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 ID: 360418
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Slide1
Parenteral Nutrition in Critical Illness
Judy WONG
Dietitian
PMHSlide2
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 StudySlide3
What is Parenteral NutritionParenteral nutrition refers to the infusion of intravenous nutrition formula into the bloodstream
DAA, 2011Slide4
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.,2009Slide5
Access of parenteral nutritionSlide6
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
c
an be
>
900mOsm/L
M
ore suitable for volume-sensitive patients (e.g. patients with heart, renal or liver problem)Slide7
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 initiatedSlide8
Energy requirementMacronutrient requirements
Micronutrient requirements
Requirements of critically ill patientsSlide9
Requirements during metabolic stress
Adequate energy is essential for metabolically stressed patients
Avoidance of overfeeding in the critically ill patients is important
E
xcess calories can result in complications:
hyperglycaemia
hepatic
steatosis
excess CO
2
production (exacerbate respiratory insufficiency / prolong weaning from mechanical ventilation)
Krause’s, 2012Slide10
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)Slide11
Calculations of requirementEstimation of energy requirement
= Basal Metabolic Rate (BMR)
+ Activity Factor
+ Stress FactorSlide12
Calculations of requirementEstimation of energy requirement
Basal Metabolic Rate (BMR) estimation (Schofield Equation):
Age
Male
Female
18-29
15.1 x W + 692
14.8
x W + 487
30-59
11.5
x W +873
8.3 x
W + 846
60-74
11.9 x W + 700
9.2 x W
+ 687
Over 75
8.4 x W + 821
9.8 x W + 624
W = body weight in kg; Calculated BMR in kilocalorie (kcal)
Department of Health (UK), 1991Slide13
Activity Factors
Activity
Level
Bedbound, immobile
+10%
Bedbound, mobile
or sitting
+
15-20%
Mobile, on ward
+25%
Todorovic
and
Micklewright
(2004)Slide14
Stress Factors
Condition
Stress factor (%
BMR)
Brain Injury
Acute
(ventilated and sedated)
Recovery
0-30
5-50
Cerebral
Haemorrhage
30
CVA
5
COPD
15-20
Infection
25-45
Intensive
Care
Ventilated
Septic
0-10
20-60
Leukaemia
25-34
Pancreatitis
Chronic
Acute
3
10
Sepsis / Abscess
20
Solid
Tumours0-20Transplantation20SurgeryUncomplicatedComplicated5-2025-40
Todorovic
and
Micklewright
(2004)Slide15
Macronutrients RequirementsSlide16
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, 2012Slide17
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, 2011Slide18
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, 2011Slide19
Micronutrient RequirementsSlide20
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
, 2014Slide21
MicronutrientsVitamins and trace elements addition via the addition of:
Soluvit
® N
Vitalipid
N® Adult
Addamel
® NSlide22
Soluvit® N
provide the daily requirement of water-soluble vitamins
A
vial (10ml)
=
normal daily requirement of water-soluble vitamins
Fresenius
KabiSlide23
Vitalipid N® Adult
meet the daily requirement of the fat-soluble vitamins A, D
2
, E and K
1
in adults
&
children aged 11 years or older
O
ne ampoule (10ml)
=
daily intake of fat-soluble vitamins
Contraindications: hypersensitivity to egg protein / soybean
/
peanut protein
Fresenius
KabiSlide24
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
KabiSlide25
Refeeding SyndromeSlide26
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
electrolye
flucatuations
involving metabolic,
haemodynamic
& neuromuscular problems
Stanga
, Z et al
(2008)
Krause’s (2012)
Mehanna
et al (2008)Slide27
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)Slide28
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
F
or very malnourished patients, start with 5kcal/kg/day, with cardiac monitoring
NICE guideline (2006)Slide29
Refeeding syndrome
3. How to prevent?
Vitamin supplementation: before and for the first 10 days of
refeeding
Oral, enteral or IV supplements of
K
, PO
4
,
Ca
& Mg should be given unless blood levels are
before
refeeding
NICE guideline (2006)Slide30
PN formulationsSlide31
Currently available formulations in PMHSlide32
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
F
ish oil
other multi-lipids (a mixture of soy, MCT, olive and fish oil)
DAA, 2011
ASPEN Position Paper, 2012Slide33
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)Slide34
Soybean oil + MCTExamples:
Nutriflex
Lipid Special,
Nutriflex
Lipid Plus
S
oybean oil : MCT = 50 : 50
MCT:
readily oxidizable
Safe source of lipid
p
ro-inflammatory propertiesSlide35
Soybean oil + Olive oil
Examples:
Oliclinomel
O
live 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)Slide36
Multi-lipidsExamples:
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)Slide37
How to choose?Slide38
How to choose?
Based on calculated energy / protein requirements
Disease Specific:
Renal / Cardiac diseases
Vs
Fluid content of PN
BGA /
pCO2
Vs
CHO contentSlide39
Initiation of parenteral nutritionSlide40
Initiation of Parenteral Nutrition
Ensure the selected formulation is
compatible with the route
of parenteral nutrition (central / peripheral)
Choice of parenteral nutrition regimen
C
ontinuous PN (Q24H)
Cyclic / intermittent (Q16H/Q12H)
Ensure final infusion rate DOES NOT exceed the
maximum infusion rate
for fat and CHOSlide41
Case StudySlide42
Case Study
Background Information
KC, 57 year-old male, admitted to PMH on 5 Aug 2013
Admission Diagnosis: Malnutrition
Past Medical History: HT,
a
naemia
,
Ca
cardia
with
oseophago-gastrectomy
, short bowel syndrome, CHB
Relevant Medications:
Aminoleban
EN (1 sachet),
Entecavir
, Vitamin K
1
, Slow K, Vitamin B complexSlide43
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)Slide44
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
Slide45
Case Study
Formula selection:
Peripheral access =
Kabiven
Peripheral
Plan to start with small infusion rate and grade up as toleratedSlide46
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)Slide47
One Month later (5 Sept 2013)Slide48
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 daySlide49
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)Slide50
One month later
Recommendation:
Nutriflex
Lipid Special (+
Addamel
N /
Vitalipid
N Adult /
Soluvit
N)
Start with 20ml/
hr
x 24hr, gradually step up to 52ml/
hr
x 24hr (~1475kcal, 72g protein)Slide51
10 months since first admissionSlide52
10 months later
Date
Weight (kg)
BMI (kgm
-2
)
6/8/2013
37.6
12.4
11/12/2013
41.2
13.6
15/1/2014
44.9
14.8
22/1/2014
46
15.2
29/1/2014
48.1
15.9
5/2/2014
48.4
16.0
11/2/2014
48.8
16.1
26/2/2014
49
16.2
17/3/2014
50
16.5
24/3/2014
50.8
16.831/3/20145116.83/6/2014
54.5kg
18.0Slide53
10 months laterLaboratory Values:
Alb
36
, LFT normal, Cr 121
BO normal (once per day)
Oral Intake improved significantly: providing majority of nutrition orally (~1800kcal, 55g protein)Slide54
10 months later
PN:
Continuously titrating with oral intake
Previously:
Nutriflex
Lipid Special (+ trace elements) 300ml/day (354kcal, 17g protein)
Discussion with case MO:
protein provision
Now:
Kabiven
Peripheral 1440ml (+trace elements) 500ml/day (347kcal, 12g protein)
Total: (oral + PN) = (~2100-2200kcal, ~67g protein)Slide55
Q & A SessionSlide56
References
Stanga
, Z et al. Nutrition in clinical practice – the
refeeding
syndrome: illustrative cases and guidelines for prevention and treatment.
Eur
J
Clin
Nutr
2008; 62: 687-94
Mehanna
HM,
Moledina
J, Travis J.
Refeeding
syndrome: what it is, and how to prevent and treat it. BMJ 2008; 336: 1495-8
Singer P, Berger MM, Van den
Berghe
G, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care.
Clin
Nutr
2009: 28: 387-400
Casaer
MP,
Ven
den
Berghe G. Nutrition in the Acute Phase of Critical Illness. N Engl J Med 2014:370: 1227-35Thomas B, Bishop J. Manual of dietetic practice, 4th edition.2007. Blackwell Publishing. P 71-79, p.858-860A.S.P.E.N. Position Paper: Clinical Role of Alternative Intravenous Fat Emulsions. Nutr Clin Pract
2012 27: 150-192Mahan L.K., Escott-Stump S., Raymond J.L. Krause’s Food and the Nutrition Care Process. 13
th
edition. 2012. Elsevier Saunders. p307-321
Parenteral Nutrition Manual for Adults in Health Care Facilities, DAA 2011Slide57
Ireton-Jones Energy Equations
Spontaneously breathing patients:
EEE(s) = 629 – 11 (A) + 25 (W) – 609 (O)
Ventilator-dependent patients:
EEE(v) = 1784 – 11 (A) + 5 (W) + 244 (G) + 239 (T) + 804 (B)
EEE = Estimated Energy Expenditure (kcal/day) s = spontaneously breathing v= ventilator-dependent
O = Presence of obesity: >30% above ideal body weight or BMI > 27 (0 = absent, 1 = present)
A = Age (years) W = Weight (kg) G = Gender (0 = female, 1 = male)
T = Trauma diagnosis (0 = absent, 1 = present) B = Burn diagnosis (0 = absent, 1 = present)