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The studies in this journal club represent the current state of TPN in the home setting.  All three articles pointed out that nutritional support methodology has changed over the years. Where the medical community used to firmly support the use of TPN as the feeding solution in most all cases of inadequate intake, enteral feeding has since become the preferred feeding method due to difficulties and complications associated with TPN. And with TPN's more recent positioning as a short term or last resort solution, the consensus now appears to be shifting back to the middle ground from these two extreme views.

With the advent of widespread home care it was only a matter of time before TPN was brought into the home setting. Not only did TPN allow patients to go home on a therapy that used to keep them in the hospital, it also allowed patients with conditions requiring intense follow-up care to go home. It also played a significant role in achieving better outcomes through increased compliance, more accurately meeting nutrition goals and giving more control to caregivers in the home setting.

And while TPN was recognized as being an ideal way to solve feeding associated problems, it has also been viewed to have certain problems.

While these complications deserve merit, the Jeejeebhoy study identifies several misconceptions about the safety and efficacy of TPN in the home setting; the Buchman study notes that when these complications are anticipated and managed appropriately, the nutritional advantages of TPN far outweigh the potential side effects.  And while enteral nutrition remains an integral part of the nutritional careplan for certain types of patients, TPN has its place as the preferred feeding method for many diagnoses (see Sundaram/Short Bowel Syndrome).

There are, in fact, many definitive uses for TPN where enteral feeds alone will not work. Bowel resection, short bowel syndrome and Crohn's Disease are three such examples. Jeejeebhoy points out that there has been a wealth of bad press on TPN that is unfounded. Reports from many leading medical institutions, anecdotal evidence from hospitals and home care, and clinical research have all added to this impression in recent years. Add in the changing reimbursement landscape, and TPN's reputation could only get tarnished. Perhaps Jeejeebhoy's most salient point is that TPN, in his findings, allowed nutritional therapy goals to be met where enteral nutrition tended to underfeed (for a variety of reasons). Buchman admits that using TPN is a more complicated therapy than enteral feeding. Overfeeding and risk of infection are the most common problems, followed by inadequate patient and family caregiver education. He also points out that even with this additional complexity TPN remains an excellent choice for feeding if the potential for these problems is anticipated. Careful patient management, good patient and caregiver education, close clinical follow-up and realistic expectations help to ensure a good outcome. In fact, Buchman gives some interesting M&M statistics highlighting TPN's effectiveness with Crohn's Disease and patients suffering from other benign intestinal disorders. Where patients used to die from the underlying disease, survival is now seen in the vast majority of patients. Sundaram specifically looks at short bowel syndrome. He makes the point that there is a definitive place for both parenteral and enteral therapy with SBS. Weaning the patient off TPN and onto enteral therapy is essential for the patient's recovery. He also states that before TPN was in common use, patients with SBS often died. Hence his opinion that parenteral and enteral therapy need to be used adjunctively.

From these three articles it becomes apparent that there is a wealth of research relating to TPN, its uses and current opinion regarding its use. It is the opinion of this author that TPN remains a viable, preferred feeding method in certain therapies and is a safe and effective alternative to enteral feeding when using the gut is not a good option. Home care in particular, with its inherent disadvantages (those of not being in a hospital setting with 24-hour nursing care and daily physician visits), seems a difficult place for a complex therapy but, as the authors demonstrated, these potential problems are avoidable with a little extra planning and care, and are far outweighed by the benefits TPN delivers.