Osama Tabbara, RPh R.Ph., BCNSP Senior Director, Pharmacy Department

Transcription

1 Clinical Scenarios in Parenteral Nutrition Osama Tabbara, RPh R.Ph., BCNSP Senior Director, Pharmacy Department Cleveland Clinical Scenarios Clinic Abu in Parenteral Dhabi (CCAD) Nutrition

2 King Faisal Specialist Hospital & Research Center, 900 beds, Riyadh, SA Clinical Scenarios in Parenteral Nutrition

3 King Fahad Medical City (KFMC), 1100 beds, Riyadh, SA Clinical Scenarios in Parenteral Nutrition

4 Cleveland Clinic Abu Dhabi, March 2011 Clinical Scenarios in Parenteral Nutrition

5 CCAD, June 2012 Clinical Scenarios in Parenteral Nutrition

6 Cleveland Clinic Abu Dhabi, March 2015 Clinical Scenarios in Parenteral Nutrition

7 "Placing patients first is our highest priority. Patients are the reason we exist and the reason we come to work each day." Delos M. Cosgrove, M.D. Chief Executive Officer and President Cleveland Clinic 7 Clinical Scenarios in Parenteral Nutrition 7

8 OBJECTIVES 9 Case Scenarios: Refeeding R f syndrome (1 scenario) Potassium (4 scenarios) Sodium (2 scenarios) Peripheral P i h l PN (1 scenario) Hepatotoxicity p y (1 scenario) Clinical Scenarios in Parenteral Nutrition 8

9 IVPN Experts Network - Gulf Region 312 members from 130 hospitals Purpose: To promote learning organization, spread and exchange the knowledge and experience of IV & TPN Si Sciences in the Middle East & beyond. IVPNgulf@googlegroups.com We are 350 members from 130 Hospitals Clinical Scenarios in Parenteral Nutrition

10 True or False?? The majority of serious errors associated with PN are related to the electrolyte composition of the formulation? TRUE: The 2003 Safety Task Force Survey revealed that 69% of PN errors were related to electrolytes. Clinical Scenarios in Parenteral Nutrition 10

11 2003 Survey of PN Practices ASPEN Task Force: Error Results Electrolytes: 69% Dextrose/insulin: 31% Fat F t Emulsion 26% Seres D. et al., JPEN 2006; 30: Clinical Scenarios in Parenteral Nutrition 11

12 Refeeding Syndrome Clinical Scenarios in Parenteral Nutrition

13 Scenario #1: Refeeding Syndrome 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? Clinical Scenarios in Parenteral Nutrition 13

14 Scenario #1: Refeeding Syndrome How much dextrose in D15%W at 100 ml/hr? 360g 16mg/kg/minute / i t Clinical Scenarios in Parenteral Nutrition 14

15 Scenario #1: Refeeding Syndrome Refeeding Syndrome: Very common in Peds Well W described d in the literatures t Crook MA. et al., Nutrition 17:632, 2001 Faintuch J. et al., Nutrition 17(2):100-4, 2001 Marek PE. et al., Arch Surg. 124:1325,1996 Brooks MJ., et al., Pharmacotherapy 15: , 1995 Solomon S. et al., JPEN 14(1):90-97, Clinical Scenarios in Parenteral Nutrition 15 Tabbara O., Al-Rahba Hospital

16 Scenario #1: Refeeding Syndrome K, PO4, Mg Insulin/Dextrose K, PO4, Mg Na Na Intracellular Interstitial Intravascular Clinical Scenarios in Parenteral Nutrition 16

17 Take Home Message Identify patient at risk Treat the patient not the lab Monitoring is key to success Clinical Scenarios in Parenteral Nutrition 17

18 POTASSIUM Clinical Scenarios in Parenteral Nutrition

19 Scenario #2 POTASSIUM Identified as the drug most commonly implicated in fatal incidents in acute care facilities National Patient Safety Agency, UK, 2002 JCAHO, USA, 1998 Medication Safety Alerts, CJHP, Canada, 2002 Clinical Scenarios in Parenteral Nutrition 19

20 Potentially Dangerous Drugs 1.IV Potassium 2.Insulin 3.Heparin USP/MedMarx 1996 Institute of Safe Medication Practice (ISMP), 2003 Clinical Scenarios in Parenteral Nutrition 20

21 21 Clinical Scenarios in Parenteral Nutrition 21

22 Scenario #2 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 Na 135 Cl 101 BUN 12 Glucose 9 ( ) 147) (98-111) (2.4 7) (3-8) K 2.1 CO2 30 Cr 44 PO ( ) (3.5-5) 5) (22-21) 21) (44-123) Mg 0.3 (0.7-1) Clinical Scenarios in Parenteral Nutrition 22

23 Scenario #2 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 QUESTIONS: 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 CO2 30 Cr 44 PO ( ) (3.5-5) (22-21) (44-123) Mg 0.3 (0.7-1) Clinical Scenarios in Parenteral Nutrition 23

24 Why too much K requirement? Amphotericin B Insulin / Dextrose load Diuretics GI Loss Steroids / Salbutamol NPO Magnesium wasting drugs DKA Clinical Scenarios in Parenteral Nutrition 24

25 Investigate first, then add POTASSIUM 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?!!! Clinical Scenarios in Parenteral Nutrition 25

26 How to prevent severe HYPOKALEMIA? Onset of hypokalemia with Ampho-B is hours Increase I K in IV empirically ii Reduce dextrose load!! Clinical Scenarios in Parenteral Nutrition 26

27 How to prevent severe HYPOKALEMIA? If more than 100 mmol of K required per day: Triamterene 100mg po bid or Spironolactone: 100mg bid x 5 d, then 100mg qd Onset of action is hours Do not hold K-sparing drugs if K level is adjusted Clinical Scenarios in Parenteral Nutrition 27

28 How to prevent severe HYPOKALEMIA? Keep Magnesium levels between mmol/dl Start Ranitidine with upper GI loss Clinical Scenarios in Parenteral Nutrition 28

29 POTASSIUM Clinical Scenarios in Parenteral Nutrition

30 Scenario # 3: IV POTASSIUM for 6-year old with ALL MD order: D5W 1/4NS + KCl 60 70ml/hr x 2 hrs Pharmacist: 140ml of D5W 1/4NS + KCl 60 70ml/hr x 2 hrs Nurse: Check & Administer Patient: Expired during infusion Clinical Scenarios in Parenteral Nutrition 30

31 Scenario # 3: POTASSIUM MD order D5W 1/4NS + KCl 60 70ml/hr x 2 hrs He meant: D5W 1/4NS + KCL 60mmol/L 140ml of KCL 60 mmol/l = 8.2 mmol Pharmacist 140ml of D5W 1/4NS + KCl ml/hr x 2 hrs Total = 60 mmol Nurse? Patient Expired Clinical Scenarios in Parenteral Nutrition 31

32 POTASSIUM Clinical Scenarios in Parenteral Nutrition

33 Scenario # 4: POTASSIUM 2-y-old female, 10kg, K 2.9 Order: TPN with KCL 20 10ml/hr Pharmacist: TPN with KCL 10ml/hr Nurse: 100ml/hr Patient: K 5.9? harm Clinical Scenarios in Parenteral Nutrition 33

34 BAD DRAW Clinical Scenarios in Parenteral Nutrition

35 Scenario # 5: Blood Draw 18 y-old male Dx. Crohns disease; home PN day +45 PMH: Not significant Dextrose 20%, K 80 mmol/l Metabolically stable. No PN adjustment for past 10 days Day Asymptomatic. Lab shows: Na 135 Cl 99 BUN 6 Gl ( ) (95-107) (2.4 7) (3-8) Glucose 18 K 6.5 (3.5-5) CO2 22 (22-21) Cr 48 (44-123) PO4 1.6 ( ) Mg 1.1 (0.7-1) Clinical Scenarios in Parenteral Nutrition 35

36 PN Dextrose 20% K 80 mmol/l Dex 1% (100mg/dL) K Intracellular Interstitial (3.5-5 mmol/l) 30L 10L 4L Clinical Scenarios in Parenteral Nutrition 36

37 Signs of Hypoglycemia Polydipsia Polyurea Muscle weakness ECG changes Clinical Scenarios in Parenteral Nutrition 37

38 SODIUM Clinical Scenarios in Parenteral Nutrition

39 Scenario # 6: SODIUM 10-y-old-female Dx: Severe intractable diarrhea, severe dehydration Na: ( ), Cl (95-107), K: 4.9, BUN: 15 (2.4-7), 42 Albumin: (35-48) Start PN 80ml/hour How much Na shall we add in PN? Clinical Scenarios in Parenteral Nutrition 39

40 Sodium & Fluid Balance High intake of Na: 10% of all cases NS, ABx, Albumin, etc. Urine Na > 20mmol/L Rx: D5W + Furosemide Volume depletion: 90% of all cases Fever, Hyperventilation, Sweating, GI losses Symptoms: Thirst, Weight loss, High BUN, Albumin, Hct, Rx: NS or D5 NS Clinical Scenarios in Parenteral Nutrition 40

41 SODIUM Clinical Scenarios in Parenteral Nutrition

42 Scenario # 7: HYPONATREMIA 42-y-old lady admitted with Pneumonia PMH: Home PN due to SBS, Type II DM, HTN, High Chol and TG Lab: Na 129 ( mmol/l) Cl 90 ( mmol/l) BUN 20 (2.4-7 mmol/l) BG 16 (3-8mml /L) K 4.1 (3.5-5 mmol/l) CO2 25 (23-30 mmol/l) Cr 60 (44 123mcmol/L) TG 4 ( mmol/l Dx? Should you increase Na in PN? Clinical Scenarios in Parenteral Nutrition 42

43 Scenario # 7: Factitious Hyponatremia Excess BG in serum: Serum Osmolarity Correct BG + NS + fluid restriction ti Excess BUN, Lipid: Isotonic serum NS + fluid restriction Clinical Scenarios in Parenteral Nutrition 43

44 Peripheral PN Clinical Scenarios in Parenteral Nutrition

45 Scenario # 8 Phlebitis & PN 54-yr-old female, cachexia, severely malnourished Dx: Partial Esophageal Obstruction Can drink limited i volume of oral formula PPN to be started Poor peripheral veins QUESTIONS: How can we reduce the chance of phlebitis? Clinical Scenarios in Parenteral Nutrition 45

46 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: , Clinical Scenarios in Parenteral Nutrition 46

47 IV Lipid Protect veins from phlebitis Safe at any dose with PPN Clinical Scenarios in Parenteral Nutrition 47

48 PN & Hepatotoxicity Clinical Scenarios in Parenteral Nutrition

49 Scenario#9 PN Cholestasis: KFSHRC Experience 2-yr-old girl with SBS (5cm): PN day yr-old boy with FTT, Diarrhea: PN day yr-old boy with FTT, Diarrhea: PN day How PN-induced hepatotoxicity can be reduced? Clinical Scenarios in Parenteral Nutrition 49

50 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 Reduce Manganese & Copper Ursodecoxycholic acid/ Oral Metronidazole L-Glutamine* Rule out drug-induced *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 Clinical Scenarios in Parenteral Nutrition 50

51 PN & Liver Disease Early enteral feeding is the most effective strategy in preventing PN- induced liver disease Clinical Scenarios in Parenteral Nutrition 51

52 Avoid Bowel Rest NPO + PN = More infections NPO + PN = More cholestasis Buchman AL. et al., JPEN 19: , Border JR. et al., Ann Surg. 206: , 1980 Deitch EA. et al., Ann Surg. 205: , 1987 Clinical Scenarios in Parenteral Nutrition 52

53 THANK YOU Clinical Scenarios in Parenteral Nutrition