parenteral nutrition policy - nhs gateshead from medical and surgical teams to advise on the...

Parenteral Nutrition Policy v2 1

Policy No: RM60 Version: 2.0

Name of Policy: Parenteral Nutrition Policy

Effective From: 28/08/2012

Date Ratified 14/03/2012 Ratified SafeCare Council Review Date 01/03/2014 Sponsor Director of Nursing and Midwifery Expiry Date 13/03/2015 Withdrawn Date

This policy supersedes all previous issues.


Version Control

Version Release Author / Reviewer

Ratified by / Authorised

by

Date Changes (Please identify

page no.) 1.0

February

2009 Nutrition and

Dietetics SafeCare Council

Feb 2009 General update in line with national

guidelines Page 7, 9, 14, 18,

20, 22

2.0

28/08/2012 N&DS SafeCare Council

14/03/2012 Appendix 3 added to meet NCEPOD

a mixed bag requirements.


Contents Section Page 1 Introduction ............................................................................................................ 4 2 Policy Scope ........................................................................................................... 4 3 Aim of policy ............................................................................................................ 4 4 Roles and responsibilities ....................................................................................... 4 5 Definitions ............................................................................................................... 5 6 Managing parenteral nutrition ................................................................................. 5

6.1 Indications of parenteral nutrition ..................................................................... 5 6.2 Patient Assessment .......................................................................................... 6 6.3 Parenteral access routes ................................................................................... 7 6.4 Types of catheters used for parenteral nutrition ................................................ 8 6.5 Composition of parenteral nutrition ................................................................... 8 6.6 Prescribing parenteral nutrition ........................................................................ 8 6.7 Storing parenteral nutrition ............................................................................... 9 6.8 Administrating parenteral nutrition .................................................................... 9 6.9 Discontinuing parenteral nutrition ..................................................................... 10 6.10 Monitoring for patient on parenteral nutrition .................................................. 10 6.11 Laboratory monitoring for patient on parenteral nutrition ................................. 10 6.12 Ethical Considerations ..................................................................................... 11

7 Training ................................................................................................................... 11 8 Equality and Diversity ............................................................................................. 11 9 Monitoring compliance with the policy ..................................................................... 11 10 Consultation and review .......................................................................................... 11 11 Implementation of the policy ................................................................................... 11 12 References ............................................................................................................. 11 13 Associated documentation ...................................................................................... 12 Appendices Appendix 1 Nutrition Risk Score ....................................................................................... 13 Appendix 2 Nutrition Support team referral document ...................................................... 14 Appendix 3 Parenteral nutrition proforma including prescription ........................................ 15 Appendix 4 Parenteral Nutrition Regimen form ................................................................. 17 Appendix 5 Emergency out of hours guidelines ................................................................ 18 Appendix 6 Monitoring patients on PN ............................................................................... 21 Appendix 7 Biochemical monitoring of patients on PN. ..................................................... 23


1 Introduction Many patients who were previously managed by parenteral nutrition (PN) can be treated more effectively, safely and less expensively by enteral nutrition. However there remains a significant cohort of patients who require PN, for example those suffering from intestinal failure and those whose intestinal tract is unavailable due obstruction, perforation or therapeutic interventions. Parenteral nutrition is a specialised form of nutrition support, with associated complications and should not be considered without careful planning and monitoring. This PN policy was reviewed in line with national guidance ‘Nutrition Support in adults NICE clinical guideline No 32 (2006)’, and National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June 2010’.

2 Policy scope This is a trust wide policy aimed at all health care professionals involved in the care of patients receiving parenteral nutrition, to ensure best practice is applied in accordance with national guidelines.

3 Aim of Policy The aim of the PN policy is to ensure that PN is administered safely and with appropriate monitoring and prevent related complications.

4 Roles and Responsibilities Nursing Staff Ward nurses have a responsibility to assess all patients’ nutritional status using the Trust’s Nutrition Risk Score (NRS) tool on admission, weekly and if a patient’s clinical condition changes, e.g. post-operatively (Appendix 1). Nursing staff must inform the Nutrition and Dietetics department if a patient is due to begin PN. Nursing staff are responsible for administering PN with aseptic technique and monitoring the patient for signs of line sepsis. Medical Staff Medical staff have a responsibility to consider patients for PN if they are unable to maintain or improve their nutritional status via the oral or enteral route. Nasogastric and nasojejunal feeding must be considered prior to requesting PN. Medical staff are responsible for organising insertion of appropriate venous access, ideally a single lumen central line. They are also responsible for monitoring biochemistry and considering whether the patient is at risk of refeeding syndrome. If there is a significant risk Pabrinex should be prescribed in addition to PN. The medical staff are responsible for assessing the patient’s fluid balance and prescribing appropriate fluids. The volume of PN prescribed should always be taken into account to avoid inappropriate fluid overload. The decision to commence PN should be taken by the Consultant with overall clinical care for the patient.


Dietitian Patients who are identified as requiring PN should be referred to the ward dietitian immediately. The dietitian has a responsibility to ensure that each patient receives adequate and appropriate nutritional support. The dietitian will highlight if the patient is at risk of refeeding syndrome which requires close monitoring of electrolytes and the prescription of additional vitamins. Pharmacy The aseptic services pharmacist must check biochemistry results every day (Monday to Friday) for each PN patient and liaise with the ward pharmacist to ensure that appropriate monitoring of serum electrolytes is undertaken at ward level. The aseptic services pharmacist must check that the PN regimen made is chemically and physically stable and is appropriate to the patient’s weight and the route of administration. The Pharmacist should check that the regimen and rate of administration is appropriate to the patient’s body weight. The Pharmacist should check that the alterations to the electrolytes are clinically appropriate and within the limits of stability for the regimen. Nutrition Support Team This is a multidisciplinary team led by a Gastroenterologist. The team will accept referrals from medical and surgical teams to advise on the management of patients with complicated nutritional issues. The team is happy to review patients being considered for PN. The team is also responsible for providing support and education on the methods of PN and also to ensure that policies and guidelines are up to date in accordance with national guidelines to ensure best practice. Critical Care Outreach Team CCOT provide daily reviews of all central lines, to ensure that best practice is maintained. CCOT provide support and advice regarding all aspects of central line management and PN administration. Infection Control Team The Infection Control Team provides support and advice regarding good aseptic technique for all staff administering PN. They also have a responsibility to monitor and investigate episodes of line sepsis.

5 Definitions Parenteral nutrition (PN) is the administration of nutrient solutions via a Central vein, where the venous catheters can be inserted into subclavian, jugular, or femoral veins, whether directly into the vein or tunnelled under the skin; or a large Peripheral vein. The term ‘total parenteral nutrition’ (TPN) will also be used within the policy, which is PN with the addition of vitamins and trace elements.

6.0 Managing parenteral nutrition 6.1 Indications for Usage of parenteral nutrition

PN should be avoided when it is possible to meet the patients nutritional requirements using oral and enteral feeding routes (nasogastric or nasojejunal feeding), i.e. if the gut works, use it.


PN is required when the intestine is unavailable or the intestinal function is insufficient to absorb or digest an adequate supply of nutrients on a temporary or permanent basis. Examples of appropriate conditions where PN may be used: • Extended non-absorption of enteral nutrition (This must include a trial

of Nasojejunal feeding) • Post operative ileus • Intractable vomiting • Major GI surgery where enteral nutrition is contraindicated, e.g.

perforation • Short bowel syndrome • Extensive Crohn’s disease unable to meet nutrient absorption • High output fistula where position and volume prevent enteral feeding • Motility disorders such as Sclerodema and chronic intestinal

obstruction syndromes This list is not exhaustive and the risks/benefits of providing PN and the expected duration of PN should be considered on an individual basis.

6.2 Patient Assessment Studies have shown that a multidisciplinary team can improve patient care while reducing the complications and cost of PN. When concerns are expressed about a patient’s nutritional status contact the dietitian who covers your ward on the bleep or on ext 2074 (Nutrition and Dietetic Department) or refer to the Nutrition Support Team (see Appendix 2). The dietitian will assess the patient’s nutritional requirements. The following assessments should also be carried out within the team:

Initial Assessment Rationale

Responsibility

Weight and height Measured on admission and weekly thereafter. To assess nutritional status

Nursing staff and dietitian

Hydration status To ensure adequate hydration. Oedema and ascites should be noted.

Nursing and medical staff

Fluid balance Input and output should be clearly documented. Ensure adequate hydration and avoid over hydration. NB volume of PN should be taken into account when calculating fluid input.


Temperature To ensure no underlying infections or complications.



Initial Assessment Rationale

Responsibility

Biochemistry Urea and electrolytes, glucose, liver function tests, phosphate, magnesium, calcium, haemoglobin, coagulation and trace elements

Medical staff

Gut function Is the gut functioning? Are there any gastrointestinal problems?

Medical staff

Nutritional assessment

Any changes in weight? Any changes in appetite? History of oral intake? Any intake at present?

Nursing and medical staff, dietitian

Venous access Ensure good venous access with no complications

Medical staff

6.3 Parenteral Access Routes

Peripheral access Peripheral PN may be considered via a large peripheral vein but it is not routinely recommended. Peripheral PN carries a high risk of thrombophlebitis and venflons need to be changed on a daily basis. With care and attention the peripheral route can be used for short term PN prior to central access being obtained. It should be ensured that the osmolarity of the solution is compatible with the peripheral route. When using peripheral access a small cannula should be used only for PN. Cyclical delivery of parenteral nutrition should be considered with planned routine cannula change, eg, deliver PN over 18 hrs, remove the cannula post infusion and resite a new cannula in the other arm. Central access Central access is normally used for those patients requiring PN. The decision regarding appropriate line insertion should be taken by the referring team on discussion with the Nutrition team. Only healthcare professionals competent in catheter placement should place catheters and should be aware of monitoring and managing them safely. Catheter insertion should be planned and performed using aseptic precautions. (See Central Venous Line Policy.) The referring team need to discuss tunnelled line insertion with the Interventional radiology department or Vascular Surgery (currently Mr Mudawi). If there is a significant delay in inserting a tunnelled line or the duration of PN is such that this is deemed unnecessary the referring team should refer the patient to Anaesthetics for line insertion. The referrer needs to ensure that the Anaesthetist inserting the line is aware it will be used for


PN so that an appropriate line is inserted (single rather than a quadruple lumen). An X-ray will confirm the correct placement of the catheter tip. A single lumen dedicated catheter is recommended for PN to minimise the risk of line sepsis. The tip should be positioned in the lower one third of the SVC or at the junction of the SVC and right atrium. Correct positioning reduces the risk of thrombotic and mechanical complications. The date and site of insertion and tip position should be documented in the patient’s notes. Other Access Routes PICC lines are not commonly used in Gateshead. These can also be used to deliver hyperosmolar solutions as the catheter tip lies in the superior vena cava.

6.4 Types of Central Catheters Used Multi-lumen These are used in patients who require other additional infusions, however can be associated with an increased risk of infection due to increased handling and greater number of ports available for bacterial colonisation. Strict aseptic techniques should be carried out when changing infusion or handling the multiple ports. If a multi lumen line is used for PN a line should be dedicated to PN only. Single lumen Traditionally preferred lumen to be used for administration of PN as there is reduced risk of infection. Tunnelled Central Line Tunnelled lines such as Groshong or Hickman Lines are sited for long term PN access, ie more than 7 days.

6.5 Composition of parenteral nutrition An all-in-one parenteral bag is used in Gateshead Health NHS Foundation Trust which contains a combination of amino acid solution, fat emulsion, glucose solution, water and fat soluble vitamins, trace elements, minerals and electrolytes to desired volume. Additional ingredients may be added if required. Additions must be added aseptically in the hospital pharmacy only.

6.6 Prescribing parenteral nutrition Nutritional requirements must be assessed by the ward’s dietitian. Following a dietetic assessment a bag of PN will be recommended based on the patient’s nutritional requirements. A PN proforma, which includes a prescription, must be completed to ensure PN is given safely and appropriately (see Appendix 3). The dietitian will complete a PN regimen form for the ward staff to follow (see appendix 4). The prescription must be completed and signed by the doctor. It should be delivered to the pharmacy department before 2pm on the day it is required.


When a patient is stable a PN a prescription may be written for a week at a time. It also must be prescribed on the fluid balance chart on a daily basis. PN is not an emergency intervention and is therefore rarely indicated outside normal working hours. However if PN is required outside pharmacy hours then an emergency Triomel 6 g bag can be used (see Appendix 5 for emergency out of hours regimen). These are stored in the pharmacy emergency drug cupboard and may be accessed via the site manager. The on-call pharmacist is available for advice via switchboard. Each PN bag will be prescribed according to their nutritional requirements. Modifications of parenteral nutrition bags The electrolyte content (sodium etc) of the PN bag can be altered within certain limits. The ward dietitian will advise and liaise with pharmacy regarding changes to the PN electrolyte content. Manipulation of the PN in Pharmacy is time consuming and carries a very small risk of introducing infection, therefore minor changes should be avoided.

6.7 Storage of parenteral nutrition

PN should be stored in a drug refrigerator and has a limited storage life. Occasional minor separation of the emulsion may be visible. Always agitate the bag gently before use. Protect PN from strong light using the red bag covers supplied by pharmacy. Once removed from the refrigerator the bag should be warmed to room temperature before use. Warming should be achieved gradually by putting the bag on a work surface in the treatment room at ambient temperature for a period of 1-2 hours out of direct sunlight. Artificial heat, for example, placing the bag on a radiator or using a light source should never be used as it poses a significant risk to bag stability. Any bag that has been stored below 0 C must not be used.

6.8 Administering parenteral nutrition The PN bag will arrive on the ward late afternoon or early evening. if the patient is at risk of Refeeding Syndrome, PN should be introduced progressively as advised by the dietitian, usually starting at no more than 50% of estimated requirements for the first 24-48 hours. (See Refeeding Syndrome Guidelines). All PN mixtures will be administered through a volumetric pump with occlusion and air line alarms. Continuous administration of PN should be offered as the preferred method of infusion in severely ill patients. Gradual change from continuous to cyclical delivery should be considered in patients requiring PN for more than 2 weeks, it is important to adhere to recommendations from the CCOT reduce central line associated sepsis. Cyclical delivery of PN may be considered when using short term peripheral venous cannulae with planned routine catheter changes. The rate of administration is usually identified on the label of the PN bag; however alterations to the rate can be made following discussion with the dietitian or aseptic pharmacist. PN should only be administered over a maximum 24 hour period and bags should be changed every 24 hours.


6.9 Discontinuing parenteral nutrition

PN can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. There is usually a period of overlap while enteral feeding is being established and the rate of PN can be reduced. The dietitian will provide a step by step weaning plan for the PN and introduction of enteral or oral nutrition which will be reviewed daily.

6.10 Monitoring of parenteral nutrition (NICE, 2006) It is the responsibility of the ward doctors to monitor the patient appropriately for possible complications of PN. These are predominately metabolic and line related complications. The functioning of the gut and the possibility of introducing enteral feeding should also be monitored (see appendix 6).

6.11 Laboratory Monitoring (NICE, 2006) Please refer to Appendix 7. The Nutrition team, ward dietitian and pharmacist can advise regarding vitamin supplementation and the addition of electrolytes to PN. Manganese, selenium and bone densitometry need to be measured in patients on long term home PN, however home PN is managed by the Nutrition team at Freeman Hospital Biochemical Abnormalities in patients on PN Both acute and long-term liver function abnormalities are associated with the provision of parenteral nutrition. It can be difficult to establish whether the liver problem is caused by the administration of parenteral nutrition in the acute setting, or if it is due to other clinical problems eg: • Sepsis • Biliary obstruction • Unrecognised previous chronic liver disease • New-onset liver disease (eg liver abscess, adverse drug reaction,

hepatitis) • Portal bacterial translocation A modest increase in ALT sometimes seen within the first few days to weeks is usually a consequence of steatosis and is commonly seen following excessive glucose provision in a malnourished patient. There is usually very little or no change in the liver’s synthetic function and the increase in ALT is generally not clinically significant. Following prolonged administration (several weeks to months) of parenteral nutrition a cholestatic picture may develop. The commonest reason for the development of intra-hepatic cholestasis is the overprovision on lipid and patients at risk of developing intra-hepatic cholestasis may benefit from a reduction in lipid-load (contact ward dietitian for advice). Cholestatic problems are also commonly encountered in patients with very short bowel syndrome or high stomal losses. Bacterial translocation across the damaged gut wall may also result in liver damage and a course of appropriate antibiotics may be required.


6.12 Ethical Considerations Parenteral nutrition is an invasive procedure, and therefore members of staff are expected to have assessed the patient’s capacity to consent, and taken into consideration any advanced decision to refuse treatment, or best interest assessment. Further information is available in OP 57 Deprivation of Liberty Safeguards and OP25 Advanced Decisions to Refuse Treatment.

7 Training The trust’s nutrition team can provide training to all health care professionals involved in parenteral nutrition. The team is actively involved in the F1 and F2 teaching program and parenteral nutrition forms part of their training. Dietitians working within the hospital receive training by the critical care dietitian.

8 Equality and Diversity Patients who cannot be fed sufficiently via enteral nutrition have a fundamental right to consideration of parenteral nutrition, because this supports the right to life. This policy therefore promotes a human rights based approach to healthcare. However staff should refer to other policies for information about issues of consent, capacity, advance care plans, refusing or withdrawing treatment. This policy has been appropriately equality impact assessed.

9 Monitoring compliance with the policy The effectiveness of the policy will be monitored by the nutrition & dietetics service in line with national guidance. PN audits will be undertaken on a yearly basis as part of Nutrition Support Team audit program. Any incident involving parenteral nutrition should be recorded via Datix reporting.

10 Consultation and review The policy will be reviewed every 2 years. Consultation will include Nutrition and Dietetics, Pharmacy, the trust’s Nutrition, Critical care outreach and Infection control teams.

11 Implementation of the policy The policy will be shared with all staff involved in the direct care of patients receiving parenteral nutrition, all ward managers and modern matrons, and all staff receiving training on parenteral nutrition.

12 References

1 Nutrition Support in adults NICE clinical guideline No 32 (2006). 2 Bozzetti F, Braga, Gianotti C, Mariani L, Cozzaglio L et al. Perioperative PN

in malnourished, gastrointestinal cancer patients: a randomized, clinical trial. JPEN (2000),24(1):7-14.

3 The Veterans Affairs Total PN Cooperative Study Group. Perioperative total PN in surgical patients. New England Journal of Medicing (1991), 325(8):525-32.


4 Infection control: prevention of healthcare-associated infection in primary and community care. NICE Clinical Guideline. No 2 (2003).

5 Mallet, J Bailey C. Manual of clinical nursing procedures. The Royal Marsden Trust 1996.

6 National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June 2010.

7 Prescribing Adult Intravenous Nutrition (eds. Austin and Stroud). 2007. Pharmaceutical Press

13 Associated documentation

• Care standards: 9C and 9D • Nutrition policy RM61 • Central Venous Line policy OP41 • Refeeding Syndrome guidelines • Nutrition Risk Score • Parenteral Nutrition proforma • Parenteral Nutrition regimen information


Appendix 1


Appendix 2 Gateshead Health NHS Foundation Trust

Nutrition Support Team

REFERRAL FORM

Date of referral: ………………………………………………….. Patient’s name: ………………………………………………….. Hospital No: …………………………….. Address: ………………………………………………….. DOA: …………………………….. …………………………………………………..

…………………………………………………..

Contact number: ………………………………………………….. Ward: …………………… Directorate: ……………………………… Consultant: ………………………….. DOB: …………………… Age: ……………………………...

Medical History: …………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Social History: ………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Reason for referral to NST: ……………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Medication: …………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………… Weight: ………………… NRS: ………………

Current nutritional support: Y/N If Y: date started: ...............................

Naso-gastric feeding IV fluids

Sub cut fluids Other Please specify ………………………

Oral nutrition ………………………………………… Note: Please complete page two if referring for PEG Referred by: ………………………………………… (Print) ……………………………………………

Signed: …………………………………………………..


Appendix 3

Parenteral Nutrition (PN) Proforma

Name: Ward:

DOB: Consultant:

Hospital number: NHS no.

Start Date:

Indication for PN:

Appropriate indications include: intestinal failure, extended non-absorption of enteral nutrition (including a trial of nasojejunal (NJ) feeding), perforated or obstructed gut not expected to recover within 7 days. Is nasogastric and nasojejunal feeding contraindicated or has it been unsuccessful?

Please circle Yes/No

PN treatment goal

Is there a risk of refeeding syndrome? Please CircleYes/No

Access: Central/peripheral (delete as appropriate)

Type: Single/multiple lumen (delete as appropriate)

Date of insertion: Weight (kg):

Mid upper arm circumference (cm): (if not possible to obtain weight) Doctor’s signature …………………...........……...…........... Name: ................................... (print)

Date …….........…….. Bleep/Ext ………………….…....... Time ......................

Please refer to Nutrition and Dietetics intranet page for guidelines on the use of PN out of hours. Please file behind Section 5 of the Health Record


Parenteral Nutrition Prescription

Patient Name

Ward Consultant Hospital No Weight (kg) Date of birth Start Date NHS No

Tick required regimen – for further information contact pharmacy (ext 2316) gN Volume

ml Kcal

(total) Na

mmol K

mmol Mg

Mmol Ca

Mmol PO4

mmol

Adult 6 6 1545 1050 31.5 24 3.3 3 12.7

Starter/refeeding bag Triomel N4 E 1500ml

Adult 10 10 2545 1750 52.5 40 5.5 5 21.2

Low requirements Triomel N4 E 2500ml

Adult 13 13 2545 2480 87.5 75 10 8.8 37.5

Increased requirements Triomel N5 E 2500ml

Adult 18 18 2045 2140 70 60 8 7 30

Increased N requirements Triomel N9 E 2000ml

Other

Rate of administration:

Route (delete as appropriate): Central/Peripheral*

*Check that the regimen is appropriate for the route of administration - only Adult 6 and Adult 10 can be given peripherally

Dietitian’s Name (print): Signature: Date:

Grade: Bleep: Time:

Doctor’s Name (print): Signature: Date:

Grade: Bleep: Time: Prescription record

Date

Dietitian Biochemistry checked?

Is PN still indicated?

Time commenced

Administered by:

Checked by:


Appendix 4 NUTRITION AND DIETETIC SERVICE

Parenteral Nutrition Regimen

Name ........................................................................ Hospital ………………………

Date of Birth ....................................................................... Ward ………………………

Weight ........................................................................

Estimated daily requirements: Kcal ………………………

Nitrogen (g) ………………………

Fluid (ml) ………………………

Sodium (mmol) ………………………

Route of feeding: Peripheral/Central* Potassium (mmol) ………………………

Phosphate (mmol) ………………………

Parenteral Nutrition Bag: ……………………………………... Magnesium (mmol) ……………………… Calcium (mmol) . ................................

Day Rate ml/hr

Time (hr)

Rest (hr)

Provides per 24 hours Kcal Nitrogen

(g) Fluid (ml)

Na+

(mmol) K+

(mmol) Ca2+

(mmol) Mg2+

(mmol) PO2-4

(mmol)

Continue as Day: ……………………………. of regimen.

Additional instructions: ...……………………………………………………………………...

……………………………………………………………………………………………………

• Daily bloods including U&E’s, magnesium, phosphate and calcium until stable. • Check blood glucose 1-2 times daily (more often if needed) • Check bag is suitable to be given via chosen route • Change bag every 24 hours, discard any remaining solution • Document volume administered on fluid balance chart Dietitian (print name) ………………………… Date....../....../...... Time: ...................... Signature: ..................................................... Contact No: ................ Bleep: .....................


Appendix 5 Out of hours Parenteral Nutrition Guideline for Adults

This guideline is for use in adult patients only when there is no dietitian to advise on parenteral nutrition (e.g. weekends, bank holidays). Parenteral nutrition is a highly specialised form of nutritional support and has associated complications. In the majority of cases parenteral nutrition is not an emergency and its use out of hours should be avoided. Step 1 Baseline blood tests: Electrolytes including magnesium and phosphate and correct any levels if needed. Is the patient at risk of refeeding syndrome? Please use following table as a guideline.

Any of the following Two or more of the following

Body Mass Index (BMI) less than 16kg/m²

BMI less than 18.5kg/m²

Unintentional weight loss over 15% within the last 3-6 months

Unintentional weight loss over 10% within the last 3-6 months

Very little or no nutrition for over 10 days

Very little or no nutrition for over 5 days

Low levels of potassium, magnesium or phosphate prior to feeding

A history of alcohol abuse or some drugs including: insulin, chemotherapy, antacids or diuretics.

Low levels of potassium, magnesium or phosphate prior to feeding

(Gateshead Health NHS Trust Refeeding Syndrome Guidelines) Step 2 The only PN bag available out of hours is the Triomel Peripheral N4 1500ml (referred to as Triomel 6gN) which is kept in the pharmacy emergency drug cupboard. Do not increase the rate of PN until potassium, phosphate and magnesium levels are within normal range. PN should only be administered over a maximum 24 hour period and bags should be changed every 24 hours, any remaining solution in the bag must be discarded. Please use the flow chart overleaf until the Dietitian’s regimen is available. Mixing guidelines • Remove the overpouch by tearing from the notch close to the ports along the upper edge, then tear the long sides, pull off the overpouch and discard it along with the oxygen absorber. • Place the bag on a flat surface. Tightly roll up the bag from the handle side until the vertical seals are broken. Ensure that the liquids mix easily although the horizontal seal remains closed. • Mix the contents of the three chambers by inverting the bag a minimum of three times until all the components are thoroughly mixed.


Out of hours Parenteral Nutrition Regimen

Access Route Peripheral* Central

At risk of refeeding syndrome? (use table as guideline)

At risk of refeeding syndrome? (use table as guideline)

Yes No Yes No

Day 1:

Commence Triomel 6gN 42 ml/hr x 18 hrs

Day 1:


Day 1:


Day 1:


Day 2:

Triomel 6gN 83 ml/hr x 18 hrs

Day 2: Triomel 6gN 62 ml/hr x 24 hrs

Key points

For peripheral access: rotate site of entry every 24 hours Do not increase rate until potassium, phosphate and magnesium are within normal range. Final regimen (i.e. day 2) provides 1050 kcal, 6g nitrogen, 1500ml, 31.5mmol Na, 24mmol K, 3.3mmol Mg, 3mmol Ca, 12.7mmol Phosphate


Step 3 Monitoring

Parameter Frequency Rationale

Urea and electrolytes, magnesium, phosphate and calcium

Daily until stable

Assessment of renal function, depletion is common

Glucose

Baseline 1 or 2 times a day (or more if needed) until stable

Good glycaemic control is necessary

Fluid balance

Daily

Ensure PN taken into account when prescribing additional fluids

References 1 National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June 2010. 2 Nutrition Support in adults NICE clinical guideline No 32 (2006). 3 Parenteral Nutrition Policy, Gateshead Health NHS Foundation Trust

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Appendix 6

Montitoring patients on parenteral Nutrition

Parameter Frequency Rationale Responsibility

Nutritional Nutrient intake from oral, enteral or PN (including any change in conditions that are affecting food intake). Actual volume of PN delivered. Fluid balance charts

Daily, reducing to twice weekly when stable. Daily initially, reducing to twice weekly when stable. Daily initially, reducing to twice weekly when stable.

To ensure that patient is receiving nutrients to meet requirements and that current method of feeding is still the most appropriate. To allow alteration of intake as indicated. To ensure patient is not becoming over/ under hydrated. To ensure appropriate prescription of additional fluids if required. Always take into account the volume of PN when assessing a patient’s fluid requirements to avoid fluid overload.

Dietitian and nursing staff. Dietitian, nursing and medical staff. Medical and nursing staff.

Anthropometric Weight. Mid arm circumference/mid arm muscle circumference.

Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly. If clinical condition changes. Weekly if patient cannot be weighed, reduce to monthly once stable.

To assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle.

Nursing staff and dietitian. Dietitian

22

Parameter Frequency Rationale Responsibility

Gastrointestinal symptoms Nausea/vomiting. Diarrhoea. Constipation. Abdominal distension.

Daily initially, reducing to twice weekly. Daily initially, reducing to twice weekly. Daily initially, reducing to twice weekly. As necessary

To identify and rule out any cause of vomiting, eg obstruction. To identify and rule out any causes of diarrhoea. To rule out other causes of constipation. To identify cause.

Nursing and medical staff, dietitian. Nursing and medical staff, dietitian. Nursing and medical staff, dietitian. Nursing and medical staff.

Devices and equipment Catheter entry site. Dressings.

Daily. Daily.

To identify signs of infection. To ensure they are secure and hygienic

Nursing staff. Nursing staff.

Clinical Condition General condition Temperature. Blood pressure. Drug therapy.

Daily. Daily initially then as needed. Daily initially then as needed. Daily initially and then monthly when stable.

To ensure the PN is tolerated. To identify any signs of infection. Monitor clinical condition and fluid balance. To prevent/reduce drug nutrient interaction.

All team. Nursing and medical staff. Nursing and medical staff. Nursing and medical team

23

Appendix 7 Biochemical monitoring of patients on PN

Parameter Frequency Rationale Interpretation

Sodium, potassium, urea, creatinine.

Baseline. Daily until stable. Then 1-2 times a week.

Assessment of renal function, fluid status and Na and K status.

Interpret with knowledge of fluid balance and medication.

Glucose. Baseline. 1 or 2 times a day (or more if needed) until stable. Then weekly.

Good glycaemic control is necessary.

Glucose intolerance is common – administer insulin if necessary.

Magnesium, phosphate.

Baseline. Daily if risk of refeeding syndrome.Three times a week until stable. Then weekly.

Depletion is common and under recognised.

Low concentrations indicate poor status. Replacement vital to avoid refeeding syndrome.

Liver function tests including International Normalised Ratio (INR)/PT

Baseline. Twice weekly until stable. Then weekly.

Abnormalities common during PN.

Complex. May be due to sepsis, other disease or nutritional intake. May need to consider reducing fat content of PN.

Calcium, albumin. Baseline. Then weekly.

Hypocalcaemia or hypercalcaemia may occur. Correct measured serum calcium concentration for albumin.

Hypocalcaemia may be secondary to Mg deficiency. Low albumin reflectsdisease not protein status.

C-reactive protein Baseline. Then 2 or 3 times a week until stable.

Assists interpretation of protein, trace elements and vitamin results

To assess the presence of an acute phase reaction (APR). The trends of the results are important.

Zinc, copper Baseline. Deficiency common, especially when increased losses.

People most at risk when anabolic APR causes Zn and Cu deficiency

Selenium Baseline for risk of depletion. Further testing dependent on baseline

Se deficiency likely if severe illness and sepsis, or long-term Nutrition support.

APR causes Se depletion. Long term status better assessed by glutathione peroxidise.

24

Parameter Frequency Rationale Interpretation

Full blood count and MCV

Baseline. 1 or 2 times a week until stable. Then weekly

Anaemia due to iron and folate deficiency is common.

Effects of sepsis may be important.

Iron, ferritin. Baseline. Then every 3-6 months.

Iron deficiency common to long-term PN.

Iron status difficult to assess if there is an acute phase reaction.

Folate, B12. Baseline. Iron deficiency is common

Serum folate/B12 sufficient, with full blood count.

parenteral nutrition policy - nhs gateshead from medical and surgical teams to advise on the...

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