Tpn and triglycerides

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mkennaley

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Nov 1, 2016, 4:40:29 AM11/1/16
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Hello!
My pt is on tpn
Ischemic bowel post g tube perforation - now open abdomen with vac dressing. To the or x 5 times.
Intubated on min vent settings.
Tpn x 3 weeks.
I am worried about her triglycerides now at 4.2. They were 2 at start of tpn.

I am doing a combo of a bit of SMOF lipids + the propofol to get a nice profile of 25% kcal from fat, 55% kcal from cho, 20% kcal from pro. Getting 2 g pro/kg.
Kcal about 38 kcal/kg. May be too high - Our travasol is 16.6%dextrose and 5%aa so difficult to get protein in without getting more dextrose and kcal
BS are ok so far

Not sure what to do.
-I am assuming both propofol and SMOF lipids contribute to high TG. Do I ask to wean propofol if able ? Then I can cycle the SMOF and give her a chance to clear the lipid?
-should I be worried with TG at 4.2
-if propofol is not d/c should I d/c my SMOF and let kcal from CHO go up to 60%. Will this still contribute to the TG
-should I ask for med to bring TG down?
-she is only 44 kg very tiny and sick lady. Terrible situation with g tube insertion gone wrong.
Thanks in advance for any help.
Monica



Corilee Watters

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Nov 1, 2016, 3:18:53 PM11/1/16
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Monica,
Do you have access to indirect calorimetry?  Might be helpful to avoid over-feeding.  The increase in TG may be related to infection, and the suggestion to cycle SMOF might be helpful, and depending on kidney function might be able to increase protein given loss through open abdomen.  Changing from balanced lipid (eg. SMOF)  to fish oil emulsion (eg. Omegaven) can also help reduce TG.

Regards,
Corilee Watters, PhD, RD, CNSC




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Dr. Corilee Watters, MSc, RD, PhD, CNSC
Asst. Professor Nutrition, University of Hawaii
Department of Human Nutrition, Food and Animal Science
1955 East-West Road, Agricultural Science 314 J,    Honolulu, HI  96822
ph: 808-956-7581  fax:  808-956-4024
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Drover, Dr. John W.

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Nov 2, 2016, 4:49:42 PM11/2/16
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This does sound like a challenging case. There are a couple considerations that you allude to in your note.

 

First would be a consideration of the anatomy and whether there is an opportunity to establish enteral access and start at least some GI feeding. This would get around some of the issues and be good for the gut. Along that line is the issue of protein loss from the open abdomen. This may not be as much as you think and therefore you may not need to deliver 2g/kg/d.

 

You mention the patient is on minimal settings on the vent which would usually imply that there is no longer a need for deep sedation and therefore an opportunity to stop sedation including the propofol.

 

Overall I would be concerned that the patient may be getting more calories than they are able to utilize (even without IC) and reducing lipid delivery would certainly be a good first step. I too think that the higher TG levels may be a reflection of the inflamed state and the patient is just not able to metabolize the lipids regardless of the type being used. I don’t think there is much risk in having mildly elevated TG levels as you describe but there is no advantage in delivering lipids that are not being used for energy. As a result you may be able to stop lipids for a while and restart in a few days giving them intermittently.

 

Respectfully,

 

John W. Drover, MD, FRCSC, FACS, CCPE
Professor
Departments of Critical Care Medicine and Surgery
Queen’s University
Critical Care Physician Lead, South East LHIN
Kingston General Hospital

Davies 2
76 Stuart Street
Kingston, Ontario
Canada
K7L 2V7
Phone 613-549-6666 ext 6336
Fax 613-548-1325

 


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Dr. Corilee Watters, MSc, RD, PhD, CNSC
Asst. Professor Nutrition, University of Hawaii
Department of Human Nutrition, Food and Animal Science
1955 East-West Road, Agricultural Science 314 J,    Honolulu, HI  96822
ph: 808-956-7581  fax:  808-956-4024
e-mail: cwat...@hawaii.edu

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