Intestinal Failure Unit 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

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 %

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

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 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

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

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 teams e.g. catheter sepsis rates % Before %After Freeman 21 1.3 Sanders 29 4.7 Ryan 33 3 Nehme 25 Keohane 4 Jacobs 24 Faubion 3.5 Mean 27 2.5

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

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

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

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 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 7.65 Addiphos 10 7.5 15% KCl 20 40 50% Mg SO4 2 4 Ca Cl 3.6 30% NaCl 50 100 Vitlipid + Solovito 10 each vial Additrace Requirements 2330 1900 9.5 108 48 19 3.8 Total 2116 1800 107.5 47.5 4.3 17.6

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

BAPEN British Association Enteral & Parenteral Nutrition