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Parenteral Nutrition

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Parenteral Nutrition Made simple . in 15 minutes Jon Shaffer Intestinal Failure Unit Hope Hospital Parenteral nutrition Importance of malnutrition Nutrition ... – PowerPoint PPT presentation

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Title: Parenteral Nutrition


1
Parenteral Nutrition
  • Made simple.
  • in 15 minutes
  • Jon Shaffer
  • Intestinal Failure Unit
  • Hope Hospital

2
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

3
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

4
CONSEQUENCES OF MALNUTRITION DIMINSHED
QUALITY OF LIFE INCREASED CLINICAL
COMPLICATIONS POORER OUTCOME INCREASED COSTS
5
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6
Malnutrition on admission Sweden
  • 382 pts
  • Infection
  • Surgery
  • Internal medicine
  • Oncology
  • Well nourished
    73
  • Moderately malnourished 20
  • Severely malnourished 7

7
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

8
Nutritional assessment
  • Problem
  • No blood urea for malnutrition
  • Risk scores v malnutrition
  • Multiple examples
  • Lack of a Gold Standard
  • Validation

9
Nutritional screening
  • ALBUMIN
  • Long half life
  • Overly sensitive- liver/renal disease
  • Reduction redistribution
  • Slow to react with recovery
  • negative acute phase protein

10
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

11
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12
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

13
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

14
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
15
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

16
  • Appropriateness varies
  • Few ABSOLUTE indications
  • 1. Intestinal Failure
  • 2. If the gut works use it
  • 3. Enteral preferable

17
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18
If the gut works1
  • Technology -- 1970s1990
  • Parenteral gt Enteral
  • Better catheters/ better feeds/better research
  • Industry/ Surgery driven
  • Most - Surgical/Intensive care/Cancer

19
If the gut works2
  • 1990s
  • Enteral tubes especially PEGs
  • Medical gt Surgical
  • Erosion of traditional markets e.g. Pancreatitis,
    ICU

20
Enteral ? preferable
  • Simpler
  • Less complications
  • Cheaper
  • Equieffective

21
Parenteral nutrition
  • Importance of malnutrition
  • Nutrition assessment
  • Nutrition teams
  • Indications
  • Access
  • Prescribing
  • Monitoring

22
IV ACCESS
  • Peripheral - short term
  • Midline - short/medium
  • PICC ( Peripherally inserted central line )
    -medium
  • Central medium/long term
  • Central tunnelled ultra long term HPN

23
Prescribing
  • Standard bags
  • A la carte
  • All in one bags
  • Re-feeding syndrome Po4, K

24
Design of Regimen
  • Osmolality
  • peripheral lt 900 mosmol/L, (1800kcals)
  • PICC lt 1200 mosmol/L (2000kcals)
  • Central lt 1700 mosmol/L (gt 2000kcals)

25
Fluid
  • 30-35mls/kg body weight (adjust for age)

26
Energy
  • Normal to provide a ratio of
  • Glucose fat 5050 or 6040
  • Overfeeding can result in lipogenesis, fatty
    infiltration of the liver

27
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

28
Vitamins and Minerals
  • Water soluble
  • Fat Soluble
  • Trace Elements

29
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
30
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)

31
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
32
BAPEN
  • British
  • Association
  • Enteral
  • Parenteral
  • Nutrition
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