Awareness of dietitians about their role in

providing parenteral nutrition service in some

Khartoum State hospitals – Sudan.

ATHESIS SUBMITTED IN THE FULFILLMENT OF THE

REQUIREMENTS OF M.Sc. DEGREE IN HUMAN NUTRITION

AND DIETETICS.

By:Reem Osama Yousif Ali

Supervisor:Prof. Omer Musa Izzeldin

December, 2016

The National Ribat University

Faculty of Graduate Studies and Scientific Research

I

اآلية

بِّ ِزْدنِي ِعْلًما(قال تعالى: ) َوقُل رَّ

(114)طه

II

Dedication This work is dedicated to my parents who never stop

giving support and hope, to my brother, sisters, other

beloved family members and friends.

I also dedicate this research to my teachers all through

my learning milestone since childhood up to

postgraduates.

Special dedication to my husband.

Reem.

III

Acknowledgements All praise is to Allah the most merciful most compassionate.

I would like to express my deepest gratitude to the people

who have extended their assistance for the completion of

this dissertation.

I am heartily thankful to my supervisor Prof.Omer Musa for

his continuousencouragement, support and kind supervision.

I am grateful to my father Dr. Osama AlGibali for his

unlimitedand priceless consultations he always shares.

I thank Mss. Ikhlas Abdo for her direction and corrections.

Special thanks to all the dietitians who participated in

responding to the questionnaire for their cooperation.

IV

Abstract:

When balanced nutrition is needed for all human beings, it is more required and essential

when they get sick. It helps in keeping the cell metabolism integrity, energy, maintain

the immunity functions, and fasten cure. Occasionally sick patients cannot tolerate oral

or enteral feeding, in such situations parenteral nutrition (PN) is the most suitable

alternative route for nutritional support. Dietitians are fundamental personnel in the

nutrition support team that provide different routes of nutritional support.

This research has been prepared to recognize the dietitian’s awareness about parenteral

nutrition and their role in providing this service.

Fifty formulated questionnaire forms were distributed to the working dietitians in the

targeted hospitals. The majority of the dietitians who responded to the questionnaire

were nutritional bachelor graduates, about 60% of them with working experience of less

than three years.

The results of this research showed that 76% of responded dietitians defined PN

correctly and more than 80% of them have exposed in their clinical practice to patients

whom were in need of PN. All the responders were aware about the advantages of PN,

and 60% of them were mindful about the PN side effects. Eighty four percent of the

responders recommend usage of PN as an alternative therapy whenever oral and eternal

feeding are unfeasible. Most of the dietitians were aware of the different assessment

measurements, have the knowledge for calculating parenteral nutrition prescription but

only 30% had a chance to formulate or participate in formulating a PN prescription for

real patients. The unavailability of the multidisciplinary team, lack of the required

equipment and financial support, and associated complications found the fundamental

obstacles to the provision of long term PN service in Khartoum state hospitals.

The study concludes that although the targeted dietitians in Khartoum State hospitals-

Sudan have good knowledge and information about PN definition, indications, accesses,

and assessment measures, they do not have the enough knowledge and clinical exposure

that make them confident to provide the PN service. Establishing few models of

parenteral nutrition units in tertiary hospitals will be of great help in providing this

service, as well as providing the dietitian’s training in the area of parenteral nutrition.

V

ملخص البحث:

إذا كانت التغذية المتوازنة ضرورية لإلنسان الصحيح فإنها بالنسبة للمرضى أكثر حوجه ألنها تحافظ على كمالية

الخاليا ووظائف المناعة وتساعد على تعجيل الشفاء. في بعض األحيان ال يستطيع المرضى تناول غذاءهم استقالب

عن طريق التغذية الفموية أو المعوية )التغذية باألنابيب(، في هذه الحاالت تعتبر التغذية الوريدية هي الخيار البديل

فراد أساسيون في فريق الدعم الغذائي لتوفير الطرق المختلفة األمثل لتقديم الدعم الغذائي. يعتبر أخصائيو التغذية أ

من الدعم الغذائي.

أجريت هذه الدراسة للتعرف على وعي أخصائيو التغذية عن التغذية الوريدية ودورهم في تقديم هذا النوع من الدعم

الغذائي.

المستشفيات المستهدفة والذي وجد أن تم توزيع استمارة االستبيان على خمسين من أخصائيين التغذية العاملين في

% ذوو خبرة أقل من ثالث سنوات.60أغلبهم خريجو مستوى البكالوريوس، وحوالي

% 80% من اختصاصي التغذية عّرفوا التغذية الوريدية بشكل صحيح وأكثر من 76أكدت نتائج هذا البحث أن

للتغذية الوريدية. أّكد جميع المستجيبين لهذه الدراسة منهم صادفوا خالل عملهم السريري حاالت مرضية في حوجه

% قد يوصون 84% منهم لهم المعرفة حول التأثيرات الجانبية لها، وأن 60إيجابيات استخدام التغذية الوريدية و

ق باستخدام التغذية الوريدية كوسيلة بديلة للدعم الغذائي لحاالت المرضى الغير قادرين على تحمل التغذية عن طري

الفم أو األنابيب. وجدت الدراسة أن معظم أخصائي التغذية المشاركين يملكون المعرفة حول طرق التقييم المختلفة

% فقط كانت لهم الفرصة 30للمرضى تحت التغذية الوريدية، ولديهم المعرفة لحساب وصفة التغذية الوريدية ولكن

ريدية لمريض خالل سنوات خبرتهم. ووجدت الدراسة كذلك الحقيقية لعمل او المشاركة في عمل وصفة للتغذية الو

أن العقبات األساسية لتوفير خدمة التغذية الوريدية الطويلة األمد في المستشفيات قد تكمن في عدم توفر الفريق

المتكامل، ونقص المعدات الالزمة والدعم المالي، إضافة الى المضاعفات المرتبطة باستخدام التغذية الوريدية.

السودان لديهم -وخلصت الدراسة إلى أنه بالرغم من أن خبراء التغذية المستهدفين في مستشفيات والية الخرطوم

الكمية الجيّدة من المعرفة حول تعريف التغذية الوريدية، ومؤشرات استخدامها، وطرق إيصال محاليلها، وتدابير

لهم باتخاذ الدور الحقيقي لتوفير ة المؤهلة تجربة السريرية الكافيالتقييم الالزمة لها، اال أنه ليس لديهم المعلومات أو ال

خدمة التغذية الوريدية.

وضع عدد قليل من النماذج لوحدات التغذية الوريدية في المستشفيات التخصصية سيكون عونا كبيرا في توفير هذه

دية.الخدمة، فضال عن توفير التدريب الختصاصي التغذية في مجال التغذية الوري

VI

List of Contents:

No. Title Page number

I آية

Dedication II

Acknowledgment III

Abstract (English) IV

Abstract (Arabic) V

List of contents VI

List of tables X

Abbreviations XI

Chapter one: Introduction & objectives

1-1 Introduction 1

1-2 General objective 2

1-3 Specific objectives 2

1-4 Justification 2

1-5 Hypothesis 2

Chapter two: Literature review

2-1 Introduction to nutrition support 3

2-1-1 Nutrition Support Team (NST) 4

2-2 History 4

2-2-1 History in Sudan 5

2-3 Definition 6

2-4 Types 6

2-4-1 Total Parenteral Nutrition (TPN) 6

2-4-2 Partial Parenteral Nutrition (PPN) 6

2-4-3 Comparison 7

2-4-4 Regimen 7

2-4-5 Osmolality and osmolarity 7

2-5 Indications 8

2-6 Nutrients 10

2-6-1 Macronutrients 10

VII

2-6-1-1 Carbohydrate 10

2-6-1-2 Protein 10

2-6-1-3 Fat 10

2-6-2 Micronutrients 10

2-6-2-1 Vitamins 11

2-6-2-2 Minerals 11

2-6-2-3 Electrolytes 12

2-7 Administration 13

2-7-1 Peripheral access 13

2-7-2 Central access 13

2-8 Complications 14

2-8-1 Refeeding syndrome 15

2-9 Monitoring 15

2-9-1 Nutritional status monitoring 15

2-9-1-1 Anthropometric measurements 16

2-9-1-2 Clinical parameters 16

2-9-1-3 Biochemical 17

2-10 Transitional feeding 17

2-11 Role of dietitians 17

2-11-1 Assessment 18

2-11-1-1 Weight data 18

2-11-1-2 Clinical examination 18

2-11-1-3 Diet history 19

2-11-2 Calculations 19

2-11-2-1 Energy requirements 19

2-11-2-2 Protein requirements 20

2-11-2-3 Carbohydrate requirements 20

2-11-2-4 Fat requirements 21

2-11-2-5 Fluid requirements 21

Chapter three: Research methodology

3-1 Study design& duration 22

VIII

3-2 Study area 22

3-3 Study population 22

3-4 Sampling 22

3-5 Data collection 22

3-6 Data analysis 22

3-7 Data presentation 23

3-8 Ethical considerations 23

Chapter four: Results

4-1 Academic qualification of the study population 24

4-2 Experience of the population in nutrition field 24

4-3 Are you aware about parenteral nutrition: 25

4-4 Definition of parenteral nutrition: 25

4-5 Have you come across medical conditions in need of

Parenteral nutrition

26

4-6 The most exposed category for parenteral nutrition 26

4-7 Parenteral nutrition is more indicated for 27

4-8 Positive influence of parenteral nutrition 27

4-9 Alternative route of oral or enteral nutrition support 28

4-10 Parenteral nutrition assessment measurements 28

4-11 Knowledge about parenteral nutrition calculations 29

4-12 Have you ever formulated a parenteral nutrition prescription

or participated in that

29

4-13 Negative influence of parenteral nutrition 30

4-14 Parenteral nutrition obstacles 30

Chapter five: Discussion

5-1 Discussion 31

5-2 Conclusions 32

5-3 Recommendations 33

*References 34

*Appendices

Appendix 1- Picture of nutrition support routes 38

Appendix 2- Picture of access to superior vena cava 39

IX

Appendix 3- Picture of peripheral inserted central catheter 40

Appendix 4- Questionnaire (Arabic) 41

Appendix 5- Questionnaire (English) 43

X

List of Tables:

Table No Title Page number

1 Academic qualification of the study population 24

2 Experience of the population in nutrition field 24

3 Are you aware about parenteral nutrition: 25

4 Definition of parenteral nutrition 25

5 Have you come across medical conditions in need of

Parenteral nutrition

26

6 The most exposed category for parenteral nutrition 26

7 Parenteral nutrition is more indicated for 27

8 Positive influence of parenteral nutrition 27

9 Alternative route of oral or enteral nutrition support 28

10 Parenteral nutrition assessment measurements 28

11 Knowledge about parenteral nutrition calculations 29

12 Have you ever formulated a parenteral nutrition

prescription or participated in that

29

13 Negative influence of parenteral nutrition 30

14 Parenteral nutrition obstacles 30

XI

Abbreviations:

GIT Gastrointestinal tract

PN Parenteral nutrition

EN Enteral nutrition

Kg Kilogram

Gm Gram

Mg Milligram

NST Nutrition support team

TPN Total parenteral nutrition

CPN Central parenteral nutrition

PPN Peripheral/Partial parenteral nutrition

IV Intravenous

mOsm Milliosmole

L Liter

dL Deciliter

PICC Peripheral inserted central catheter

BMI Body mass index

NFPE Nutrition focused physical examination

RD Registered dietitian

IBW Ideal body weight

EFA Essential fatty acid

SPSS Statistical package for social sciences

I

Chapter One

Introduction

1

1-1. Introduction:

Nutrition support is the delivery of formulated enteral or parenteral nutrients for the

purpose of maintaining or restoring nutritional status when patients are unable to support

their nutritional needs for more than few days. (Mahan et al, 2012).Parenteral nutrition

(PN) is part of the nutrition support therapy, which is a method of getting nutrition into

the body through the veins directly into the bloodstream when it is not possible to meet

nutritional requirements via the gastrointestinal tract for significant time.(Baker

&Bojczuk, 2016)

The nonfunctional gastrointestinal tract (GIT) and inadequate gut function as in cases

of gastrointestinal obstructions, severe gastrointestinal inflammatory diseases, short

bowel syndrome, and intractable diarrhea or vomiting are some indications for

supplying PN.

A PN solution may comprise different nutrients of carbohydrate as dextrose, protein

as amino acids, lipid as fat emulsion, and micronutrients. When the prepared solution

contains all the nutritional requirements and given by a central vein it is called Total

Parenteral Nutrition (TPN), and when it supplies part of the nutritional needs and given

by a peripheral vein it is called Partial/Peripheral Parenteral Nutrition (PPN).

Although there are different associated complications of this therapy which might be

mechanical, infectious, or metabolic, with proper case selection and careful monitoring,

providing PN can improve clinical outcome, reduce hospitalization time, and reduce the

cost of patient care, (Thomovsky, 2007).

Dietitians are important personnel in the nutrition support team (NST) that is often

consist of physicians, dietitians, nurses, and pharmacists (Delegge& Kelley, 2013). NST

provides different routes of nutritional support by choosing proper nutritional support

interventions for the needy patients. They facilitate the appropriate initiation of PN and

avoid unnecessary episodes of the therapy. (Bhagavatula&Tuthill, 2011)

Nutrition assessment, determination of macronutrient and micronutrient

requirements, and monitoring the nutritional status are vital aspects of the provision of

PN support that benefit from the knowledge and experience of a dietitian. (McCare et

al,1993)

In Sudan, Total Parenteral Nutrition (TPN) services had been introduced in the

1980's in Soba University Hospital, soon after it has been used in developed countries,

and some other hospitals thereafter. However, it was mainly used for surgical patients

and was in the form of ready to infuse amino-acid solutions. TPN therapy was not

available for newborns and children until recently. Gaffar Ibn Ouf Children Teaching

2

Hospital in Khartoum was the first pediatric hospital to offer this kind of therapy in

Sudan. (Elamin&Norri, 2010)

This study was conducted to assess the awareness of the dietitians working in the

targeted chosen hospitals in Khartoum State about PN and their role in providing this

service.

1-2 General objective:

To study the awareness of dietitians about their role in providing PN service in some

Khartoum State hospitals.

1-3 Specific objectives: 1) To explore the dietitians awareness about the importance, indications, and

obstacles of PN.

2) To assess the current awareness of dietitians about their role in providing PN

service.

1-4 Justification: The researcher is interested in the topic and has accomplished a previous study

as a BSc graduation research in 2014. (AlGibali&AlSaad, 2014)

1-5 Hypothesis: The role of dietitians in providing PN service in Khartoum State hospitals is

ignored.

Chapter Two

Literature Review

2-1. Introduction to nutrition support:

Nutrition support therapy is part of nutrition therapy, which is a component of medical

treatment that can include oral, enteral, and parenteral nutrition. Nutrition support is the

delivery of formulated enteral or parenteral nutrients for the purpose of maintaining or

restoring nutritional status when patients are unable to support their nutritional needs

for more than few days. (Mahan et al, 2012)

The overall aim of nutrition support is to try to ensure that total nutrient intake (food

+ nutrition support) provides enough energy, protein, fluid and micronutrients to meet

all the patients’ needs. When feasible, it should be given via the gastrointestinal (GI)

tract. If the GI tract cannot be accessed or there is either partial or complete intestinal

failure, some or all of a patient’s nutritional needs may be met using an intravenous

infusion of PN. (National Collaborating Centre for Acute Care, 2006)

Because timely proper nutritional support aims to prevent malnutrition in those who

are at risk and treat those who are malnourished, healthcare professionals should

consider using oral, enteral or parenteral nutrition support, alone or in combination, for

people who are either malnourished (eg: BMI<18.5 kg/m2, have unintentional weight

loss greater than 10% within the last 3–6 months), or people who are at risk of

malnutrition (eg: have a poor absorptive capacity, and/or have high nutrient losses

and/or have increased nutritional needs). Potential swallowing problems should be taken

into account. (National Institute for Health and Care Excellence NICE Guidance, 2006)

The provision of nutritional support can be seen as an inverted triangle in which the

majority of patients have their needs met by hospital food, a smaller number need

supplementation or sip feeds, still fewer need tube feeding and just a small minority

need PN. (Powell et al, 2007)

4

*From hospital food to parenteral nutrition: (Powell et al, 2007)

2-1-1. Nutrition support team (NST):

Nutrition support team (NST) is interdisciplinary support team with specialty

training in nutrition that are often comprised of physicians, dietitians, nurses, and

pharmacists. (Delegge & Kelley, 2013)

The roles of the NST are nutritional assessments, checking whether the nutritional

support provided is adequate, recommending the best nutritional therapy for each

patient, preventing complications during nutritional therapy, and responding to

consultations on nutritional support.(Zasshi&Higashiguchi, 2004)

Early Nutrition Support Team involvement and intervention can prevent and/or treat

malnutrition by choosing appropriate nutritional interventions and help in early

identification and prevention of central line infections. In addition they facilitate the

appropriate initiation of PN and avoid unnecessary episodes of PN. Staff education is

also a key role. (Bhagavatula&Tuthill, 2011)

2-2. History of Parenteral Nutrition:

History in this field goes back more than 350 years with the first landmark being the

description of general blood circulation by William Harvey in 1628. His discovery is

the anatomical basis for intravenous infusions. (Wretlind&Szczygiel, 1998). It was

mentioned in the journal of the American College of Nutrition in June 2009 that most

of clinicians in the 1950's were aware of the negative impact of starvation on morbidity,

mortality, and outcomes, but only few understood the necessity for providing adequate

nutritional support to malnourished patients if optimal clinical results were to be

achieved. (Dudrick, 2009)

All admissions: hospital food.

Some patients require oral

nutritional supplements

Enteral feeds

Parenteral Nutrition

The many

The few

5

The idea of providing nutrients intravenously in humans was first realized when Sir

Christopher Wren injected wine in dogs' way back in the middle of the 17th century

(Shamsuddin, 2003). In the late 1960s hypertonic parenteral nutrition solution were used

which was a major success in providing nutrition to patients with non-functional GIT.

Crystalline amino acids isolated from soyabeans and fat solutions were tried for PN in

1970. By 1983 three in one solution comprising carbohydrates, protein and fat were

tried as PN supplements.( Joshi, 2008)

Better understanding of the metabolic and pharmacological properties of the

macronutrients (protein, carbohydrates, and lipid), the micronutrients (trace elements,

and vitamins), and the electrolytes have made it possible to administer PN safely to all

types of patients where it is indicated. Continuous development and improvement in the

pharmaceutical presentations of these nutrients have helped to minimize the metabolic

problems seen in the early days of PN administration. (Shamsuddin, 2003)TPN has been

shown to be of very great clinical importance to prevent and treat starvation often related

to high morbidity and mortality.

2-2-1. History in Sudan:

In the Sudanese Journal for Medical Sciences (March - 2010) it was mentioned that TPN

services have been introduced in Sudan in the 1980 in Soba University Hospital, soon

after it has been used in developed countries, and some other hospitals thereafter.

However, it was mainly used for surgical patients and was in the form of ready to infuse

amino-acid solutions. It was also mentioned that IbnSeena Hospital in Khartoum was

the first to establish a unit, where TPN is prepared and different components mixed

according to patient’s requirement under completely aspetic conditions. TPN therapy

was not available for newborns and children until recently. Gaffar Ibn Ouf Children

Teaching Hospital in Khartoum is the first pediatric hospital to offer this kind of therapy

in Sudan. Patients in the neonatal and the gastroenterology units of the hospital are the

usual customers. The pharmacy department at Gaffar Ibn Ouf Hospital had the

expertise, the will and the resources to provide TPN mixtures to the in-patients of the

hospital and the needy children in other pediatric hospitals in Khartoum.

(Elamin&Norri, 2010)

Referring to the previous study of the researcher (In 2014), titled the present status

of PN in Khartoum State in Sudan, 110 different health professionals responded to the

questionnaire forms. Eighty percent of the responders believe that there are many

indications to provide PN in the targeted hospitals of the study, 50% of them believe

that PN is more needed in surgical cases, 85% of them agreed that provision of proper

PN service requires specialized team, knowledge, and the needed equipments. The study

showed that 50% of the responders think that lacking of the trained personnel, enough

6

knowledge, and lacking of the required instruments are the main factors hinder the

starting proper PN service in Sudan. (AlGibali&AlSaad, 2014)

2-3. Definition:

Parenteral nutrition (PN), also known as intravenous feeding, is a method of getting

nutrition into the body through the veins directly into the bloodstream. (Stubblefield,

2014). PN is feeding a person intravenously, bypassing the gastrointestinal (GI) tract

and the usual process of eating, digestion and absorption. The designated person

receives nutritional formulas containing salts of minerals, glucose, amino acids, lipids

and added vitamins. (Elamin&Norri, 2010)

PN is intravenous administration of nutrition, which may include protein, carbohydrate,

fat, minerals and electrolytes, vitamins and other trace elements for patients who cannot

eat or absorb enough food through tube feeding formula to maintain good nutrition

status. (American Society for Parenteral and Enteral nutrition ASPEN, 2012).

Compared with enteral nutrition, PN is more technically demanding, less physiologic

that it does not preserve gastrointestinal (GI) tract structure and function, and is more

expensive. (Prittie, 2004)

2-4: Types of parenteral nutrition:

There are two types of PN:

2-4-1. Total Parenteral Nutrition (TPN), or Central Parenteral

Nutrition (CPN):

A solution containing all the required nutrients including protein, fat, carbohydrate,

vitamins, minerals, and electrolytes, is injected for several hours into a central vein. It

provides a complete and balanced source of nutrients for patients who cannot consume

a normal diet or use their gastrointestinal tract. (The Gale Group, 2008)

2-4-2. Partial Parenteral Nutrition (PPN):

A supplemental form of nourishment delivered intravenously to patients who are sick

or injured and cannot adequately feed themselves or use a feeding tube. Partial

parenteral nutrition (PPN) supplies only part of the daily nutritional requirements

intravenously, supplementing oral intake. (Harkin & Ling, 2014)

7

2-4-3. A simple comparison between the two types:

Difference TPN PPN

Used when patient Does not receive any other form of

nutrition.

he relies on it completely

The patient may be getting

nutrition from other sources

along with the PPN.

Contents concentration Higher concentration and can only

be administered through a central

vein.

Lesser concentration, and can

be delivered through a

peripheral vein.

Time Can be used for a very long time as

it is delivered through a central

vein.

It's unsafe to be used for long

time in peripheral line because

it is hyperosmolar solutions

2-4-4. Regimen of two types:

Central Peripheral

Osmolarity

>= 1800mOsm/L

650-900 mOsm/L

Caloric intake/day

2000-3000

700-1800

Lipid emulsion Minor caloric source, for essential

fatty acids (EFA)

Major caloric source

Duration >= 7days 5-7 days

(Joshi, 2008)

2-4-5. Osmolality and Osmolarity:

Osmolality is the number of millimoles of liquid or solid in a liter of solution.

Osmolarity is the number of attracting particles per weight of water in Kilograms. The

serum osmolarity is maintained in a narrow range (280-300 mOsm/kg), changes above

or below this range may lead to serious metabolic problems. Changes caused by PN in

serum osmolarity are regulated by rapid blood flow and by kidneys. However,

osmolality more than 900 mOsm/L cause irritation to peripheral veins, so solution

greater than this osmolality are infused through central vein. (Joshi, 2008)

8

2-5. Indications:

With proper case selection, providing PN can improve clinical outcome, reduce

hospitalization time, and reduce the cost of patient care. (Thomovsky, 2007)

PN should be used only when it is not possible to meet nutritional requirements via the

gastrointestinal tract for significant time: 1 to 3 days in infants, 4 to 5 days for children

and adolescents, and 7 to 10 days in adults. (Baker&Bojczuk, 2016) The major indication

of PN is nonfunctional GI tract. PN is also indicated for high caloric supplements, for

rapid buildup and to correct nitrogen balance. (Joshi, 2008)

Examples of inadequate gut function might include:

• Bowel obstruction or suspected gut ischaemia

• Some types/locations of gastrointestinal fistula

• Short bowel syndrome

• Persistent severe diarrhoea or significant malabsorption

• Persistent signs of significant gut dysmotility (a distended and/or painful

abdomen, persistent large gastric aspirates, no bowel output). (Ferry et al, 2011)

The gut is not accessible when oral intake is not possible, or an enteral feeding tube

cannot be inserted, due to:

• Facial injuries/surgery or malformation

• Upper gastrointestinal tract obstruction or malformation

• Risk of upper gastrointestinal tract bleeding (eg presence of oesophageal varices).

(Ferry et al, 2011)

In children, PN is indicated to prevent the adverse effects of malnutrition in

newborns and children who are unable to obtain adequate nutrients by oral or enteral

routes because of prematurity, necrotizing enterocolitis or other neonatal complications.

(Elamin&Norri, 2010) It may be used as a primary source of nutrition, providing full

nutrition support, or as a partial source, providing nutrition repletion or augmentation in

patients who are unable to tolerate full enteral nutrition. (Aqilina et al, 2007)

One study was done in London, UK (Oct 2013 – March 2014) to estimate if the

indications for PN prescribing in a tertiary referral children’s hospital were appropriate.

303 children (67 newborns) were enrolled. Patients were referred from different

departments across the hospital. The median duration of PN was 18 days. PN was

mainly prescribed to critically ill children on intensive care (66/303), those undergoing

surgery (63/303) and bone marrow transplantation (28/303). The use of PN was

considered inappropriate in 12/303 patients. The study was concluded by that although

the indications for inpatient PN in children is mostly justified, there is still a proportion

9

of patients receiving intravenous nutrition unnecessarily highlighting the need for more

PN training and better access to nutritional support teams. (Mantegazzaet al, 2016)

Different types of intravenous solutions deliver nutrients for different purposes. The

solution composition and the delivery method depend on the person’s medical and

nutrient needs, his nutritional status, and the length of time on intravenous (IV) nutrition

support. (Whitney et al, 2001)

Peripheral parenteral nutrition (PPN) is best for people with normal renal functions

who need only short term nutrition support (7-14 days), for people who need additional

nutrients temporarily to supplement oral or tube feeding, and when central veins are

medically unsound for intravenous (IV) catheter insertion. PPN relies on IV lipid

emulsions to provide concentrated source of calories in the form that is isotonic and less

irritating compared with dextrose which irritates peripheral veins and may collapse it.

(Whitney et al, 2001)

Central parenteral nutrition (CPN) or total parenteral nutrition (TPN) allows infusion

of concentrated IV solutions. Central veins lie close to the heart so large volume of

blood rapidly dilutes TPN solutions. CPN is best when PN is required for long periods,

when nutrients requirements are high, and when people are severely malnourished with

no capability of using GIT.

Possible indications for central TPN:

• Bone marrow transplants.

• Extensive small bowel resections.

• GI tract obstructions.

• High out-put enterocutaneous fistulas.

• Hypermetabolic disorders, or major surgery, when it is anticipated that the GI

tract will be unusable for more than 2 weeks.

• Intractable diarrhea.

• Intractable vomiting.

• Low birthweight with necrotizing enterocolitis (severe GI inflammatory disease)

or bronchopulmonary dysplasia (chronic lung disease).

• Severe acute pancreatitis.

• Severe malnutrition if surgical or intensive medical intervention is necessary.

• Severe nausea and vomiting associated with pregnancy (hyperemesis

gravidarum) when they last more than 14 days.

• When it is anticipated that enteral nutrition can not be established within 7-14

days of hospitalization. (Whitney et al, 2001)

10

2-6.Nutrients:

2-6-1. Macronutrients:

2-6-1-1. Carbohydrates:

Standard IV solutions provide carbohydrates as dextrose monohydrate. It is

concentrations range from 5-70% by volume. Dextrose monohydrate provides

3.4kcalories /gm. Excessive administration of carbohydrates may lead to

hyperglycemia, hepatic abnormalities, and respiratory problems. (Whitney et al, 2001)

Glucose is the body’s main source of energy, and a daily minimum of about 2g/kg

body weight is required to meet the needs of those cells (eg brain, kidney, erythrocytes)

that cannot readily use other fuels. (Ferry et al, 2011)

2-6-1-2. Protein:

Standard IV solutions contain essential and some of nonessential amino acids to meet

the body's protein needs. (Whitney et al, 2001) Amino acids in PN solutions are

available from 3-20% by volume, 10% of this solution provides 100gm/liter (1000 ml),

and 1 gram of it provides 4kcalories. Approximately 15-20% of total energy intake

should come from protein. (Mahan et al, 2012) Most patients receive protein at around

1.0 – 1.2 g/kg body weight if their energy needs are fully met with a standard parenteral

nutrition solution. (Ferry et al, 2011)

2-6-1-3. Fat:

Standard IV solutions provide lipid as lipid emulsion,Lipid emulsion is a soluble

form of fat that allows it to be infused safely into the blood. (Ferry et al, 2011) It is

considered to be as source of essential fatty acids and energy. (Whitney et al, 2001)

Lipid emulsions available in 10%, 20%, and 30% concentrations composed of soybean

oil, safflower oil, and egg yolk phospholipid as the emulsifier. (Mahan et al, 2012)

Cautious use of IV fat to severely stressed people, patients with atherosclerosis,

moderate liver disease, blood coagulation disorders, pancreatitis, and some lung

problems. (Whitney et al, 2001) A general recommendation has been made to keep lipid

around 1g/kg body weight. (Ferry et al, 2011) Patients can receive 25 to 30% total

calories as lipids. (Chowdary& Reddy, 2010)

2-6-2. Micronutrients:

It is highly likely that most patients commencing on PN will have had prior poor

nutrition intake and hence have suboptimal stores of micronutrients in addition to high

demands and losses. Vitamins, minerals and trace elements should be a standard

inclusion in PN.

2-6-2-1. Vitamins:

11

Most of the commercial preparation contain adequate amount of vitamins.

The current recommended daily amounts of vitamins for adults:

Water-soluble vitamins:

Thiamine 3 mg

Riboflavin 3.6 mg

Niacin 40 mg

Pantothenic acid 7.5 mg

Pyridoxine 4 mg

Vitamin B12 5 µg

Folic Acid 400 µg

Vitamin C 100 mg

Biotin 60 µg

Lipid-soluble vitamins

Vitamin A 1000 µg (1mg)

Vitamin D 5 µg (5mcg)

Vitamin E 10 mg

Vitamin K no recommendation made

(Sriram&Lonchyna, 2009)

2-6-2-2. Minerals:

Requirements of minerals in PN is less compared to enteral nutrition since absorption

is not required. Iron is not usually included in the PN solution due to increased risk of

infection especially in critically ill patients. (Joshi, 2008)

Recommended amounts in adult PN:

Chromium 0.2-0.4 µmol (10-20 µg)

Copper 5-20 µmol (0.3-1.2 mg)

Iodide 1.0 µmol (0.13 mg)

Iron 20 µmol (1 mg)

Manganese 5 µmol (275 µg)

12

Molybdenum 0.4 umol (38 µg)

Selenium 0.4-1.5 µmol (31.6-118 µg)

Zinc 50-100 µmol (3.3-6.6 mg)

Fluoride no recommendation made

(Russell, 1999)

2-6-2-3. Electrolytes:

Standard PN solutions usually contain electrolytes. Electrolyte requirements in PN

varies depending on electrolyte depletion, renal function, disease status, electrolyte loss,

body weight, catabolism, and other drug therapy. Close monitoring of inputs and losses

must be made to prevent electrolyte deficiencies and overloads. An important hazard of

excess cations in PN is formation of insoluable precipitates. (Joshi, 2008)

Daily electrolyte additions to adult PN formulation:

Electrolyte Standard Requirement

Calcium 10–15 mEq

Magnesium 8–20 mEq

Phosphorus 20–40 mmol

Sodium 1–2 mEq/kg

Potassium 1–2 mEq/kg

Acetate As needed to maintain acid-base balance

Chloride As needed to maintain acid-base balance

(Mirtallo et al, 2004)

Other components commonly added to parenteral solutions may include albumin

which can be added if serum albumin levels are very low, heparin the anticoagulant used

to prevent blood clots from forming on the IV catheter, and insulin which is used if

needed to regulate blood glucose levels.

2-7. Administration:

PN is administered through a needle or catheter and is usually delivered using an

ordinary intravenous (IV) pump. In general, IV pumps are a very expensive part of PN

therapy. (Ferry et al, 2011)

13

2-7-1. Peripheral access:

Nutrient solutions not exceeding 800-900 mOsm/kg of solvent can be infused

through a routine peripheral intravenous antigocatheter. Close monitoring should be

done to avoid thrombophlebiteis, the principle complication of peripheral catheters.

Extended Dwell Catheter or midline or midclavicular catheter is a beneficial

development in peripheral catheter technology that can remain for 3-6 weeks. (Mahan

et al, 2012)

2-7-2. Central Access:

Short-term central catheters commonly inserted in the subclavian vein and advanced

until the catheter tip is in the superior vena cava, other veins to superior vena cava are

external or internal Jugular veins. The tunneled catheter is commonly used for long-

term central PN which can be placed in the Cephalic, Subclavian, and internal Jugular

veins into the Seuperior Vena Cava vein. A subcutaneous tunnel is created where the

catheter exits the skin several inches from its venous entry site. Care of long-term

catheters requires specialized handling and extensive patient education. (Mahan et al,

2012)

The peripheral inserted central catheter (PICC) is a catheter inserted into a peripheral

vein and advanced into a central vein. It can be used for short or long term. Compared

with a direct central catheter, PICC has fewer insertion and infection related

complications. (Whitney et al, 2001)

There are a number of considerations that need to be made when choosing the route

of venous access. These include:

• History of patient (e.g thrombosis, lymphedema)

• Individual circumstances (e.g hematological stability,allergies)

• Osmolarity of the solution

• Risk of infection

• Duration of PN

• Type of line access available

• Other IV therapies required by the patient. (Agency of Clinical Innovation ACI, 2011)

2-8. Complications:

PN is associated with different complications categorized in four groups:

• Mechanical complications : during insertion or the use of the catheter such as:

14

▪ Air embolism

▪ Pneumothorax (Presence of air in the chest cavity)

▪ Hemothorax ( Presence of blood in the chest cavity)

▪ Central vein thrombophlebitis

▪ Catheter perforation

• Infection and sepsis: which can be caused through:

▪ Catheter entrance site

▪ Contamination during insertion

▪ Long-term catheter placement

▪ Solution contamination

• Gastrointestinal complications: Such as:

▪ Cholestasis

▪ Gastrointestinal villous atrophy

▪ Hepatic abnormalities

• Metabolic complications: Many can arise during PN therapy such as:

▪ Dehydration

▪ Electrolyte imbalance

▪ Essential fatty acids deficiency

▪ Trace minerals deficiency

▪ Uremia

▪ Hyperammonemia

▪ Hyperglycemic coma

▪ Hyperlipidemia

▪ Hypercalcemia, hypocalcemia

▪ Hyperphosphatemia, hypophosphatemia

▪ Hypomagnesemia (Mahan et al, 2012)

The physician mostly monitors the mechanical, infection, and gastrointestinal

complications, while the metabolic complications are highly associated with the

dietitian's involvement and monitoring.

2-8-1. Refeeding syndrome:

Aggressive administration of nutrition, particularly via the intravenous route can

develop refeeding syndrome which is defined as derangements in serum electrolytes

(phosphate, potassium, magnesium), vitamin deficiency, and fluid as well as sodium

retention occurring in malnourished patients after initiation of PN (Schneeweiss,

2016)

15

Metabolic abnormalities include:

• Hypophosphataemia

• Hypokalaemia

• Hypomagnesaemia and occasionally hypocalcaemia

• Altered glucose metabolism (hyperglycaemia)

• Vitamin deficiency

• Cardiac failure, pulmonary oedema and dysrhythmias

• Acute circulatory fluid overload or fluid depletion

These abnormalities can lead to cardiac, respiratory, neuromuscular, haematologic,

hepatic and gastrointestinal complications. If untreated they can be fatal. (Nutrition team

and referrals, 2010)

The refeeding syndrome occurs when energy substrates, particularly carbohydrates,

are introduced into the plasma of anabolic patients. Proliferation of new tissue requires

increased amounts of glucose, potassium, phosphorus, magnesium, and other nutrients

essential for tissue growth. Rapid infusion of carbohydrate stimulates insulin release,

which reduces water and salt excretion and increases the chance of cardiac and

pulmonary complications from fluid overload. (Mahan et al, 2012)

The initial PN formulation should usually contain 25-50% of goal dextrose

concentration and be increased slowly to avoid the consequences of hypophosphatemia,

hypokalemia, and hypomagnesemia.

2-9. Monitoring:

Monitoring during PN is particularly important because the patient is at greater risk

of toxicity, deficiency, and other complications.

2-9-1. Monitoring of nutritional status:

Nutritional status is most effectively assessed and monitored through a combination

of anthropometric data, biochemical and clinical measures.

2-9-1-1 Some important anthropometric measurements:

Parameter Frequency To assess

Weight Daily if fluid balance concerns.

Otherwise weekly.

Fluid balance and

nutritional status.

Height Baseline.

Review with growth/degeneration.

Body Mass Index

16

(British Association for Parenteral and Enteral Nutrition (BAPEN), 2016)

2-9-1-2. Clinical parameters:

Parameter Frequency To assess

Temperature Daily Signs of sepsis and review fluid

requirements.

Fluid balance Daily, then at each

planned review once

stable.

Hydration and compare nutrition

prescribed vs delivered.

Access route Daily Signs of line infection or access issues.

Clinical condition

and medical plan

Daily initially,

reducing to twice

weekly once stable

Whether goals of PN are being met.

Nutritional requirements.

Appropriateness of PN and manage

potential complications.

Medications Baseline then at each

review once stable

Drug-nutrient interactions. Establish

whether medications are affecting gastro-

intestinal function/clinical condition.

GI function and

enteral intake

Daily initially,

reducing to twice

weekly

Ability to take enteral nutrition. Tolerance

to enteral nutrition. Establish the amount

of PN required to meet nutritional needs.

(British Association for Parenteral and Enteral Nutrition (BAPEN), 2016)

2-9-1-3. Biochemistry:

These are some variables to be monitored for inpatient PN:

Variable

Suggested frequency

initial period Later period (A steady

Metabolic State)

BMI Baseline, then repeated if dry weight or

height changes.

Nutritional status

Mid-arm

circumference

Baseline, then monthly Estimate body

composition and

function.

Triceps skin fold Baseline, then weekly Estimate body

composition and

function.

17

Serum electrolytes Daily 1-2/week

Blood Urea Nitrogen 3/week Weekly

Serum calcium, inorganic

phosphorus, magnesium

3/week Weekly

Serum glucose Daily 3/week

Serum triglycerides Weekly Weekly

Liver function enzymes 3/week Weekly

Hemoglobin, hematocrit Weekly Weekly

Platelets Weekly Weekly

WBC count As indicated As indicated

(Mahan et al, 2012)

2-10. Transitional feeding:

The decision to recommence oral or enteral nutrition requires an assessment of GI

tract anatomy, function and absorption. (Agency of Clinical Innovation (ACI), 2011)

The transition from IV feeding to an enteral diet can be accomplished in different

ways and often involves a combination of feeding methods. One way is to start an oral

diet while the person is still on IV nutrition. The diet is often progressive, beginning

with liquids provided in small amounts. If the person cannot eat enough food to meet at

least 50 percent of daily nutrient needs within a few days, and intake does not seem to

be improving, a tube feeding may be considered. The volume of IV solution is reduced

as the volume of enteral feeding is increased. PN can be discontinued when at least 70

to 75 percent of estimated energy needs are being met by oral intake, tube feeding, or

combination of the two. (Whitney et al, 2001)

2-11. Role of the dietitian in Parenteral nutrition:

The role of the dietitian in PN support involves direct patient care, consultative

services, education, program development, and research. Nutrition assessment,

determination of macronutrient and micronutrient requirements and monitoring are vital

aspects of the provision of PN support that benefit from the knowledge and experience

of a dietitian. (McCare et al, 1993) The dietitians therefore need to develop hospital

protocols and care pathways on nutrition support, and to participate in the nutritional

education of the entire clinical workforce. (National Collaborating Centre for Acute

Care, 2006)

2-11-1. Assessment of the patients requiring parenteral nutrition:

When providing nutrition support to patients it is important to assess their nutritional

status. A formal assessment based on anthropometry, biochemistry, clinical and diet

18

history should be carried out by the dietitian. The nutrition assessment is used to

determine priorities of nutritional management, to estimate the patient’s nutritional

requirements, and to provide a baseline measure for monitoring the effectiveness of

intervention. Based on this assessment, a treatment goal can be set and a nutrition care

plan developed. This care plan will change over time, particularly for patients on long-

term PN (longer than three to six months). (Ferry et al, 2011) Nutrition assessment also

helps to gather necessary data to direct the timing of nutrition support in hospitalized

patients based on the route for feeding. Malnutrition usually refers to protein-energy

malnutrition resulting from extended periods of negative balance of energy and protein

below metabolic requirements. (Kirby & Corrigan, 2013)

2-11-1-1. Weight Data:

Body mass index (BMI) is commonly used to compare height and weight and is

calculated as weight in kilograms divided by height in meters squared [BMI= weight

(kg) / height (m2)]. A BMI less than 18.5 meets criteria for malnutrition, a BMI between

18.5 and 24.9 indicates a healthy weight status, a BMI from 25-29.9 is overweight, and

a BMI greater than or equal to 30 is classified as obese.

BMI is simple to calculate and provides a snapshot of the current weight category.

Changes in recent weight most accurately assess current nutritional risk. Involuntary

weight loss of greater than 10% of usual body weight over 6 months or loss of greater

than 5% of usual body weight in 1 month is considered strong evidence of malnutrition.

(Kirby & Corrigan, 2013)

2-11-1-2. Clinical Examination:

A Nutrition Focused Physical Examination (NFPE) assists clinicians in gathering

information about the patient's nutritional status. It begins with a general visual

inspection of the patient from head to toe. Overt or obscure signs of malnutrition may

be identified and require further testing to confirm the presence of the nutritional

deficiency. (Kirby & Corrigan, 2013)

2-11-1-3. Diet History:

A registered dietitian (RD) utilizes many tools to obtain a diet history including

dietary recall methods, food diaries, or intake and output records. The RD also obtains

information on changes in weight, appetite, and oral intake along with physical activity

levels/functional status, food allergies/intolerances, bowel habits, use/dose of vitamin

supplements, religious diet restrictions, and nutrition support regimes (oral nutritional

19

supplements, enteral tube feeding regimes, or PN regimes). If a change in oral intake

was noted, the RD would also gather more data on the time frame and identify possible

reasons for the change (i.e. chewing/swallowing problems, nausea/vomiting, early

satiety, pain associated with oral intake, reflux, depression, inability to prepare or

procure food, etc.). (Kirby & Corrigan, 2013)

Combining findings from the NFPE, diet history, laboratory studies, and

anthropometric measures, helps determine the presence of malnutrition.

2-11-2. Calculations:

2-11-2-1. Energy requirements:

Dextrose solution and lipid emulsions are common macronutrients used to provide

energy in parenteral solution. Nitrogen for protein synthesis is obtained from synthetic

crystalline amino acid solutions. (Maynard, 2015)

After assessing the patient and determining the need for the PN to supply full or part

of energy requirements, energy needs (as kcal/day) can be calculated by using Harris-

Benedict equation putting into consideration the activity and stress factors.

• Harris-Benedict equation:

Males Basal Energy Expenditure (BEE) =

66.47 + (13.75 x Weight in kg) + [(5.0 x Height in cm) - (6.75 x Age in years)]

Females Basal Energy Expenditure (BEE) =

665.1 + (9.65 x Weight in kg) + [(1.86 x Height in cm) - (4.668 x Age in years)]

(Spodayrk&Kobylarz, 2005)

In addition, energy requirements can be estimated as Kcal/Kg based on the following

scale:

Normal need: 25-30 Kcal/kg/day

Elective surgery: 28-30 kcal/kg/day

Severe injury: 30-40 kcal/kg/day

Extensive trauma/burn: 45-55 kcal/kg/day

20

(Maynard, 2015)

For the obese patients who require PN adjusted body weight must be calculated as

below:

Adjusted IBW for obesity

Female: ([actual weight – IBW] x 0.32) + IBW

Male: ([actual weight – IBW] x 0.38) + IBW

Ideal body weight (wt) may be calculated using the Hamwi method

Men: 50 kg + 2.3 kg for each inch over 5 feet

Women: 45.5 kg + 2.3 kgfor each inch over 5 feet

(Chowdary& Reddy, 2010)

2-11-2-2. Protein requirements:

The common recommendation for the amino acid dose ranges from 1.2 to 1.5 g per

kilogram of the ideal body weight per day for most patients with normal renal and

hepatic function, although some guidelines recommend higher doses (2.0 to 2.5 g per

kilogram per day) under specific conditions (eg; burns or severe trauma). Patients with

chronic renal failure should be given 0.6 – 0.8 gm/kg/day and patients with acute hepatic

encephalopathy should have a temporary restriction of protein to 0.8 gm/kg/day.

Patients on haemodialysis or peritonealdialysis would require 1.2 – 1.3 gm/kg/day.

Parenteral proteins were earlier provided as casein solutions, which had higher

microbicidal growth rates due to contamination, but now they are provided in the form

of crystalline amino acids, which have better nitrogen balance and do not promote

microbial growth. (Chowdary& Reddy, 2010)

2-11-2-3. Carbohydrate requirements:

In central venous PN, a reasonable initial guideline is to provide 60 to 70% of non–

amino acid calories as dextrose and 30 to 40% of non–amino acid calories as fat

emulsion (Ziegler, 2009) but in peripheral PN, solutions may contain lipid up to 60% of

total non-protein calories to reduce the osmolarity of the PN solution and minimise the

risk of peripheral vein thrombosis. (Agency of Clinical Innovation (ACI), 2011)

Carbohydrate intake of 3.0–3.5 g of /kg body weight/day is recommended. In patients

with a high risk of hyperglycaemia (critically ill, diabetes, sepsis, or steroid therapy) 1–

2 g/kg body weight/day is recommended to achieve normoglycaemia. The blood glucose

level should be maintained between 80–110 mg/dL. At least a glucose level of <145

21

mg/dL should be achieved, because levels above 145 mg/dL have been associated with

higher morbidity and mortality. (Ebener C et al, 2009)

2-11-2-4. Fat requirements:

Patients can receive 25 to 30% total calories as lipids. It is estimated that 2-4% of

Kcal must be from essential fatty acids (EFA) and a per needs 1 to 2.5 gram of fat/Kg.

Maximal tolerance level of lipid is considered to be 2.5 gm/Kg body weight and 60%

of energy from fat is also considered to be upper limit. More than 60% of energy from

fat may result in hyperlipidemia due to impaired lipid clearance by the body. (Maynard,

2015)

2-11-2-5. Fluid requirements:

Fluid management in PN depends on the hydration status of the patient and the

clinical conditions, such as, renal failure, congestive heart failure and so on. The total

amount of fluid taken is restricted by making the nutritional fluid more hypertonic in

patients with renal failure, patients with CHF and so on. (Chowdary& Reddy, 2010)

In general, 30-50ml/kg body weight is suggested. Maximum volume of central

parenteral nutrition (CPN) rarely exceeds 3L, with typical prescriptions of 1.5-3L daily.

(Mahan et al, 2012)One method of calculating fluid needs is by adding 100 cc/kg for

first 10 kg body weight + 50 cc/Kg for the second 10 Kg + 20 cc/Kg for each additional

Kg. (Maynard, 2015)

22

Chapter Three

Research Methodology

22

3-1. Study design and duration:

This is a descriptive cross-sectional study conducted in four tertiary hospitals, in

Khartoum State-Sudan, during the period September to December 2016.

3-2. Study area:

The four selected hospitals were Soba University Hospital, Gafar Bin Ouf Children

Teaching Hospital, The Omdurman Military Hospital, and Royal Care Hospital where

three are located in Khartoum locality and one in Omdurman locality. The selection

based on their tertiary level and they also possess variable nutrition services through

recognized dietary departments.

3-3. Study population:

The study focused on a number of dietitians selected randomly from the working

dietitians in the targeted hospitals. All of them were available during the period of data

collection.

3-4. Sampling: Hospital name Number of dietitians

available in hospital

Number of dietitians

responded to the questionnaire

Royal Care Hospital 7 5

Soba University Hospital 10 5

Gafar Bin Ouf Hospital 8 6

Omdurman Military

Hospital

* 34

*It’s a military hospital so the number of dietitians working in the hospital could not be

known.

3-5. Data collection:

Fifty questionnaire forms were distributed to the target group composed of 12

questions.

The questionnaire has two main goals. The first was to collect the demographic data

of the responded dietitians including their gender, educational qualification, and clinical

experience. The second was to evaluate their understanding and awareness of parenteral

nutrition including PN definition, indications, assessment measurements, calculations,

advantages, disadvantages, undesired outcomes, complications, difficulties, and the

obstacles of providing PN in Khartoum state hospitals.

3-6. Data analysis:

The statistical package for 2Wsocial sciences (SPSS) program was used for data

entry and analysis.

23

3-7. Data presentation:

The data were presented in tables.

3-8. Ethical considerations:

An official letter was sent to the hospitals for permission and cooperation. Verbal

consent was taken from the study population to participate in the study and filling the

questionnaire.

Chapter Four

Results

24

4-1. Academic qualification of the study population:

Table (1): Academic qualification of the study population:

Percentage Frequency Qualification

4% 2 Diploma

82% 41 Bachelor

14% 7 Master

0 0 PhD

100% 50 Total

From the dietitians working in the targeted hospitals, more than 80% have Bachelor

academic qualification.

4-2. Experience of the population in nutrition field:

Table (2): Experience of the population in nutrition field:

Percentage Frequency Experience

62% 31 Less than 3 years

16% 8 4-6 years

22% 11 More than 6 years

100% 50 Total

More than 60% of the participants have less than 3 years of experience in the nutrition

practice, 22% have more than 6 years of experience.

25

4-3. Are you aware about parenteral nutrition:

Table (3): Are you aware about parenteral nutrition:

Percentage Frequency Option

94% 47 Yes

6% 3 No

100% 50 Total

Surprising enough that 94% of the targeted population reported that they are aware

about the basics of providing parenteral nutrition.

4-4. Definition of parenteral nutrition:

Table(4): The comprehensive definition of parenteral nutrition:

Percentage Frequency Parenteral nutrition is:

6% 3 Supply the patient with nutritional needs through a

special tube into the stomach or intestines.

10% 5 Supply the patient with nutritional needs through a

peripheral vein.

8% 4 Supply the patient with nutritional needs through a

central vein.

76% 38 Both 2 & 3

100% 50 Total

Three quarters of the responders define parenteral nutrition as supplying the nutritional

needs to the patient through central or peripheral vein. however 6% of the responders

mixed parenteral nutrition with enteral nutrition.

26

4-5. Have you come across medical conditions in need of Parenteral

nutrition:

Table (5): Have you come across medical conditions in need of Parenteral

nutrition:

Percentage Frequency Option

84% 42 Yes

16% 8 No

100% 50 Total

More than 80% of the dietitians revealed that they have exposed in their practice of

clinical nutrition to patients in need of parenteral nutrition. Only 16% have not had such

experience.

4-6.The most exposed category for parenteral nutrition:

Table(6):The most exposed category for parenteral nutrition:

Percentage Frequency Category

10% 5 Pediatrics

4% 2 Adults

24% 12 Elderly

62% 31 All mentioned

100% 50 Total

Most of the responders show that the need of parenteral nutrition is distributed in a wide

range of patients in different age groups.

27

4-7. Parenteral nutrition is more indicated for:

Table (7): Parenteral nutrition is more indicated for:

Percentage Frequency Condition

4% 2 Surgical cases

4% 2 Medical cases

0 0 Oncology patients

4% 2 Malnutrition and disabilities

88% 44 All mentioned

100% 50 Total

88% of the working dietitians in the targeted hospitals confirm that all the mentioned

conditions (Surgical, medical, oncology, malnutrition) may be in need for parenteral

nutrition.

4-8. Positive influence of parenteral nutrition:

Table (8): parenteral nutrition has a positive influence:

Percentage Frequency Option

100% 50 Yes

0 0 No

100% 50 Total

All the respondents confirm the positive influence of using parenteral nutrition.

28

4-9. Alternative route of oral or enteral nutrition support:

Table (9): When patient is unable to tolerate oral or enteral nutrition for a week,

do you recommend parenteral nutrition with the medical team?

Percentage Frequency Option

84% 42 Yes

16% 8 No

100% 50 Total

The study shows that most of the responders recommend parenteral nutrition as an

alternative way to support their patients whenever the sick people are not able to tolerate

oral or eternal feeding.

4-10.Parenteral nutrition assessment measurements:

Table (10): Parenteral nutrition assessment measurements:

Percentage Frequency Parameter

2% 1 Anthropometric measurements

10% 5 Biochemical analysis

88% 44 All mentioned

100% 50 Total

88% of the responders agree that both anthropometric assessment and biochemical data

form basics for the assessment of a patient in need of parenteral nutrition.

29

4-11. Knowledge about parenteral nutrition calculations:

Table (11): Do you have knowledge about calculating the nutritional requirements

for a patient receiving parenteral nutrition?

Percentage Frequency Option

62% 31 Yes

38% 19 No

100% 50 Total

About 60% of the respondents believe that they have knowledge about calculating the

nutritional needs for parenteral nutrition. About 40% do not have that knowledge.

4-12. Have you ever formulated a parenteral nutrition prescription or

participated in that:

Table (12): Have you ever formulated a parenteral nutrition prescription or

participated in that?

Percentage Frequency Option

30% 15 Yes

70% 35 No

100% 50 Total

Although most of the targeted population are aware about the indications, assessment

measurements, and calculating the energy requirements for patients in need of parenteral

nutrition, the study shows that the majority of the responded dietitians have not had a

chance to formulate or participate in formulating a parenteral nutrition prescription for

real patients.

30

4-13. Negative influence of parenteral nutrition:

Table (13): Parenteral nutrition has a negative influence:

Percentage Frequency Option

72% 36 Yes

28% 14 No

100% 50 Total

Two third of the participants confirm the negative influence of using parenteral

nutrition.

4-14. Parenteral nutrition obstacles:

Table (14): If (yes), Parenteral nutrition obstacles:

Percentage Frequency Option

2% 1 Associated Complications (eg; Metabolic

complications and infections)

2% 1 Financial cost

0 0 Unavailability of required equipment

2% 1 Unavailability of multidisciplinary team

68% 34 All mentioned

6% 3 Else

20% 10 Option (No) , missed

100% 50 Total

About 70% of the respondents answered (yes) to the previous question suggest that all

the mentioned options (Associated complications, unavailability of multidisciplinary

team, unavailability of required equipment, financial cost) are the obstacles of using

parenteral nutrition.

Note that 28% answered (no) to the previous question are not included in this question.

Chapter Five

Discussion

31

5-1. Discussion:

The aim of the present study is to recognize the dietitian’s awareness about the

importance, indications, obstacles of parenteral nutrition, and their role in providing this

service whenever it is required.

In this study, three quarters of the dietitians have enough knowledge to define correctly

what is parenteral nutrition and its usable routes. One quarter of the responders missed

the right definition of parenteral nutrition or mixed between parenteral nutrition and

enteral nutrition or were not aware about the proper accesses through which parenteral

nutrition is given (central and peripheral).

More than 80% of the dietitians in the study population revealed that they had the

chance coming across patients who were in need of parenteral nutrition as a part of

therapeutic support. This finding demonstrates that there are a quite number of patients

who are in need for parenteral nutrition in Khartoum State hospitals. It was observed

that most of the newly graduate dietitians (graduated three years ago or less) in this

study have not come across such experience.

Although the review of the literature concerning parenteral nutrition in Sudan

showed that the surgical patients were in more need of parenteral nutrition

(Elamin&Norri, 2010), unlike the results of this study show that most of the working

dietitians in the targeted hospitals confirm that there is no preference among patients

who are in need of parenteral nutrition. They stated that wide spectrum of patients are

equally in need of parenteral nutrition including surgical, medical, oncology, and

malnutrition patients.

Thomovsky (2007) reported that with proper case selection, providing parenteral

nutrition (PN) can improve clinical outcome, reduce hospitalization time, and reduce

the cost of patient care. All the participants confirm the positive impact of using

parenteral nutrition when it's used for the needy patients.

When patients are not able to tolerate oral or enteral feeding to meet their nutritional

requirements, this is one of the main indications for using parenteral nutrition. Five-

sixths of the responders in this study recommend parenteral nutrition as an alternative

way to give the patients their nutritional needs whenever they are not able to tolerate

oral or eternal feeding for a period of week regardless of the age. Few of the responders

do not recommend the use of parenteral nutrition, most likely they are unaware of

parenteral nutrition as an alternative nutritional support route, or they are overbalancing

the risks of using parenteral nutrition.

Ferry et al(2011) mentioned that the dietitians should carry a formal assessment

based on anthropometry and biochemistry measurements for starting and monitoring

32

parenteral nutrition for the needy patients. It is the same opinion of the participants in

this research as most of them answered that they are going to use the same measures to

assess their patients before and after the starting parenteral nutrition. About 12% of the

responders revealed in their answers that they are either going to use biochemical

assessment alone or anthropometry measurements alone.

Regarding calculations of parenteral nutrition formulation, about two-third of the

dieticians in this study have enough knowledge to carry it for the patients who are in

need of parenteral nutrition, and one-third do not have sufficient knowledge to carry it.

Although most of the targeted population are aware about the indications, assessment

measurements, and calculating the energy requirements for patients in need of parenteral

nutrition, the study shows that the majority of the responded dietitians have not had a

chance to formulate or participate in formulating a parenteral nutrition prescription for

real patients. From the previous study of the researcher, it seems that the facilities and

resources in Khartoum State hospitals are not feasible for the dietitians to get the proper

chance to calculate or prescribe parenteral nutrition.

Nutrition assessment, determination of the required macronutrient and micronutrient,

and monitoring the patient's nutritional status are essential to provide proper parenteral

nutrition support and minimize the side effects. This usually requires well trained

dietitian (McCare J D et al,1993). The result of this study shows clearly that dietitians

who spent more than 6 years in clinical practice are more knowledgeable and familiar

with the preparation and the calculation of parenteral nutrition compared with the newly

dietitians whom their clinical experience is less than 3 years.

Although all the participants were found aware about the benefits and advantages of

parenteral nutrition when indicated, one third of them do not aware about the risks and

side effects of it.

The unavailability of the multidisciplinary team, lack of the required equipment and

financial support. In addition to the associated complications including but not limited

to metabolic complications, infections, and catheter related complications, those are

considered the fundamental obstacles to the provision of long term parenteral nutrition

service in Khartoum State hospitals.

5-2. Conclusions:

• In this study the dietitian’s awareness about the importance, indications,

obstacles of parenteral nutrition, and their role in providing this service whenever

it is required in the targeted chosen hospitals in Khartoum state were

investigated.

33

• Most of the dietitians who participated in this study were found knowledgeable

about parenteral nutrition definition, indications, accesses, and assessment

measurements. However in this review about 40% of the dietitians do not have

the enough knowledge and the enough clinical experience that allow them to

take the real role to provide the parenteral nutrition service in form of

calculations, prescription, and overcome any emerge undesired complications in

Khartoum state hospitals.

• The study showed that the majority of the responded dietitians (70%) have not

had a chance to formulate or participate in formulating a parenteral nutrition

prescription for real patients.

• Although all the participants were found aware about the benefits and advantages

of parenteral nutrition when indicated, one third of them do not aware about the

risks and side effects of it.

5-3. Recommendations:

• From the present results, the awareness of parenteral nutrition among all

dietitians work in hospitals should be raised by using different education media

(Such as manuals, brochures, simulation sessions) and by holding workshops.

• Academic courses and educational syllabuses about parenteral nutrition must be

included in the curriculum of dietician’s colleges in the Sudanese universities.

• The high health authority may need to take levelheaded plans and decisions to

give all logistic support that helps in providing PN services in Sudan.

• Establishing models of PN units in few of the tertiary level health institutes and

hospitals will be of great help in providing this service, as well will be

appreciable environment for the dietitian’s training in the area of parental

nutrition.

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34

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Appendixes

38

• Appendix-1: Nutrition Support routes (Enteral and Parenteral

Nutrition)

(Amy Speech & Language Therapy, 2010)

39

*Appendix-2: Peripheral Inserted Central Catheter (PICC line)

(Cancer research UK, 2015)

40

*Appendix-3: Access to Superior Vena Cava

(Tonk R S et al, 2015)

41

هل لديك فكرة عن التغذية الوريدية؟ -1 *نعم *ال

في تقديرك ما هو التعريف األشمل للتغذية الوريدية؟ -2

*إعطاء المريض احتياجاته الغذائية عن طريق أنبوب معوي *إعطاء المريض احتياجاته الغذائية عن طريق وريد طرفي

*إعطاء المريض احتياجاته الغذائية عن طريق وريد مركزي

هل صادفت حاالت مرضية في حوجه للتغذية الوريدية؟ -3 *نعم *ال

احتياجاً للتغذية الوريدية في تقديرك هي:الفئة األكثر -4

*األطفال *البالغين *كبار السن * كل ما ذكر

تعتقد أن أهمية التغذية الوريدية تكمن أكثر في: -5 *األمراض الباطنية*الحاالت الجراحية

سوء التغذية واإلعاقات*أمراض *األورام والسرطانات كل ما ذكر*

المؤهل العلمي: • دكتوراه دبلوم بكالوريوس ماجستير

الخبرة في مجال التغذية:• أقل من ثالث سنوات

ستة سنوات –أربعة

أكثر من ستة سنوات

بسم هللا الرحمن الرحيم

The National Ribat University

Faculty of graduate studies – MSc of human nutrition & dietetics

Awareness of dietitians about their role in providing

parenteral nutrition service in some Khartoum state

hospitals – Sudan.

42

حسب خبرتك ومعرفتك هل تعتقد أن التغذية الوريدية لها مردود إيجابي؟ -6 *نعم *ال

هل توصي بالتغذية الوريدية مع الفريق الطبي في حالة عدم تناول التغذية الكافية عن -7 المعوية لمدة أسبوع؟ طريق الفم أو التغذية

*نعم *ال

حسب خبرتك ومعرفتك ما هي أهم مقاييس تقييم مريض يعتمد على التغذية الوريدية؟ -8 * القياسات الجسمانية

* التحاليل المعملية * االثنان معاً

عن كيفية حساب االحتياجات الغذائية لمريض تحت التغذية هل تتوفر لديك معلومات -9

الوريدية؟ *نعم *ال

هل قمت بعمل وصفة للتغذية الوريدية لمريض أو شاركت في ذلك؟ -10

*نعم *ال

وريدية لها مردود سلبي؟حسب خبرتك ومعرفتك هل تعتقد أن التغذية ال -11 *نعم *ال

معّوقات استخدام التغذية الوريدية؟إذا كانت إجابتك السابقة )نعم( ما هي أهم -12

* التعقيدات المصاحبة الستخدامها كااللتهابات والتعقيدات االستقالبية *التكلفة.

* عدم توفر المعدات الالزمة. * عدم وجود فريق متكامل.

* كل ما ذكر

شكراً لحسن تعاونك

43

1- Are you aware about parenteral nutrition?

*Yes * No

2- In your opinion, the comprehensive definition of parenteral

nutrition is:

* Supply the patient with nutritional needs through a special tube into

the stomach or intestines.

* Supply the patient with nutritional needs through a peripheral vein.

* Supply the patient with nutritional needs through a central vein.

* Both answers 2 & 3

3- Have you come across medical conditions in need of Parenteral

nutrition?

*Yes *No

4- The most exposed category for parenteral nutrition: *Pediatrics *Adults *Elderly *All mentioned

• Academic qualification: DiplomaBachelorMasterPhD

• Experience in nutrition field:

Less than 3 years

4-6 years

More than 6 years

بسم هللا الرحمن الرحيم

The National Ribat University

Faculty of graduate studies – MSc of human nutrition & dietetics

Awareness of dietitians about their role in providing

parenteral nutrition service in some Khartoum state

hospitals – Sudan.

44

5- In your opinion,Parenteral nutrition is more indicated for:

* Surgical cases

* Medical cases * Oncology patients

* Malnutrition and disabilities

* All mentioned

6- Depending on your experience and knowledge, parenteral

nutrition has a positive influence:

* Yes * No

7- When patient is unable to tolerate oral or enteral nutrition for a

week, do you recommend parenteral nutrition with the medical

team?

*Yes *No

8- Depending on your experience and knowledge, the most

important assessment measurement for a patient on Parenteral

nutrition is: *Anthropometric measurements

*Biochemical analysis

*All mentioned

9- Do you have knowledge about calculating the nutritional

requirements for a patient receiving parenteral nutrition? * Yes * No

10- Have you ever formulated a parenteral nutrition

prescription or participated in that? *Yes * No

11- Depending on your experience and knowledge, parenteral

nutrition has a negative influence:

*Yes * No

45

12- If (yes), the main obstacles to the use of parenteral nutrition

are:

* Associated Complications (eg; Metabolic complications and

infections) * Financial cost

* Unavailability of required equipment

*Unavailability of multidisciplinary team

*All mentioned

Thank you for

your cooperation