First Things First (assess & treat for the following)

• Is TPN appropriate?
  • Indications:
    • Enteral nutrition always preferred
    • Nonfunctioning GI tract (malabsorption, massive small bowel resection, intractable nausea/vomiting/diarrhea, intestinal obstruction)
    • Moderate/severe stress
    • Severely malnourished
  • Contraindications
    • Functioning GI tract
    • Functioning GI tract anticipated in 5-7 days
    • Inability to gain venous access
    • Risks outweigh benefits (see Complications section)
    • Terminal illness/comfort measures only
• Which is better, central or peripheral parenteral nutrition?
  • Central parenteral nutrition: line tip in SVC
    • May be placed percutaneously via subclavian (preferred), internal jugular or femoral veins . A peripheral vein may be used to insert a long catheter (PICC, “long arm Groshong”).
    • May be placed surgically (Hickman, Port-a-cath, Groshong)
  • Peripheral parenteral nutrition: administered through a peripheral vein
    • Infused solution must be dilute (< 900 mOsm).
    • Difficult to meet nutritional needs if fluid restriction required
    • Short-term use only (< 10-14 days) because of increased risk of thrombophlebitis
    • Not intended for severely malnourished pts