Transcript The Role of Parenteral Nutrition in Post

The Role of Parenteral Nutrition in
Post-Bariatric Surgery
Joseph Ybarra, PharmD, BCNSP
November 7, 2015
Obesity in the US
• Obesity BMI > 30
• Extreme obesity BMI > 40
• 35.7% adults are obese
• 6.3% adults have extreme obesity
• Men and women are equally obese (36%)
• Ethnic and racial groups
• African Americans 49.5%
• Native Hawaiians/Pacific Islanders 43.5%
• American Indians/Alaka Natives 39.9%
• Hispanics 39.1%
• Caucasian 34.3%
• Asian Americans 11.6%
http://www.niddk.nih.gov/health-information/health-statistics/Pages/overweightobesity-statistics.aspx
Obesity in the US
http://www.cdc.gov/obesity/data/prevalence-maps.html
Obesity-Related Comorbidities
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Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Obstructive sleep apnea
Obesity-hypoventilation syndrome
Pickwickian syndrome
Nonalcoholic fatty liver disease
Pseudotumor cerebri
Gastroesophageal reflux disease
Asthma
Venous stasis disease
Severe urinary incontinence
Debilitating arthritis
Endocr Pract. 2013 Mar-Apr;19(2):337-72.
Bariatric Surgery in the US
• Candidates?
• BMI ≥ 40 without excessive risk
• BMI ≥ 35 + ≥ 1 cormorbidities
• BMI 30-34.9 + DM or metabolic syndrome
• Other criteria
• Preoperative glycemic control optimized
• Fasting lipid panel
• Avoid pregnancy preoperative and 12-18 months postoperatively
• Stop estrogen therapies
• Cardiac testing (non-invasive)
• Tobacco cessation
• Psychosocial-behavioral evaluation
• Nutritional evaluation (including micronutrient measurements)
Endocr Pract. 2013 Mar-Apr;19(2):337-72.
Bariatric Surgery in the US
• Which procedure is best?
• Laparoscopic preferred over open procedures
• Not a clear consensus on which malabsorptive
surgery is optimal
• Adjustable gastric banding
• Sleeve gastrectomy
• Roux-en-Y gastric bypass
• Biliopancreatic diversion +/- duodenal switch
Endocr Pract. 2013 Mar-Apr;19(2):337-72.
Bariatric Surgery in the US
Bariatric Surgery in the US
Bariatric Surgery in the US
Bariatric Surgery in the US
Complications of Bariatric Surgery
• Ileus
• Short bowel syndrome (SBS)
• Fistulas
Ileus
• Impairment of the
gastrointestinal tract (GIT)
• Lack of motility
• Panintestinal
• Upper GIT
• Lower GIT
• Most common in pelvic
and abdominal surgeries
Short Bowel Syndrome
• Defined as < 120-200 cm of
viable small bowel
• Causes
• Vascular insufficiency
• Inflammatory bowel disease
• Malignancy
• Necrotic bowel as a surgical
complication
• Resolution
• May take up to 2 years for
intestinal adaptation
Fistulas (Fistulae)
• Enterocutaneous fistula (ECF)
• Communication between an abscess
or hollow organ to another part of the
body
• Causes
• Post-operative
• Mesh erosion
• Diverticulitis
• Radiation
• “High output” > 500 mL/day
• Resolution
• Spontaneous closure < 25%
• Delayed by malnutrition and
infection
Complications of Bariatric Surgery - Management
• Ileus, fistula
• Bowel rest
• Enteral nutrition (EN)
• Parenteral nutrition (PN)
• SBS
• Modified diets +/- EN
• “Designer IV fluids”
• PN
• Medications (Gattex®)
• Transplantation
Parenteral Nutrition - The Beginnings
• Discover of the circulation of blood - 1616
• First infusion of olive oil, vinegar salts, and urine
(canine) - 1678
• First infusion of IV cottonseed oil - 1895
• First infusion of amino acids - 1940
• First patient supported by home PN (6 months) - 1968
Parenteral Nutrition - The Beginnings
• Stanley Dudrick, MD, FACS
• Goal (or obsession): completely
support a dog from birth to death on
PN
• Research gave way to:
• Internal resistors on IV pumps
• In-line filters
• Injectable fat-soluble vitamins
• Nutrition support team
• A.S.P.E.N.
• First home PN company (Houston)
Dudrick SJ. JPEN 2005;29:272-287
Parenteral Nutrition… How Much To Feed?
• Protein requirements
• 1.5-2.1 grams/kg of
ideal body weight
(IBW)
• Additional amounts
may be needed
• Caloric requirements
Endocr Pract. 2013 Mar-Apr;19(2):337-72.
PN Saves Lives… BUT…
• Micronutrient imbalances
• Fluid provision
/dehydration
• Hyperglycemia
• Hypoglycemia
Micronutrients
• Common Deficiencies
• Vitamin A
• Vitamin D
• B vitamins (B1/thiamine, B6, B12)
• Folate (folic acid)
• Calcium
• Iron
• Copper
• Zinc
Micronutrients
• Why?
• Baseline deficiencies / malnutrition
• Non-compliance to prescribed
multivitamin regimen
• Standard provision of multiple
vitamins and trace elements provided
in PN
• Medication shortages
Micronutrients
• Addressing medication shortages
• “Gray market” (CAUTION and avoid)
• Imported products (Glycophos® and
Addamel-N®)
• Rationing
• Oral alternatives
Micronutrients
• Monitoring
• All Surgeries: baseline; 3 months post-surgery, 6-9 months post-surgery,
yearly
• B vitamins and methylmalonic acid
• Vitamin D (25-hydroxyvitamin D)
• Calcium w/ intact PTH
• Folate
• Iron studies (serum iron, TIBC, ferritin, CBC)
• Biliopancreatic diversion: yearly
• Vitamin K
• Roux-en-Y, Biliopancreatic diversion: yearly
• Vitamin A
• Zinc
• Copper
Hydration
• Dehydration an issue
• High ostomy output
• High output ECFs
• Wound output (also a protein issue)
• Intractable vomiting
• Inadequate provision in PN
Adapted from Parrish CR. Practical Gastroenterology. Sept 2005. pp. 68.
Adapted from Marino PL. The ICU Book. 2nd ed. 2007. pp. 235.
Hydration
Body
Fluid
Na
(mEq/L)
K
(mEq/L)
HCO3
(mEq/L)
H
(mEq/L)
Cl
(mEq/L)
pH
Volume
per 24 hr
Sweat
30-50
5
-
-
45-55
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0.5
Saliva
45
20
60
-
44
7
0.5-1.5
Gastric
40-65
10
-
90
100-140
2
2-4
Pancreas
135-155
5
70-90
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55-75
8
1
Bile
135-155
5
35-50
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80-110
7
1.5
Jejunum/i
leum
100-120
10
50-70
-
50-60
7
1.8
Diarrhea
25-50
35-60
30-45
-
20-40
-
-
Normal
stool
5
10
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-
10
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0.1
• Hydration
Adapted from Parrish CR. Practical Gastroenterology. Sept 2005. pp. 68.
Hydration
Fluid
Na
(mEq/L)
Cl
(mEq/L)
K
(mEq/L)
Ca
(mEq/L)
Mg
(mEq/L)
Dextrose
(g/L)
Buffer
(mEq/L)
pH
Osmol.
(mosm/L)
Plasma
140
103
4
5
2
Variable Bicarb. (25)
7.4
290
D5W/D10W
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-
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50 / 100
-
4.7 / 4.6
250 / 505
0.45% NaCl
77
77
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-
-
-
-
5.6
154
LR
130
109
4
3
-
-
Lactate
(28)
6.4
273
0.9% NaCl
154
154
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-
-
-
-
5.7
308
7.4
294
5.8
1030
Plasmalyte-A
140
98
5
-
3
-
Acetate
(27)
+
Gluconate
(23)
3% NaCl
513
513
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-
-
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-
Adapted from Marino PL. The ICU Book. 2nd ed. 2007. pp. 235.
Hydration
• PN provision
• Outside PN provision
• IV fluids on a PRN basis (in addition to PN)
• On demand electrolyte bolus
• Laboratory monitoring
• Strict input / output
• Chem-7 + Magnesium + Phosphorus
Adapted from Parrish CR. Practical Gastroenterology. Sept 2005. pp. 68.
Adapted from Marino PL. The ICU Book. 2nd ed. 2007. pp. 235.
Hyperglycemia
• Causes
• IV replacement fluids outside PN (containing D5W)
• Improper cycling regimen
• Starting at “high rate” with no taper up
• Maybe sign of infection
• Suggestions
• Remove dextrose from IV fluids
• Cycle with “taper up”
• Cycle over a longer period of time
• Check blood cultures (x2 different sites) along with CBC +
physical exam
Hyperglycemia
• Dextrose in PN and Insulin
• Anticipated glucose intolerance = 0.1-0.15
units/g dextrose
• Obese / DM2 = 0.2 units/g dextrose
• DM1 = 0.05 units/g dextrose
• Insulin outside PN?
• Check “off PN” blood glucose (if cycled)
• Consider if > 0.3 units/g dextrose needed in PN
Hypoglycemia
• Insulin management
• Occurs with rapid weight loss
• Occurs with renal failure
• Abrupt discontinuation of PN may lead to
“rebound hypoglycemia”
• Important to “taper down” when cycling
PN
• Decrease by ~50% of the
maintenance rate x 1 hour
• Check blood glucose 30-60 minutes
after infusion stops
• May need to do a two-step taper
Questions? …any one…?
The Role of Parenteral Nutrition in
Post-Bariatric Surgery
Joseph Ybarra, PharmD, BCNSP
November 7, 2015