Parenteral Nutrition Policy

Transcription

1 Policy No: RM60 Version: 3.0 Name of Policy: Parenteral Nutrition Policy Effective From: 18/08/2015 Date Ratified 12/08/2015 Ratified SafeCare Council Review Date 01/08/2017 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 11/08/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Parenteral Nutrition Policy v3

2 Version Control Version Release Author/Reviewer Ratified by/authorised by 1.0 February 2009 Nutrition and Dietetics SafeCare Council Date Feb 2009 Changes (Please identify page no.) General update in line with national guidelines Page 7, 9, 14, 18, 20, December 2011 N&DS SafeCare Council Dec 2011 General update page /08/2015 N&DS SafeCare Council 12/08/2015 General update page 4, 5, 7,8, 9, 17, 18 Parenteral Nutrition Policy v3 2

3 Contents Section Page 1 Introduction Policy Scope Aim of policy Roles and responsibilities Definitions Managing parenteral nutrition Indications of parenteral nutrition Patient Assessment Parenteral access routes Types of catheters used for parenteral nutrition Composition of parenteral nutrition Prescribing parenteral nutrition Storing parenteral nutrition Administrating parenteral nutrition Discontinuing parenteral nutrition Monitoring for patient on parenteral nutrition Laboratory monitoring for patient on parenteral nutrition Ethical Considerations Training Equality and Diversity Monitoring compliance with the policy Consultation and review Implementation of the policy References Associated documentation Appendices Appendix 1 Nutrition Risk Score Appendix 2 Nutrition Support team referral document Appendix 3 Parenteral nutrition proforma including prescription Appendix 4 Parenteral Nutrition Regimen form Appendix 5 Emergency out of hours guidelines Appendix 6 Monitoring patients on PN Appendix 7 Biochemical monitoring of patients on PN Parenteral Nutrition Policy v3 3

4 Parenteral Nutrition Policy 1 Introduction Parenteral nutrition (PN) is the administration of nutrients through the intravenous route. It is a specialised form of nutrition support, with associated complications and should be carefully considered and planned on an individual basis. This PN policy was reviewed in line with national guidance Nutrition Support in adults NICE clinical guideline No 32 (2006), and National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June Policy scope This is a trust wide policy aimed at all health care professionals involved in the care of patients receiving parenteral nutrition, to ensure best practice is applied in accordance with national guidelines. 3 Aim of Policy The aim of the PN policy is to ensure that PN is used in appropriate circumstances, that it is administered safely and with appropriate monitoring to prevent potential complications. 4 Roles and Responsibilities Nursing Staff Ward nurses have a responsibility to assess all patients nutritional status using the Trust s Nutrition Risk Score (NRS) tool on admission, and then repeated weekly and if a patient s clinical condition changes (Appendix 1). Nursing staff must inform the Nutrition and Dietetics department if a patient is due to begin PN. Nursing staff are responsible for administering PN with aseptic technique and monitoring the patients fluid balance, GI function and vital signs for potential line sepsis. Medical Staff Medical staff have a responsibility to consider patients for PN if they are unable to maintain or improve their nutritional status via the oral or enteral route. The decision to commence PN should be discussed with the Consultant with overall clinical care for the patient. Nasogastric and nasojejunal feeding must be considered prior to requesting PN. Medical staff are responsible for organising insertion of appropriate venous access, ideally a central line. They are also responsible for requesting and monitoring daily biochemistry and considering whether the patient is at risk of re-feeding syndrome. If there is a significant risk of re-feeding, Pabrinex should be prescribed in addition to PN. The medical staff are responsible for assessing the patient s fluid balance and prescribing appropriate fluids. The volume of PN prescribed should always be taken into account to avoid inappropriate fluid overload. Dietitian Patients who are identified as requiring PN should be referred to the ward dietitian immediately. The dietitian has a responsibility to assess the patient s nutritional requirements and to ensure that the most appropriate PN solution and infusion rate is chosen. They should highlight if the patient is at risk of re-feeding syndrome, which requires close monitoring of electrolytes and the prescription of additional vitamins. They should review the patient on a daily basis until the patient is established on PN to allow alterations to the prescription in terms of electrolytes, macronutrients and volume delivered. Parenteral Nutrition Policy v3 4

5 Pharmacy The aseptic services pharmacist should liaise with the dietitian on a daily basis (Monday to Friday) to check for updates on the patient, discuss biochemistry and the PN prescription. They should check that the alterations to the electrolytes are clinically appropriate and within the limits of stability for the regimen and the route of administration. Nutrition Support Team This is a multidisciplinary team led by a Gastroenterologist. The team will accept referrals from medical and surgical teams to advise on the management of patients with complicated nutritional issues. The team is happy to review patients being considered for PN. The team is also responsible for providing support and education on the methods of PN and also to ensure that policies and guidelines are up to date in accordance with national guidelines to ensure best practice. Acute Response Team ART provide daily reviews of all central lines, to ensure that best practice is maintained. ART provide support and advice regarding all aspects of central line management and PN administration. Infection Control Team The Infection Control Team provides support and advice regarding good aseptic technique for all staff administering PN. They also have a responsibility to monitor and investigate episodes of line sepsis. 5 Definitions The term total parenteral nutrition (TPN) is used when patients are receiving their full requirements through the venous route without any enteral nutrition. 6. Parenteral Nutrition Policy v3 6.1 Indications for Usage of parenteral nutrition PN should only be considered when it is not possible to meet the patients full nutritional requirements using oral or enteral feeding routes (nasogastric or nasojejunal feeding), i.e. if the gut works, use it. Examples of appropriate conditions where PN may be used: Extended non-absorption of enteral nutrition (This must include a trial of Nasojejunal feeding) Post operative ileus Intractable vomiting Major GI surgery where enteral nutrition is contraindicated, e.g. perforation Short bowel syndrome Extensive Crohn s disease where nutrient absorption is severely impaired High output fistula where position and volume prevent enteral feeding Motility disorders such as Sclerodema and chronic intestinal obstruction syndromes This list is not exhaustive and the risks/benefits of providing PN and the expected duration of PN should be considered on an individual basis. 6.2 Patient Assessment A multidisciplinary team can improve patient care while reducing the complications of PN. Parenteral Nutrition Policy v3 5

6 When concerns are expressed about a patient s nutritional status contact the dietitian who covers your ward via bleep or on ext 2074 (Nutrition and Dietetic Department) or refer to the Nutrition Support Team (see Appendix 2). The following assessments should also be carried out within the team: Initial Assessment Weight and height Hydration status Fluid balance Temperature Biochemistry Gut function Rationale Measured on admission and weekly thereafter. To assess nutritional status To ensure adequate hydration. Oedema and ascites should be noted. Input and output should be clearly documented. Ensure adequate hydration and avoid over hydration. NB volume of PN should be taken into account when calculating fluid input. To ensure no underlying infections or complications. Urea and electrolytes, glucose, liver function tests, phosphate, magnesium, calcium, haemoglobin, coagulation and trace elements Is the gut functioning? Are there any gastrointestinal problems? Tolerance to enteral nutrition? Responsibility Nursing staff and dietitian Nursing and medical staff Nursing and medical staff Nursing and medical staff Medical staff, dietitian Medical staff Nutritional assessment Any changes in weight? Any changes in appetite? History of oral intake? Any intake at present? Venous access Ensure good venous access with no complications Nursing and medical staff, dietitian Medical staff Medications Drug-nutrient interactions. Establish whether medications are affecting GI function/clinical condition. Medical staff, pharmacist, dietitian Adapted from NICE (2006) Nutrition support in adults 6.3 Parenteral Access Routes Peripheral access Peripheral PN may be considered via a large peripheral vein but it is not routinely recommended. Peripheral PN carries a high risk of thrombophlebitis and venflons need to be changed on a daily basis. With care and attention the peripheral route can be used for short term PN prior to central access being obtained. It should be ensured that the osmolarity of the solution is compatible with the peripheral route. When using peripheral access a small (20G) cannula should be used only for PN. Cyclical delivery of parenteral Parenteral Nutrition Policy v3 6

7 nutrition should be considered with planned routine cannula change, eg, deliver PN over 18 hrs, remove the cannula post infusion and resite a new cannula in the other arm. Central access Central access is normally used for those patients requiring PN. The decision regarding appropriate line insertion should be taken by the referring team on discussion with the Nutrition team. Only healthcare professionals competent in catheter placement should place catheters and should be aware of monitoring and managing them safely. Catheter insertion should be planned and performed using aseptic precautions. (See Central Venous Line Policy.) The referring team need to discuss tunnelled line insertion with the Interventional radiology department or Vascular Surgery. If there is a significant delay in inserting a tunnelled line or the duration of PN is such that this is deemed unnecessary the referring team should refer the patient to Anaesthetics for line insertion. The referrer needs to ensure that the Anaesthetist inserting the line is aware it will be used for PN so that an appropriate line is inserted (single rather than a quadruple lumen). An X-ray will confirm the correct placement of the catheter tip. A single lumen dedicated catheter is recommended for PN to minimise the risk of line sepsis. The tip should be positioned in the lower one third of the SVC or at the junction of the SVC and right atrium. Correct positioning reduces the risk of thrombotic and mechanical complications. The date and site of insertion and tip position should be documented in the patient s notes. Other Access Routes PICC lines are not commonly used in Gateshead. These can also be used to deliver hyperosmolar solutions as the catheter tip lies in the superior vena cava. 6.4 Types of Central Catheters Used Multi-lumen These are used in patients who require other additional infusions, however can be associated with an increased risk of infection due to increased handling and greater number of ports available for bacterial colonisation. Strict aseptic techniques should be carried out when changing infusion or handling the multiple ports. If a multi lumen line is used for PN a line should be dedicated to PN only. Single lumen Traditionally preferred lumen to be used for administration of PN as there is reduced risk of infection. Double lumen May be appropriate if the patient is likely to require an additional infusion alongside the PN (e.g. antibiotics, or fluid). Tunnelled Central Line Tunnelled lines such as Groshong or Hickman Lines are sited for long term PN access, ie more than 7 days. 6.5 Composition of parenteral nutrition An all-in-one parenteral bag is used in Gateshead Health NHS Foundation Trust which contains a combination of amino acid solution, fat emulsion, glucose solution, water and fat soluble vitamins, trace elements, minerals and electrolytes to desired volume. Additional Parenteral Nutrition Policy v3 7

8 ingredients may be added if required. Additions must be added aseptically in the hospital pharmacy only. 6.6 Prescribing parenteral nutrition Nutritional requirements must be assessed by the ward s dietitian. Following a dietetic assessment a bag of PN will be recommended based on the patient s nutritional requirements. A PN proforma, which includes a prescription, must be completed to ensure PN is given safely and appropriately (see Appendix 3). The dietitian will complete a PN regimen form for the ward staff to follow (see appendix 4). The prescription must be completed and signed by the doctor. It should be delivered to the pharmacy department before 2pm on the day it is required. When a patient is stable a PN a prescription may be written for a week at a time. It also must be prescribed on the fluid balance chart on a daily basis. PN is not an emergency intervention and is therefore rarely indicated outside normal working hours. However if PN is required outside pharmacy hours then an emergency Triomel 6 g bag can be used (see Appendix 5 for emergency out of hours regimen). These are stored in the pharmacy emergency drug cupboard and may be accessed via the site manager. The on-call pharmacist is available for advice via switchboard. Each PN bag will be prescribed according to their nutritional requirements. Modifications of parenteral nutrition bags The electrolyte content (sodium etc) of the PN bag can be altered within certain limits. The ward dietitian will advise and liaise with pharmacy regarding changes to the PN electrolyte content. Manipulation of the PN in Pharmacy is time consuming and carries a very small risk of introducing infection, therefore minor changes should be avoided. 6.7 Storage of parenteral nutrition PN should be stored in a drug refrigerator (2-8 o C) and has a limited storage life. Occasional minor separation of the emulsion may be visible. Always agitate the bag gently before use. Protect PN from strong light using the grey bag covers supplied by pharmacy. Once removed from the refrigerator the bag should be warmed to room temperature before use. Warming should be achieved gradually by putting the bag on a work surface in the treatment room at ambient temperature for a period of 1-2 hours out of direct sunlight. Artificial heat, for example, placing the bag on a radiator or using a light source should never be used as it poses a significant risk to bag stability. Any bag that has been stored below 2 o C must not be used. 6.8 Administering parenteral nutrition The PN bag will arrive on the ward late afternoon or early evening. If the patient is at risk of Refeeding Syndrome, PN should be introduced progressively as advised by the dietitian, usually starting at no more than 50% of estimated requirements for the first hours. (See Refeeding Syndrome Guidelines). All PN mixtures will be administered through standard IV giving set using a volumetric pump with occlusion and air line alarms. Continuous administration of PN should be offered as the preferred method of infusion in severely ill patients. Gradual change from continuous to cyclical delivery should be considered in patients requiring PN for more than 2 weeks, it is important to adhere to recommendations from the CCOT reduce central line associated sepsis. Parenteral Nutrition Policy v3 8

9 Cyclical delivery of PN may be considered when using short term peripheral venous cannulae with planned routine catheter changes. The rate of administration is usually identified on the label of the PN bag; however alterations to the rate can be made following discussion with the dietitian or aseptic pharmacist. PN should only be administered over a maximum 24 hour period and bags should be changed every 24 hours. 6.9 Discontinuing parenteral nutrition PN can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. There is usually a period of overlap while enteral feeding is being established and the rate of PN can be reduced. The dietitian will provide a step by step weaning plan for the PN and introduction of enteral or oral nutrition which will be reviewed daily. Stopping PN abruptly may put the patient at risk of rebound hypoglycaemia and should be avoided Monitoring of parenteral nutrition (NICE, 2006) It is the responsibility of the ward doctors to monitor the patient appropriately for possible complications of PN. These are predominately metabolic and line related complications. The functioning of the gut and the possibility of introducing enteral feeding should also be monitored (see appendix 6) Laboratory Monitoring (NICE, 2006) Please refer to Appendix 7. The Nutrition team, ward dietitian and pharmacist can advise regarding vitamin supplementation and the addition of electrolytes to PN. Manganese, selenium and bone densitometry need to be measured in patients on long term home PN, however home PN is managed by the Nutrition team at Freeman Hospital Biochemical Abnormalities in patients on PN Both acute and long-term liver function abnormalities are associated with the provision of parenteral nutrition. It can be difficult to establish whether the liver problem is caused by the administration of parenteral nutrition in the acute setting, or if it is due to other clinical problems eg: Sepsis Biliary obstruction Unrecognised previous chronic liver disease New-onset liver disease (eg liver abscess, adverse drug reaction, hepatitis) Portal bacterial translocation A modest increase in ALT sometimes seen within the first few days to weeks is usually a consequence of steatosis and is commonly seen following excessive glucose provision in a malnourished patient. There is usually very little or no change in the liver s synthetic function and the increase in ALT is generally not clinically significant. Following prolonged administration (several weeks to months) of parenteral nutrition a cholestatic picture may develop. The commonest reason for the development of intra-hepatic cholestasis is the overprovision on lipid and/or glucose. Patients at risk of developing intra-hepatic cholestasis may benefit from a reduction in lipid and glucose load (contact ward dietitian for advice). Cholestatic problems are also commonly encountered in patients with very short bowel syndrome or high stomal losses. Bacterial translocation across the damaged gut wall may also result in liver damage and a course of appropriate antibiotics may be required. Parenteral Nutrition Policy v3 9

10 6.12 Ethical Considerations 7 Training Parenteral nutrition is an invasive procedure, and therefore members of staff are expected to have assessed the patient s capacity to consent, and taken into consideration any advanced decision to refuse treatment, or best interest assessment. Further information is available in OP 57 Deprivation of Liberty Safeguards and OP25 Advanced Decisions to Refuse Treatment. The trust s nutrition team can provide training to all health care professionals involved in parenteral nutrition. The team is actively involved in the F1 and F2 teaching program and parenteral nutrition forms part of their training. Dietitians working within the hospital receive training by the critical care dietitian. 8 Equality and Diversity Patients who cannot be fed sufficiently via enteral nutrition have a fundamental right to consideration of parenteral nutrition, because this supports the right to life. This policy therefore promotes a human rights based approach to healthcare. However staff should refer to other policies for information about issues of consent, capacity, advance care plans, refusing or withdrawing treatment. This policy has been appropriately equality impact assessed. 9 Monitoring compliance with the policy Standard/process/issue NICE G32 Adult nutrition support PN policy compliance exceptions All patients on TPN in the Queen Elizabeth Assurance Method By Committee Frequency Regional PN Nutrition Nutrition Annually audits and Steering Dietetics committee All exceptions to be Datix Discussion By staff who identify exception Nutrition tean MDT Correlated by Risk Management Department Nutrition Steering Committee As required quarterly The effectiveness of the policy will be monitored by the nutrition & dietetics service in line with national guidance. PN audits will be undertaken on a yearly basis as part of Nutrition Support Team audit program. Any incident involving parenteral nutrition should be recorded via Datix reporting. 10 Consultation and review The policy will be reviewed every 2 years. Consultation will include Nutrition and Dietetics, Pharmacy, the trust s Nutrition, Critical care outreach and Infection control teams. 11 Implementation of the policy The policy will be shared with all staff involved in the direct care of patients receiving parenteral nutrition, all ward managers and modern matrons, and all staff receiving training on parenteral nutrition. Parenteral Nutrition Policy v3 10

11 12 References 1 Nutrition Support in adults NICE clinical guideline No 32 (2006). 2 Bozzetti F, Braga, Gianotti C, Mariani L, Cozzaglio L et al. Perioperative PN in malnourished, gastrointestinal cancer patients: a randomized, clinical trial. JPEN (2000),24(1): The Veterans Affairs Total PN Cooperative Study Group. Perioperative total PN in surgical patients. New England Journal of Medicing (1991), 325(8): Infection control: prevention of healthcare-associated infection in primary and community care. NICE Clinical Guideline. No 2 (2003). 5 Mallet, J Bailey C. Manual of clinical nursing procedures. The Royal Marsden Trust National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June Prescribing Adult Intravenous Nutrition (eds. Austin and Stroud) Pharmaceutical Press 13 Associated documentation Care standards: 9C and 9D Nutrition policy RM61 Central Venous Line policy OP41 Refeeding Syndrome guidelines Nutrition Risk Score Parenteral Nutrition proforma Parenteral Nutrition regimen information Parenteral Nutrition Policy v3 11

12 Appendix 1 Parenteral Nutrition Policy v3 12

13 Appendix 2 Gateshead Health NHS Foundation Trust Nutrition Support Team REFERRAL FORM Date of referral:.. Hospital Patient s name:.. No:.. Address:.. DOA: Contact number:.. Ward: Directorate: Consultant:.. DOB: Age:... Medical History:.. Social History: Reason for referral to NST:. Medication: Weight: NRS: Current nutritional support: Y/N Naso-gastric feeding If Y: date started:... IV fluids Sub cut fluids Other Please specify Oral nutrition Note: Please complete page two if referring for PEG Referred by: (Print) Signed:.. Parenteral Nutrition Policy v3 13

14 Appendix 3 Parenteral Nutrition (PN) Proforma Name: DOB: Hospital number: Ward: Consultant: NHS no. Start Date: Indication for PN: Appropriate indications include: intestinal failure, extended non-absorption of enteral nutrition (including a trial of nasojejunal (NJ) feeding), perforated or obstructed gut not expected to recover within 7 days. Is nasogastric and nasojejunal feeding contraindicated or has it been unsuccessful? Please circle Yes/No PN treatment goal Is there a risk of refeeding syndrome? Please Circle Yes/No Access: Central/peripheral (delete as appropriate) Type: Single/multiple lumen (delete as appropriate) Date of insertion: Weight (kg): Mid upper arm circumference (cm): (if not possible to obtain weight) Doctor s signature Name:... (print) Date..... Bleep/Ext.... Time... Please refer to Nutrition and Dietetics intranet page for guidelines on the use of PN out of hours. Please file behind Section 5 of the Health Record Parenteral Nutrition Policy v3 14

15 Parenteral Nutrition Prescription Name: DOB: Hospital number: Ward: Consultant: Weight (kg): Date PN started: Prescription start date: Tick required regimen - For further information contact pharmacy (ext. 2316) Figures in brackets represent usual maximum electrolyte content per bag these limits may be extended in certain circumstances contact pharmacy for advice. g N Volum e ml Kcal Total non-protein Na mmol K mmol Mg mmol Ca mmol PO 4 Mmol Adult Adult Adult Adult Fat-free Starter/refeed ing bag Low requirements Increased requirements Increased N requirements Fat free bag Other to electrolyte-free N9 2000ml bag *Note phosphate limit is only 16mmol if adding Addiphos Rate of administration: Route (delete as appropriate): Central/Peripheral* *Check that the regimen is appropriate for the route of administration - only Adult 6 and Adult 10 can be given peripherally Please ensure that the regimen is prescribed on the fluid balance chart on a daily basis. Dietitian s Name (print): Signature: Date: Grade: Bleep: Time: Doctor s Name (print): Signature: Date: Parenteral Nutrition Policy v3 15

16 Grade: Bleep: Time: Date Dietitian Confirmed By (pharmacy staff) Pharmacist Check Given by: Checked by: Time Commenced Version 10 Approved by David Sproates June 2015 Please check Trust Intranet for the latest version of this document. Page 16 of 24 Parenteral Nutrition Policy v3 16

17 Appendix 4 NUTRITION AND DIETETIC SERVICE Parenteral Nutrition Regimen Name... Hospital Date of Birth... Ward Weight... Estimated daily requirements: Kcal Nitrogen (g) Fluid (ml) Sodium (mmol) Route of feeding: Peripheral/Central* Potassium (mmol) Phosphate (mmol) Parenteral Nutrition Bag:... Magnesium (mmol) Calcium (mmol).... Day Rate ml/hr Time (hr) Rest (hr) Kcal Nitrogen (g) Fluid (ml) Provides per 24 hours Na + K + (mmol) (mmol) Ca 2+ (mmol) Mg 2+ (mmol) PO 2-4 (mmol) Continue as Day:. of regimen. Additional instructions: Daily bloods including U&E s, magnesium, phosphate and calcium until stable. Check blood glucose 1-2 times daily (more often if needed) Check bag is suitable to be given via chosen route Change bag every 24 hours, discard any remaining solution Document volume administered on fluid balance chart Dietitian (print name) Date.../.../... Time:... Signature:... Contact No:... Bleep:... Parenteral Nutrition Policy v3 17

18 Appendix 5 Nutrition and Dietetic Service Out of hours Parenteral Nutrition Guideline for Adults This guideline is for use in adult patients only when there is no dietitian to advise on parenteral nutrition (e.g. weekends, bank holidays). Parenteral nutrition is a highly specialised form of nutritional support and has associated complications. In the majority of cases parenteral nutrition is not an emergency and its use out of hours should be avoided. Refer to Dietetics through the intranet: Quick launcher forms, as soon as possible for a formal assessment Step 1 A doctor must complete and sign the PN proforma (attached page 4) to ensure PN is used appropriately. Step 2 Baseline blood tests: Electrolytes including potassium, magnesium and phosphate and correct any levels if needed. This should be done daily while the patient is established on PN. Step 3 Is the patient at high risk of refeeding syndrome? Please use following table as a guideline and follow the trusts refeeding guidelines. Percentage weight loss = previous weight (kg) current weight (kg) x 100 previous weight (kg) Any of the following Body Mass Index (BMI) less than 16kg/m² Two or more of the following BMI less than 18.5kg/m² Unintentional weight loss over 15% within the last 3-6 months Unintentional weight loss over 10% within the last 3-6 months Very little or no nutrition for over 10 days Very little or no nutrition for over 5 days Low levels of potassium, magnesium or phosphate prior to feeding A history of alcohol abuse or some drugs including: insulin, chemotherapy, antacids or diuretics. Low levels of potassium, magnesium or phosphate prior to feeding (Gateshead Health NHS Trust Refeeding Syndrome Guidelines) Parenteral Nutrition Policy v3 18

19 Step 4 Contact pharmacy to request the PN. The only PN bag available out of hours is the Triomel Peripheral N4 1500ml (referred to as Triomel 6gN) which is kept in the pharmacy emergency drug cupboard. Step 5 Mixing guidelines Remove the overpouch by tearing from the notch close to the ports along the upper edge, then tear the long sides, pull off the overpouch and discard it along with the oxygen absorber. Place the bag on a flat surface. Tightly roll up the bag from the handle side until the vertical seals are broken. Ensure that the liquids mix easily although the horizontal seal remains closed. Mix the contents of the three chambers by inverting the bag a minimum of three times until all the components are thoroughly mixed. Step 6 Follow the flow chart (page 5) to establish the correct rate of administration for the PN. Do not increase the rate of PN until potassium, phosphate and magnesium levels are within normal range. PN should only be administered over a maximum 24 hour period and bags should be changed every 24 hours, any remaining solution in the bag must be discarded. Note if you are unsure whether the patient is at risk of refeeding syndrome, exercise caution by following the steps for refeeding syndrome. Parenteral Nutrition Policy v3 19

20 Peripheral* Out of hours Parenteral Nutrition Regimen Access Route Central At risk of refeeding syndrome? (use table as guideline) At risk of refeeding syndrome? (use table as guideline) Yes No Yes No Day 1: Commence Triomel 6gN 42 ml/hr x 18 hrs Day 1: Commence Triomel 6gN 83 ml/hr x 18 hrs Day 1: Commence Triomel 6gN 31 ml/hr x 24 hrs Day 1: Commence Triomel 6gN 62 ml/hr x 24 hrs Day 2: Day 2: Triomel 6gN 83 ml/hr x 18 hrs Triomel 6gN 62 ml/hr x 24 hrs Key points For peripheral access: rotate site of entry every 24 hours Do not increase rate until potassium, phosphate and magnesium are within normal range. Final regimen (i.e. day 2) provides 1050 kcal, 6g nitrogen, 1500ml, 31.5mmol Na, 24mmol K, 3.3mmol Mg, 3mmol Ca, 12.7mmol Phosphate Parenteral Nutrition Policy v3 20

21 Step 3 Monitoring Parameter Frequency Rationale Urea and electrolytes, magnesium, phosphate and calcium Daily until stable Assessment of renal function, depletion is common Glucose Baseline 1 or 2 times a day (or more if needed) until stable Good glycaemic control is necessary Fluid balance Daily Ensure PN taken into account when prescribing additional fluids References 1 National confidential enquiry into patient outcome and death: A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. June Nutrition Support in adults NICE clinical guideline No 32 (2006). 3 Parenteral Nutrition Policy, Gateshead Health NHS Foundation Trust Parenteral Nutrition Policy v3

22 Appendix 6 Montitoring patients on parenteral Nutrition Parameter Frequency Rationale Responsibility Nutritional Nutrient intake from oral, enteral or PN (including any change in conditions that are affecting food intake). Daily, reducing to twice weekly when stable. To ensure that patient is receiving nutrients to meet requirements and that current method of feeding is still the most appropriate. Dietitian and nursing staff. Actual volume of PN delivered. Daily initially, reducing to twice weekly when stable. To allow alteration of intake as indicated. Dietitian, nursing and medical staff. Fluid balance charts Daily initially, reducing to twice weekly when stable. To ensure patient is not becoming over/ under hydrated. To ensure appropriate prescription of additional fluids if required. Always take into account the volume of PN when assessing a patient s fluid requirements to avoid fluid overload. Medical and nursing staff. Anthropometric Weight. Daily if concerns regarding fluid balance, otherwise weekly reducing to monthly. If clinical condition changes. To assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle. Nursing staff and dietitian. Mid arm circumference/mid arm muscle circumference. Weekly if patient cannot be weighed, reduce to monthly once stable. Dietitian Gastrointestinal symptoms Nausea/vomiting. Daily initially, reducing to twice weekly. To identify and rule out any cause of vomiting, eg obstruction. Nursing and medical staff, dietitian. Diarrhoea. Daily initially, reducing to twice weekly. To identify and rule out any causes of diarrhoea. Nursing and medical staff, dietitian. Constipation. Daily initially, reducing to twice weekly. To rule out other causes of constipation. Nursing and medical staff, dietitian. Parenteral Nutrition Policy v3 22

23 Abdominal distension. As necessary To identify cause. Nursing and medical staff. Devices and equipment Catheter entry site. Daily. To identify signs of infection. Nursing staff. Dressings. Daily. To ensure they are secure and hygienic Nursing staff. Clinical Condition General condition Daily. To ensure the PN is tolerated. All team. Temperature. Daily initially then as needed. To identify any signs of infection. Nursing and medical staff. Blood pressure. Daily initially then as needed. Monitor clinical condition and fluid balance. Nursing and medical staff. Drug therapy. Daily initially and then monthly when stable. To prevent/reduce drug nutrient interaction. Nursing and medical team Parenteral Nutrition Policy v3 23

24 Appendix 7 Biochemical monitoring of patients on PN Parameter Frequency Rationale Interpretation Sodium, potassium, urea, creatinine. Glucose. Magnesium, phosphate. Baseline. Daily until stable. Then 1-2 times a week. Baseline. 1 or 2 times a day (or more if needed) until stable. Then weekly. Baseline. Daily if risk of refeeding syndrome. Three times a week until stable. Then weekly. Assessment of renal function, fluid status and Na and K status. Good glycaemic control is necessary. Depletion is common and under recognised. Interpret with knowledge of fluid balance and medication. Glucose intolerance is common administer insulin if necessary. Low concentrations indicate poor status. Replacement vital to avoid refeeding syndrome. Liver function tests including International Normalised Ratio (INR)/PT Baseline. Twice weekly until stable. Then weekly. Abnormalities common during PN. Complex. May be due to sepsis, other disease or nutritional intake. May need to consider reducing fat content of PN. Calcium, albumin. C-reactive protein Baseline. Then weekly. Baseline. Then 2 or 3 times a week until stable. Hypocalcaemia or hypercalcaemia may occur. Correct measured serum calcium concentration for albumin. Assists interpretation of protein, trace elements and vitamin results Zinc, copper Baseline. Deficiency common, especially when increased losses. Selenium Full blood count and MCV Baseline for risk of depletion. Further testing dependent on baseline Baseline. 1 or 2 times a week until stable. Then weekly Iron, ferritin. Baseline. Then every 3-6 months. Se deficiency likely if severe illness and sepsis, or long-term Nutrition support. Anaemia due to iron and folate deficiency is common. Iron deficiency common to long-term PN. Folate, B12. Baseline. Iron deficiency is common Hypocalcaemia may be secondary to Mg deficiency. Low albumin reflects disease not protein status. To assess the presence of an acute phase reaction (APR). The trends of the results are important. People most at risk when anabolic APR causes Zn and Cu deficiency APR causes Se depletion. Long term status better assessed by glutathione peroxidise. Effects of sepsis may be important. Iron status difficult to assess if there is an acute phase reaction. Serum folate/b12 sufficient, with full blood count. Parenteral Nutrition Policy v3 24