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

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

Spontaneous Non-Traumatic Iatrogenic Complications of surgery/ Interventional procedure, Anticoagulation therapy . Vascular legion Aneurysm, pseudoaneurysm of visceral artery Tumour associated haemorrhage Gynaecologic condition Ruptured ovarian cyst, Ectopic pregnancy, HELP syndrome

Symptoms Severe ↓ Hct Hypovolemic shock abdominal pain levels (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 Tachyc Abdo Non CT abd Required ER + ardic + minal bloody + blood T/F hypo- pain emesis pelvis tensive Spontaneous Non-Traumatic Hemoperitoneum

Next step: Ex Lap Omental resection Repair of serosal tears The omentum is a large fatty Small bowel resection: part of (thin membranes that cover structure which literally hangs ileum resected, anastomosis of the walls and some organs of off the middle of your colon remainder of ileum to Jejunum the thoracic and abdominal and drapes over the cavities) intestines inside the abdomen)

Progression of Day 1 Leave abd Pt Wound Post- intubated open= unsta Vac op MI ventilated prevent CS ble placed = ICU Vacuum is placed over wound to draw out fluid and increase blood flow to the area.

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

Today (2 nd day hospital Yesterday (1 st day hospital adm.) Normal adm.) Biochemistry 16 ↑ 21 ↑ Urea 2.8-7.2 200 ↑ 221 ↑ Creatinine 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 11 ↑ 11 ↑ Lactate (gas) 150 ↑ 180 ↑ CRP <5 Ca (corrected) 2.05 (2.15) 2.1-2.55 Mg - 0.8 0.73-1.06 PO 4 - 0.83 0.81-1.45 5.3 ↑ K 5.1 3.5-5.1

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

Diet history Previously seems to be well nourished 2 nd 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 Physical examination malnutrition (P =.02). The reasons for the surprisingly high rate of General assessment of body composition, muscle mass, strength malnutrition in obese patients may stem in part from unintentional Any patient staying in ICU > 48 hours weight loss early after admission to the ICU and a lack of attentio Mechanically ventilated n from clinicians who misinterpret the high BMI to represent additi Underfed >5 days onal nutrition reserves that protect the patient from insult. 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 Disease burden/ inflammation symptoms Stage 1 Moderat 5-10% in last < 6 mo OR <20 if >70 Mild to moderate Reduced intake of ER >2 weeks Acute disease/ injury / chronic e malnutrition 10-20% > 6 mo <22 if > 70 deficit / moderate malabsorption/ GI sy disease related <20 if > 70 mptoms moderate Stage 2 Severe >10% within last 6 mo or <18.5 if <70 Severe deficit < 50% intake of ER/ severe mala Acute disease/ injury / chronic malnutrition >20% in >6 mo <20 if >70 bsorption/ GI symptoms severe disease related

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

EN ESPEN 2018 ASPEN 2016 EN within 48 hrs EN within 24-48 hrs in hemodynamic stable patient Even after GI surgery/ After abdominal aortic surgery Abdominal trauma when continuity of GI tract is confirmed/ restored + bowel sounds/ passing flatus/ stool not required to Receiving neuromuscular blocking agents start EN Patients with an open abdomen Regardless of the presence of bowel sounds unless bowel ischemia / May give EN to patients on chronic, stable, low obstruction is suspected in patients with diarrhoea 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

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

PN 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 SPN- 7-10 days if not meeting 60% of protein and Energy day 3 if not meeting 60 % of requirements) requirements

TPN + EN Trickle TPN Lactate high feed Final decision: TPN only day 1. Perhaps re-evaluate mane for trickle feeds. Pt not on stable/ low dose Atrophy of villi vasopressors + MAP low Important to start with enteral feeds ASAP- high risk for ileus. Higher risk for refeeding the Would likely not tolerate feed due longer we wait to poor blood perfusion to the gut 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 Continue Start with with PN + Clamp Intolerance trickle PN NGT feeds glutamine Arginine containing formula @ 10ml/h SA weaning protocol Abdominal distention Pt was extubated early We suggest the routine use of this morning. GCS 12, CRP increased to 110, Lactate 6 immune-modulating formula (contai propofol and adrenalin and HGT spikes observed. NGT ning both arginine and fish oils) stopped feeds were stopped as per surgeon in the SICU for the and TPN resumed postop patient who requires EN Therapy (ASPEN, 2016)

Hospitalization- Day 4 TPN + Ileus Stop NGT Glutamine Trickle feed X-Ray confirm Weaning protocol As per surgeon Ileus was treated non- operatively. Early enteral nutrition NB Bowel rest (2 days) + SA protocol post op to prevent post-op hydration ileus, maintain intestinal (as per surgeon) 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