Back to the Top
Good day to all,
We currently have two small (2.33kg and 3.88kg) children in our PICU.
Both were premature but with no pulmonary complications. They came in with
cases of RSV which subsequently led to ARDS. They were very sick puppies
from the start.
We started giving them parenteral nutrition early on. Initially the feeding
was conservative and now, because of lower TP and Albumin levels, the docs
have decided to get aggressive. Both are currently on High Frequency
Oscillation Vents, and sedated. One is also on Vecuronium. Not good
candidates for enteral feeds.
The attendings want to add Albumin to the TPN to increase serum levels.
There is no sign of hepatic dysfunction or acute renal failure so I can only
surmise that the lowered TP and Albumin levels are due to malnutrition. My
argument was to increase glucose and protein and the TP and Albumin would
follow shortly after.
A second reason for wanting Albunin was to increase oncotic pressure?? I
believe that there are other ways to do this that are less expensive and
more effective.
Does anyone have any data to support or dismiss the addition of Albumin
to TPNs for the purpose of increasing serum levels. Are there any studies
of the kinetics involved in the absorption and distribution of Albumin in
neonates. Is the addition of lipids to the mix going to promote the
distribution of Albumin as one attending contends?
This is a recuring argument. I need the literature to either convince me
or the docs once and for all. I am also doing a med-line search to augment
any information that you may have.
Please, antidoctal accounts are also welcomed.
Respond to me personally if you do not believe this question suitable for
discussion on the list.
Cheers.................Robert
Robert G. Aucoin RPh
Peds Clinical Pharmacist
OLOL RMC
Baton Rouge, LA
mraucoin.at.linknet.net
Back to the Top
Robert-
From my basic science perspective, both you and the physicians have good
points.
Malnutrition seems the likely explanation for the hypoproteinemia, and
unless there is
an undetected hepatic problem, increased parenteral glucose and amino acids
should
solve it. But this process may be too slow or there may be a defect in
hepatic albumin
secretion as a consequence of the infants' prematurity. Especially if the
patients are
showing signs of edema, the priming dose of albumin sounds like a good idea
assuming
there are no immune-system consequences in response to i.v. albumin.
Combining your
proposal with the physicians' proposal will result in a sort of primed
infusion of
albumin with the priming dose consisting of albumin itself and the infusion
consisting
of its biosynthetic precursors.
If the plan is to infuse albumin i.v., absorption should not be an issue, and
distribution should be as it normally is for hepatocellular-secreted
albumin. If the
parenteral route is not i.v., then addition of albumin could be detrimental
since it
will increase extravascular oncotic pressure and actually promote edema.
You are of course correct that there are other ways to increase oncotic
pressure, but
albumin is certainly the way evolution solved the problem.
I'm unsure I understand the point you make about adding lipids to the mix
and the
consequences for albumin distribution. Distribution should not be an issue
if the
parenteral route is i.v.
Good luck.
Regards,
Bob
--
Robert D Phair PhD: rphair.aaa.ix.netcom.com
BioInformatics Services: http://www.webcom.com/rphair
Partnering and Outsourcing for Computational Biology
Back to the Top
Bob,
There is rarely a second reason for giving iv albumin.
The main reason and often the only one is to increase plasma oncotic
pressure.
Thus, the short answer to your question is that in the absence of fluid /
hemodynamic problems, there is no rational for exogenous albumin. The best
way to elevate plasma albumin is support hepatic protein production through
good nutrition.
N. Anaizi, PhD RPh
Univ of Rochester Med. Center
----------
From: david
To: Multiple recipients of PharmPK - Sent by
Subject: Albumin in TPN
Date: Tuesday, November 19, 1996 5:08PM
PharmPK - Discussions about Pharmacokinetics
Pharmacodynamics and related topics
Good day to all,
We currently have two small (2.33kg and 3.88kg) children in our PICU.
Both were premature but with no pulmonary complications. They came in with
cases of RSV which subsequently led to ARDS. They were very sick puppies
from the start.
We started giving them parenteral nutrition early on. Initially the feeding
was conservative and now, because of lower TP and Albumin levels, the docs
have decided to get aggressive. Both are currently on High Frequency
Oscillation Vents, and sedated. One is also on Vecuronium. Not good
candidates for enteral feeds.
The attendings want to add Albumin to the TPN to increase serum levels.
There is no sign of hepatic dysfunction or acute renal failure so I can only
surmise that the lowered TP and Albumin levels are due to malnutrition. My
argument was to increase glucose and protein and the TP and Albumin would
follow shortly after.
A second reason for wanting Albunin was to increase oncotic pressure?? I
believe that there are other ways to do this that are less expensive and
more effective.
Does anyone have any data to support or dismiss the addition of Albumin
to TPNs for the purpose of increasing serum levels. Are there any studies
of the kinetics involved in the absorption and distribution of Albumin in
neonates. Is the addition of lipids to the mix going to promote the
distribution of Albumin as one attending contends?
This is a recuring argument. I need the literature to either convince me
or the docs once and for all. I am also doing a med-line search to augment
any information that you may have.
Please, antidoctal accounts are also welcomed.
Respond to me personally if you do not believe this question suitable for
discussion on the list.
Cheers.................Robert
Robert G. Aucoin RPh
Peds Clinical Pharmacist
OLOL RMC
Baton Rouge, LA
mraucoin.-a-.linknet.net
Also see: http://www.cpb.uokhsc.edu/pkin/pkin.html
Back to the Top
You wrote:
>
>PharmPK - Discussions about Pharmacokinetics
> Pharmacodynamics and related topics
>
> Good day to all,
> We currently have two small (2.33kg and 3.88kg) children in our
PICU.
>Both were premature but with no pulmonary complications. They came in
with
>cases of RSV which subsequently led to ARDS. They were very sick
puppies
>from the start.
.....
[deleted DB]
.....
>distribution of Albumin as one attending contends?
> This is a recuring argument. I need the literature to either
convince me
>or the docs once and for all. I am also doing a med-line search to
augment
>any information that you may have.
> Please, antidoctal accounts are also welcomed.
>
> Respond to me personally if you do not believe this question
suitable for
>discussion on the list.
>Cheers.................Robert
>Robert G. Aucoin RPh
>Peds Clinical Pharmacist
>OLOL RMC
>Baton Rouge, LA
>mraucoin.aaa.linknet.net
>
>Also see: http://www.cpb.uokhsc.edu/pkin/pkin.html
>
>Robert,
This isn't my area so I won't even pretend I have any of the answers.
I'm the clinical specialist for a spinal cord injury unit. On the few
occasions when we do use albumin it will only maintain oncotic pressure
for a short period of time, right? Isn't this because extrinsic
albumin has a vert short half-life? Anyway, I have passed this message
to a collegue in Orlando Florida who is a peds. specialist like
yourself. Hopefully, he will be able to respond.
>
Back to the Top
> The attendings want to add Albumin to the TPN to increase serum levels.
> There is no sign of hepatic dysfunction or acute renal failure so I can only
> surmise that the lowered TP and Albumin levels are due to malnutrition.
Not necessarily. Premies and term neonates are hypoalbuminemic,
relative to older kids. And if these two have active ARDS, lung
capillaries are leakier to albumin.
> My
> argument was to increase glucose and protein and the TP and Albumin would
> follow shortly after.
Agree, to the point that you have to provide enough amino acid
substrate to prevent albumin from being scavenged as an
energy/protein source.
> A second reason for wanting Albunin was to increase oncotic pressure?? I
> believe that there are other ways to do this that are less expensive and
> more effective.
Can't think of anything else except mannitol or hypertonic saline,
neither one of which seems like a good idea to me. Do the
neonatologists want to increase oncotic pressure to supernormal or
simply give the kids pressure they would otherwise have? If the
former, is that a treatment modality for ARDS? If the latter, better
to do it before they become edematous.
> Does anyone have any data to support or dismiss the addition of Albumin
> to TPNs for the purpose of increasing serum levels.
Can't say for neonates. Our adult patients on TPN are, however,
always hypoalbuminemic, and they don't catch up very quickly on TPN
alone.
> Is the addition of lipids to the mix going to promote the
> distribution of Albumin as one attending contends?
Have never heard of this. I'd be interested in learning the
mechanism, if it's true. Wouldn't be why I'd use lipids, anyway.
********************************
Randy Trinkle, BScPharm, BA
Dept. of Pharmacy
Dawson Creek & District Hospital
Dawson Creek, BC
mailto://rtrinkle.-at-.pris.bc.ca
********************************
Every now and then when your life gets complicated...
HST
|
Want to post a follow-up message on this topic?
If this link does not work with your browser send a follow-up message to PharmPK@lists.ucdenver.edu with "Albumin in TPN" as the subject | Support PharmPK by considering my eBooks |
Copyright 1995-2014 David W. A. Bourne (david@boomer.org)