Parenteral Nutrition

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Parenteral Nutrition

• Made simple.
• in 15 minutes
• Jon Shaffer
• Intestinal Failure Unit
• Hope Hospital

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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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CONSEQUENCES OF MALNUTRITION DIMINSHED
QUALITY OF LIFE INCREASED CLINICAL
COMPLICATIONS POORER OUTCOME INCREASED COSTS
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Malnutrition on admission Sweden

• 382 pts
• Infection
• Surgery
• Internal medicine
• Oncology
• Well nourished
  73
• Moderately malnourished 20
• Severely malnourished 7

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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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Nutritional assessment

• Problem
• No blood urea for malnutrition
• Risk scores v malnutrition
• Multiple examples
• Lack of a Gold Standard
• Validation

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Nutritional screening

• ALBUMIN
• Long half life
• Overly sensitive- liver/renal disease
• Reduction redistribution
• Slow to react with recovery
• negative acute phase protein

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Nutritional screening

• Subjective Global Assessment
• Pt questions e.g weight loss
• diet
  changes
• GI symptoms
• Physical appearance-
• loss of fat
• muscle
  wasting
• Grading
• A
  Well nourished
• B
  Moderately malnourished
• C
  Severely malnourished
• 
  Detsky 1987

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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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Nutrition support teams

• Appropriate screening /referral
• Appropriate nutrition support
• Education/training staff and pts
• Cost effective
• PN x10 v EN
• Better outcomes
• Reduced complications
• Bowling 2002

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Efficacy of nutrition support teamse.g. catheter
sepsis rates
Before After
Freeman 21 1.3
Sanders 29 4.7
Ryan 33 3
Nehme 25 1.3
Keohane 33 4
Jacobs 24 0
Faubion 24 3.5
Mean 27 2.5
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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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• Appropriateness varies
• Few ABSOLUTE indications
• 1. Intestinal Failure
• 2. If the gut works use it
• 3. Enteral preferable

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If the gut works1

• Technology -- 1970s1990
• Parenteral gt Enteral
• Better catheters/ better feeds/better research
• Industry/ Surgery driven
• Most - Surgical/Intensive care/Cancer

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If the gut works2

• 1990s
• Enteral tubes especially PEGs
• Medical gt Surgical
• Erosion of traditional markets e.g. Pancreatitis,
  ICU

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Enteral ? preferable

• Simpler
• Less complications
• Cheaper
• Equieffective

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Parenteral nutrition

• Importance of malnutrition
• Nutrition assessment
• Nutrition teams
• Indications
• Access
• Prescribing
• Monitoring

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IV ACCESS

• Peripheral - short term
• Midline - short/medium
• PICC ( Peripherally inserted central line )
  -medium
• Central medium/long term
• Central tunnelled ultra long term HPN

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Prescribing

• Standard bags
• A la carte
• All in one bags
• Re-feeding syndrome Po4, K

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Design of Regimen

• Osmolality
• peripheral lt 900 mosmol/L, (1800kcals)
• PICC lt 1200 mosmol/L (2000kcals)
• Central lt 1700 mosmol/L (gt 2000kcals)

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Fluid

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

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Energy

• Normal to provide a ratio of
• Glucose fat 5050 or 6040
• Overfeeding can result in lipogenesis, fatty
  infiltration of the liver

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Nitrogen

• Range from 0.17-0.3gN/kg
• Rarely give gt14g / day
• Need to ensure maximal metabolic effect of
  protein 200kcals / gN
• I.e. excess nitrogen extra calories

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Vitamins and Minerals

• Water soluble
• Fat Soluble
• Trace Elements

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Parenteral Nutrition Regimen
Solution Volume (mls) Energy (kcals) Nitrogen (g) Na (mmol) K (mmol) Ca 9mmol) PO4 (mmol) Mg (mmol)
Vamin 9 EF 1000 9.4
Glucose 40 500 800
20 Intralipid 500 1000 7.65
Addiphos 10 7.5 7.5 10
15 KCl 20 40
50 Mg SO4 2 4
Ca Cl 4 3.6
30 NaCl 50 100
Vitlipid Solovito 10 each vial
Additrace 10
Requirements 2330 1900 9.5 108 48 3.6 19 3.8
Total 2116 1800 9.4 107.5 47.5 4.3 17.6 4
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Requirements

• Energy 8.1x45656 1020 (153kcals)15
  activity (153kcals) 15 stress 500kcals
  1826kcals
• Nitrogen 0.2g/kg 9gN
• Fluid 4 L (35mls/kg (1575mls) losses 2.5L)
• Na 295mmol (1mmol / kg, GI losses 250mmol/L)
• K 45mmol (1mmol / kg)
• PO 22.5mmol (0.5-0.7mmol/kg)
• Mg 4.5mmol (0.1-0.2mmol/kg)
• Ca 4.5mmol (0.1-0.2mmol/kg)

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Monitoring
Parameter Frequency Rationale
Weight Daily - weekly Nutritional Status fluid balance
Anthropometry Fortnightly Nutritional Status
Temperature Daily Infection
Line Site Daily Infection
Fluid Balance Daily Fluid / electrolyte requirement
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BAPEN

• British
• Association
• Enteral
• Parenteral
• Nutrition