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

• 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

NF

Mitochondria

ATPCO2

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

IntravascularIntracellullar

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, 1995Anderson ADG., et al. Brit J Surg 90:1048-1054, 2003Isaacs JW. et al., AJCN 30(4):552-9, 1977Tighe 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 rateAdults: 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 15% at 100 ml/hr?

•360g

•16mg/kg/minute

• Hypophosphatemia

• Myocardial ischemia

• Respiratory arrest

• Hypokalemia

• Arrythmia

Refeeding Syndrome

• Advance TPN gradually

• Increase K, Mg, PO4

• Minimize Na

• Extra Vitamins and Trace Elements

• Daily lab

Crook MA. et al., Nutrition 17:632, 2001

Solomon S. JPEN 14(1):90-97,1990

Marek PE. et al., Arch Surg 124:1325, 1996

Refeeding Syndrome: Prevention

• K: Up to 16 mMol/kg/day

• PO4: Up to 4 mMol/kg/day

• Mg: Up to 2 mMol/kg/day

Tabbara O., KFSHRC Refeeding Syndrome:

KFSHRC Experience

• Day 1: Start with 150g (2mg/kg/min)

• Day 2: increase by 50g every day up to 400 g/day

• Do not exceed 4mg/kg/minute

• More dextrose = more electrolytes

• Do not dose by concentration

Dextrose Dosing Guidelines

Dex 17% of 5 ml/hr

= 20.4gDex 18% of 4ml/hr

= 17.2g

Which Concentration Gives More Sugar per Day?

• BG

• Acid-Base

• LFTs

• Electrolytes

Monitor

• Avoid adding Insulin to PN bag

Safer PN

• Dex 20%

• AA 3g/kg/day

• K 4 mMol/kg/d

@ 6 ml/hr

• 9ml/hr of TPN = 50% extra of all nutrients + running out earlier

Catching-up Fluid with PN

• Abrupt discontinuation of PN

Common NICU PN Complication

Amino Acids

• Specialized formulas

• 10% of total calories

• 1g = 4 Kcal

Protein = Amino Acids

• Day 1: 0.7 g/kg/day

• Day 2: 1.2 g/kg/day

• Day 3: 1.5-2g/kg/day

Protein Dosing Guidelines

• BUN

• Acid-Base

• LFTs

• Albumin

Protein Tolerance Monitoring

Lipids

IVFE is a Good Media for Microbial Growth

Neutral pH of 8

Isotonic

High Fat content

•Substantial growth of E. coli, C. albicans, Ps. aeruginosa and coag-neg Staph spp.

• Flourished 12- 48 hrs post contamination

Keammerer D. et al., Am J Health Syst Pharm. 1983;40(10:1650-1653

Crill CM. et al., Am J Health Syst Pharm. 2010;67(11):914-918

• Concentrated source of calories

• 1g = 10 Kcal

• 20-40% of total calories

• Isotonic

• MCT: LCT / SMOF Lipid

Lipids

• Day 1: Start with 0.5 g/kg/day

• Day 2: 1 g/kg/day

• Day 3: 1.2 – 1.5 g/kg/day

• Do not exceed 0.15 g/kg/hour

• Better to be infused over 12 hours

IV Lipid Dosing Guidelines

• TG

• LFTs

• Platelets

Lipid Tolerance Monitoring

PN & Fat Allergy

Fat Allergy

4 different types:

1. Egg Phospholipid (Fat emulsifier)• Is patient allergic to eggs?

2. Soya Bean• Check with the patient if he/she ever had food allergy particularly to Soya bean.

3. Glycerine: to render IV isotonic• Check with the patient if he/she has any allergy to particular soaps, prepacked food, drugs containing

glycerine containing lozenges, laxatives, suppositories, etc.

4. MCT allergy• in case you use MCT:LCT. Check with the patient if she/he has peanut allergy.

PN Allergy

• Some AA products contain metabisulfite• Few reported allergic reactions

• Paraben preservatives in the product also may be associated with systemic reaction

• Multivitamins and trace elements could cause allergic reactions.

- Noura Albenyan, Mason Assaf

Interpretation of Lab Data

Treat the patient•Not only numbers

PN: What is Wrong & What

is Right?

What is Right?

10-y-old-female

Dx: Severe intractable diarrhea, severe dehydration

Start PN 80ml/hour

How much Na shall we add in PN?

Add 150 mMol/L + Close monitoring

Na 158 Cl 116 BUN 15 Glucose 90

K 4.9 CO2 20 Cr. 2.5 PO4 1.4

What is Right? Treat the Patient not the Numbers

10% of all cases: High intake of Na: NS, ABx, Albumin, etc.

Rx: D5W + Furosemide

90% of all cases: Volume depletion Fever, Hyperventilation, Sweating, GI losses

Symptoms: Thirst , Weight loss,

Signs: High BUN, Albumin, Hct

Rx: NS or D5 NS

What is Right About Hypernatremia?

• Eliminate Manganese and Copper with cholestasis

• ½ regular doses of TE

PN in Cholestasis

IV Lipid Dosing & Infusion Time

IVFE Dosing

Neonates & Infants:• 0.25 g/kg per day minimum to prevent EFAD• Maximum of 3–4 g/kg per day • (0.13–0.17 g/kg/hour) in infants

Term Infants & Older Children• 0.1 g/kg per day minimum to prevent EFAD• Maximum of 2–3 g/kg per day• 0.08-0.13g/kg/hour in older children.

Adults:• 0.1 g/kg/day minimum to prevent EFAD• Maximum of 1.5-2g/kg/day• 0.11 g/kg/hour for most cases and increase MAX to 0.15g/kg/hour

IV Fat Emulsion

•Absolute contraindication:•TG more than 4 mmol/L

•Acute Pancreatitis induced by Hypertriglyceridemia

Filtering Lipid

Shall we Filter IV Lipid

• Yes if manipulated

• No if original container is used.

• IVPN:

“1.22 micron filter with IV lipid infused with 2-in-1 only if the required volume is mixed/transferred and not to filter if we use the original Lipid bottle.”

http://www.nutritioncare.org/News/General_News/Parenteral_Nutrition_%E2%80%93_New_Recommendati

ons_for_In-line_Filters/

Shortage of 0.2 micron Filters

•Use 1.2 micron filters for 2-in 1 and TNA

- List References here

Case Scenario

POTASSIUM

“ Identified as the drug most commonly implicated in fatal incidents

in acute care facilities”

National Patient Safety Agency, UK, 2002Medication Safety Alerts, CJHP, Canada, 2002

Potassium

1.IV Potassium2.Insulin3.Heparin

USP/MedMarx 1996Institute of Safe Medication Practice (ISMP), 2003

78

• 14 yr-old male

• Dx: s/p BMT, complicated with GVHD, diarrhea, severe malnutrition

• On Ampho B, Furosemide, Steroids, Insulin

• PN day +4, 40 Kcal/kg/day, 2g protein/kg/d, Dextrose 4 mg/kg/min

Na 135(135-147)

Cl 101(98-111)

BUN 12(2.4 – 7)

Glucose 9(3-8)

K 2.1(3.5-5)

CO2 30(22-21)

Cr 44(44-123)

PO4 0.39 (0.7-1.45)

Mg 0.3 (0.7-1)

Potassium

Potassium

• 14 yr-old male

• Dx: s/p BMT, complicated with GVHD, diarrhea, severe malnutrition

• On Ampho B, Furosemide, Steroids, Insulin

• TPN day +4, 40 Kcal/kg/day, 2g protein/kg/d, Dextrose 4 mg/kg/min

• Why severe hypokalemia?

• How can we reduce potassium requirements?

Na 135(135-147)

Cl 101(98-111)

BUN 12(2.4 – 7)

Glucose 9(3-8)

K 2.1(3.5-5)

CO2 30(22-21)

Cr 44(44-123)

PO4 0.39 (0.7-1.45)

Mg 0.3 (0.7-1)

• Amphotericin B

• Insulin / Dextrose load

• Diuretics

• GI Loss

• Steroids / Salbutamol

• NPO

• Magnesium wasting drugs

• DKA

Why High K Requirement?

Investigate First then Add K

• Why hypokalemic?

• Symptomatic?

• Acute or chronic hypokalemia

• Lab error

• Check previous K level

• Kidney function?

• Central or peripheral?

• Magnesium level?

• Can take PO? Absorption?

• Need for a STAT order ?!!!

• Onset of hypokalemia with Ampho-B is 24-36 hours

• Increase K in IV empirically

• Reduce dextrose load!!

•Keep Magnesium levels between 0.9-1 mmol/dL

•Start Ranitidine with upper GI loss

How To Prevent Severe Hypokalemia?

Case Scenario

Hyponatremia

Hyponatremia

• 42-year-old lady admitted with Pneumonia

• PMH: Home PN due to SBS, Type II DM, HTN

• Dx?

• Should you increase Na in PN?

Factitious Hyponatremia

• Excess BG in serum:• ↑Serum Osmolarity

• Correct BG + NS + fluid restriction

• Excess BUN, Lipid:• Isotonic serum

• NS + fluid restriction

Sodium in PN

• Always ¼ to NS in PN

• PN is not the vehicle to correct severe hyponatremia (less than 120)

Scenario #2CPN or PPN?

Case Scenario: CPN

• Adel to start CPN, 2 liters:• Dextrose 8%• Amino Acid 3%• Sodium 80 mmol• Potassium 80 mmol• Ca 6 mmol

• Central line, through External Jugular Vein

• RN started CPN at 80 ml/hour

• After 2 hours: Neck swelling with severe pain

• What went wrong?• RN started CPN / CXR not checked

Case Scenario: CPN

• Adel to start CPN 2 Liters:• Dextrose 8%• Amino Acid 3%• Sodium 80 mmol• Potassium 80 mmol• Ca 6 mmol

• MD ordered to give same formula peripherally

• Can we infuse above formula peripherally?• Always calculate the osmolarity.

Central or Peripheral PN?

• Always calculate the Osmolarity• Dextrose 8% x 50 = 400• Amino Acids 3% x 100 = 300 mOsm/L• Sodium 40 mmol/L x 2 = 80 mOsml/L• Potassium 40mmol/L x 2 = 80 mOsm/L• Calcium 6 mmol/L

• Total = 860 mOsm/L

• Can we infuse peripherally?

• Answer: YES….. Reduce Ca to 2 mmol

• Caution: Monitor venous tolerance.

PN Cholestasis: Treatment & Prevention

• Do not overfeed

• Avoid NPO: Minimal PO even if not tolerated

• Manage Sepsis

• Specialized amino acids

• Omega 3 FA instead of omega 6

• Ursodecoxycholic acid/ Oral Metronidazole

• L-Glutamine*

• Rule out drug-induced

• Reduce Manganese & Copper*Babu R. et al., J Ped Surg. 36(2):282-6, 2001Teitlbaum DH. et al. JPEN 21(2):100-3, 2000Dotty et al. Ann Surg. 210(1):76-80, 1993Kubota A. et al., J Ped Surg 25:618, 1990

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

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

• Teitlbaum DH. et al. JPEN 21(2):100-3, 2000

• Babu R. et al., J Ped Surg. 36(2):282-6, 2001

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

• Worthington P. et al., 41:324-377, 2017

Additional Literature/References