TPN using AIO What does it mean and what are the benefits?

Transcription

1 TPN using AIO What does it mean and what are the benefits? Staffan Bark. MD. PhD. Visby, Sweden Boracay, 2006 PENSA 2007 Satellite

2 What is TPN and what is AiO? To prescribe PN as an order of a treatment is comparable to prescribe antibiotics, or... cardiac drug, or... tranquilizer as a treatment

3 Human metabolism PROTEIN GLUCOSE FAT + Micronutrients

4 Where is the food?

5 In the hospital cantina, at home or in the restaurant, we anticipate TON* * TON = Total Oral Nutrition

6 Where is the food?

7 Preoperative TPN reduces complications Noninfectious complications in severely malnourished cancer patients 43% p=0.03 5% TPN Control The VA Study, 1991

8 The Veterans Affair Study A sugar festival

9 Urinary excretion of norepinephrine before/during TPN Nordenström et al. Clin Physiol 1:525, n.s. Lipid p<0.01 Glucose East WestDual 3-D Column 3 3-D Column 50:504 3-D Column 5 3-D Column 6 3-D Column 7 3-D Column 100:08 3-D Column 9 energy Glucose energy

10 Some water and sugar will do. Let s wait and see! In the wards and ICU, we often serve IPN* * IPN = Incomplete Parenteral Nutrition

11 Sometimes, the IPN* is somewhat improved * IPN = Incomplete Parenteral Nutrition

12 Fridays = party-time = some fat Some days the body can even get what it needs Maybe even some micronutrients

13 She can wait. There is no evidence that she needs any TON this week

14 Glucose Amino acids Electrolytes Lipids Micronutrients Things move better if they are complete

15 A deficiency can be life threatening Anson s Expedition 1317 out of 1955 sailors died 75% due to scurvy

16 Scurvy : recommended cures Keeping crew dry and the ship clean serving bread and diluted wine for breakfast sprinkling vinegar about the ship burning tar bleeding 8oz blood from the left arm cooking in iron boilers instead of copper punishing the idle sailor eating the ship s s rats

17 James Lind registered as apprentice, aged 15yrs, at RCS Edinburgh 1739 began serving as naval surgeon 1748 admitted Edinburgh University to take MD

18 20 May 1747 James Lind, senior surgeon on HMS Salisbury selected 12 sailors with advanced Scurvy Conducted the first known nutritional epidemiological study on the causes of scurvy

19 The twelve sailors were put on different interventions: quart of cider to gargle and swallow 2 spoons of vinegar 3 x per day & on foods 1/2 pint of sea water every day 2 oranges & 1 lemon every day on empty stomach nutmeg and barley water Group 4, i.e. on orange & lemon, was back on duty after 6 days

20 A deficiency can be life-threatening Anson s s Expedition 1317/1955 sailors die 75% due to scurvy 1754 James Lind & RCT 12 severe scurvy to 6 treatments 2 on lemons better in 6 days 1768 James Cook cure by complex management 1795 Nelson s s Navy Lemon juice adopted Scurvy & the British Navy (Vitamin C deficiency)

21 A deficiency can be life-threatening Anson s s Expedition 1317/1955 sailors die 75% due to scurvy 1754 James Lind & RCT 12 severe scurvy to 6 treatments 2 on lemons better in 6 days 1768 James Cook cure by complex management 1795 Nelson s s Navy Lemon juice adopted after 1805 Navy cost-saving saving cheaper lime juice 1/3rd Vit C & scurvy re- appears Scurvy & the British Navy (Vitamin C deficiency)

22 Vitamin C defiency in Residential Institutions in UK 60 P<0.001 Significant 50 differences P<0.007 within the same country South Central North 0 Mild Severe!!! Elia & Stratton 2005

23 Thiamine (B ) 1 N NH 2 Methylene bridge N N Pyrimidine S Thiazole CH 2 CH 2 OH Absorptive capacity ~ 5 mg/day Body stores mg (80% as di-phosphate, the rest as mono- and tri-p Coenzyme for cleavage of carbon-carbon bonds

24 Micronutrients Water soluble vitamins To think about: Vit B 1 Thiamin Amino acids with bisulphite rapidly degrades Thiamin 3 mg/day is recommended by AMA for TPN

25 Wernicke s Encephalopathy during parenteral nutrition Francini-Pesenti et al. JPEN 2007, 31(1):69 A case report A 66 year old man, well-nourished underwent surgery for acute necrotic-haemorrhagic pancreatitis related to the gallbladder. No alcohol abuse or weight loss On PO Day 7 (on TPN) nausea and vomiting Gastroscopy negative On PO Day 12 diplopia, ataxia, confusion, stiffness and gradual fall in platelets (from 270,000 to 18,000) CT-scan (brain) negative, EEG non-specific changes

26 Wernicke s Encephalopathy during parenteral nutrition Francini-Pesenti et al. JPEN 2007, 31(1):69 A case report The nutrition team became involved and the diagnosis was established and confirmed by MRI 100 mg Thiamine daily was started IV All neurological signs disappeared after 4 days Platelet count started to rise after 3 days and was normal after 12 days MRI after 40 days normal

27 Beri-Beri Wet beriberi - cardiovascular manifestations and the Dry beriberi - neurological The typical patient has mixed symptoms Occurs in alcoholics or food faddists Thiamine-free diet (e.g. milled rice) or excessive intake of foods containing thiaminases (e.g. seafood) Chronic PD, hemodialysis, refeeding after starvation Glucose administration to asymptomatic thiamine depleted patients

28 Fat soluble vitamins Can be administered separately in a lipid emulsion or mixed with the water soluble vitamins (MVI) (but then you need to add a detergent) and is there Vit K in it?

29 This is a solid chain

30 Awareness is crucial This could be the result of a missing micronutrient

31 The utilisation of peripherally-administered administered intravenous nutrient solutions 42 patients/3 groups Glucose/saline (DS), AA or glucose, AA & fat (GAF) DS AA n Infusion GAF l Glucose 1.5 l Vamin 1 l Saline 1.5 l water 1.5 l water mix 2 l Vitri- mix Kcal/Nitrogen 400/0 (350)/ /14.1 Cum 4d N-balanceN ± ± ± 2.3 Hansell et al, Clin Nutr 1989, 8:289-97

32 Better utilisation - Nitrogen balance Gram +1-4 Continuous Bolus Sequential Days Sandström et al, JPEN 1995, 19;5

33 There are different limits for different people There are different limits for different nutrients

34 Fat burning capacity 0.15 g/kg/h Glucose burning capacity 0.25 g/kg/h

35 0.25 g glucose/kg/h = 1 kcal/kg/h 0.15 g fat/kg/h = 1.35 kcal/kg/h

36 If the metabolic borderlines for healthy people should be used, means NPE as: 57.4% fat and 42.6% glucose

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39 A freedom as long as the metabolic capacity is recognized

40 Requirements Hyperalimentation was for long the state of art Resulted in overfeeding according to today s s knowledge Studies have shown that very few patients need more than 2000 kcal even in ICU

41 With hyperalimentation, the aim was to feed 40% - 100% above BMR to avoid weight loss. Since that time we know that BMR is not markedly increased in most patients with critical illness without burns Jeejeebhoy. NCP, Oct 2004, 19(5):477

42 Caloric need Resting Energy Expenditure Kcal/min = 3.94 x VO x VCO 2 RQ fat 0.7 protein 0.8 CHO 1.0 Category Studies Pat Range kcal Surgical Oncology Mixed Nordenström & Thörne, E J Clin Nutr, 1994;48:531-37

43 Roulet et al. Clin Nutr 2:97-105, 1983 Baker et al. Gastroenterology 87:53-9, 1984 McCall et al. JPEN 27:27-35, 2003 Summarized in Jeejeebhoy. NCP 19(5):477-80, 2004 The mean REE in sedated and ventilated patients was 1500 kcal/day

44 Jeejeebhoy. NCP, Oct 2004, 19(5):477 The data given, suggest that a high energy intake is not required irrespective of the route of feeding, hyperglycemia increases mortality, and increased energy intake promotes the risk of hyperglycemia

45 Resting Energy Expenditure during mechanical ventilation and its relationship with the type of lesion Raurich JM, Ibánez J, Marsé P et al. JPEN 2007, 31(1):58 Matched subgroups of ICU-patients on ventilator (n = 87) Surgical vs Medical (S M) Medical vs Trauma (M T) Trauma vs Surgical (T S) No statistically significant difference in REE between groups Mean REE 1834 kcal/day (± 320) Difference: S M: 52 kcal/d M T: 5 kcal/d T S: 43 kcal/d

46 These figures indicate that less attention can be paid on exact need of Energy/kg bw/day (especially when the estimated need is >2000 kcal) but energy should be given

47 Energy balance and outcome in critically-ill ill patients Mault J, ICU Nutrition Study group, Denver, CO, USA JPEN 2000, 24(1):S4 67 patients likely to require mechanical ventilation >72 h MEE and urea N excretion measured every day Controls (n=35) received nutrition according to standard estimations Study group (n=32) nutrition according to MEE and N-excretion to maintain neutral balance of energy and nitrogen

48 Energy balance and outcome in critically-ill ill patients Mault J, ICU Nutrition Study group, Denver, CO, USA JPEN 2000, 24(1):S4 Controls Study Vent.days ICU Days Pos. Energy 24 (69%) 27 (84%) 10.6 ± ± 1.6 balance P<0.005 p<0.05 Neg. Energy 11 (31%) 5 (16%) 19.9 ± ± 4.0 balance No difference in mortality (27%)

49 Hospital Malnutrition Is here, will always be here and must be recognized if we care about our patients

50 facilitates labelling Total parenteral nutrition manipulation bags Dual energy supply All in One Parenteral nutrition osmolality Cost effective facilitates delivery & storage

51 Peripheral nutrition possible with AiO A few % use peripheral veins for PN in USA >50% use PPN world-wide Consider this when reading scientific papers on clinical nutrition

52 Summary All-in in-one All-in-One. Even sick people have some relationship to physiology, i.e. a need of balanced nutrition All-in-One. Reduces stress All-in-One. Reduces the risk of hyperglycemia All-in-One. Safety. Less prescription errors. Less manipulations. PPN = Less line infections All-in-One. Convenient

53 She can wait. There is no evidence that she needs any TON this week

54 I got it finally. An All-in-One meal. But what about the poor guy in the hospital?

55 Where is the food? He is still waiting (when we look on this globally) We should all follow the ideas of Hippocrates

56 A slender and restricted diet is always dangerous in chronic diseases, and also in acute diseases Hippocrates (440 B.C.) From Corpus Hippocraticum in the 4th century BC in Alexandria

57 Thanks for your attention Boracay, 2006