Parenteral nutrition (Guidelines)

Parenteral nutrition is indicated for:

• Intestinal failure, due to non-function, proximal enterocutaneous fistula causing nutritional and/or fluid deficit or surgical resection, with an expected requirement of at least 7 days
• Inaccessible GI tract expected to be longer than 7 to 10 days.
• Post-operative patients who cannot meet their nutritional requirements enterally after 5 to 7 days.
• PN will be considered pre-operatively in malnourished patients/at severe nutritional risk where nutritional requirements cannot be adequately met orally or by enteral nutrition (EN).

• Referrals are made for Artificial Nutrition support using the qr Code:

Pre-assessment should be done by the requesting team and includes:

• Measure:
  • Premorbid and current weight, height and BMI
• Blood tests:
  • Including: U+E, Mg, PO4, Ca, FBC, Clotting, LFTs, CRP, and micronutrient profile: B12 and folate, (selenium, zinc for selected patients), Vitamin D.
• Observations:
  • Temperature, pulse, BP and respiratory rate to be measured every 6 hours at a minimum.
•  Charts:
  
  • An accurate fluid balance chart should be kept, including all oral and IV intake and all output including vomit, NG, stoma, fistula, drain, urine and stool measurements.
  • Food chart, if relevant.
• Prescribe:
  
  • Ensure appropriate vitamins are prescribed if refeed risk e.g. Oral thiamine or IV high potency vitamins B & C (unlicensed thiamine injection in event of shortage) PLUS multivitamin or trace element supplement e.g. Forceval.

Consideration of route of administration needs to be made.

Do NOT request line placement until PN is agreed by the Nutrition Team.

If it is anticipated that PN may be required i.e at laparotomy with major small bowel resection, and central access is being placed, reserve a lumen of the central line for future PN USE ONLY

The tip of the CVC must lie in between the lower third of superior vena cava and upper third of right atrium to minimise the risk of thrombosis.

If a PICC line is required for PN this will be organised by the responsible ward team, once PN provision is agreed.

• If PN is being considered elsewhere in NHS Highland, early discussion with the surgical or gastroenterology consultants is imperative to facilitate prompt transfer.

• See: ANTT® Guidance | Turas | Learn
• (CRBSI) (Ryder, 2006) (Boyce & Pittett, 2002).

• If disconnected, the PN bag and giving set MUST be disposed of and the volume infused recorded on the fluid chart and in the medical notes.

The PN prescription will be developed by the Nutrition Team and signed, ideally, by the consultant or other prescriber from the Nutrition Team. If there is no prescriber from the nutrition team available, the ward team doctors may be approached to sign the prescription.

• Monitoring blood tests will be performed daily until stable and then twice per week. All blood tests required for monitoring of PN will be recommended by the Nutrition Team.
• Additional blood tests should only be requested if required for other clinical reasons.
• The ward team are responsible for ensuring the necessary blood tests are taken.
• All blood tests should be taken early in the morning; if blood tests results are not available by 12:30 it may not be possible to supply PN.

At weekends

• The ward doctors are responsible for acting on the blood results and correcting any electrolyte derangements.
• The current PN prescription will provide the electrolyte content of the bag.
• Patients will be reviewed at least once weekly by the Nutrition Team, and more frequently depending on clinical need.

Capillary blood glucose

• Should be measured once per day at the start of each infusion of PN, or more if needed until stable during PN and during rest period for cyclical infusions by ward staff.
• This is to ensure there is adequate pancreatic endocrine function to manage the glucose load of the PN.
• More frequent CBG may be required if the patient is diabetic or exhibits impaired glucose tolerance.
• Frequency of monitoring may be reduced in stable patients as advised by the nutrition team

Observations

• Temperature, pulse, BP and respiratory rate to be measured every 6 hours at a minimum.
• An accurate fluid balance chart should be kept including all oral and IV intake and all output including vomit, NG aspirates and free drainage, stoma, fistula, drain, urine and stool measurements.
• Weekly weights should be taken, or more often if indicated, as advised by the nutrition team.
• Urine sodium will be requested by the Nutrition team, if needed for fluid/PN requirement.

Escalation

• A spike in temperature during the administration of PN requires:
  • Prompt clinical review
  • Stop, disconnect and discard PN infusion
  • Taking of peripheral and line cultures
  • Peripheral IV fluids if necessary

If PN has been required for 2 weeks, then the need for more long-term PN and potentially Home PN should be considered (Pironi, et al., 2015).

• CBG: capillary blood glucose
• CRBSI: Catheter Related Blood Stream Infection
• CRP: C-reactive protein
• CVC: Central Venous Catheter
• EN: Enteral Nutrition
• GI: Gastrointestinal
• LFTs: liver function tests
• NG: nasogastric
• PN: Parenteral Nutrition