Parenteral Nutrition in Critical Illness

Judy WONGDietitian

PMH

OverviewWhat is parenteral nutritionSelection Criteria of parenteral nutritionParenteral nutrition accessRequirements of critically ill patientsRefeeding SyndromeParenteral Nutrition formulations & How to chooseCase Study

What is Parenteral NutritionParenteral nutrition refers to the infusion of

intravenous nutrition formula into the bloodstream

DAA, 2011

Selection Criteria for Parenteral NutritionShould be used in patients who are or will

become malnourished, and

Who do not have sufficient gastrointestinal function to be able to restore / maintain nutritional status

McClave et al.,2009

Access of parenteral nutrition

Access of parenteral nutritionCentral parenteral nutrition (CPN)

To large, high blood flow vein (e.g. superior vena cava)

For long term parenteral nutrition

Central Parenteral Nutrition solution osmolarity can be > 900mOsm/L

More suitable for volume-sensitive patients (e.g. patients with heart, renal or liver problem)

Access of parenteral nutritionPeripheral parenteral nutrition (PPN)

Catheter tip placement in a small vein (e.g. forearm)

PeripherallParenteral Nutrition solution osmolarity < 900 mOsm/L

Usually do not fully meet nutrition requirements

Use as:Supplemental feedingTransition to oral/enteral feedingTemporary PN when central access has not been initiated

Energy requirementMacronutrient requirementsMicronutrient requirements

Requirements of critically ill patients

Requirements during metabolic stress

Adequate energy is essential for metabolically stressed patients

Avoidance of overfeeding in the critically ill patients is important

Excess calories can result in complications: hyperglycaemia hepatic steatosis excess CO2 production (exacerbate respiratory insufficiency /

prolong weaning from mechanical ventilation)

Krause’s, 2012

How much energy should critically ill patients receive?

ESPEN Guidelines 2009:

“as close as possible to the energy expenditure in order to decrease negative energy balance” (Grade B);

“in the absence of indirect calorimetry, ICU patients should receive 25kcal/kg/day increasing to target over the next 2-3 days” (Grade C)

Singer P et al (2009)

Calculations of requirementEstimation of energy requirement

= Basal Metabolic Rate (BMR) + Activity Factor

+ Stress Factor

Calculations of requirement

Estimation of energy requirementBasal Metabolic Rate (BMR) estimation

(Schofield Equation):

Age Male Female

18-29 15.1 x W + 692 14.8 x W + 487

30-59 11.5 x W +873 8.3 x W + 846

60-74 11.9 x W + 700 9.2 x W + 687Over 75 8.4 x W + 821 9.8 x W + 624

W = body weight in kg; Calculated BMR in kilocalorie (kcal)Department of Health (UK), 1991

Activity FactorsActivity Level

Bedbound, immobile +10%

Bedbound, mobile or sitting + 15-20%

Mobile, on ward +25%

Todorovic and Micklewright (2004)

Stress FactorsCondition Stress factor (%

BMR)Brain Injury

Acute (ventilated and sedated)Recovery

0-305-50

Cerebral Haemorrhage 30CVA 5COPD 15-20Infection 25-45Intensive Care

VentilatedSeptic

0-1020-60

Leukaemia 25-34Pancreatitis

ChronicAcute

310

Sepsis / Abscess 20Solid Tumours 0-20Transplantation 20Surgery

UncomplicatedComplicated

5-2025-40

Todorovic and Micklewright (2004)

Macronutrients Requirements

Macronutrient requirements

Protein

depending on the baseline nutritional status, degree of injury and metabolic demand, or any abnormal losses (e.g. open wound or burned skin)

Varies between 0.9-1.5g/kg/day for various conditions

Krause’s, 2012

Macronutrient requirements

Carbohydrate

Ensures that protein is not catabolised for energy during metabolism

Excessive administration:hyperglycaemiahepatic abnormalities ventilatory drives

Maximum infusion rate of carbohydrate: <5mg/minute/kg body weight

DAA, 2011

Macronutrient requirements

Fat

~ 10% of calories/day from fat provide 2% to 4% of calories from linoleic acid (LA) in order to prevent Essential Fatty Acid Deficiency

Soybean and safflower oils: rich sources of LA

LA: pro-inflammatory & immunosuppressive

Maximum infusion rate of fat: <0.11g/hour/kg body weight

DAA, 2011

Micronutrient Requirements

Micronutrient requirements

Ready-made Parenteral Nutritional Products are free of vitamins and trace elements

The addition of vitamins and trace elements are always required

ESPEN Guidelines 2009;Casaer & Van den Berghe,

2014

MicronutrientsVitamins and trace elements addition via

the addition of:

Soluvit® N

Vitalipid N® Adult

Addamel® N

Soluvit® Nprovide the daily requirement of water-

soluble vitamins

A vial (10ml) = normal daily requirement of water-soluble vitamins

Fresenius Kabi

Vitalipid N® Adultmeet the daily requirement of the fat-soluble

vitamins A, D2, E and K1 in adults & children aged 11 years or older

One ampoule (10ml) = daily intake of fat-soluble vitamins

Contraindications: hypersensitivity to egg protein / soybean / peanut protein

Fresenius Kabi

Addamel® Ncovers basal or moderately trace elements needs

The recommended daily does for adult patients with basal or moderately elevated needs is 10ml (one ampoule)

Contraindications: in patients with blocked bile flow, and manganese levels must be checked if treatment lasts > 4 weeks

Fresenius Kabi

Refeeding Syndrome

Refeeding Syndrome1. What is refeeding syndrome?

A metabolic disorder as a consequence of too aggressive administration of nutrition after a prolonged inadequate nutrition supply

Characterized by hypophosphataemia, hypomagnesiumaemia and hypokalaemia; with excessive sodium and fluid retention

May cause potentially lethal electrolye flucatuations involving metabolic, haemodynamic & neuromuscular problemsStanga, Z et al (2008)

Krause’s (2012)Mehanna et al (2008)

Refeeding Syndrome2. Who is at risk?

Meet ANY of the criteria:

BMI < 16kgm-2

NPO ≥ 10 days (or with minimal nutrition intake > 10 days)

Weight loss > 15% in 3 to 6 months

Hypophosphataemia, hypokalaemia, hypomagnesaemia Stanga, Z et al (2008)

Refeeding syndrome3. How to prevent?

Start feeding at < 50% of energy requirement, rate can then be if no refeeding problem detected

For high risk of refeeding: start with 10kcal/kg/day

For very malnourished patients, start with 5kcal/kg/day, with cardiac monitoring

NICE guideline (2006)

Refeeding syndrome3. How to prevent?

Vitamin supplementation: before and for the first 10 days of refeeding

Oral, enteral or IV supplements of K, PO4, Ca & Mg should be given unless blood levels are before refeeding

NICE guideline (2006)

PN formulations

Currently available formulations in PMH

PN FormulationsBesides carbohydrate and protein content varies, type

of fat emulsions used also differ

Most commonly used is soybean oil based fat emulsion

Alternatively fat emulsions: Soybean oil + MCT Soybean oil + Olive Oil Fish oil other multi-lipids (a mixture of soy, MCT, olive and fish oil)

DAA, 2011ASPEN Position Paper, 2012

Soybean oil Examples: Kabiven Central, Kabiven Peripheral

The most commonly used fat emulsion type

Linoleic Acid (LA, n-6) comprise a 50% of total fatty acid profile

Alpha Linolenic Acid (ALA, n-3) about 10% of total fatty acid profile

omega 6 content drawback due to its pro-inflammatory potential

ASPEN Position Paper (2012)

Soybean oil + MCTExamples: Nutriflex Lipid Special, Nutriflex Lipid Plus

Soybean oil : MCT = 50 : 50

MCT:readily oxidizableSafe source of lipidpro-inflammatory properties

Soybean oil + Olive oilExamples: Oliclinomel

Olive oil : soybean oil = 80 : 20

the content of omega 6 in formulation by ~ 75%

Higher vitamin E content for its anti-oxidating properties

ASPEN Position Paper (2012)

Multi-lipidsExamples: SMOF Kabiven

A mixture of soybean oil, MCT, olive oil and fish oil in a ratio of 30 : 30 : 30 : 10

Fish Oil:rich in omega 3 (anti-inflammatory properties)

ASPEN Position Paper (2012)

How to choose?

How to choose?1. Based on calculated energy / protein

requirements

2. Disease Specific:

Renal / Cardiac diseases Vs Fluid content of PN

BGA / pCO2 Vs CHO content

Initiation of parenteral nutrition

Initiation of Parenteral Nutrition

1. Ensure the selected formulation is compatible with the route of parenteral nutrition (central / peripheral)

2. Choice of parenteral nutrition regimenContinuous PN (Q24H)Cyclic / intermittent (Q16H/Q12H)

3. Ensure final infusion rate DOES NOT exceed the maximum infusion rate for fat and CHO

Case Study

Case StudyBackground Information

KC, 57 year-old male, admitted to PMH on 5 Aug 2013Admission Diagnosis: MalnutritionPast Medical History: HT, anaemia, Ca cardia with

oseophago-gastrectomy, short bowel syndrome, CHBRelevant Medications: Aminoleban EN (1 sachet),

Entecavir, Vitamin K1, Slow K, Vitamin B complex

Case StudyAnthropometry:

Height 1.74m Weight 37.6kg BMI 12.4kgm-2 Ideal Body Weight: 56-69kg

Laboratory Values: Spot glucose 3.3 Alb 17 ALP 357 ALT 194

Wound x 1 (stage III)

Case StudyEstimated energy requirement: ~ 2000-2100kcal (bedbound + wound + weight )

Estimated protein requirement:~56-69g per day

Route of nutrition:1. Oral (as much as tolerated)2. Peripheral parenteral nutrition

Case Study1. Formula selection:

Peripheral access = Kabiven Peripheral

Plan to start with small infusion rate and grade up as tolerated

Case Study2. Starting PN:

30ml/hr x 16hrs Kabiven Peripheral (+ Addamel N / Vitalipid N Adult / Soluvit N) (~333kcal, 11g protein)

Gradually stepped up to 100ml/hr x 16hrs (~1167kcal, 37g protein)

(Note: Maximum infusion rate: < 139ml/hr for 37.6kg)

One Month later (5 Sept 2013)

One month later Laboratory values: Spot glu 5.7, Alb 13, ALP/ALT normal

Wound healed

Oral intake: ~200ml/meal

Stool: BOx1 per day

PICC (central line) to be inserted the next day

One month laterPN consideration:1. To central formula (for more nutrition to meet

requirement)2. Per case MO, patient cannot tolerate excessive

volume

Nutriflex Lipid Special(1250ml/1475kcal/72g protein)

One month laterRecommendation:

1. Nutriflex Lipid Special (+ Addamel N / Vitalipid N Adult / Soluvit N)

2. Start with 20ml/hr x 24hr, gradually step up to 52ml/hr x 24hr (~1475kcal, 72g protein)

10 months since first admission

10 months laterDate Weight (kg) BMI (kgm-2)6/8/2013 37.6 12.411/12/2013 41.2 13.615/1/2014 44.9 14.822/1/2014 46 15.229/1/2014 48.1 15.95/2/2014 48.4 16.011/2/2014 48.8 16.126/2/2014 49 16.217/3/2014 50 16.524/3/2014 50.8 16.831/3/2014 51 16.8

3/6/2014 54.5kg 18.0

10 months laterLaboratory Values: Alb 36, LFT normal, Cr 121

BO normal (once per day)

Oral Intake improved significantly: providing majority of nutrition orally (~1800kcal, 55g protein)

10 months laterPN:Continuously titrating with oral intakePreviously: Nutriflex Lipid Special (+ trace

elements) 300ml/day (354kcal, 17g protein)Discussion with case MO: protein provisionNow: Kabiven Peripheral 1440ml (+trace

elements) 500ml/day (347kcal, 12g protein)

Total: (oral + PN) = (~2100-2200kcal, ~67g protein)

Q & A Session

ReferencesStanga, Z et al. Nutrition in clinical practice – the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008; 62: 687-94Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008; 336: 1495-8Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clin Nutr 2009: 28: 387-400Casaer MP, Ven den Berghe G. Nutrition in the Acute Phase of Critical Illness. N Engl J Med 2014:370: 1227-35Thomas B, Bishop J. Manual of dietetic practice, 4th edition.2007. Blackwell Publishing. P 71-79, p.858-860A.S.P.E.N. Position Paper: Clinical Role of Alternative Intravenous Fat Emulsions. Nutr Clin Pract 2012 27: 150-192Mahan L.K., Escott-Stump S., Raymond J.L. Krause’s Food and the Nutrition Care Process. 13th edition. 2012. Elsevier Saunders. p307-321Parenteral Nutrition Manual for Adults in Health Care Facilities, DAA 2011

Ireton-Jones Energy EquationsSpontaneously breathing patients:EEE(s) = 629 – 11 (A) + 25 (W) – 609 (O)

Ventilator-dependent patients:EEE(v) = 1784 – 11 (A) + 5 (W) + 244 (G) + 239 (T) + 804 (B)

EEE = Estimated Energy Expenditure (kcal/day) s = spontaneously breathing v= ventilator-dependent

O = Presence of obesity: >30% above ideal body weight or BMI > 27 (0 = absent, 1 = present)

A = Age (years) W = Weight (kg) G = Gender (0 = female, 1 = male)

T = Trauma diagnosis (0 = absent, 1 = present) B = Burn diagnosis (0 = absent, 1 = present)