0:05 hello I'm Todd Maddox a nutrition
0:07 support and critical care pharmacist at
0:08 the Moffitt Cancer Center in Tampa Florida
0:09 Florida
0:11 in this session avoiding over feeding in
0:14 glucose control management is part three
0:19 of the smart PN video series over
0:21 feeding can occur with both parenteral
0:23 and neutral nutrition therapy the
0:25 excessive administration of any
0:27 individual nutrient micro or macro
0:29 nutrient can be associated with
0:32 complications this presentation will
0:34 address over feeding associated with
0:36 parental nutrition therapy with focus on
0:38 excessive carbohydrate or glucose
0:40 administration but let's start with a
0:42 brief review of the complications of
0:44 over feeding with all macronutrients
0:47 we'll start with protein excessive
0:49 protein or amino acids intake can result
0:52 in pre renal as leukemia for patients
0:54 requiring long term parental nutrition
0:56 that provides excessive amounts of amino
0:58 acids kidney stones can occur and there
1:00 is an increased risk of developing
1:03 osteoporosis with excessive or rapid
1:05 administration of intravenous lipid
1:08 emulsion hypertriglyceridemia can occur
1:10 this is usually associated with
1:13 infusions exceeding 0.11 grams per
1:15 kilogram per hour
1:17 excess dextrose or glucose
1:19 administration has been associated with
1:22 hyperglycemia hypertriglyceridemia
1:25 hepatic steatosis and increased carbon
1:30 dioxide production the remainder of this
1:32 presentation will focus on the
1:34 complications of excessive carbohydrate
1:37 administration approaches to avoid over
1:39 feeding appropriate nutrient intake and
1:42 strategies for glucose control
1:44 hyperglycemia is defined as a blood or
1:46 serum glucose greater than a hundred and
1:48 eighty milligrams per deciliter for
1:51 hospitalized or acutely ill patients it
1:53 is the most common complication
1:55 associated with parenteral nutrition and
1:57 an independent factor for poor wound
1:59 healing and an increased risk of
2:02 infection elevated serum glucose
2:04 concentrations impair the immune
2:06 response by altering granulocyte at
2:09 heejun chemotaxis phagocytosis and
2:12 intracellular bacterial death
2:14 hyperglycemia has also
2:16 associated with increased mortality
2:18 patients with hyperglycemia have an
2:20 increased risk of death following a
2:22 myocardial infarction or stroke
2:26 prolonged uncontrolled hyperglycemia may
2:28 also lead to glucose area and an osmotic
2:31 diuresis resulting in the loss of water
2:34 and electrolytes this is referred to as
2:37 hyperosmolar nonketotic dehydration
2:42 which can lead to coma and death this
2:44 classic study by Wolfe and colleagues
2:45 demonstrated that there is a limit to
2:47 the amount of energy that can be derived
2:50 from glucose in adult patients receiving
2:52 parenteral nutrition glucose infusions
2:54 exceeding 6 to 7 milligrams per kilogram
2:57 per minute there was not a significant
2:59 increase in glucose oxidation is shown
3:00 here in Figure 1
3:02 furthermore as presented in Figure two
3:05 glucose infusion rates beyond 4
3:06 milligrams per kilogram per minute
3:09 resulted in increases in carbon dioxide
3:12 production represented here as V co2
3:14 this may be problematic for patients
3:17 with pulmonary disease by exacerbating
3:19 respiratory insufficiency resulting in
3:22 hypercapnia and respiratory acidosis and
3:25 prolonged leaning from mechanical
3:30 ventilation the mechanism of liver
3:31 dysfunction associated with parental
3:33 nutrition is not completely known and
3:36 it's thought to be multifactorial but
3:38 excessive energy intake is thought to
3:40 promote hepatic fat deposition by
3:42 stimulating an increase in the release
3:44 of insulin in turn this promotes
3:46 lipogenesis and inhibits fatty acid
3:49 oxidation potential causes of parental
3:51 nutrition associated liver dysfunction
3:54 include over feeding excessive glucose
3:57 or intravenous lipid dosage lack of
4:00 interest emulation infection choline or
4:02 carnitine deficiency and aluminum
4:05 toxicity from contamination of parental
4:07 Nutrition components more recently
4:09 phytosterols which are naturally
4:11 occurring plant sterols found in
4:14 vegetable oil based IV lipid emulsion
4:16 have been implicated as potential
4:18 contributor to development of parenteral
4:24 nutrition associated liver disease the
4:27 goal of nutrition support therapy is to minimize
4:27 minimize
4:29 the energy deficit and avoid overfeeding
4:32 the first strategy to avoid overfeeding
4:33 is to obtain the most accurate
4:36 determination of resting metabolic rate
4:39 or energy expenditure the gold standard
4:41 for this is in direct calorimetry but
4:43 not all institutions have indirect
4:45 calorimetry technology and even those
4:48 that do may be selective with its use in
4:50 certain patient populations as well as
4:52 the frequency of measurements if the
4:54 latter in direct calorimetry is most
4:57 useful for underweight critically ill or
4:59 acutely ill patients because use of
5:01 predictive equations for these patients
5:03 is more likely to in accurately estimate
5:06 metabolic rates than that for those with
5:09 normal weight or obese patients indirect
5:12 calorimetry is also useful for patients
5:14 with pre-admission fluid overload such
5:17 as societies and there is no reported
5:19 reliable weight with normal hydration
5:22 there is no absolute indication for
5:25 indirect calorimetry all indications are
5:28 relative in most instances when a
5:30 perennial nutrition formulation is being
5:32 developed a measured resting metabolic
5:35 rate is not available so the clinician
5:37 must rely on a method to estimate energy
5:39 expenditures predictive equations have
5:41 been used for over a hundred years
5:43 equations have been derived for various
5:45 populations including healthy
5:47 individuals acutely ill and critically
5:50 ill patients efforts have also been made
5:52 to calculate energy expenditure from the
5:55 mechanical ventilator vco2 measurement a
5:57 thorough discussion on the use of
5:59 indirect calorimetry predictive
6:00 equations and other methods used to
6:03 determine or estimate energy expenditure
6:06 is beyond the scope of this session
6:09 another strategy for avoiding over
6:11 feeding is the appropriate amount of
6:13 nutrients the rate of dextrose infusion
6:15 should not exceed four to five
6:17 milligrams per kilogram per minute are
6:21 2225 calories per kilogram per day has
6:23 discussed previously glucose oxidation
6:26 plateaus at this point and the risk of
6:29 hypoglycemia increases clinical studies
6:31 have reported that for non diabetic
6:33 patients receiving parenteral nutrition
6:36 50% will develop hyperglycemia when the
6:38 dextrose infusion exceeds 4 milligrams
6:40 per kilogram per minute
6:42 when determining the amount of dextrose
6:44 a patient receives clinicians should
6:46 consider other sources of dextrose such
6:49 as IV fluids and IV medications and
6:52 dextrose for IV lipid emotions the
6:55 maximum rate of infusion is 0.1 1 grams
6:58 per kilogram per hour which is the same
7:00 for both soybean oil based emotions and
7:04 the for oil or smoth emulsion lipid
7:06 should provide 15 to 30 percent of
7:09 energy medications such as propofol
7:11 which is at a 10 percent soybean oil
7:13 emulsion vehicle can contribute a
7:16 significant amount of energy the
7:17 contribution of this lipid derived
7:19 energy should be accounted for when
7:21 developing the parenteral nutrition
7:23 formulation and monitoring a patient's
7:27 daily energy intake the appropriate or
7:29 desired amount of protein for a patient
7:31 is based on many factors including
7:33 baseline nutrition status disease
7:37 clinical State and organ function the
7:40 values here are general rules there is
7:41 extensive literature on this topic
7:43 especially the protein needs of
7:45 critically ill patients a complete
7:47 discussion about the optimal protein
7:49 dose for patients has beyond the scope
7:51 and time limitations of this presentation
7:58 friendo nutrition is usually continued
8:00 until the patient consistently consumes
8:03 at least 50 to 75 percent of energy and
8:05 protein needs from internal nutrition or
8:08 oral diet if the patient has signs of
8:10 continued improvement parental nutrition
8:12 can be discontinued over a short period
8:14 without adjusting the parenteral
8:16 nutrition formulation however those with
8:18 a complicated course may need a longer
8:22 waiting period durva and colleagues used
8:24 a parental nutrition waning protocol in
8:26 which parental nutrition was decreased
8:28 by 30 milliliters an hour once enteral
8:31 nutrition achieved the same rate and was
8:32 discontinued when enteral nutrition
8:35 reached goal infusion rate they
8:37 demonstrated less overfeeding with the
8:40 protocol than prior to the protocol for
8:42 many patients transitioning to interval
8:44 tube feeding or an oral diet simply
8:47 decreasing or discontinuing the IV lipid
8:49 emulsion portion of the p-n regimen is a
8:51 simple and practical interview
8:53 their results in less risk of
8:56 overfeeding fat and total calories for
9:00 many patients Aspen recommends a target
9:03 blood glucose concentration of 140 to
9:05 180 milligrams per deciliter for
9:08 hospitalized acutely ill adult patients
9:11 receiving parenteral nutrition the Aspen
9:12 in society of critical care medicine
9:14 clinical guidelines suggest a target
9:17 range of 150 to 180 milligrams per
9:20 deciliter for general ICU patients
9:23 ranges for other specific patient
9:25 populations such as head trauma may
9:27 exist but will not be addressed in this
9:32 discussion insulin corrective regimens
9:34 may be administered via the subcutaneous
9:37 route an IV infusion or added to the
9:39 parenteral nutrition admixture
9:42 subcutaneous administration of short or
9:44 rapid-acting insulin may be used as the
9:47 first approach to glucose control for
9:48 patients with blood glucose is exceeding
9:50 a hundred and eighty milligrams per
9:52 deciliter and receiving parenteral
9:54 nutrition an IV insulin infusion
9:57 provides consistent and safe glucose
9:59 control as it can be adjusted based on
10:01 frequent blood glucose concentrations
10:03 this method is frequently used for
10:06 critically ill patients however this
10:08 method may not be feasible outside of
10:10 the ICU because it requires intense
10:12 nursing time for the blood glucose
10:15 monitoring and adjusting the insulin
10:19 infusion an initial insulin regimen of
10:23 0.05 to 0.1 units per gram of dextrose
10:25 and the parenteral nutrition solution is
10:29 common or 0.15 to 0.2 units per gram of
10:32 dextrose may be used in patients who are
10:35 already hyperglycemic in addition to
10:37 this initial insulin added to the
10:38 perennial nutrition formulation a
10:41 correctional insulin regimen using a
10:43 short or rapid-acting insulin should be
10:45 used as an effort to achieve blood
10:47 glucose concentrations within the target
10:50 range two-thirds of the total amount of
10:52 the correctional insulin required over
10:55 24 hours may be then added to the next
10:57 day's parenteral nutrition formulation
11:00 as the dextrose content is increased or
11:02 decreased the amount of insulin should
11:05 also be proportionally adjusted
11:06 the administration of insulin to
11:08 patients receiving parental nutrition
11:11 does have some risk of hypoglycemia
11:13 and measures should be in place to
11:19 manage this adverse event this slide
11:21 presents a guidance for determining the
11:23 dextrose content of the initial parental
11:25 Nutrition formulation for adult patients
11:28 without a history of diabetes mellitus
11:29 and those patients with a history of
11:32 diabetes mellitus or baseline
11:34 hyperglycemia for those patients without
11:37 a elevated blood glucose the initial
11:40 dextrose dose is 150 to 200 grams per
11:42 day this should be decreased to a
11:44 hundred to 150 grams per day for those
11:47 patients with diabetes or baseline
11:50 hyperglycemia capillary glucose should
11:52 be assessed every six to eight hours and
11:54 more frequently in those who are
11:56 critically ill if blood glucose is
11:58 consistently within the target range the
12:00 dextrose can be advanced towards goals
12:03 if blood glucoses are greater than 180
12:06 milligrams per deciliter insulin therapy
12:09 should be initiated for those patients
12:11 for whom dextrose has advanced toward
12:13 goals and do not require insulin therapy
12:16 capillary glucose monitoring should be
12:17 continued until stable and then
12:20 discontinued a daily assessment of serum
12:24 glucose can be decreased to once daily
12:28 so in summary excessive energy or over
12:30 feeding can result in hyperglycemia
12:32 increased carbon dioxide production and
12:35 steatosis hyperglycemia is the most
12:37 common complication of parenteral
12:39 nutrition therapy and is associated with
12:42 increased morbidity and mortality
12:45 strategies to avoid over feeding include
12:47 appropriate dosing of macronutrients and
12:49 the parental nutrition formulation and
12:51 insulin therapy may be used in the
12:53 management of hyperglycemia in adult
12:55 patients receiving parental nutrition
13:00 therapy and finally a more detailed
13:01 discussion of the information presented
13:03 here today is available in these references
13:13 this educational offering was provided
13:15 to you by Aspen and supported by an
13:17 educational grant provided by Baxter healthcare
