back to the basic: parenteral nutrition 101 .disclosure information back to the basic: parenteral

Back to the Basic: Parenteral Nutrition 101

Osama Tabbara

Disclosure Information

Back to the Basic: Parenteral Nutrition 101

Osama Tabbara

• I have no financial relationship to disclose.

AND

• I will not discuss off label use and/or investigational use in my presentation.

OR

• I will discuss the following off label use and/or investigational use in my presentation

3.5 years in Operation

JCIA

HIMSS 7

CCAD

• 364-bed facility (Max 480)

• Five centers of excellence: • Heart and Vascular

• Neurology

• Digestive Diseases

• Ophthalmology

• Respiratory & Critical Care

• 300 Physicians

• 120 Pharmacy Caregivers

• 1000 Nurses

• Cleveland Clinic USA • #2 in USA

• #1 in Cardiology x 24 years

IVPN Experts Network - Gulf Region

ivpngulf@googlegroups.com

•1251 IVPNeers from 400 hospitals

mailto:ivpngulf@googlegroups.com

• At the completion of this activity, you will be able to:

• Apply the basic physiology and biochemistry knowledge in understanding PN

• Interpret the biochemical markers with PN therapy

• Utilize scenarios to describe the complications of PN

- List References here

Learning Objectives

Multiple Choice Question:

Which lab marker is not important to monitor with Protein therapy

• Liver Function Tests

• BUN

• Dextrose

• Albumin

Polling/ Assessment Questions

Multiple Choice Question:

As classified by ISMP, which of the following are high Alert medications

• IV Potassium

• Insulin

• Heparin

• All of the above

Polling/ Assessment Questions [For Workshops]

Multiple Choice Question:

As per 2003 Survey, major errors with PN are originated:

• Protein

• Lipid

• Electrolytes

• Trace elements

Polling/ Assessment Questions [For Workshops]

Background

• PN represents of the most notable achievements of modern medicine

• PN can serve as a therapeutic modality for all age groups across the

health care continuum

• PN offers life-sustaining option in intestinal failure patients

• PN is artificial, expensive and associated with serious adverse

events10

K

Na

PO4, K, Mg

Insulin

C

N F

Mitochondria

ATP CO2

Vitamins

Tr.Elem.

Na-K-ATPase pump

K (135-145mEq/L)

K (3.5-5mEq/L)

Na (3.5-5mEq/L)

Na (135-145mEq/L)

Intravascular

Intracellular

Interstitial

Albumin

Na+ 10 mmol/L

K+ 155 mmol/L

Mg++ 26 mmol/L

PO4 -- 100 mmol/L

Protein 65 mmol/L

Na+ 142 mmol/L

K+ 4 mmol/L

Mg++ 1 mmol/L

PO4-- 1 mmol/L

Protein-- 16 mmol/L

Intravascular Intracellullar

3.5 L 30 L 10 L

Electrolyte Distribution

Dextrose

(100mg/dl)

(0.1%)

K:

60 mMol/L

K (3.5 – 5 mMol/L)

Dextrose

20%

SERUM PN

TPN replaced with PN: •PPN •CPN

Parenteral Nutrition

Central or Peripheral PN?

• Iso-Osmolar

• Physiological pH

• Sterile

What is Safe Admixture?

• SVC = 2000 ml/min

• SCV= 800ml/min

• Cephalic/Basilic: 40-95ml/min

• Partial support

• Phlebitis

• No surgery

• Low risk Sepsis

• Max Dextrose

• Neonate: 12.5%

• Peds: 10%

• Adult: 7.5%

• Max Protein: 2.5%

• Max osmolarity: 900/L

• Full support

• No Phlebitis

• Surgery

• Sepsis

• No Max for Dextrose

• No max for Protein

• No max osmolarity

PERIPHERAL CENTRAL

 No limit with CPN

 Maximum Dextrose with PPN: 7.5 - 12.5% in neonates

 Maximum Osmolarity with PPN: 900 - 1100 mOsm/L

What is Maximum Dextrose % and Osmolarity?

Central or Peripheral PN?

• Adel c/o severe pain at injection site; Phlebitis!

• RN called R.Ph. and asked if she can reduce the rate from 80ml to 40ml/hour to reduce venous intolerance!

• Does rate reduction reduce venous intolerance?

• NO!!!

• It is not the rate, it is the components!

• Hold PN and replace with D5W at same rate of PN

Considerations for Vascular Access for PPN

• Extravasation of nutrients can lead to tissue injury and

necrosis

• Risk Factors for Vascular Access

• Obesity

• Extremes in age (neonates and elderly)

• History of multiple venous cannulations

• History of IV drug use

Worthington P. JPEN, 2017;41:324-377

What is Phlebitis?

• Inflammation of vein (typically

endothelial cells)

• Most common causes: • High Osmolarity of IV solution

• Traumatic IV Placement

• Prolonged use of IV Site

Signs of Phlebitis

• Redness of the vein

• Swelling of the vein

• Tenderness over the vein

• Site warm to touch

• Sluggish flow of infusate

Preventing Peripheral PN Complications

• Maximum dextrose = 12.5%

• Maximum Protein = 2.5%

• Calculate final osmolarity (< 1100 mOsm/L)

• Minimize Na, K, Ca

• Add Heparin and Hydrocortisone

• Re-site the veins q 24-48 hours

• Maximize IV LIPID

Preventing Peripheral PN Complications

• Protect veins from phlebitis

• Safe at any dose with PPN

IV Lipid is Safe!

Scenario #1 Peripheral PN

• Mona is a 54-yr-old female, cachexia, severely malnourished

• Dx: Partial Esophageal Obstruction

• Can drink limited volume of oral formula

• PPN to be started

• Poor peripheral veins

QUESTION:

• How can we reduce the chance of phlebitis?

Phlebitis Prevention

• Frequent site changes

• Filter

• Hydrocortisone 6mg/L

• Heparin 1unit/ml

• Less K

• Less Ca

• Extra IV lipid

Tighe MJ., et al., JPEN 19:507-509, 1995 Anderson ADG., et al. Brit J Surg 90:1048-1054, 2003 Isaacs JW. et al., AJCN 30(4):552-9, 1977 Tighe MJ., et al., JPEN 19:507-509, 1995

Peripheral PN

• No standard Patient = No standard Osmolarity.

• To program your software, use a max of 1100 mOsm/L.

• If your patient is osteopenic, don’t go with peripheral PN.

• If a patient is severely hypokalemic, consider central line.

• Consider Heparin 0.5 -1 unit/ml with Peripheral PN unless contraindicated.

• Less Sodium, Less K, Less Ca with PN means better tolerance of peripheral PN.

• “Outside ICU, PPN is the choice for short courses with early PO/NG feeding”

How Much Calories?

The Science and Art of PN

FEED AS TOLERATED

“ A total caloric intake of 25 Kcal/kg usual body

weight per day appears to be adequate for

ALL patients”

Cerra FB, et al. “Applied nutrition in ICU patients: A consensus

Statement of ACCP”. Chest 1997 111:769-777

ACCP Recommendation

• 11-14 Kcal/kg actual BW • or 22-25 Kcal/kg IBW/d

• Protein at 2-2.5 g/kg IBW/d

SCCM & ASPEN Guidelines, Crit Care Med, 37(5), 2009

How Much Calories for Obese ICU Pts. (BMI > 30)?

Chwals WJ. New Horiz 2:147-155, 1994

Clein CG. Et al., J Am Diet Assoc 98:795-806, 1998

“Underfeeding is safer than overfeeding.”

• RQ = VCO2/ VO2

• Dextrose = 1

• Protein = 0.8

• Fat = 0.7

• Liponeogenesis= 8

RQ > 1 : Overfeeding

RQ = 0.825: Ideal

RQ < 0.82: Underfeeding

Melinda S. et al. JPEN Vol23, No5, p300, 1999

Indirect Calorimetry

Dextrose

• Basal metabolic rate Adults: 2mg/kg/min (150g)

Pediatrics: 6mg/kg/min (6g/kg/d)

• 50-60% of total calories

• 1g = 3.4 Kcal

• Watch Refeeding Syndrome

Dextrose

2003 Survey of PN Practices ASPEN Task Force: Error Results

•Electrolytes: 69%

•Dextrose/insulin: 31%

•Fat Emulsion 26%

Seres D. et al., JPEN 2006; 30:259-265

• 12-yr-old male with chronic intractable diarrhea, severe dehydration, severe malnutrition, cachexic, hypoglycemic

• Wt = 15 kg

• Admitted to ER

• Rx: Dextrose 15% @ 100ml/hr

• Few hours after, admitted to PICU with myocardial infarction

• What was wrong?

How much dextrose in DW