Indications for PN

PN can be a lifesaving therapy in patients with intestinal failure, but the oral or enteral route is preferred when providing nutrition support therapy ("when the gut works, use it"). Compared with PN, enteral nutrition is associated with lower risk of hyperglycemia and fewer infectious complications (e.g., pneumonia, intra-abdominal abs-

cess, and catheter-related infections). ' However, if used appropriately (i.e., in patients with altered intestinal function or when the intestine cannot be used), PN can be safe, effective, and improves nutrient delivery. Indications for PN are listed in Table 1 2

100-1. ' More detailed recommendations on appropriate PN indications in specific disease states, as well as when to initiate PN, can be found in the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Guidelines for the Use of Parenteral and Enteral Nutrition.1 More recently, A.S.P.E.N. and the Society of Critical Care Medicine (SCCM) published detailed guidelines for nutrition support therapy in critically ill adult patients, including patients undergoing major upper GI surgical procedures.

Table 100-1 Indications for PNaè

• Bowel obstruction

• Physical/mechanical (e.g., tumor compressing intestinal lumen)

• Functional (e.g., postoperative ileus)

• Major small bowel resection (e.g., short-bowel syndrome)

• Adult patients with less than 100 cm small bowel distal to the ligament of Treitz without a colon

• Adult patients with less than 50 cm of small bowel if the colon is intact

• Diffuse peritonitis

• GI fistulas if enteral nutrition cannot be provided above or below the fistula

• Pancreatitis—if patients have failed enteral nutrition beyond the ligament of Treitz or cannot receive enteral nutrition (e.g., due to intestinal obstruction)

• Severe intractable vomiting

• Severe intractable diarrhea

• Preoperative nutrition support in patients with moderate to severe malnutrition who cannot tolerate enteral nutrition and in whom surgery can be delayed safely for at least 7 days a When anticipated that adequate oral or enteral nutrition will not be possible for approximately 7 days or more, and if anticipated that PN will be used for approximately 7 days or more.

b In patients with evidence of malnutrition, nutrition support therapy should be initiated as soon as possible (e.g., within 24-48 hours of hospital admission) after the patient has been resuscitated.

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