Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dietitians Role in HPN Kirstine Farrer, Consultant Dietitian – Intestinal Failure Intestinal Failure Unit, Hope Hospital, Salford, Manchester

Similar presentations


Presentation on theme: "Dietitians Role in HPN Kirstine Farrer, Consultant Dietitian – Intestinal Failure Intestinal Failure Unit, Hope Hospital, Salford, Manchester"— Presentation transcript:

1 Dietitians Role in HPN Kirstine Farrer, Consultant Dietitian – Intestinal Failure Intestinal Failure Unit, Hope Hospital, Salford, Manchester kirstine.farrer@srht.nhs.uk

2 Home Parenteral Nutrition Nutritional &/or water/electrolyte imbalance that cannot be corrected by enteral feeding Nutritional &/or water/electrolyte imbalance that cannot be corrected by enteral feeding Acute (type 2) or chronic (type 3) intestinal failure Acute (type 2) or chronic (type 3) intestinal failure PN feasible at home PN feasible at home Patient Patient Family Family Healthcare professionals Healthcare professionals

3

4

5 HPN - indications Type 2 Intestinal Failure – short term Type 2 Intestinal Failure – short term Pending Pending spontaneous recovery (e.g. some fistulas) spontaneous recovery (e.g. some fistulas) intestinal reconstructive surgery intestinal reconstructive surgery death (some cancer patients) death (some cancer patients) Type 3 Intestinal Failure - long term Type 3 Intestinal Failure - long term Pending Pending intestinal adaptation? intestinal adaptation? small bowel transplantation? small bowel transplantation?

6 IF Aetiology Admitted patients (1999-2006)

7 All Treated Patients Regional Data (2005/6)

8 HPN centres Hope 132 Hope 132 St Marks 105 St Marks 105 Royal Victoria, Belfast Royal Victoria, Belfast Cardiff/Swansea/ Cardiff/Swansea/ Wrexham Wrexham Oxford Oxford Cambridge (SB Tx) Cambridge (SB Tx) Royal London Royal London Southampton Southampton Bristol Dudley (DGH) Leicester Liverpool Newcastle Nottingham Sheffield Leeds

9 The Patients Views (PINNT) Mean Distance for Routine check: 84 (240) & for emergencies:71(400) Mean Distance for Routine check: 84 (240) & for emergencies:71(400) Average cost/trip: £16.48 (£230) Average cost/trip: £16.48 (£230) Accompanied: >50% Accompanied: >50% Local care out of Hours: 63% Local care out of Hours: 63% Dissatisfied: 30% Dissatisfied: 30% Would like service nearer home – 78% Would like service nearer home – 78%

10 Outcome New patients Hope St Marks UKWales%UKWales% Discharged home HPN2435524043 S/c fluids 000305 Artificial enteral 409305 Oral alone 1212722142 Died409000 Transfer (hospital) 000305

11 Demographic Details 132 HPN patients at Hope 132 HPN patients at Hope mean 50 years (range 18-78 years) mean 50 years (range 18-78 years) 79 female 79 female Mean length of time on HPN 5.4 years (range 0 -25years) Mean length of time on HPN 5.4 years (range 0 -25years) Mean No of nights on HPN=5 Mean No of nights on HPN=5

12 The two most common types of short bowel Jejuno-colic anastomosis Ileum and some of jejunum resected leaving jejuno-colic anastomosis Jejunostomy Colon, ileum and some of jejunum resected, leaving a jejunostomy Jejunocolic anastomosisJejunostomy

13 Fistuloclysis/Distal Feeding – a new HETF indication?

14

15 Multidisciplinary Team for HPN Clinic – the patients journey Dietitian Dietitian Nurses Nurses (Psychologist) (Psychologist) Pharmacist Pharmacist Biochemist Biochemist Clinical Director Clinical Director Surgical and Medical Registrars Surgical and Medical Registrars

16 Nutritional Requirements Nitrogen 0.17-0.2gN/kg/day Nitrogen 0.17-0.2gN/kg/day 150-350g Glucose / day 150-350g Glucose / day <1g fat /kg lipid / day <1g fat /kg lipid / day Fat soluble vitamins 1-2/ week Fat soluble vitamins 1-2/ week Water soluble vitamins Water soluble vitamins Minerals Minerals

17 HPN – dietetic monitoring Weight Height BMI MAC TSF MAMC Comments

18

19 Nutritional Status of HPN Patients Weight Median 60kg (Range 41-94kg) Weight Median 60kg (Range 41-94kg) BMI Median 22.5 (Range 15-30) BMI Median 22.5 (Range 15-30) TSF Median 11mm (Range 2.8-22) TSF Median 11mm (Range 2.8-22) MAC Median 27cm (Range 18-42cm) MAC Median 27cm (Range 18-42cm) MAMC Median 23.6cm (Range 17.2-34) MAMC Median 23.6cm (Range 17.2-34)

20 Oral Intake Actively encouraged – psychological and physiological reasons Actively encouraged – psychological and physiological reasons Improves QOL / social interaction Improves QOL / social interaction Decreases biliary sludge and promotes intestinal adaptation - may result in a reduction of HPN. Decreases biliary sludge and promotes intestinal adaptation - may result in a reduction of HPN.

21

22 Biochemistry Monitoring 3/12 3/12 FBC, bone, liver profiles FBC, bone, liver profiles Cu, Zn, Se, Vitamin D status Cu, Zn, Se, Vitamin D status CRP, ESR CRP, ESR Ferritin Ferritin Coagulation Screen Coagulation Screen

23 Incidence of HPN related MBD Incidence is unknown but reports range from 40-100%. Incidence is unknown but reports range from 40-100%. Analysis has shown a reduced bone formation rate in most patients Analysis has shown a reduced bone formation rate in most patients No clear answer- most likely to be a combination of causes No clear answer- most likely to be a combination of causes General and lifestyle factors- age, menopause, alcohol and tobacco General and lifestyle factors- age, menopause, alcohol and tobacco Other drugs- corticosteriods, heparin, tinzaparin. Other drugs- corticosteriods, heparin, tinzaparin. Underlying disease- Underlying disease- Malabsorption of Ca, Mg and Vit D in IBD Malabsorption of Ca, Mg and Vit D in IBD

24 Summary of Clinical Trials Pironi et al (2002)- Bone Mineral Density, 165 patients, MBD seen in 84% of pts, 35% had bone pain and 10% had fractures.symptoms. No difference seen between primary diseases. Age of starting TPN and BMI main factors to predict morbidity. Pironi et al (2002)- Bone Mineral Density, 165 patients, MBD seen in 84% of pts, 35% had bone pain and 10% had fractures.symptoms. No difference seen between primary diseases. Age of starting TPN and BMI main factors to predict morbidity. The studies suggest anywhere from immediately up to three years The studies suggest anywhere from immediately up to three years Shaffer et al- 52 pts- review of bone scans in HPN pts. Shaffer et al- 52 pts- review of bone scans in HPN pts. Average significant reduction of bone mass was ~ 2years. Average significant reduction of bone mass was ~ 2years. Guidelines recommend baseline scan and then yearly. (ASPEN) Guidelines recommend baseline scan and then yearly. (ASPEN)

25 Parenteral Nutrition + Liver Disease Shaffer and Lumen (2002) Shaffer and Lumen (2002) Retrospective Study of 107 case notes. Median duration of HPN was 40 months. The main underlying diagnoses were Crohns Disease (40%) and ischaemic bowel (28%). Retrospective Study of 107 case notes. Median duration of HPN was 40 months. The main underlying diagnoses were Crohns Disease (40%) and ischaemic bowel (28%). Derranged LFTs were defined as 1.5 times above the reference range, at least 6 months after initiation of HPN. Persistently abnormal LFTs were present in 39% adult patients on long-term HPN. Derranged LFTs were defined as 1.5 times above the reference range, at least 6 months after initiation of HPN. Persistently abnormal LFTs were present in 39% adult patients on long-term HPN. Clinical Nutrition 2002; 21(4): 337-43.

26 Parenteral Lipid and Hepatic Dysfunction Lipid emulsion >1g/kg increased hepatic dysfunction (retrospective). 1 Lipid emulsion >1g/kg increased hepatic dysfunction (retrospective). 1 MCT/LCT emulsions rather than LCT alone more efficient oxidative metabolism reduce hepatic dysfunction? 2 (In practice, only lower serum bilirubin). 3 MCT/LCT emulsions rather than LCT alone more efficient oxidative metabolism reduce hepatic dysfunction? 2 (In practice, only lower serum bilirubin). 3 Olive oil-based lipid emulsion (case report: improvement in LFTs possibly due to vitamin E content?). 4 Olive oil-based lipid emulsion (case report: improvement in LFTs possibly due to vitamin E content?). 4 1.Ann Intern Med 2000; 132: 525-32 2.JPEN 1991; 15: 601-3 3.Clin Nutrition 1998; 17: 23-9 4.Clin Nutr 2004; 23: 1418-25

27 Preventing & Treating TPN-associated Liver Disease Encourage oral intake! Encourage oral intake! Avoid Dextrose Overfeeding (<40kcal/kg/d) Avoid Dextrose Overfeeding (<40kcal/kg/d) Reduce Fat Calories (<1g/kg/d) Reduce Fat Calories (<1g/kg/d) Cyclical PN Cyclical PN Choline Choline Liver/Small Bowel Transplant Liver/Small Bowel Transplant ? Total intravenous calorie intake JPEN 2002; 26(5): S43-8.

28 HPN – case study 35 year old male – Mr W 35 year old male – Mr W Admitted to IFU in May 2002 Admitted to IFU in May 2002 Diagnosis – mesenteric volvulus Diagnosis – mesenteric volvulus Remaining small bowel – 30cm of jejunum and 10cm of ileum, brought out as a jejunostomy and mucous fistula Remaining small bowel – 30cm of jejunum and 10cm of ileum, brought out as a jejunostomy and mucous fistula

29 HPN Case Study Social history – engineer, married, wife just had a baby and interests include running marathons! Social history – engineer, married, wife just had a baby and interests include running marathons! Physical examination – thin and jaundiced Physical examination – thin and jaundiced Alk phos 160, ALT 480 and bilirubin 76 Alk phos 160, ALT 480 and bilirubin 76 Otherwise haemodynamically stable Otherwise haemodynamically stable

30 Dietetic Assessment Weight 56.6kg (Weight history – 63kg) Weight 56.6kg (Weight history – 63kg) BMI 19.6 BMI 19.6 MAC 26cm MAC 26cm TSF 10.6mm TSF 10.6mm MAMC 22.7cm MAMC 22.7cm Nutritional Requirements – 2100kcals and 11gN Nutritional Requirements – 2100kcals and 11gN Not eating – too scared increased his output Not eating – too scared increased his output

31 Dietetic Plan Low fibre diet Low fibre diet Glucose-saline drink 1litre /day Glucose-saline drink 1litre /day Restrict hypotonic fluids Restrict hypotonic fluids Commence on PPN until line cultures come back clear (3L, 1800kcals and 9gN) Commence on PPN until line cultures come back clear (3L, 1800kcals and 9gN)

32 PLAN HPN training and home, trained quickly, home by 24 th July. HPN training and home, trained quickly, home by 24 th July. Drugs on discharge – loperamide 6mg qds, Drugs on discharge – loperamide 6mg qds, codeine PO 60mg qds and omeprazole 80mg bd codeine PO 60mg qds and omeprazole 80mg bd Reconstructive surgery at a later date to close jejunostomy Reconstructive surgery at a later date to close jejunostomy

33 HPN px on discharge 2/7 fat 3.5L bag 2/7 fat 3.5L bag 2200kcals, 11gN, 244mmol Na, 50mmol K, 9mmol Ca 11mmol Mg, 27.7mmol PO, additrace and cernevit 2200kcals, 11gN, 244mmol Na, 50mmol K, 9mmol Ca 11mmol Mg, 27.7mmol PO, additrace and cernevit 5/7 glucose bags – 3.5L 5/7 glucose bags – 3.5L 2200kcals, 13gN, + same electrolytes + additrace 2200kcals, 13gN, + same electrolytes + additrace

34 HPN – dietetic monitoring 19.5.0220.8.0219.11.0216.1.032.12.03 Weight56.654.4606770.8 Height1.721.721.721.721.72 BMI19.618.420.32323.8 MAC2625.527.52930.5 TSF10.61013.815.815.8 MAMC22.722.423.22425.5 Comments 7/7 PN Increase kcals + N Surgery25/11 5/7 PN 2/7 PN

35

36

37 No man is really an accomplished physician or surgeon who has not made dietetic principles and practice an important part of his professional education SIR HENRY THOMPSON, F.R.C.S, 1897


Download ppt "Dietitians Role in HPN Kirstine Farrer, Consultant Dietitian – Intestinal Failure Intestinal Failure Unit, Hope Hospital, Salford, Manchester"

Similar presentations


Ads by Google