Supplemental parenteral nutrition (SPN) is a valuable adjunct to enteral nutrition (EN) for patients unable to meet their energy and protein needs via EN alone, with specific timing and patient selection crucial for optimal outcomes in both adult and pediatric populations.
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this session the role of supplemental
parenteral nutrition is part two of the
smart PM video series i'm chris Mogensen
and i'm a team leader dietitian
specialist in the department of
nutrition at Brigham and Women's
before we can talk about supplemental
parenteral nutrition we need to define it
it
supplemental parenteral nutrition is
defined as the addition of parental
nutrition to enteral nutrition to
increase energy and protein intake to
goals when enteral nutrition is not
sufficient to meet needs this is
sometimes called a bridge therapy
meaning that pn is provided to bridge
patients to the ultimate goal of ntral
tolerance and meeting all of their
energy and protein needs by the entró
root so what about our critically ill
adult patients the 2016 Society of
critical care medicine and Aspen
clinical guidelines for nutrition
therapy and adult patients also
addresses the role of supplemental P n
similar to the when is parenteral
nutrition appropriate consensus
recommendations this document recommends
using supplemental pn after seven to ten
days for critically ill patients unable
to exceed 60 percent of energy protein
requirements by en the authors cautioned
that issue initiating supplemental pn
prior to the seven to ten day period for
patients receiving some en does not
improve outcomes and may be detrimental
to the patient three studies evaluating
early supplemental pen showed no benefit
and one multicenter randomized control
trial called the early parenteral
nutrition completing enteral nutrition
in adult critically ill patients or the
a panic study showed that patients
starting supplemental pn after day eight
had a higher likelihood of being
discharged alive from the ICU had a
shorter IC length of stay fewer
infections and a greater reduction in
healthcare costs compared to those
patients who started supplemental pn on
the question often arises about what to
do with the hemodynamically unstable
patient should exclusive or supplemental
PN added to en providing less than 60
percent of goal be used in the acute
phase of severe sepsis or septic shock
the authors suggest not using exclusive
pian or supplemental pn in conjunction
with in early in the acute phase of
severe sepsis or septic shock regardless
of the patient's degree of nutrition
risk as some studies have shown
increased complications in this patient
population including longer hospital and
ICU admissions longer duration of organ
support such as mechanical ventilation
and renal replacement therapy higher
infectious complications and higher mortality
so let's move on to pediatric and
neonatal populations the use of
supplemental PN for neonatal and
pediatric patients is also addressed in
the P and appropriateness consensus
recommendations as with adults the
question is posed are there any
circumstances in which P n is the
optimal or preferred route for nutrition
support for the neonatal and pediatric
patient populations PN is recommended
when en is not sufficient to meet
nutrient needs the practice of
supplementing en with PN in an effort to
meet energy and protein requirements
seems to be the standard of care for
what about the timing of supplemental
pan in neonates and pediatric patients
the consensus recommendations do not
offer specific guidance for the neonatal
population as PM has begun after birth
an infant's with a birth weight less
than 1,500 grams data are not available
for a specific timeframe for more mature
preemies or critically ill neonates
there is guidance for infants and older
children for infants who are not
expected to tolerate full oral or en for
an extended time should begin p-n within
one to three days for older children and
adolescents the timeframes a little bit
let's move on to critically ill
pediatric patients the 2017 Society of
critical care medicine and Aspen
clinical guideline for nutrition care of
pediatric critically ill patients
addresses the role of supplemental Penn
based on available evidence the role of
supplemental Penn as well as the
timeframe for initiation of supplemental
Penn is not known the consensus of this
expert panel is that patients who are
severely malnourished or at risk of
nutrition deterioration supplemental
peein may be started in the first week
if en cannot be advanced past low
volumes the group writing the pediatric
critical care nutrition guidelines use
the concepts of the grading of
recommendations assessment development
and evaluation or grade working group
concepts in developing the clinical
guidelines the adult guidelines use the
same process in this case the grade
recommendation was week for starting
supplemental peon as previously
discussed ian is the preferred route of
nutrition support for the critically ill child
child
but pan should be considered when in is
not feasible or as contraindicated the
use timing and targeted macronutrient
goal when using PN as a supplement to en
requires much more research as there's
currently little evidence to guide
practice a recent three Center
randomized control trial early versus
late nutrition in the pediatric
intensive care unit or pet panic just
like the adult panic trial address the
timing of supplemental pian and
critically ill children the results were
similar to adults where the late
initiation of PN on day eight of ICU
stay demonstrated better outcomes
including fewer new infections shorter
PICU length of stay shorter duration of
mechanical ventilation lower odds of
renal replacement therapy and a higher
likelihood of an earlier live discharge
compared to those in the early pn group
who started peeing within 24 hours of
admission the optimal timing of
supplemental pain and children failing
to meet their nutrient delivery goals
enterely must be individualized based on
the nutrition and clinical status of the
patient and anticipated
trade deficits during the course of the illness
illness
so now let's talk about a similar
patient so we have an adult with a
history of COPD have been did to the
hospital for an acute exacerbation this
patient reports a decrease in oral and
taken recent weight loss with a current
body mass index of 19 so this patient is
absolutely at nutritional risk this
patient has had on intentional weight
loss they're not eating well and their
BMI is at the very low end of the normal
range so on Hospital day two and
nasogastric enter all access devices
place and enteral nutrition is initiated
with orders to advance to goal now we're
in hospital day four and the patient the
patient central nutrition is meeting
only 30 percent of energy and protein
requirements advancing en to goals has
been hindered by GI intolerance the
patient does not have an ileus or
constipation so in this case is
supplemental P appropriate for this
patient and answers yes the patient is
nutritionally at risk and unlikely to
achieve desired energy and protein goals
with en or an oral diet it is reasonable
to begin supplemental PN to increase
energy and protein to goals this caucus
is supported by the P an appropriateness
consensus recommendations that PN should
be initiated within three to five days
in those who are nutritionally at risk
and unlikely to achieve desired oral
so now let's revisit this case so our
adult with COPD had been to the hospital
of the exacerbation nutritionally
at-risk based on decreased oral intake
weight loss and in the BMI at the low
end of the normal range so we've started
our supplemental pen and now we're at
Hospital day 8 the patient's oral intake
remains minimal but the en is now
meeting 70% of energy and protein
requirements there are no signs and
symptoms of GI intolerance and
supplemental pen is providing about 40
percent of energy and protein
requirements so the question comes up
should supplemental PN be discontinued
so yes essential nutrition has been
advanced in GI tolerance has improved
it's expected that en can advance to the
goal a plan or a protocol should be in
place to wean the Supplemental pen as in
as advanced to avoid over feeding so
this can be particularly problematic in
this patient with respiratory compromise
so this is one of last patients that we
want to overfeed so for many patients
tolerating oral intake or Etro nutrition
is advancing without problems parenteral
nutrition can be abruptly discontinued
however for patients who've been slow to
advance or enteral nutrition a much
slower weaning process is in order the
goal is to avoid over feeding as well as
under feeding and strong protocols can
so in summary supplemental peon has a
role in the nutrition care of patients
who are unable to meet their energy and
protein requirements with enteral
nutrition the timing to initiate and
identification of appropriate candidates
for supplemental peon is really
dependent on nutrition status and
clinical condition guidelines to help
you are available on the peon
appropriateness consensus
recommendations and the Society of
critical care medicine and Aspen
critical care guidelines for both adults
and pediatric patients and we really
encourage you to read all of those
references carefully here you can see a
list of references and readings that may
help you in learning more about the use
of supplemental parenteral nutrition
this educational offering was provided
to you by Aspen supported by an
educational grant provided by Baxter
finally this slide has a number of links
to Aspen resources to help you in
managing your patients receiving
nutrition support therapy we hope this
presentation in their these resources
are useful to you in your clinical practice
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