1 / 57

Parenteral Nutrition in Critical Illness

Parenteral Nutrition in Critical Illness. Judy WONG Dietitian PMH. Overview. What is parenteral nutrition Selection Criteria of parenteral nutrition Parenteral nutrition access Requirements of critically ill patients Refeeding Syndrome Parenteral Nutrition formulations & How to choose

rue
Télécharger la présentation

Parenteral Nutrition in Critical Illness

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Parenteral Nutrition in Critical Illness Judy WONG Dietitian PMH

  2. Overview • What is parenteral nutrition • Selection Criteria of parenteral nutrition • Parenteral nutrition access • Requirements of critically ill patients • Refeeding Syndrome • Parenteral Nutrition formulations & How to choose • Case Study

  3. What is Parenteral Nutrition • Parenteral nutrition refers to the infusion of intravenous nutrition formula into the bloodstream DAA, 2011

  4. Selection Criteria for Parenteral Nutrition • Should be used in patients who are or will become malnourished, and • Who do not have sufficient gastrointestinal function to be able to restore / maintain nutritional status McClave et al.,2009

  5. Access of parenteral nutrition

  6. Access of parenteral nutrition • Central parenteral nutrition (CPN) • To large, high blood flow vein (e.g. superior vena cava) • For long term parenteral nutrition • Central Parenteral Nutrition solution osmolarity can be > 900mOsm/L • More suitable for volume-sensitive patients (e.g. patients with heart, renal or liver problem)

  7. Access of parenteral nutrition • Peripheral parenteral nutrition (PPN) • Catheter tip placement in a small vein (e.g. forearm) • PeripherallParenteral Nutrition solution osmolarity< 900 mOsm/L • Usually do not fully meet nutrition requirements • Use as: • Supplemental feeding • Transition to oral/enteral feeding • Temporary PN when central access has not been initiated

  8. Energy requirementMacronutrient requirementsMicronutrient requirements Requirements of critically ill patients

  9. Requirements during metabolic stress • Adequate energy is essential for metabolically stressed patients • Avoidance of overfeeding in the critically ill patients is important • Excess calories can result in complications: • hyperglycaemia • hepatic steatosis • excess CO2 production (exacerbate respiratory insufficiency / prolong weaning from mechanical ventilation) Krause’s, 2012

  10. How much energy should critically ill patients receive? • ESPEN Guidelines 2009: • “as close as possible to the energy expenditure in order to decrease negative energy balance” (Grade B); • “in the absence of indirect calorimetry, ICU patients should receive 25kcal/kg/day increasing to target over the next 2-3 days” (Grade C) Singer P et al (2009)

  11. Calculations of requirement • Estimation of energy requirement = Basal Metabolic Rate (BMR)+ Activity Factor + Stress Factor

  12. Calculations of requirement • Estimation of energy requirement • Basal Metabolic Rate (BMR) estimation (Schofield Equation): W = body weight in kg; Calculated BMR in kilocalorie (kcal) Department of Health (UK), 1991

  13. Activity Factors Todorovic and Micklewright (2004)

  14. Stress Factors Todorovic and Micklewright (2004)

  15. Macronutrients Requirements

  16. Macronutrient requirements Protein • depending on the baseline nutritional status, degree of injury and metabolic demand, or any abnormal losses (e.g. open wound or burned skin) • Varies between 0.9-1.5g/kg/day for various conditions Krause’s, 2012

  17. Macronutrient requirements Carbohydrate • Ensures that protein is not catabolised for energy during metabolism • Excessive administration: • hyperglycaemia • hepatic abnormalities • ventilatory drives • Maximum infusion rate of carbohydrate: <5mg/minute/kg body weight DAA, 2011

  18. Macronutrient requirements Fat • ~ 10% of calories/day from fat provide 2% to 4% of calories from linoleic acid (LA) in order to prevent Essential Fatty Acid Deficiency • Soybean and safflower oils: rich sources of LA • LA: pro-inflammatory & immunosuppressive • Maximum infusion rate of fat: <0.11g/hour/kg body weight DAA, 2011

  19. Micronutrient Requirements

  20. Micronutrient requirements • Ready-made Parenteral Nutritional Products are free of vitamins and trace elements • The addition of vitamins and trace elements are always required ESPEN Guidelines 2009; Casaer & Van den Berghe, 2014

  21. Micronutrients • Vitamins and trace elements addition via the addition of: • Soluvit® N • Vitalipid N® Adult • Addamel® N

  22. Soluvit® N • provide the daily requirement of water-soluble vitamins • A vial (10ml) = normal daily requirement of water-soluble vitamins Fresenius Kabi

  23. Vitalipid N® Adult • meet the daily requirement of the fat-soluble vitamins A, D2, E and K1 in adults & children aged 11 years or older • One ampoule (10ml) = daily intake of fat-soluble vitamins • Contraindications: hypersensitivity to egg protein / soybean / peanut protein Fresenius Kabi

  24. Addamel® N • covers basal or moderately  trace elements needs • The recommended daily does for adult patients with basal or moderately elevated needs is 10ml (one ampoule) • Contraindications: in patients with blocked bile flow, and manganese levels must be checked if treatment lasts > 4 weeks Fresenius Kabi

  25. Refeeding Syndrome

  26. Refeeding Syndrome • What is refeeding syndrome? • A metabolic disorder as a consequence of too aggressive administration of nutrition after a prolonged inadequate nutrition supply • Characterized by hypophosphataemia, hypomagnesiumaemia and hypokalaemia; with excessive sodium and fluid retention • May cause potentially lethal electrolyeflucatuations involving metabolic, haemodynamic & neuromuscular problems Stanga, Z et al(2008) Krause’s (2012) Mehanna et al (2008)

  27. Refeeding Syndrome 2. Who is at risk? • Meet ANY of the criteria: • BMI < 16kgm-2 • NPO ≥10 days (or with minimal nutrition intake > 10 days) • Weight loss > 15% in 3 to 6 months • Hypophosphataemia, hypokalaemia, hypomagnesaemia Stanga, Z et al (2008)

  28. Refeeding syndrome 3. How to prevent? • Start feeding at < 50% of energy requirement, rate can then be  if no refeeding problem detected • For high risk of refeeding: start with 10kcal/kg/day • For very malnourished patients, start with 5kcal/kg/day, with cardiac monitoring NICE guideline (2006)

  29. Refeeding syndrome 3. How to prevent? • Vitamin supplementation: before and for the first 10 days of refeeding • Oral, enteral or IV supplements of K, PO4, Ca & Mg should be given unless blood levels are before refeeding NICE guideline (2006)

  30. PN formulations

  31. Currently available formulations in PMH

  32. PN Formulations • Besides carbohydrate and protein content varies, type of fat emulsions used also differ • Most commonly used is soybean oil based fat emulsion • Alternatively fat emulsions: • Soybean oil + MCT • Soybean oil + Olive Oil • Fish oil • other multi-lipids (a mixture of soy, MCT, olive and fish oil) DAA, 2011 ASPEN Position Paper, 2012

  33. Soybean oil • Examples: Kabiven Central, Kabiven Peripheral • The most commonly used fat emulsion type • Linoleic Acid (LA, n-6) comprise a 50% of total fatty acid profile • Alpha Linolenic Acid (ALA, n-3) about 10% of total fatty acid profile •  omega 6 content  drawback due to its pro-inflammatory potential ASPEN Position Paper (2012)

  34. Soybean oil + MCT • Examples: Nutriflex Lipid Special, Nutriflex Lipid Plus • Soybean oil : MCT = 50 : 50 • MCT: • readily oxidizable • Safe source of lipid • pro-inflammatory properties

  35. Soybean oil + Olive oil • Examples: Oliclinomel • Olive oil : soybean oil = 80 : 20 •  the content of omega 6 in formulation by ~ 75% • Higher vitamin E content for its anti-oxidating properties ASPEN Position Paper (2012)

  36. Multi-lipids • Examples: SMOF Kabiven • A mixture of soybean oil, MCT, olive oil and fish oil in a ratio of 30 : 30 : 30 : 10 • Fish Oil: • rich in omega 3(anti-inflammatory properties) ASPEN Position Paper (2012)

  37. How to choose?

  38. How to choose? • Based on calculated energy / protein requirements • Disease Specific: • Renal / Cardiac diseases Vs Fluid content of PN • BGA / pCO2 Vs CHO content

  39. Initiation of parenteral nutrition

  40. Initiation of Parenteral Nutrition • Ensure the selected formulation is compatible with the route of parenteral nutrition (central / peripheral) • Choice of parenteral nutrition regimen • Continuous PN (Q24H) • Cyclic / intermittent (Q16H/Q12H) • Ensure final infusion rate DOES NOT exceed the maximum infusion rate for fat and CHO

  41. Case Study

  42. Case Study Background Information • KC, 57 year-old male, admitted to PMH on 5 Aug 2013 • Admission Diagnosis: Malnutrition • Past Medical History: HT, anaemia, Cacardia with oseophago-gastrectomy, short bowel syndrome, CHB • Relevant Medications: Aminoleban EN (1 sachet), Entecavir, Vitamin K1, Slow K, Vitamin B complex

  43. Case Study • Anthropometry: • Height 1.74m • Weight 37.6kg • BMI 12.4kgm-2 • Ideal Body Weight: 56-69kg • Laboratory Values: • Spot glucose 3.3 Alb 17 ALP 357 ALT 194 • Wound x 1 (stage III)

  44. Case Study • Estimated energy requirement: ~ 2000-2100kcal (bedbound + wound + weight ) • Estimated protein requirement: ~56-69g per day • Route of nutrition: • Oral (as much as tolerated) • Peripheral parenteral nutrition

  45. Case Study • Formula selection: • Peripheral access = Kabiven Peripheral • Plan to start with small infusion rate and grade up as tolerated

  46. Case Study 2. Starting PN: • 30ml/hr x 16hrs Kabiven Peripheral (+ Addamel N / Vitalipid N Adult / Soluvit N) (~333kcal, 11g protein) • Gradually stepped up to 100ml/hr x 16hrs (~1167kcal, 37g protein) (Note: Maximum infusion rate: < 139ml/hr for 37.6kg)

  47. One Month later (5 Sept 2013)

  48. One month later • Laboratory values: Spot glu 5.7, Alb 13, ALP/ALT normal • Wound healed • Oral intake: ~200ml/meal • Stool: BOx1 per day • PICC (central line) to be inserted the next day

  49. One month later PN consideration: • To central formula (for more nutrition to meet requirement) • Per case MO, patient cannot tolerate excessive volume Nutriflex Lipid Special (1250ml/1475kcal/72g protein)

  50. One month later Recommendation: • Nutriflex Lipid Special (+ AddamelN / Vitalipid N Adult / Soluvit N) • Start with 20ml/hr x 24hr, gradually step up to 52ml/hr x 24hr (~1475kcal, 72g protein)

More Related