PRESENTING: PN CASE STUDY ASPEN, ESPEN, SA Lindie Mosehuus, RD SA - - PowerPoint PPT Presentation

PRESENTING: PN CASE STUDY

ASPEN, ESPEN, SA

Lindie Mosehuus, RD SA

Spontaneous Non-Traumatic Hemoperitoneum

Hemo- peritoneum

The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs Presence of blood in the peritoneal cavity

Spontaneous Non-Traumatic

Tumour associated haemorrhage

Iatrogenic

Complications of surgery/ Interventional procedure, Anticoagulation therapy

.

Gynaecologic condition

Ruptured ovarian cyst, Ectopic pregnancy, HELP syndrome

Vascular legion

Aneurysm, pseudoaneurysm of visceral artery

Symptoms

Severe abdominal pain ↓ Hct levels Hypovolemic shock (Rare)

Patient Background:

65 y/o Caucasian ♂ Married, Accountant No previously reported medical history Surgical history: Multiple Inguinal hernia repairs + Lipoma excision Clinically appears to be well nourished and presents with est. N BMI .

Hospitalisation- Day 1

ER + Abdo minal pain Non bloody emesis CT abd + pelvis

Spontaneous Non-Traumatic Hemoperitoneum

Tachyc ardic + hypo- tensive Required blood T/F

Next step: Ex Lap

Omental resection The omentum is a large fatty structure which literally hangs

• ff the middle of your colon

and drapes over the intestines inside the abdomen) Repair of serosal tears (thin membranes that cover the walls and some organs of the thoracic and abdominal cavities) Small bowel resection: part of ileum resected, anastomosis of remainder of ileum to Jejunum

Progression of Day 1

Pt unsta ble Leave abd

• pen=

prevent CS Wound Vac placed

Vacuum is placed over wound to draw out fluid and increase blood flow to the area.

Post-

• p MI

intubated ventilated = ICU

.

Hospitalisation- Day 2

Patient more stable, went back to operating room to remove VAC and close abdomen Now back in ICU Dietician called for nutritional intervention

Anthropometry

1.8 m 79 kg BMI 24 No recent weight loss reported

Biochemistry

Today (2nd day hospital adm.) Yesterday (1st day hospital adm.) Normal Urea 16 ↑ 21 ↑ 2.8-7.2 Creatinine 200 ↑ 221 ↑ 59-104 Vasopressors 1 mcg/ kg/min 1.3 mcg/kg/min high dose LFT’s N N

• Propofol dose

8 micrograms/kg/min 8 micrograms/kg/min High dose Lactate (gas) 11 ↑ 11 ↑ CRP 150 ↑ 180 ↑ <5 Ca (corrected) 2.05 (2.15) 2.1-2.55 Mg

• 0.8

0.73-1.06 PO4

• 0.83

0.81-1.45 K 5.1 5.3 ↑ 3.5-5.1

Clinical

Intubated Ventilated CVP line access NGT free drainage @600 ml in last 20 hrs Urine output < 0.5 ml/ kg HGT’s 6-10mmol/L MAP 60 mmHg GCS 3 (False low as pt is sedated), if not sedated properly 8 NRS 4 SOFA score 10

Diet history

Previously seems to be well nourished 2nd day NPO + possible poor oral intake +- 2 days prior to hospitalisation due to pain = 4 days poor/ no feeding

.

Nutrition Intervention

Interactive question: Is this patient at risk for malnutrition? a) Yes b) No

ESPEN 2018 consensus guidelines ASPEN 2016 consensus guidelines Patient medical history NRS 2002= >3 at risk/ >5 high risk NUTRIC score >6 or > 5 if interleukin-6 not included (insufficient data to calculate) Unintentional weight loss Do not use albumin/ pre-albumin/ transferrin/ CRP/ TNF in critical care setting Decrease physical performance prior to ICU admission 57% of hospitalized patients with a BMI >25 show evidence of m

• alnutrition. Patients with a BMI >30 have an OR of 1.5 for having

malnutrition (P =.02). The reasons for the surprisingly high rate of malnutrition in obese patients may stem in part from unintentional weight loss early after admission to the ICU and a lack of attentio n from clinicians who misinterpret the high BMI to represent additi

• nal nutrition reserves that protect the patient from insult.

Physical examination General assessment of body composition, muscle mass, strength Any patient staying in ICU > 48 hours Mechanically ventilated Underfed >5 days Infected Present with severe/ chronic disease

ESPEN Glim criteria: Severity grading of malnutrition stage 1 (moderate) and stage 2 (severe) Phenotype Etiology Weight loss (%) BMI Muscle mass Food intake, malabsorption or GI symptoms Disease burden/ inflammation Stage 1 Moderat e malnutrition 5-10% in last < 6 mo OR 10-20% > 6 mo <20 if >70 <22 if > 70 <20 if > 70 Mild to moderate deficit Reduced intake of ER >2 weeks / moderate malabsorption/ GI sy mptoms moderate Acute disease/ injury / chronic disease related Stage 2 Severe malnutrition >10% within last 6 mo or >20% in >6 mo <18.5 if <70 <20 if >70 Severe deficit < 50% intake of ER/ severe mala bsorption/ GI symptoms severe Acute disease/ injury / chronic disease related

.

Nutrition Intervention

Interactive question: Feeding route choice: a) TPN b) TPN and trickle feeds c) Enteral feeds

ESPEN 2018 ASPEN 2016 EN within 48 hrs Even after GI surgery/ After abdominal aortic surgery Abdominal trauma when continuity of GI tract is confirmed/ restored Receiving neuromuscular blocking agents Patients with an open abdomen Regardless of the presence of bowel sounds unless bowel ischemia /

• bstruction is suspected in patients with diarrhoea

EN within 24-48 hrs in hemodynamic stable patient + bowel sounds/ passing flatus/ stool not required to start EN May give EN to patients on chronic, stable, low dose vasopressors Low dose EN if: Intra-abdominal HPT without compartment syndrome- proceed with caution Start with low dose EN if shock controlled with fluids and vasopressors/ Inotropes- remain vigilant for bowel ischemia

EN

ESPEN 2018 ASPEN 2016 Delay EN if: Tissue perfusion not reached (lactate high + ↑ vasopressors dose MAP < 65) Hypoxemia bowel ischemia / obstruction is suspected in patients with diarrhoea Withhold EN if MAP < 50 mmHg Patients that require increasing amounts of nor-epinephrin e/ Phenyl-epinephrine/ epinephrine/ dopamine to mainta in hemodynamic stability

ESPEN 2018 ASPEN 2016 PN start within 3-7 days Withhold exclusive PN in low nutrition risk patients for first 7 days SPN- unclear, 4-7 days (previous guidelines stated start on day 3 if not meeting 60 % of requirements) SPN- 7-10 days if not meeting 60% of protein and Energy requirements

PN

TPN

Lactate high Pt not on stable/ low dose vasopressors + MAP low Would likely not tolerate feed due to poor blood perfusion to the gut

TPN + EN Trickle feed

Atrophy of villi Higher risk for refeeding the longer we wait High risk for ileus

Final decision: TPN only day 1. Perhaps re-evaluate mane for trickle feeds. Important to start with enteral feeds ASAP- high risk for ileus.

.

Nutrition Intervention

Energy requirement: Name 2 things to consider when calculating TPN E req?

SA guidelines: Monitoring patient on TPN

du Toit et al, 2017

Suggested composition of parenteral multivitamin and trace-element product

(Sriram & Lonshyng, 2009)

Micronutrient supplementation should begin as soon as parenteral nutrition is started and continued daily as its role is crucial”. Berger & Shenkin, 2006

Hospitalisation- Day 3

Lactate now ↓3; AKI- improved; CRP ↓90, PCT levels (bacterial infection)- < 0.5 Weaning adrenalin and propofol Urine output ↑1 ml/g No flatus, no bowel sounds; BP 112/77 MAP 80 HGT’s= N NGT drainage < 100 ml Pt will be NPO from tonight for ? Extubating mane morning

Interactive question: Should we initiate enteral/ oral feeds: 4 days NPO + 2 days poor intake=6 days a) Yes b) No

Hospitalization- Day 3

Clamp NGT Start with trickle feeds Continue with PN + PN glutamine

Pt was extubated early this morning. GCS 12, propofol and adrenalin stopped

Arginine containing formula @ 10ml/h

We suggest the routine use of immune-modulating formula (contai ning both arginine and fish oils) in the SICU for the postop patient who requires EN Therapy (ASPEN, 2016)

SA weaning protocol Intolerance Abdominal distention

CRP increased to 110, Lactate 6 and HGT spikes observed. NGT feeds were stopped as per surgeon and TPN resumed

Hospitalization- Day 4

Ileus Stop NGT TPN + Glutamine X-Ray confirm

As per surgeon Ileus was treated non-

• peratively.

Bowel rest (2 days) + hydration (as per surgeon)

Trickle feed Weaning protocol

SA protocol Early enteral nutrition NB post op to prevent post-op ileus, maintain intestinal barriers, improve blood flow and healing.

Interactive question How would you manage HGT spikes in this patient

Know complications associated with TPN, to identify early

Interactive question: Starting dose of EN when weaning a patient from TPN to EN a) 5-9 ml/h b) 10-20ml/h c) 21-30 ml/h Within how many days do you aim to be on full EN feeds? a) 2 days b) 3 days c) 4 days

Suggested SA weaning protocol

When considering weaning of patients from PN two outcomes should be considered: 1. Whether it is necessary for a patient to achieve full nutrition intake from an alternative route e.g. oral/enteral before PN is discontinued 2. Whether or not the clinical symptoms, which required the use of PN have sufficiently abated

Thank you

Reference list

Berger MM, Shenkin A. Vitamins and trace elements: practical aspects of supplementation. Nutrition. 2006 Sep; 22(9):952-5. PubMed PMID: 16928476 Du Toit AL, Blaauw R, Naiker N, van Niekerk L, de Lange C. National Parenteral Nutrition practice guidelines for

• adults. National Department of Health. 2017, 1-35

McClave SA, Taylor BE, RD, Martindale RG, Warren MM et al., Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J of Paren Enteral Nutr. 2016; Feb; 40(2): 159-211 Sriram K & Lonshyna VA. Micronutrient supplementation in Adult nutrition therapy: Practical considerations. J Paren Enteral Nutr 2009; 33: 548 – 562 Singer P, Berger MM, Blaser AR, Berger MM, et al., ESPEN Guidelines on clinical nutrition in the intensive care unit, Clinical Nutrition 2019, 1 – 32