. Biochem. 10:2-7, 1999) (C) Elsevier Science Inc. 1999. All rig hts reserved.