Unconventional use of Total Parental Nutrition in Patients with Gastrointestinal Barriers to Enteral Nutritional Supplementation

Traditionally in a long-term acute care facility the use of total parental nutrition (TPN) is indicated for patients who fail enteral tube feeding, have an extended postoperative ‘nothing by mouth’ status or diminished gastrointestinal function or access. An unconventional approach was initiated to aggressively supplement patients who had barriers to traditional enteral supplementation. Continuous TPN infusions were formulated based on patient’s metabolic requirements in collaboration with registered dietician (RD). In the following scenarios, within three weeks of therapy, the average wound surface area decreased 52.5%, with the exception of one patient. In the outlying patient, there was noticeable improvement of quality of wound bed tissue. All patients experienced improvement in granulating tissue and ability for autolytic debridement. 

Case #1 patient presented with complex abdominal wall wound with known high output enterocutaneous fistula (ECF). Identified barrier for enteral tube feeding (ETF) was high output fistula.

Case #2 patient presented with large wound surface area exceeding 1600cm squared. Amount of protein rich wound exudate lost exceeded the patient’s ability to consume protein requirements for wound healing.

Case #3 patient presented with complex abdominal wall wound with known inoperable high output ECF.

Case #4 patient presented with large complex abdominal wall wound, with copious amounts of wound exudate. Barrier to ETF was frequent nausea and vomiting.

Case #5 patient with large abdominal wall wound dehiscence. Barrier to ETF, identified as patient inability to follow or tolerate duotube placement.

Unconventional use of TPN may need to be re-evaluated when developing plan of care for patients who require additional nutritional support to optimize wound healing. The patient scenarios presented here demonstrate significant improvements in wound size within three weeks of TPN support. In collaboration with RD it is suggested that patients be evaluated for short term duration of TPN therapy to expedite wound outcomes.