Parenteral Nutrition

Parenteral Nutrition Made simple…. in 15 minutes Jon Shaffer Intestinal Failure Unit Hope Hospital

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

CONSEQUENCES OF MALNUTRITION DIMINSHED QUALITY OF LIFE INCREASED CLINICAL COMPLICATIONS POORER OUTCOME INCREASED COSTS

Malnutrition on admission –Sweden 382 pts • Infection • Surgery • Internal medicine • Oncology • Well nourished 73 % • Moderately malnourished 20 % • Severely malnourished 7 %

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

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

Nutritional screening • Subjective Global Assessment • Pt questionse.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

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

Efficacy of nutrition support teamse.g. catheter sepsis rates

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

If the gut works……1 • Technology -- 1970’s—1990 • Parenteral > Enteral • Better catheters/ better feeds/better research • Industry/ Surgery driven • Most - Surgical/Intensive care/Cancer

If the gut works……2 • 1990’s • Enteral tubes especially PEG’s • Medical > Surgical • Erosion of traditional markets e.g. Pancreatitis, ICU

Enteral ? preferable • Simpler • Less complications • Cheaper • Equieffective

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

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

Design of Regimen • Osmolality peripheral < 900 mosmol/L, (1800kcals) PICC < 1200 mosmol/L (2000kcals) Central < 1700 mosmol/L (> 2000kcals)

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

Energy • Normal to provide a ratio of • Glucose: fat 50:50 or 60:40 • Overfeeding can result in lipogenesis, fatty infiltration of the liver

Nitrogen • Range from 0.17-0.3gN/kg • Rarely give >14g / day • Need to ensure maximal metabolic effect of protein – 200kcals / gN • I.e. excess nitrogen = extra calories

Vitamins and Minerals • Water soluble • Fat Soluble • Trace Elements

Parenteral Nutrition Regimen

Requirements • Energy = 8.1x45+656 =1020 + (153kcals)15% activity + (153kcals) 15 % stress + 500kcals = 1826kcals • Nitrogen = 0.2g/kg = 9gN • Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L) • Na 295mmol (1mmol / kg, GI losses 250mmol/L) • K 45mmol (1mmol / kg) • PO 22.5mmol (0.5-0.7mmol/kg) • Mg 4.5mmol (0.1-0.2mmol/kg) • Ca 4.5mmol (0.1-0.2mmol/kg)

Monitoring

BAPEN British Association Enteral & Parenteral Nutrition

Parenteral Nutrition