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    Anthropometric assessment in the form of height-weight ratio and total body surface area gives a rather crude assessment.

    Serum albumin and transferrin levels are readily assessable biochemical parameters and have been extensively used in clinical practice. Retinol-binding protein and thyroxin-binding globulin also reflect visceral reserves but are rarely available clinically.

    Total lymphocytic count not only assesses the immunological status but is also reflective of visceral protein reserves. Immunological status can be further assessed by delayed cutaneous hypersensitivity to PPD and candida antigens.

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    A combination of these factors is highly predictive of outcome in terms of morbidity and mortality or survival. Nutritional Requirements and Delivery of TPN The delivery of TPN is via a large bore central venous catheter placed in the superior vena cava through the subclavian or the internal jugular vein.

    Strict asepsis is to be observed during the placement of the catheter. A chest radiograph should be taken prior to the commencement of feeding to confirm the position of the catheter-tip and to exclude traumatic pneumothorax, the commonest complication related to catheter placement. The catheter should be flushed with dilute heparin daily, to avoid catheter thrombosis.

    With proper care, a central catheter can be maintained for several days or even weeks for the delivery of TPN. While energy requirements can be calculated by the Harris-Benedict equation or the Long's modification of the same [ 9 ], in practice the institution of TPN is not so complicated. The therapy is now well standardized, yet it allows a fair deal of freedom to the treating physician.

    However, certain basic principles must be adhered to. The entire TPN requirement for the day should be constituted in the hospital pharmacy under strict aseptic conditions. Lipid emulsions are not only an important source of energy, but also prevent development of essential fatty acid deficiency.

    While there are several special formulations available for specific clinical situations, an outline of basic TPN solution is given below [ 10 ]. Compensations should be made for additional losses e. Total energy requirement may vary considerably between to or more calories daily. Proteins: Protein requirement varies from 1. The ratio of nitrogen to calories should be 1: — Branched-chain amino acids have been recommended as an integral part of TPN.

    However their benefits have so far not been conclusively proved. Electrolytes: Daily maintenance requirements of sodium are 1—1. Micronutrients: Trace elements are an important component of TPN.

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