TPN in the Critically Ill Patient: Case Study

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TPN in the Critically Ill Patient Case Study

• April 24, 2003
• Cathy Alberda, RD
• Royal Alexandra Hospital

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Case Study Outline

• Patient Presentation (Weight Loss NYD)
• Nutritional History Status
• Diagnosis
• Nutritional Assessment of Lean Patients
• TPN concerns
• Refeeding Syndrome
• Indirect Calorimetry
• Anabolic Agents

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Presentation to hospital

• 73 year old male, admitted to medicine with
  weight loss, lethargy, NV, night sweats
• PMHx peptic ulcer disease
• U/S abdomen splenic enlargement, fatty
  infiltrates of liver
• Echo aortic insufficiency atrial fib
• Cultures sent HIV serology

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Social History

• Originally from Bosnia/ Croatia
• Emigrated to Canada in 1997
• Speaks little English
• Wife died 6 months ago lives alone, children
  living nearby

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Nutritional History

• Ht 172 cm
• Wt 46 kg
• IBW 72 kg (Hamwi method)
• BMI 15.5
• Appr. 65 of IBW 70 of UBW
• Wt loss estimated to be 20 kg
• Dysphagia in hospital

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Nutritional Assessment

• 30 loss of body weight within last 3 months
• Obvious physical signs of muscle wasting
• Prealbumin level 0.02 g/l (N 0.1-0.4)
• Serum albumin 16 g/l (N 35-50g/l)
• Functional ability diminished
• SGA C

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Course in hospital

• Tx to ICU 10 days after admission for respiratory
  failure/ ? Aspiration
• CXR CHF/ pulmonary edema/ bilateral pleural
  effusions
• Intubated/ required pressors for BP control
• FiO2 70-80

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Course in hospital, contd

• Initiated EN on Day 2 of ICU admission- Jevity
  Plus _at_ 20ml/hr (no advancement due to increasing
  ventilatory and inotropic reqts)
• Profuse diarrhea switched to low volume
  semi-elemental (Peptamen 1.5)
• Dx active TB started on anti-TB medications
• Diarrhea worsens ongoing issues with B.P. and
  ventilation

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Prevalence of TB in Canada

• Remains low (6.2/100,000 popn)
• High risk groups migrants from areas of the
  world where TB is prevalent (63) Aboriginal
  population, people with HIV/AIDS, people with
  malnutrition or in poor living conditions
• Prevalence is increasing for the first time since
  WWII

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Medications

• TB meds
• Rifampin
• Isoniazid
• Pyrozinamide
• Ethambutol
• Pyridoxine 25mg/d

• Cardiac
• Levophed
• Albumin q8h
• Amiodarone

• Nutritional
• Codeine
• Lomotil
• Centrum Select

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Nutritional Care

• Attempts at EN unsuccessful diarrhea,
  increasing ventilatory requirements and labile
  B.P. Start TPN
• Energy Requirements
• 30-35 kcals/kg (46kg) 1380-1610kcals
• 1.5 g/kg protein (46kg) 70 g/ day

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TPN initiation

• Pre-TPN labs
• Hgb 102 g/l Gluc 10.3mmol/
• WBC 11.2 x 109/l Alk Phos 212U/l
• Na 147 mmol/l Creat 67 umol/l
• K 3.4 mmol/l Urea 13.4 mmol/l
• CO2 30 mmol/l Alb 13 g/l
• Phos 0.82mmol/l Prealb .02g/l

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TPN Initial Orders
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TPN fluid electrolytes

• Minimize fluids with concentrated solns (ie.70
  dextrose, 10 a.a., 20 or 30 lipids)
• 0 Na (60-150mmol) 10 mls MVI
• 80 mmol K (1mmol/kg)1 ml T.E.
• 10 mmol Mg (4-8mmol/d)
• 25 mmol P04 (10-30mmol)
• 100 mg thiamine (3mg/d)

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Bloodwork post-TPN

• Pre-TPN Day 2 post-TPN
• Na 147 mmol/l 145 mmol/l
• K 3.4 mmol/l 2.9 mmol/l
• Phos 0.82 mmol/l 0.36 mmol/l
• Mg 0.70mmol/l 0. 72 mmol/l
• Gluc 10.3 mmol/l 4.9 mmol/l

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Refeeding Syndrome

• Severe hypophosphatemia, along with changes in
  potassium, magnesium, and glucose metabolism, in
  patients being refed after severe weight loss
• Infusion of carbohydrates causes insulin release
• Insulin ? K and PO4 uptake into the cells

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Refeeding syndrome

• Recognize the patient at risk
• Increase carbohydrate intake slowly
• Daily monitoring of electrolytes
• Phosphorus
• Sodium Potassium
• Magnesium
• Glucose
• Vitamin supplementation esp. thiamine and
  Selenium
• Monitor ins outs

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Indirect Calorimetry

• Unable to complete initially due to high FiO2
  needs , and later due to infection control
  concerns
• Predictive Formulas
• HBE1065 x 1.3 1384 kcals
• Ireton-Jones1455 kcals
• 25 kcals/kg 1150 kcals
• Indirect Calorimetry results Day 14 ICU
• EE1550 kcals (34 kcals/kg)
• RQ 0.80

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Energy Needs in the Lean Pt
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Why are energy needs higher in lean patients?

• Higher proportion of visceral organ mass in
  relation to stores of muscle and fat
• Visceral organs have a higher oxygen consumption
  than muscle and fat
• Therefore, relatively speaking the kcals/kg for
  patients with lower BMIs is greater

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Role for anabolic agents?

• Serum testosterone level checked, and level of
  3.2nmol/l (Normal 8.0-29.5nmol/l)
• Initiated Androderm patches 2.5mg bid to
  facilitate protein accretion and ventilatory
  weaning
• Testosterone levels within normal range 1 month
  later

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Patient Progress

• Slow ventilatory wean, complicated by
  multiresistant Pseudomonas
• ICU stay 4 months
• Gradual transition to Peptamen VHP feeds
• Nutritional monitoring q2 weeks
• N Balance (requires 2.5g/kg protein)
• prealbumin
• Micronutrients (vitamins A, D, E Se, Zn)
• Recovering on medical ward (trached and on EN)
  mobilizing swallowing assessments
• Wt 40 kg (? 6 kg since admission)

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Take home message

• Be aware of patients at high risk for refeeding
  syndrome
• Go slow! Dont aim for target!
• Monitor electrolytes daily
• Indirect calorimetry when possible

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Future Research Malnutrition TB

• Nutritional status is shown to be an important
  predictor of survival from TB, yet unstudied in
  the past decade
• Early and aggressive attention to nutritional
  status a factor that may affect survival of TB
  patients

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Future Research

• Is there a role for anabolic agents in the ICU?
• .which patients, which anabolic agents, at what
  time after the onset of the inflammatory
  response???

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Thank you

• Enjoy the
• Conference!