Title The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline. Author s job title Consultant Gastroenterologist Directorate Medicine

Transcription

1 Document Control Title The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline Author Author s job title Consultant Gastroenterologist Directorate Medicine Department Medicine Version Date Issued Status Comment / Changes / Approval 0.1 Oct Draft Initial version for consultation Jan 2015 Final Approved by the Nutritional Group on 8 February Main Contact Consultant Gastroenterologist Tel: Direct Dial North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Medical Director Superseded Documents None Issue Date Jan 2016 Review Date Jan 2019 Review Cycle Three years Consulted with the following stakeholders: (list all) Surgeons Intensivists Nutrition Support Sub-Group Nutritional Steering Group Senior Nurses IV Management Nurse Gastroenterologists / Clinical Lead Medicine Approval and Review Process Nutritional Group Local Archive Reference G:\Corporate Governance\Compliance Team\Polices\Published\Medicines Management Filename PN Policy v1.0 08Jan2016 Policy categories for Trust s internal website (Bob) Gastroenterology, Medicine, Tags for Trust s internal website (Bob) Parenteral Nutrition, TPN The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 1 of 12

2 CONTENTS Document Control Purpose Responsibilities... 2 Role of Nutrition Support Team:... 2 Members of Nutrition Team Implementation of Policy Monitoring Compliance with and the Effectiveness of the Guideline... 5 Standards/Key Performance Indicators... 5 Process for Implementation and Monitoring Compliance and Effectiveness References... 6 Appendix 1 Recommendations for prescribing PN... 7 Appendix 2 Request to Start PN Form Appendix 3 Prescription for PN Purpose 1.1. These guidelines provide advice on the prescribing of Parenteral Nutrition (PN, also known as total parenteral nutrition) with Northern Devon Healthcare NHS Trust and are based on NICE Clinical Guideline 32 Nutrition Support in Adults, February FEEDING VIA THE ENTERAL ROUTE SHOULD ALWAYS BE FIRST CHOICE. This is the normal physiological route for feeding, is much safer in terms of complications (septic, metabolic and mechanical) as well as being much more cost effective PN is only required in order to prevent/treat malnutrition if there is intestinal failure and this dysfunction is likely to persist for more than 5 days. Parenteral nutrition is not an emergency treatment and has a high risk of potentially life threatening complications. Nutrition support needs to be considered early in the patient s treatment. Serum albumin is not an indicator of nutritional status and will not be raised by PN infusions The following general principles can be applied in order to: Ensure parenteral nutrition is appropriately prescribed Standardise monitoring of patients on parenteral nutrition to improve patient safety 2. Responsibilities Role of Nutrition Support Team: The Nutrition support team is responsible for; Providing advice for staff using PN Ensuring that guidelines are followed and staff education takes place Ensuring that alternative feeding options have been considered and are unlikely to be successful The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 2 of 12

3 Members of Nutrition Team Dietician Consultant Intensivists Primary medical/surgical team Pharmacist Nutrition Nurse (to be appointed) Consultant gastroenterologist Estimates requirements, chooses appropriate formulation/nutrition prescription and infusion rate in consultation with other team members for patients on general wards Estimates requirements, chooses appropriate formulation/nutrition prescription and infusion rate in patients on intensive care Maintains ownership of the patient. Requests PN taking into account clinical and nutrition factors. Oversees/consults on the choice of formulation, additives and dispensing. Coordinates team, performs nutritional assessment and monitoring of the patient. Staff education, audit of practice. Link between departments. Support for enteral feeding options Consults on medical management of the patient on general wards 3. Implementation of Policy All adult patients receiving parenteral nutrition must be managed under the auspices of this policy. Appendix 1 can be used to guide decision making for the initiation of PN. Initial nutrition assessment is required to identify patients at high risk of re-feeding complications. Using the MUST (malnutrition screening tool) identify those patients at high risk of re-feeding. Table 1: Criteria for determining people at high risk of developing re-feeding syndrome Patient has one or more of the following: BMI less than 16 kg/m 2 unintentional weight loss greater than 15% within the last 3 6 months little or no nutritional intake for more than 10 days low levels of potassium, phosphate or magnesium prior to feeding. Or patient has two or more of the following: BMI less than 18.5 kg/m 2 unintentional weight loss greater than 10% within the last 3 6 months little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics. i) Referral: All patients requiring PN must be referred to the nutrition team for assessment and appropriate management using the referral for nutritional support on BOB (Request for in-patient nutrition and dietetic service: Intranet). Patients will be seen within 24 hours by a member of the team during week days and on the same The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 3 of 12

4 day for Fridays. During weekends, PN can be started at the discretion of the consultant responsible for the patient according the standard regimen. Vascular access for PN: All patients received PN will need a central line. PN can only be give via a peripheral line under exceptional circumstances after discussion with a consultant gastroenterologist. This is high risk and ideally be done on a ward where PN is used. There needs to be clear documentation as to the rationale. Use single lumen catheters wherever possible. Double lumen lines can be used, particularly if insulin is needed. In critical areas (ITU) can be PN be infused via a multi-lumen line, but must have a dedicated, lumen for PN use only. This should be labelled for PN use only for ease of identification. Evidence shows that good nursing practice can reduce sepsis rates from >30% to <10% by involvement of a nutrition team and adhering to line care protocols. The patient will need central venous access for PN - usually a PICC or central line which will be assessed on an individual patient basis. The anaesthetic team will NOT place a line for PN unless the patient has been seen and assessed for PN by a member of the Nutrition Support Team (usually dietician or nutrition nurse in discussion with consultant gastroenterologist). Patients transferred from critical care may continue to use the dedicated lumen for PN. ALWAYS USE THE DEDICATED LINE i.e. no other fluids, drugs or blood sampling. DO NOT use multi-lumen IV connectors on the line. ii) Prescription for PN: The available bags are Triomel N4-700E, N5-990E and N7-1140E. Additions are no longer available so standard bags only. These are supplemented bags as per the prescription containing Cernevit, Additrace and Vitamin C. Appendix 2 should be used for the prescription of Parenteral Nutrition. This needs to be sent to pharmacy before 14h00 daily. There a separate insulin prescription sheet for those needing insulin. Initial regimen: Calculating nutritional requirements in critically ill patients is inexact. Their metabolic requirements are high, but they diminish quickly and net catabolism cannot be stopped (resulting in nutrient supply from tissue breakdown). Critically ill patients are therefore at risk of overfeeding. Survival in intensive care patients is thought to be best in those receiving between 33 and 66% of their estimated nutritional needs. NICE recommends that a full regimen should provide 25 kcal/kg/day. If the patient is high risk for refeeding complications (see Table 1 above) then a ¼ rate for 48 hours is recommended (usually a maximum of 10kcal/kg/day). If electrolytes remain stable, this can be increased to starting regimen at ½ rate for 48 hours. For all other patients, PN should be started at ½ rate for 48 hours, then go to the full target rate if there are no electrolyte abnormalities. iii) Blood Tests: Blood tests need to be requested daily until a patient is stabilised on PN, then twice weekly (renal, liver, bone profile, CRP, Mg, FBC). Bicarb, Chloride, vitamins, INR, iron studies and trace elements are requested on an as required basis. iv) Supply and storage of Parenteral Nutrition Solution: Bags must be stored at between 2 and 8 C until used and must be at room temperature before administration. Further information on the administration is available in the SOP for administration of Parental nutrition (Total Parenteral Nutrition (TPN): Intranet). The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 4 of 12

5 v) Monitoring: Patients on PN will initially need 6 hourly monitoring of temperature, pulse, blood glucose, close monitoring of the line site, strict charting of fluid balance (including bowel activity and stoma output) with twice weekly weights and MUST score. vi) Nursing care of a patient receiving PN: Patients on PN should ideally be managed in a side room to reduce the chances of infection. All infection control policies must be adhered to when dealing with PN including strict asepsis and non-touch technique at all times. Chlorhexidine impregnated dressings should be used. The IV closed system must be changed once a week. Do not re-connect PN if line disconnected. vii) Management of suspected line sepsis: If a patient on PN develops a temperature of >38 C, tachycardia, increased white cell count, raised CRP or rigors then blood cultures should be taken from the central line and a peripheral vein. It is essential to label which culture it is line or peripheral and the time the sample was taken. The cultures from the line should be taken at the time of changing the PN to limit any breaks in the line. Do not discard any aspirated blood (and PN solution) from the line this is a good culture medium and will increase the yield. A full septic screen should be undertaken (urine, sputum, wound, peripheral and central lines. Broad spectrum antibiotics as per trust guidelines can be commenced via a peripheral cannula until culture results are known. If the line culture is positive then sensitivity specific antibiotics should be commenced and the line flushed with 10mls of 0.9% sodium chloride and locked with an antibiotic solution or an alcohol lock. PN should be suspended until the line is clear of infection or replaced. viii) Patients requiring long term home parenteral nutrition will need referral to the nutrition team at the Royal Devon and Exeter Hospital. Referrals can be made directly by the responsible clinical team or via the nutrition team. 4. Monitoring Compliance with and the Effectiveness of the Guideline Standards/Key Performance Indicators Rate of parenteral nutrition use Rates of line sepsis Rates of metabolic complications Weekend institution of PN Length of PN use Process for Implementation and Monitoring Compliance and Effectiveness Implementation will be by publishing on BOB and also circulating to all relevant surgical, intensive care, nursing and medical. There will also be educational presentations to staff members periodically. Monitoring Patients started on PN will be identified by the nutrition team. Audit will be led by nutrition support team Audit results will be communicated to relevant staff Audit will be annual and with action points according to results If guidelines are not followed this will be reported to Lead clinicians and Senior Nurses for surgery, intensive care and medicine where appropriate. The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 5 of 12

6 5. References NICE guidelines: Nutrition Support in Adults (2006) Krishnan J, Parce P, Martinex et al. Caloric intake in medical ICU patients. Consistency of care and relationship to clinical outcomes. Chest 2003; 124: Macdonald K, Page K, Brown L et al. Parenteral Nutrition in critical care. Continuing Education in Anaesthesia, Critical Care and Pain. 2013; 13:1-5. Austin P, Stroud M. Prescribing Adult Intravenous Nutrition Pharmaceutical Press Todorovic V, Micklewright A. A Pocket Guide to Clinical Nutrition 4 th Edition 2007 PENG, BDA. Timsit et al (2009). Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults. A Randomized Controlled Trial JAMA. 2009;301(12): Loveday H, Wilson J, Pratt R et al. epic3: National Evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014; S1-S70. The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 6 of 12

7 Appendix 1 Recommendations for prescribing PN DOES YOUR PATIENT NEED PARENTERAL NUTRITION? This information is to act as a guide to prescribing PN. PN is not a safe feed. It is a serious treatment option and prescribing should involve several steps which are highlighted below. NICE recommend good practice points be carried out for every patient All patients needing PN should be referred to a dietician. Step 1 Screen all patients for nutrition status MUST score Re check all inpatients weekly Step 2 Identify and recognise malnourished patients Step 3 Treat Orally Check for dysphagia If safe, consider oral nutritional support incorporating an oral multivitamin and mineral supplement if concerned about micronutrient intake. Stop oral supplements when normal food intake is established. In post-abdominal surgical patients consider post-operative oral intake within 24 hours of surgery. Monitor for and treat nausea and vomiting. The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 7 of 12

8 Treat Enteral OBTAIN CONSENT Access Upper GI function intact: Nasogastric tube Upper GI dysfunction: consider post-pyloric feeding If dysfunction will be for more than 4 weeks: consider gastrostomy PEG tubes can be used 4 hours after insertion Consider a motility agent in patients with delayed gastric emptying Consider post-pyloric enteral tube feeding and/or parenteral nutrition if delayed gastric emptying is severely limiting feeding, despite the use of motility agents Treat Parenterally OBTAIN CONSENT Request a dietician review for appropriate choice of PN within 24 hours Introduce PN progressively and monitor closely; at no more than 50% of estimated needs for the first hours. WITHDRAW PN slowly once adequate oral intake and/or enteral support is established. Withdrawal of PN should be planned and in a stepwise manner with daily review of patients metabolic balance. Extra information for surgical patients The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 8 of 12

9 Re-feeding problems People at high risk for refeeding syndrome as per Table 1 should have PN introduced at no more than 25% daily requirements for first 2 days. Increase feeding rates gradually to meet full needs if clinical and biochemical monitoring reveals no re-feeding problems. Prescription for patients at risk of re-feeding syndrome: Step 4 Monitoring PN is not a safe feed. It acts more like a medicine and it is essential it is prescribed appropriately and correctly. Half of all metabolic complications in PN patients are avoidable. Out of Hours prescribing of PN should be avoided at all times. The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 9 of 12

10 Appendix 2 Request to Start PN Form Request to start PN Form (send to pharmacy with the FIRST PN prescription for each patient) Baseline bloods must be known and completion of this form must be fully completed before your patient can receive PN. Once it is fully completed, bleep your ward pharmacist and send a copy to the nutrition team. Ward: Patient label Consultant: Indication for PN: 1) Current weight: kg (date: ) 2. MUST score 3) Type of line inserted? Peripheral / central (if central has it been confirmed? Yes / No) 4) Number of Days since last received full enteral / parenteral feeds? 5) Proposed duration of PN required: days 6) Has enteral feeding been attempted? Yes, but failed (please specify) No No, contraindicated (please specify) 8) Other relevant information: (please tick relevant boxes) Bowel surgery resection Bowel surgery other Ventilation Liver disease Sepsis Renal Other intervention: 9) If fluid restricted, what volume will be allowed for feeding? ml/day 10) Any other relevant information? Name (Printed in Block Capitals): Grade:. Signature: Date: Bleep No: The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 10 of 12

11 Appendix 3 Prescription for PN Parenteral Nutrition (PN) Prescription form Before prescribing please read the prescribing guide over leaf. Affix patient ID label here Ward: Consultant: Weight Dietitian review by: Indication for PN (MUST be completed) Prescription for PN to be administered Triomel Regimen To be completed by prescriber Total Electrolytes *** Prescriber Print, Sign, GMC No. and Bleep No. Date:... To be completed by pharmacy Regime supplied Infuse over. Hours (start over 24 hours) Nursing staff to complete on initiation of PN Date to be administered:.. Time infusion started Rate of infusion Date given Sign & print PARENTERAL NUTRITION CONTENTS OF EACH BAG (Prescriber to Circle prescribed formulation) SUPPLEMENTED TRIOMEL BAGS All supplemented bags contain Cernevit, Additrace and Ascorbic acid 300mg N4-700E N5-990E N7-1140E Total Volume 2018mls 2018mls 2018mls Nitrogen Content 8g 10.4g 14g Lipid Calories 600kcal 800kcal 800kcal Glucose Calories 600kcal 920kcal 1120kcal Calories non-protein 1200kcal 1720kcal 1920kcal Calories Total 1400kcal 1980kcal 2270kcal Sodium 42mmol 70mmol 70mmol Potassium 32mmol 60mmol 60mmol Calcium 4mmol 7mmol 7mmol Magnesium 4.4mmol 8mmol 8mmol Phosphate - organic 17mmol 24mmol 24mmol Chloride 48mmol 90mmol 90mmol The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 11 of 12

12 Dietician comments Sign Bleep Patient label Pharmacist comments Sign Bleep Additional Notes Before commencing PN please contact the Dietician on bleep 343; Ext 2306 Please inform your ward pharmacist that a patient is on PN The additional monitoring sheet associated with PN should be filed within patient s medical notes and completed daily by junior medical staff. This is to ensure safe and effective PN. Patients should commence PN with a maximum of ½ bag over 24hrs and increase as indicated by the dietician. Those at risk of refeeding syndrome should introduce PN more slowly; please consult with the dietician regarding starting PN with patients at risk of refeeding syndrome. PN should not be stopped abruptly. Use half a bag of PN on cessation days. Obtain baseline results for: Patients weight FBC U&Es LFTs Calcium Magnesium Phosphate Glucose Vitamins and minerals are added to all standard PN bags. PN bags without additional vitamins and minerals are available if required. Complete a new prescription for each patient each day. On a Friday complete 3 prescriptions to cover the weekend (or 4 for a bank holiday) Infection risk PN is an infection risk. The high nutrient content of the PN bags act as an excellent growth medium for bacteria. Any bags disconnected from a patient for any reason cannot be reconnected and must be discarded. PN must not be hung for over 24 hours. PN is not appropriate in the following situations: 1 Patients with a functional and useable GI tract, capable to absorb adequate nutrients. 2 When dependence on PN is anticipated to be less than 5 days. 3 Patients whose prognosis does not warrant aggressive nutritional support. Ratified by: (Clinician) Approved by: (D&TG Lead) / / Signed: / / Signed: The Prescription of Adult Inpatient Parenteral Nutrition (PN) Guideline V1.0 08Feb16 Page 12 of 12