Parenteral NutritionParenteral Nutrition

Made simple….Made simple….

in 15 minutesin 15 minutes

Jon ShafferJon ShafferIntestinal Failure UnitIntestinal Failure Unit

Hope HospitalHope Hospital

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutrition

Nutrition assessmentNutrition assessment

Nutrition teamsNutrition teams

IndicationsIndications

AccessAccess

PrescribingPrescribing

MonitoringMonitoring

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring

CONSEQUENCES OF MALNUTRITION

DIMINSHED QUALITY OF LIFE

INCREASED CLINICAL COMPLICATIONS

POORER OUTCOME

INCREASED COSTS

0

20

40

60

80

100

wt function

Effects of 6/12 semi-starvation

Malnutrition on admission –Malnutrition on admission –SwedenSweden

382 pts382 pts

InfectionInfection

SurgerySurgery

Internal medicineInternal medicine

OncologyOncology

Well nourished Well nourished 73 %73 %

Moderately malnourished Moderately malnourished 20 %20 %

Severely malnourished Severely malnourished 7 %7 %

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutrition

Nutrition assessmentNutrition assessment

Nutrition teamsNutrition teams

IndicationsIndications

AccessAccess

PrescribingPrescribing

MonitoringMonitoring

Nutritional assessmentNutritional assessment

ProblemProblem

No “blood urea “ for malnutritionNo “blood urea “ for malnutrition

Risk scores v malnutritionRisk scores v malnutrition

Multiple examplesMultiple examples

Lack of a Gold StandardLack of a Gold Standard

ValidationValidation

Nutritional screeningNutritional screening

ALBUMINALBUMIN

Long half lifeLong half life

Overly sensitive- liver/renal diseaseOverly sensitive- liver/renal disease

Reduction – redistributionReduction – redistribution

Slow to react with recoverySlow to react with recovery

“ “ negative acute phase protein”negative acute phase protein”

Nutritional screeningNutritional screeningSubjective Global AssessmentSubjective Global Assessment

Pt questionsPt questions e.g weight losse.g weight loss

diet changesdiet changes

GI symptomsGI symptoms

Physical appearancePhysical appearance--

loss of fatloss of fat

muscle wastingmuscle wasting

GradingGrading

A A Well nourishedWell nourished

BB Moderately malnourished Moderately malnourished

C C Severely malnourished Severely malnourished

Detsky 1987Detsky 1987

0

10

20

30

40

50

60

70

%

A B C SGA

Infection rate and SGA

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutrition

Nutrition assessmentNutrition assessment

Nutrition teamsNutrition teams

IndicationsIndications

AccessAccess

PrescribingPrescribing

MonitoringMonitoring

Nutrition support teamsNutrition support teams

Appropriate screening /referralAppropriate screening /referral

Appropriate nutrition supportAppropriate nutrition support

Education/training – staff and ptsEducation/training – staff and pts

Cost effectiveCost effective

PN x10 v ENPN x10 v EN

Better outcomesBetter outcomes

Reduced complicationsReduced complications

Bowling 2002Bowling 2002

Efficacy of nutrition support teamsEfficacy of nutrition support teamse.g. catheter sepsis rates e.g. catheter sepsis rates

% Before% Before %After%After

FreemanFreeman 2121 1.31.3

SandersSanders 2929 4.74.7

RyanRyan 3333 33

NehmeNehme 2525 1.31.3

KeohaneKeohane 3333 44

JacobsJacobs 2424 00

FaubionFaubion 2424 3.53.5

MeanMean 2727 2.52.5

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring

Appropriateness – variesAppropriateness – varies

Few ABSOLUTE indicationsFew ABSOLUTE indications

1. Intestinal Failure1. Intestinal Failure

22. . If the gut works – use itIf the gut works – use it

33. . Enteral preferableEnteral preferable

Intestinal Failure

“The reduction in the functioning gut mass below the minimal amount necessary for adequate digestion and absorption”

(Fleming and Remington 1981)

If the gut works……1If the gut works……1

Technology -- 1970’s—1990Technology -- 1970’s—1990

Parenteral > EnteralParenteral > Enteral

Better catheters/ better feeds/better Better catheters/ better feeds/better researchresearch

Industry/ Surgery drivenIndustry/ Surgery driven

Most - Surgical/Intensive care/CancerMost - Surgical/Intensive care/Cancer

If the gut works……2If the gut works……2

1990’s1990’s

Enteral tubes especially PEG’sEnteral tubes especially PEG’s

Medical > SurgicalMedical > Surgical

Erosion of traditional markets e.g. Erosion of traditional markets e.g. Pancreatitis, ICUPancreatitis, ICU

Enteral ? preferableEnteral ? preferable

SimplerSimpler

Less complicationsLess complications

CheaperCheaper

EquieffectiveEquieffective

Parenteral nutritionParenteral nutrition

Importance of malnutritionImportance of malnutrition

Nutrition assessmentNutrition assessment

Nutrition teamsNutrition teams

IndicationsIndications

AccessAccess

PrescribingPrescribing

MonitoringMonitoring

IV ACCESSIV ACCESS

Peripheral - short termPeripheral - short term

Midline - short/mediumMidline - short/medium

PICC ( Peripherally inserted central line )PICC ( Peripherally inserted central line ) - -mediummedium

Central – medium/long termCentral – medium/long term

Central tunnelled – ultra long term HPNCentral tunnelled – ultra long term HPN

PrescribingPrescribing

Standard bagsStandard bags

A la carteA la carte

All in one bagsAll in one bags

Re-feeding syndrome Po4, KRe-feeding syndrome Po4, K

Design of RegimenDesign of Regimen

OsmolalityOsmolality

peripheral < 900 mosmol/L, peripheral < 900 mosmol/L, (1800kcals)(1800kcals)

PICC < 1200 mosmol/L PICC < 1200 mosmol/L (2000kcals)(2000kcals)

Central < 1700 mosmol/L Central < 1700 mosmol/L (> 2000kcals)(> 2000kcals)

FluidFluid

30-35mls/kg body weight (adjust for age)30-35mls/kg body weight (adjust for age)

EnergyEnergy

Normal to provide a ratio of Normal to provide a ratio of

Glucose: fat 50:50 or 60:40Glucose: fat 50:50 or 60:40

Overfeeding can result in lipogenesis, fatty Overfeeding can result in lipogenesis, fatty infiltration of the liverinfiltration of the liver

NitrogenNitrogen

Range from 0.17-0.3gN/kgRange from 0.17-0.3gN/kg

Rarely give >14g / dayRarely give >14g / day

Need to ensure maximal metabolic effect Need to ensure maximal metabolic effect of protein – 200kcals / gNof protein – 200kcals / gN

I.e. excess nitrogen = extra calories I.e. excess nitrogen = extra calories

Vitamins and MineralsVitamins and Minerals

Water soluble Water soluble

Fat Soluble Fat Soluble

Trace Elements Trace Elements

Parenteral Nutrition RegimenParenteral Nutrition RegimenSolution Solution Volume Volume

(mls)(mls)Energy Energy (kcals)(kcals)

Nitrogen Nitrogen (g)(g)

Na Na (mmol)(mmol)

K (mmol)K (mmol) Ca Ca 9mmol)9mmol)

PO4 PO4 (mmol)(mmol)

Mg Mg (mmol)(mmol)

Vamin 9 EFVamin 9 EF 10001000 9.49.4

GlucoseGlucose

40%40%

500500 800800

20% 20% IntralipidIntralipid

500500 10001000 7.657.65

AddiphosAddiphos 1010 7.57.5 7.57.5 1010

15% KCl15% KCl 2020 4040

50% Mg SO450% Mg SO4 22 44

Ca ClCa Cl 44 3.63.6

30% NaCl30% NaCl 5050 100100

Vitlipid + Vitlipid + SolovitoSolovito

10 each 10 each vialvial

AdditraceAdditrace 1010

RequirementRequirementss

23302330 19001900 9.59.5 108108 4848 3.63.6 1919 3.83.8

Total Total 21162116 18001800 9.49.4 107.5107.5 47.547.5 4.34.3 17.617.6 44

RequirementsRequirements

Energy = 8.1x45+656 =1020 + (153kcals)15% activity + Energy = 8.1x45+656 =1020 + (153kcals)15% activity + (153kcals) 15 % stress + 500kcals = 1826kcals(153kcals) 15 % stress + 500kcals = 1826kcals

Nitrogen = 0.2g/kg = 9gNNitrogen = 0.2g/kg = 9gN

Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)

Na 295mmol (1mmol / kg, GI losses 250mmol/L)Na 295mmol (1mmol / kg, GI losses 250mmol/L)

K 45mmol (1mmol / kg) K 45mmol (1mmol / kg)

PO 22.5mmol (0.5-0.7mmol/kg)PO 22.5mmol (0.5-0.7mmol/kg)

Mg 4.5mmol (0.1-0.2mmol/kg) Mg 4.5mmol (0.1-0.2mmol/kg)

Ca 4.5mmol (0.1-0.2mmol/kg)Ca 4.5mmol (0.1-0.2mmol/kg)

MonitoringMonitoring

ParameterParameter FrequencyFrequency RationaleRationale

WeightWeight Daily - weeklyDaily - weekly Nutritional Status Nutritional Status – fluid balance– fluid balance

AnthropometryAnthropometry FortnightlyFortnightly Nutritional StatusNutritional Status

TemperatureTemperature DailyDaily InfectionInfection

Line SiteLine Site Daily Daily InfectionInfection

Fluid BalanceFluid Balance Daily Daily Fluid / electrolyte Fluid / electrolyte requirementrequirement

BAPENBAPEN

BritishBritish

AssociationAssociation

Enteral Enteral

&&

Parenteral Parenteral

NutritionNutrition