Gastrointestinal Involvement

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TPN – Total Parenteral Nutrition

by Dana Lovvorn (originally published in "Scleroderma Voice," Summer 1998 #3)

Total parenteral nutrition (TPN) consists of intravenous (IV) nutrition pumped through a major vein rather than taking food by mouth. Approximately 145,000 people in the U.S. today require this type of sustenance. Most administer the TPN to themselves, or with the help of a caregiver, during several hours at night. The task has been made easier by the patient being able to wear a lightweight backpack carrying the IV bag and its pump, rather than being hooked up to a hospital IV pole.

Dana Lovvorn

Who Needs TPN?

Individuals who need TPN are those whose digestive systems fail to absorb food taken by mouth. They experience serious weight loss, heartburn, vomiting, bloating, and alternating constipation and diarrhea on a continual basis. Typical medications have failed to alleviate those symptoms so that one can function in a normal manner.

Some reasons why a person fails to absorb oral nutrition are:

1. AIDS (Chemotherapy)
2. Cystic Fibrosis
3. Cerebral Vascular accident (stroke)
4. Ischemic bowel disease
5. Cancer
6. Colitis
7. Premature birth
8. Genetic anomaly
9. Trauma
10. Pseudo obstruction
11. Crohn's Disease
12. Malabsorption
13. Tracheal blockage or removal
14. Malrotation of the gut
15. Surgery
16. Reflux
17. Malnutrition
18. Chronic adhesive obstruction
19. Scleroderma

How is TPN administered?

1. A doctor, after determining TPN is absolutely necessary, requests that a surgeon place a permanent catheter in a patient's chest. The two types of catheters used
   most frequently in the U.S. are the Groshong (saline flush) and the Hickman (heparin flush). Usually, the line is placed in the subclavian vein near the center of the chest and follows the vein through the left atrium of the heart up into the left shoulder. A portion of the catheter line extends outside the body near the breastbone so an IV can be hooked to it.
2. FORMULATION
   A home health agency or a hospital prepares the IV bags for use by the patient. A dietician specializing in TPN formulation works with the patient's physician to determine what nutrients in varying proportions are prepared based on the patient's ideal weight in ratio to height. Most formulas consist of dextrose and sterile water with mineral and lipids dissolved in the solution. Vitamins and medications are usually added to the container by injection prior to immediate use.
   Labs are drawn once a month to determine if deficiencies exist in the formulas or if infection is present. Noncontamination of the nutrient is vital; the container bags are prepared in sterile conditions. For example, a laminar air flow wall blows a continuous contaminant-free breeze over the ingredients toward the lab technicians who are suited, capped, masked, gloved, and booted while they mix the formulations.
3. TRAINING
   Training the patient to use TPN is also a service provided by either the hospital or the home health agency. With home health care, a nurse visits the client's home to show the individual or caregiver how to "feed" the IV bag and "hook up" to the person. The nurse assesses the ability of both the individual and/or caregiver to comply with the necessities of keeping the area sterile where the additives are injected, and the site of the catheter clean and free of infection. Thereafter, one would call the home health agency for nursing visits which would need to be preapproved by the insurance company of the patient.

What are the problems with TPN?

METABOLIC DIFFICULTIES

1. Infection at catheter site
2. Infection of blood stream from unsanitary practice
3. Contaminated tubing, IV solution, heparin, or saline
4. Exposure to illness
   a) Outside body – cold, flu, chicken pox
   b) Inside body – wound, dental abscess, urinal tract infection
5. Hyperglycemia – fluids infused too fast
6. Hypoglycemia – fluids stopped without tapering down
7. Fluid/electrolytic/mineral imbalance
   a) Loss of water and mineral due to diarrhea, vomiting
   b) Irregular infusing
   c) Imbalance of minerals due to lack of formulation based on individual needs

MECHANICAL DIFFICULTIES

1. Air embolism – air in line
2. Blood in catheter
3. Cracked tubing or clave
4. Catheter clot – poor flushing technique
5. Pump or power failure
6. Ignorance of process

What is the cost of TPN?

More than the metabolic and mechanical risks associated with TPN, cost remains the greatest negative factor. A hospital may charge $2,000 just to place the catheter in the patient in day surgery. Home health agencies charge the patient's insurance or Medicare from $3,000 to $6,000 per week for the nutrition. Medicare has a set amount (about $1400 per week) that it will pay; then a secondary insurance may add another $350 or so per week. If a person is without Medicare or a very good health insurance, other avenues of payment will have to be pursued.

What are the advantages of TPN?

First, and most important, as a person who's used TPN for two years, I am still alive. Second, I am usually free of the bloating and pain I once experienced. Third, I have regained my ideal weight and feel better. I don't catch illnesses as easily because I am not on the edge nutritionally. Fourth, I can still be "normal" during the ten hours (8:00 a.m.–6:00 p.m.) I am not "hooked up." I can even eat a little at the dinner table just to be sociable. It's sort of interesting to be a "hydroponic human," ready for the 21st century.

Most of this information was obtained through my personal experience and from:

TPN Support Group
The Oley Foundation
214 Hun Memorial, A-23
Albany Medical Center
Albany, New York 12208-3278
(518) 262-5079 or (800) 776-OLEY
Fax (518) 262-5528