Managing the Complex Parenteral Nutrition (PN) Patient

Transcription

1 Managing the Complex Parenteral Nutrition (PN) Patient Carol J. Rollins, MS, RD, PharmD, CNSC, BCNSP Coordinator, Nutrition Support Team, The University of Arizona Medical Center Associate Professor, The University of Arizona College of Pharmacy Tucson, Arizona CE Credit in Four Easy Steps! 1. Scan your badge as you enter each session. 2. Carry your Evaluation Packet to every session so you can add session evaluation forms to it. 3. Track your hours on the Statement of Session Attendance Form as you go. 4. At your last session, total the hours and sign both pages of your Statement of Session Attendance Form. Keep the PINK copy for your records. Put the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended. Miss one? Extras are in a file near Registration. Fill out the information on the outside of the CE Packet envelope, seal it, and drop it in the box near Registration. Applying for Pharmacy CPE? If you have not yet registered for an NABP e-profile ID, please visit to do so before submitting your packet. You must enter your NABP e-profile ID in order to receive CE credit this year! 3/27/ Speaker Disclosures Carol J. Rollins has no conflicts of interest or potential financial conflicts to disclose. Clinical trials and off label/ investigational uses will not be discussed during this presentation. 3 1

2 Objectives 1. Discuss options for management of macronutrient intolerance, including hyperglycemia and hypertriglyceridemia. 2. Discuss the inter relationship of potassium, magnesium and phosphorus when managing a parenteral nutrition patient. 3. Assess the likelihood of an acid base imbalance developing based on a patient's clinical presentation and recommend appropriate interventions. 4 Self Assessment Question 1 The GIR for a 50 kg patient (BMI 16 kg/m 2 ) who receives 400 g dextrose (1360 kcal; 27 kcal/kg) daily in PN is generally considered to be: A. Below the maximum that can be oxidized B. Within an appropriate range for weight gain C. The maximum that does not cause fatty liver D. Excessive for a patient with metabolic stress 5 Self Assessment Question 2 For a patient with PN associated hyperglycemia, which type of insulin is most likely to be appropriate for use in a sliding scale regimen? A. Lispro B. Regular C. NPH D. Glargine 6 2

3 Self Assessment Question 3 Which nutrient source is the most appropriate for increasing calories in a patient with hyperglycemia (FSBG mg/dl) and hypertriglyceridemia (TG 250 mg/dl)? A. Dextrose B. Glycerol C. Fat emulsion D. Protein 7 Hyperglycemia Assessment New vs known Range of glucose concentrations Pattern or timing of abnormal glucose Treatment administered, if any, and response Confirmation of abnormal glucose Confounding factors 8 Hyperglycemia Potential Causes Disease related DM, pancreatic dz Medication related Glucocorticoids, octreotide Imbalance of nutritional substrates GIR Other Infection Metabolic stress, inflammatory response Chromium deficiency 9 3

4 Balance of Nutritional Substrates Glucose infusion rate (GIR) Calculate as mg/kg/minute Maximum glucose oxidized Stressed adult, 3 5 mg/kg/min ( g/kg/day) IVFE as a caloric source Minimum vs maximum Protein as a caloric source Requires energy for conversion 10 Treatment of Hyperglycemia Insulin Type based on duration of action Route Admixed in PN Separate from PN SQ, IV Schedule Routine once daily, twice daily, multiple daily doses Sliding scale Other 11 Hyperglycemia Case of C.C. 67 y.o. F with enterocutaneous fistula x2 NPO except meds (not to exceed 360 ml/day) Weight for PN calculations: 60 kg Home PN 2400 ml/day over 18 hr, 1 hr 1 hr PN order/day: Dextrose 240 g, AA 100 g, Fat 60 g Insulin: PN 20 units regular; SQ 8 units glargine FSBG(mg/dL) range from 75 to

5 Hyperglycemia C.C. How should C.C. s hyperglycemia be treated? A. Use ultra short acting insulin analog (Lispro) in sliding scale coverage B. Split glargine dose with 60% an hour before PN is started, 40% in am C. Increase taper up time to 2 hr D. Reduce dextrose in PN 13 Other Information Needed for C.C. Adherence to NPO GIR = 2.77 mg/kg/min (4 g/kg/day) [(240 g/d x 1000 mg/g) / 60 kg] / 1440 min/d Pattern of FSBG (range from 75 to 292 mg/dl) Off PN: hr after PN starts: hr after PN starts: Stability considerations Fat containing PN: minimum 10% Dextrose, 4% AA, 2% Fat [Driscoll] Hyperglycemia C.C. How should C.C. s hyperglycemia be treated? A. Use ultra short acting insulin analog (Lispro) in sliding scale coverage B. Split glargine dose with 60% an hour before PN is started, 40% in am C. Increase taper up time to 2 hr D. Reduce dextrose in PN 15 5

6 Hyperglycemia Case of M.H. 69 y.o. M with SBO, G tube to drainage Colostomy s/p hemicolectomy for colon cancer Weight for PN calculations: 73 kg Home PN 2280 ml/day continuous infusion PN order/day: Dextrose 420 g, AA 100 g, Fat 73 g FSBG mg/dl for 1 st 20 days at home No insulin added to PN FSBG mg/dl past 48 hr 16 Hyperglycemia M.H. How should M.H. s hyperglycemia be managed? A. Add regular insulin to PN B. Add a sliding scale insulin regimen C. Start long acting basal insulin and add a sliding scale insulin regimen D. Re formulate PN for lower dextrose dose 17 Other Information Needed for M.H. Has oral intake started recently? Pattern of hyperglycemia Vital signs is pt stable? Temperature, heart rate Signs of infection? CVL Surgical site/ ostomy Pneumonia 6

7 Hyperglycemia M.H. How should M.H. s hyperglycemia be managed? A. Add regular insulin to PN B. Add a sliding scale insulin regimen C. Start long acting basal insulin and add a sliding scale insulin regimen D. Re formulate PN for lower dextrose dose 19 Hyperglycemia Case of T.N. 52 y.o. F with wound vac on complex surgical site 10 weeks s/p repair of duodenal stricture Weight for PN calculations: 40 kg (BMI 15.5) Continued weight loss on PN x 3 months; stable x 3 wk Home PN 2000 ml over 16 hr, 1 hr 1hr PN order: D15% AA5% and 500 ml 20% fats MWF Insulin: PN 30 units regular; sliding scale regular FSBG mg/dl 20 Hyperglycemia T.N. How should T.N. s hyperglycemia be managed? A. Increase regular insulin in PN using sliding scale amount as a guide B. Start long acting basal insulin and make sliding scale dose more aggressive C. Lower dextrose and increase fat calories D. Reduce dextrose and total calories 21 7

8 Other Information Needed for T.N. Diet order and adherence to order NPO Pattern of hyperglycemia Units of insulin used for sliding scale coverage Assess nutrient provision and requirements Protein 100 g/day = 2.5 g/kg/d BUN 65 mg/dl Dextrose 300 g/day = GIR 5.2 mg/kg/min Total calories = 1848 average/day (46.2kcal/kg/d) 22 Hyperglycemia T.N. How should T.N. s hyperglycemia be managed? A. Increase regular insulin in PN using sliding scale amount as a guide B. Start long acting basal insulin and make sliding scale dose more aggressive C. Lower dextrose and increase fat calories D. Reduce dextrose and total calories Supported by metabolic cart 23 Hyperglycemia Case of K.S. 46 y.o. F with multiple medical issues HxRoux en Y gastric bypass for obesity 6 yr ago, followed by reversal 2 yr ago Frequent hospital admissions for c/o N,V and severe retrosternal and epigastric pain Home PN since last hospital d/c 3 weeks ago Pt s care provider reports mental status changes Lab yesterday: hyperglycemia, hypokalemia 24 8

9 Hyperglycemia K.S. Wt for PN calculations: 56.6kg (99% IBW) Lab results: Na 135 K 2.9 Cl 106 Bicarb 20 Ca 8.4 Mg 2.1 Phos 2.9 BUN 9 SCr0.9 Glucose 544 Home PN 1000 ml over 12 hr, 1 hr 1hr PN order: D20% AA5% and 250 ml 20% fats M,Th No insulin added to PN; no FSBG available 25 Hyperglycemia K.S. What other information do you want/need? How labs were drawn peripheral stick vs CVL K content of PN Glycated Hgb (from recent hospitalization) 5.3% From yesterday: WBC 4.9 Bands 2% From 1 week ago: K 4.1Glucose 94 Other potential causes of mental status change When PN cycle had ended relative to blood draw 26 Hyperglycemia K.S. Should hyperglycemia be treated in K.S? Why or why not? Question results that are inconsistent with previously stable results in stable patient Redraw labs before any treatment May see euglycemia during off cycle despite hyperglycemia when PN infuses Labs likely reflect PN contamination 27 9

10 Hypertriglyceridemia Assessment New vs known Treatment Confirmation of abnormal triglyceride Aim for TG < 200 mg/dl Avoid 400 mg/dl or higher Confounding factors Medications Hyperglycemia Micronutrient alteration Carnitine 28 Hypertriglyceridemia Case of N.B. 30 y.o. M s/p MUD HSCT, day + 35 GVHD of GI tract and liver, thrombocytopenia Weight for PN calculations: 65 kg (95% IBW) Day 6 Home PN 2400 ml/day at 100 ml/hr PN hung daily in clinic Care provider issues; limited home RN visits PN order/day: Dextrose 150 g, AA 126 g, F 110 g Triglyceride 290 mg/dl Hypertriglyceridemia N.B. How should hypertriglyceridemia be managed? A. Keep tight glucose control with current PN and monitor TG B. Add immediate release nicotinic acid to medication regimen C. Reduce fats and increase dextrose calories provided by PN D. Maintain dextrose calories and reduce fat provided by PN 10

11 Other Information Needed for N.B. Medications Glucocorticoids (High dose methylprednisolone) CSA Glucose over past 5 days: mg/dl 15 units regular insulin added to PN No routine FSBG due to thrombocytopenia Previous Triglycerides Baseline (day + 4 HSCT): 145 mg/dl Day + 20 HSCT/ Day 4 PN: 250 mg/dl Other Considerations for IVFE Maximum dose for adults 2.5 g/kg/day (rarely go above 2 g/kg/day and seldom above 1.5 g/kg/day) Not more than 60% of total calories from fat Minimum to prevent EFAD 1% 2% of total calories as linoleic acid Home PN: No EFAD with 500 ml 20% IVFE weekly Critical illness No IVFE in sepsis; limit IVFE to 1 g/kg/day in ICU 32 Hypertriglyceridemia N.B. How should hypertriglyceridemia be managed? A. Keep tight glucose control with current PN and monitor TG B. Add immediate release nicotinic acid to medication regimen C. Reduce fats and increase dextrose calories provided by PN D. Maintain dextrose calories and reduce fat provided by PN 11

12 Self Assessment Question 1 The GIR for a 50 kg patient (BMI 16 kg/m 2 ) who receives 400 g dextrose (1360 kcal; 27 kcal/kg) daily in PN is generally considered to be: A. Below the maximum that can be oxidized B. Within an appropriate range for weight gain C. The maximum that does not cause fatty liver D. Excessive for a patient with metabolic stress 34 Self Assessment Question 2 For a patient with PN associated hyperglycemia, which type of insulin is most likely to be appropriate for use in a sliding scale regimen? A. Lispro B. Regular C. NPH D. Glargine 35 Self Assessment Question 3 Which nutrient source is the most appropriate for increasing calories in a patient with hyperglycemia (FSBG mg/dl) and hypertriglyceridemia (TG 250 mg/dl)? A. Dextrose B. Glycerol C. Fat emulsion D. Protein 36 12

13 Self Assessment Question 4 In which clinical situation is bicarbonate loss from the GI tract likely to be highest? A. Nasogastric suctioning B. Aggressive diuresis C. Protracted vomiting D. Prolonged diarrhea 37 Self Assessment Question 5 Which of the following serum electrolyte patterns is associated with metabolic alkalosis? A. Decreased chloride with sodium disproportionately high compared to chloride B. Elevated bicarbonate and chloride with sodium low compared to chloride C. Decreased chloride and proportionately low sodium D. Elevated chloride and proportionately high sodium 38 Self Assessment Question 6 The primary mechanism for the acid base disorder associated with acute renal failure is: A. Inability to filter bicarbonate B. Lack of bicarbonate reabsorption in the distal tubules C. Retention of organic acids D. Loss of hydrogen ion when potassium is retained 39 13

14 Assessing Acid Base Status Many factors involved ABG s provide objective data Must gather pieces of the puzzle and fit them together when there are no ABG s Many assumptions Less accurate than ABG s A simplified interpretation 40 Can You Fit the Pieces Together? Diarrhea Renal Failure Diuresis Vomiting NG Suction Pancreatic Fistulae Dehydration Alkalosis Furosemide Lactated Ringers Enterocutaneous Fistulae Acidosis 41 Alogorithm Does the patient have respiratory problems? YES NO Obtain ABG s Assess RQ Acid-Base Disorder is Likely Metabolic Limited Nutrition Interventions: Alter amount of CHO and/or Fat Avoid excess calories Assess clinical contributors to acid-base disorder Assess laboratory data which may corroborate clinical data 42 14

15 Metabolic Acid Base Disorder Factors associated with acidosis Gain of acid [ produc on or loss] Loss of bicarbonate Factors associated with alkalosis Loss of acid Gain of bicarbonate Exogenous sources Bicarb precursors 43 Consider Physiology Stomach Gastric acid production Pancreas Bicarbonate production Renal tubules Reabsorption of acid (H + ) Reabsorption NaHCO 3 About 400 g/day 44 Stomach Loss of Hydrochloric Acid Gastric Suctioning Remove contents of the stomach Vomiting 45 15

16 Pancreas Pancreatic fluid enters duodenum Common bile duct High bicarbonate content Loss of GI fluid below this point results in bicarbonate loss 46 Acid Base Disorder Case of J.D. 69 y.o. M admitted to the hospital Height 70 inches, weight 75 kg Chief Complaint: abdominal pain, nausea and vomiting starting one day PTA Diagnosis from the ER is SBO PMH: Right hemicolectomy 9 months ago Colon cancer Otherwise healthy 47 Therapy for J.D. Conservative therapy implemented NG suction and fluids NG tube output 3200 ml removed immediately in ER 3.5 to 4.5 liters daily after this MIV: 5%Dextrose 0.45%NaCl + 20 meq KCl/L Rate of 200 ml/hr Consult for initiation of PN on day 6 SBO is not improving 48 16

17 LABS for J.D. Admit Day 2 Day 6 Na K Chloride Bicarb (CO 2 ) Glucose BUN Creatinine Acid Base Assessment J.D. Based on the history and the labs shown, how would you assess J.D. on day 6? A. NG output has resulted in hypovolemia B. Labs are diluted by the MIV at 200 ml/hr C. Metabolic acidemia (acidosis) D. Metabolic alkalemia (alkalosis) 50 Acid Base Assessment J.D. What clinical features are important? Vomiting NG suction What laboratory values support the assessment? High serum bicarb (34) Low serum chloride (93) Chloride disproportionately low vs sodium (135) 51 17

18 Acid Base Assessment J.D. Based on the history of vomiting/ high NG output, and labs shown (Na 135, Cl 93, HCO3 34), how would you assess J.D. on day 6? A. NG output has resulted in hypovolemia B. Labs are diluted by the MIV at 200 ml/hr C. Metabolic acidemia (acidosis) D. Metabolic alkalemia (alkalosis) 52 Metabolic Alkalosis Loss of H + Gastric fluid loss Vomiting, NG suction, gastrostomy drainage Extracellular loss Shift of H + into cells Hypokalemia, refeeding syndrome Renal loss Diuretics, contraction alkalosis 53 Diuretic Actions Increase sodium delivery to the distal segment of the distal tubule Loop and thiazide diuretics Increased distal tubular sodium concentration stimulates aldosterone sensitive sodium pump Increase sodium reabsorption Sodium exchanged for H + (and potassium) Increased H + [acid] loss to the urine 54 18

19 NaHCO 3 Carbonic anhydrase inhibitors Proximal Convoluted Tubules H 2 O Cortex Medulla Loop of Henle Glomerulus Filtration Thick Ascending Loop Diuretics Distal Convoluted Tubules 2 H 2 O + ADH K+ Sparing Diuretics Collecting Duct Urine Excretion 55 Metabolic Alkalosis Gain of HCO 3 Exogenous bicarbonate Exogenous bicarbonate precursors Lactate, acetate, citrate Medications 56 Metabolic Alkalosis Management Avoid bicarb or bicarb precursors Chloride, not acetate, lactate or citrate in PN, fluids Provide adequate potassium (avoid hypokalemia) Prevent dehydration with adequate fluid Consider total fluid PN, MIV, medications Consider total losses excess GI loss, insensible loss Add an H 2 antagonist to regimen (?) Reduce acid production in the stomach Reduce subsequent acid loss with NG suction 57 19

20 Case of J.D. Part 2 Day 8: J.D. is taken to the OR Exploration due to abdominal distention Total colectomy with end ileostomy Transferred to ICU post op Day 12: extubated, transferred to the floor PN transitioned to tube feeding post op Tube feeding at goal rate (80 ml/hr) 58 J.D. s Progress Post Op Day 13: Tube feeding continues (at goal) Clear liquid diet is started Patient c/o nausea, takes only sips of clears Day 15 (POD 7): c/o N, abdominal pain Temperature to 38.8 C during the night Ileostomy output 5 liters over the past 24 hours (increased from 2 liters two days ago) Tube feeding is reduced to trickle feeds PN is to re start 59 Labs for J.D. Day 12 Day 13 Day 15 Na K Chloride Bicarb (CO 2 ) Glucose BUN Creatinine

21 Acid Base Assessment J.D. Based on the history and the labs shown, what is your assessment on day 15? A. Ileostomy output and high temperature have resulted in hypovolemia B. Renal failure has resulted in excessive fluid retention C. Metabolic acidemia (acidosis) D. Metabolic alkalemia (alkalosis) 61 Acid Base Assessment J.D. What clinical features are important in your assessment on day 15? High ileostomy output Decreasing renal function. Acute renal failure? Likely inadequate fluid replacement May be reversible with adequate fluids/hydration Increased ileostomy output? Infection Increased temperature and increasing glucose 62 Acid Base Assessment J.D. What laboratory values are important in supporting the assessment? Low serum bicarb (12) High serum chloride (110) Disproportionately high chloride vs sodium (140) High anion gap (18) Na Cl bicarb= anion gap; normal 12 +/ 5 Potassium high normal Potassium shifts out of cells with acidosis 63 21

22 Acid Base Assessment J.D. Based on the history and the labs shown, what is your assessment on day 15? A. Ileostomy output and high temperature have resulted in hypovolemia B. Renal failure has resulted in excessive fluid retention C. Metabolic acidemia (acidosis) D. Metabolic alkalemia (alkalosis) 64 Metabolic Acidosis Mechanisms Loss of HCO 3 Loss from the GI tract (ileostomy) Pancreas secretes bicarbonate into the GI tract HCO 3 loss if GI losses distal to pancreatic duct Gain of acid Renal failure: retain unmeasured organic acids Ion shifts between intra and extra cellular Increased serum K K shifts out, H + in (acidosis) Reduced renal elimination 65 Metabolic Acidosis Management Reduce chloride provision Use bicarb precursors, chloride in PN, fluids General rule: >1 meq acetate/kg/day for effect Up to meq/kg/day of bicarbonate or bicarb precursors likely needed with serum bicarb of 12 Removal of organic acids Dialysis Improved renal function 66 22

23 Refractory Lactic Acidosis Case of F.R. 62 y.o. F with multiple EC fistulae Home PN for over 1 yr Shortage of adult MVI No IV vitamins for nearly 3 weeks Oral vitamin ordered Patient doing poorly when seen by home RN Labs drawn, results show bicarb 13 Patient seen in clinic and admitted to hospital 67 Refractory Lactic Acidosis F.R. Admitted then transferred to ICU ph < 7.2 Lactate > 15 Bicarb drip started No improvement over next 3 days Bicarb drip at 150 ml/hr x 3 days 3 amps NaHCO 3 /L = 150 meq Na + /L 68 Refractory Lactic Acidosis F.R

24 Lactic Acidosis: Acute Thiamine Deficiency Thiamine pyrophosphate (TPP) Required for oxidative decarboxylation of pyruvate Acetyl coenzyme A Lactic Acid Oxidizable substrate for Krebs cycle 70 Can You Fit the Pieces Together? Alkalosis Diarrhea Pancreatic Fistulae Renal Failure Metabolic Acidosis Enterocutaneous Fistulae 71 Do these Pieces Fit? Vomiting Metabolic Alkalosis Lactated Ringers Diuresis NG Suction Furosemide Acidosis Dehydration 72 24

25 Self Assessment Question 4 In which clinical situation is bicarbonate loss from the GI tract likely to be highest? A. Nasogastric suctioning B. Aggressive diuresis C. Protracted vomiting D. Prolonged diarrhea 73 Self Assessment Question 5 Which of the following serum electrolyte patterns is associated with metabolic alkalosis? A. Decreased chloride with sodium disproportionately high compared to chloride B. Elevated bicarbonate and chloride with sodium low compared to chloride C. Decreased chloride and proportionately low sodium D. Elevated chloride and proportionately high sodium 74 Self Assessment Question 6 The primary mechanism for the acid base disorder associated with acute renal failure is: A. Inability to filter bicarbonate B. Lack of bicarbonate reabsorption in the distal tubules C. Retention of organic acids D. Loss of hydrogen ion when potassium is retained 75 25

26 Self Assessment Question 7 Which of the following electrolytes are primarily intracellular? A. Sodium, potassium, chloride B. Phosphorus, potassium, magnesium C. Phosphorus, sodium, magnesium D. Chloride, calcium, phosphorus 76 Self Assessment Question 8 Which of the following electrolytes tend to decrease significantly with initiation of PN in a severely malnourished patient? A. Sodium, potassium, chloride B. Phosphorus, potassium, magnesium C. Phosphorus, sodium, magnesium D. Chloride, calcium, phosphorus 77 Electrolyte Inter Relationships Sodium and water Is there a sodium problem or a water problem? Potassium, magnesium and phosphorus Intracellular electrolytes Serum concentration is low relative to body content Shifts in and out of cells change serum concentration Renal elimination 78 26

27 Potassium, Magnesium, Phosphorus Affected by renal function Cellular damage Different concentrations in different types of cells Hemolysis RBC Tumor lysis WBC (lymphocyte) Rhabdomyolysis Muscle Shifts between intracellular and extracellular 79 Refeeding Syndrome Patients at risk Severely malnourished Significant weight loss, esp. over several weeks Calorie/energy malnutrition Aggressive nutrition, esp. with CHO Shift intracellular electrolytes from serum back into the cell Risk of cardiac failure 80 Refeeding Syndrome Serum electrolyte decreases drive by CHO Phosphorus required to phosphorylate glucose Phosphorus is part of ATP Potassium follows glucose into cells Fluid Heart failure Fat and protein Can be more aggressive with minimal risk 81 27

28 Refeeding Syndrome Not exclusive to PN occurs with po and EN Start with low CHO 10% dextrose in PN 100 g CHO/day Above standard phosphorus, potassium, magnesium Average time to stabilize electolytes: 5 7 days Daily labs until stable 82 Self Assessment Question 7 Which of the following electrolytes are primarily intracellular? A. Sodium, potassium, chloride B. Phosphorus, potassium, magnesium C. Phosphorus, sodium, magnesium D. Chloride, calcium, phosphorus 83 Self Assessment Question 8 Which of the following electrolytes tend to decrease significantly with initiation of PN in a severely malnourished patient? A. Sodium, potassium, chloride B. Phosphorus, potassium, magnesium C. Phosphorus, sodium, magnesium D. Chloride, calcium, phosphorus 84 28

29 QUESTIONS Carol J. Rollins, MS, RD, CNSC, PharmD, BCNSP Coordinator, Nutrition Support Team The University of Arizona Medical Center, Main Campus