PARENTERAL NUTRITION POCKETBOOK
PARENTERAL NUTRITIONPOCKETBOOK:FOR ADULTS
AGENCY FOR CLINICAL INNOVATIONTower A, Level 15, Zenith Centre821-843 Pacific HighwayChatswood NSW 2067PO Box 699Chatswood NSW 2057T 61 2 8644 2200 F 61 2 8644 2151E info@aci.health.nsw.gov.au www.health.nsw.gov.au/gmct/Produced by: ACI Gastroenterology NetworkACI Nutrition NetworkSHPN: ACI 100520ISBN: 978 1 74187 606 2Further copies of this publication can be obtained from the Agency forClinical Innovation website at: www.health.nsw.gov.au/gmctDisclaimer: Content within this publication was accurate at the time of publication.This work is copyright. It may be reproduced in whole or part for study or trainingpurposes subject to the inclusion of an acknowledgment of the source. It may not bereproduced for commercial usage or sale. Reproduction for purposes other than thoseindicated above, requires written permission from the Agency for Clinical Innovation. Agency for Clinical Innovation 2010Published: May 2011.
FOREWORDThe Agency for Clinical Innovation (ACI), formerly the GreaterMetropolitan Clinical Taskforce (GMCT), was established by the NSWgovernment as a board-governed statutory health corporation in January2010, in direct response to the Special Commission of Inquiry into AcuteCare Services in NSW Public hospitals. The ACI drives innovation across thehealthcare system by using the expertise of its clinical networks to design,cost and recommend innovative, evidence-based improvements to publichealth care services in NSW, for implementation on a state-wide basis.Parenteral nutrition (PN) is a life sustaining therapy for patients whocannot eat or tolerate enteral nutrition. However, there are significantinfection risks and complications associated with intravenous feeding.The ACI was approached by clinicians providing PN to develop a resourceto support colleagues working in facilities where PN is less frequently usedand to identify best care practices for PN for NSW public health facilities.The project, funded by the GMCT (now ACI), commenced in early 2008and has been a collaborative effort by the ACI’s Gastroenterology andNutrition Networks. The PN working group involved clinicians from acrossNSW, including medical practitioners from a number of specialties, nurses,dietitians, pharmacists and consumers.On behalf of the ACI, I would like to thank the Chair of the workinggroup, Professor Ross Smith and all the members for their dedicationand expertise in developing this PN Pocketbook.Hunter WattChief Executive,Agency for Clinical InnovationACI - Parenteral Nutrition Pocketbook: for Adults1
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TABLE OF CONTENTSForeword. 1Preface. 51. Principles of Nutrition Support. 71.11.21.31.41.5Malnutrition & Principles of Nutrition Support.7Malnutrition Screening.7Indications for Nutrition Support.8Indications for Parenteral Nutrition.9When is it not appropriate to use Parenteral Nutrition?.112.Nutrition Assessment of the Adult PN Patient.133. Venous Access for PN in the Adult Patient.193.1 Central Venous Access.203.2 Peripheral Venous Access.223.3 Care and Management of Vascular Access.234.PN Requirements for the Adult Patient. 274.14.24.34.44.5Patients at Risk of Refeeding Syndrome.27Patients Not at Risk of Refeeding.29Types of PN Solutions Available for Adult Ward Patients.29PN Macronutrient Requirements for the Adult Ward Patient. 30PN Micronutrient Requirements for the Adult Ward Patient.375.PN for the Critically Ill Adult Patient. 496.PN Solution Stability/Compatibility Issues.517.Monitoring Adult Patients on PN.558.Complications. 599.Transitional Feeding.6110. Ceasing PN. 63Glossary. 65Contributors. 66ACI - Parenteral Nutrition Pocketbook: for Adults3
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PREFACEParenteral nutrition (PN) refers to the intravenous infusion of specialisednutrition solution. This method of feeding may be required when thegastrointestinal tract is not functional or leaking, cannot be accessed, orthe patient cannot be adequately nourished by oral or enteral means.In NSW, there are major variations in the way PN is administered in publichospitals. Furthermore, hospitals in outer metropolitan and rural regionsof NSW may have limited support in the area of PN and its administration.Commercially premixed solutions can provide adequate nutrition over shortperiods but for more complex patients, it is important to have a flexiblesystem to personalise parenteral nutrition available in larger hospitals.This pocketbook aims to provide principles of PN therapy for adult patientsto ensure consistency throughout NSW wherever patients are managed.Children have very specific nutritional requirements which are individualisedto their age, clinical condition and disease. Therefore, PN in paediatrics is notaddressed as part of this book.PN is complex and expensive and should therefore be used with good clinicalguidance. The pocketbook provides guidance for clinicians on the indicationsfor PN, nutrition assessment of the PN patient, determining PN requirements,initiating PN, monitoring complications and ceasing PN.PN is best managed by a multidisciplinary team that should be guided by aninterested clinician (gastroenterologist, GI surgeon and intensivist), but thatimportantly involves nutrition nurses, dietitians and pharmacists, togetherwith biochemistry and microbiology laboratory support if necessary.In smaller hospitals these roles can be shared.I would like to thank all those who volunteered to undertake the tasksof reviewing a large volume of the literature to complete what hasbeen a successful project.Professor Ross SmithChairman of ACI TPN working groupProfessor of Surgery, Northern Clinical School University of SydneyACI - Parenteral Nutrition Pocketbook: for Adults5
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1. PRINCIPLES OF NUTRITION SUPPORT1.1 Malnutrition & Principles of Nutrition SupportMalnutrition is common in hospitalised patients. Prevalence rates ofmalnutrition reported in Australian hospitals are around 30%1,2.Nutritional status can decline significantly over the course of a patient’sadmission, due to a combination of reduced nutrition intake andincreased requirements secondary to the impact of the disease process(altered metabolic requirements, increased nutrient losses and reducedconsumption, digestion and absorption).Timely and appropriate nutrition support aims to prevent malnutrition inthose at risk and treat those who are malnourished.Malnutrition is associated with increased morbidity and mortality;increased length of hospital stay and hospital costs; and increased riskof infections, delayed wound healing, impaired respiratory function,electrolyte disturbances and post-operative complications.1.2 Malnutrition ScreeningMalnutrition screening enables the early identification of patients whomay benefit from nutrition support. Leading nutrition groups worldwiderecommend routine nutrition screening of hospitalised patients3,4,5.There are several validated nutrition screening tools available, the mostwell-known being the MUST and MST6,7,10. Nutrition screening should beundertaken on admission and repeated on a regular basis for long-staypatients. Patients should have their nutrition history and weight recordedand those at risk should be flagged and referred for further nutritionassessment and intervention. An automated screening tool has beendeveloped and validated in upper gastrointestinal (GI) surgical patients8.ACI - Parenteral Nutrition Pocketbook: for Adults7
If screening indicates the patient is at increased risk of malnutrition, athorough assessment should be done (Refer to Section 2).1.3 Indications for Nutrition SupportNutrition support (oral, enteral or parenteral) should be considered for allpatients who are malnourished or are at risk of malnutrition.To diagnose malnutrition, use the ICD-10-AM Sixth Edition criteria11.E43 Unspecified severe protein energy malnutrition I n adults, BMI 18.5 kg/m2 or unintentional loss of weight ( 10%) withevidence of suboptimal intake resulting in severe loss of subcutaneous fatand/or severe muscle wasting.E44 Protein-energy malnutrition of moderate and mild degree I n adults, BMI 18.5 kg/m2 or unintentional loss of weight (5–9%) withevidence of suboptimal intake resulting in moderate loss of subcutaneous fatand /or moderate muscle wasting. I n adults, BMI 18.5 kg/m2 or unintentional loss of weight (5–9%) withevidence of suboptimal intake resulting in mild loss of subcutaneous fat and/or mild muscle wastingTo identify those at risk of malnutrition9: H ave eaten little or nothing for more than five days and/or are likely to eatlittle or nothing for the next five days or longer H ave increased nutritional needs from causes such as catabolism, highnutrient losses or poor absorptive capacityThe above indications should be considered in light of results of a fullnutrition assessment.8 ACI - Parenteral Nutrition Pocketbook: for Adults
1.4 Indications for Parenteral NutritionParenteral Nutrition (PN) can sustain life when patients are unable to takesufficient nourishment via the gastrointestinal tract for prolonged periods.However, PN is associated with significant risks and complications.Alternative methods of nourishing patients should be considered in everycase. A nutrition support algorithm is presented in Figure 1.Where possible, oral or enteral nutrition are preferred options.PN is necessary when the patient cannot be sustained with eitherincreased intake of oral supplements or enteral nutrition alone. The useof PN should be considered when normal oral intake or enteral nutritioncannot be started after a period of five days.Short-term PN is appropriate in malnourished and/or severely catabolicpatients unable to be adequately nourished enterally. In this patientgroup, the risks of complications of nutrition depletion are greater andPN should be started earlier.As PN is an invasive therapy, it must be used in a manner which limitsthe risk of sepsis, catheter insertion complications and metaboliccomplications.PN is also a relatively expensive treatment which can only be justified forpatients with clearly defined indications.The basic indication for using PN is a requirement for nutrition when thegastrointestinal tract is either: not functional or leaking (e.g. obstruction, ileus, fistulae, dysmotility) cannot be accessed (e.g. intractable vomiting with inability to establishjejunal access) the patient cannot be adequately nourished by oral or enteral means (e.g.in malabsorption states such as short bowel syndrome, radiation enteritis orinability to establish full enteral feeding) 9.ACI - Parenteral Nutrition Pocketbook: for Adults9
Figure 1: Nutrition Support Algorithm12Is the gut functional and accessible?NOYESIs the patient malnourishedand/or at high nutritional risk(e.g. critically ill)?YESCan full nutrition needs be met with oral orenteral nutrition within the next 5 days?NOYESNOEarly commencementof parenteral nutrition(within first 24-48hours) may bebeneficial irrespectiveof likely duration of use.Central PN is preferred.Is the likely duration of parenteralnutrition 5 days or longer?Parenteral nutrition maynot be appropriate inpatients whose prognosisis inconsistent withaggressive nutritionsupport strategies.Parenteral nutrition may be indicated. Note that providingeven a small amount of enteral or oral nutrition, whereverpossible, may be beneficial for patients who are receivingparenteral nutrition, by stimulating normal intestinalfunctioning (including motility, secretions, gut barrier againstbacteria and endotoxin, and immune function of the gut).YESNOOral or enteralnutrition is indicatedas soon as possible.Parenteral nutrition isnot recommendedConsider periperhal PN (if this is available in the healthcare facility) if likely duration of parenteral nutrition is lessthan 10-14 days or if central venous access is not available.Peripheral PN is not appropriate for long-term PN or forpatients who are intolerant to parenteral lipid infusion orfluid-restricted.Sourced fromDietitians Associationof Australia (DAA)Parenteral nutrition may not be appropriate in patientswhose prognosis is inconsistent with aggressive nutritionsupport strategies.10 ACI - Parenteral Nutrition Pocketbook: for Adults
1.5 W hen is it not appropriate to useParenteral Nutrition?PN m
Parenteral nutrition (PN) is a life sustaining therapy for patients who cannot eat or tolerate enteral nutrition. However, there are significant infection risks and complications associated with intravenous feeding. The ACI was approached by clinicians providing PN to develop a resource
About this Pocketbook Purpose The WFP emergency field operations pocketbook is a quick-reference resource for all WFP staff engaged in the provision of humanitarian assis-tance in the field, whether in Emergency Operations (EMOPs), Protracted Relief and Recovery Operations (PRROs) or Special Operations (SOs). The Pocketbook provides:
Total parenteral nutrition, more commonly known as parenteral nutrition (PN), is a high‐alert medication1,2 and a form of nutrition support that involves the delivery of nutrients through an intravenous catheter into a large central vein (e.g., superior vena cava) or peripheral vein on the hand or arm.
Parenteral nutrition (PN) is a life sustaining therapy for patients who cannot eat or tolerate enteral nutrition. However, there are significant infection risks and complications associated with intravenous feeding. The ACI was approached by clinicians providing PN to develop a resource
Parenteral nutrition as a high-alert medication The American Society for Parenteral and Enteral Nutrition (ASPEN)iv and the Institute for Safe Medication Practices (ISMP) acknowledge PN to be a high‐alert medication.1,2,5 Classifying PN as such requires healthcare organizations to dev
TPN has classically been administered through a central vein because of the high osmolarity of TPN solutions. PERIPHERAL VERSUS PARTIAL PARENTERAL NUTRITION T
Parenteral Nutrition – Lipid Emulsions and Potential Complications Parenteral Nutrition – Lipid Emulsions and Potential Complications less deterioration of liver enzymes, better phospholipid profile, and improvement i
and parenteral nutrition administration including verification that the parenteral nutrition bag is gradually emptying, the central line site and dressing are intact; at least 2 times during the infusion, in addition to responding to pump alarms. In the event of a pump alarm, the parent must identify the cause and solve the issue .
The API Standard 2000 5th Edition takes into account Tank Volume, Liquid Flow, and Temperature Change. It was written as a basis for the pressure control of hydrocarbons, and considered industrial tanks as well. It is this 5th Edition that is probably in widest use today. In 2009, this was updated to the API Standard 2000 6th Edition.
