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
King Faisal Specialist Hospital & Research Center, 900 beds, Riyadh, SA Clinical Scenarios in Parenteral Nutrition
King Fahad Medical City (KFMC), 1100 beds, Riyadh, SA Clinical Scenarios in Parenteral Nutrition
Cleveland Clinic Abu Dhabi, March 2011 Clinical Scenarios in Parenteral Nutrition
CCAD, June 2012 Clinical Scenarios in Parenteral Nutrition
Cleveland Clinic Abu Dhabi, March 2015 Clinical Scenarios in Parenteral Nutrition
"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
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
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
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
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; 30:259-265 Clinical Scenarios in Parenteral Nutrition 11
Refeeding Syndrome Clinical Scenarios in Parenteral Nutrition
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 15% @ 100ml/hr Few hours after, admitted to PICU with Myocardial Infarction What was wrong? Clinical Scenarios in Parenteral Nutrition 13
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
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 15:713-726, 1995 Solomon S. et al., JPEN 14(1):90-97, 97 1990 Clinical Scenarios in Parenteral Nutrition 15 Tabbara O., Al-Rahba Hospital
Scenario #1: Refeeding Syndrome K, PO4, Mg Insulin/Dextrose K, PO4, Mg Na Na Intracellular Interstitial Intravascular Clinical Scenarios in Parenteral Nutrition 16
Take Home Message Identify patient at risk Treat the patient not the lab Monitoring is key to success Clinical Scenarios in Parenteral Nutrition 17
POTASSIUM Clinical Scenarios in Parenteral Nutrition
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
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 Clinical Scenarios in Parenteral Nutrition 21
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 (135-147) 147) (98-111) (2.4 7) (3-8) K 2.1 CO2 30 Cr 44 PO4 0.39 (0.7-1.45) (3.5-5) 5) (22-21) 21) (44-123) Mg 0.3 (0.7-1) Clinical Scenarios in Parenteral Nutrition 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 QUESTIONS: Why severe hypokalemia? How can we reduce potassium requirements? Na 135 (135-147) Cl 101 (98-111) BUN 12 (2.4 7) Glucose 9 (3-8) K 2.1 CO2 30 Cr 44 PO4 0.39 (0.7-1.45) (3.5-5) (22-21) (44-123) Mg 0.3 (0.7-1) Clinical Scenarios in Parenteral Nutrition 23
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
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
How to prevent severe HYPOKALEMIA? Onset of hypokalemia with Ampho-B is 24-36 hours Increase I K in IV empirically ii Reduce dextrose load!! Clinical Scenarios in Parenteral Nutrition 26
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 48-72 hours Do not hold K-sparing drugs if K level is adjusted Clinical Scenarios in Parenteral Nutrition 27
How to prevent severe HYPOKALEMIA? Keep Magnesium levels between 0.9-1 mmol/dl Start Ranitidine with upper GI loss Clinical Scenarios in Parenteral Nutrition 28
POTASSIUM Clinical Scenarios in Parenteral Nutrition
Scenario # 3: IV POTASSIUM for 6-year old with ALL MD order: D5W 1/4NS + KCl 60 mmol @ 70ml/hr x 2 hrs Pharmacist: 140ml of D5W 1/4NS + KCl 60 mmol @ 70ml/hr x 2 hrs Nurse: Check & Administer Patient: Expired during infusion Clinical Scenarios in Parenteral Nutrition 30
Scenario # 3: POTASSIUM MD order D5W 1/4NS + KCl 60 mmol @ 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 60 mmol @ 70 ml/hr x 2 hrs Total = 60 mmol Nurse? Patient Expired Clinical Scenarios in Parenteral Nutrition 31
POTASSIUM Clinical Scenarios in Parenteral Nutrition
Scenario # 4: POTASSIUM 2-y-old female, 10kg, K 2.9 Order: TPN with KCL 20 mmol/l @ 10ml/hr Pharmacist: TPN with KCL 20mmol/L @ 10ml/hr Nurse: Administer @ 100ml/hr Patient: K 5.9? harm Clinical Scenarios in Parenteral Nutrition 33
BAD DRAW Clinical Scenarios in Parenteral Nutrition
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 + 46. Asymptomatic. Lab shows: Na 135 Cl 99 BUN 6 Gl (135-147) (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 (0.7-1.45) Mg 1.1 (0.7-1) Clinical Scenarios in Parenteral Nutrition 35
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
Signs of Hypoglycemia Polydipsia Polyurea Muscle weakness ECG changes Clinical Scenarios in Parenteral Nutrition 37
SODIUM Clinical Scenarios in Parenteral Nutrition
Scenario # 6: SODIUM 10-y-old-female Dx: Severe intractable diarrhea, severe dehydration 158 135 Na: (135-148), 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
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
SODIUM Clinical Scenarios in Parenteral Nutrition
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 (135-145 mmol/l) Cl 90 (95-107 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 (0.8 1.7 mmol/l Dx? Should you increase Na in PN? Clinical Scenarios in Parenteral Nutrition 42
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
Peripheral PN Clinical Scenarios in Parenteral Nutrition
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
Phlebitis Prevention Frequent site changes Filter Hydrocortisone 6mg/L Heparin 1unit/ml Less K Less Ca Extra IV lipid Tighe MJ., et al., JPEN 19:507-509, 1995 Anderson ADG., et al. Brit J Surg 90:1048-1054, 2003 Isaacs JW. et al., AJCN 30(4):552-9, 1977 Tighe MJ., et al., JPEN 19:507-509, 509 1995 Clinical Scenarios in Parenteral Nutrition 46
IV Lipid Protect veins from phlebitis Safe at any dose with PPN Clinical Scenarios in Parenteral Nutrition 47
PN & Hepatotoxicity Clinical Scenarios in Parenteral Nutrition
Scenario#9 PN Cholestasis: KFSHRC Experience 2-yr-old girl with SBS (5cm): PN day + 780 3-yr-old boy with FTT, Diarrhea: PN day + 908 5-yr-old boy with FTT, Diarrhea: PN day + 1007 How PN-induced hepatotoxicity can be reduced? Clinical Scenarios in Parenteral Nutrition 49
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
PN & Liver Disease Early enteral feeding is the most effective strategy in preventing PN- induced liver disease Clinical Scenarios in Parenteral Nutrition 51
Avoid Bowel Rest NPO + PN = More infections NPO + PN = More cholestasis Buchman AL. et al., JPEN 19:453-460, 460 1995 Border JR. et al., Ann Surg. 206:427-448, 1980 Deitch EA. et al., Ann Surg. 205:681-690, 1987 Clinical Scenarios in Parenteral Nutrition 52
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