Long term monitoring. Dr Alison Culkin Research Dietitian St Mark s Hospital

Transcription

1 Long term monitoring Dr Alison Culkin Research Dietitian St Mark s Hospital

2 Patient 23 year old lady 1/4/14 Colectomy for UC 3-7/4/14 Ischaemic bowel 4 laparotomies Jejunostomy at 35 cm 23/5/14 Weight 39kg (height 162 cm) BMI 14.9kg/m 2 (Usual weight in health 51 kg, BMI 19.5 kg/m 2 )

3 Discharged on HPN Observations on discharge Weight 40kg BMI 15.3kg/m 2 MAMC 18.2cm (5 th -10 th centile) HPN prescription Volume 3.0L Nitrogen 11g Non-protein 1540kcal Stoma Urine 2.5L/day 800ml/day Lipid (x2/week) Na K 1000kcal 250mmol 40mmol Alk Phos ALT 205 IU/L 189 IU/L Ca Mg 4mmol 12mmol Bilirubin 30 IU/L Phosphate 15mmol Urinary Na 45 mmol/l Additrace & Cernevit Daily

4 How often do you monitor? Initial clinic visits Weekly Long term clinic visits Monthly 2 weekly 3 monthly Monthly 6 monthly 3 monthly Yearly 6 monthly

5 What does Europe do? ESPEN-HAN working group Questionnaire: 42 centres in 8 countries Wengler et al, (2008) Clin Nutr;25:693

6 Blood tests: what do they measure? Vitamins A, D, E, B12, folate Trace elements Albumin Lipids Glucose Ca, Mg, PO4 U&E, creatinine LFTs Haematology % centres Wengler et al, (2008) Clin Nutr;25:693

7 What would you measure every time? Haem & biochem FBC U&E, LFT, Ca, Mg, PO4 CRP, ESR Vitamins B12, folate A, D & E Micronutrients Ferritin Selenium & Zinc Copper, manganese Urine sodium

8 ESPEN HPN in adults Purpose of the guidelines To highlight good practice & promote use of standardised treatment protocols Identifies huge clinical experience Few controlled clinical studies of treatment effects & management of complications Framework for development of policies & procedures Staun M et al (2009) Clin Nutr; 28: 467

9 ESPEN guidelines on HPN in adults How to monitor HPN treatment Frequency All visits Measure Biochemistry & anthropometry 6 monthly Trace elements & vitamins Yearly Bone mineral density Staun M et al (2009) Clin Nutr; 28: 467

10 Scottish HPN managed clinical network Frequency of HPN monitoring & consequence for complication rates 141 HPN clinic assessments for 53 patients 16 (30%) were seen every 100days as per guideline 60% reviews were within 100days of previous appointment Duration of HPN treatment Inversely correlated with frequency of review Complication rates Not increased in HPN patients reviewed less often Hallum NS et al (2010) Nutrition, 26:1139

11 Scottish HPN managed clinical network Frequency of HPN Monitoring No difference in complications between patients reviewed within recommended time periods and those reviewed less often Hallum NS et al (2010) Nutrition, 26:1139

12 Clinic visit (4 weeks post discharge) Discharge 4 / 52 on HPN Weight 40kg 42kg BMI 15.3kg/m 2 16kg/m 2 MAMC 18.2cm (5 th -10 th ) 19.7cm (25 th 50 th ) Stoma 2.5L/day 2-3L/day Urine 800ml/day 800-1L/day Alk Phos 205 IU/L 236 IU/L ALT 189 IU/L 150 IU/L Bilirubin 30 IU/L 25 IU/L GGT n/a 82IU/L Urinary Na 45 mmol/l 26 mmol/l HPN prescription Volume 3.0L Nitrogen 11g Glucose 1400kcal Lipid (x2/week) 1000kcal Na 250mmol K 40mmol Ca 4mmol Mg 12mmol Phosphate 15mmol Additrace & Cernevit Daily What would you do?

13 What do we do? History Examination Investigations Medical illness & QoL Fluid & nutrition: oral & parenteral CVC & homecare issues CVC Anthropometrics Haem & biochem Micro nutrients Vitamins Urine Drug history Thirst, SOB, oedema, urine frequency, diet Exit site, integrity, (tip position) Weight BMI MAC TSF MAMC Grip strength FBC, ESR, CRP U&E LFT Ca, Mg & PO4 Ferritin Zinc Selenium Copper A, E, D, B12, folate Sodium

14 St Mark s monitoring Once stable Long term NICE Weight Daily 3-4 monthly Monthly Anthropometry (TST, MAMC) Monthly 3-4 monthly Monthly Handgrip Monthly 3-4 monthly - FBC, Na, K, Urea, Creatinine x2/week 3-4 monthly - Glucose monthly - Magnesium & phosphate x2/week 3-4 monthly - LFT x2/week 3-4 monthly - Ca, albumin x2/week 3-4 monthly - CRP x2/week 3-4 monthly - Iron, ferritin 3-6 monthly 3-4 monthly - B12, folate 2-4 weekly 3-4 monthly - Vitamin D 4 weekly 3-4 monthly 6 monthly Vitamin A, E Baseline Yearly - Zinc, copper & selenium 3 monthly 6 monthly - Manganese - Yearly 3-6 monthly Bone density Baseline 2 yearly 2 yearly

15 NICE recommendations HCP with relevant skills & training in nutritional monitoring should undertake monitoring Review the indications, route, risks, benefits & goals of nutrition support at regular intervals Review those on HPN every 3-6 months at a specialist hospital clinic Train patients and carers to recognise & respond to adverse changes in both their well-being and in the management of their nutritional delivery system Some clinical observations may be checked by patients or carers D grade evidence

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17 Long term glucose control 36 HPN patients On HPN 44 months 5 patients with Crohn s disease on Prednisolone 1 patient was insulin treated diabetic 1 patient on Octreotide (elevated Hb A 1c ) Median weekly glucose of 2000g at 11.8mg/kg/min Median Hb A 1c 3.1% (normal %) Conclusion: No correlation between glucose infusion and Hb A 1c Williams et al (1996) Clin Nutr, 15:141

18 Essential fatty acid deficiency Patients at risk if on PN with limited oral intake Can develop signs and symptoms within 3 weeks Dermatitis, steatosis, haematological disturbances, reduced immune function 56 HPN patients Assessed EFA status At risk if <200cm and no IV lipid 500ml of 20% Intralipid once a week was adequate Jeppesen et al (1998) Am J Clin Nutr, 68:128 Oral & cutaneous sunflower and safflower oil can treat EFAD if on lipid free PN Richardson & Sgoutas (1975) Am J Clin Nutr, 28:258. Milller et al (1987) Am J Clin Nutr, 46:419

19 Tissue trace element status Autopsy tissue from 8 HPN patients with short bowel (<110cm, 5JCA) over a 10 year period, 5-7d/week Cause of death: Opiate overdose (n=1) Catheter sepsis (n=2) Liver failure (n=3) Heart failure (n=1) Pneumonia (n=1) Daily trace element solution plus additional zinc Howard et al, (2007) JPEN;31:388

20 Normal iron & mildly increased zinc for HPN patients Howard et al, (2007) JPEN;31:388

21 Significantly raised copper & manganese in HPN patients Howard et al, (2007) JPEN;31:388

22 Significantly raised chromium & normal selenium in HPN patients Howard et al, (2007) JPEN;31:388

23 Long term monitoring 27 HPN patients compared to 11 healthy controls Fat soluble vitamins - Vitamin D - Vitamin A - Vitamin E Trace elements - Iron - Zinc - Copper - Selenium - Manganese Controls (n=11) 15 ± ± ± ± ± ± ± ± 0.5 HPN patients (n=27) 12.3 ± ± ± 4.1 a 14.9 ± ± ± ± 17.6 b 1.97 ± 0.9 a Number with low, normal & high values 5, 15, 1 8, 19, 2 12, 12, 3 5, 22, 0 3, 23, 1 3, 23, 1 9, 16, 2 0, 2, 25 Magnesium 0.84 ± ± , 10, 2 a p<0.001, b p<0.05 Reimund et al (1999) Ann Nutr Metab, 43:329

24 Micronutrients: what should you do? It depends Is that clear? Which tests analysed at your Trust? What has to be sent away? How long does it take to get results? How do you interpret the results?

25 Micronutrients: effect of inflammatory response CRP <15mg/L 15-50mg/L >50mg/L Interpretation Reliable Unlikely to be reliable No value

26 Vitamin D in HPN 199 HPN patients Mean Vitamin D = 62 ± 37nmol/L. Hypovitaminosis D in 72% 8% severely deficient, 37% deficient, 27% insufficient Not associated with gender, age or IF aetiology High dose IM supplementation (150,000IU) concentrations but still below recommended levels Tee et al (2010) UEGW 2979

27 Suggestions for monitoring micronutrient deficiency & toxicity Ensure complete nutrition daily (diet & parenteral) Verify adherence to nutrition prescription Routinely assess micronutrient status in long term HPN patients Correlate findings with medical history & physical examination Supplement suspected/proven deficiencies and then reassess Monitor for subsequent toxicity after prolonged supplementation Monitor for subsequent deficiency after prolonged omission Monitor laboratory, clinical & physical response to nutrition interventions AGA Guideline Buchman et al (2009) Micronutrients in Parenteral Nutrition: Too little or too much? The past, present & recommendations for future. Gastroenterology 137, 5:S1-134

28 Summary Underlying condition Nutrition (oral & parenteral) Catheter Biochemistry & haematology Patient Quality of life Urinalysis Micronutrients Fluid (oral & parenteral) Rapid access to advice / care from MDT