Parenteral Nutrition
in Critical Illness
Judy WONG
Dietitian
PMH
Overview
 What is parenteral nutrition
 Selection Criteria of parenteral nutrition
 Parenteral nutrition access
 Requirements of critically ill patients
 Refeeding Syndrome
 Parenteral Nutrition formulations & How to choose
 Case Study
What is Parenteral Nutrition
 Parenteral nutrition refers to the infusion of intravenous
nutrition formula into the bloodstream
DAA, 2011
Selection Criteria for Parenteral
Nutrition
 Should be used in patients who are or will become
malnourished, and
 Who do not have sufficient gastrointestinal function to
be able to restore / maintain nutritional status
McClave et al.,2009
Access of parenteral nutrition
Access of parenteral nutrition
 Central parenteral nutrition (CPN)
 To large, high blood flow vein (e.g. superior vena
cava)
 For long term parenteral nutrition
 Central Parenteral Nutrition solution osmolarity can
be > 900mOsm/L
 More suitable for volume-sensitive patients (e.g.
patients with heart, renal or liver problem)
Access of parenteral nutrition
 Peripheral parenteral nutrition (PPN)
 Catheter tip placement in a small vein (e.g. forearm)
 PeripherallParenteral Nutrition solution osmolarity < 900
mOsm/L
 Usually do not fully meet nutrition requirements
 Use as:
 Supplemental feeding
 Transition to oral/enteral feeding
 Temporary PN when central access has not been initiated
Requirements of critically ill
patients
Energy requirement
Macronutrient requirements
Micronutrient requirements
Requirements during metabolic
stress
 Adequate energy is essential for metabolically stressed patients
 Avoidance of overfeeding in the critically ill patients is important
 Excess calories can result in complications:
 hyperglycaemia
 hepatic steatosis
 excess CO2 production (exacerbate respiratory insufficiency /
prolong weaning from mechanical ventilation)
Krause’s, 2012
How much energy should
critically ill patients receive?
 ESPEN Guidelines 2009:
 “as close as possible to the energy expenditure in
order to decrease negative energy balance” (Grade
B);
 “in the absence of indirect calorimetry, ICU patients
should receive 25kcal/kg/day increasing to target
over the next 2-3 days” (Grade C)
Singer P et al (2009)
Calculations of requirement
 Estimation of energy requirement
=
Basal Metabolic Rate (BMR) + Activity
Factor
+ Stress Factor
Calculations of requirement
 Estimation of energy requirement
 Basal Metabolic Rate (BMR) estimation (Schofield
Equation):
Age
Male
Female
18-29
15.1 x W + 692
14.8 x W + 487
30-59
11.5 x W +873
8.3 x W + 846
60-74
11.9 x W + 700
9.2 x W + 687
Over 75
8.4 x W + 821
9.8 x W + 624
W = body weight in kg; Calculated BMR in kilocalorie (kcal)
Department of Health (UK), 1991
Activity Factors
Activity Level
Bedbound, immobile
Bedbound, mobile or sitting
Mobile, on ward
+10%
+ 15-20%
+25%
Todorovic and Micklewright (2004)
Stress Factors
Condition
Brain Injury
Acute (ventilated and sedated)
Recovery
Stress factor (%
BMR)
0-30
5-50
Cerebral Haemorrhage
30
CVA
5
COPD
15-20
Infection
25-45
Intensive Care
Ventilated
Septic
0-10
20-60
Leukaemia
25-34
Pancreatitis
Chronic
Acute
3
10
Sepsis / Abscess
20
Solid Tumours
0-20
Transplantation
20
Surgery
Uncomplicated
Complicated
5-20
25-40
Todorovic and Micklewright (2004)
Macronutrients Requirements
Macronutrient requirements
Protein
 depending on the baseline nutritional status, degree
of injury and metabolic demand, or any abnormal
losses (e.g. open wound or burned skin)
 Varies between 0.9-1.5g/kg/day for various
conditions
Krause’s,
2012
Macronutrient requirements
Carbohydrate
 Ensures that protein is not catabolised for energy during
metabolism
 Excessive administration:
 hyperglycaemia
 hepatic abnormalities
  ventilatory drives
 Maximum infusion rate of carbohydrate: <5mg/minute/kg
body weight
DAA, 2011
Macronutrient requirements
Fat
 ~ 10% of calories/day from fat provide 2% to 4% of
calories from linoleic acid (LA) in order to prevent
Essential Fatty Acid Deficiency
 Soybean and safflower oils: rich sources of LA
 LA: pro-inflammatory & immunosuppressive
 Maximum infusion rate of fat: <0.11g/hour/kg body
weight
DAA, 2011
Micronutrient Requirements
Micronutrient requirements
 Ready-made Parenteral Nutritional Products are free of
vitamins and trace elements
 The addition of vitamins and trace elements are always
required
ESPEN Guidelines 2009;
Casaer & Van den Berghe, 2014
Micronutrients
 Vitamins and trace elements addition via the
addition of:
 Soluvit® N
 Vitalipid N® Adult
 Addamel® N
Soluvit® N
 provide the daily requirement of water-soluble
vitamins
 A vial (10ml) = normal daily requirement of
water-soluble vitamins
Fresenius Kabi
Vitalipid N® Adult
 meet the daily requirement of the fat-soluble
vitamins A, D2, E and K1 in adults & children aged
11 years or older
 One ampoule (10ml) = daily intake of fat-soluble
vitamins
 Contraindications: hypersensitivity to egg protein /
soybean / peanut protein
Fresenius Kabi
Addamel® N
 covers basal or moderately  trace elements
needs
 The recommended daily does for adult patients
with basal or moderately elevated needs is 10ml
(one ampoule)
 Contraindications: in patients with blocked bile flow,
and manganese levels must be checked if
treatment lasts > 4 weeks
Fresenius Kabi
Refeeding Syndrome
Refeeding Syndrome
1. What is refeeding syndrome?
 A metabolic disorder as a consequence of too aggressive
administration of nutrition after a prolonged inadequate nutrition
supply
 Characterized by hypophosphataemia, hypomagnesiumaemia and
hypokalaemia; with excessive sodium and fluid retention
 May cause potentially lethal electrolye flucatuations involving
metabolic, haemodynamic & neuromuscular problems
Stanga, Z et al (2008)
Krause’s (2012)
Mehanna et al (2008)
Refeeding Syndrome
2. Who is at risk?
 Meet ANY of the criteria:
 BMI < 16kgm-2
 NPO ≥ 10 days (or with minimal nutrition intake > 10 days)
 Weight loss > 15% in 3 to 6 months
 Hypophosphataemia, hypokalaemia, hypomagnesaemia
Stanga, Z et al (2008)
Refeeding syndrome
3. How to prevent?
 Start feeding at < 50% of energy requirement, rate can
then be  if no refeeding problem detected
 For high risk of refeeding: start with 10kcal/kg/day
 For very malnourished patients, start with 5kcal/kg/day,
with cardiac monitoring
NICE guideline (2006)
Refeeding syndrome
3. How to prevent?
 Vitamin supplementation: before and for the first 10
days of refeeding
 Oral, enteral or IV supplements of K, PO4, Ca & Mg
should be given unless blood levels are  before
refeeding
NICE guideline (2006)
PN formulations
Currently available formulations in
PMH
PN Formulations
 Besides carbohydrate and protein content varies, type of fat
emulsions used also differ
 Most commonly used is soybean oil based fat emulsion
 Alternatively fat emulsions:




Soybean oil + MCT
Soybean oil + Olive Oil
Fish oil
other multi-lipids (a mixture of soy, MCT, olive and fish oil)
DAA, 2011
ASPEN Position Paper, 2012
Soybean oil
 Examples: Kabiven Central, Kabiven Peripheral
 The most commonly used fat emulsion type
 Linoleic Acid (LA, n-6) comprise a 50% of total fatty acid profile
 Alpha Linolenic Acid (ALA, n-3) about 10% of total fatty acid profile
  omega 6 content  drawback due to its pro-inflammatory potential
ASPEN Position Paper (2012)
Soybean oil + MCT
 Examples: Nutriflex Lipid Special, Nutriflex Lipid Plus
 Soybean oil : MCT = 50 : 50
 MCT:
 readily oxidizable
 Safe source of lipid
 pro-inflammatory properties
Soybean oil + Olive oil
 Examples: Oliclinomel
 Olive oil : soybean oil = 80 : 20
  the content of omega 6 in formulation by ~ 75%
 Higher vitamin E content for its anti-oxidating properties
ASPEN Position Paper (2012)
Multi-lipids
 Examples: SMOF Kabiven
 A mixture of soybean oil, MCT, olive oil and fish oil in a
ratio of 30 : 30 : 30 : 10
 Fish Oil:
 rich in omega 3 (anti-inflammatory properties)
ASPEN Position Paper (2012)
How to choose?
How to choose?
1. Based on calculated energy / protein requirements
2. Disease Specific:

Renal / Cardiac diseases Vs Fluid content of PN

BGA / pCO2 Vs CHO content
Initiation of parenteral nutrition
Initiation of Parenteral
Nutrition
1. Ensure the selected formulation is compatible with the
route of parenteral nutrition (central / peripheral)
2. Choice of parenteral nutrition regimen
 Continuous PN (Q24H)
 Cyclic / intermittent (Q16H/Q12H)
3. Ensure final infusion rate DOES NOT exceed the
maximum infusion rate for fat and CHO
Case Study
Case Study
Background Information
 KC, 57 year-old male, admitted to PMH on 5 Aug 2013
 Admission Diagnosis: Malnutrition
 Past Medical History: HT, anaemia, Ca cardia with oseophagogastrectomy, short bowel syndrome, CHB
 Relevant Medications: Aminoleban EN (1 sachet), Entecavir,
Vitamin K1, Slow K, Vitamin B complex
Case Study
 Anthropometry:
 Height 1.74m
 Weight 37.6kg
 BMI 12.4kgm-2
 Ideal Body Weight: 56-69kg
 Laboratory Values:
 Spot glucose 3.3 Alb 17 ALP 357 ALT 194
 Wound x 1 (stage III)
Case Study
 Estimated energy requirement:
~ 2000-2100kcal (bedbound + wound + weight )
 Estimated protein requirement:
~56-69g per day
 Route of nutrition:
1. Oral (as much as tolerated)
2. Peripheral parenteral nutrition
Case Study
1. Formula selection:
 Peripheral access = Kabiven Peripheral
 Plan to start with small infusion rate and grade up
as tolerated
Case Study
2. Starting PN:
 30ml/hr x 16hrs Kabiven Peripheral (+ Addamel N /
Vitalipid N Adult / Soluvit N) (~333kcal, 11g protein)
 Gradually stepped up to 100ml/hr x 16hrs
(~1167kcal, 37g protein)
(Note: Maximum infusion rate: < 139ml/hr for 37.6kg)
One Month later (5 Sept 2013)
One month later
 Laboratory values: Spot glu 5.7, Alb 13, ALP/ALT normal
 Wound healed
 Oral intake: ~200ml/meal
 Stool: BOx1 per day
 PICC (central line) to be inserted the next day
One month later
PN consideration:
1. To central formula (for more nutrition to meet
requirement)
2. Per case MO, patient cannot tolerate excessive
volume
Nutriflex Lipid Special
(1250ml/1475kcal/72g protein)
One month later
Recommendation:
1. Nutriflex Lipid Special (+ Addamel N / Vitalipid N Adult
/ Soluvit N)
2. Start with 20ml/hr x 24hr, gradually step up to 52ml/hr
x 24hr (~1475kcal, 72g protein)
10 months since first admission
10 months later
Date
Weight (kg)
BMI (kgm-2)
6/8/2013
37.6
12.4
11/12/2013
41.2
13.6
15/1/2014
44.9
14.8
22/1/2014
46
15.2
29/1/2014
48.1
15.9
5/2/2014
48.4
16.0
11/2/2014
48.8
16.1
26/2/2014
49
16.2
17/3/2014
50
16.5
24/3/2014
50.8
16.8
31/3/2014
51
16.8

3/6/2014

54.5kg

18.0
10 months later
 Laboratory Values: Alb 36, LFT normal, Cr 121
 BO normal (once per day)
 Oral Intake improved significantly: providing majority of
nutrition orally (~1800kcal, 55g protein)
10 months later
PN:
 Continuously titrating with oral intake
 Previously: Nutriflex Lipid Special (+ trace elements)
300ml/day (354kcal, 17g protein)
 Discussion with case MO:  protein provision
 Now: Kabiven Peripheral 1440ml (+trace elements)
500ml/day (347kcal, 12g protein)
Total: (oral + PN) = (~2100-2200kcal, ~67g protein)
Q & A Session
References
Stanga, Z et al. Nutrition in clinical practice – the refeeding syndrome: illustrative cases
and guidelines for prevention and treatment. Eur J Clin Nutr 2008; 62: 687-94
Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to
prevent and treat it. BMJ 2008; 336: 1495-8
Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines on Parenteral
Nutrition: Intensive care. Clin Nutr 2009: 28: 387-400
Casaer MP, Ven den Berghe G. Nutrition in the Acute Phase of Critical Illness. N Engl
J Med 2014:370: 1227-35
Thomas B, Bishop J. Manual of dietetic practice, 4th edition.2007. Blackwell Publishing.
P 71-79, p.858-860
A.S.P.E.N. Position Paper: Clinical Role of Alternative Intravenous Fat Emulsions. Nutr
Clin Pract 2012 27: 150-192
Mahan L.K., Escott-Stump S., Raymond J.L. Krause’s Food and the Nutrition Care
Process. 13th edition. 2012. Elsevier Saunders. p307-321
Parenteral Nutrition Manual for Adults in Health Care Facilities, DAA 2011
Ireton-Jones Energy Equations
Spontaneously breathing patients:
EEE(s) = 629 – 11 (A) + 25 (W) – 609 (O)
Ventilator-dependent patients:
EEE(v) = 1784 – 11 (A) + 5 (W) + 244 (G) + 239 (T) + 804 (B)
EEE = Estimated Energy Expenditure (kcal/day)
s = spontaneously breathing
v= ventilator-dependent
O = Presence of obesity: >30% above ideal body weight or BMI > 27 (0 = absent, 1 = present)
A = Age (years)
W = Weight (kg)
T = Trauma diagnosis (0 = absent, 1 = present)
G = Gender (0 = female, 1 = male)
B = Burn diagnosis (0 = absent, 1 = present)