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Trust Policy and Procedure Document Ref. No: PP (15) 289 Policy Parenteral Nutrition

For use in: All clinical areas

For use by: All clinical staff involved in treating patients on Parenteral Nutritional

For use for: All patients requiring Parenteral Nutrition

Document owner: Nutrition Steering Group

Status: Approved

Contents Page

1. Introduction and Aim 2

2. Use of Parenteral Nutrition at WSH 2

3. Parenteral Nutrition Options 3

4. Access/Lines 3-4

5. Before Starting Parenteral Nutrition 4

5a. How to refer 5

6. Starting/Connecting Parenteral Nutrition 5-6

6a Out of hours 6

7. Disconnecting Parenteral Nutrition 6

8. Storing Parenteral Nutrition 7

9. Monitoring Parenteral Nutrition 7

10. Documenting Parenteral Nutrition 7

11. Stopping Parenteral Nutrition 8

12. Trouble Shooting 8-9

13. Potential Complications of PN 9-11

14. Paediatric Parenteral Nutrition 11

References 12

Review and monitoring of policy 13

Appendices

1. Flow chart – appropriate use of PN 14

2. Parenteral nutrition proforma 15-18

3. Parenteral nutrition guidance notes 19-20

4. Nutrition Support Team 21

5. Constituents of PN Base Bags 22

6. MUST tool 23

Source: Dietetic Department Status: Approved Ref PP(15)289 Issue date: September 2015 Review date: September 2018 of 23

1. Introduction and Aim

The purpose of this document is to provide clarity for clinical staff regarding the application and administration of Parenteral Nutrition at West Suffolk Hospital.

This policy gives guidance on the use of parenteral nutrition (PN) at West Suffolk Hospital. It takes account of clinical guidance on the administration of PN relating to nutritional content, administration (infection control), monitoring and documentation. It also takes into account established ward practices. This document relates to in-patients at West Suffolk Hospital, it does not relate to persons who may receive PN in the community. The aim of this document is to achieve safe and effective provision of PN at West Suffolk Hospital, avoiding potential problems associated with line insertion, catheter related sepsis and biochemical abnormalities.

Definition

Parenteral nutrition (PN) is the administration of nutrient solutions via a venous route. It can often be confused with total parenteral nutrition (TPN), which is the administration of all of a patient’s nutritional needs via a venous route. The aim of PN is to meet the individual’s nutritional needs, maintain body mass and organ function and maintain immune-competence, thereby maximising recovery potential. 2. Use of Parenteral Nutrition at West Suffolk Hospital

PN is a safe and effective way of providing nutrition to patients who cannot be fed enterally. PN, however, can be potentially dangerous and is also a more expensive mode of feeding & should, therefore, only be used when the enteral tract is not viable/sufficient (please see Appendix 4 for indications for PN). PN is generally used where there is; a. failure of the gut function (e.g., with obstruction, ileus, dysmotility, fistulae, surgical resection or severe malabsorption) to a degree that definitely prevents adequate gastrointestinal absorption of nutrients and b. the 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. (NICE, 2006)

Previously well-nourished patients rarely benefit from the acute (short term) administration of PN. The benefits are seen largely in patients who are malnourished and unable to receive adequate enteral nutrients as a result of gastrointestinal insufficiency. In many of these patient groups, PN can be life-saving (Zaloga, 2006.) In exceptional circumstances, PN may be used for persons who are malnourished or at risk of malnutrition, with inadequate or unsafe enteral intake. All patients should be screened for malnutrition on admission to West Suffolk Hospital, using the Malnutrition Universal Screening Tool ‘MUST’ (See Appendix 6.) PN is not more effective than enteral nutrition at promoting patient recovery and should be kept as a last resort. Wherever possible, enteral intake, however small, should be maintained during parenteral feeding and enteral nutrition should be re-established at the earliest opportunity.


3. Parenteral Nutrition Options

There are three types of Parenteral Nutrition: o Base bags - They are suitable for most persons. These bags do not contain vitamins or trace elements*. The bags contain three chambers, separating the fat, nitrogen &

carbohydrate, which increases the shelf-life. Recently WSH have change over from the standard Kabiven bags (all soybean oil) to a SmofKabiven base bag range - SmofKabiven 9.8, SmofKabiven 12 and SmofKabiven 16. These bags contain a different Lipid profile (mixture of soybean oil, MCT, olive oil and fish oil) which has been clinically proven to show benefits to the liver function and cholestasis, reduce the inflammatory response, infection rates and LOS in ICU and post-surgery patients (Pradelli et al 2012, Shade et al 2008, Klek et al 2012 and Pipr et al 2009.

o Base bags with additions – these are the above base bags, but with extra nutrient content

e.g. added potassium, nitrogen, sodium, vitamin & trace elements, etc. o Special order bags (commonly known as ‘tailored bags’ or ‘scratch bags’) – these can have

nutrient contents tailored to an individuals needs e.g. low volume, fat-free etc and are ordered on an individual patient basis.

West Suffolk Hospital does not have the capacity to make base bags with additions or tailored bags on site. All additions to base bags & all tailored bags are ordered from an external company. Additions should never be made on the ward.

Base bags must be ordered by 15.30hrs for same day delivery. Base bags ordered after this time or before 17:00hrs can be obtained from pharmacy but will not contain any patient details. Base bags with additions & special order bags need to be ordered by 11.00hrs, as they are ordered from an outside company (currently Hospira) and are subject to 24 hour delivery time. Bags with additions & tailored bags needed for same day delivery need to be ordered by 10am (used more for neonatal PN.) In all cases, the bag used should be chosen according to the individual’s needs, taking into account access, catabolism, risk of refeeding syndrome, lipidaemia, electrolyte levels and fluid balance. *Currently, at West Suffolk Hospital, if a patient is on PN as the sole means of nutrition, vitamins & trace elements are not added into base bags until the patient has been on PN for 10 days. If the patient can have some oral intake a multivitamin and mineral preparation is advisable, however, if there is no other source of nutrition, IV Pabrinex can be considered as a separate infusion.

4. Access/Lines

PN is administered via a dedicated central or peripheral placed line. Exceptional cases should

be discussed with the ward dietitian and/or pharmacist.

Central access

PN should be given via a PICC (Peripherally Inserted Central Catheter) or CVC (Central Venous Catheter) line where possible for patients requiring long-term PN (needed for 14 days or more.) Central access can also be used when peripheral access is not possible. CVCs need to be replaced every 10 days. With appropriate care, PICC lines can remain in situ for several months and are, therefore, a good alternative to CVCs. Any types of PN can be administered centrally. A double lumen is preferable. More lumens may be necessary, especially if line access is an issue, but there must be a clearly marked, dedicated lumen for the PN (TPN claves are available.)


Note, the exclusive use of one lumen in a multi-lumen line has a greater risk of line sepsis than a single lumen line. The major complication with CVCs is line sepsis, therefore, strict aseptic technique when handling these lines is paramount. The sub-clavian route is preferred to the jugular or femoral routes, as it has a lower associated infection risk and it is easier to maintain dressings at the insertion site. Other common complications are thrombus formation & pneumothorax. With PICC lines the major complications, other than site infection/line sepsis are, failure to insert, phlebitis, incorrect positioning & catheter failure/leakage. If line infection is suspected, the line tip should be sent to microbiology for analysis (see section 13 for more guidance.) For more information on preventing central access infections, please refer to the Trusts ‘Guidelines for the Prevention of Infections Associated with CVCs, including PICCs’ – CG10036.

Peripheral access

Peripheral PN is suitable for those needing PN for less than 14 days, or for highly catabolic patients awaiting the insertion of central venous access, or when central access is not possible. Ideally a 22G (Blue) cannula should be used and placed in as large a peripheral vein as possible, away from a joint. The cannula must be changed every 72 hours. A 5mg glyceryl trinitrate (GTN) skin patch must be secured over the vein just distal to the puncture site. This must be prescribed on the drug chart & changed every 48 hours. Only SmofKabiven 9.8 may be given peripherally because of risk of thrombosis and phlebitis due to the higher osmolality of the other feeds (see Trusts’ Protocol for Peripheral Parenteral Nutrition.’) For more guidance on site care, maintaining patency and infusing PN, please refer to the Nutrition Section of the ‘Standards for Infusion Therapy’ document (2010) on the Royal College of Nursing website. (www.rcn.org.uk)

5. Before Starting Parenteral Nutrition

Alternative feeding routes should be considered before commencing PN (Appendix 1). Informed consent must be obtained from the patient where possible and documented clearly in their medical notes, as PN is a prescription only medicine. Patients requiring parenteral nutrition should be referred to the dietitian at the earliest opportunity (see Appendix 2.) The dietitian will initially assess the patient for suitability of PN, as well as for

the risk of refeeding syndrome (see the Trusts Clinical Guideline for Re-feeding Syndrome – CG10236-1.) The dietitian will then calculate the individual’s requirements and recommend the most appropriate starting parenteral nutrition regimen. The dietitian will complete a parenteral nutrition prescription form, which will require agreement and signature from the doctor (Appendix 2).

The dietitian will order the parenteral nutrition from pharmacy using the prescription form. The prescription form will be returned to the ward with the delivery of the bag from pharmacy.

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10036Preventionofinfectionassociatedwithcentralvenouscatheters.pdf

http://staff.wsha.local/Extranet/SupportServices/NutritionandDietetics/docs/PROTOCOLFORPERIPHERALINTRAVENOUSNUTRITION.doc

http://staff.wsha.local/Extranet/SupportServices/NutritionandDietetics/docs/PROTOCOLFORPERIPHERALINTRAVENOUSNUTRITION.doc

http://www.rcn.org.uk/

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10236Re-feedingSyndromeIdentificationandTreatment.pdf



5a. How to Refer The Doctor will need to complete a referral form found in the Trusts PN Proforma (see Appendix 2) and attach to patient’s notes. The Doctor will then need to bleep the ward dietitian or leave a message on ex: 3609, with the referral details.

On referral it is helpful if the following details are available: Weight & height Fluid balance chart Blood tests (U&E, LFT, Bone Profile, Mg)

6. Starting/Connecting PN

PN is never an emergency and if undertaken without appropriate care can be hazardous to the patient. PN will not be provided where the appropriate preparation has not taken place.

If started too quickly, PN can cause life-threatening plasma electrolyte shifts in certain patients; this is called refeeding syndrome. Identification of those patients at risk of refeeding syndrome is therefore vital so that initiation of parenteral nutrition can be tailored to their needs (see the Trusts Clinical Guideline for Re-feeding Syndrome – CG10236-1.) Unmixed bags should be mixed according to the bag instructions (see posters on wards or if not available, posters can be obtained from Dietitians) and allowed to rest for 1 hour prior to connecting, to prevent bubbles causing line/vein occlusion as well as allowing the bag contents to mix properly. Ready mixed or tailored bags should be kept in the ward fridge and taken out 2 hours prior to infusing, in order for the contents to be brought up to room temperature. Administration of cold parenteral nutrition is also likely to cause discomfort to the patient.

Parenteral Nutrition can usually meet a person’s fluid needs. In some circumstances e.g. during a gradual initiation of parenteral nutrition or where there are significant losses, additional fluids may be needed. This is the responsibility of the Doctors to provide any additional fluids and to monitor this. The prescription chart must carry a doctor’s signature. Check the access route to make sure it is suitable for the type of bag. The bag of parenteral nutrition should be checked for

Expiry date

Visible particles, froth, oily streaks, leakages. Contact pharmacy if any of these are noticed.

The bag of parenteral nutrition should be checked against the prescription chart to match for

Bag name

Infusion date

Rate

Duration

Additions of Calcium, Phosphate, Magnesium, Potassium, Nitrogen, etc

Any additional instructions in ‘comments’ box and signed off by two trained nurses to ensure the correct substance is being given. The date and time that the feed is started should also be documented on the prescription chart, as bags should not run for more than 24 hours (Trust policy).



When setting up parenteral nutrition, strict asepsis should be applied to the procedure. For more information, see the Trusts Clinical Guideline 10036-5, Infection Control Manual Feb 2013 & also for ‘Standards for infusion therapy’ (www.rcn.org.uk, Jan 2010). These guidelines give details on

preparation and administration of IV drugs (which applies to PN.) There are examples of protocols available for the preparation of IV drugs (Beaney, 2010.) For further administration details, as well as guidance on care of the cannula site and management of the line, please see the Trusts Guideline A8 Intravenous Infusion – peripheral (Nursing and Midwifery Practices

Manual November 2012) A plastic bag is supplied by pharmacy, which needs to cover the PN bag to prevent degradation of nutrients by light. This also prevents dust from collecting on the bag.

6a Out of Hours Parenteral Nutrition

PN is not considered as urgent and should only be initiated in exceptional circumstances.

Dietitians are available Mon-Fri 08.30-16.30, except bank holidays. PN is unlikely to be so urgent that it needs to be started outside of these hours. If a Doctor considers it urgent, parenteral nutrition can be started outside of these hours by following the guidelines in Appendix 4. Critical Care Services have their own algorithm for starting patients on parenteral nutrition outside of the dietitian’s working hours in intensive care.

7. Disconnecting Parenteral Nutrition

If the infusion of PN needs to be disconnected, under NO circumstances should the remainder of

the infusion be reconnected. The remainder should be discarded, including the giving set. It is not necessary to disconnect parenteral nutrition if the patient is going off the ward for investigations (e.g., for an x-ray). The PN should be turned off but remain connected to help prevent risk of infection. The PN also does not need to be disconnected for the purpose of ward-based treatments e.g. physiotherapy or having a bath (but the insertion site must be kept dry & covered.) For procedures such as MRI scans, parenteral nutrition must be disconnected before a patient can go in the MRI scanner. The x-ray department recommend that ward staff notify them if a patient is on PN so they can schedule scans when PN is disconnected. If PN has to be disconnected for whatever reason, an infusion of 10% glucose solution should be started immediately to prevent rebound hypoglycaemia and infused until it is time for the next bag of PN to go up. If connection to PN is limiting certain treatments, staff should liaise with the ward dietitian or pharmacist. It is possible for the patient to have a rest period from PN during the day if felt necessary, e.g., having daily treatments like physiotherapy, if continuous PN feeding is affecting liver function or when patients are start mobilising, etc.

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10036Preventionofinfectionassociatedwithcentralvenouscatheters.pdf


https://www.wsh.nhs.uk/Extranet/ClinicalServices/NursingManual/SectionA/Docs/A8-PeripheralIntravenousInfusion.doc

https://www.wsh.nhs.uk/Extranet/ClinicalServices/NursingManual/SectionA/Docs/A8-PeripheralIntravenousInfusion.doc


8. Storing Parenteral Nutrition

Parenteral nutrition is an excellent growing medium for microorganisms. Unmixed base bags can be stored at room temperature, and should be stored away from sunlight. Protective bags are supplied to cover the PN bags, to protect it from light, prevent deterioration of light sensitive vitamins & avoid dust collection. Mixed base bags and bags with additions must be refrigerated at 2-8oC to reduce bacterial growth. Do not store at the top of the fridge because ice crystals can form if the bag touches the freezer compartment, plus the emulsion can separate.

9. Monitoring Parenteral Nutrition

Regular monitoring of patients receiving PN is essential to ensure safe & effective nutritional therapy. Bloods - Parenteral nutrition bypasses the regulatory systems of the gut and so close monitoring of bloods is required. Na, K, Ca, Phos, Mg, ALT and Alk Phos are most subject to change and should be monitored (see Appendix 3.) Temperature, pulse & respirations – should be checked & documented every 6 hours.

Weight – Initial, plus weekly weights are needed in order to make sure an appropriate PN prescription is provided. Daily weight might be necessary if there are renal, liver or cardiac issues. Short-term changes in weight reflect changes in fluid status. Long-term changes are indicative of nutritional status. Fluid balance – Daily, both clinically & by means of accurate fluid balance charts, to ensure that the patient is not over-hydrated or under-hydrated. Blood glucose – Check finger prick glucose before starting PN and 1 hour after starting. Monitoring should then be carried out every 6 hours in the first 24hrs of feeding. If <11mmols/L check finger prick glucose daily thereafter. If >11mmols/L report to Drs as sliding scale insulin may be required. Catheter site – Daily observation of line exit site for signs of infection, phlebitis, inflammation or leakage, changing dressing if soiled, loose or wet.

10. Documenting Parenteral Nutrition

It is the responsibility of the doctor to complete the referral form (Appendix 2).

The dietitian will record the starting plan for parenteral nutrition in the medical notes.

Parenteral nutrition should be recorded hourly on the patient’s fluid balance chart.

The PN prescription chart (page 4 of the Trusts PN Proforma – Appendix 2) should be completed by the nurse commencing the bag, to detail the bag batch number, start time and date and nurse’s initials. It should then be kept at the patients bed end.

If the label on the parenteral nutrition conflicts with the prescription, check the patient’s notes for the dietitian’s most recent entry.

Legally, the PN prescription needs to be signed by a prescriber before administration begins.

Base bags with additions and tailored bags have a sheet of A4 paper sent with them detailing the bags content. This piece of paper needs to be filed in the back of the patients medical notes.


11. Stopping Parenteral Nutrition

Enteral nutrition is the preferred route and however small, should be reintroduced at the earliest opportunity. If oral intake is affected by appetite, consider naso-gastric feeding. Any patient starting enteral intake must have that intake documented on a food and/ or fluid chart. The dietitian will assess enteral intake and advise on the titrating of parenteral nutrition to ensure adequate nutrition. As a guide, when titrating PN the following guidance is recommended;

1. Establish enteral feeding for at least 24 hours 2. Reduce PN rate by 50% for 24 hours (or an amount as specified by ward dietitian) 3. Monitor BMs 4 hourly for 24 hours, then after stopping PN 4. 10% glucose solution if hypoglycaemic (100mls/hr for 5 hours)

Unused parenteral nutrition should be returned to pharmacy. 12. Trouble Shooting ‘Delayed start of PN.’

Continue to run maintenance fluids & document reason for delay in medical notes.

‘The parenteral nutrition bag hasn’t arrived on the ward.’ PN bags are usually delivered to wards from pharmacy around 4pm. Bags may have been delivered directly to your fridge if they are already mixed (i.e., bags with additions or tailored bags). If the patient has recently been transferred from another ward, it might be possible that the bag is still being delivered to that ward by mistake. If the bag is not in the fridge, in the drugs room or at the nurse’s station and it is before 4.30pm, contact your ward Dietitian or if it is before 5pm, telephone pharmacy on 3788. You could also check the patient’s medical notes, as it should be documented whether PN has actually been ordered and when it is scheduled to start. Out-of-hours, contact site manager on 652 who can access bags from the emergency drug cupboard. There is limited stock in this cupboard so the on-call pharmacist would need contacting for further supplies. Document details in the patients’ medical notes.

‘I can’t find the prescription chart.’

PN prescription charts form part of the Trusts PN Proforma document (appendix 2, page 4.) With the initial PN bag or where there have been changes to parenteral nutrition, the prescription chart will have been sent to pharmacy. It should be returned to the ward, with the next PN bag at approximately 4pm. If it is a base bag, pharmacy usually place the charts between the bag & red cover. If it does not arrive with the bag contact pharmacy on 3788 before 5pm, 3232 after 5pm. Alternatively, check the ‘Drs to do’ tray, as it may be waiting to be signed. If the patient has recently been transferred from another ward, check that the prescription chart has not been filed in their notes. If the prescription cannot be found, contact your ward Dietitian. Out-of-hours if the prescription chart cannot be found, the Dietitian should have documented the planned prescription in the patients’ medical notes. Get a Dr to either complete a new PN prescription chart from the PN Proforma, pg 4 (see appendix 2) or add the PN prescription on a fluid chart. Document details in the patients’ medical notes.

‘The detail on the bag does not match the prescription chart.’

If changes to the prescription chart have been made after the bag was ordered from pharmacy, the bag label may not have been updated (particularly if it is a tailored bag.) Check the medical notes where any such changes should have been documented. The details on the prescription chart are more likely to be up-to-date than the details on the bag.


‘The PN base bag has been mixed prematurely.’ PN base bags should be mixed 1 hour before needing to be used in order to let any air bubble settle, preventing the infusion pump from alarming. If this is done prematurely by accident, label the time the bag was mixed & put straight in ward fridge. Take bag out of fridge 2 hours before being needed. Once mixed and put in a fridge, bags can last for up to 7 days. If the time the bag was mixed is not known the bag will need to be discarded of and documented in patients’ medical notes. ‘The PN bag has been removed from the fridge but has not been hung up.’ The PN bag should be taken out of the fridge 2 hours before being used. This prevents a built up of air in the bag which will cause the pump to alarm. It also allows the contents to reach room temperature, preventing possible irritation to the patient. The bag should then be infused for a maximum of 24hrs. PN bags can be left out of the fridge unused for a maximum of 6 hours. If the seals have not been broken, it can be returned to the fridge during this time ready for later use. If the length of time the bag has been out of the fridge is not known, the bag will need to be discarded.

‘The bag is split, contents is frothy, has visible particles, oily streaks, has discoloured or has separated.’

Do not give the PN. Do not throw away the bag. Contact pharmacy on 3788 who can replace the bag & take the faulty bag away. If out-of-hours, contact the on-call pharmacist for guidance and if a supply is required. (NB, fat-free bags will be yellow in colour.)

13. Potential Complications of PN

Intravenous access-related trauma - Insertion of catheters for PN carries some immediate risk, dependent on the type of line, the skill of the professional placing it and the clinical condition of the patient. The placement of central lines in the subclavian or internal jugular veins carries more risk than peripheral cannula placement. Problems with arterial puncture, bleeding, pneumothorax and malposition can occur. The jugular vein is favoured if the patient has any clotting issues. Risks of pneumothorax are greater with subclavian than jugular veins. A chest x-ray is needed to exclude a pneumothorax and to confirm position of the catheter tip.

Air embolus – this can occur with central or PICC line placements, since the high blood flow in central vessels can pull significant quantities of air into the circulation (including major vessels, heart, lungs and brain) if the catheter is left open to the atmosphere. It can be fatal if not recognised and treated promptly. It can be caused by accidental disconnection or because of faulty equipment.

Catheter-related infection and associated sepsis – Catheter-related sepsis (CRS) is one of the most common complications of PN. CRS usually occurs following infection of an internal lumen of the feeding catheter from poor aseptic technique during catheter access. Strict aseptic protocols must, therefore be used. Occasionally, a catheter can be is contaminated during insertion and skin infections at catheter exit sites. If the patient shows signs of sepsis (e.g., rigors, pyrexia, raised pulse/respiratory rates, raised WCC/CRP) samples will need to be sent for culture to determine the source. Since PN is an ideal growth medium for many micro-organisms, all PN should be discontinued where CRS is suspected. Whilst awaiting results IV fluids should be commenced via a peripheral cannula. If CRS is not thought to be the cause of infection, PN can be restarted. If CRS is thought to be the cause, the line should be removed and the tip sent for culture. Antibiotic treatment can then be given. Replace line after 24/48 hours or when cultures are negative. If it is suspected that a peripheral catheter is infected, it should be removed immediately and its tip sent for culture.


Thrombophlebitis - peripheral vein thrombophlebitis (PVT) is common. Signs include, local erythema (redness), swelling, inflammation, pain, soreness and aching. To help prevent PVT use topical 5mg GTN patches, use midline rather than peripheral cannula where possible, use intermittent PN infusions (e.g., over 12 hours), alternate arms with each cannula change.

Line Occlusion – Occlusion of a line prevents its use and the break-up of and solid material can risk embolization, vein blockage and thrombosis. Occlusion results from a range of factors;

- Mechanical obstruction e.g., closed clamp, kink in line, line tip against vein wall – check tap is not closed, check line for kink or try repositioning patient to allow free catheter flow.

- Pharmacological incompatibility e.g., drug-drug precipitate, drug-nutrient precipitate – avoid putting incompatible therapies down the same lumen, therefore, always use a dedicated line for PN.

- Lipid deposition – lines should be flushed & locked between use and once- weekly alcohol locks should be considered in long-term PN.

- Thrombosis e.g., in the central veins, line lumen or line tip – ‘trapdoor’ effect, allowing the line to be flushed but difficult to draw back blood. Short-term lines should be removed. Long-term lines try anticoagulation or fibrinolytics.

Metabolic – Metabolic complications of PN usually result from inadequate, excessive or unbalanced provision of PN components.

- Hyperglycaemia – most common. Caused by high levels of glucose provision, particularly if patients are insulin-resistant. Can increase risk of sepsis & refeeding syndrome, increase carbon dioxide production & result in abnormal liver function.

- Refeeding syndrome – most dangerous (See Trusts Clinical Guideline for Re-feeding Syndrome – CG10236-1.

- Fluid overload - can result in oedema, congestive cardiac failure & worsening ascites. It can also precipitate partial ileus or delay the recovery of gut function following surgery.

- Fluid deficiency – results in dehydration with may possible consequences e.g., low BP, concentration of serum electrolytes, nausea, vomiting, confusion and renal failure.

- Liver function – both acute & long-term abnormalities can occur. Check whether it is due to others sources first e.g., portal bacterial translocation, sepsis, biliary obstruction, previous chronic liver disease, drugs. Early liver function changes due to PN (<3 weeks) are usually due to steatosis (fatty liver), causing a modest rise in ALT. Excessive glucose provision is the likely cause & should be reviewed.

Longer-term changes due to PN tend to be cholestatic (weeks/months), initially causing increases in ALP. Later there may be rises in bilirubin & ALT. (Stroud et al, 2007.) Note – the changeover to SmofKabiven base bags. These bags contain a different Lipid profile (mixture of soybean oil, MCT, olive oil and fish oil) which has been clinically proven to show benefits to the liver function and cholestasis.




Note - Base bags can be given fat-free (unlicensed) by not mixing the lipid chamber in with the nitrogen & carbohydrate chambers. It is, therefore, important that the nitrogen & carbohydrate chambers are mixed together 1 hour before commencing the infusion, to make sure the seal between this mixture and the fat chamber is secure. If any of the white (fat) contents is found to be leaking into the carbohydrate/nitrogen mix, the bag will need to be discarded. It is also important to check under the plastic bag covering the PN bag every hour during infusion, to make sure that no leakage is occurring from the fat chamber into the carbohydrate/nitrogen mix. Again, if this is seen, the bag will need to be discarded.

14. Paediatric Parenteral Nutrition Neonatal Unit: (Also see East of England Perinatal Network executive summary- parenteral feeding of infants on the Neonatal Unit) Parenteral nutrition should be commenced within the first day of life for any infant unlikely to receive >100mls/kg/day enteral feeds by day 3- 5 of life. Ideally this should be within 6 hours of birth or following confirmation of UVC or long line placement. The standardised Perinatal network standard bags can be ordered from Pharmacy and prescribed on the Preterm Standard prescription chart by the clinician. The chart should indicate the total PN volume and volume of aqueous and lipid. The total fluid volume including any other infusions or enteral intake should also be prescribed. Lipid should be commenced on the first day of life and no later than the third day of life. If an infant requires a bespoke bag of PN this can be ordered Monday to Friday before 11am. This is made outside the hospital by Hospira and delivered the next day. If the infant is born term/near term a Term Standard bag can be ordered and the Preterm Standard bag should be started until this is available. Please refer to the paediatric dietitians if there are concerns regarding growth once full volume of PN has been reached. Both lipid and aqueous PN should be weaned proportionately as enteral feeds increase and discontinued only when 120mls/kg/day enteral feed is tolerated. Children over 2 years: Kabiven are licensed for children over 2 years of age. Please refer to the paediatric dietitians to calculate nutritional requirements and assess which bag is most suitable. They will also consider if the child is at risk of refeeding syndrome. If a child requires PN for a longer period, over 1 week, additional vitamins and minerals can be added to the Kabiven bag by Hospira or it may be more appropriate to order a bespoke/ tailor made bag.


References

- Beaney AM (2010) Preparation of parenteral medicines in clinical areas: how can the risks be managed – a UK perspective? Journal of Clinical Nursing, 19, pp 1569-1577.

- Infection Control Manual, (Feb 2013), Guidelines for the prevention of infection associated with central venous catheters, including peripherally inserted central venous Catheters, Pink Book, CG10036-2.

- Klek et al (2012) Four-week parenteral nutrition using a third generation lipid emulsion

(SMOFlipid) – A double-blind, randomised, multicentre study in adults. Clinical Nutrition, PP1-8.

- National Institute for Health & Clinical Excellence (Feb 2006) Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute Care.

- Nursing and Midwifery Practices Manual, (November 2012) Guideline A8: Intravenous

Infusion (peripheral). Pink Book.

- Piper et al (2009), Hepatocellular integrity sfter parenteral nutrition: comparison of a fish-oil-containing lipid emulsion with an olive-soybean oil-based lipid emulsion. European Society of Anaesthesiology, 26: PP 1076-1082

- Pradelli et al (2012), n-3 fatty acid-enriched parenteral nutrition regimens in elective surgical and ICU patients: a meta-analysis. Critical Care, 16; PP 184-194

- Shade et al (2008), Inflammatory response in aptients requiring parenteral nutrition: comparison of a new fish-oil containing emulsion (SMOF) verses and olive/soybean oil-based formula, Critical Care, 12 (suppl 2): PP 144

- Stroud M & Austin P (2007) Prescribing Adult Intravenous Nutrition. Pharmaceutical Press. First Edition.

- www.rcn.org.uk, (Jan 2010) ‘Standards for infusion therapy’ Third edition, pg 33, 48-49.

- Zaloga GP (1 April 2006) Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: Assessment of outcomes. Lancet, Vol 367, Issue 9516, pp 1101-1111.



Review and Monitoring

Author(s): Clare Merchant, Senior Specialist Dietitian for Critical Care Services/NST

Other contributors: Krishna Basavaraju, NST Gastroenterology Consultant; Pauline Lesiak, Nutrition Nurse; Infection Control Team; Clinical Skills Team; Andrew Dann, PN Pharmacist; Radiology; General Surgeons; Critical Care Consultants; Infection Control Team; Nursing.

Approvals and endorsements: Nutrition Steering Group Information Governance Clinical Governance Risk Office

Consultation: Nutrition Steering Group (NSG)

Issue no: 2

File name: PP(11) 289

Supercedes: NA

Equality Assessed Yes

Implementation

Monitoring: (give brief details how this will be done)

The NSG will monitor implementation, compliance and effectiveness of the policy on a 2 yearly basis.

Other relevant policies/documents & references:

As per reference list

Additional Information:

‘We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any group in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age or any other characteristics.’ The person responsible for equality impact assessment for this policy is Clare Merchant Senior Specialist Dietitian, Ext 3609. ‘This policy has been screened to determine equality relevance. This policy is considered to have little or no equality relevance.’


Appendix 1: Flow chart - appropriate usage of parenteral nutrition

Oral diet FFT/ONS NG NJ Special menu/Elemental

PEG/RIG

ONLY when all of these options are contraindicated

PN FFT – Food Fortification ONS – Oral Nutritional Supplements NG – Nasogastric NJ – Nasojejunal PEG – Percutaneous Endoscopic Gastrostomy RIG – Radiologically Inserted Gastrostomy PN – Parenteral Nutrition

Insufficient oral

intake

Insufficient oral intake with FFT/SUP

Lack of gastric function

Allergy/intolerance/ absorption/ulceration

problems

Long-term problem

Or Unsafe

oral intake


Appendix 2: PN Proforma

ADULT PARENTERAL NUTRITION PROFORMA

REFERRAL RECORD FOR ADULT PARENTERAL NUTRITION (PN)

Any queries, please contact: Dietetics 3609, or Pharmacy 3942/3788

For assessment on day of referral, referral must be completed & left at patients bed end by the referring Doctor and Dietetics notified A.S.A.P. PN ‘Base Bags’ cut-off time for ordering is 15.30hrs. ‘Base Bags’ can be ordered after this time, but will not contain patient details. Cut-off times for ‘Tailored Bags’ or ‘Bags with Additions’ is 11.00hrs. For out-of-hours PN (after 17:00 and at weekends), see ‘Ordering PN Out-of-Hours’ in the Pink Book.

Diagnosis:

Reason for NOT feeding enterally: (*see below)

Other relevant clinical information: (e.g. issues with fluid balance, blood results, refeeding syndrome risk etc.)

Predicted duration of PN feeding/review date:

Has the line been inserted? If yes: Has the line been verified?

Venous access: Central PICC Peripheral/Mid line (Please note, if a line has not been inserted/verified at time of referral, a Kabiven 9 PN bag will automatically be ordered)

The ward team is responsible for organising appropriate monitoring (see ‘Monitoring Guidance’ in pink book) Signature of requesting doctor:

Grade: Bleep No Consultant

Name(Capitals) Date & time of referral:

*See Pink Book (‘Referral Forms’, ‘Nutrition & Dietetics’, ‘Referral for Adult PN’) for PN indications & monitoring info.

Initial bloods to be taken A.S.A.P. on referral for PN (see guidance in pink book)

PLEASE GIVE COMPLETE REFERRING DETAILS AS REQUESTED

Addressograph

Yes/No

Yes/No


Appendix 2: PN Proforma ADULT PARENTERAL NUTRITION PROFORMA

To be completed by ward Dietitian/Nutrition Support Team.

NAME: CRN: NHS NO: FLUID BALANCE SUMMARY WEIGHT RECORD

Date Fluid Intake Oral/EN/PN

(please circle)

24hr Fluid

Balance

Date Weight

LINE

MONITORING

Date Type of Line Comments


Appendix 2: PN Proforma ADULT PARENTERAL NUTRITION PROFORMA

NAME: CRN: NHS NO:

BLOOD MONITORING

To be completed by ward Dietitian.

Date Na K Ur Cr Gl Cor

Ca

P04 TPro Alb Bil ALP ALT Mg CRP

Appendix 2: PN Proforma

ADULT PARENTERAL NUTRITION PRESCRIPTION CHART

Assessed requirements:- House Officer Bleep:- Type of Line:- Addressograph:-

Total

Energy kcaL Consultant Name

Nitrogen g Ward Date of birth

Fluid mL Weight estimated/actual Hosp no.

If given peripherally a 5mg GTN patch should be secured over the vein distal to the venflon puncture site. Change every 48hours. This must be prescribed on the drug chart.

PARENTERAL NUTRITION BAGS MUST NOT BE HUNG FOR LONGER THAN 24 HOURS

For elemental content of bag please see overleaf label on bag Detail any additions made to base bag in boxes below For nurses use only

Date of Bag Type/Infusion rate Total volume Doctors Ordered Na K Ca Mg PO 4 Vitamin & trace Comments Batch Start End Administered

infusion (ml/hr) over (hr/bag) in 24 hours Signature By:- (mmol) (mmol) (mmol) (mmol) (mmol) elements Y/N Number (time&date) (time&date) by nursing staff

Source: Dietetic Department Status: Approved Ref PP(15)289 Issue date: March 2016 Review date: September 2018 of 23

Appendix 3:

GUIDANCE FOR REFERRING FOR PARENTERAL NUTRITION

When to refer for Parenteral Nutrition:

The decision to feed should be based on the patient’s nutritional status

and the degree of catabolic stress. The decision to feed parenterally is based mainly on the inability to feed

enterally, and conditions where it is necessary to rest the bowel for a significant period of time. (See indications below.)

EXAMPLES OF INDICATIONS FOR PN

G.I tract rest - G.I Fistula

GI tract dysfunction - Malignancy - Stricture

G.I tract with limited absorption – Short bowel syndrome

G.I tract has had major surgery or trauma

G.I tract has developed paralytic ileus

G.I tract inaccessible

Hyperemesis

Severe acute pancreatitis (only when enteral feeding has failed)

Burns

Sepsis

Mucositosis (following chemotherapy)

REMEMBER – IF THE GUT WORKS USE IT


Appendix 3:

GUIDANCE FOR REFERRING FOR PARENTERAL NUTRITION Continues

OUT-OF-HOURS PN

Ideally, PN should not be commenced out-of-hours (see NICE guidelines on Adult Nutrition Support), but if the team decide to do this;

Doctors must complete the PN prescription charts fully.

Doctors to prescribe a SmofKabiven 9.8. This can be given peripherally, but also

centrally. It is also the most suitable bag for patients to be commenced on if they may be at risk of refeeding syndrome.

Prescription charts can be found at the front of the ward nutrition file, or in the ward nutrition drawer.

Suggested regimen for out-of-hours/weekends: SmofKabiven 10:

Day 1) 20mls/hr x 24hrs = 480mls Day 2) 40mls/hr x 24hrs = 960mls

Day 3) 60mls/hr x 24hrs = 1440mls Day 4) 79mls/hr x 24hrs = 1896mls

To access PN bags between 16.00-17.00hrs please take completed prescription chart to the pharmacy dispensary.

To access bags after 17.00hrs, please liaise with the site coordinator on bleep 652.

PN bags can be found in the far left hand corner of the emergency drug cupboard.

Record the bag(s) taken onto the clipboard hanging on the shelf opposite the fridge.

Please leave a message for your ward dietitian on Ext: 3609.

Completed referral forms will be collected from the patients medical notes by your

ward dietitian on the next working day.

MONITORING GUIDANCE

Basic tests as below, but note that patient’s requirements may vary e.g. if at refeeding syndrome risk.

Daily: (until stable) Urea, electrolytes. Accurate daily fluid balance

Blood sugars as required.

Twice weekly: FBC, magnesium, Ca, PO4, LFTs, CRP.

Weekly: WEIGHT Please make sure bloods are taken as early as possible during the day, so that

results are back in time for ordering (i.e. before 11.00hrs for bags with additions or 14.00hrs for base bags) – writing URGENT on blood request forms might help to speed up this process.


Appendix 4: Nutrition Support Team

Members of the Nutrition Support Team (NST) meet every Tuesday in the gastroenterologists’ office at 8.45am, followed by a ward round. Who is involved and their roles:

o Consultant Gastroenterologist – Dr K Basavaraju (Ext 3650/Bleep 991) leads the weekly NST ward rounds, monitoring & advising on: indications for PN, lines, biochemistry & fluid balance.

o Senior Dietitians – Elizabeth Cave (Ext 3609/Bleep 346), Prill Yan (Ext 3609/Bleep 199)

Assess suitability of referral, refeeding syndrome risk, calculate patients nutritional requirements & recommend PN bag type/rate, monitor enteral intake/fluid balance/biochemistry, liaises with team/nurses, order PN bag from pharmacy, attend & support consultant on weekly NST ward rounds (as detailed above.)

o Nutrition Nurse Specialist – Pauline Lesiak (Ext 3866/Bleep 503) Attends weekly Nutrition Support Team ward rounds, helping to monitor infusion sites, collecting audit information & supporting consultant on weekly NST ward rounds (as detailed above.)

Staff who support the Nutrition Support Team & who are involved with PN patients:

o Other Dietitians who are PN competent – Assess suitability of PN referral, refeeding syndrome risk, calculate patients nutritional requirements & recommends PN bag type/rate, monitors enteral intake/fluid balance/biochemistry, liaises with team/nurses, NST & orders PN bag from pharmacy.

o Pharmacy – (ext 3788) Take PN orders from Dietitians, order tailored TPN bags from Hospira, label PN bags, distribute PN bags to wards, advise on additions/stability of bags, check bags before delivery.

o Ward Doctors – decide on appropriateness of PN referrals, complete PN referral forms,

request blood samples as appropriate, take blood samples if from PICC lines, prescribe vitamins/minerals, Monitor & prescribe additional fluids, electrolyte supplements as necessary, monitor line access sites.

o Ward Nurses – care of IV access/monitoring site, set up PN infusion using aseptic technique, and administer PN as prescribed.

o Phlebotomy – Take PN blood samples for analysis (unless a PICC line)

o Pathology – Analyse blood samples.

o Clinical Skills Team – James Whatling (Ext 2777/Bleep 913) Teaching medical staff on placement of lines and placing PICC lines.

o Microbiology – Advise on episodes of catheter sepsis and the treatment for this. o Infection Control Team.


Appendix 5: CONSTITUENTS OF SMOFKABIVEN PN BASE BAGS

Contents/Base Bag SmofKabiven 9.8

Total Volume (ml) 1904

Glucose anhydrous (g) 135

Fat (Triglycerides) (g) 54

Amino Acids (g) 60

Energy, Total (kcal) 1300

Energy, Non protein (kcal) 1100

Nitrogen (g) 9.8

Na (mmol) 48

K (mmol) 36

Ca (mmol) 3

Mg (mmols) 6

P04 (mmols) 15.6

Cl (mmols) 42

Osmolality (mosmol/kg water) 950

pH

Contents/Base Bag SmofKabiven 12




Amino Acids (g) 75



Nitrogen (g) 12

Na (mmol) 60

K (mmol) 45

Ca (mmol) 3.8

Mg (mmols) 7.5

P04 (mmols) 19

Cl (mmols) 52

Osmolality (mosmol/kg water) 1800

pH

Contents/Base Bag SmofKabiven 16




Amino Acids (g) 100



Nitrogen (g) 16

Na (mmol) 80

K (mmol) 60

Ca (mmol) 5

Mg (mmols) 10

P04 (mmols) 25

Cl (mmols) 70

Osmolality (mosm/kg water) 1800

pH


Appendix 6: MUST

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