0:02 this session the role of supplemental
0:05 parenteral nutrition is part two of the
0:08 smart PM video series i'm chris Mogensen
0:10 and i'm a team leader dietitian
0:12 specialist in the department of
0:13 nutrition at Brigham and Women's
0:21 before we can talk about supplemental
0:24 parenteral nutrition we need to define it
0:24 it
0:26 supplemental parenteral nutrition is
0:28 defined as the addition of parental
0:30 nutrition to enteral nutrition to
0:32 increase energy and protein intake to
0:34 goals when enteral nutrition is not
0:37 sufficient to meet needs this is
0:38 sometimes called a bridge therapy
0:41 meaning that pn is provided to bridge
0:43 patients to the ultimate goal of ntral
0:45 tolerance and meeting all of their
0:47 energy and protein needs by the entró
0:51 root so what about our critically ill
0:54 adult patients the 2016 Society of
0:56 critical care medicine and Aspen
0:57 clinical guidelines for nutrition
0:59 therapy and adult patients also
1:01 addresses the role of supplemental P n
1:04 similar to the when is parenteral
1:05 nutrition appropriate consensus
1:08 recommendations this document recommends
1:11 using supplemental pn after seven to ten
1:13 days for critically ill patients unable
1:16 to exceed 60 percent of energy protein
1:19 requirements by en the authors cautioned
1:22 that issue initiating supplemental pn
1:24 prior to the seven to ten day period for
1:27 patients receiving some en does not
1:29 improve outcomes and may be detrimental
1:32 to the patient three studies evaluating
1:34 early supplemental pen showed no benefit
1:37 and one multicenter randomized control
1:39 trial called the early parenteral
1:41 nutrition completing enteral nutrition
1:44 in adult critically ill patients or the
1:46 a panic study showed that patients
1:48 starting supplemental pn after day eight
1:50 had a higher likelihood of being
1:53 discharged alive from the ICU had a
1:56 shorter IC length of stay fewer
1:58 infections and a greater reduction in
1:59 healthcare costs compared to those
2:02 patients who started supplemental pn on
2:10 the question often arises about what to
2:11 do with the hemodynamically unstable
2:15 patient should exclusive or supplemental
2:18 PN added to en providing less than 60
2:20 percent of goal be used in the acute
2:22 phase of severe sepsis or septic shock
2:25 the authors suggest not using exclusive
2:28 pian or supplemental pn in conjunction
2:30 with in early in the acute phase of
2:33 severe sepsis or septic shock regardless
2:35 of the patient's degree of nutrition
2:37 risk as some studies have shown
2:39 increased complications in this patient
2:42 population including longer hospital and
2:45 ICU admissions longer duration of organ
2:47 support such as mechanical ventilation
2:49 and renal replacement therapy higher
2:52 infectious complications and higher mortality
2:58 so let's move on to pediatric and
3:01 neonatal populations the use of
3:03 supplemental PN for neonatal and
3:05 pediatric patients is also addressed in
3:07 the P and appropriateness consensus
3:09 recommendations as with adults the
3:11 question is posed are there any
3:13 circumstances in which P n is the
3:15 optimal or preferred route for nutrition
3:18 support for the neonatal and pediatric
3:22 patient populations PN is recommended
3:24 when en is not sufficient to meet
3:26 nutrient needs the practice of
3:29 supplementing en with PN in an effort to
3:31 meet energy and protein requirements
3:32 seems to be the standard of care for
3:41 what about the timing of supplemental
3:43 pan in neonates and pediatric patients
3:45 the consensus recommendations do not
3:48 offer specific guidance for the neonatal
3:50 population as PM has begun after birth
3:52 an infant's with a birth weight less
3:55 than 1,500 grams data are not available
3:57 for a specific timeframe for more mature
3:59 preemies or critically ill neonates
4:02 there is guidance for infants and older
4:04 children for infants who are not
4:07 expected to tolerate full oral or en for
4:10 an extended time should begin p-n within
4:13 one to three days for older children and
4:14 adolescents the timeframes a little bit
4:22 let's move on to critically ill
4:25 pediatric patients the 2017 Society of
4:27 critical care medicine and Aspen
4:30 clinical guideline for nutrition care of
4:31 pediatric critically ill patients
4:33 addresses the role of supplemental Penn
4:36 based on available evidence the role of
4:38 supplemental Penn as well as the
4:40 timeframe for initiation of supplemental
4:43 Penn is not known the consensus of this
4:45 expert panel is that patients who are
4:47 severely malnourished or at risk of
4:50 nutrition deterioration supplemental
4:51 peein may be started in the first week
4:54 if en cannot be advanced past low
4:57 volumes the group writing the pediatric
4:58 critical care nutrition guidelines use
5:00 the concepts of the grading of
5:02 recommendations assessment development
5:05 and evaluation or grade working group
5:07 concepts in developing the clinical
5:09 guidelines the adult guidelines use the
5:13 same process in this case the grade
5:15 recommendation was week for starting
5:18 supplemental peon as previously
5:20 discussed ian is the preferred route of
5:22 nutrition support for the critically ill child
5:23 child
5:25 but pan should be considered when in is
5:28 not feasible or as contraindicated the
5:30 use timing and targeted macronutrient
5:33 goal when using PN as a supplement to en
5:35 requires much more research as there's
5:37 currently little evidence to guide
5:39 practice a recent three Center
5:42 randomized control trial early versus
5:44 late nutrition in the pediatric
5:47 intensive care unit or pet panic just
5:50 like the adult panic trial address the
5:51 timing of supplemental pian and
5:54 critically ill children the results were
5:56 similar to adults where the late
5:59 initiation of PN on day eight of ICU
6:01 stay demonstrated better outcomes
6:04 including fewer new infections shorter
6:07 PICU length of stay shorter duration of
6:09 mechanical ventilation lower odds of
6:11 renal replacement therapy and a higher
6:14 likelihood of an earlier live discharge
6:16 compared to those in the early pn group
6:19 who started peeing within 24 hours of
6:21 admission the optimal timing of
6:23 supplemental pain and children failing
6:25 to meet their nutrient delivery goals
6:27 enterely must be individualized based on
6:30 the nutrition and clinical status of the
6:31 patient and anticipated
6:34 trade deficits during the course of the illness
6:36 illness
6:38 so now let's talk about a similar
6:41 patient so we have an adult with a
6:43 history of COPD have been did to the
6:46 hospital for an acute exacerbation this
6:48 patient reports a decrease in oral and
6:51 taken recent weight loss with a current
6:54 body mass index of 19 so this patient is
6:57 absolutely at nutritional risk this
6:58 patient has had on intentional weight
7:01 loss they're not eating well and their
7:03 BMI is at the very low end of the normal
7:06 range so on Hospital day two and
7:07 nasogastric enter all access devices
7:10 place and enteral nutrition is initiated
7:12 with orders to advance to goal now we're
7:16 in hospital day four and the patient the
7:18 patient central nutrition is meeting
7:19 only 30 percent of energy and protein
7:23 requirements advancing en to goals has
7:26 been hindered by GI intolerance the
7:27 patient does not have an ileus or
7:30 constipation so in this case is
7:32 supplemental P appropriate for this
7:36 patient and answers yes the patient is
7:38 nutritionally at risk and unlikely to
7:40 achieve desired energy and protein goals
7:43 with en or an oral diet it is reasonable
7:45 to begin supplemental PN to increase
7:48 energy and protein to goals this caucus
7:50 is supported by the P an appropriateness
7:53 consensus recommendations that PN should
7:54 be initiated within three to five days
7:57 in those who are nutritionally at risk
8:00 and unlikely to achieve desired oral
8:08 so now let's revisit this case so our
8:10 adult with COPD had been to the hospital
8:12 of the exacerbation nutritionally
8:14 at-risk based on decreased oral intake
8:16 weight loss and in the BMI at the low
8:19 end of the normal range so we've started
8:22 our supplemental pen and now we're at
8:24 Hospital day 8 the patient's oral intake
8:26 remains minimal but the en is now
8:28 meeting 70% of energy and protein
8:31 requirements there are no signs and
8:33 symptoms of GI intolerance and
8:35 supplemental pen is providing about 40
8:36 percent of energy and protein
8:39 requirements so the question comes up
8:42 should supplemental PN be discontinued
8:45 so yes essential nutrition has been
8:47 advanced in GI tolerance has improved
8:49 it's expected that en can advance to the
8:52 goal a plan or a protocol should be in
8:55 place to wean the Supplemental pen as in
8:58 as advanced to avoid over feeding so
9:00 this can be particularly problematic in
9:02 this patient with respiratory compromise
9:04 so this is one of last patients that we
9:07 want to overfeed so for many patients
9:09 tolerating oral intake or Etro nutrition
9:12 is advancing without problems parenteral
9:14 nutrition can be abruptly discontinued
9:17 however for patients who've been slow to
9:19 advance or enteral nutrition a much
9:22 slower weaning process is in order the
9:25 goal is to avoid over feeding as well as
9:28 under feeding and strong protocols can
9:37 so in summary supplemental peon has a
9:39 role in the nutrition care of patients
9:41 who are unable to meet their energy and
9:42 protein requirements with enteral
9:45 nutrition the timing to initiate and
9:47 identification of appropriate candidates
9:49 for supplemental peon is really
9:51 dependent on nutrition status and
9:54 clinical condition guidelines to help
9:56 you are available on the peon
9:57 appropriateness consensus
9:59 recommendations and the Society of
10:00 critical care medicine and Aspen
10:02 critical care guidelines for both adults
10:05 and pediatric patients and we really
10:07 encourage you to read all of those
10:11 references carefully here you can see a
10:13 list of references and readings that may
10:15 help you in learning more about the use
10:17 of supplemental parenteral nutrition
10:20 this educational offering was provided
10:23 to you by Aspen supported by an
10:25 educational grant provided by Baxter
10:31 finally this slide has a number of links
10:33 to Aspen resources to help you in
10:35 managing your patients receiving
10:37 nutrition support therapy we hope this
10:39 presentation in their these resources
10:41 are useful to you in your clinical practice
