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HOW TO OPTIMIZE

PN AND EN

DR THIRA SIRIARCHAWATANA

SURGICAL DEPARTMENT, BUDDHASHINARAJ HOSPITAL.



OUTCOMES WITH NUTRITIONALINTERVENTION

Historically, diseases was treated with starvation.

Malnutrition affects outcomes in surgical patients

was first reported in 1936 A study showing that malnourished patients

undergoing ulcer surgery had a 33 percent mortality compared with 3.5 percent in well nourishedindividuals (JAMA 1936; 106:458.)



Systematic review (Clin Nutr. 1997 Aug;16(4)

Preoperative parenteral nutrition (13 randomized trials)decreased postoperative complications by 10%

Postoperative TPN alone (8 randomized trials) resultedin a 10 % increase in complication rates.

These findings were not confirmed by a subsequent meta-analysis ( Gastroenterology 2001 Oct;121(4)

OUTCOMES WITH NUTRITIONAL INTERVENTION




Meta-analysis (26 randomized trials) Can J Surg 2001

Apr;44(2):

Parenteral nutrition decreased hospitalcomplications in studies where lipid-free solutions

were used, and for patients who were malnourished

These findings were also not confirmed by another

study Gastroenterology 2001 Oct;121(4)




Meta-analysis (41 trials) ( Gastroenterology 2001 Oct;121(4)

Parenteral nutrition, provided before and/or after s

urgery had no effect on postoperative mortality. th

ere was no significant effect on postoperative comp

lication rates, although trends for all evaluated outc

omes favored TPN over no nutrition.




An early study suggested that parenteralnutrition was beneficial inpatients with upper gastrointestinal malignancies .

Lancet 1982 Jan 9;1(8263): World J Surg 1986;

Mortality and postoperative complications were

decreased in patients with G.I. malignancies and weigh

t loss (>10%) who received 10 days of preoperative TP

N and 9 days of postoperative TPN .

JPEN J Parenter Enteral Nutr 2000 Jan-Feb; 24(1):




One study randomly assigned patients to TPN for

seven days preoperatively and three days

postoperatively or to control groups who either

received no nutrition or were fed enterally . ( N Engl J Med 1991 Aug 22;325(8):)

Patients who received TPN had a higher rate of

infectious complications (14.1 versus 6.4 percent)and a non significant reduction in mortality (7.3

percent vs. 4.9 percent at 30 days).




In the severely malnourished subgroup,

those treated with TPN had fewer major

postoperative complications than controls(20 to 25 percent versus 40 to 50 percent).




A systematic review evaluated 44 randomizedcontrolled trials of EN in the perioperative

period. ( Am J Gastroenterol. 2007 Feb;102(2):412-29.)

Trials were grouped into 3 comparisons:

EN versus no artificial nutrition.

EN versus parenteral nutrition.

Oral supplemental feeding versus no artificial nutrition.




There were no mortality differences for any of the

comparator groups .

EN had fewer infections compared to no artificial

nutrition, but there was no significant impact on

duration of hospitalization.

EN had decreased rates of infections, fewer major

complications , and shorter duration of

hospitalization compared to parenteral nutrition.




CONCLUSION

คนไข้ที ่ไม malnourished หรือ mild to moderate

malnutrition ไมควร ชะลอการผาตัด เพื ่อให้preoperative nutritional support.

ไมควรให้ routine P.O. TPN. ยกเว้น ตอ้ง NPO > 7-10

วัน คนไข้ severe malnutrition ได้ประโยชน์จาก nutritional

support. ควรให้ EN ถ้าเป็นไปได้ การให้ TPN. จะเพิ ่มinfectious complication. ( ให้ 10-14 วัน)



ENTERAL

NUTRITION



ENTRAL FORMULA SELECTION

Type Modification Rationale

Diabetes High fiberLows simple sugarHigh fat

hyperglycemia

Hepatic Low proteinHigh BCA

Encephalopathy

Pulmonary High fatHigh calories

CO2 production

Renal High caloriesLow electrolyte

Fluid, electrolyteOverload

Critically illMultiple trauma

L arginineGlutamine W-3-FA Ribonucleic acid

Infectious complicationHospital stay.Mortality

Impaired GIfunction

Elemental diet Improved absorption



ROUTE OF FEEDING

Enteral NutritionNeeded

Jejunostomy



Advantage of gastric feedingMore physiological

Ease of tube placement

Convenience

ไมเหมาะที ่จะใชก้ับคนไข ้ Delayed gastric emptying,

gastroesophageal reflux and aspiration

Gastric vs Postpyloric Feeding



Advantage of postpyloric feeding

Minimize aspiration risk

Benefit in critically ill, acute pancreatitis

Early feeding (within 24 hour)

Disadvantages

Difficulty of tube placement

Feeding intolerance

Gastric vs Postpyloric Feeding

B l f di I t itt t ti



Bolus feeding vs Intermittent, continuousinfusion

Bolus feeding

The bolus, gravity method are tolerated when infused into the

stomach.

Initiated with full strength 50 – 100 ml, 3 – 8 time / day

Increase of 50 – 100 ml as tolerated up to the goal volume.

In stable adult patient, can begin at goal rate.

B l f di I t itt t ti



Bolus feeding vs Intermittent, continuousinfusion

Intermittent, continuous infusion

Critically ill patient

Small bowel feeding

Initiated at 10 – 40 ml / hr and advanced to the goal

rate in increment of 10 – 20 ml / hr every 8 – 12 hr

as tolerated.



Early vs Delayed Feeding

Evidence suggests that early E.N., initiated at alow rate within 24 hours of injury.

Reduce the incidence of gastroparesis andileus.

Reduce rate of infectious complications

and the length of hospital Practice management guidelines for nutritional support of the trauma patient. April 7, 2003.

http://www.east.org.



Undergoing major head and neck orgastrointestinal

Surgery for cancer Severe trauma

Obvious undernutrition at the time of surgery

ESPEN Guidelines on Enteral Nutrition: Surgery including Organ Transplantation 2009

Which patients benefit from earlypostoperative EN



Should be considered in patients in whom there is an indication for nutritio

nal support and in whom >60% of energy needs cannot be met via the

enteral route.

ESPEN Guidelines on Parenteral Nutrition: Surgery Clinical Nutrition 28 (2009)

Combinations of enteral and parenteral nutrition



Immuno nutrition

. META ANALYSIS HAVE EXAMINED THE BENEFIT

OF immuno enhancing diet

INFECTION COMPLICATIONS

LENGTH OF HOSPITAL STAY.

NO MORTALITY BENEFIT.

Crit Care Med 1999 Dec;27(12): JAMA 2001 Aug 22-29;286(8):

World J Gastroenterol. 2006 Dec 14;12(46):



Immono nutrition ควรพิจารณาให้ ในผ้ ปวยตอไปนี (recommendation group B, fair evidence to support the recommendation)

Am J Clin Nutr 2003;77:

ผ้ ปวยมะเร็งทางเดินอาหารที ่จะผาตัด โดยเฉพาะกล มที ่มีภาวะทพโภชนาการ

ผ้ ปวยภาวะวิกฤตใน ICU

ที ่มีAPACHE Score

ระหวาง10-20

ผ้ ปวย multiple trauma.

Immuno nutrition



Arginine ใน IN ตอ้งมากกวา 12 gm/l

ระยะเวลาที ่ให้ IN ตอ้งมากกวา 5 วัน การให้กอน ผาตัดอยางเดียว ได้ผลเทากับให้กอนและหลัง

ผาตัด

ปริมาณ IN ต้องมากกวา 800 ml/d และผ้ ปวย ตอ้งได้รับพลังงานอยางน้อย 25 kcal/kg/d

Immuno nutrition



PARENTERALNUTRITION



Parenteral nutrition

สวนประกอบของ PN ประกอบด้วย Energy

substrate (dextrose, fat emulsion) protein(amino acid), electrolyte, vitamins, trace

elements, water.

ให้ ได้ทั ง peripheral vein (PPN) ถา้ Osmolarity< 1,000 mOsm

หรือให้ทาง Central vein (CPN) ถ้า Osmolarity> 1,000 mOsm



mOsm

Dextrose 5/gm

Amino acid 10/gm

Electrolyte 1/mEq

20 % IVFE 1.3 – 1.5/gm





mOsm

Dextrose 10% 500

Amino acid 2.5% 250

Electrolyte 243

20 % IVFE 26 – 30




mOsm

Dextrose 17% 850

Amino acid 5% 500

Electrolyte 243

20 % IVFE 26 – 30



Which is the optimal PN mixture?

2 in 1 VS 3 in 1Optimal nitrogen sparing has been shown to

be achieved when all components of the

parenteral nutrition mix are administered

simultaneously over 24 h( ESPEN Guidelines on Parenteral Nutrition 2009)



Which is the optimal PN mixture?

การให้ FAT EMULSION ใน 2 in 1

อาจให้ FAT. เพื ่อป้องกัน EFA deficiency เทานั น( ให้ 10% FAT. 500 ml. หรือ 20% FAT 250 ml.อาทิตยล์ะ 2 ครั ง)

FAT. ตอ้งให้ช้า ๆ 8-10 ชั ่วโมง (<0.11gm./kg./hr.)

FAT. ให้นานกวา 12 ชั ่วโมง จะเกิด bacterialcontamination



Modified amino acid Hepatic encephalopathy BCAA aromatic AA

Renal failure Essential amino acid only

Metabolic stress,severe trauma BCAA

FAT EMULSIONLCT, LCT+MCTFish oil base emulsionOlive oil Fat emulsionStructure lipid

PARENTRAL FORMULA SELECTION

Glutamine diphosphate Argine

Metabolic stress,severe trauma



PARENTRAL FORMULA SELECTION

Carbohydrate/Lipid ratio

Energy, Protein ที ่เหมาะสม

20 Kcal/Kg of ideal body weight

25-35 Kcal/Kg of ideal body weight for severe

stress

Protein 0.8-1.5 gm/kg



Administration of TPN.

ในวันแรก ควรให้ calorie เพียงคร ึ่ง

เดียวที ่ผ้ ปวยต้องการกอน (เชน 1,000kcal) ถ้า blood sugar ไมสง จึงคอยๆ เพิ ่มไปถึง caloric goal ใน 1-2 วัน

ADMINISTRATION



Discontinuation of TPN.

ลด rate ของ PN. ลงคร ่ึงหนึ ่งทก 1-2 ชั ่วโมง กอนหยด

ถ้าหยด PN. ทันที ควรให้ 5-10 % Dextrosesolution อีก 2-4 ชั ่วโมง

Weaning from PN is not necessary. ( ESPEN Guidelines on Parenteral Nutrition 2009)

DISCONTINUATION



Catheter-related complications

Metabolic complications

Refeeding syndrome

Hepato biliary complications

COMPLICATION OF PN.



Steatosis

Cholestasis

Gall bladder sloudge / stone, acalculuscholeystitis

Hepatobiliary Complications

Risk factor for Hepato biliary



Excessive calories

Dextrose

Fat emulsion MCT-LCT Mixture

Phytosterol

Dose

Carnitine, choline

Type of infusion

Risk factor for Hepato biliaryComplication

Management of Hepatobiliary



Modification of PN.

decrease calories

balance energy source

carbohydrate ไมเ่กิน 7 g/kg/d

fat emulsion ไมเ่กิน 1 g/kg/d

fish oil base fat emulsion

Management of HepatobiliaryComplication

Management of Hepatobiliary



Management of HepatobiliaryComplication

Cyclic infusion

Enteral nutrition

Medication ursodeoxycholic acid

CCK-OP.



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