CICM SAQ 2015.1 Q7

Question

A 26-year-old female is admitted to the ICU post operatively with faecal peritonitis as a result of multiple bowel perforations secondary to Crohn’s disease. She has had the majority of her small bowel resected and is to be prescribed total parenteral nutrition (TPN).

  • a) Describe the available methods to estimate total energy expenditure in critically ill patients and outline their advantages and limitations. (70% marks)

The basal energy expenditure of this patient is determined to be 2000 kcal (8400 kJ) / day and she weighs 50 kg.

  • b) Describe how you would prescribe her TPN. (30% marks)

Answer

Answer and interpretation

a) Describe the available methods to estimate total energy expenditure in critically ill patients and outline their advantages and limitations

Empiric:

  • This may be based just upon weight or surface area – Most critically ill patients will have requirements of approx. 25 kCal/kg/day.
  • Advantages – quick, simple and cheap. Universally available
  • Disadvantages – may be inaccurate

Predictive equations:

  • Many versions such as Harris-Benedict, PennState, Faisy etc., based upon various direct measurements.
  • Advantages – quick, simple and cheap. Universally available
  • Disadvantages – Inaccuracy, usually underestimate requirements. Need for multiple correction factors.

Indirect Calorimetry:

  • Measures oxygen uptake and carbon dioxide production using the assumption that all of the oxygen uptake is used for oxidation of substrates.
  • Advantages: Most accurate method. Bedside monitor than can be integrated with ventilator.
  • Disadvantages: Expensive; requires technical expertise, limited availability. Inaccurate in the setting of high FiO2 or PEEP, leaks in circuit, recent ventilator changes, changes in oxygen concentration, hemodynamic instability, temperature changes or haemodialysis.

Fick method

  • Determines oxygen consumption from indwelling pulmonary artery catheter, then uses caloric value for oxygen to calculate energy expenditure.
  • Advantages: More accurate than predictive equations, cheaper and more available than indirect calorimtery.
  • Disadvantages: Highly invasive. Does not account for pulmonary oxygen consumption.

b) Describe how you would prescribe her TPN

Standard TPN delivery 2 litre bags

If the total non-protein kCal required is 2000/day, ratio for CHO to fat is 70:30

Dextrose:

  • 1400Kcal
  • 824mls (412g dextrose at 50% solution at 3.4Kcal/gram and requiring 1400KCal)

Lipid:

  • 600Kcal
  • Using 10% lipid (1.1kcal/ml), will need 545mls 10% lipid
  • Adjust if using propofol as sedation (approx. 1kcal/ml as fat)

Protein 1.5-2g/kg/day

  • 2 x 50 = 100 grams/day of amino acids
  • Using 10% solution amino acid solution (100g/L) 1 Litre of 10% amino acid solution

Electrolyte, vitamins and trace elements are added to the solution in a standard fashion, but may be individually tailored to the patient’s requirements.

  • Pass rate: 69%
  • Highest mark: 7.8

Additional comments:

  • Other valid methods for measurement of energy expenditure were given credit. Detail on nutritional requirements was lacking in some answers
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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