Back to the Basic: Parenteral Nutrition 101 .Disclosure Information Back to the Basic: Parenteral

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  • 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