NOTE: Complications of total parenteral nutrition (including hepatic dysfunction) are discussed in Section 12.26.
Patient selection: Patients with pre-existing liver disease were excluded. Other exclusions were are < 18 years, expected survival < 24 hours or previous cardiopulmonary resuscitation (CPR).
Manifestations of hepatic dysfunction:
(1) cholestatic (alkaline phosphatase >= 280 IU/L, GGT >= 50 IU/L and/or bilirubin > 1.2 mg/dL)
(2) hepatocellular necrosis (ALT > 40 IU/L, AST > 42 IU/L and/or INR > 1.4 not due to anticoagulation)
(3) mixed (combination of above parameters)
Parameters:
(1) type of artificial nutrition
(2) sepsis
(3) calculated energy requirements (based on actual weight)
(4) day artificial nutrition started
|
Parameter
|
Findings
|
Points
|
|
type of artificial nutrition
|
enteral nutrition
|
0
|
|
|
total parenteral nutrition (TPN)
|
1
|
|
sepsis
|
absent
|
0
|
|
|
present
|
1
|
|
calculated energy requirements
|
<= 25 kcal per kg per day
|
0
|
|
|
> 25 kcal per kg per day
|
1
|
|
day artificial nutrition started
|
first day after admission
|
0
|
|
|
after first day
|
1
|
where:
• The cutoffs for the tests used to determine hepatic dysfunction is based on 1.1 times the upper limit of normal (ULN) for the test.
• Pre-existing liver disease is a risk factors for TPN-associated liver dysfunction (see Section 12.26.06).
total score =
= SUM(points for all 4 parameters)
Interpretation:
• minimum number of risk factors: 0
• maximum number of risk factors: 4
• The higher the number of risk factors the greater the risk of hepatic dysfunction.
• Initiation of artificial nutrition during the first 24 hours after admission to the ICU is protective against hepatic dysfunction.
