Parenteral Nutrition in Critical Illness
Download
Report
Transcript 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
Case Study
What is Parenteral Nutrition
Parenteral nutrition refers to the infusion of intravenous
nutrition formula into the bloodstream
DAA, 2011
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
Access of parenteral nutrition
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)
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
Requirements of critically ill
patients
Energy requirement
Macronutrient requirements
Micronutrient requirements
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
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)
Calculations of requirement
Estimation of energy requirement
=
Basal Metabolic Rate (BMR) + Activity
Factor
+ Stress Factor
Calculations of requirement
Estimation 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), 1991
Activity Factors
Activity Level
Bedbound, immobile
Bedbound, mobile or sitting
Mobile, on ward
+10%
+ 15-20%
+25%
Todorovic and Micklewright (2004)
Stress Factors
Condition
Brain Injury
Acute (ventilated and sedated)
Recovery
Stress factor (%
BMR)
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 Tumours
0-20
Transplantation
20
Surgery
Uncomplicated
Complicated
5-20
25-40
Todorovic and Micklewright (2004)
Macronutrients Requirements
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
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
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
Micronutrient Requirements
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
Micronutrients
Vitamins and trace elements addition via the
addition of:
Soluvit® N
Vitalipid N® Adult
Addamel® N
Soluvit® N
provide the daily requirement of water-soluble
vitamins
A vial (10ml) = normal daily requirement of
water-soluble vitamins
Fresenius Kabi
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
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
Refeeding Syndrome
Refeeding Syndrome
1. 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)
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)
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)
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)
PN formulations
Currently available formulations in
PMH
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
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)
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
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)
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)
How to choose?
How to choose?
1. Based on calculated energy / protein requirements
2. Disease Specific:
Renal / Cardiac diseases Vs Fluid content of PN
BGA / pCO2 Vs CHO content
Initiation of parenteral nutrition
Initiation of Parenteral
Nutrition
1. Ensure the selected formulation is compatible with the
route of parenteral nutrition (central / peripheral)
2. Choice of parenteral nutrition regimen
Continuous PN (Q24H)
Cyclic / intermittent (Q16H/Q12H)
3. Ensure final infusion rate DOES NOT exceed the
maximum infusion rate for fat and CHO
Case Study
Case Study
Background Information
KC, 57 year-old male, admitted to PMH on 5 Aug 2013
Admission Diagnosis: Malnutrition
Past Medical History: HT, anaemia, Ca cardia with oseophagogastrectomy, short bowel syndrome, CHB
Relevant Medications: Aminoleban EN (1 sachet), Entecavir,
Vitamin K1, Slow K, Vitamin B complex
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)
Case Study
Estimated energy requirement:
~ 2000-2100kcal (bedbound + wound + weight )
Estimated protein requirement:
~56-69g per day
Route of nutrition:
1. Oral (as much as tolerated)
2. Peripheral parenteral nutrition
Case Study
1. Formula selection:
Peripheral access = Kabiven Peripheral
Plan to start with small infusion rate and grade up
as tolerated
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)
One Month later (5 Sept 2013)
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
One month later
PN consideration:
1. To central formula (for more nutrition to meet
requirement)
2. Per case MO, patient cannot tolerate excessive
volume
Nutriflex Lipid Special
(1250ml/1475kcal/72g protein)
One month later
Recommendation:
1. Nutriflex Lipid Special (+ Addamel N / Vitalipid N Adult
/ Soluvit N)
2. Start with 20ml/hr x 24hr, gradually step up to 52ml/hr
x 24hr (~1475kcal, 72g protein)
10 months since first admission
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
16.8
31/3/2014
51
16.8
3/6/2014
54.5kg
18.0
10 months later
Laboratory Values: Alb 36, LFT normal, Cr 121
BO normal (once per day)
Oral Intake improved significantly: providing majority of
nutrition orally (~1800kcal, 55g protein)
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)
Q & A Session
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: 1227-35
Thomas B, Bishop J. Manual of dietetic practice, 4th edition.2007. Blackwell Publishing.
P 71-79, p.858-860
A.S.P.E.N. Position Paper: Clinical Role of Alternative Intravenous Fat Emulsions. Nutr
Clin Pract 2012 27: 150-192
Mahan L.K., Escott-Stump S., Raymond J.L. Krause’s Food and the Nutrition Care
Process. 13th edition. 2012. Elsevier Saunders. p307-321
Parenteral Nutrition Manual for Adults in Health Care Facilities, DAA 2011
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)
T = Trauma diagnosis (0 = absent, 1 = present)
G = Gender (0 = female, 1 = male)
B = Burn diagnosis (0 = absent, 1 = present)