What happened to total parenteral nutrition? The disappearance of its use in a trauma intensive care unit.
BACKGROUND
Total parenteral nutrition (TPN) is associated with known costs, including the use of invasive procedures, which may be necessary to optimize care. Our purpose was to document TPN use in trauma patients over time as well as concurrent changes in TPN-associated complications.


METHODS
Retrospective analysis of all consecutive trauma patients admitted to the surgical intensive care unit during a period of 6 years from a Level I trauma center. Comparative cohorts and the matched case-control approaches were used to analyze the difference in outcomes between patients with and without TPN during hospitalization. Logistic regression model was used to compare the outcomes of the two groups of patients adjusting for significant risk factors. The McNemar's test was used to assess the differences in outcomes between the cases and their matched controls.


RESULTS
There were 2,964 patients admitted to the surgical intensive care unit during the 6-year period and 464 patients received TPN during their hospital course. TPN use decreased significantly from 26% in the year 2000 to 3% in 2005 (p < 0.0001). Excluding those who died in the first 72 hours, the mortality rate was significantly lower (5.4% no TPN vs. 10.2% TPN, p = 0.001) in patients who were managed without TPN. Complication rates (wound infection, dehiscence, line sepsis, bacteremia, sepsis, pneumonia, renal failure, acute respiratory distress syndrome, multiple organ dysfunction syndrome, deep venous thrombosis, pulmonary embolism) were significantly higher in patients that were managed with TPN. Multivariate analysis adjusting for abbreviated injury score, injury severity score, mechanism, admission year, dialysis, ventilator use, hollow viscous injury, and solid organ injury found that TPN use was still an independent risk factor for increased complications but not death. The matched case-control approach confirmed this finding. TPN use was also associated with increase intensive care unit and hospital length of stay.


CONCLUSIONS
The rate of TPN use has declined significantly from 26% to 3% during the 6-year period. The change in practice of minimizing TPN was concurrent with decreased complications and less hospital resource utilization without negatively impacting mortality.
Rhee
Peter
P
Trauma Division, University of Arizona, Phoenix, Arizona, USA. prhee@surgery.arizona.edu
Hadjizacharia
Pantelis
P
Trankiem
Christine
C
Chan
Linda
L
Salim
Ali
A
Brown
Carlos
C
Green
Donald
D
Inaba
Kenji
K
Law
Jenifer
J
Demetriades
Demetrios
D
D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010289:Parenteral Nutrition, Total / Q000009:adverse effects* / Q000191:economics / Q000639:trends; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000145:classification / Q000401:mortality / Q000628:therapy*