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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
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring
CONSEQUENCES OF MALNUTRITION
DIMINSHED QUALITY OF LIFE
INCREASED CLINICAL COMPLICATIONS
POORER OUTCOME
INCREASED COSTS
0
20
40
60
80
100
wt function
Effects of 6/12 semi-starvation
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 %
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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
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”
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
0
10
20
30
40
50
60
70
%
A B C SGA
Infection rate and SGA
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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
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
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutritionNutrition assessmentNutrition assessmentNutrition teamsNutrition teamsIndicationsIndicationsAccessAccessPrescribingPrescribingMonitoringMonitoring
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
Intestinal Failure
“The reduction in the functioning gut mass below the minimal amount necessary for adequate digestion and absorption”
(Fleming and Remington 1981)
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
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
Enteral ? preferableEnteral ? preferable
SimplerSimpler
Less complicationsLess complications
CheaperCheaper
EquieffectiveEquieffective
Parenteral nutritionParenteral nutrition
Importance of malnutritionImportance of malnutrition
Nutrition assessmentNutrition assessment
Nutrition teamsNutrition teams
IndicationsIndications
AccessAccess
PrescribingPrescribing
MonitoringMonitoring
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
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
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)
FluidFluid
30-35mls/kg body weight (adjust for age)30-35mls/kg body weight (adjust for age)
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
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
Vitamins and MineralsVitamins and Minerals
Water soluble Water soluble
Fat Soluble Fat Soluble
Trace Elements Trace Elements
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
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)
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
BAPENBAPEN
BritishBritish
AssociationAssociation
Enteral Enteral
&&
Parenteral Parenteral
NutritionNutrition
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