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