Adult Parenteral Nutrition Guidelines

Transcription

1 RESTRICTED NOT YET APPROVED Policy Number: 338 Supercedes: Standards For Healthcare Services No/s 7,8,11,13,14,15,16, 18, 19 Version No: Date Of Review: 0.2 April 2013 Reviewer Name: Rachel Lewis & Linda Morgan Completed Action: Approved by: Clinical Policy Review Group Date Approved: New Review Date: April 2015 Brief Summary of Document: Guidance to support the safe and appropriate administration of Parenteral Nutrition in Adults patients within secondary care. To be read in conjunction with: Policy 008: Policy for consent to examination and treatment Policy 209: Hywel Dda Adult Refeeding Guidelines Policy : Hywel Dda Enteral feeding policy NICE CG32 Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. NCEPOD (2010) A mixed Bag An enquiry into the care of hospital patients receiving parenteral nutrition Classification: Clinical Category: Policy Freedom Of Information Status Open Authorised by: Caroline Oakley Job Title Director of Nursing Signature:

2 Responsible Officer/Author: Contact Details: Rachel Lewis Linda Morgan Nutrition and Dept Dietetics Job Title: Base Tel No Clinical Lead Dietitian Clinical Nutrition Nurse Specialist Glangwili Hospital Scope ORGANISATION WIDE DIRECTORATE DEPARTMENT ONLY COUNTY ONLY Staff Group Administrative/ Estates Medical & Dental Nursing Allied Health Professionals Ancillary Maintenance Scientific & Professional Other CONSULTATION Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained. Individual(s) Group(s) Committee(s) Parenteral Nutrition working group Nutrition support Clinical focus group Nutrition and Hydration Steering group Date(s) Date(s) Date(s) July 2012 July 2012 RATIFYING AUTHORITY (in accordance with the Schedule of Delegation) NAME OF COMMITTEE Clinical Policy Review Group A = Approval Required FR = Final Ratification FR KEY Date Approval Obtained COMMENTS/ POINTS TO NOTE Date Equality Impact Assessment Undertaken 22 nd April 2013 Group completing Equality impact assessment Rachel Lewis Linda Morgan Jackie Hooper Please enter any keywords to be used in the policy search system to enable staff to locate this policy Parenteral Nutrition, Enteral feeding, Nutrition Support, Refeeding syndrome Database No: 338 Page 2 of 46 Version 0.2

3 How Will This Policy Be Implemented? Document Implementation Plan Through a co-ordinated launch of the policy facilitated by the county nutrition groups (for local launch) and the NSG (for launch to key professional groups). The policy will be adopted by the professions involved with its development once approved; this will support incremental implementation of the policy Who Should Use The Document? What (if any) Training/Financial Implications are Associated with this document? All members of the multi-disciplinary team involved with nutritional care Training needs will be identified by the relevant professional leads; meeting the training needs will depend on the specific need. Financial: This policy supports the appropriate use of PN and therefore there is unlikely to be an increased cost associated with implementing this policy. Optimal PN provision and related care may reduce costs by ensuring PN is only used in appropriate circumstances, reducing line infections and optimising nutritional care Action By Whom By When What are the Action Plan/Timescales for implementing this policy? Approved guideline sent for signing Signed guideline made active on intranet Active guideline advertised via global e- mail Awareness sessions across the health board Cascade of guideline through locality nutrition groups Post graduate teaching sessions in each locality Promotion of guideline via nutrition steering groups Rachel Lewis Policy Coordinator Dietetics Dietetics Dietetics Dietetics Dietetics Database No: 338 Page 3 of 46 Version 0.2

4 Contents 1. INTRODUCTION POLICY STATEMENT SCOPE AIM OBJECTIVE NUTRITIONAL ASSESSMENT Nutritional screening Consent to treatment Withdrawing PN DEFINITION OF PARENTERAL NUTRITION Total parenteral nutrition (TPN) Supplementary Parenteral nutrition (SPN) INDICATIONS OF PARENTERAL NUTRITION CONTRAINDICATIONS Precautions of use ROUTES OF ACCESS Types Of Lines STARTING PARENTERAL NUTRITION Assessment Referral and prescription Patients admitted who are on Home Parenteral Nutrition (HPN) Composition of PN Storage Administration Rate of administration Undesired effects of PN CONNECTING AND DISCONNECTING PN INFUSION FLUSHING A CENTERAL LINE FOR PN GIVING MEDICATION OUT OF HOURS PN MONITORING Clinical monitoring Laboratory monitoring Other Monitoring: COMPLICATIONS Metabolic complications Catheter related complications DISCONTINUING PN Unplanned stops in PN LONG TERM PN RESPONSIBILITY TRAINING IMPLEMENTATION FURTHER INFORMATION CLINICAL POLICIES REVIEW REFERENCES APPENDIX 1: ENTERAL & PARENTERAL ALGORITHM APPENDIX 2: REFEEDING SYNDROME APPENDIX 3: ADULT PARENTERAL NUTRITION REFERRAL PROCESS Database No: 338 Page 4 of 46 Version 0.2

5 30. APPENDIX 4: ADULT PARENTERAL NUTRITION REFERRAL FORM APPENDIX 5: ADULT PARENTERAL NUTRITION PHARMACY REQUEST FORM APPENDIX 6: ADULT PARENTERAL NUTRITION PHARMACY CHANGE OF REGIMEN FORM APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS APPENDIX 9: GUIDELINE FOR CONNECTING A PARENTERAL NUTRITION INFUSION APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A PARENTERAL NUTRITION INFUSION Database No: 338 Page 5 of 46 Version 0.2

6 1. INTRODUCTION Parenteral nutrition (PN) is the administration of nutrients by the intravenous route. It is a well established technique of providing artificial nutrition support to patients who have an inaccessible or non-functioning gut. Parenteral nutrition is a high risk intravenous therapy, the use of which must be supervised and monitored by suitably trained staff. It should not be given without appropriate forethought and planning. 2. POLICY STATEMENT To establish consensus within Hywel Dda Health board on the management of adult patients requiring PN. 3. SCOPE This clinical policy is for use with all adult patients requiring PN within Hywel Dda Health board. It should be used by dietitians, registered nursing staff, chemical pathologist, pharmacists, doctors, allied health professionals (AHPs) and students alike within the scope of the individual s clinical competence. 4. AIM To ensure that PN is considered in appropriate adult patients in order to prevent and treat disease related malnutrition and complications related to poor nutritional status. To minimise clinical risk and promote the safe and appropriate administration of PN to all adult patients. To ensure a co-ordinated multi-disciplinary approach to PN within Hywel Dda Health board 5. OBJECTIVE To provide guidance on identifying patients at nutritional risk and early identification of Patients requiring PN To recommend best practice for the safe administration and monitoring of PN Database No: 338 Page 6 of 46 Version 0.2

7 6. NUTRITIONAL ASSESSMENT Half of all patients admitted to hospital are suffering from malnutrition (BAPEN, 2011). The consequences of malnutrition are diverse, and can affect all organs in the body. Failure to provide adequate nutrition is both a cause and consequence of ill health, which can lead to immune dysfunction, disordered physiological function and delayed wound healing Nutritional screening All patients admitted to hospital should be screened for malnutrition within the first 24hours of admission using the agreed Hywel Dda Health Board nutritional screening tool and rescreened on a weekly basis. Any patient with existing malnutrition or those screened as being at high risk of malnutrition must have a nutrition care plan in place and be highlighted to the responsible consulting team. Always consider risk of Refeeding syndrome (RFS) in patients with existing malnutrition or at high risk (further information of refeeding syndrome available in the appendix 2) Organisation of Nutrition support (NICE., 2006) Screen Recognise Treat Oral Enteral Parenteral Monitor & Review Refer to appendix 1 for further information on selecting the most appropriate means of providing nutrition support for patients. Database No: 338 Page 7 of 46 Version 0.2

8 6.2. Consent to treatment Patient consent All patients with a poor nutritional status should be actively involved in decision making regarding their nutritional plan. The Royal College of Physicians (2010) state Those with intact cognitive function who are unable to eat or drink must be involved in decision making as their perception of the process resulting from absence of food will be different from those with absent cognitive function. In relation to any aspects of commencing PN, the patients consent should be sought wherever possible. The Health Board s Consent Policy (008) should be adhered to and referred to for guidance Mental capacity For the purposes of Mental Capacity Act (MCA) 2005, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. A person lacks capacity if they have an impairment or disturbance (for example, a disability, condition or trauma) that affects the way their mind or brain works, and the impairment or disturbance means that they are unable to make specific decision at the time it needs to be made. An assessment of a person s capacity must be based on their ability to make a specific decision at the time it needs to be made, and not their ability to make decisions in general. The impairment or disturbance does not have to be permanent. A person can lack capacity to make a decision at the time it needs to be made even if: the loss of capacity is partial, temporary or their capacity changes over time. A person may also lack capacity to make a decision about one issue but not about others. The MCA Code of Practice supports the MCA and provides guidance to all those who care for and/or make decisions on behalf of adults who lack capacity. The Code includes case studies and clearly explains in more detail the key features of the MCA Patients who have necessary decision-making capacity If PN is considered to be beneficial by the clinician and MDT then the patient who has the necessary decision-making capacity should be asked for their informed consent to the procedure. In these cases the patient s decision is final. A person can be said to have given consent when their decision is based on an appreciation and understanding of the salient facts and the reasonably foreseeable consequences of their decision (MCA, 2005 s.3(4)). Relevant information about the benefits and risks of the proposed treatment and available alternative treatments must be provided in an appropriate format to help the person to understand and in accordance with the Hywel Dda Health Board Policy to Consent to Examination and Treatment (Policy No. 008). Consent can be written, verbal or non-verbally implied. A consent form does not itself prove that consent is valid. The point of the form is to record the discussion that has taken place. Patients have the right to change their mind at any point and can withdraw their consent at any time Patients who lack decision-making capacity The Mental Capacity Act, 2005, provides a framework for acting and making decisions on behalf of individuals who lack the mental capacity to make the decision for themselves. Where there are reasons to doubt a person s capacity to make a decision the individual who wishes to Database No: 338 Page 8 of 46 Version 0.2

9 take some action in relation to the person s care or treatment is responsible for ensuring an assessment of capacity is undertaken. The act emphasises that in some cases an MDT approach is best using the skills and experience of different professional s. Further guidance and support in respect of the Mental Capacity Act can be found in Health Board policy HD018: Guidance on the Mental Capacity Act, by visiting the Mental Capacity Act Intranet page. Parenteral Nutrition in the context of the mental disorder where a patient is subject to Part 4 of the Mental Health Act (2007), the issue of feeding may not rest on the persons consent and there are circumstances where feeding can be given despite the patient s objections Best interest For patients who are assessed as lacking decision-making capacity or who are unable to communicate their wishes, then a decision should be made in the patient s best interests. The decision-maker, in consultation with professional colleagues and other people interested in the person s welfare should consider a number of factors including: Patient s past and present wishes and feelings, beliefs and values Clinical judgement around effectiveness of treatment Views of relatives and others close to the patient, including any attorney or courtappointed deputy who does not have decision-making authority for this decision In difficult clinical situations it is recommended that a second opinion should be sought from another senior clinician or a clinical ethics committee Clinical Resource Efficiency Support Team (CREST) Advanced Decisions, Lasting Power of Attorney Court Appointed Deputies and IMCAs Some patients may have made an advanced decision to refuse artificial nutritional support (ANS), including PN. If this decision is valid and applicable healthcare professionals are legally obliged to respect it. Where the effect of an advanced decision to refuse ANS is likely to lead to the patient s death there are special rules that apply. For further guidance see Health Board policy HD014: Policy on Advance Decisions. A patient may have also indicated their preferences which, whilst not legally binding, must be considered when making a decision in the person s best interests. Some patients may have granted a Lasting Power of Attorney to a specific person who they wish to have the authority to make decisions on their behalf in the event of their losing decision-making capacity. There are different types of Lasting Power of Attorney which provide different levels of decision-making authority and the person can also limit the attorney s authority to make specific decisions. If patients are assessed as lacking capacity, then the decision-maker must ask the person and/or others close to the patient if someone has been granted a Lasting Power of Attorney. If the decision about ANS falls within the attorney s authority the attorney would be the decision-maker. In circumstances where a person lacks capacity and it is likely that they will lack capacity for future decisions the Court of Protection has the power to appoint a deputy to make those decisions for the person. The scope and duration of a deputy s powers are defined by the Court but, as with attorneys, if the decision about ANS falls within their authority the deputy would be the decision-maker. Deputies cannot make decisions to refuse a treatment considered to be life-sustaining as this would require the authority of the court. If there is no-one appropriate for the decision-maker to consult with about a decision in respect of ANS and the treatment is considered a serious medical treatment (MCA Code of Practice, paragraph 10.42) then an Independent Mental Capacity Advocate must be instructed to represent and support the person. Further guidance and support in respect of the Mental Database No: 338 Page 9 of 46 Version 0.2

10 Capacity Act can be found in Health Board policy HD018: Guidance on the Mental Capacity Act Withdrawing PN Parenteral Nutrition is considered a treatment. If it is providing no benefit (e.g. if the patient is dying) then it may be discontinued. Where the patient lacks the capacity to consent to such a decision the safeguards provided by the Mental Capacity Act must be followed as part of the consideration of withdrawal of feeding. In ethical terms there is no legal difference between starting and withdrawing treatment. In emotional terms it is more difficult to withdraw a treatment once begun than not to start it at all. For this reason there can sometimes be a reluctance to commence PN for fear it will be difficult to stop. In such circumstances it may be appropriate to start treatment for a time or period, with the provision that the outcome will be reviewed at the end of a specific time period or earlier if needed, to be stopped, changed or continued as appropriate (CREST 2004). 7. DEFINITION OF PARENTERAL NUTRITION Parenteral nutrition (PN) involves the provision of an artificially prepared solution containing amino acids, glucose, lipids, electrolytes, trace elements and vitamins that are needed to maintain health. Nutrients are delivered directly into the circulatory system via a dedicated venous catheter Total parenteral nutrition (TPN) TPN is the provision of parenteral nutrition as a sole source of nutrition 7.2. Supplementary Parenteral nutrition (SPN) SPN is the provision of PN given in conjunction with enteral nutrition to meet patient s daily nutritional requirements. 8. INDICATIONS OF PARENTERAL NUTRITION Failure of gut function to a degree that definitely prevents adequate gastrointestinal absorption of nutrients Consequent intestinal failure has either persisted for several days (e.g. > 5 days) or is likely to persist for many days (e.g. 5 days or longer) before significant improvement Database No: 338 Page 10 of 46 Version 0.2

11 Patients with reasonable gut function who cannot eat and when enteral tube feeding is impossible or impractical for reasons of tube access (NICE, 2006) Short Term Surgical complications such as anastomotic leak, intestinal obstruction, adhesions or fistulation Patients with severe pancreatitis if there is gastric outlet obstruction secondary to duodenal stenosis or complex fistulation Patients with multi-organ failure, severe sepsis or burns where nutritional requirements cannot be met by enteral nutrition alone Failure of gut motility despite the use of prokinetics Short bowel syndrome, high output stoma or evidence of malabsorption where nutritional requirements cannot be met by enteral nutrition alone Patients with swallowing difficulties mechanical or neurological, oesophageal or stomach problems such as obstructions awaiting enteral access, stenting or surgery Incurable cancer patients in hypophagic / obstructions, if there is an acceptable performance status if they are expected to die from starvation / under nutrition prior to tumour spread Oral mucositis that prevents enteral access being established Long Term Short bowel syndrome of any aetiology (i.e. small intestine <200cm) Intestinal failure Motility disorders such as scleroderma and chronic idiopathic intestinal pseudo-obstruction syndromes Chronic radiation enteritis 9. CONTRAINDICATIONS Patients who are able to absorb adequate nutrition via the enteral route Well nourished or mildly undernourished patients in preoperative period who are consuming adequate enteral nutrition 9.1. Precautions of use Patients with pre-existing malnutrition who will be at high risk of refeeding syndrome (Further information on refeeding syndrome is available in appendix 2) PN may not be appropriate for patients with advanced cancer who have been unresponsive to treatment Allergies, hypersensitivity and restrictions Vegetarian / vegan: PN is suitable for most vegetarians but the lipid may contain eggs vegans may therefore insist on lipid free products. Egg allergy: Normal lipid products should not be administered to patients with an egg allergy without close supervision. Lipid free products may have to be used. Database No: 338 Page 11 of 46 Version 0.2

12 Soya protein allergy: lipids based on soybean oil do not contain soya protein so can be used with caution in patients with soybean allergy. Refer to section for further advice on lipids 10. ROUTES OF ACCESS The type of central line used will depend upon the length of time PN is required and the condition of the patient s veins. A planned approach to central line access is required in patients who are likely to require longer periods of PN to minimise the need for repeated insertion of short term catheters. The type of access required will depend on a number of factors including the length of time PN is required, the availability of suitable veins and staff expertise. Establishing and maintaining suitable access to the circulation is essential for the successful management of PN. A number of veins are suitable to provide central access for parenteral nutrition: Subclavian Vein The subclavian route is often the preferred route for long-term parenteral nutrition i.e. lasting over thirty days (NICE, 2006). In practice jugular vein is used instead of subclavian. However as there is an associated risk of pneumothorax during the insertion procedure the jugular route is often used in preference for short term administration. There is a lower risk of infection with this route and dressings can be safely secured over the line reducing movement and increasing patient comfort (Masoorli et al., 2002). Jugular Veins Accessing the jugular veins for central access is associated with a lower risk of complication during the insertion procedure; there is an increased risk of infection post insertion due to the position of the exit site on the neck. Dressing application is difficult requiring more frequent replacement due to neck movement and hair growth in men. Catheter position also often makes head movement uncomfortable for the patient as a pulling sensation is felt. Basilic and Cephalic veins Accessing the basilic or cephalic veins carries a much lower complication rate during insertion and infection risk post insertion. Dressing application is easy. However in the acutely ill patient these veins may be difficult to access due to previous cannulations, the need for repeated blood tests or oedema. Femoral vein Wherever possible the femoral route should be avoided for PN. Use of the femoral vein carries a high risk of infection and thrombosis (Hamilton., 2006). There is also a much higher demand for nursing management for skin hygiene due to the risk of contamination from urine and faeces. Dressing application may also be an issue particularly in patients who are mobile or incontinent as frequent dressing changes may be required Types of Lines Peripheral cannula Although easy to insert the use of a peripheral cannula for PN places restrictions on the type of feeding solution that can be used, as not all products are suitable for peripheral administration. Database No: 338 Page 12 of 46 Version 0.2

13 There is an associated risk of developing thrombophlebitis with a peripheral cannula therefore it is advisable to change the site of the cannula every hours according to patient need and availability of veins. For the administration of PN peripheral access should only be used for short term therapy (up to 14 days) as the patient may at risk of phlebitis, infiltration and extravasation (Campbell et al., 2011) Non tunnelled central venous catheters Short term venous central catheters are non-tunnelled, cm long polyurethane (PUR) catheters inserted in a central vein (subclavian vein, internar jugular vein, innominate vein, axillary vein or femoral vein): they may have a single lumen or multiple lumens, and they should be used only in hospitalized patients (Ryder, 2006). Medium term central catheters are non-tunnelled central venous devices: they include PICCs (peripherally inserted central catheters) and Hohn catheters. PICCs are non-tunnelled central catheters inserted through a peripheral vein of the arm (basilica or brachial or cephalic vein); they are cm long and usually made of silicone or 2nd- 3rd generation PUR. Both PICCs and Hohn catheters can be used for prolonged PN, up to 3-6 months. (Ryder., 2006). With regards to PN in the hospitalized patient, there is no clear data showing significant advantages of PICCs vs. centrally inserted central venous catheters (CVC). Some evidence suggests that PICC may be preferable because associated with fewer mechanical complications at insertion, lower costs of insertion, and a lower rate of infection (Timmis., 1998) it is accepted that placement in the antecubital fossa or at midarm carries the important advantage of removing the exit site of the catheter away from endotracheal, oral and nasal secretions (Pratt., 2007) Tunnelled Lines Long term (> 3 months) requires a long term venous access device, such as a tunnelled central catheter (Hickman, Broviac, Groshong, etc.) or a totally implanted port. The choice between a tunnelled catheter vs. a port depends on many factors, mainly related to patient s compliance, experience of the nursing staff, and frequency of venous access. According to CDC Guidelines (CDC., 2002) totally implantable access devices should be reserved for patients who require long-term, intermittent vascular access, while for patients requiring long term frequent or continuous access (which is the case of PN), a tunnelled CVC is preferable (Class C recommendation according to CDC). NB: PN must be delivered through a dedicated lumen (proximal port) and clearly labelled. If a lumen has been previously used for other substances, flush with saline before using for PN. Care bundles for Central lines should be used in the care of patients with PN via central lines. 11. STARTING PARENTERAL NUTRITION Where possible, patients should be informed of the potential risks and benefits of PN before the treatment begins. Refer to section 6.0 for further information on gaining consent to treatment Assessment Careful assessment of all patients referred for PN is essential in order to understand their nutritional requirements and how they might best be met. A full clinical assessment must include the following: Patient details and reason for referral Clinical history History of nutrient intake and body weight changes Database No: 338 Page 13 of 46 Version 0.2

14 History of gastrointestinal function Laboratory results Risk of re-feeding syndrome Potential length of treatment Referral and prescription A multidisciplinary approach to PN improves patient care and reduces complications as recommended in NICE guideline 32. The referral process within Hywel Dda is based on completion of a specific PN referral form (appendix 4) which requires clinical, dietetic and pharmacy input. If PN is considered as an appropriate route for nutrition, a senior or middle grade clinician responsible for the patients care must document the request in the medical notes, including the indication for PN, likely duration and route of administration. The dietitian will complete the PN request form and make recommendations for the PN regime to enable appropriate prescription form (appendix 5) to be completed by the clinician after consultation with the ward pharmacist. The prescription should be written on the IV section of the prescription chart Patients admitted who are on Home Parenteral Nutrition (HPN) If a patient on HPN is admitted to any hospital within Hywel Dda LHB, the centre managing their HPN should be contacted for advice about the prescription and line care Composition of PN All-in-one 3 chamber parenteral bags will be used within the Health Board. These contain a combination of an amino acids solution, fat emulsion, glucose solution and water. Fat soluble vitamins, trace elements, minerals and electrolytes additions will be made under aseptic conditions. Further modification of PN bags, such as adding extra electrolytes is only available in special circumstances. Further information on the range of bags available and their composition is available in the appendix 7 and Nitrogen The Nitrogen solution used will contain a mixture of essential and non essential amino acids. Requirements are based on a number of factors including body weight and clinical condition. Glutamine is not present in most commercially available amino acid solutions due to its instability. However it can be added to a PN bag prior to administration Carbohydrate PN formulation contains carbohydrate in the form of glucose only. The maximum amount of glucose should not exceed 7mg/kg/minute. Other glucose sources such as glucose in IV fluids need to be considered when deciding on the final prescription. During critical illness patients demonstrate increased gluconeogenesis and glycogenolysis together with suppressed insulin levels and insulin resistance, all of which can lead to increased glucose levels. Exogenous insulin therapy is likely to be required in this patient group to control blood glucose levels. Database No: 338 Page 14 of 46 Version 0.2

15 Lipid Traditional lipid emulsions are commonly long-chain triglycerides from soybean and/or safflower oils. They contain essential fatty acids to maintain cell membrane integrity and immune function. These lipid emulsions are rich in pro-inflammatory omega-6 fatty acids. Some trials have shown lower complication rates in patients receiving fewer of these fatty acids. Omega-3 fatty acids have an anti-inflammatory effect and there is a growing body of evidence looking at the benefit of using omega-3 based lipid emulsions in PN. Omega 3 containing lipid emulsions may be considered in critical care patients and any patients showing lipid related complications. A minimum of 0.5g fat/kg/day is required to prevent essential fatty acid deficiency and should not exceed 2g fat/kg/day to prevent lipid associated complications (Pullicino & Elia., 2001). In cases of egg allergy where a lipid free PN solution is used, sunflower oil should be rubbed into the patient s skin to prevent essential fatty acid deficiency Fluid Baseline fluid requirements are 30-35mls/kg/day. Additional fluid will be required to compensate for losses e.g. increased body temperature, large drain outputs etc. Caution is needed regarding the amount of additional salt administered in Intra Venous (IV) fluids to avoid fluid retention leading to odema. Further advice is provided in the GIFTASUP guidelines Storage PN bags must be stored in the medication refrigerator (between 2*c and 8*c). Bags stored in the refrigerator must be kept well away from any freezer compartment to prevent ice crystal formation within the PN bag. Each bag must be removed from the refrigerator 1-2hours prior to infusion to allow the solution to reach room temperature away from direct sunlight Administration PN should be introduced progressively and closely monitored, usually starting at no more than 50% of estimated needs for the first 24-48hrs (NICE., 2006) The integrity of each PN bag must be checked prior to administration to ensure there are no leaks in the bag. If a leak is identified the bag must not be used as the risk of microbial contamination is high. All PN bags must be covered by a light protective bag during infusion to reduce vitamin degradation. PN solution must be administered using a volumetric pump fitted with occlusion and airin-line alarms. This will reduce the risk of continued administration when there is a potential embolus in the line (air/precipitate). All PN bags must be discarded 24 hours after the infusion has commenced and a new PN bag started even if solution remains in the bag. Under no circumstances can additions of any kind be made to the PN bag on the ward. Any unused PN bags should be returned to pharmacy as soon as possible A gradual change from continuous to cyclical feeding should be made with patients who have received PN for more than 2 weeks Rate of administration Rate of administration of PN will be recommended by the dietitian. The patient s risk of refeeding syndrome, glycaemic control and fluid balance will all be incorporated in the decision. Database No: 338 Page 15 of 46 Version 0.2

16 Rate of infusion should not exceed 2.6ml/kg body weight/hour in central bags and 3.7ml/kg body weight/hour in peripheral bags Undesired effects of PN Common >1/100, <1/10 Blood & lymphatic disorder Respiratory, thoracic & mediastinal disorders Gastrointestinal disorders Immune system disorders Investigations Uncommon >1/1000, <1/100 Abdominal pain, nausea, vomiting Increase in plasma levels of liver enzymes Headache Very rare <1/10000 Haemolysis, reticulocytosis Tachypoena Hypersensitivity reactions e.g anaphylactic reaction, skin rash, urticaria Nervous system disorders Reproductive system Priapism and breast disorders Vascular disorders Thrombophlebitis Hypotension, hypertension General disorders & Rise in body Chills, tirdness administration site temperature conditions Overdose of PN Symptoms such as nausea, vomiting and sweating have been observed during amino acid infusion at rates exceeding the recommended maximum rate. Additionally, overdose might cause fluid overload, electrolyte imbalances, hyperglycaemia and hyperosmolality. If symptoms of overdose occur, the infusion should be slowed down or discontinued Fat overload syndrome An impaired capacity to eliminate fat may lead to fat overload syndrome. It is characterized by hyperlipidaemia, fever, hepatosplenomegaly, anaemia, leucopenia, thrombocytopenia, coagulopathies and coma. It may occur as a result of overdose in the amount of lipid given or exceeding the infusion rate. It can also occur at recommended infusion rates due to a sudden change in the patient s clinical condition resulting in severe renal or hepatic impairment Allergic reaction In the case of an allergic reaction, PN should be stopped immediately until the cause is identified. 12. CONNECTING AND DISCONNECTING PN INFUSION Nurses should be IV trained and competent to set up and disconnect PN. Staff must attend the Health Board PN Study Day. Guidelines for connecting and disconnecting a PN infusion are available in appendix 9 and 10. Database No: 338 Page 16 of 46 Version 0.2

17 13. FLUSHING A CENTERAL LINE FOR PN Flush lumen before starting and on completion of PN with 20mls of sterile normal saline. Flush using rapid push/pause technique on Hickman lines, draw back and flush for central lines. This creates turbulence within the lumen decreasing the risk of occlusion. If feed is stopped for any reason the lumen must be flushed immediately. Syringe size must be 10mls or larger. Smaller syringes increase the pressure exerted upon the catheter potentially leading to venous damage or rupture of the lumen. 14. GIVING MEDICATION No medication may be given through a lumen required for PN. The line must be labelled. Do not disconnect PN to give medication. 15. OUT OF HOURS PN Malnutrition is a culmination of a gradual process and cannot be considered as an emergency. Out of hours PN in fact increases the risks of complications including sepsis and metabolic disturbances. There is rarely, if ever, an indication to start PN out of normal working hours (NCEPOD., 2011). The best nutritional care out of hours is to ensure appropriate fluids and vitamin and electrolyte replacement in preparation for PN to start safely and at the earliest opportunity. New patients: The approach advised is as follows: Consider the patients risk of refeeding syndrome (Refer to appendix) Check U&E s including magnesium, phosphate and calcium and correct as indicated Give IV thiamine (Pabrinex) Ensure IV fluids in situ Monitor blood glucose levels frequently Refer to Dietitian / Ward Pharmacist on the next working day Existing patients: In the event of the need to replace an existing bag due to leakage or similar damage, a limited range of bags are located in the main pharmacy refrigerator. These can only be obtained via the on-call pharmacist. 16. MONITORING In view of potential risks associated with PN regular review and monitoring of PN patients is essential. The aim is both to prevent and recognise complications as early as possible in order to limit their consequences. Both clinical and laboratory review are needed on a daily basis during the early phases of PN. In the longer term when the patent is more stable biochemical monitoring can become less frequent Clinical monitoring Parameter Frequency Rationale Fluid balance Daily Early identification of under / over hydration Database No: 338 Page 17 of 46 Version 0.2

18 Weight HYWEL DDA LOCAL HEALTH BOARD Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly To assess ongoing nutritional status Temperature / blood pressure 4 hourly To detect signs of infection / line malposition Line entry and dressing sites Daily To detect signs of infection / inflammation or thrombohlebitis Gastrointestinal function Daily To assess continued need for PN Laboratory monitoring Parameter Frequency Rationale Interpretation Sodium, potassium, urea, creatinine Glucose Baseline Daily until stable Then 1 or 2 times a week Baseline (send to lab) 4 hourly random BM s initially Daily once stable Assessment of renal function, fluid status, and Na and K status Glucose intolerance is common Interpret with knowledge of fluid balance and medication Urinary sodium may be helpful if patient hyponatraemic, or in complex cases with gastrointestinal fluid loss Good glycaemic control is necessary Magnesium, phosphate Liver function tests including International Normalised Ratio (INR) Calcium, albumin If diabetic refer to ward guidelines Baseline Daily if risk of refeeding syndrome Three times a week until stable Then weekly Baseline Twice weekly until stable Then weekly Baseline Then weekly Depletion is common and under recognised High risk of depletion in refeeding syndrome Abnormalities common during parenteral nutrition Hypocalcaemia or hypercalcaemia may occur Low concentrations indicate poor status Complex. May be due to sepsis, other disease or nutritional intake Correct measured serum calcium concentration for albumin Hypocalcaemia may be secondary to Mg deficiency Low albumin reflects disease not protein status Database No: 338 Page 18 of 46 Version 0.2

19 Full blood count and MCV HYWEL DDA LOCAL HEALTH BOARD Baseline 1 or 2 times a week until stable Then weekly Anaemia due to iron or folate deficiency is common Effects of sepsis may be important C-reactive protein Baseline Then 2 or 3 times a week until stable Assists interpretation of protein, trace element and vitamin results To assess the presence of an acute phase reaction (APR). The trend of results is important The following tests should be requested on an individual patient basis - discuss with lab as necessary. May not be indicated for short term PN or in acute illness Parameter Frequency Rationale Interpretation Folate, B12 Iron, ferritin (if FBC not informative) Baseline Then every 2 4 weeks Baseline Then every 3 6 months Folate deficiency is common Always check if terminal ileum missing Iron deficiency common in long-term Serum folate/b12 sufficient, with full blood count Iron status difficult if APR (Fe, ferritin ) parenteral nutrition The following on an individual patient basis for those on long-term or home PN (Discussion with lab needed) Parameter Frequency Rationale Interpretation Zinc, copper Selenium Manganese 25-OH Vit D Baseline Then every 2 4 weeks, depending on results Baseline if risk of depletion Further testing dependent on baseline Every 3 6 months if on home parenteral nutrition 6 monthly if on longterm support Deficiency common, especially when increased losses Se deficiency likely in severe illness and sepsis, or long-term nutrition support Excess provision to be avoided, more likely if liver disease Low if housebound People most at risk when anabolic APR causes Zn and Cu APR causes Se Long-term status better assessed by glutathione peroxidase Red blood cell or whole blood better measure of excess than plasma Requires normal kidney function for effect Other Monitoring: Parameter Frequency Rationale Interpretation Bone densitometry b On starting home parenteral nutrition Then every 2 years Metabolic bone disease diagnosis Together with lab tests for metabolic bone disease Database No: 338 Page 19 of 46 Version 0.2

20 Albumin Hypoalbuminaemia is not a marker of malnutrition and in itself is never an indication for PN (Austin & Scott.,). Albumin levels drop within 6hours of an acute injury, decreasing by up to 50% in severe cases due to trans-capillary escape rate and reduced return via a lymphatic system. It has been shown that PN does not improve serum albumin over 10days (Gogos et al., 1990) and a failure to rise during a period of nutritional support should not be considered to reflect inadequacy of the nutrition provided (BMJ, 2001). 17. COMPLICATIONS PN can cause a range of complications. All staff dealing with PN must therefore understand PN related complications and recognise the problem as soon as possible Metabolic complications Complication Cause Action Salt and water imbalance Excessive provision of salt and water Excessive fluid losses from high output stomas, fistula or drains Hyperglycaemia Poorly controlled diabetes insulin resistance secondary to sepsis excessive provision of glucose Hypoglycaemia Sudden cessation of rapidly infused glucose/pn solution Inadequate provision of glucose Excessive use insulin Refeeding syndrome Excessive provision of glucose in patients with preexisting malnutrition Derranged LFTS / Hepatic stenosis / Cholestasis Infection / sepsis Portal Bacterial translocation Biliary obstruction Unrecognised previous liver disease New liver disease Drug reaction Excessive provision of lipids / glucose Accurate fluid balance charts Daily weights Monitor pulse, blood pressure, respiration and signs of oedema Review additional sources of fluid Monitor urine sodium levels Careful monitoring Ensure Glucose requirements not exceeded Consider timing of current medication if diabetic Consider use of sliding scale Refer patient to diabetes specialist team Avoid sudden cessation of glucose / PN solutions, taper infusion down prior to disconnection Review current medications Identify at risk patients Refer to Hywel Dda guidelines on Adult patients identified as at risk of re-feeding syndrome Rule out other causes Review total calorie intake and ensure not excessive Consider cyclical feeding Consider alternative lipid formulations Consider frequency of lipid administration Consider introduction of enteral nutrition If Jaundice continues despite above measures, PN should be stopped for 3-4 days. It is also possible to consider oral urosodeoxycholic acid, although further studies are required Database No: 338 Page 20 of 46 Version 0.2

21 in this field Hypertriglyceridaemia Excessive provision of lipids Ensure fat requirements not exceeded Consider reduction in lipid provision Consider frequency of lipid administration Catheter related complications Complication Cause Action Catheter related sepsis Contamination of line Catheter occlusion Mechanical obstruction closed clamp, kink in line or line tip against vein wall Pharmacological incompatibility IV nutrition incompatibility, instability, drug-drug precipitate, drugnutrient precipitate Deposition lipid Thrombosis Catheter damage Too much force applied and catheter splits often during high pressure flushing to clear blockage Stop PN Contact medical team Peripheral / central line blood cultures NEWS score chart Exit swab site swab Consider other sources of infection Establish peripheral IV access Management depends on cause Check for kinks Try changing position of patient or elevate arm Clamp line immediately above damaged portion, as there is a risk of air embolism Inform medical team to obtain alternative peripheral access Thrombosis Central venous clot Stop PN Contact medical team immediately to consider Venogram Extravasation Peripheral vein thrombophlebitis Line placement / erosion through vein wall Hyperosmolar PN Stop PN Inform medical team Establish alternative IV access Stop PN Contact medical team Establish alternative IV access 18. DISCONTINUING PN Withdrawal of PN should be planned and stepwise with a daily review of patient s progress (NICE, 2006). Prematurely stopping PN may lead to further nutritional depletion in patients with pre-existing malnutrition. Establishing another route of feeding is important prior to discontinuing PN. PN can be discontinued when adequate oral and/or enteral support is established. If the patient is taking food and fluids, then accurate food charts should be kept to ensure the patient is eating at least half their meals or tolerating a minimum of 500mls of nutritious fluids per day prior to stopping PN (Austin & Stroud., 2008). Database No: 338 Page 21 of 46 Version 0.2

22 In other instances e.g. the decision for palliative care, it may be appropriate to withdraw PN. This decision must be made in association with the clinical team and patient / relatives. PN should not be stopped abruptly due to the risks of rebound hypoglycaemia. Rates of PN should be reduced to at least 50% for a short period of time before stopping and blood glucose levels monitored after cessation Unplanned stops in PN There are some occasions when reducing the rate of administration is not possible. The most common reasons include: Suspected line sepsis Failed IV access e.g. line has become blocked, fallen out or been pulled out Peripheral vein thrombophlebitis Significant intervention e.g. surgery Iv access required for other therapy Significant change in the patients fluid balance or electrolytes e.g. acute fluid overload or acute renal failure In any case where PN is disconnected for any length of time, disconnect and discard the PN bag. Blood glucose levels should be monitored for rebound hypoglycaemia and any drugs to control blood glucose, especially insulin, will need urgent review Recommencing PN after an unplanned break In the even of any interruptions of PN, previous bags must never be reconnected once it has been disconnected due to increased microbial risks. If the break is less than 4days and the patient was already receiving PN at the full rate for several days before the interruption occurred and was clinically stable on the regimen, then the patient can go straight back on their previous regimen. If the interruption is longer than 4 days, the PN was never fully established at full rate, or the patient was clinically unstable on the regimen given, recommencement may need to be at 25-50% and gradually increased (Austin & Stroud, 2007). 19. LONG TERM PN Hywel Dda LHB is currently unable to provide a homecare package for patient s being discharged on PN. Should a patient require discharge home on PN or if it is anticipated that they will need home PN in the near future, they will need to be referred to an adult Home Parental Nutrition (HPN) Team at one of the following centres: Cardiff or Wrexham. Once referred, the centre will fill in an Individualised Patient Commissioning (ICP) request form, which will allow that centre to apply for funding from the Health Commission Wales. Following training the patient is discharged back into the local area and they will then be followed up by M.D.T. clinics held by the HPN centres. 20. RESPONSIBILITY All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. Optimal care for patients with nutritional problems is enhanced by a M.D.T approach that acknowledges the skills and training of the individuals and professions involved. Best practice suggests a multi-disciplinary nutrition support team should be responsible for managing PN or for advising the Consultant team with respect to PN. Database No: 338 Page 22 of 46 Version 0.2

23 Nutrition Steering Group: Responsible for the oversight of all aspects of nutritional and hydration care within the Health Board. This includes ensuring appropriate policies and procedures are in place and compliance monitored. Doctors: Consider PN in those patients who are unable to maintain nutrition via the oral / enteral route. Hold responsibility for prescribing PN, should it be indicated, as well as the ongoing clinical and laboratory monitoring. Senior Doctors with relevant PN expertise support the training and education of staff in relation to clinical aspects of PN. Nursing staff: Ward nurses have a responsibility to screen patients for nutrition risk using a Health board agreed screening tool on admission and weekly thereafter. Highlight any patients with pre existing malnutrition or those patients deemed at high risk of malnutrition to the medical team and make referral for patients at high nutritional risk to dietetics. Follow prescribed feeding and electrolyte replacement regimes, highlighting any problems on a day to day level. Clinical Nutrition Nurse Specialist: Troubleshoot any line-relate problems whilst the IV line is being used for PN. Support training and education with respect to best practice in nursing care for patients on PN. Dietitian: Responsible for ensuring each patient receives adequate and appropriate nutritional support. Educate and train staff on PN, highlight at risk patients, formulate feeding regimens and monitor nutritional status. Ward Pharmacist: Responsible for checking that the indication for PN is appropriate and checking the accuracy of the PN prescription. Support training and education in relation to prescribing of PN and drug nutrient interactions Aseptic Pharmacist: Responsible for checking that the PN regimen prepared is chemically and physically stable and is appropriate to the route of administration. The aseptic pharmacist is responsible for checking that the electrolyte content is clinically appropriate and within the limits of stability for the regimen. Chemical Pathologist: Advise on treatment of altered blood biochemistry and appropriate investigations. Support training and education in relation to monitoring and responding to biochemical changes related to PN. Clinical biochemist: Advise on interpretation of altered blood biochemistry and appropriate investigations. Infection control team and Microbiology: Investigate any PN line infections that do occur and provide advice to minimise their future occurrence. Support training and education in relation to line care. 21. TRAINING Training will be overseen and co-ordinated via the Nutrition and Hydration steering group, practice development leads and Learning and development department Health Board wide. A log of all staff trained / made aware of the guideline will be kept within each locality of the Health Board. Database No: 338 Page 23 of 46 Version 0.2

24 22. IMPLEMENTATION An implementation plan will be overseen and co-ordinated via the Nutrition and Hydration Steering group. Monitoring of this guideline will be through clinical audit. 23. FURTHER INFORMATION Audit Commission briefing: A spoonful of sugar. Medicines management in NHs Hospitals (2001) British Pharmaceutical Nutrition Group (BPNG). Position statement on the use of multichamber parenteral nutrition bags for use in adult patients European Society for Parenteral and Enteral Nutrition (ESPEN) Guidelines on Parenteral Nutrition British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP), Hywel Dda Nutrition Web page available via the LHB intranet National Institute of Clinical Excellence (NICE): Clinical Guideline 32 Nutritional Support in Adults (2006) National Confidential Enquiry into Patient Outcome and Death (NCEPOD) A mixed bag. An enquiry into the care of hospital patients receiving parenteral nutrition (2010) National Patient Safety Alert (NPSA). Promoting safer use of injectable medicines (2007) Royal College Physicians (RCP). Oral Feeding Difficulties & Dilemmas 2010 Royal College of Nursing (RCN). Standards for infusion therapy (2010) 24. CLINICAL POLICIES 209: Hywel Dda Adult Refeeding Syndrome Guidelines Hywel Dda Adult Enteral Feeding Policy 215: Interim Policy For the Insertion of CVP Lines HD018: Guidance on the Mental Capacity Act 4306: Policy & Procedures for Instructing the Independent Mental Capacity Advocate (IMCA) service 25. REVIEW This guideline will be reviewed in two years time. Earlier review may be required in response to any relevant changes in national guidance. 26. REFERENCES Austin P & Stroud M. (2007) Prescribing Adult Intravenous Nutrition. Pharmaceutical press. Ayliffe G. et al. (2000) Control of Hospital Infection: A practical handbook (4 th edition). Hodder Arnold Campbell C (2011) Peripheral vascular access devices: Care and maintenance. British Journal of cardiac nursing. Volume 6 (3). Department of Health (DOH):London. High quality care for all (2008). Dimond B (2002) Legal aspects of consent. Salisbury, Quay books. Hamilton, H. (2006). Complications associated with venous access devices: Part one. Nursing Standard, 20(26): Masoorli, S. (2002). Getting a line on CVAD: Central vascular access devices. Nursing. 32(4) Database No: 338 Page 24 of 46 Version 0.2

25 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) A mixed bag. An enquiry into the care of hospital patients receiving parenteral nutrition (2010) National Institute for Clinical Excellence (2006) Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. NICE. London. NMC (2008) The code: standards of conduct, performance and ethics for nurses and midwives. Pratt et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 65S, S1 S64. Ryder M. Evidence-Based Practice in the Management of Vascular Access Devices for Home Parenteral Nutrition Therapy. JPEN 2006, 30:S82 S93. Timmis L. PICC of the bunch. Peripherally inserted central catheter. Nurs Times 1998;94:70-73 Todd (1998). Peripherally inserted central catheters. Professional Nurse. 13(5) (111). Rowley JS (2001) Aseptic no touch technique. Nursing times 97: 7 Yebenes J et al (2008). Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect handling. Critical care medicine Vol 36, issue APPENDIX 1: ENTERAL & PARENTERAL ALGORITHM Patient unable to meet nutritional needs through oral route alone Do you anticipate that intestinal absorptive function will meet all nutritional needs? Yes Is the patient s GI tract accessible & functioning? No No Yes Yes Is the oesophagus &/- stomach absent? No Is the GI tract obstructed? No Yes Is there impaired gastric emptying? Database No: 338 Page 25 of 46 Version 0.2

26 Yes No Are methods to improve gut function (e.g prokinetics) successful? No Yes After consideration of risk v benefit, is trial of NG tube feeding +/- oral nutrition appropriate? No Gastrostomy +/- oral nutrition Is feeding likely to be short term (eg <4weeks)? No Jejunal feeding +/- oral nutrition Yes NG tube feeding +/- oral Review of indications for route, risks, benefits & goals of nutritional support at regular intervals depending on the patient, care setting & duration of nutrition support. Intervals between monitoring may increase as the patient is stabilised on nutrition Is adequate nutrient intake achieved & tolerated? No Yes Review need to continue nutrition support 28. APPENDIX 2: REFEEDING SYNDROME when oral intake meet Refeeding syndrome (RFS) is severe fluid and electrolyte shifts associated adequate with nutritional initiating needs & nutritional support in malnourished patients and the metabolic implications, maintain which nutritional occur status as a result of this (Solomon and Kirby 1990). Potential consequences of RFS include: Cardiac failure, pulmonary oedema and dysrhythmias Acute circulatory fluid overload or circulatory fluid depletion Hypophosphataemia Hypokalaemia Hypomagnesaemia and occasionally hypocalcaemia Hyperglycaemia IDENTIFICATION OF PATIENTS AT RISK OF REFEEDING SYNDROME (NICE, 2006) At Risk: Those who have one or more of the following:! Very little or no food intake for more than 5 days especially if already undernourished! BMI < 20kg/m 2 *! Unintentional weight loss > 5% within the last 3-6 months* High Risk: Patient has one or more of the following:! BMI < 16kg/m 2 *! Unintentional weight loss > 15% within the previous 3-6 months*! Very little or no nutritional intake for > 10 days Consider parenteral nutrition +/- enteral / oral nutrition Stop parenteral nutrition if / when adequate oral +/- enteral nutrition support meets nutritional needs & maintains nutritional status. Stop enteral tube feeding if / Database No: 338 Page 26 of 46 Version 0.2

27 ! Low levels of potassium, phosphate or magnesium prior to feeding Or patient has two or more of the following:! BMI < 18.5kg/m 2 *! Unintentional weight loss > 10% within the previous 3-6 months*! Those with very little or no intake for > 5 days! A history of alcohol or drug abuse or some drugs including insulin, antacids or diuretics and patients on chemotherapy. Extremely high risk: Patient has one or more of the following:! BMI < 14kg/m 2 *! Negligible intake for > 15 days! Pre-feeding hypokalemia, hypophosphataemia or hypomagnesaemia Other considerations! Refeeding syndrome can occur in patients receiving oral, enteral or parenteral nutrition. It is less likely to occur in those fed orally (although it is possible) since starvation is usually accompanied by a reduction in appetite! There have been reported cases of re-feeding syndrome occurring in patients with chronic vomiting (hyperemesis gravidarum), prolonged diarrhoea, gastrointestinal obstruction, malabsorption diseases, and poorly controlled diabetes! Refeeding problems can also occur in overweight patients who have eaten nothing for prolonged periods. Particular caution needed in bariatric surgical patients who have developed complications resulting in a significant period of starvation.! Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels. The combined effect of rehydration and refeeding can cause significant changes in biochemistry within hours to very low levels. (PENG, 2011) STARTING NUTRITION FOR PATIENTS AT RISK OF REFEEDING SYNDROME At risk patients Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before increasing to full requirements if clinical and biochemical monitoring reveals no abnormalities. Meet full requirements for fluid, electrolytes, vitamins, minerals and trace elements from day 1 of feeding High risk and extremely high Risk patients Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days. Any increase in feed should be dependent on trends in biochemistry. Using only 5kcal/kg/day in extremely high risk patients, monitoring cardiac rhythm in this group and any others who have or develop cardiac arrhythmias is recommended Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary Provide immediately before and during the first 10 days of feeding: oral thiamine, vitamin B- co strong (or full dose daily intravenous vitamin B preparation if necessary) Provide a balanced multivitamin/trace element supplement once a day Database No: 338 Page 27 of 46 Version 0.2

28 Please refer to Adult Refeeding guidelines (Guideline 209) on the Hywel dda intranet for more detailed information on RFS. Starter regimens are available in the appendix of this guideline for safe management of at risk patients requiring enteral feeding out of hours. 29. APPENDIX 3: ADULT PARENTERAL NUTRITION REFERRAL PROCESS Decision made for PN Referral form completed by clinical team and left in medical notes Medical team / Nursing staff to contact Dietitian for full assessment Nutritional assessment completed by Dietitian highlighting / discussing concerns with clinical team. Referral form and nutritional assessment to be filed within dietetic records. Once PN regimen decided, Dietitian to contact Pharmacy and complete pharmacy request form Pharmacy to check prescription request, informing Dietitian / clinical team of any concerns Database No: 338 Page 28 of 46 Version 0.2

29 Clinical team to ensure appropriate prescription written on IV section of the prescription chart Pharmacy to label PN bag with patient information and inform ward staff when the bags are available on the ward Any changes to the PN prescription need to be highlighted to clinical team and pharmacy and change of regimen form completed 30. APPENDIX 4: ADULT PARENTERAL NUTRITION REFERRAL FORM DATE:. ADDRESSOGRAPH WARD:... CONSULTANT:. RELEVANT PMH:..... INDICATION FOR PARENTERAL NUTRITION: Intestinal obstruction [ ] Inflammatory bowel disease [ ] Intestinal failure [ ] Severe pancreatitis [ ] Short bowel [ ] Inadequate enteral nutrition [ ] Radiation enteritis [ ] Oral mucositis [ ] Surgical complications e.g. anastomotic leak, adhesions, fistulation [ ] Has enteral nutrition been considered: Y [ ] N [ ] ROUTE OF ADMINISTRATION: Central Line [ ] Peripheral Line [ ] Dedicated cannula available for PN? Y [ ] N [ ] Date line inserted: Database No: 338 Page 29 of 46 Version 0.2

30 LIKELY DURATION OF PN: 5-14 days [ ] days [ ] >28days [ ] ASSESSMENT Weight:..Kg Estimated / actual weight:.. Odema present Y [ ] N [ ] Ascities present Y [ ] N [ ] Need for fluid restriction: Y [ ] N [ ] if yes, volume of restriction: mls Date of last bloods:. Has the patient consent been obtained to start PN: Yes [ ] No [ ] Signature: Name:.. Designation:. Date:. Once completed Please contact the ward Dietitian for a full assessment NUTRITIONAL ASSESSMENT to be completed by Dietitian Nutrition Screening tool score:... Duration of restricted oral nutritional intake:.. If ascites / odema present est dry weight:.kg % weight loss:.. BMI:.Kg/m 2 Re-feeding syndrome risk: No risk [ ] At Risk [ ] High risk [ ] GI losses: Diarrhoea / fistula out put / drain out put / NG out put Estimated fluid losses:. Estimated electrolyte losses (mmol\l): Na. K+. Mg. Po 4-. Blood Glucose levels (mmol/l):.. Is the patient Diabetic? Y [ ] N [ ] If yes, what medication are they receiving for their diabetes?.. Current Fluid intake:.. CALCULATED REQUIREMENTS: Energy (Kcals) Nitrogen (g) Fluid (mls) Potassium (mmol) Sodium (mmol) Magnesium (mmol) Phosphate (mmol) Calcium (mmol) GOR (g) Database No: 338 Page 30 of 46 Version 0.2

31 OTHER NUTRITIONAL INTAKE: e.g. IV fluids, sedation APPENDIX 5: ADULT PARENTERAL NUTRITION PHARMACY REQUEST FORM DATE:. ADDRESSOGRAPH WARD:... CONSULTANT:. RELEVANT PMH:..... NAME OF RESPONSIBLE DIETITIAN: BLEEP: LIKELY DURATION OF PN: 5-14 days [ ] days [ ] >28days [ ] ROUTE OF ADMINISTRATION: Central Line [ ] Peripheral Line [ ] RECOMMENDED PN BAG:.. GLUTAMINE RECOMMENDED: Y [ ] N [ ] OTHER ADDITIONS:.. RECOMMENDED REGIMEN: Day 1: Volume:.. Rate: Duration: Day 2: Volume:.. Rate: Duration: Day 3: Volume:.. Rate: Duration: TARGET REGIMEN: Volume:.. Rate: Duration: Pharmacist signature:. 32. APPENDIX 6: ADULT PARENTERAL NUTRITION PHARMACY CHANGE OF REGIMEN FORM DATE:. ADDRESSOGRAPH Database No: 338 Page 31 of 46 Version 0.2

32 WARD:... CONSULTANT:. NAME OF RESONSIBLE DIETITIAN: BLEEP:. CURRENT PN REGIMEN:... CHANGE OF REGIMEN: NAME OF BAG: VOLUME:.. RATE: DURATION: DATE EFFECTIVE FROM: Database No: 338 Page 32 of 46 Version 0.2

33 33. APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS Product Kabiven 8gN Kabiven11gN Kabiven 14gN Kabiven 5gN Kabiven 7gN Administration Central Peripheral Kabiven 9gN Volume (mls) Amino acids (g) Nitrogen (g) Fat (g) Glucose (g) Calories (Kcals) Total Non-protein Lipid CHO Electrolytes (mmols) Sodium Potassium Magnesium Calcium Phosphate Chloride Acetate Maximum infusion rate 2.6ML/KG BODY WEIGHT/HOUR 3.7ML/KG BODY WEIGHT/HOUR

34 34. APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS Drug name Additrace (per 10 ml vial) Solivito (per 10ml vial) Vitlipid (per 10ml vial) Pabrinex (vial 1&2) Route Intra venous(iv) I.V I.V I.V Contents A units - B1 Thiamine - 3.1mg - 250mg B2 Riboflavine - 4.9mg - 4mg B3 Niacin mg B5 Pantothenic mg - - acid B6 Pyridoxine - 4.9mg - 50mg B7 Biotin - 60mcg - - (Vitamin H) B8 Inositol B9 Folic Acid - 400mcg - - B12-5mcg - - C - 100mg - 500mg D - - 5mcg - E mg - K mcg - Zinc 100micromol Copper 20 micromol Selenium 0.4 micromol Manganese 5 micromol Iron 20micromol Molybdenum 0.2 micromol Chromium 0.2 micromol Iodine 1 micromol Fluoride 50 micromol Calcium Phosphorus Magnesium Potassium Database No: 338 Page 34 of 46 Version 0.2

35 35. APPENDIX 9: GUIDELINE FOR CONNECTING A PARENTERAL NUTRITION INFUSION Nurses should be IV trained and competent to set up and disconnect parenteral nutrition Equipment required Bag of parenteral nutrition (PN) labelled for the patient Patient prescription chart Basic wound dressing pack Sterile gloves Sterile giving set Needle-free connector (if it is due to be changed) Drawing up needle 10 ml 0.9% Sodium chloride for injection Alcohol hand gel 70% alcohol or alcohol/ chlorhexidine wipes 70% alcohol spray for hard surfaces Sharps bin Procedure Connecting a PN infusion using aseptic technique Equipment required as listed above. Check patient identity, explain procedure, gain verbal consent Ensure patient is comfortable Rationale PN readily supports bacterial growth therefore it is an independent risk factor for sepsis. In order to reduce the risk of sepsis, all PN regimens (central and peripheral) need to be administered using aseptic technique (Pratt et al, 2007). Aseptic technique prevents contamination by ensuring only sterile items come into contact with the connection to the patient (Ayliffe et al, 2000). Preparation will prevent interruption to aseptic technique and connection process. The environment in which the procedure is carried out must be visibly clean, free of dust and soilage before an aseptic is commenced (DOH, 2008) To ensure the patient understands the procedure and gives his/her valid consent (NMC, 2008) Transfer to treatment room to conduct procedure in clean, uncluttered environment, free of interruptions Decontaminate dressing trolley first with detergent solution and dry carefully with paper towels. Prior to use for aseptic technique. Cleaning physically removes a high proportion of microorganism and protein material using detergent and water (Ayliffe et al, 2000) Decontaminate the dressing trolley before and after each use

36 Collect the equipment needed, check packaging for expiry date and damage and place on bottom shelf of a clean trolley. Check prescription against PN bag contents and patient identity as per Health Board IV policy Social hand wash with liquid soap Effective hand washing requires three stages: Preparation: requires wetting hands before applying liquid soap. Washing & Rinsing: the hand washing solution must come into contact with all surfaces of the hand and the hands must be rubbed together vigorously for seconds paying particular attention to the tips of the fingers, the thumbs and the area between the fingers Hands should be rinsed thoroughly. Drying: with good quality paper towels If an infusion has just finished (i.e. the patient is receiving PN infusion over 24 hours without a break) switch off the pump, close roller clamp on the giving set and close the clamp of the PN lumen on the intravenous catheter Snap port off PN bag infusion port, Decontaminate the infusion port with disinfection wipe for 5-10 seconds with a vigorous back and forth motion, and allow to air dry. HYWEL DDA LOCAL HEALTH BOARD To check no equipment is out of date or damaged To reduce the time sterile field is exposed to potential contaminants. To ensure the correct solution (script dose and time) is administered to the correct patient via the correct route To remove dirt and transient organisms. Hand mediated transmission is a major contributing factor to infection. Handwashing is the single most important procedure for preventing hospital acquired infection. Effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands and decreases the incidence of preventable hospital acquired infections Ensure hands are dry - damp hands transfer bacteria more readily than dry. To close the system to the patient Port is not sterile and needs to be decontaminated. Database No: 338 Page 36 of 46 Version 0.2

37 Wash hands and put on apron HYWEL DDA LOCAL HEALTH BOARD To help prevent risk of transmission of micro-organisms (refer to Infection Control Guidelines) Open the dressing pack unfold the sterile field touching corners and edges only- and place on trolley Open onto the centre of the sterile towel: Giving set Sterile gloves Replacement needle-free connector if required (e.g. change once weekly, or more frequently if cracked or damaged as according to manufacturer s instructions) Drawing up needle 10mL syringe Place the sterile towel underneath the intravenous catheter, unfold touching corners and edges only Clean hands with alcohol hand gel: Only 1 squirt of the hand gel is required. The hand gel solution must come into contact with all surfaces of the hand. Hands must be rubbed together vigorously paying particular attention to the tips of the fingers, the thumbs and the area between the fingers and until the solution has evaporated and the hands are dry (approximately 15 seconds). Put on sterile gloves Touching only the edges ensures that the centre of the pack remains sterile To maintain sterility of items. No smaller than a 10mL syringe to be used (smaller syringes exert greater pressure, which might cause catheter fracture) Todd, 1998 To provide a sterile environment. Touching only the edges ensures that the centre of the pack remains sterile. To eliminate contamination from handling outer surface of packaging. To eliminate any micro-organisms from hands. Gloves provide a barrier that minimises passage of micro-organisms (Rowley, 2001) Database No: 338 Page 37 of 46 Version 0.2

38 Draw up the flush place drawing up needle on to syringe and draw up 10mLs of 0.9% sodium chloride for injection. Expel air and remove drawing up needle (discard in sharps bin) If a previous giving set is attached to the intra-venous catheter (i.e. no break between PN infusions) using gauze from the pack to hold the line and to allow a non touch technique, detach the previous giving set Take the disinfection wipe and open out holding edges and use untouched surfaces to clean hub. Only the wipe surface is in contact with the hub. Decontaminate the hub / access connector70% alcohol wipes (Pratt et al, 2007) for 5-10 seconds with a vigorous back and forth motion, and allow to dry. Place the intra-venous catheter end on a dry part of the sterile towel HYWEL DDA LOCAL HEALTH BOARD The use of a drawing up needle protects the tip of the syringe and hence the needle-free connector, from contamination. Sterile 0.9% sodium chloride for injection should be used to flush the catheter lumen (Pratt et al, 2007) (See Sharps policy) To maintain a non touch aseptic technique Contamination of the catheter hub is an important contributor to intra-luminal microbial colonisation of catheters (Pratt et al, 2007) A sterile barrier that has become wet is considered contaminated Attach syringe to connector and flush Clamp intra-venous catheter while flushing the last ml of fluid The catheter should be clamped while the final 0.5mls of the flush is being injected, to maintain a positive pressure to help prevent blood entering the catheter after flushing, which might lead to thrombus formation (Todd, 1998) Ensure to then release the pressure on the syringe plunger before twisting off to remove. This allows the valve of the needle-free connector to return to the closed (i.e. non recessed) position Database No: 338 Page 38 of 46 Version 0.2

39 * If a replacement needlefree connector is required: Using gauze from the pack to hold in each hand, use a non touch technique to detach the previous needlefree connector and discard. Wipe with a disinfection wipe (as above) and allow to dry. Attach the new needle-free connector HYWEL DDA LOCAL HEALTH BOARD A needle free connector can be used for up to 100 activations and over a period of 96 hours; replace when either limit is reached. As above, ensure clamp on intra-venous catheter is closed, to ensure a closed system and prevent air entering the system and risk of air embolism. Interruptions to the closed system should be kept to a minimum to decrease risk of contamination Ensure the needle free device is intact and flush with housing (i.e. not recessed). If the valve has been incorrectly accessed with a needle, appears recessed or cracked or damaged in any way, replace immediately When using / changing a needle-free device ensure that all components of the system are secured, to minimise breaks and leaks in the system (Pratt et al, 2007) Needle-free IV access devices reduce risk of needle stick injury, and with correct handling and disinfection before handling, reduce transmission of blood borne pathogens and contamination of the fluid pathway (Yebenes et al, 2008) Close roller clamp on the giving set. Remove protective cover off the giving set spike and insert into PN bag infusion port, taking care that the other end of the giving set does not move off the sterile field Half fill the chamber of the giving set. Carefully prime the line Attach the giving set to the intra-venous catheter Set the volumetric pump volume to be infused and rate according to the prescription Un-clamp the PN lumen of the catheter and commence the infusion (proximal port) Removing the cover off the giving set spike just before insertion will reduce the risk of contamination Carefully prime the giving set to remove all air from the line before administration. Air must not be allowed to enter the catheter due to risk of air embolism All PN admixtures should be administered via dedicated intravenous catheters, through an electronic volumetric pump /controller with an occlusion and air in line alarm (NCCAC, 2006). It is an MHRA directive that all staff receive documented training in the use of any medical device they use (Dimond, 2002) Database No: 338 Page 39 of 46 Version 0.2

40 Remove gloves, clear away rubbish Social hand wash with liquid soap Sign the prescription, record fluid volume on fluid chart and document in nursing notes HYWEL DDA LOCAL HEALTH BOARD Gloves provide an ideal climate for micro-organism growth. Gloves must be disposed of as clinical waste and hands decontaminated by washing with liquid soap and water after the gloves have been removed (Pratt et al, 2007) To follow national and Trust documentation guidelines If the intra-venous catheter has more than one lumen, label one lumen for PN use ONLY. (Do not use for taking routine bloods, only for central blood culture if required). Monitor for complications as per PN guidelines below To dedicate one lumen for PN use only Decreasing manipulation and use of the PN lumen decreases risk of contamination and catheter related infection Nurses are accountable for knowledge and monitoring of intra-venous catheter and PN related complications as per Health Board Guidelines Database No: 338 Page 40 of 46 Version 0.2

41 36. APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A PARENTERAL NUTRITION INFUSION Use the following guideline when disconnecting / discontinuing a parenteral nutrition infusion. (If a new PN bag is to be attached (i.e. a 24 hour infusion without a break) or the needle-free connector is due to be changed please refer to the above guideline Connecting a Parenteral Nutrition Infusion ). Nurses should be IV trained and competent to set up and disconnect parenteral nutrition Equipment required Basic wound dressing pack Sterile gloves 10 ml syringe Drawing up needle 10 ml 0.9% Sodium chloride for injection Alcohol hand gel 70% alcohol wipes 70%alcohol hard surface wipes Sharps bin Procedure Disconnecting a PN infusion using aseptic technique Gather equipment required as listed above Check patient identity, explain procedure, gain verbal consent / acting in patient s best interests Ensure patient is comfortable Rationale PN is a particularly good media for microorganisms and readily supports bacterial growth, therefore PN is an independent risk factor for sepsis. In order to reduce the risk of sepsis, all PN regimens (central and peripheral) need to be administered using aseptic technique (Pratt et al, 2007). Aseptic technique prevents contamination by ensuring only sterile items come into contact with the connection to the patient. Preparation will prevent interruption to aseptic technique and disconnection process. The environment in which the procedure is carried out is as clean and safe as possible. To inform the patient about the procedure and gain consent to proceed. Transfer to treatment room to conduct procedure in clean, uncluttered environment, free of interruptions Database No: 338 Page 41 of 46 Version 0.2

42 Social hand wash with liquid soap HYWEL DDA LOCAL HEALTH BOARD Switch off the pump, close roller clamp on the giving set and close the clamp of the PN lumen on the intra-venous catheter Clean the trolley. If visibly dirty clean trolley first with soap and water. Clean the trolley with alcohol spray Collect the equipment needed, check packaging for expiry date and damage and place on bottom shelf of a clean trolley. Wash hands and put on apron Open the dressing pack unfold the sterile field touching corners and edges only- and place on trolley Open onto the centre of the sterile towel: Sterile gloves Drawing up needle 10mL syringe Disinfection wipe To remove dirt and transient organisms. Ensure hands are dry - damp hands transfer bacteria more readily than dry To close the system to the patient To remove dirt and transient organisms To check no equipment is out of date or damaged To reduce the time sterile field is exposed to potential contaminants. To help prevent contamination Touching only the edges ensures that the centre of the pack remains sterile To maintain sterility of items. No smaller than a 10mL syringe to be used (smaller syringes exert greater pressure, which might cause catheter fracture) Take a second disinfection wipe and clean the 0.9% sodium chloride ampoule, snap it open and place on the edge of the trolley OR alternatively pour into sterile galipot / tray of infusion pack Place the sterile towel underneath the intra-venous catheter, unfold touching corners and edges only Clean hands with alcohol hand gel Only 1 squirt of the hand gel is required. The hand gel solution must come into contact with all surfaces of the hand. Hands must be rubbed together vigorously paying particular attention to the tips of the fingers, the thumbs and the area between the fingers, and until the solution has evaporated and the hands are dry (approximately 15 seconds). Put on sterile gloves Ready for use in aseptic technique To provide a sterile environment. Touching only the edges ensures that the centre of the pack remains sterile To eliminate contamination from handling outer surface of packaging To eliminate any micro-organisms from hands. Gloves provide a barrier that minimises passage of micro-organisms (Rowley, 2001) Database No: 338 Page 42 of 46 Version 0.2

43 Draw up the flush place drawing up needle on to syringe and draw up 10mLs of 0.9% sodium chloride for injection. Expel air and remove drawing up needle (discard in sharps bin) Using gauze from the pack to hold the line and to allow a non touch technique, detach the previous giving set from the catheter hub / needle-free connector Take the disinfection wipe from the sterile field and open out holding edges and use untouched surfaces to clean hub. Only the wipe surface is in contact with the hub. Allow to air dry. Place the intra-venous catheter end on a dry part of the sterile towel Attach syringe to connector and flush The use of a drawing up needle protects the tip of the syringe and hence the needle-less connector, from contamination To maintain a non touch aseptic technique (A needle-free connector should be in place. See Connecting a Parenteral Nutrition Infusion for guidance on changing the connector) To disinfect the hub / needle-free connector A sterile barrier that has become wet is considered contaminated Clamp intra-venous catheter while flushing the last ml of fluid Remove gloves, clear away rubbish Social hand wash with liquid soap Document on the fluid balance chart Monitor for complications as per PN and central venous catheter guidelines The catheter should be clamped while the final 0.5mls of the flush is being injected, to maintain a positive pressure to help prevent blood entering the catheter after flushing, which might lead to thrombus formation Ensure to then release the pressure on the syringe plunger before twisting off to remove. This allows the valve of the needle-free connector to return to the closed (i.e. non recessed) position Gloves provide an ideal climate for microorganism growth. Safe disposal of clinical waste prevents spread of infection To follow national and Trust documentation guidelines Nurses are accountable for knowledge and monitoring of intra-venous catheter and PN related complications as per Health Board guidelines Database No: 338 Page 43 of 46 Version 0.2

44 9.4 Parenteral feeding HYWEL DDA LOCAL HEALTH BOARD Patient Details/Addressograph: Patient Problem: Nursing Intervention: Patient Objective/outcome: Patient has a poor dietary intake and Anxiety Reduction is unable to provide nutritional Feeding requirements enterally, requires parenteral feeding through a (tick all Nutrition Therapy that apply) Nutrition Management Fluid Management Peripheral line Central line PLEASE COMPLETE DAILY Plan of care - Please tick all that apply Date Explain all procedures, care and treatment to patient To meet the patient s nutritional and fluid requirements as per patient s stated wishes To prevent and identify potential complications to ensure safe feeding Review Maintain privacy, dignity and comfort throughout. Take appropriate measures to prevent cross-infection e.g. hand washing, when changing the administration set Peripheral parenteral feeding (Less than 14 days) Assist with the insertion of the peripherally inserted central catheter Ensure that this is used only for parenteral feeding Note any signs of infection, inflammation or thrombophlebitis and inform Dr Central parenteral feeding (more than 14 days) Ensure a dedicated centrally placed central venous catheter. (A dedicated free lumen in a multi-lumen centrally placed catheter maybe used but needs to be appropriately labelled to avoid confusion) Central/peripheral parenteral feeding Refer to Dietitian for nutritional assessment prior to commencing feeding DATE OF REFERRAL Order Parenteral nutrition as requested by dietitian from pharmacy Ask Dr to review Intravenous fluids. Ensure that aseptic technique is used when changing/handling peripheral/central line Monitor catheter entry site daily for signs of infection/inflammation. If noticed consult medical team Record temperature and blood pressure and inform Dr of any abnormalities Complete All Wales fluid balance charts daily and monitor and Database No: 338 Page 44 of 46 Version 0.2