1. Intestinal Failure Unit
Parenteral Nutrition
Made simple….
in 15 minutes
Jon Shaffer
Intestinal Failure Unit
Hope Hospital

2. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

3. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

4. CONSEQUENCES OF MALNUTRITION
DIMINSHED QUALITY OF LIFE
INCREASED CLINICAL COMPLICATIONS
POORER OUTCOME
INCREASED COSTS

6. Malnutrition on admission – Sweden
382 pts
Infection
Surgery
Internal medicine
Oncology
Well nourished %
Moderately malnourished %
Severely malnourished %

7. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

8. Nutritional assessment
Problem
No “blood urea “ for malnutrition
Risk scores v malnutrition
Multiple examples
Lack of a Gold Standard
Validation

9. Nutritional screening
ALBUMIN
Long half life
Overly sensitive- liver/renal disease
Reduction – redistribution
Slow to react with recovery
“ negative acute phase protein”

10. Nutritional screening
Subjective Global Assessment
Pt questions e.g weight loss
diet changes
GI symptoms
Physical appearance-
loss of fat
muscle wasting
Grading
A Well nourished
B Moderately malnourished
C Severely malnourished
Detsky 1987

12. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

13. Nutrition support teams
Appropriate screening /referral
Appropriate nutrition support
Education/training – staff and pts
Cost effective
PN x10 v EN
Better outcomes
Reduced complications
Bowling 2002

14. Efficacy of nutrition support teams e.g. catheter sepsis rates
% Before
%After
Freeman 21
1.3
Sanders 29
4.7
Ryan 33 3
Nehme 25
Keohane 4
Jacobs 24
Faubion
3.5
Mean 27
2.5

15. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

16. Appropriateness – varies
Few ABSOLUTE indications
1. Intestinal Failure
2. If the gut works – use it
3. Enteral preferable

18. If the gut works……1 Technology -- 1970’s—1990 Parenteral > Enteral
Better catheters/ better feeds/better research
Industry/ Surgery driven
Most - Surgical/Intensive care/Cancer

19. If the gut works……2 1990’s Enteral tubes especially PEG’s
Medical > Surgical
Erosion of traditional markets e.g. Pancreatitis, ICU

20. Enteral ? preferable
Simpler
Less complications
Cheaper
Equieffective

21. Parenteral nutrition Importance of malnutrition Nutrition assessment
Nutrition teams
Indications
Access
Prescribing
Monitoring

22. IV ACCESS Peripheral - short term Midline - short/medium
PICC ( Peripherally inserted central line ) -medium
Central – medium/long term
Central tunnelled – ultra long term HPN

23. Prescribing Standard bags A la carte All in one bags
Re-feeding syndrome Po4, K

24. Design of Regimen Osmolality peripheral < 900 mosmol/L, (1800kcals)
PICC < 1200 mosmol/L (2000kcals)
Central < 1700 mosmol/L (> 2000kcals)

25. Fluid
30-35mls/kg body weight (adjust for age)

26. Energy Normal to provide a ratio of Glucose: fat 50:50 or 60:40
Overfeeding can result in lipogenesis, fatty infiltration of the liver

27. Nitrogen Range from 0.17-0.3gN/kg Rarely give >14g / day
Need to ensure maximal metabolic effect of protein – 200kcals / gN
I.e. excess nitrogen = extra calories

28. Vitamins and Minerals
Water soluble
Fat Soluble
Trace Elements

29. Parenteral Nutrition Regimen
Solution
Volume (mls)
Energy (kcals)
Nitrogen (g)
Na (mmol)
K (mmol)
Ca 9mmol)
PO4 (mmol)
Mg (mmol)
Vamin 9 EF
1000
9.4
Glucose
40%
500
800
20% Intralipid
7.65
Addiphos 10
7.5
15% KCl 20 40
50% Mg SO4 2 4
Ca Cl
3.6
30% NaCl 50
100
Vitlipid + Solovito
10 each vial
Additrace
Requirements
2330
1900
9.5
108 48 19
3.8
Total
2116
1800
107.5
47.5
4.3
17.6

30. Requirements
Energy = 8.1x = (153kcals)15% activity + (153kcals) 15 % stress + 500kcals = 1826kcals
Nitrogen = 0.2g/kg = 9gN
Fluid = 4 L (35mls/kg (1575mls) + losses 2.5L)
Na 295mmol (1mmol / kg, GI losses 250mmol/L)
K 45mmol (1mmol / kg)
PO 22.5mmol ( mmol/kg)
Mg 4.5mmol ( mmol/kg)
Ca 4.5mmol ( mmol/kg)

31. Monitoring Parameter Frequency Rationale Weight Daily - weekly
Nutritional Status – fluid balance
Anthropometry
Fortnightly
Nutritional Status
Temperature
Daily
Infection
Line Site
Fluid Balance
Fluid / electrolyte requirement

32. BAPEN
British Association Enteral & Parenteral Nutrition