Parenteral Nutrition Policy - NHS Gateshead · Parenteral Nutrition Policy v3 ... check that the alterations to the electrolytes are clinically appropriate and within the limits

Parenteral Nutrition Policy v3

Policy No: RM60

Version: 3.0

Name of Policy: Parenteral Nutrition Policy

Effective From: 18/08/2015

Date Ratified 12/08/2015

Ratified SafeCare Council

Review Date 01/08/2017

Sponsor Director of Nursing, Midwifery and Quality

Expiry Date 11/08/2018

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues

Parenteral Nutrition Policy v3 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify page

no.)

1.0

February

2009

Nutrition and

Dietetics

SafeCare

Council

Feb 2009 General update in line

with national guidelines

Page 7, 9, 14, 18, 20, 22

2.0

December

2011

N&DS SafeCare

Council

Dec 2011 General update page 4

3.0

18/08/2015 N&DS SafeCare

Council

12/08/2015 General update page 4,

5, 7,8, 9, 17, 18


Contents

Section Page

1 Introduction ................................................................................................................................. 4

2 Policy Scope .................................................................................................................................. 4

3 Aim of policy ................................................................................................................................. 4

4 Roles and responsibilities ............................................................................................................. 4

5 Definitions .................................................................................................................................... 5

6 Managing parenteral nutrition ..................................................................................................... 5

6.1 Indications of parenteral nutrition ................................................................................. 5

6.2 Patient Assessment ........................................................................................................ 5

6.3 Parenteral access routes ................................................................................................. 6

6.4 Types of catheters used for parenteral nutrition ............................................................ 7

6.5 Composition of parenteral nutrition .............................................................................. 7

6.6 Prescribing parenteral nutrition ..................................................................................... 8

6.7 Storing parenteral nutrition ........................................................................................... 8

6.8 Administrating parenteral nutrition ............................................................................... 8

6.9 Discontinuing parenteral nutrition ................................................................................. 9

6.10 Monitoring for patient on parenteral nutrition ............................................................. 9

6.11 Laboratory monitoring for patient on parenteral nutrition ............................................ 9

6.12 Ethical Considerations ..................................................................................................... 10

7 Training ......................................................................................................................................... 10

8 Equality and Diversity .................................................................................................................. 10

9 Monitoring compliance with the policy ....................................................................................... 10

10 Consultation and review ............................................................................................................... 10

11 Implementation of the policy ....................................................................................................... 10

12 References ................................................................................................................................... 11

13 Associated documentation ........................................................................................................... 11

Appendices

Appendix 1 Nutrition Risk Score ........................................................................................................ 12

Appendix 2 Nutrition Support team referral document .................................................................... 13

Appendix 3 Parenteral nutrition proforma including prescription .................................................... 14

Appendix 4 Parenteral Nutrition Regimen form ............................................................................... 17

Appendix 5 Emergency out of hours guidelines ................................................................................ 18

Appendix 6 Monitoring patients on PN .............................................................................................. 22

Appendix 7 Biochemical monitoring of patients on PN. .................................................................... 24


Parenteral Nutrition Policy

1 Introduction

Parenteral nutrition (PN) is the administration of nutrients through the intravenous route. It is a

specialised form of nutrition support, with associated complications and should be carefully

considered and planned on an individual basis. This PN policy was reviewed in line with national

guidance ‘Nutrition Support in adults NICE clinical guideline No 32 (2006)’, and National confidential

enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients

receiving parenteral nutrition. June 2010’.

2 Policy scope

This is a trust wide policy aimed at all health care professionals involved in the care of patients

receiving parenteral nutrition, to ensure best practice is applied in accordance with national

guidelines.

3 Aim of Policy

The aim of the PN policy is to ensure that PN is used in appropriate circumstances, that it is

administered safely and with appropriate monitoring to prevent potential complications.

4 Roles and Responsibilities

Nursing Staff

Ward nurses have a responsibility to assess all patients’ nutritional status using the Trust’s Nutrition

Risk Score (NRS) tool on admission, and then repeated weekly and if a patient’s clinical condition

changes (Appendix 1). Nursing staff must inform the Nutrition and Dietetics department if a patient

is due to begin PN. Nursing staff are responsible for administering PN with aseptic technique and

monitoring the patients fluid balance, GI function and vital signs for potential line sepsis.

Medical Staff

Medical staff have a responsibility to consider patients for PN if they are unable to maintain or

improve their nutritional status via the oral or enteral route. The decision to commence PN should

be discussed with the Consultant with overall clinical care for the patient. Nasogastric and

nasojejunal feeding must be considered prior to requesting PN. Medical staff are responsible for

organising insertion of appropriate venous access, ideally a central line. They are also responsible

for requesting and monitoring daily biochemistry and considering whether the patient is at risk of

re-feeding syndrome. If there is a significant risk of re-feeding, Pabrinex should be prescribed in

addition to PN. The medical staff are responsible for assessing the patient’s fluid balance and

prescribing appropriate fluids. The volume of PN prescribed should always be taken into account to

avoid inappropriate fluid overload.

Dietitian

Patients who are identified as requiring PN should be referred to the ward dietitian immediately.

The dietitian has a responsibility to assess the patient’s nutritional requirements and to ensure that

the most appropriate PN solution and infusion rate is chosen. They should highlight if the patient is

at risk of re-feeding syndrome, which requires close monitoring of electrolytes and the prescription

of additional vitamins. They should review the patient on a daily basis until the patient is

established on PN to allow alterations to the prescription in terms of electrolytes, macronutrients

and volume delivered.


Pharmacy

The aseptic services pharmacist should liaise with the dietitian on a daily basis (Monday to Friday)

to check for updates on the patient, discuss biochemistry and the PN prescription. They should

check that the alterations to the electrolytes are clinically appropriate and within the limits of

stability for the regimen and the route of administration.

Nutrition Support Team

This is a multidisciplinary team led by a Gastroenterologist. The team will accept referrals from

medical and surgical teams to advise on the management of patients with complicated nutritional

issues. The team is happy to review patients being considered for PN. The team is also responsible

for providing support and education on the methods of PN and also to ensure that policies and

guidelines are up to date in accordance with national guidelines to ensure best practice.

Acute Response Team

ART provide daily reviews of all central lines, to ensure that best practice is maintained. ART

provide support and advice regarding all aspects of central line management and PN

administration.

Infection Control Team

The Infection Control Team provides support and advice regarding good aseptic technique for all

staff administering PN. They also have a responsibility to monitor and investigate episodes of line

sepsis.

5 Definitions

The term ‘total parenteral nutrition’ (TPN) is used when patients are receiving their full

requirements through the venous route without any enteral nutrition.

6. Parenteral Nutrition Policy v3

6.1 Indications for Usage of parenteral nutrition

PN should only be considered when it is not possible to meet the patients full nutritional

requirements using oral or enteral feeding routes (nasogastric or nasojejunal feeding), i.e. if

the gut works, use it.

Examples of appropriate conditions where PN may be used:

• Extended non-absorption of enteral nutrition (This must include a trial of

Nasojejunal feeding)

• Post operative ileus

• Intractable vomiting

• Major GI surgery where enteral nutrition is contraindicated, e.g. perforation

• Short bowel syndrome

• Extensive Crohn’s disease where nutrient absorption is severely impaired

• High output fistula where position and volume prevent enteral feeding

• Motility disorders such as Sclerodema and chronic intestinal obstruction syndromes

This list is not exhaustive and the risks/benefits of providing PN and the expected duration

of PN should be considered on an individual basis.

6.2 Patient Assessment

A multidisciplinary team can improve patient care while reducing the complications of PN.


When concerns are expressed about a patient’s nutritional status contact the dietitian who

covers your ward via bleep or on ext 2074 (Nutrition and Dietetic Department) or refer to

the Nutrition Support Team (see Appendix 2).

The following assessments should also be carried out within the team:

Initial

Assessment

Rationale

Responsibility

Weight and

height

Measured on admission and weekly

thereafter. To assess nutritional status

Nursing staff and dietitian

Hydration

status

To ensure adequate hydration. Oedema

and ascites should be noted.

Nursing and medical staff

Fluid balance Input and output should be clearly

documented. Ensure adequate

hydration and avoid over hydration. NB

volume of PN should be taken into

account when calculating fluid input.


Temperature To ensure no underlying infections or

complications.


Biochemistry Urea and electrolytes, glucose, liver

function tests, phosphate, magnesium,

calcium, haemoglobin,

coagulation and trace elements

Medical staff, dietitian

Gut function Is the gut functioning?

Are there any gastrointestinal

problems?

Tolerance to enteral nutrition?

Medical staff

Nutritional

assessment

Any changes in weight?

Any changes in appetite?

History of oral intake?

Any intake at present?

Nursing and medical staff,

dietitian

Venous access Ensure good venous access with no

complications

Medical staff

Medications Drug-nutrient interactions.

Establish whether medications are

affecting GI function/clinical condition.

Medical staff, pharmacist,

dietitian

Adapted from NICE (2006) Nutrition support in adults

6.3 Parenteral Access Routes

Peripheral access

Peripheral PN may be considered via a large peripheral vein but it is not routinely

recommended. Peripheral PN carries a high risk of thrombophlebitis and venflons need to

be changed on a daily basis. With care and attention the peripheral route can be used for

short term PN prior to central access being obtained. It should be ensured that the

osmolarity of the solution is compatible with the peripheral route. When using peripheral

access a small (20G) cannula should be used only for PN. Cyclical delivery of parenteral


nutrition should be considered with planned routine cannula change, eg, deliver PN over 18

hrs, remove the cannula post infusion and resite a new cannula in the other arm.

Central access

Central access is normally used for those patients requiring PN. The decision regarding

appropriate line insertion should be taken by the referring team on discussion with the

Nutrition team. Only healthcare professionals competent in catheter placement should

place catheters and should be aware of monitoring and managing them safely. Catheter

insertion should be planned and performed using aseptic precautions. (See Central Venous

Line Policy.)

The referring team need to discuss tunnelled line insertion with the Interventional

radiology department or Vascular Surgery. If there is a significant delay in inserting a

tunnelled line or the duration of PN is such that this is deemed unnecessary the referring

team should refer the patient to Anaesthetics for line insertion. The referrer needs to

ensure that the Anaesthetist inserting the line is aware it will be used for PN so that an

appropriate line is inserted (single rather than a quadruple lumen).

An X-ray will confirm the correct placement of the catheter tip. A single lumen dedicated

catheter is recommended for PN to minimise the risk of line sepsis. The tip should be

positioned in the lower one third of the SVC or at the junction of the SVC and right atrium.

Correct positioning reduces the risk of thrombotic and mechanical complications. The date

and site of insertion and tip position should be documented in the patient’s notes.

Other Access Routes

PICC lines are not commonly used in Gateshead. These can also be used to deliver

hyperosmolar solutions as the catheter tip lies in the superior vena cava.

6.4 Types of Central Catheters Used

Multi-lumen

These are used in patients who require other additional infusions, however can be

associated with an increased risk of infection due to increased handling and greater number

of ports available for bacterial colonisation. Strict aseptic techniques should be carried out

when changing infusion or handling the multiple ports. If a multi lumen line is used for PN a

line should be dedicated to PN only.

Single lumen

Traditionally preferred lumen to be used for administration of PN as there is reduced risk of

infection.

Double lumen

May be appropriate if the patient is likely to require an additional infusion alongside the PN

(e.g. antibiotics, or fluid).

Tunnelled Central Line

Tunnelled lines such as Groshong or Hickman Lines are sited for long term PN access, ie

more than 7 days.

6.5 Composition of parenteral nutrition

An all-in-one parenteral bag is used in Gateshead Health NHS Foundation Trust which

contains a combination of amino acid solution, fat emulsion, glucose solution, water and fat

soluble vitamins, trace elements, minerals and electrolytes to desired volume. Additional


ingredients may be added if required. Additions must be added aseptically in the hospital

pharmacy only.

6.6 Prescribing parenteral nutrition

Nutritional requirements must be assessed by the ward’s dietitian. Following a dietetic

assessment a bag of PN will be recommended based on the patient’s nutritional

requirements. A PN proforma, which includes a prescription, must be completed to ensure

PN is given safely and appropriately (see Appendix 3). The dietitian will complete a PN

regimen form for the ward staff to follow (see appendix 4).

The prescription must be completed and signed by the doctor. It should be delivered to the

pharmacy department before 2pm on the day it is required. When a patient is stable a PN a

prescription may be written for a week at a time. It also must be prescribed on the fluid

balance chart on a daily basis.

PN is not an emergency intervention and is therefore rarely indicated outside normal

working hours. However if PN is required outside pharmacy hours then an emergency

Triomel 6 g bag can be used (see Appendix 5 for emergency out of hours regimen). These

are stored in the pharmacy emergency drug cupboard and may be accessed via the site

manager. The on-call pharmacist is available for advice via switchboard. Each PN bag will

be prescribed according to their nutritional requirements.

Modifications of parenteral nutrition bags

The electrolyte content (sodium etc) of the PN bag can be altered within certain limits. The

ward dietitian will advise and liaise with pharmacy regarding changes to the PN electrolyte

content. Manipulation of the PN in Pharmacy is time consuming and carries a very small risk

of introducing infection, therefore minor changes should be avoided.

6.7 Storage of parenteral nutrition

PN should be stored in a drug refrigerator (2-8oC) and has a limited storage life. Occasional

minor separation of the emulsion may be visible. Always agitate the bag gently before use.

Protect PN from strong light using the grey bag covers supplied by pharmacy. Once

removed from the refrigerator the bag should be warmed to room temperature before use.

Warming should be achieved gradually by putting the bag on a work surface in the

treatment room at ambient temperature for a period of 1-2 hours out of direct sunlight.

Artificial heat, for example, placing the bag on a radiator or using a light source should

never be used as it poses a significant risk to bag stability. Any bag that has been stored

below 2oC must not be used.

6.8 Administering parenteral nutrition

The PN bag will arrive on the ward late afternoon or early evening. If the patient is at risk

of Refeeding Syndrome, PN should be introduced progressively as advised by the dietitian,

usually starting at no more than 50% of estimated requirements for the first 24-48 hours.

(See Refeeding Syndrome Guidelines). All PN mixtures will be administered through

standard IV giving set using a volumetric pump with occlusion and air line alarms.

Continuous administration of PN should be offered as the preferred method of infusion in

severely ill patients. Gradual change from continuous to cyclical delivery should be

considered in patients requiring PN for more than 2 weeks, it is important to adhere to

recommendations from the CCOT reduce central line associated sepsis.


Cyclical delivery of PN may be considered when using short term peripheral venous

cannulae with planned routine catheter changes. The rate of administration is usually

identified on the label of the PN bag; however alterations to the rate can be made following

discussion with the dietitian or aseptic pharmacist. PN should only be administered over a

maximum 24 hour period and bags should be changed every 24 hours.

6.9 Discontinuing parenteral nutrition

PN can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional

status is stable. There is usually a period of overlap while enteral feeding is being

established and the rate of PN can be reduced. The dietitian will provide a step by step

weaning plan for the PN and introduction of enteral or oral nutrition which will be reviewed

daily. Stopping PN abruptly may put the patient at risk of rebound hypoglycaemia and

should be avoided.

6.10 Monitoring of parenteral nutrition (NICE, 2006)

It is the responsibility of the ward doctors to monitor the patient appropriately for possible

complications of PN. These are predominately metabolic and line related complications.

The functioning of the gut and the possibility of introducing enteral feeding should also be

monitored (see appendix 6).

6.11 Laboratory Monitoring (NICE, 2006)

Please refer to Appendix 7. The Nutrition team, ward dietitian and pharmacist can advise

regarding vitamin supplementation and the addition of electrolytes to PN. Manganese,

selenium and bone densitometry need to be measured in patients on long term home PN,

however home PN is managed by the Nutrition team at Freeman Hospital

Biochemical Abnormalities in patients on PN

Both acute and long-term liver function abnormalities are associated with the provision of

parenteral nutrition. It can be difficult to establish whether the liver problem is caused by

the administration of parenteral nutrition in the acute setting, or if it is due to other clinical

problems eg:

• Sepsis

• Biliary obstruction

• Unrecognised previous chronic liver disease

• New-onset liver disease (eg liver abscess, adverse drug reaction, hepatitis)

• Portal bacterial translocation

A modest increase in ALT sometimes seen within the first few days to weeks is usually a

consequence of steatosis and is commonly seen following excessive glucose provision in a

malnourished patient. There is usually very little or no change in the liver’s synthetic

function and the increase in ALT is generally not clinically significant. Following prolonged

administration (several weeks to months) of parenteral nutrition a cholestatic picture may

develop. The commonest reason for the development of intra-hepatic cholestasis is the

overprovision on lipid and/or glucose. Patients at risk of developing intra-hepatic

cholestasis may benefit from a reduction in lipid and glucose load (contact ward dietitian

for advice). Cholestatic problems are also commonly encountered in patients with very

short bowel syndrome or high stomal losses. Bacterial translocation across the damaged

gut wall may also result in liver damage and a course of appropriate antibiotics may be

required.


6.12 Ethical Considerations

Parenteral nutrition is an invasive procedure, and therefore members of staff are expected

to have assessed the patient’s capacity to consent, and taken into consideration any

advanced decision to refuse treatment, or best interest assessment. Further information is

available in OP 57 Deprivation of Liberty Safeguards and OP25 Advanced Decisions to

Refuse Treatment.

7 Training

The trust’s nutrition team can provide training to all health care professionals involved in parenteral

nutrition. The team is actively involved in the F1 and F2 teaching program and parenteral nutrition

forms part of their training. Dietitians working within the hospital receive training by the critical

care dietitian.

8 Equality and Diversity

Patients who cannot be fed sufficiently via enteral nutrition have a fundamental right to

consideration of parenteral nutrition, because this supports the right to life. This policy therefore

promotes a human rights based approach to healthcare. However staff should refer to other

policies for information about issues of consent, capacity, advance care plans, refusing or

withdrawing treatment. This policy has been appropriately equality impact assessed.

9 Monitoring compliance with the policy

Standard/process/issue Assurance

Method By Committee Frequency

NICE G32 Adult nutrition

support

Regional PN

audits

Nutrition

and

Dietetics

Nutrition

Steering

committee

Annually

PN policy compliance

exceptions

All exceptions to

be Datix

By staff

who

identify

exception

Correlated by

Risk

Management

Department

As required

All patients on TPN in the

Queen Elizabeth

Discussion Nutrition

tean MDT

Nutrition

Steering

Committee

quarterly

The effectiveness of the policy will be monitored by the nutrition & dietetics service in line with

national guidance. PN audits will be undertaken on a yearly basis as part of Nutrition Support Team

audit program. Any incident involving parenteral nutrition should be recorded via Datix reporting.

10 Consultation and review

The policy will be reviewed every 2 years. Consultation will include Nutrition and Dietetics,

Pharmacy, the trust’s Nutrition, Critical care outreach and Infection control teams.

11 Implementation of the policy

The policy will be shared with all staff involved in the direct care of patients receiving parenteral

nutrition, all ward managers and modern matrons, and all staff receiving training on parenteral

nutrition.


12 References

1 Nutrition Support in adults NICE clinical guideline No 32 (2006).

2 Bozzetti F, Braga, Gianotti C, Mariani L, Cozzaglio L et al. Perioperative PN in

malnourished, gastrointestinal cancer patients: a randomized, clinical trial. JPEN

(2000),24(1):7-14.

3 The Veterans Affairs Total PN Cooperative Study Group. Perioperative total PN in surgical

patients. New England Journal of Medicing (1991), 325(8):525-32.

4 Infection control: prevention of healthcare-associated infection in primary and community

care. NICE Clinical Guideline. No 2 (2003).

5 Mallet, J Bailey C. Manual of clinical nursing procedures. The Royal Marsden Trust 1996.

6 National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into

the care of hospital patients receiving parenteral nutrition. June 2010.

7 Prescribing Adult Intravenous Nutrition (eds. Austin and Stroud). 2007. Pharmaceutical

Press

13 Associated documentation

• Care standards: 9C and 9D

• Nutrition policy RM61

• Central Venous Line policy OP41

• Refeeding Syndrome guidelines

• Nutrition Risk Score

• Parenteral Nutrition proforma

• Parenteral Nutrition regimen information


Appendix 1


Appendix 2

Gateshead Health NHS Foundation Trust

Nutrition Support Team

REFERRAL FORM

Date of referral: …………………………………………………..

Patient’s name: …………………………………………………..

Hospital

No: ……………………………..

Address: ………………………………………………….. DOA: ……………………………..

…………………………………………………..

…………………………………………………..

Contact number: …………………………………………………..

Ward: …………………… Directorate: ……………………………… Consultant: …………………………..

DOB: …………………… Age: ……………………………...

Medical History: …………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Social History: ………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Reason for referral to NST: ……………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Medication: …………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Weight: ………………… NRS: ………………

Current nutritional support:

Y/N If Y: date started: ...............................

Naso-gastric feeding IV fluids

Sub cut fluids Other Please specify ………………………

Oral nutrition …………………………………………

Note: Please complete page two if referring for PEG

Referred by: …………………………………………

(Print) ……………………………………………

Signed: …………………………………………………..


Appendix 3

Parenteral Nutrition (PN) Proforma

Name: Ward:

DOB: Consultant:

Hospital number: NHS no.

Start Date:

Indication for PN:

Appropriate indications include: intestinal failure, extended non-absorption of enteral nutrition (including a

trial of nasojejunal (NJ) feeding), perforated or obstructed gut not expected to recover within 7 days.

Is nasogastric and nasojejunal feeding contraindicated or has it been unsuccessful? Please circle

Yes/No

PN treatment goal

Is there a risk of refeeding syndrome? Please Circle

Yes/No

Access: Central/peripheral (delete as appropriate)

Type: Single/multiple lumen (delete as appropriate)

Date of insertion:

Weight (kg):

Mid upper arm circumference (cm): (if not possible to obtain weight)

Doctor’s signature …………………...........……...…........... Name: ...................................

(print)

Date …….........…….. Bleep/Ext ………………….….......

Time ......................

Please refer to Nutrition and Dietetics intranet page for guidelines on the use of PN out of hours.

Please file behind Section 5 of the Health Record


Parenteral Nutrition Prescription

Name: Ward:

DOB: Consultant:

Hospital number: Weight (kg):

Date PN started: Prescription start date:

Tick required regimen - For further information contact pharmacy (ext. 2316)

Figures in brackets represent usual maximum electrolyte content per bag – these limits may be extended in

certain circumstances – contact pharmacy for advice.

� g

N

Volum

e

ml

Kcal

Total

non-protein

Na

mmol

K

mmol

Mg

mmol

Ca

mmol

PO4

Mmol

Adult 6

6

1515

1050

900

31.5

(225)

24

(225)

3.3

(8.4)

3

(5.3)

12.7

(22.5)

Starter/refeed

ing bag

Adult 10

1

0

2515

1750

1500

52.5

(375)

40

(375)

5.5

(14)

5

(8.7)

21.2

(37.5)

Low

requirements

Adult 14

1

4

2015

2270

1920

70

(300)

60

(300)

8

(11.2)

7

(7)

30

(30)

Increased

requirements

Adult 18

1

8

2015

2140

1680

70

(300)

60

(300)

8

(11.2)

7

(7)

30

(30)*

Increased N

requirements

Fat-free

14

1

4

2015

1540

1200

70

(300)

60

(300)

5

(30)

4.5

(15)

30

(30)

Fat free bag

Clinimix 14

Other

..............

*Note phosphate limit is only 16mmol if adding Addiphos®

to electrolyte-free N9 2000ml bag

Rate of administration:

Route (delete as

appropriate):

Central/Peripheral*

*Check that the regimen is appropriate for the route of administration - only Adult 6 and Adult 10 can be given

peripherally

Please ensure that the regimen is prescribed on the fluid balance chart on a daily basis.

Dietitian’s Name (print): Signature: Date:

Grade: Bleep: Time:

Doctor’s Name (print): Signature: Date:


Grade: Bleep: Time:

Date

Dietitian

Confirmed

By

(pharmacy

staff)

Pharmacist

Check

Given by: Checked by: Time

Commenced

Version 10 – Approved by David Sproates June 2015 Please check Trust Intranet for the

latest version of this document. Page 16 of 24


Appendix 4

NUTRITION AND DIETETIC SERVICE

Parenteral Nutrition Regimen

Name ........................................................................ Hospital ………………………

Date of Birth ....................................................................... Ward ………………………

Weight ........................................................................

Estimated daily requirements: Kcal ………………………

Nitrogen (g) ………………………

Fluid (ml) ………………………

Sodium (mmol) ………………………

Route of feeding: Peripheral/Central* Potassium (mmol) ………………………

Phosphate (mmol) ………………………

Parenteral Nutrition Bag: ……………………………………... Magnesium (mmol) ………………………

Calcium (mmol) . ................................

Day Rate

ml/hr

Time

(hr)

Rest

(hr)

Provides per 24 hours

Kcal Nitrogen

(g)

Fluid

(ml)

Na+

(mmol)

K+

(mmol)

Ca2+

(mmol)

Mg2+

(mmol)

PO2-

4

(mmol)

Continue as Day: ……………………………. of regimen.

Additional instructions: ...……………………………………………………………………...

……………………………………………………………………………………………………

• Daily bloods including U&E’s, magnesium, phosphate and calcium until stable.

• Check blood glucose 1-2 times daily (more often if needed)

• Check bag is suitable to be given via chosen route

• Change bag every 24 hours, discard any remaining solution

• Document volume administered on fluid balance chart

Dietitian (print name) ………………………… Date....../....../...... Time: ......................

Signature: ..................................................... Contact No: ................ Bleep: .....................


Appendix 5

Nutrition and Dietetic Service

Out of hours Parenteral Nutrition Guideline for Adults

This guideline is for use in adult patients only when there is no dietitian to advise on parenteral nutrition

(e.g. weekends, bank holidays). Parenteral nutrition is a highly specialised form of nutritional support and

has associated complications. In the majority of cases parenteral nutrition is not an emergency and its use

out of hours should be avoided.

Refer to Dietetics through the intranet: Quick launcher forms, as soon as possible for a formal assessment

Step 1 A doctor must complete and sign the PN proforma (attached page 4) to ensure PN is used

appropriately.

Step 2 Baseline blood tests: Electrolytes including potassium, magnesium and phosphate and correct any

levels if needed. This should be done daily while the patient is established on PN.

Step 3 Is the patient at high risk of refeeding syndrome? Please use following table as a guideline and

follow the trusts refeeding guidelines.

Percentage weight loss = previous weight (kg)– current weight (kg) x 100

previous weight (kg)

Any of the following Two or more of the following

Body Mass Index (BMI) less than 16kg/m²

BMI less than 18.5kg/m²

Unintentional weight loss over 15% within the

last 3-6 months

Unintentional weight loss over 10% within the

last 3-6 months

Very little or no nutrition for over 10 days

Very little or no nutrition for over 5 days

Low levels of potassium, magnesium or

phosphate prior to feeding

A history of alcohol abuse or some drugs

including: insulin, chemotherapy, antacids or

diuretics.

Low levels of potassium, magnesium or

phosphate prior to feeding

(Gateshead Health NHS Trust Refeeding Syndrome Guidelines)


Step 4 Contact pharmacy to request the PN. The only PN bag available out of hours is the Triomel

Peripheral N4 1500ml (referred to as Triomel 6gN) which is kept in the pharmacy emergency drug

cupboard.

Step 5 Mixing guidelines

• Remove the overpouch by tearing from the notch close to the ports along the upper edge, then

tear the long sides, pull off the overpouch and discard it along with the oxygen absorber.

• Place the bag on a flat surface. Tightly roll up the bag from the handle side until the vertical

seals are broken. Ensure that the liquids mix easily although the horizontal seal remains closed.

• Mix the contents of the three chambers by inverting the bag a minimum of three times until

all the components are thoroughly mixed.

Step 6 Follow the flow chart (page 5) to establish the correct rate of administration for the PN.

Do not increase the rate of PN until potassium, phosphate and magnesium levels are within normal range.

PN should only be administered over a maximum 24 hour period and bags should be changed every 24

hours, any remaining solution in the bag must be discarded.

Note if you are unsure whether the patient is at risk of refeeding syndrome, exercise caution by following

the steps for refeeding syndrome.


Out of hours Parenteral Nutrition Regimen

Access Route Peripheral* Central

At risk of refeeding syndrome? (use table as guideline)

At risk of refeeding syndrome? (use table as guideline)

Yes No Yes No

Day 1:

Commence Triomel 6gN 42 ml/hr x 18 hrs

Day 1:


Day 1:


Day 1:


Day 2:

Triomel 6gN 83 ml/hr x 18 hrs

Day 2: Triomel 6gN 62 ml/hr x 24 hrs

Key points

For peripheral access: rotate site of entry every 24 hours Do not increase rate until potassium, phosphate and magnesium are within normal range. Final regimen (i.e. day 2) provides 1050 kcal, 6g nitrogen, 1500ml, 31.5mmol Na, 24mmol K, 3.3mmol Mg, 3mmol Ca, 12.7mmol Phosphate

Parenteral Nutrition Policy v3

Step 3 Monitoring

Parameter Frequency Rationale

Urea and electrolytes,

magnesium, phosphate and

calcium

Daily until stable

Assessment of renal

function, depletion is

common

Glucose

Baseline

1 or 2 times a day (or

more if needed) until

stable

Good glycaemic control is

necessary

Fluid balance

Daily

Ensure PN taken into

account when prescribing

additional fluids

References

1 National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the

care of hospital patients receiving parenteral nutrition. June 2010.

2 Nutrition Support in adults NICE clinical guideline No 32 (2006).

3 Parenteral Nutrition Policy, Gateshead Health NHS Foundation Trust


Appendix 6

Montitoring patients on parenteral Nutrition

Parameter Frequency Rationale Responsibility

Nutritional

Nutrient intake from oral,

enteral or PN (including

any change in conditions

that are affecting food

intake).

Actual volume of PN

delivered.

Fluid balance charts

Daily, reducing to twice

weekly when stable.

Daily initially, reducing to

twice weekly when

stable.


twice weekly when

stable.

To ensure that

patient is receiving

nutrients to meet

requirements and

that current method of

feeding is still the most

appropriate.

To allow alteration of

intake as indicated.

To ensure patient is not

becoming over/ under

hydrated. To ensure

appropriate prescription

of additional fluids if

required. Always take

into account the volume

of PN when assessing a

patient’s fluid

requirements to avoid

fluid overload.

Dietitian and nursing

staff.

Dietitian, nursing

and medical staff.

Medical and nursing

staff.

Anthropometric

Weight.

Mid arm

circumference/mid arm

muscle circumference.

Daily if concerns

regarding fluid balance,

otherwise weekly

reducing to monthly. If

clinical condition

changes.

Weekly if patient cannot

be weighed, reduce to

monthly once stable.

To assess ongoing

nutritional status,

determine whether

nutritional goals are

being achieved and take

into account both body

fat and muscle.

Nursing staff and

dietitian.

Dietitian

Gastrointestinal symptoms

Nausea/vomiting.

Diarrhoea.

Constipation.


twice weekly.


twice weekly.


twice weekly.

To identify and rule out

any cause of vomiting, eg

obstruction.

To identify and rule out

any causes of diarrhoea.

To rule out other causes

of constipation.

Nursing and medical

staff, dietitian.

Nursing and medical

staff, dietitian.

Nursing and medical

staff, dietitian.


Abdominal distension.

As necessary

To identify cause.

Nursing and medical

staff.

Devices and equipment

Catheter entry site.

Dressings.

Daily.

Daily.

To identify signs of

infection.

To ensure they are secure

and hygienic

Nursing staff.

Nursing staff.

Clinical Condition

General condition

Temperature.

Blood pressure.

Drug therapy.

Daily.

Daily initially then as

needed.

Daily initially then as

needed.

Daily initially and then

monthly when stable.

To ensure the PN is

tolerated.

To identify any signs of

infection.

Monitor clinical condition

and fluid balance.

To prevent/reduce drug

nutrient interaction.

All team.

Nursing and medical

staff.

Nursing and medical

staff.

Nursing and medical

team


Appendix 7

Biochemical monitoring of patients on PN

Parameter Frequency Rationale Interpretation

Sodium, potassium,

urea, creatinine.

Baseline.

Daily until stable.

Then 1-2 times a week.

Assessment of renal

function, fluid status

and Na and K status.

Interpret with knowledge

of fluid balance and

medication.

Glucose. Baseline.

1 or 2 times a day (or more

if needed) until stable.

Then weekly.

Good glycaemic control

is necessary.

Glucose intolerance is

common – administer

insulin if necessary.

Magnesium,

phosphate.

Baseline.

Daily if risk of refeeding

syndrome.

Three times a week until

stable. Then weekly.

Depletion is common

and under recognised.

Low concentrations

indicate poor status.

Replacement vital to

avoid refeeding

syndrome.

Liver function tests

including

International

Normalised Ratio

(INR)/PT

Baseline. Twice weekly

until stable. Then weekly.

Abnormalities common

during PN.

Complex. May be due to

sepsis, other disease or

nutritional intake. May

need to consider reducing

fat content of PN.

Calcium, albumin. Baseline.

Then weekly.

Hypocalcaemia or

hypercalcaemia may

occur.

Correct measured

serum calcium

concentration for

albumin.

Hypocalcaemia may be

secondary to Mg

deficiency.

Low albumin reflects

disease not protein

status.

C-reactive protein Baseline.

Then 2 or 3 times a week

until stable.

Assists interpretation of

protein, trace elements

and vitamin results

To assess the presence

of an acute phase

reaction (APR). The

trends of the results are

important.

Zinc, copper Baseline. Deficiency common,

especially when

increased losses.

People most at risk

when anabolic APR

causes Zn and Cu

deficiency

Selenium Baseline for risk of

depletion. Further testing

dependent on baseline

Se deficiency likely if

severe illness and

sepsis, or long-term

Nutrition support.

APR causes Se depletion.

Long term status better

assessed by glutathione

peroxidise.

Full blood count and

MCV

Baseline. 1 or 2 times a

week until stable. Then

weekly

Anaemia due to iron

and folate deficiency is

common.

Effects of sepsis may be

important.

Iron, ferritin. Baseline. Then every 3-6

months.

Iron deficiency common

to long-term PN.

Iron status difficult to

assess if there is an acute

phase reaction.

Folate, B12. Baseline. Iron deficiency is

common

Serum folate/B12

sufficient, with full blood

count.

Documents

Parenteral Nutrition Policy - NHS Gateshead · Parenteral Nutrition Policy v3 ... check that the alterations to the electrolytes are clinically appropriate and within the limits