Back to the Basic: Parenteral Nutrition 101. Osama Tabbara

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1 Back to the Basic: Parenteral Nutrition 101 Osama Tabbara

2 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 3.5 years in Operation JCIA HIMSS 7

4 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

5 IVPN Experts Network - Gulf Region ivpngulf@googlegroups.com 1251 IVPNeers from 400 hospitals

6 Learning Objectives 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

7 Polling/ Assessment Questions Multiple Choice Question: Which lab marker is not important to monitor with Protein therapy Liver Function Tests BUN Dextrose Albumin

8 Polling/ Assessment Questions [For Workshops] Multiple Choice Question: As classified by ISMP, which of the following are high Alert medications IV Potassium Insulin Heparin All of the above

9 Polling/ Assessment Questions [For Workshops] Multiple Choice Question: As per 2003 Survey, major errors with PN are originated: Protein Lipid Electrolytes Trace elements

10 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

11 C N F Insulin PO 4, K, Mg Mitochondria K Vitamins Tr.Elem. Na ATP CO2

12 Na-K-ATPase pump K ( mEq/L) Na (3.5-5mEq/L) K (3.5-5mEq/L) Na ( mEq/L) Intracellular Albumin Interstitial Intravascular

13 Electrolyte Distribution Na+ 142 mmol/l K+ 4 mmol/l Mg++ 1 mmol/l Intravascular PO4-- 1 mmol/l Protein-- 16 mmol/l Na+ 10 mmol/l K+ 155 mmol/l Mg++ 26 mmol/l Intracellullar PO mmol/l Protein 65 mmol/l 3.5 L 30 L 10 L

14 K SERUM (3.5 5 mmol/l) K: PN 60 mmol/l Dextrose (100mg/dl) (0.1%) Dextrose 20%

15 Parenteral Nutrition TPN replaced with PN: PPN CPN

16 Central or Peripheral PN?

17 What is Safe Admixture? Iso-Osmolar Physiological ph Sterile

18 SVC = 2000 ml/min SCV= 800ml/min Cephalic/Basilic: 40-95ml/min

19 PERIPHERAL CENTRAL Partial support Phlebitis No surgery Low risk Sepsis Max Dextrose Neonate: 12.5% Peds: 10% Adult: 7.5% Full support No Phlebitis Surgery Sepsis No Max for Dextrose Max Protein: 2.5% Max osmolarity: 900/L No max for Protein No max osmolarity

20 What is Maximum Dextrose % and Osmolarity? No limit with CPN Maximum Dextrose with PPN: % in neonates Maximum Osmolarity with PPN: mosm/l

21 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

22 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:

23 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

24 Signs of Phlebitis Redness of the vein Swelling of the vein Tenderness over the vein Site warm to touch Sluggish flow of infusate

25 Preventing Peripheral PN Complications

26 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 hours Maximize IV LIPID

27 IV Lipid is Safe! Protect veins from phlebitis Safe at any dose with PPN

28 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?

29 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: , 1995 Anderson ADG., et al. Brit J Surg 90: , 2003 Isaacs JW. et al., AJCN 30(4):552-9, 1977 Tighe MJ., et al., JPEN 19: , 1995

30 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 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

31 How Much Calories?

32 The Science and Art of PN FEED AS TOLERATED

33 ACCP Recommendation 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 :

34 How Much Calories for Obese ICU Pts. (BMI > 30)? Kcal/kg actual BW or Kcal/kg IBW/d Protein at g/kg IBW/d SCCM & ASPEN Guidelines, Crit Care Med, 37(5), 2009

35 Underfeeding is safer than overfeeding. Chwals WJ. New Horiz 2: , 1994 Clein CG. Et al., J Am Diet Assoc 98: , 1998

36 Indirect Calorimetry RQ = VCO2/ VO2 Dextrose = 1 Protein = 0.8 Fat = 0.7 Liponeogenesis= 8 RQ > 1 : RQ = 0.825: RQ < 0.82: Overfeeding Ideal Underfeeding Melinda S. et al. JPEN Vol23, No5, p300, 1999

37 Dextrose

38 Dextrose Basal metabolic rate Adults: Pediatrics: 2mg/kg/min (150g) 6mg/kg/min (6g/kg/d) 50-60% of total calories 1g = 3.4 Kcal Watch Refeeding Syndrome

39 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:

40 12-yr-old male with chronic intractable diarrhea, severe dehydration, severe malnutrition, cachexic, hypoglycemic Wt = 15 kg Admitted to ER Rx: Dextrose 100ml/hr Few hours after, admitted to PICU with myocardial infarction What was wrong?

41 How much dextrose in DW 15% at 100 ml/hr? 360g 16mg/kg/minute

42 Refeeding Syndrome Hypophosphatemia Myocardial ischemia Respiratory arrest Hypokalemia Arrythmia

43 Refeeding Syndrome: Prevention 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

44 Tabbara O., KFSHRC Refeeding Syndrome: KFSHRC Experience K: PO4: Mg: Up to 16 mmol/kg/day Up to 4 mmol/kg/day Up to 2 mmol/kg/day

45 Dextrose Dosing Guidelines 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

46 Which Concentration Gives More Sugar per Day? Dex 17% of 5 ml/hr = 20.4g Dex 18% of 4ml/hr = 17.2g

47 Monitor BG Acid-Base LFTs Electrolytes

48 Safer PN Avoid adding Insulin to PN bag

49 Catching-up Fluid with PN Dex 20% AA 3g/kg/day K 4 6 ml/hr 9ml/hr of TPN = 50% extra of all nutrients + running out earlier

50 Common NICU PN Complication Abrupt discontinuation of PN

51 Amino Acids

52 Protein = Amino Acids Specialized formulas 10% of total calories 1g = 4 Kcal

53 Protein Dosing Guidelines Day 1: 0.7 g/kg/day Day 2: 1.2 g/kg/day Day 3: 1.5-2g/kg/day

54 Protein Tolerance Monitoring BUN Acid-Base LFTs Albumin

55 Lipids

56 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 hrs post contamination Keammerer D. et al., Am J Health Syst Pharm. 1983;40(10: Crill CM. et al., Am J Health Syst Pharm. 2010;67(11):

57 Lipids Concentrated source of calories 1g = 10 Kcal 20-40% of total calories Isotonic MCT: LCT / SMOF Lipid

58 IV Lipid Dosing Guidelines Day 1: Start with 0.5 g/kg/day Day 2: 1 g/kg/day Day 3: g/kg/day Do not exceed 0.15 g/kg/hour Better to be infused over 12 hours

59 Lipid Tolerance Monitoring TG LFTs Platelets

60 PN & Fat Allergy

61 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.

62 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

63 Interpretation of Lab Data

64 What is Right? Treat the patient Not only numbers PN: What is Wrong & What

65 What is Right? Treat the Patient not the Numbers 10-y-old-female Dx: Severe intractable diarrhea, severe dehydration Na 158 Cl 116 BUN 15 Glucose 90 K 4.9 CO2 20 Cr. 2.5 PO4 1.4 Start PN 80ml/hour How much Na shall we add in PN? Add 150 mmol/l + Close monitoring

66 What is Right About Hypernatremia? 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

67 PN in Cholestasis Eliminate Manganese and Copper with cholestasis ½ regular doses of TE

68 IV Lipid Dosing & Infusion Time

69 IVFE Dosing Neonates & Infants: 0.25 g/kg per day minimum to prevent EFAD Maximum of 3 4 g/kg per day ( 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 g/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

70 IV Fat Emulsion Absolute contraindication: TG more than 4 mmol/l Acute Pancreatitis induced by Hypertriglyceridemia

71 Filtering Lipid

72 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. ons_for_in-line_filters/

73 Shortage of 0.2 micron Filters Use 1.2 micron filters for 2-in 1 and TNA - List References here

74 Case Scenario POTASSIUM

75 Potassium Identified as the drug most commonly implicated in fatal incidents in acute care facilities National Patient Safety Agency, UK, 2002 Medication Safety Alerts, CJHP, Canada, 2002

76 1.IV Potassium 2.Insulin 3.Heparin USP/MedMarx 1996 Institute of Safe Medication Practice (ISMP), 2003

77 78

78 Potassium 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 ( ) 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) PO ( ) Mg 0.3 (0.7-1)

79 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 ( ) 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) PO ( ) Mg 0.3 (0.7-1)

80 Why High K Requirement? Amphotericin B Insulin / Dextrose load Diuretics GI Loss Steroids / Salbutamol NPO Magnesium wasting drugs DKA

81 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?!!!

82 Onset of hypokalemia with Ampho-B is hours Increase K in IV empirically Reduce dextrose load!!

83 How To Prevent Severe Hypokalemia? Keep Magnesium levels between mmol/dl Start Ranitidine with upper GI loss

84 Case Scenario Hyponatremia

85 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?

86 Factitious Hyponatremia Excess BG in serum: Serum Osmolarity Correct BG + NS + fluid restriction Excess BUN, Lipid: Isotonic serum NS + fluid restriction

87 Sodium in PN Always ¼ to NS in PN PN is not the vehicle to correct severe hyponatremia (less than 120)

88 Scenario #2 CPN or PPN?

89 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

90 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.

91 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.

92 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, 2001 Teitlbaum DH. et al. JPEN 21(2):100-3, 2000 Dotty et al. Ann Surg. 210(1):76-80, 1993 Kubota A. et al., J Ped Surg 25:618, 1990

93 Additional Literature/References Chwals WJ. New Horiz 2: , 1994 Clein CG. Et al., J Am Diet Assoc 98: , 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: , 2017