BNF CHAPTER 9: NUTRITION & BLOOD

Transcription

1 9.1 ANAEMIAS BNF CHAPTER 9: NUTRITION & BLOOD IRON-DEFICIENCY ANAEMIAS ORAL IRON Use of modified release iron preparations is not recommended since these preparations release iron beyond the duodenum, an area where iron absorption is low. Ferrous gluconate should only be used if the patient has proven intolerant of ferrous sulphate; however any reduction in side effects is mainly due to the lower iron content of this preparation. Ferrous sulphate 200mg tablets (equivalent to 60mg iron) Ferrous fumarate 140mg/5mL syrup (equivalent 45mg/5mL iron) Ferrous gluconate 300mg tablets (equivalent to 35mg iron) PARENTERAL IRON Iron sucrose (Venofer) 100mg/2mL injection Iron carboxymaltose 50mg/mL injection (Ferinject) Limited indications Contact the ward pharmacist or pharmacy department to determine the dose required to restore iron stores. Iron deficiency should have been established prior to this by checking serum ferritin. The patient s most recent haemoglobin result will also be needed. The calculated total required dose of iron sucrose is split into 200mg doses and given up to three times a week. Iron carboxymaltose may be given as a single dose of up to 1000mg.

2 MHRA safety advice: Anaphylaxis is uncommon but remains a possible adverse reaction to iron preparations. Resuscitation facilities must be available and patients must be observed for at least 30 minutes following every iron infusion DRUGS USED IN MEGALOBLASTIC ANAEMIAS Hydroxocobalamin 1mg/mL injection Folic acid 5mg tablets 2.5mg/5mL syrup DRUGS USED IN HYPOPLASTIC, HAEMOLYTIC, AND RENAL ANAEMIAS Erythropoietins For use by Renal, Haematology & Oncology only Oncology use, see NICE TA142 Erythropoietin (alfa and beta) and darbepoetin for the treatment of cancer-treatment induced anaemia Darbepoetin alfa Epoetin alfa DRUGS USED IN PLATELET DISORDERS See haematology guidelines for regimes Romiplostim available according to NICE TA221 Eltrombopag available according to NICE TA293

3 9.2 FLUIDS AND ELECTROLYTES ORAL POTASSIUM Sando K 12mmol K + /tablet Potassium chloride 1mmol/mL syrup SF 600mg m/r tablets (Slow K) (8mmol K + /tablet) Prescribing note Avoid modified release potassium preparations unless effervescent tablets or liquid preparations are inappropriate or not tolerated. Modified release potassium preparations must be taken sitting upright and with plenty of water to avoid oesophageal damage, which may occur if they become trapped in the oesophagus ORAL BICARBONATE Sodium bicarbonate 500mg capsules PARENTERAL PREPARATIONS FOR FLUID AND ELECTROLYTE IMBALANCE ELECTROLYTES AND WATER Intravenous sodium Contact pharmacy for availability of preparations Intravenous potassium See COCH SharePoint for list of preparations and administration guidelines Bicarbonate and lactate Sodium bicarbonate 1.26% infusion (75mmol HCO - 3 /500mL) 8.4% injection (50mmol HCO - 3 / 50mL

4 9.3 INTRAVENOUS NUTRITION Contact Nutrition Team

5 9.4 ENTERAL NUTRITION Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY Core feed - may be used prior to Dietetic referral when commencing the starter enteral feeding regimen. Product Name Presentation Indications* Comments** Availability Jevity 1.0kcal/ml, isonitrigenous, contains mixed fibre and FOS*** 500/1000/1500ml RTH**** To help maintain normal bowel function in patients requiring enteral feeds. Core feeds may NOT be used without Dietetic/Medical supervision. Core feed. Not suitable for low residue diets. Regular stock item (see key to availability below). Product Name Presentation Indications* Comments** Availability Jevity Plus Jevity 1.5kcal Jevity Promote 1.2 kcal/ml, high nitrogen, contains mixed fibre and FOS, 500/1000/1500ml RTH. 1.5 kcal/ml, high nitrogen, contains mixed fibre and FOS, 500/1000/1500ml RTH. 1.0kcal/ml, high nitrogen, contains mixed fibre and FOS, 1000ml RTH. Higher energy than standard feed. Nutritionally complete balanced feed. For increased energy requirements. Nutritionally complete balanced feed. Nutritionally complete in 1000ml excluding potassium and chloride. Not suitable for low residue diets. * All enteral feeds are indicated for patients with existing malnutrition or risk for malnutrition. ** Not suitable for intravenous administration; not suitable for infants under 1 year. *** FOS Fruco-oligosaccharides. **** RTH Ready-To-Hang container. Not suitable for low residue diets or in hepatic or renal failure. Not suitable for low residue diets or in hepatic or renal failure.

6 Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY Alternative/specialist feeds - must NOT be used without Dietetic/Medical supervision. Product Name Presentation Indications Comments Availability Ensure Plus Osmolite Osmolite Plus Perative Nepro 1.5kcal/ml, high nitrogen, complete balanced liquid, Non fibre, 500/1000/1500ml RTH. 1.0kcal/ml, non-fibre, isonitrogenous, 500/1000/1500ml RTH. 1.2kcal/ml, non-fibre, isonitrogenous, 500/1000/1500ml RTH. 1.3kcal/ml, semi elemental, non-fibre, 500/1000ml RTH. 2.0kcal/ml, low electrolyte feed, nitrogen dense, low volume, 500ml RTH. As Jevity 1.5kcal. High energy and protein needs. Fluid restricted regimens. Standard feed for patients requiring enteral feeds. For patients with increased energy and protein needs. Severe maldigestion/ malabsorption. Jejunostomy feeds. Electrolyte and fluid restrictions. May not be suitable for hepatic or renal failure. May be suitable for patients requiring low residue feed. May be suitable for patients requiring low residue feed. Requires order request (see key to availability below). Requires order request. Requires order request.

7 Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY Alternative/specialist enteral feeds continued. Product Name Presentation Indications Comments Availability Modulen IBD Elemental 028 Elemental 028 Extra 5kcal/g, elemental powder feed to be made up to various concentrations with H2O, contains antiinflammatory factors, 400g tin. 3.8kcal/g, elemental powder feed to be made up to various concentrations with H2O, 100g sachet. 4.4kcal/g, elemental powder feed to be made up to various concentrations with H2O, 100g sachet. Exclusively designed for Crohn s disease. Nutritionally complete in 400g. IBD, short bowel syndrome, malabsorption. IBD, short bowel syndrome, malabsorption. Can be sole source of nutrition or used as a supplement to diet Can be given via oral route. Can be sole source of nutrition or used as a supplement to diet. Can be given via oral route. Can be sole source of nutrition or used as a supplement to diet. Can be given via oral route.. Requires order request. Requires order request.

8 Countess of Chester Hospital NHS Foundation Trust ADULT NUTRITION SUPPLEMENT FORMULARY Protocol for commencing oral supplements without the supervision of a Dietician. Always refer the patient to the Dietetic department electronically. In the event that a Dietician is unable to attend the ward to assess a patient in order to commence oral supplements staff may trial the patient with Ensure plus and/or Enlive plus bd if oral intake and/or appetite is poor. Food record charts should be commenced to monitor intake. Where possible the patient should be weighed. Standard supplements may be commenced prior to Dietetic assessment. Product Name Presentation Indications** Comments*** Availability Ensure Plus Ensure Plus Juce 220ml Chocolate, Banana, Strawberry, Vanilla, Raspberry, Blackcurrant. Milkshake style drink. 220ml Apple, Lemon & lime, Fruit punch, Orange Grapefruit, Peach. Juice style Increased energy and protein needs, e.g. post operatively. Dysphagia to solids. Poor oral intake of food. As above. Fat intolerance/ Steatorrhoea. Use in caution in renal failure. Nutritionally complete in 5 servings. Use in caution in renal failure. drink. clinical conditions (ACBS endorsed for FP10 prescribing). See Appendix 7, BNF. ** Disease related malnutrition, increased nutrient requirements in patients unable to take oral diet and fluids. *** Not suitable for intravenous administration; not suitable for children under 1 year; not to be used a sole source of nutrition.

9 Countess of Chester Hospital NHS Foundation Trust ADULT FSMP FORMULARY Alternative/specialist supplements - may NOT be used without Dietetic/Medical supervision. Product Name Presentation Indications Cautions Comments Ensure Plus Fibre Ensure Plus Yogurt Style Enshake Nepro 200ml Vanilla, Raspberry, Banana, Chocolate. Milkshake style drink with added fibre. 200ml Orange burst, Orchard peach, Pineapple twist, Strawberry swirl. Yogurt shake style drink. Powdered high energy shake drink, 96.5g sachet to be made up with 240ml whole milk. Strawberry, Banana, Vanilla, Chocolate. 200ml carton Vanilla, strawberry High energy, low electrolyte, low volume. Contains fibre may help to maintain normal bowel function. Constipation. Nutritionally complete. Increased energy and protein needs, e.g. post operatively. Dysphagia to solids. Poor oral intake of food. Taste changes. Increased energy and protein needs. Patients who do not tolerate readymade carton supplements. For patients with renal failure. Dialysis. Not suitable for low residue diets or fibre free diets. Nutritionally complete in 5 servings. Use in caution in renal failure. Nutritionally complete in 5 servings. Not suitable as a sole source of nutrition. Caution in renal patients. Not suitable for sole source of nutrition. Requires order request. Requires order request.

10 Countess of Chester Hospital NHS Foundation Trust ADULT FSMP FORMULARY Alternative/specialist supplements continued - may NOT be used without Dietetic/Medical supervision. Product Name Presentation Indications Comments Availability Pro-Cal Pro-Cal Shot Maxijul Super Soluble Powder 15g sachet, 510g/1.5kg/12.5kg/25kg tub. Protein and calorie food enricher. Unflavoured Can be added to a variety of foods and drinks. 250mL bottle Protein and calorie food enricher. Unflavoured Can be added to a variety of foods and drinks. 132g sachet, 200g/2.5kg/25g tub. Calorie dense food and drink enricher Unflavoured, protein free. Calogen 250ml/1000ml bottle - Neutral, Strawberry, Butterscotch. LCT ****fat emulsion. **** LCT Long Chain Triglyceride. Fortification of foods contains protein, fat and carbohydrate modules. Not suitable for patients with lactose or milk intolerance. As for Pro-Cal As for Pro-Cal Regular stock item Energy/carbohydrate module for fortification of food and drinks. Fat module suitable for fluid &/or electrolyte restrictions. Low volume, energy dense supplement. Not suitable for use in diabetes. Not suitable for use in fat malabsorption or steatorrhoea. Does not contain protein.

11 Countess of Chester Hospital NHS Foundation Trust ADULT FSMP FORMULARY Alternative/specialist supplements continued - may NOT be used without Dietetic/Medical supervision. Product Name Presentation Indications Comments Availability Forticreme Resource Thicken Up Key to availability: 125g pot Vanilla, Forest Fruits, Chocolate. High energy, High protein, ready to eat dessert style supplement. 227g tub Unflavoured. Modified food starch for thickening food and fluids. Semi solid texture can be used in those with dysphagia to liquids. Fluid restricted patients. Dysphagia patients requiring modified consistency diet and fluids. Only to be used as a supplement to diet. Not suitable as a sole source of nutrition. Not a nutritional supplement. Regular stock item: this product is routinely kept in the Pharmacy Department and may be stock on some wards. Requires order request: this product may only be supplied from the Pharmacy Department on an individual patient basis following a request by a Dietician or Pharmacist or by taking the patient s prescription chart, along with a requisition, to the dispensary. There may be a delay in obtaining some of these products as they are not routinely stocked in Pharmacy.

12 Countess of Chester Hospital NHS Foundation Trust PAEDIATRIC ENTERAL PRODUCT FORMULARY Oral supplements Product Name Presentation Indications Cautions Availability Infatrini 100ml glass bottle. High energy infant Not suitable for formula for faltering premature babies or in growth. Suitable birth renal or hepatic failure. 8kg. Nutramigen 1 425g tub. Hydrolysed infant milk for food allergies / intolerances. Pregestimil 450g tub. Hydrolysed infant milk for malabsorption or food allergies / intolerances. Contains MCT fats. Neocate LCP 400g tub Amino acid based, hypoallergenic infant formula. Wysoy 430g tub. Soya infant formula. Not suitable for infants under 6 months.

13 Oral supplements continued Product Name Presentation Indications Cautions Availability Maxijul Super Soluble Powder Box of 4 x 132g sachets Calorie dense food and drink supplement. Unflavoured, protein free. Energy/carbohydrate module for fortification of food and drinks. Not suitable for use in diabetes. Paediasure 200ml carton vanilla, strawberry. Oral supplement. Suitable 8-30kg Not suitable for children under 1 year. Ensure Plus Yogurt Style 220ml carton Orange, peach, pineapple, strawberry Nutritional supplement drink suitable over 30kg Use with caution under 30kg Enshake Powdered high energy shake drink, to be made up with milk. Strawberry, banana, vanilla, chocolate. Increased energy and protein needs. Patients who dislike readymade carton supplements. Not suitable as a sole source of nutrition. Caution in renal patients. Not suitable under 5 years. Ensure Plus Juce 220ml carton apple, fruit punch, orange, peach, grapefruit, lemon & lime. Fruit juice style nutritional supplement drink. Not suitable for children under 5 years. Use with caution in renal failure. None of these products need to be kept as regular ward top-up. July 2008

14 Countess of Chester Hospital NHS Foundation Trust PAEDIATRIC ENTERAL PRODUCT FORMULARY Tube feed products Product Name Presentation Indications Cautions Availability Paediasure 500ml flexitainer Standard enteral feed. Not suitable for patients Suitable 8-30kg under 1 year. Paediasure Plus Fibre 500ml flexitainer Fibre enriched feed with increased energy and protein. 8-30kg As for Paediasure Fibre and Paediasure Plus. Paediasure Plus 500ml flexitainer Increased energy and protein needs or where fluid restriction is required. 8-30kg Paediasure Fibre 500ml flexitainer To help maintain normal bowel function in patients requiring enteral feeds. 8-30kg Modulen IBD 400g tub. Powdered feed, to be reconstituted with water. For Crohn s disease. Can be taken orally, or as an enteral feed. May not be suitable in hepatic or renal failure or children under 1 year. Not suitable for patients requiring low residue or fibre-free diets, or children under 1 year. Requires order request. Requires order request. Key to availability: Regular stock item: this product is routinely kept in the Pharmacy Department Requires order request: this product may only be supplied from the Pharmacy Department on an individual patient basis following a request by a Dietician or Pharmacist or by taking the patient s prescription chart, along with a requisition, to the dispensary. There may be a delay in obtaining some of these products as they are not routinely stocked in Pharmacy.

15 9.5 MINERALS CALCIUM AND MAGNESIUM Calcium supplements Calcium carbonate 1.25g tablet (500mg, 12.6mmol Ca 2+ ) (Calcichew ) Sandocal mmol Ca 2+ (1g calcium)/ effervescent tablet Calcium-Sandoz 2.7mmol Ca 2+ (108.3mg calcium) / 5mL syrup Calcium gluconate 10% injection (2.25mmoL Ca 2+ ) Calcium chloride 6.8mmol Ca 2+ /10mL Injection (Min-I-Jet ) 10mmol Ca 2+ /10mL ampoule Management of symptomatic hypocalcaemia Administer a dose of 10mL calcium gluconate 10% (2.25mmol) over 5 minutes into a large vein. If the injection is given too quickly, it may lead to a fall in blood pressure and heart rate. Alternatively, 10mL calcium gluconate 10% can be diluted in 100mL 0.9% sodium chloride and infused over 20 to 30 minutes. This may be followed by repeat injections every 6 to 8 hours or a continuous infusion of 40mL (9mmol) over 24 hours. If further calcium supplements are required give: 1. Alfacalcidol 1microgram orally daily. Adjust dose according to serum calcium. The usual dose range is 1 to 3 micrograms daily. 2. Sandocal 1000 (1 tablet) daily only if diet is inadequate. Monitor calcium and phosphate closely Hypercalcaemia and hypercalciuria Cinacalcet As per NICE TA117 guidance (renal only)

16 Magnesium Magnesium sulphate Magnesium glycerphosphate 50% injection (2mmol /ml) 2mL, 5mL ampoules 4mmol tablet (unlicensed) NB capsules are not prescribable on FP10 Magnesium-Laspartate (Magnaspartate) 10mmol Mg 2+ /dissolvable sachet usual dose = one sachet once daily For long term oral replacement therapy, magnesium aspartate may be preferred to magnesium glycerophosphate (see above). It is a commercially available preparation and therefore more obtainable for FP10 prescribing and dispensing. Management of hypomagnesaemia Please refer to guidelines on Hypomagnesaemia Management PHOSPHORUS Phosphate Supplements Phosphate-Sandoz 16.1mmol PO 4 3- / tablet Phosphates Intravenous infusion Phosphate-Binding Agents See Drug Management of Chronic Kidney Disease for preparations and doses ZINC Zinc sulphate 125mg Effervescent tablets (45mg zinc)

17 9.6 VITAMINS Vitamin D See local guidelines: Vitamin D deficiency clinical guidelines for adults Aviticol colecalciferol 20,000 IU capsules (N.B. contains gelatin) InVita D3 colecalciferol 25,000 IU/ml oral solution (suitable for vegetarians and patients with swallowing difficulties) Desunin colecalciferol 800 IU tablets (gelatin free)