Parenteral Nutrition
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Parenteral NutritionParenteral Nutrition
Made simple….Made simple….
in 15 minutesin 15 minutes
Jon ShafferJon ShafferIntestinal Failure UnitIntestinal Failure Unit
Hope HospitalHope Hospital
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring
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CONSEQUENCES OF MALNUTRITION
DIMINSHED QUALITY OF LIFE
INCREASED CLINICAL COMPLICATIONS
POORER OUTCOME
INCREASED COSTS
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0
20
40
60
80
100
wt function
Effects of 6/12 semi-starvation
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Malnutrition on admission –Malnutrition on admission –SwedenSweden
382 pts382 pts
InfectionInfection
SurgerySurgery
Internal medicineInternal medicine
OncologyOncology
Well nourished Well nourished 73 %73 %
Moderately malnourished Moderately malnourished 20 %20 %
Severely malnourished Severely malnourished 7 %7 %
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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Nutritional assessmentNutritional assessment
ProblemProblem
No “blood urea “ for malnutritionNo “blood urea “ for malnutrition
Risk scores v malnutritionRisk scores v malnutrition
Multiple examplesMultiple examples
Lack of a Gold StandardLack of a Gold Standard
ValidationValidation
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Nutritional screeningNutritional screening
ALBUMINALBUMIN
Long half lifeLong half life
Overly sensitive- liver/renal diseaseOverly sensitive- liver/renal disease
Reduction – redistributionReduction – redistribution
Slow to react with recoverySlow to react with recovery
“ “ negative acute phase protein”negative acute phase protein”
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Nutritional screeningNutritional screeningSubjective Global AssessmentSubjective Global Assessment
Pt questionsPt questions e.g weight losse.g weight loss
diet changesdiet changes
GI symptomsGI symptoms
Physical appearancePhysical appearance--
loss of fatloss of fat
muscle wastingmuscle wasting
GradingGrading
A A Well nourishedWell nourished
BB Moderately malnourished Moderately malnourished
C C Severely malnourished Severely malnourished
Detsky 1987Detsky 1987
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0
10
20
30
40
50
60
70
%
A B C SGA
Infection rate and SGA
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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Nutrition support teamsNutrition support teams
Appropriate screening /referralAppropriate screening /referral
Appropriate nutrition supportAppropriate nutrition support
Education/training – staff and ptsEducation/training – staff and pts
Cost effectiveCost effective
PN x10 v ENPN x10 v EN
Better outcomesBetter outcomes
Reduced complicationsReduced complications
Bowling 2002Bowling 2002
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Efficacy of nutrition support teamsEfficacy of nutrition support teamse.g. catheter sepsis rates e.g. catheter sepsis rates
% Before% Before %After%After
FreemanFreeman 2121 1.31.3
SandersSanders 2929 4.74.7
RyanRyan 3333 33
NehmeNehme 2525 1.31.3
KeohaneKeohane 3333 44
JacobsJacobs 2424 00
FaubionFaubion 2424 3.53.5
MeanMean 2727 2.52.5
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring
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Appropriateness – variesAppropriateness – varies
Few ABSOLUTE indicationsFew ABSOLUTE indications
1. Intestinal Failure1. Intestinal Failure
22. . If the gut works – use itIf the gut works – use it
33. . Enteral preferableEnteral preferable
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Intestinal Failure
“The reduction in the functioning gut mass below the minimal amount necessary for adequate digestion and absorption”
(Fleming and Remington 1981)
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If the gut works……1If the gut works……1
Technology -- 1970’s—1990Technology -- 1970’s—1990
Parenteral > EnteralParenteral > Enteral
Better catheters/ better feeds/better Better catheters/ better feeds/better researchresearch
Industry/ Surgery drivenIndustry/ Surgery driven
Most - Surgical/Intensive care/CancerMost - Surgical/Intensive care/Cancer
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If the gut works……2If the gut works……2
1990’s1990’s
Enteral tubes especially PEG’sEnteral tubes especially PEG’s
Medical > SurgicalMedical > Surgical
Erosion of traditional markets e.g. Erosion of traditional markets e.g. Pancreatitis, ICUPancreatitis, ICU
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Enteral ? preferableEnteral ? preferable
SimplerSimpler
Less complicationsLess complications
CheaperCheaper
EquieffectiveEquieffective
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Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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IV ACCESSIV ACCESS
Peripheral - short termPeripheral - short term
Midline - short/mediumMidline - short/medium
PICC ( Peripherally inserted central line )PICC ( Peripherally inserted central line ) - -mediummedium
Central – medium/long termCentral – medium/long term
Central tunnelled – ultra long term HPNCentral tunnelled – ultra long term HPN
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PrescribingPrescribing
Standard bagsStandard bags
A la carteA la carte
All in one bagsAll in one bags
Re-feeding syndrome Po4, KRe-feeding syndrome Po4, K
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Design of RegimenDesign of Regimen
OsmolalityOsmolality
peripheral < 900 mosmol/L, peripheral < 900 mosmol/L, (1800kcals)(1800kcals)
PICC < 1200 mosmol/L PICC < 1200 mosmol/L (2000kcals)(2000kcals)
Central < 1700 mosmol/L Central < 1700 mosmol/L (> 2000kcals)(> 2000kcals)
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FluidFluid
30-35mls/kg body weight (adjust for age)30-35mls/kg body weight (adjust for age)
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EnergyEnergy
Normal to provide a ratio of Normal to provide a ratio of
Glucose: fat 50:50 or 60:40Glucose: fat 50:50 or 60:40
Overfeeding can result in lipogenesis, fatty Overfeeding can result in lipogenesis, fatty infiltration of the liverinfiltration of the liver
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NitrogenNitrogen
Range from 0.17-0.3gN/kgRange from 0.17-0.3gN/kg
Rarely give >14g / dayRarely give >14g / day
Need to ensure maximal metabolic effect Need to ensure maximal metabolic effect of protein – 200kcals / gNof protein – 200kcals / gN
I.e. excess nitrogen = extra calories I.e. excess nitrogen = extra calories
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Vitamins and MineralsVitamins and Minerals
Water soluble Water soluble
Fat Soluble Fat Soluble
Trace Elements Trace Elements
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Parenteral Nutrition RegimenParenteral Nutrition RegimenSolution Solution Volume Volume
(mls)(mls)Energy Energy (kcals)(kcals)
Nitrogen Nitrogen (g)(g)
Na Na (mmol)(mmol)
K (mmol)K (mmol) Ca Ca 9mmol)9mmol)
PO4 PO4 (mmol)(mmol)
Mg Mg (mmol)(mmol)
Vamin 9 EFVamin 9 EF 10001000 9.49.4
GlucoseGlucose
40%40%
500500 800800
20% 20% IntralipidIntralipid
500500 10001000 7.657.65
AddiphosAddiphos 1010 7.57.5 7.57.5 1010
15% KCl15% KCl 2020 4040
50% Mg SO450% Mg SO4 22 44
Ca ClCa Cl 44 3.63.6
30% NaCl30% NaCl 5050 100100
Vitlipid + Vitlipid + SolovitoSolovito
10 each 10 each vialvial
AdditraceAdditrace 1010
RequirementRequirementss
23302330 19001900 9.59.5 108108 4848 3.63.6 1919 3.83.8
Total Total 21162116 18001800 9.49.4 107.5107.5 47.547.5 4.34.3 17.617.6 44
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RequirementsRequirements
Energy = 8.1x45+656 =1020 + (153kcals)15% activity + Energy = 8.1x45+656 =1020 + (153kcals)15% activity + (153kcals) 15 % stress + 500kcals = 1826kcals(153kcals) 15 % stress + 500kcals = 1826kcals
Nitrogen = 0.2g/kg = 9gNNitrogen = 0.2g/kg = 9gN
Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)
Na 295mmol (1mmol / kg, GI losses 250mmol/L)Na 295mmol (1mmol / kg, GI losses 250mmol/L)
K 45mmol (1mmol / kg) K 45mmol (1mmol / kg)
PO 22.5mmol (0.5-0.7mmol/kg)PO 22.5mmol (0.5-0.7mmol/kg)
Mg 4.5mmol (0.1-0.2mmol/kg) Mg 4.5mmol (0.1-0.2mmol/kg)
Ca 4.5mmol (0.1-0.2mmol/kg)Ca 4.5mmol (0.1-0.2mmol/kg)
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MonitoringMonitoring
ParameterParameter FrequencyFrequency RationaleRationale
WeightWeight Daily - weeklyDaily - weekly Nutritional Status Nutritional Status – fluid balance– fluid balance
AnthropometryAnthropometry FortnightlyFortnightly Nutritional StatusNutritional Status
TemperatureTemperature DailyDaily InfectionInfection
Line SiteLine Site Daily Daily InfectionInfection
Fluid BalanceFluid Balance Daily Daily Fluid / electrolyte Fluid / electrolyte requirementrequirement
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BAPENBAPEN
BritishBritish
AssociationAssociation
Enteral Enteral
&&
Parenteral Parenteral
NutritionNutrition