1. 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
2. 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
3. • Diagnosis/Problems:
Sepsis 2° to HAP
Emphysema
AKI 2° to dehydration
• Past Medical History:
Esophageal perforation 2° post ERCP
Ascending cholangitis with acute pancreatitis
2° to periampullary tumour
DM Type II
HPT
4. 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
5. Current Medications
Medications 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
6. 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
7. Indication for TPN
1. Patient have oesophageal perforation
2. Patient was initially unconscious, weak
and bed ridden
Objective of TPN
To provide energy, hydrate patient(resolve
KI) and improve nutrition status
8. 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
9. 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
10. 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
11. 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.
12. 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
13. 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
14. 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
20. 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
21. 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.
22. 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.
23. Elevated levels of ALP and ALT are because of patient’s
bile duct disease and usage of TPN.
24. 3. Electrolytes Level
Potassium chloride is given to patient on 22nd
and
23rd
Oct in order to ensure she is not having
hypokalemia.
26. 5. Culture & Sensitivity Test
• 19th
Oct 2014
TEST: Blood Culture Anaerobic (Gram
Negative)
RESULT: + Bacteriodes sp.
27. 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.
28. 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.
29. • 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.
30. 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.
31. 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.
32. 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
