Outcomes in Esophageal Atresia and Tracheoesophageal Fistula by ert554898

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									      Intern Seminar

Total Parenteral Nutrition
          (TPN)

         Ri 周維國
             Questions

Q1. Early Use of Post-Op TPN?



Q2. TPN – Continuous vs “3-Meals”?
      Part Ⅰ .

Early Post-Op TPN?
            Hypothesis

• Healthy people need good nutrition
                 ↓
    • Post-Op patient also need
           good nutrition

              • True?
           TPN after Major
  Pancreatic Resection for Malignancy
• Prospective Randomized Trial
• Case number: 117
TPN group (n=60): TPN since 1st post-op day
Control group (n=57): Dextrose water
• Morbidity (major & minor complication)
  Mortality
• Statistics: χ2 (p < 0.05)
                      Brennan, et al. Ann. Surg. 220:436-44, 1994
TPN after Major Pancreatic Resection for Malignancy
             – Major Complication



             Significant




                 Significant

                           Brennan, et al. Ann. Surg. 220:436-44, 1994
TPN after Major Pancreatic Resection for Malignancy
             – Minor Complication




                No significant difference




                          Brennan, et al. Ann. Surg. 220:436-44, 1994
TPN after Major Pancreatic Resection for Malignancy
                  – Morbidity




                          Significant higher




                          Brennan, et al. Ann. Surg. 220:436-44, 1994
TPN after Major Pancreatic Resection for Malignancy
                   – Mortality


                                                    No Differ.




                          Brennan, et al. Ann. Surg. 220:436-44, 1994
  TPN after Major Pancreatic Resection for Malignancy
                    – Conclusion

• TPN group:
    higher morbidity; same mortality
• Major complication:
    Infection (intra-abd. abscess)
• TPN ↑ immuno-suppression after Op. ?
• Routine TPN use: Not Justified


                            Brennan, et al. Ann. Surg. 220:436-44, 1994
The Effect of TPN on Outcome Following Major
   Surgery Evaluated in a Randomized Study
• Prospective Randomized Trial
• Case number: 300
Group 1 (n=122): TPN since 1st post-op day
Group 2 (n=126): Dextrose water
Group 3 (n=24): unable to feed on Dextrose
                day 15  TPN
Group 4 (n=28): complication on TPN  daily adjust
                                         (reduction)
                           Rolf, et al. Ann. Surg. 217:185-95, 1993
The Effect of TPN on Outcome Following Major
   Surgery Evaluated in a Randomized Study
•   Mortality rate
•   Severe complication
•   Functional disturbance
•   Need of additional medical support
•   Abn. in nutritional state

• Statistics: χ2 (p < 0.05)
                         Rolf, et al. Ann. Surg. 217:185-95, 1993
Functional & Physiologic Variables
                gr1 < gr3




        No Difference             gr3 < gr4
                   Rolf, et al. Ann. Surg. 217:185-95, 1993
Outcome Variables & Additional Medical Tx
                   gr1 < gr3




            No Difference             gr3 < gr4

                       Rolf, et al. Ann. Surg. 217:185-95, 1993
Severe Complications



 P < 0.15         Significant Differ.




            Rolf, et al. Ann. Surg. 217:185-95, 1993
            Result & Discussion
• Group 1 vs. Group 2: No Difference
 Sub-optimal nutrition is Not a limiting factor for
  most (60%) surgical patient
• Group 3 vs. Group 1: ↑morbidity & mortality
 TPN is Life-supporting
• Group 4: Cardiopulmonary complication & high
  mortality
 Not tolerate the metabolic & fluid burden
                          Rolf, et al. Ann. Surg. 217:185-95, 1993
            Result & Discussion
• Most (60%) surgical patient:
Post-op semi-starvation: not influence outcome
• Other (40%) patient:
1. Inadequate nutrition (too much & too little)
    ↑ morbidity & mortality
2. Overfeeding > Underfeeding
3. TPN as life-saving in 20% unselected patient
    Unable to identify Pre-op
                         Rolf, et al. Ann. Surg. 217:185-95, 1993
Review of Literature




     Dan L. W., et al. World J. Surg. 23(6):560-4, 1999
Review of Literature




     Dan L. W., et al. World J. Surg. 23(6):560-4, 1999
           Postoperative TPN
• Routine post-op TPN:
1. Not beneficial to clinical state & outcome
2. ↑ Complications
   (even peo-op under-nourished)
• TPN as Life-saving in 20%

•   When to use?
                   Dan L. W., et al. World J. Surg. 23(6):560-4, 1999
                     Postoperative TPN
• Indications:
(defined by French consensus conference 1997)
1. Pre-op TPN use
2. Severely malnourished prior to Op. & not pre-
    op TPN use
3. Op. / Complication  unable to regain normal
    nutrition after 1 wk
4. Severe post-op complications
(ex. Infection, acute resp. or renal failure, fistula, or acute pancreatits)
•    Timing: Early; as soon as hemodynamic stable
                               Dan L. W., et al. World J. Surg. 23(6):560-4, 1999
        Part Ⅱ .

Continuous vs. “3-Meals”?
 Metabolic Rate & Nitrogen Balance in Patients
  Receiving Bolus Intermittent TPN Infusion

• Purpose of Nutrition:
   Protection or Resynthesis of lean body mass
• Predictive factor of amino acid uptake:
   [Amino acid]artery
• Non-physiologic kinetics  less efficient N use
• ↑energy & protein load  ↑side effect,
                            morbidity, & mortality
                      Anders H., et al., JPEN 17:158-64, 1993
  Metabolic Rate & Nitrogen Balance in
  Patients Receiving Bolus Intermittent
             TPN Infusion
• Hypothesis:
   Modified infusion Rate ↑ nutritional efficiency?
• Material: 30 otherwise healthy volunteer
• Op.: elective conventional cholecystectomy due to gall
  stone
• Non-protein calories:
   160% of measured resting energy expenditure
   (60% -- Carbohydrate & 40% -- Fat)
• Amino acid: crystalline solution (0.2g N/kg/d)
                         Anders H., et al., JPEN 17:158-64, 1993
          Infusion Regimens
              9 pm




                                                    (116mL/h)
1 hr

                                                    (470mL/h)
   3 hr




                 Anders H., et al., JPEN 17:158-64, 1993
 Measurement of Energy & Nitrogen Metabolism


• Energy Expenditure:
   Heart rate + IC (indirect calorimetry)
• Nitrogen balance:
   Nitrogen intake – N excretion (urine + drainage)
• Biochemical tests:
   Plasma albumin, insulin, amino acid

                      Anders H., et al., JPEN 17:158-64, 1993
Result – Energy Balance




                 >             >




        Anders H., et al., JPEN 17:158-64, 1993
Result – Nitrogen Balance




         Anders H., et al., JPEN 17:158-64, 1993
Result – Plasma Insulin




        Anders H., et al., JPEN 17:158-64, 1993
Result – Plasma Amino Acid




                 <             <

          Anders H., et al., JPEN 17:158-64, 1993
 Metabolic Rate & Nitrogen Balance in Patients
 Receiving Bolus Intermittent TPN Infusion --
                  Conclusion
• Intermittent Bolus infusion:
1. Best nitrogen balance
    High insulin  protein synthesis?
2. Positive energy balance
3. High plasma amino acid
     disposal to intracellular (protein synthesis)
• Infusion modality matters
                       Anders H., et al., JPEN 17:158-64, 1993
                 Questions


• Elective cholecystectomy
    Minor stress & No indications for TPN
• Limited clinical application
• Major Surgical Procedure?
                       Rolf S., et al., JPEN 19:333-40, 1995
 The Effect on Energy & Nitrogen Metabolism by Continuous,
 Bolus, or Sequential Infusion of a defined TPN Formulation in
            Patients After Major Surgical Procedures

• Material: 65 patient
• Op.: acute or elective major surgery
• Non-protein calories:
   100% of predicted energy expenditure
     (Harris & Benedict Formula)
   (60% -- Carbohydrate & 40% -- Fat)
• Amino acid: crystalline solution (0.2 g N/kg/day)
                                   Rolf S., et al., JPEN 19:333-40, 1995
            Infusion Regimens
          4 pm
                                                    (168mL/h)

                                            (101mL/h)


                                                   (3L)
                                            (125mL/h)
1 hr

                                               (580mL/h)
   2 hr


                       Rolf S., et al., JPEN 19:333-40, 1995
  Measurement of Energy & Nitrogen Metabolism
• Energy Expenditure:
   24 hr Heart rate + IC (indirect calorimetry)
• Nitrogen balance: Nitrogen intake – N excretion (urine + drainage)
  “Minimum” : only infused amino acid
  “Maximum” : infused + blood & plasma product
• Biochemical tests:
   Plasma glucose, BCS + e-, renal & liver function
• Daily urine glucose & nitrogen


                                        Rolf S., et al., JPEN 19:333-40, 1995
       Result – Estimate of Energy Balance

• Sequential group: -318 ± 25 kcal/d
• Continuous group: -368 ± 25 kcal/d
• Bolus group: - 292 ± 20 kcal/d

• Significant different (p < .01) from 0 balance
• No difference among groups



                             Rolf S., et al., JPEN 19:333-40, 1995
Result – Nitrogen Provided




                Rolf S., et al., JPEN 19:333-40, 1995
Result – “Minimum” Nitrogen Balance




                    Rolf S., et al., JPEN 19:333-40, 1995
Result – “Maximum” Nitrogen Balance




                    Rolf S., et al., JPEN 19:333-40, 1995
                       Discussion
Major surgery (1995)        Minor surgery (1993)

Non-protein calories:    Non-protein calories:
100% of predicted        160% of predicted
Energy Balance: Negative Energy Balance: Positive

N. Balance: Negative        N. Balance: Positive

Best N utilization:         Best N utilization:
Continuous                  Bolus

                               Rolf S., et al., JPEN 19:333-40, 1995
                 Conclusion

• TPN after Major Surgery –
   Hypocaloric & Continuous infusion
      At least N. balance

• Most favorable regimens:
   All-in-one IV nutrition

                             Rolf S., et al., JPEN 19:333-40, 1995
Thank you for your attention!

								
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