Acute liver failure

[Kathleen Standafer]

We've got a CABG patient (POD25) on TPN (21 days), obese, ventilated, recent hemicolectomy (POD5) due to ischemic bowel, with new acute liver failure (likely shock per MD). MD took lipids out of TPN and wants to give 50g protein/day (.5g/kg) due to acute liver failure. MD is concerned patient 'can't metabolize protein' with ALF. Thoughts anyone? Thanks.

Kathleen

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[JRCF]

http://ncp.sagepub.com/content/26/2/155.short

Let me know if you cannot get this and I will try another way.....
This should help him understand... for the patient's sake.

Sounds like a poor prognosis ... : - (

Cyndy

Kathleen

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[Murch, Lauren]

approve
________________________________________
From: Merin Kinikini [Merin.K...@imail.org]
Sent: April 23, 2012 3:06 PM
To: criticalca...@googlegroups.com
Subject: RE: [Critical Care Nutrition] Acute liver failure

I agree - I put my liver patients in low CHO, high-protein tube feeds with antioxidants and fish oils (such as Impact Peptide).

Perhaps the intermittent lipids, especially being so sick, but the protein restriction should be lifted.

Merin

[Kathleen Standafer]

The closest formula we have to that composition is Glucerna. I recommended it a couple weeks ago and continue to recommend lifting the protein restriction. Thanks everyone!

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[Kathleen Standafer]

Thanks for the reference. I found a vague article to give to him but I'm not sure it was helpful. I'll check this one out. Have a good day.

Kathleen

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[Merin Kinikini]

I agree - I put my liver patients in low CHO, high-protein tube feeds with antioxidants and fish oils (such as Impact Peptide).

Perhaps the intermittent lipids, especially being so sick, but the protein restriction should be lifted.

Merin

-----Original Message-----
From: criticalca...@googlegroups.com [mailto:criticalca...@googlegroups.com] On Behalf Of JRCF
Sent: Friday, April 20, 2012 5:53 PM
To: criticalca...@googlegroups.com

[Kathleen Standafer]

This pt is not tolerating TF (abd significantly distended), and TPN
was held by surgeons due to jaundice (72hrs now). He's had two major
surgeries (CABG & right colectomy due to ischemic bowel) and has been
here 2 months, has large abd and sternal wounds with wound vac. I've
been recommending TPN with 100g protein/d and 50g dextrose/d without
lipids. Pharmacist and surgeons still want to hold PN. Caloric deficit
in this patient is LARGE. Last bili was 15. TRIG trending downward
last check (198). Recommendations for TPN vs holding TPN?

--
*Kathleen Standafer MS RD CNSD*
*Clinical Nutrition Support Specialist*
*Columbia, MO*

[Kathleen Standafer]

Do you have any literature on how to manage TPN specifically in the
acute liver patient? I have looked extensively and most of it refers
to acute liver failure patients on enteral nutrition. Most of the TPN
literature is on chronic liver failure patients. Cycling is not
backed up by any solid literature (that I'm aware of)- but I have done
this from time to time also. I really appreciate hearing from a liver
expert. Thanks a lot! Here's his Alk Phos trend. Any more thoughts?

Alk Phos 109 (4/23)
123 (4/21)
156 (4/18)

On 5/1/12, Leanne Mulesa <Leanne...@albertahealthservices.ca> wrote:
> We do hold TPN even for our liver transplant patients (pre and post)- I
> would cycle the TPN if they are that concerned and easily provide 150 g dex
> and full protein (1.5 g/kg). Lipid could be given Mon/Wed/Friday. This all
> would minimize risk of further liver damage- I would monitor the Alk phos
> more as a sign of TPN related cholestasis- as long as it is stable I would
> have no concern running the TPN.
>
> We see a large population of liver disease patients in our region and
> definitely would not restrict protein- the literature shows the patient will
> break down there own muscle stores leading to far worse issues.
>
> I hope this helps :)

>
> -----Original Message-----
> From: criticalca...@googlegroups.com
> [mailto:criticalca...@googlegroups.com] On Behalf Of Kathleen
> Standafer
> Sent: Tuesday, May 01, 2012 7:42 AM
> To: criticalca...@googlegroups.com

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[sarah...@rocketmail.com]

Did you look at the ESPEN guidelines for parenteral nutrition in
critical care and in liver failure?
Sarah

[Kathleen Standafer]

Yes

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[Sandeep Kantor]

How do you manage lipids in patients with liver dysfunction??
Sandeep Kantor MD

[Kathleen Standafer]

This is a difficult question to answer, because of the fentanyl
shortage. Most of our patients are on sufficient amounts of propofol.
Usually, I recommend completely removing lipids from the TPN formulas
because of the propofol infusions. In the past when I've had ALF
patients on TPN and not on propofol, I mimize lipid infusion to 2-3
times per week. How do you manage the lipids your patients?

Kathleen