Transcript Parenteral Nutrition

Parenteral Nutrition
Made simple….
in 15 minutes
Jon Shaffer
Intestinal Failure Unit
Hope Hospital
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
CONSEQUENCES OF MALNUTRITION
DIMINSHED QUALITY OF LIFE
INCREASED CLINICAL COMPLICATIONS
POORER OUTCOME
INCREASED COSTS
Effects of 6/12 semi-starvation
100
80
60
40
20
0
wt
function
Malnutrition on admission –
Sweden
382 pts
Infection
Surgery
Internal medicine
Oncology
Well nourished
Moderately malnourished
Severely malnourished
73 %
20 %
7%
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
Nutritional assessment
Problem
No “blood urea “ for malnutrition
Risk scores v malnutrition
Multiple examples
Lack of a Gold Standard
Validation
Nutritional screening
ALBUMIN
Long half life
Overly sensitive- liver/renal disease
Reduction – redistribution
Slow to react with recovery
“ negative acute phase protein”
Nutritional screening
Subjective Global Assessment
Pt questions
e.g weight loss
diet changes
GI symptoms
Physical appearance-
loss of fat
muscle wasting
Grading
A
B
C
Well nourished
Moderately malnourished
Severely malnourished
Detsky 1987
Infection rate and SGA
70
60
50
40
%
30
20
10
0
A
B
SGA
C
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
Nutrition support teams
Appropriate screening /referral
Appropriate nutrition support
Education/training – staff and pts
Cost effective
PN x10 v EN
Better outcomes
Reduced complications
Bowling 2002
Efficacy of nutrition support teams
e.g. catheter sepsis rates
Freeman
Sanders
Ryan
Nehme
Keohane
Jacobs
Faubion
Mean
% Before
21
29
33
25
33
24
24
27
%After
1.3
4.7
3
1.3
4
0
3.5
2.5
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
Appropriateness – varies
Few ABSOLUTE indications
1. Intestinal Failure
2. If the gut works – use it
3. Enteral 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……1
Technology -- 1970’s—1990
Parenteral > Enteral
Better catheters/ better feeds/better
research
Industry/ Surgery driven
Most - Surgical/Intensive care/Cancer
If the gut works……2
1990’s
Enteral tubes especially PEG’s
Medical > Surgical
Erosion of traditional markets e.g.
Pancreatitis, ICU
Enteral ? preferable
Simpler
Less complications
Cheaper
Equieffective
Parenteral nutrition
Importance of malnutrition
Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring
IV ACCESS
Peripheral short term
Midline
short/medium
PICC ( Peripherally inserted central line ) medium
Central – medium/long term
Central tunnelled – ultra long term HPN
Prescribing
Standard bags
A la carte
All in one bags
Re-feeding syndrome Po4, K
Design of Regimen
Osmolality
peripheral < 900 mosmol/L, (1800kcals)
PICC < 1200 mosmol/L (2000kcals)
Central < 1700 mosmol/L (> 2000kcals)
Fluid
30-35mls/kg body weight (adjust for age)
Energy
Normal to provide a ratio of
Glucose: fat 50:50 or 60:40
Overfeeding can result in lipogenesis, fatty
infiltration of the liver
Nitrogen
Range from 0.17-0.3gN/kg
Rarely give >14g / day
Need to ensure maximal metabolic effect
of protein – 200kcals / gN
I.e. excess nitrogen = extra calories
Vitamins and Minerals
Water soluble
Fat Soluble
Trace Elements
Parenteral Nutrition Regimen
Solution
Volume
(mls)
Energy
(kcals)
Nitrogen
(g)
Na
(mmol)
K (mmol)
Ca
9mmol)
PO4
(mmol)
Mg
(mmol)
Vamin 9 EF
1000
Glucose
40%
500
800
20%
Intralipid
500
1000
Addiphos
10
15% KCl
20
50% Mg SO4
2
Ca Cl
4
30% NaCl
50
Vitlipid +
Solovito
10 each
vial
Additrace
10
Requirement
s
2330
1900
9.5
108
48
3.6
19
3.8
Total
2116
1800
9.4
107.5
47.5
4.3
17.6
4
9.4
7.65
7.5
7.5
10
40
4
3.6
100
Requirements
Energy = 8.1x45+656 =1020 + (153kcals)15% activity +
(153kcals) 15 % stress + 500kcals = 1826kcals
Nitrogen = 0.2g/kg = 9gN
Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)
Na 295mmol (1mmol / kg, GI losses 250mmol/L)
K 45mmol (1mmol / kg)
PO 22.5mmol (0.5-0.7mmol/kg)
Mg 4.5mmol (0.1-0.2mmol/kg)
Ca 4.5mmol (0.1-0.2mmol/kg)
Monitoring
Parameter
Frequency
Rationale
Weight
Daily - weekly
Nutritional Status
– fluid balance
Anthropometry
Fortnightly
Nutritional Status
Temperature
Daily
Infection
Line Site
Daily
Infection
Fluid Balance
Daily
Fluid / electrolyte
requirement
BAPEN
British
Association
Enteral
&
Parenteral
Nutrition