PRESENTING: PN CASE STUDY

PRESENTING: PN CASE STUDY

ASPEN, ESPEN, SA

Lindie Mosehuus, RD SA

Spontaneous

Non-Traumatic

Hemoperitoneum

Hemo-

peritoneum

The blood accumulates in the

space between the inner lining of

the abdominal wall and the

internal abdominal organs

Presence of blood in the peritoneal

cavity

Spontaneous Non-Traumatic

Tumour associated haemorrhage

IatrogenicComplications of surgery/ Interventional procedure,

Anticoagulation therapy.

Gynaecologic condition

Ruptured ovarian cyst, Ectopic

pregnancy, HELP syndrome

Vascular legion

Aneurysm, pseudoaneurysm of

visceral artery

Symptoms

Severe

abdominal pain↓ Hct

levelsHypovolemic shock

(Rare)

Patient Background:

65 y/o Caucasian ♂

Married, Accountant

No previously reported medical history

Surgical history: Multiple Inguinal hernia repairs + Lipoma excision

Clinically appears to be well nourished and presents with est. N BMI

.

Hospitalisation- Day 1

ER + Abdo

minal

pain

Non

bloody

emesis

CT abd

+

pelvis

Spontaneous

Non-Traumatic

Hemoperitoneum

Tachyc

ardic +

hypo-

tensive

Required

blood T/F

Next step: Ex Lap

Omental resection

The omentum is a large fatty

structure which literally hangs

off the middle of your colon

and drapes over the

intestines inside the abdomen)

Repair of serosal tears

(thin membranes that cover

the walls and some organs of

the thoracic and abdominal

cavities)

Small bowel resection: part of

ileum resected, anastomosis of

remainder of ileum to Jejunum

Progression of Day 1

Pt

unsta

ble

Leave abd

open=

prevent CS

Wound

Vac

placed

Vacuum is placed over wound to draw out fluid and increase blood flow to the area.

Post-

op MIintubated

ventilated

= ICU

.


Patient more stable, went back to operating room to remove

VAC and close abdomen

Now back in ICU

Dietician called for nutritional intervention

Anthropometry

1.8 m

79 kg

BMI 24

No recent weight loss reported

Bio

ch

em

istr

y

Today (2nd day hospital

adm.)

Yesterday (1st day hospital adm.) Normal

Urea 16 ↑ 21 ↑ 2.8-7.2

Creatinine 200 ↑ 221 ↑ 59-104

Vasopressors 1 mcg/ kg/min 1.3 mcg/kg/min high dose

LFT’s N N -

Propofol dose 8 micrograms/kg/min 8 micrograms/kg/min High dose

Lactate (gas) 11 ↑ 11 ↑

CRP 150 ↑ 180 ↑ <5

Ca (corrected) 2.05 (2.15) 2.1-2.55

Mg - 0.8 0.73-1.06

PO4 - 0.83 0.81-1.45

K 5.1 5.3 ↑ 3.5-5.1

Clinical

Intubated

Ventilated

CVP line access

NGT free drainage @600 ml in last 20 hrs

Urine output < 0.5 ml/ kg

HGT’s 6-10mmol/L

MAP 60 mmHg

GCS 3

(False low as pt is sedated),

if not sedated properly 8

NRS 4

SOFA score 10

Diet history

Previously seems to be well nourished

2nd day NPO + possible poor oral intake +- 2 days prior to hospitalisation due to pain = 4 days poor/ no feeding

.

Nutrition Intervention

Interactive question:

Is this patient at risk for malnutrition?

a) Yes

b) No

ESPEN 2018 consensus guidelines ASPEN 2016 consensus guidelines

Patient medical history NRS 2002= >3 at risk/ >5 high risk

NUTRIC score >6 or > 5 if interleukin-6 not included (insufficient

data to calculate)

Unintentional weight loss Do not use albumin/ pre-albumin/ transferrin/ CRP/ TNF in critical

care setting

Decrease physical performance prior to ICU admission 57% of hospitalized patients with a BMI >25 show evidence of m

alnutrition. Patients with a BMI >30 have an OR of 1.5 for having

malnutrition (P =.02). The reasons for the surprisingly high rate of

malnutrition in obese patients may stem in part from unintentional

weight loss early after admission to the ICU and a lack of attentio

n from clinicians who misinterpret the high BMI to represent additi

onal nutrition reserves that protect the patient from insult.

Physical examination

General assessment of body composition, muscle mass, strength

Any patient staying in ICU > 48 hours

Mechanically ventilated

Underfed >5 days

Infected

Present with severe/ chronic disease

ESPEN Glim criteria: Severity grading of malnutrition stage 1 (moderate) and stage 2 (severe)

Phenotype Etiology

Weight loss (%) BMI Muscle mass Food intake, malabsorption or GI

symptoms

Disease burden/ inflammation

Stage 1 Moderat

e malnutrition

5-10% in last < 6 mo OR

10-20% > 6 mo

<20 if >70

<22 if > 70

<20 if > 70

Mild to moderate

deficit

Reduced intake of ER >2 weeks

/ moderate malabsorption/ GI sy

mptoms moderate

Acute disease/ injury / chronic

disease related

Stage 2 Severe

malnutrition

>10% within last 6 mo or

>20% in >6 mo

<18.5 if <70

<20 if >70

Severe deficit < 50% intake of ER/ severe mala

bsorption/ GI symptoms severe

Acute disease/ injury / chronic

disease related

.



Feeding route choice:

a) TPN

b) TPN and trickle feeds

c) Enteral feeds

ESPEN 2018 ASPEN 2016

EN within 48 hrs

Even after GI surgery/ After abdominal aortic surgery

Abdominal trauma when continuity of GI tract is confirmed/ restored

Receiving neuromuscular blocking agents

Patients with an open abdomen

Regardless of the presence of bowel sounds unless bowel ischemia /

obstruction is suspected in patients with diarrhoea

EN within 24-48 hrs in hemodynamic stable patient

+ bowel sounds/ passing flatus/ stool not required to

start EN

May give EN to patients on chronic, stable, low

dose vasopressors

Low dose EN if:

Intra-abdominal HPT without compartment syndrome- proceed with

caution

Start with low dose EN if shock controlled with fluids and vasopressors/

Inotropes- remain vigilant for bowel ischemia

EN


Delay EN if:

Tissue perfusion not reached (lactate high + ↑ vasopressors dose

MAP < 65)

Hypoxemia

bowel ischemia / obstruction is suspected in patients with

diarrhoea

Withhold EN if

MAP < 50 mmHg

Patients that require increasing amounts of nor-epinephrin

e/ Phenyl-epinephrine/ epinephrine/ dopamine to mainta

in hemodynamic stability


PN start within 3-7 days Withhold exclusive PN in low nutrition risk patients for first 7

days

SPN- unclear, 4-7 days (previous guidelines stated start on

day 3 if not meeting 60 % of requirements)

SPN- 7-10 days if not meeting 60% of protein and Energy

requirements

PN

TPN

Lactate high

Pt not on stable/ low dose

vasopressors + MAP low

Would likely not tolerate feed due

to poor blood perfusion to the gut

TPN + EN Trickle

feed

Atrophy of villi

Higher risk for refeeding the

longer we wait

High risk for ileus

Final decision: TPN only day 1. Perhaps re-evaluate mane for trickle

feeds.

Important to start with enteral feeds ASAP- high risk for ileus.

.


Energy requirement:

Name 2 things to consider when calculating TPN E req?

SA guidelines: Monitoring patient on TPN

du Toit et al, 2017

Suggested composition of parenteral multivitamin and trace-element product(Sriram & Lonshyng, 2009)

Micronutrient supplementation should begin as soon as parenteral nutrition is started and continued daily as its

role is crucial”. Berger & Shenkin, 2006


Lactate now ↓3; AKI- improved; CRP ↓90, PCT levels (bacterial infection)- < 0.5

Weaning adrenalin and propofol

Urine output ↑1 ml/g

No flatus, no bowel sounds;

BP 112/77 MAP 80

HGT’s= N

NGT drainage < 100 ml

Pt will be NPO from tonight for ? Extubating mane morning


Should we initiate enteral/ oral feeds: 4 days NPO + 2 days poor intake=6 days

a) Yes

b) No

Hospitalization- Day 3

Clamp

NGT

Start with

trickle

feeds

Continue

with PN +

PN

glutamine

Pt was extubated early

this morning. GCS 12,

propofol and adrenalin

stopped

Arginine containing formula @ 10ml/h

We suggest the routine use of

immune-modulating formula (contai

ning both arginine and fish oils)

in the SICU for the

postop patient who requires EN

Therapy (ASPEN, 2016)

SA weaning protocol

Intolerance

Abdominal distention

CRP increased to 110, Lactate 6

and HGT spikes observed. NGT

feeds were stopped as per surgeon

and TPN resumed

Hospitalization- Day 4

Ileus Stop NGTTPN +

Glutamine

X-Ray confirm As per surgeon Ileus was treated non-

operatively.

Bowel rest (2 days) +

hydration(as per surgeon)

Trickle feed

Weaning protocol

SA protocolEarly enteral nutrition NB

post op to prevent post-op

ileus, maintain intestinal

barriers, improve blood

flow and healing.

Interactive question

How would you manage HGT spikes in this patient

Know complications associated with TPN,

to identify early


Starting dose of EN when weaning a patient from TPN to EN

a) 5-9 ml/h

b) 10-20ml/h

c) 21-30 ml/h

Within how many days do you aim to be on full EN feeds?

a) 2 days

b) 3 days

c) 4 days

Suggested SA weaning protocolWhen considering weaning of patients from PN two outcomes should be considered:

1. Whether it is necessary for a patient to achieve full nutrition intake from an alternative route e.g. oral/enteral before PN is discontinued

2. Whether or not the clinical symptoms, which required the use of PN have sufficiently abated

Thank you

Reference list

Berger MM, Shenkin A. Vitamins and trace elements: practical aspects of supplementation. Nutrition. 2006 Sep; 22(9):952-5. PubMed PMID: 16928476

Du Toit AL, Blaauw R, Naiker N, van Niekerk L, de Lange C. National Parenteral Nutrition practice guidelines for adults. National Department of Health. 2017, 1-35

McClave SA, Taylor BE, RD, Martindale RG, Warren MM et al., Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J of Paren Enteral Nutr. 2016; Feb; 40(2): 159-211

Sriram K & Lonshyna VA. Micronutrient supplementation in Adult nutrition therapy: Practical considerations. J Paren Enteral Nutr 2009; 33: 548 – 562

Singer P, Berger MM, Blaser AR, Berger MM, et al., ESPEN Guidelines on clinical nutrition in the intensive care unit, Clinical Nutrition 2019, 1 – 32

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PRESENTING: PN CASE STUDY