3/26/18. Total Parenteral Nutrition Roundtable Discussion. Disclosure Information. Objectives. Monitoring Parameters & Complications

Transcription

1 Total Parenteral Nutrition Roundtable Discussion Monitoring Parameters & Complications Jessica Pech MSN, APN, CPNP-PC Division of Pediatric Surgery Ann & Robert H. Lurie Children's Hospital of Chicago I have no disclosures. Disclosure Information Objectives Identify standard monitoring parameters and complications associated with TPN administration including infection, mechanical and metabolic complications. Define significance of glucose infusion rate (GIR) and describe methods for adjustment of TPN composition and fluid volume. 1

2 Intravenous vs Enteral Nutrition Enteral nutrition = GI tract Parenteral nutrition = IV Parenteral Nutrition is used when significant nutrition is not obtained by other routes GOAL = initiate enteral feedings & STOP TPN to decrease TPN associated complications! IF GUT WORKS - USE IT! TPN Considerations Risk versus Benefit -Cost, PN associated complications, Efficacy PN may be initiated with Prolonged NPO status in.. -Premature infants/full term newborns 1-3 days -Suboptimal nutrition in children 3-5 days -Well-nourished children 3-7 days TPN Considerations Acute malnutrition: Perforated appendicitis, Hirschsprung s disease, SBO/prolonged ileus, bowel resection, pyloric stenosis, burns, trauma, GT dependent/wound breakdown, sepsis, IBD Chronic malnutrition (NPO >3 months): Short bowel syndrome (SBS), malabsorption, failure to thrive (FTT), SMA syndrome, NEC, IBD, gastroschisis, pediatric oncology 2

3 TPN Initiation Nutrition consult Recommendations for TPN calories, fluid volume, composition Review of laboratory data Anthropometric Measurements Weight (3x/week) Length/Height & Head circumference (1x/week) Fluid volume status, Strict I/O s TPN Monitoring Parameters TPN labs prior to & after TPN Initiation BMP, Mg, Phos, Ionized Ca, triglycerides, LFT s, Pre-albumin, Albumin Labs twice per week while IP or once per week if stable as IP/OP Additional labs with electrolyte or TPN composition/weight adjustments Q Monday BMP, Mg, Phos, ica Q Thursday BMP, Mg, Phos, ica, LFT s, triglycerides TPN Complications 1. Mechanical 2. Infection 3. Metabolic/Nutritional TRUE OR FALSE: Administration of lipids through peripheral IV access is not recommended. TRUE OR FALSE: Peripheral PN should not exceed a dextrose concentration greater than 10%. 3

4 Mechanical Complications Pneumothorax Line occlusion or breakage Thrombophlebitis or IV extravasation Mineral or drug precipitation or incompatibility Pulmonary or Air Embolism Intravenous Access Peripheral Short term PN Lower concentration solution Maximum dextrose = 12.5%, Maximum amino acids = < 3% Central Long term PN Prolonged NPO Higher concentration solution Maximum dextrose = 30% Maximum amino acids = 6% Heparin additive Infection Complications CLABSI à Sepsis Bacterial overgrowth/translocation (intraoperative, SBS) Risk Factors: prolonged hospitalization/cvc access, premature infants, oncology/neutropenia, SBS/TPN dependent FEVER in child with CVC access is SEPTIC until proven otherwise! 4

5 The Facts (CDC, 2011) 41,000 = estimated CVC associated BSI s annually in hospital setting Estimated mortality rate 12-25% Average cost to healthcare system = $25,000 per episode Antibiotic resistance Think Sepsis, Time Matters BSI s in the hospital setting reduced by 58% since 2001 The Facts (CDC, 2014) Most common Pathogens in acquired PEDIATRIC Blood Stream Infections (BSI s) Coagulase-negative staphylococci 37% Gram-negative bacteria 25% Enterococci 10% Candida 9% Minimize Risk of Infection 1. Appropriate IV Insertion site Peripheral vs Central Access (Subclavian, femoral, IJ, PICC) 2. Appropriate choice of CVC Short vs. long term catheter, number of lumens, presence of cuff 3. Proper Hand hygiene & Aseptic techniques 4. Antibiotic or 70% ethanol locks 5. Promote vaccinations 6. Remove CVC s as soon as medically able! 7. Prevention is the KEY! 8. Refer to your institution for proper care of CVC s 5

6 1. Hyperglycemia/Hypoglycemia Metabolic Complications 2. Parenteral Nutrition Associated Liver Disease (PNALD) -Hepatic steatosis -TPN associated cholestasis 3. Refeeding syndrome & Electrolyte Imbalances 4. Metabolic bone deficiency (imbalance ratio of calcium phosphorus) Blood Glucose Complications Sudden discontinuation/ PN cycling can cause hypoglycemia in children within minutes TPN cycle should generally not exceed > 4 hours in neonatal population Close monitoring of blood glucose levels Prolonged hypoglycemia can result in neurodevelopmental impairment, CP, visual disturbances & epilepsy Hyperglycemia can lead to osmotic diuresis resulting in dehydration and electrolyte imbalances. Dextrose is hypertonic and should be gradually advanced by 2.5-5% per day to allow the pancreas and liver to adjust to glucose concentration Glucose Infusion Rate (GIR) GIR is the amount of glucose the liver can oxidize in mg/kg/min Cycling TPN = Increase GIR! Decrease in PN fluid volume = Increase in the carbohydrate load infusion rate GIR should not exceed > 16mg/kg/min GIR Calculation: Age Maximum GIR IV rate (ml/hr) x Dextrose (g/dl) x 1000 (mg/g) Premature infant mg/kg/min Infant mg/kg/min Weight (kg) x 60 (min/hr) x 100 (ml/dl) Child 8-10 mg/kg/min Adolescent 5-6 mg/kg/min 6

7 Hepatic Steatosis (Fatty Liver) Excessive collection of triglycerides & fats within liver cells resulting from high dextrose/fat PN solutions GIR > 12 mg/kg/min is associated with fatty liver disease related to the conversion of excess glucose to glycogen or lipid Acute Hepatic Steatosis is usually reversible with discontinuation of PN Goal = Optimize intestinal function & gut adaptation PREVENTION! PNALD Cholestasis Results from disuse of GI tract causing bile stasis in the gallbladder & biliary tract. ~30-60% of children develop PNAC with chronic TPN administration Average length of PN prior to develop cholestasis is 42 days Risk factors: SBS, gastroschisis, hyperbilirubinemia, chronic TPN Gallbladder sludge may disappear after 4 weeks of enteral nutrition Chronic PNALD may be irreversible and lead to liver cirrhosis, liver failure or death PNALD Cholestasis Ursodeoxycholic acid (Actigall) may improve bile flow, displace cytotoxic bile acid & correct bile acid deficiency SMOF lipids (soybean/mct/olive/fish oil emulsion) may decrease intrahepatic inflammation & improve biliary flow Interventions: Remove Copper & Manganese, trophamine solution, add levocarnitine & selenium to increase lipid clearance, MWF lipids, Maximum lipid dose 1g/kg/day Monitor weekly LFT s & triglycerides Initiate ENTERAL FEEDS, Cycle or STOP TPN! 7

8 Refeeding Syndrome Metabolic abnormality caused by rapid reintroduction of carbohydrates from enteral or PN in malnourished patients Hypophosphatemia is classic sign May include decreased levels of K+, Na+, Mg May lead to cardiac dysrhythmias, heart failure, acute respiratory failure, coma, paralysis, nephropathy & liver dysfunction Management of Refeeding Syndrome Electrolyte supplementation (K+, Mg, Phos) may be needed until PN at therapeutic dosing Monitor routine TPN labs 2x/week or PRN with electrolyte supplementation or excessive losses Electrolyte adjustments take time to be reflected in serum Weaning fluid volume may increase concentration of electrolytes Slow introduction of PN/Enteral Nutrition is KEY!! Questions???? 8

9 References Arsenault, D., Brenn, M., Sendia, K., Gura, K., Compher, C., Simpser, E. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors, & Mark Puder (2012). A.S.P.E.N. clinical guidelines: Hyperglycemia and hypoglycemia in the neonate receiving parenteral nutrition. Journal of Parenteral and Enteral Nutrition, 36(1), Dierdre, K. (1998). Liver complications of pediatric parenteral nutrition. Epidemiology, 14(1) Giuseppe, O., Mandato, C., Veropalumbo, C., Cecchi, N., Garzi, A., & Pietro, V. (2016). Pediatric parenteral nutrition associated liver disease and cholestasis: Novel advances in pathomechanism-based prevention and treatment. Digestive and Liver Disease, 48(3), Martin, S. (2012). Practice pearls for prescribing parenteral nutrition. Presented at Children s Memorial Hospital Chicago, IL. Meadows, N.(1998). Monitoring and complications of parenteral nutrition. Current Opinion in Gastroenterology, 14(10) Centers for Disease Control and Prevention. (2011). Making health care safer by reducing bloodstream infections. Vital Signs: Centers for Disease Control and Prevention, Retrieved from Wales, P, Allen, N., Worthington, P., George, D., & Compher, C. (2014). The American society for parenteral and enteral nutrition. Journal of Parenteral and Enteral Nutrition, 38(5) Wilhelm, L. (2010). Pediatric Parenteral Nutrition. Presented at Children s Memorial Hospital Chicago, IL. 9