ABSTRACT

Introduction .................................................................................................................................... 416 Patient Selection ............................................................................................................................. 416 TPN Indications ............................................................................................................................. 418 Relative TPN Contraindications .................................................................................................... 420 Venous Access ................................................................................................................................ 421 Peripheral Access ........................................................................................................................... 421 Central Venous Access ................................................................................................................... 422 Central Venous Positioning ............................................................................................................ 423 Peripherally Inserted Central Catheter Lines .................................................................................424 Specialized TPN Catheters.............................................................................................................424 Challenge of Initiating TPN in Severely Malnourished Individuals .............................................. 425

Refeeding Syndrome ................................................................................................................. 425 Wernicke’s Syndrome ............................................................................................................... 426 Beriberi ...................................................................................................................................... 427 TPN Admixture ......................................................................................................................... 427

Components of TPN Solutions ...................................................................................................... 428 Dextrose .................................................................................................................................... 428 Lipids......................................................................................................................................... 429 Protein ....................................................................................................................................... 430 Electrolytes ................................................................................................................................ 431

Recommended Range of Electrolytes for TPN .............................................................................. 432 Vitamins ......................................................................................................................................... 433 Trace Elements ............................................................................................................................... 434 Osmolarity ...................................................................................................................................... 435 Writing the TPN Order .................................................................................................................. 436 Complications ................................................................................................................................ 437

Mechanical Complications ........................................................................................................ 437 Metabolic Complications .......................................................................................................... 439 Fluid and Electrolyte Disturbances ........................................................................................... 439 Abnormal Glucose Metabolism ................................................................................................ 439 Hypertriglyceridemia, EFAD, and Hepatic Dysfunction ..........................................................440 Metabolic Bone Disease ............................................................................................................ 441 GI Atrophy ................................................................................................................................442 Gastric Hyperacidity .................................................................................................................442 Infectious Complications ..........................................................................................................442

It would not be appropriate to write a book on metabolic medicine and surgery without including a chapter on nutritional support of hospitalized patients. This therapy is one of the transformative modalities that have dened the specialty. The complexity of the required formulas and the potential for metabolic complications created a need for specialists who were willing to take on the challenge of caring for patients requiring specialized nutritional support. Furthermore, the development of individualized home enteral and parenteral nutrition methods and techniques for patients requiring long-term ambulatory nutrition support has become a major daily activity for practitioners in the eld.