Oesophageal Perforation

HOSPITAL CLINICAL PHARMACY PRESENTATION

Parenteral Nutrition

Group Member:

1.Saw Phin Khye A136315

2.Erma Zufira binti Zuknaini A136657

Preceptor: Assoc. Prof Fuad Ahmad bin ShamsuddinAssoc. Prof Fuad Ahmad bin Shamsuddin

Patient’s Background• Ward/Bed: Surgery 2 Bed 7• Name: LPL• Gender: Female• Race: Chinese• Age: 86 years old• Weight: 50kg• Height: 180cm• BMI: 15.4kg/m2 • BSA: 1.58m2 • DOA: 18th October 2014

*Date of starting peripheral parenteral nutrition (Kabiven®): 20th October 2014

• Diagnosis/Problems:Sepsis 2° to HAPEmphysemaAKI 2° to dehydration

• Past Medical History:Esophageal perforation 2° post ERCPAscending cholangitis with acute pancreatitis

2° to periampullary tumourDM Type IIHPT

Medications Upon Admission (18th Oct 2014)

Medications Indications

IV Ceftriaxone 2g Serious infection- septicemia and pneumonia.

IV Hydrocortisone 100mg Septic shock

IV Calcium Chloride 1g Impaired absorption of Ca2+

IV Adrenaline 0.08mg Cardiopulmonary resuscitation

Current MedicationsMedications Indications Date

IV Noradrenaline 0.2% 4mg/4ml inj.

Acute hypotension 19th Oct 2014

Esomeprazole 40mg inj. Gastro-esophageal reflux 19th until 28th Oct 2014

Acetylcystein 600mg effervescent tab.

Paracetamol poisoning 19th until 22nd Oct 2014

Piperacillin 4g + Tazobactam 500mg inj.

(Tazocin)

Septicemia 19th until 28th Oct 2014

Potassium chloride 10% inj. 10ml

Hypokalemia 22nd and 23rd Oct 2014

Magnesium sulphate 50% inj. 5ml

Arrhythmias due to hypokalemia

23rd Oct 2014

Human albumin 25% inj. 50ml

Hypoalbuminaemia 25th until 28th Oct 2014

Cont..Medications Indications Date

Enoxaparin 60mg inj. 0.6ml Prophylaxis of venous thromboembolism

27th and 28th Oct 2014

Metronidazole 500mg/100ml inj.

Antibiotic (for anaerobic bacteria)

26th until 28th Oct 2014

Imipenem 500mg, Cilastatin 500mg inj.

Antibiotic 28th Oct 2014

Indication for TPN

1. Patient have oesophageal perforation

2. Patient was initially unconscious, weak and bed ridden

Objective of TPNTo provide energy, hydrate patient(resolve

KI) and improve nutrition status

Calculation of PN Regimen

1.Energy Requirement

BMI = 50kg/ (1.8m)2

= 15.43kg/m2 (Underweight)

Harris Benedict Formula

Women:

BEE= 665 + 9.6 x weight (kg) + 1.8 x height(cm) – 4.7 x age(years)

= 665+ 9.6 x 50 kg + 1.8 x 180 cm – 4.7 x 86 years

= 1064.8 kcal/day

Other factors to consider…

1. Confined to Bed - activity factor 1.2

2. Septic Shock - activity factor 1.6

So:

1064.8 kcal x 1.2 x 1.6 = 2044.42kcal2044.42kcal

2. Fluid Requirement

= 100 mL/kg for first 10kg body weight

+ 50 mL/kg for next 10kg body weight + 25mL/kg for each kg >20

= 100 mL/kg x 10kg + 50 mL/kg x 10kg +

25 mL/kg x 30kg

= 2250mL2250mL

3. Protein Requirement

Adult:

2 g/kg/day x 50 kg

= 100 g/day100 g/day

1g nitrogen = 6.25 g protein

So, 100g protein contain 16 g nitrogen.

Going back to the kcal..

1 g protein = 4 kcal

100 g protein will contain 400 kcal.

NPC = Total calorie – Protein calorie

= 2044.42kcal – 400kcal

= 1644.42 kcal

NPC:N ratio = Total NPC (kcal) / N (g)

• =1644.42kcal/ 16 g

• = 102 : 1 (Match NPC : N for Stressed Pt)

Condition NPC : N

Maintenance 150 : 1

Stress 90-120 : 1

Infant 200 : 1

NPC : N Ratio

NPC: 43% glucose and 57% lipid

Glucose: 1644.42 kcal x 43%

= = 707 kcal707 kcal

Lipid: 1644.42 kcal x 57%

= 937.32 kcal= 937.32 kcal

4. Lipid Requirement

Calories required = 937.32 kcal

Total lipid = 937.32 kcal / 9 kcal/g

= 104.14 g

5. Carbohydrate Requirement5. Carbohydrate Requirement

Calories required = 707 kcal

Total carbohydrate = 707 kcal / 4 kcal/g

= 176.75g

Calculated Requirement

Daily Requirement

Volume of The Preparation

Content in the Calculated Volume

Final Volume

Protein 100g 100g contains 16g N

16g/13.5g x1000mL = 1185.19 mL ≈ 1185mL

VaminTM14 contains:Na+ = 0.1 x 1185= 118.5mmolK+ = 0.05 x 1185= 59.25mmolCa+ = 0.005 x 1185= 5.925mmolMg+= 0.008 x 1185= 9.48mmolCl- = 0.1x 1185 = 118.5mmolSO42- = 0.008 x 1185 =9.48mmol

N=13.5gm/1000mL

1185mL

Lipid 104g 20%= 30g / 100mL104/30 x 100 = 346.67mL≈ 347mL

Intralipid 20% 347mL

Dextrose 177g 50% = 50g / 100mL177/50 x 100 = 354mL

Dextrose 50% 354 mL

Calculated Requirement (Cont.)Daily Requirement

Volume of the Preparation

Content in the Calculated Volume

Final Volume

Trace Element (Additrace)

10mL 10mL

Phosphate: 50mmol (Use K2HPO4Inj )

50 x1 =50mL K2HPO4 Inj contains:

K+ = 2.0 mmol/mlPhosphate = 1 mmol/l

50 mL

Sodium : 100mmol

From Vamin: 118mmol

0mL

Mg2+: 10 mmol From Vamin: 9.48mmol

0mL

Calcium : 10 mmol

(Use CaGlu 10% Inj)

From Vamin: 5.925mmol

4mmol / 0.22mmol x 1mL = 18mL

CaGlu 10% Inj contains: Ca2+

= 0.22 mmol/ml

18mL

Calculated Requirement (Cont.)Daily Requirement

Volume of the Preparation

Content in the Calculated Volume

Final Volume

Potassium: 100 mmol

From K2HPO4 Inj:2.0 mmol/mL x 50mL = 100mmol

0mL

Water soluble vitamin :(Use Solivito)

10mL

Lipid soluble vitamin(Use Vitlipid Adult)

10mL

Fluid(Water for Injection)

2250mL – 1984mL = 266mL

266mL

TOTAL VOLUME 2250mL

TPN REGIMEN PROVIDED

Date Regimen Contents

20-10-2014 - 28-10-2014 Kabiven Peripheral Amino Acid 34gNitrogen 5.4 gGlucose 97gLipid 51gTotal Energy 1000 kcalNPC 900kcalSodium 32 mmolChloride 47 mmolCalcium 2 mmolPotassium 24 mmolMagnesium 4 mmolPhosphate 11 mmolTotal Volume 1440mL

22-10-2014 & 23-10-2014

Potassium chloride 10% inj. 10ml

150mg KCl/mL:Potassium 37mmolChloride 42mmol

Overall Comparison and Comments

TPN Content TPN Prescribed TPN Calculated

Protein 34g 100g

Lipid 51g 104g

Carbohydrate 97g 177g

Total Energy 1900kcal 2044kcal

Sodium 32mmol 90mmol

Chloride 47mmol 80mmol

Calcium 2mmol 10mmol

Potassium 24mmol 100mmol

Magnesium 4mmol 10mmol

Phosphate 11mmol 50mmol

Total Fluid Volume

1440mL 2250

1. Renal Profile

Increase of urea level --- indication of high protein catabolism.

Decreasing level of creatinine towards normal range indicated that AKI is treated properly.

2. Liver Profile

Low level of total protein and albumin is an indicator for malnutrition. Low level of protein may be due to high protein catabolism.

Elevated levels of ALP and ALT are because of patient’s bile duct disease and usage of TPN.

3. Electrolytes Level

Potassium chloride is given to patient on 22nd and 23rd Oct in order to ensure she is not having hypokalemia.

4. Platelet Count

Reduced platelets count indicated the septicemia.

5. Culture & Sensitivity Test

• 19th Oct 2014TEST: Blood Culture Anaerobic (Gram

Negative)RESULT: + Bacteriodes sp.

6. I/O Chart

• + balance shown that patient is having fluid retention since DOA, 19th Oct.

This is due to her AKI problem.Edema should be noted.

Monitoring Efficacy and Progress

• Vital signs BP, body temperature should be monitored closely as the

patient has septic shock.

• I/O Chart To prevent fluid retention or dehydration in patient.

• Anthropometry Patient’s body weight and fluid balance monitored. Negative fluid balance show success TPN.

• Serum/urine glucose level Patient had a history of DM Type II. Need to ensure patient can tolerate the glucose content in TPN. Blood glucose level should be monitored.

• Renal + electrolytes status Indicates appropriate provision or other complicating clinical activity. AKI.

• Proteins Albumin level is quite low. The patient is malnourished. Liver enzymes; ALT and ALP are elevated because of liver duct

problem and usage of TPN.

Monitoring Safety

• Metabolic/ Nutritional complication Monitored level of blood glucose level. Monitor level of potassium and phosphate to avoid

refeeding syndrome.

• Technical/Mechanical complication Check for infection from catheter. Monitor vital signs.

Conclusion

The current TPN regimen is not sufficient to fulfill patient’s daily nutrition requirement.

However, intervention to increase the doses should be taken only after serious monitoring and consideration on patient’s current kidney and liver functions

I/O chart should continue to be monitored closely.

References

1. Calvin L. Long, Neal Schaffel, John W. Geiger, William R. Schiller and William S. Blakemore. 1979. Metabolic Response to Injury and Illness: Estimation of Energy and Protein Needs from Indirect Calorimetry and Nitrogen Balance. Journal of Parenteral and Enteral Nutrition 3: 452-456.

2. DR Garrel, N Jobin, LHM De Jonge .1996. Should We Still Use the Harris and Benedict Equations? Nutrition in Clinical Practice Journal 11: 99-103

3. Koneru Veera Raghava Chowdary and Pothula Narasimha Reddy. 2010. Parenteral nutrition: Revisited. Indian Journal of Anaesthesia 54(2): 95-103

4. Gail A. Cresci. 2005. Nutrition Support for the Critically Ill Patient: A Guide to Practice. CRC/Taylor & Francis Group.

5. http://www.cancer.org/healthy/toolsandcalculators/calculators/app/body-mass-calculator

6. Assoc. Prof Fuad Ahmad bin Shamsuddin’s lecture notes on Parenteral Nutrition Support

THANK YOU

Terima Kasih