HYWEL DDA LOCAL HEALTH BOARD
RESTRICTED NOT YET APPROVED
Adult Parenteral Nutrition Guidelines
Standards For 7,8,11,13,14,15,16, Policy Number: 338 Supercedes: Healthcare Services No/s 18, 19
Version Date Of Reviewer Completed Approved Da te New Review No: Review: Name: Action: by: Approved: Date: Rachel Lewis & Clinical Policy 0.2 April 2013 April 2015 Linda Morgan Review Group
Guidance to support the safe and appropriate administration of Parenteral Brief Summary of Document: Nutrition in Adults patients within secondary care.
Policy 008: Policy for consent to examination and treatment Policy 209: Hywel Dda Adult Refeeding Guidelines Policy : Hywel Dda Enteral feeding policy To be read in conjunction with: NICE CG32 – Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. NCEPOD (2010) A mixed Bag – An enquiry into the care of hospital patients receiving parenteral nutrition
Freedom Of Classification: Clinical Category: Policy Information Open Status
Caroline Director of Authorised by: Job Title Signature: Oakley Nursing
HYWEL DDA LOCAL HEALTH BOARD
Responsible Rachel Lewis Job Clinical Lead Dietitian Officer/Author: Linda Morgan Title: Clinical Nutrition Nurse Specialist Nutrition and Dept Base Glangwili Hospital Dietetics Contact Details: [email protected] Tel No 01267 227067 E-mail: [email protected]
ORGANISATION DEPARTMENT Scope DIRECTORATE COUNTY ONLY WIDE ONLY
Administrative/ Allied Health Ancillary Maintenance Estates Professionals Staff Group Scientific & Medical & Dental Nursing Other Professional
Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained. Individual(s) Date(s) Parenteral Nutrition working July 2012 CONSULTATION group July 2012 Nutrition support Clinical Group(s) Date(s) focus group Nutrition and Hydration Steering group Committee(s) Date(s)
RATIFYING AUTHORITY (in accordance with the KEY Schedule of Delegation) COMMENTS/ A = Approval POINTS TO NOTE Required Date Approval NAME OF COMMITTEE Obtained FR = Final Ratification Clinical Policy Review Group FR
Group Date Equality Impact nd Rachel Lewis 22 April completing Assessment Equality impact Linda Morgan Undertaken 2013 assessment Jackie Hooper
Please enter any keywords to be Parenteral Nutrition, Enteral feeding, Nutrition Support, used in the policy search system to enable staff to locate this policy Refeeding syndrome
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Document Implementation Plan Through a co-ordinated launch of the policy facilitated by the county nutrition groups (for local launch) and the NSG (for launch to key professional groups). How Will This Policy Be Implemented? The policy will be adopted by the professions involved with its development once approved; this will support incremental implementation of the policy
Who Should Use The Document? All members of the multi-disciplinary team involved with nutritional care
Training needs will be identified by the relevant professional leads; What (if any) meeting the training needs will depend on the specific need. Training/Financial Financial: This policy supports the appropriate use of PN and therefore Implications are there is unlikely to be an increased cost associated with implementing Associated with this this policy. Optimal PN provision and related care may reduce costs by document? ensuring PN is only used in appropriate circumstances, reducing line infections and optimising nutritional care Action By Whom By When
Approved guideline sent for signing Rachel Lewis Signed guideline made active on Policy
intranet Coordinator Active guideline advertised via global e- Dietetics What are the Action mail Plan/Timescales for Awareness sessions across the health implementing this policy? Dietetics board Cascade of guideline through locality Dietetics nutrition groups Post graduate teaching sessions in Dietetics each locality Promotion of guideline via nutrition Dietetics steering groups
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HYWEL DDA LOCAL HEALTH BOARD Contents 1. INTRODUCTION ...... 6 2. POLICY STATEMENT ...... 6 3. SCOPE ...... 6 4. AIM ...... 6 5. OBJECTIVE ...... 6 6. NUTRITIONAL ASSESSMENT ...... 7 6.1. Nutritional screening ...... 7 6.2. Consent to treatment ...... 8 6.3. Withdrawing PN ...... 10 7. DEFINITION OF PARENTERAL NUTRITION ...... 10 7.1. Total parenteral nutrition (TPN) ...... 10 7.2. Supplementary Parenteral nutrition (SPN) ...... 10 8. INDICATIONS OF PARENTERAL NUTRITION ...... 10 9. CONTRAINDICATIONS ...... 11 9.1. Precautions of use ...... 11 10. ROUTES OF ACCESS ...... 12 10.1. Types Of Lines ...... 12 11. STARTING PARENTERAL NUTRITION ...... 13 11.1. Assessment ...... 13 11.2. Referral and prescription ...... 14 11.3. Patients admitted who are on Home Parenteral Nutrition (HPN) ...... 14 11.4. Composition of PN ...... 14 11.5. Storage ...... 15 11.6. Administration ...... 15 11.7. Rate of administration...... 15 11.8. Undesired effects of PN ...... 16 12. CONNECTING AND DISCONNECTING PN INFUSION ...... 16 13. FLUSHING A CENTERAL LINE FOR PN...... 17 14. GIVING MEDICATION ...... 17 15. OUT OF HOURS PN ...... 17 16. MONITORING ...... 17 16.1. Clinical monitoring ...... 17 16.2. Laboratory monitoring...... 18 16.3. Other Monitoring: ...... 19 17. COMPLICATIONS ...... 20 17.1. Metabolic complications ...... 20 17.2. Catheter related complications ...... 21 18. DISCONTINUING PN ...... 21 18.1. Unplanned stops in PN ...... 22 19. LONG TERM PN ...... 22 20. RESPONSIBILITY ...... 22 21. TRAINING ...... 23 22. IMPLEMENTATION ...... 24 23. FURTHER INFORMATION ...... 24 24. CLINICAL POLICIES ...... 24 25. REVIEW ...... 24 26. REFERENCES ...... 24 27. APPENDIX 1: ENTERAL & PARENTERAL ALGORITHM...... 25 28. APPENDIX 2: REFEEDING SYNDROME...... 26 29. APPENDIX 3: ADULT PARENTERAL NUTRITION REFERRAL PROCESS ...... 28
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HYWEL DDA LOCAL HEALTH BOARD 30. APPENDIX 4: ADULT PARENTERAL NUTRITION REFERRAL FORM ...... 29 31. APPENDIX 5: ADULT PARENTERAL NUTRITION PHARMACY REQUEST FORM .. 31 32. APPENDIX 6: ADULT PARENTERAL NUTRITION PHARMACY CHANGE OF REGIMEN FORM ...... 31 33. APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS ...... 33 34. APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS …………………………………………………………………………………………………...34 35. APPENDIX 9: GUIDELINE FOR CONNECTING A PARENTERAL NUTRITION INFUSION ...... 35 36. APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A PARENTERAL NUTRITION INFUSION ...... 41
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1. INTRODUCTION Parenteral nutrition (PN) is the administration of nutrients by the intravenous route. It is a well established technique of providing artificial nutrition support to patients who have an inaccessible or non-functioning gut.
Parenteral nutrition is a high risk intravenous therapy, the use of which must be supervised and monitored by suitably trained staff. It should not be given without appropriate forethought and planning.
2. POLICY STATEMENT To establish consensus within Hywel Dda Health board on the management of adult patients requiring PN.
3. SCOPE This clinical policy is for use with all adult patients requiring PN within Hywel Dda Health board. It should be used by dietitians, registered nursing staff, chemical pathologist, pharmacists, doctors, allied health professionals (AHPs) and students alike within the scope of the individual’s clinical competence.
4. AIM • To ensure that PN is considered in appropriate adult patients in order to prevent and treat disease related malnutrition and complications related to poor nutritional status. • To minimise clinical risk and promote the safe and appropriate administration of PN to all adult patients. • To ensure a co-ordinated multi-disciplinary approach to PN within Hywel Dda Health board
5. OBJECTIVE • To provide guidance on identifying patients at nutritional risk and early identification of Patients’ requiring PN • To recommend best practice for the safe administration and monitoring of PN
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HYWEL DDA LOCAL HEALTH BOARD 6. NUTRITIONAL ASSESSMENT Half of all patients admitted to hospital are suffering from malnutrition (BAPEN, 2011). The consequences of malnutrition are diverse, and can affect all organs in the body. Failure to provide adequate nutrition is both a cause and consequence of ill health, which can lead to immune dysfunction, disordered physiological function and delayed wound healing.
6.1. Nutritional screening All patients admitted to hospital should be screened for malnutrition within the first 24hours of admission using the agreed Hywel Dda Health Board nutritional screening tool and re- screened on a weekly basis. Any patient with existing malnutrition or those screened as being at high risk of malnutrition must have a nutrition care plan in place and be highlighted to the responsible consulting team. Always consider risk of Refeeding syndrome (RFS) in patients with existing malnutrition or at high risk (further information of refeeding syndrome available in the appendix 2).
6.1.1. Organisation of Nutrition support (NICE., 2006)
Screen
Recognise
Treat
Oral Enteral Parenteral
Monitor & Review
Refer to appendix 1 for further information on selecting the most appropriate means of providing nutrition support for patients.
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HYWEL DDA LOCAL HEALTH BOARD 6.2. Consent to treatment 6.2.1. Patient consent All patients with a poor nutritional status should be actively involved in decision making regarding their nutritional plan. The Royal College of Physicians (2010) state ‘Those with intact cognitive function who are unable to eat or drink must be involved in decision making as their perception of the process resulting from absence of food will be different from those with absent cognitive function’ .
In relation to any aspects of commencing PN, the patients consent should be sought wherever possible. The Health Board’s Consent Policy (008) should be adhered to and referred to for guidance.
6.2.2. Mental capacity For the purposes of Mental Capacity Act (MCA) 2005, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. • A person lacks capacity if they have an impairment or disturbance (for example, a disability, condition or trauma) that affects the way their mind or brain works, and the impairment or disturbance means that they are unable to make specific decision at the time it needs to be made. • An assessment of a person’s capacity must be based on their ability to make a specific decision at the time it needs to be made, and not their ability to make decisions in general. • The impairment or disturbance does not have to be permanent. A person can lack capacity to make a decision at the time it needs to be made even if: the loss of capacity is partial, temporary or their capacity changes over time. • A person may also lack capacity to make a decision about one issue but not about others. The MCA Code of Practice supports the MCA and provides guidance to all those who care for and/or make decisions on behalf of adults who lack capacity. The Code includes case studies and clearly explains in more detail the key features of the MCA. 6.2.3. Patients who have necessary decision-making capacity If PN is considered to be beneficial by the clinician and MDT then the patient who has the necessary decision-making capacity should be asked for their informed consent to the procedure. In these cases the patient’s decision is final.
A person can be said to have given consent when their decision is based on an appreciation and understanding of the salient facts and the reasonably foreseeable consequences of their decision (MCA, 2005 s.3(4)). Relevant information about the benefits and risks of the proposed treatment and available alternative treatments must be provided in an appropriate format to help the person to understand and in accordance with the Hywel Dda Health Board ‘Policy to Consent to Examination and Treatment (Policy No. 008).
Consent can be written, verbal or non-verbally implied. A consent form does not itself prove that consent is valid. The point of the form is to record the discussion that has taken place. Patients have the right to change their mind at any point and can withdraw their consent at any time. 6.2.4. Patients who lack decision-making capacity The Mental Capacity Act, 2005, provides a framework for acting and making decisions on behalf of individuals who lack the mental capacity to make the decision for themselves. Where there are reasons to doubt a person’s capacity to make a decision the individual who wishes to
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HYWEL DDA LOCAL HEALTH BOARD take some action in relation to the person’s care or treatment is responsible for ensuring an assessment of capacity is undertaken. The act emphasises that in some cases an MDT approach is best using the skills and experience of different professional’s. Further guidance and support in respect of the Mental Capacity Act can be found in Health Board policy HD018: Guidance on the Mental Capacity Act, by visiting the Mental Capacity Act Intranet page. Parenteral Nutrition in the context of the mental disorder where a patient is subject to Part 4 of the Mental Health Act (2007), the issue of feeding may not rest on the persons consent and there are circumstances where feeding can be given despite the patient’s objections.
6.2.5. Best interest For patients who are assessed as lacking decision-making capacity or who are unable to communicate their wishes, then a decision should be made in the patient’s best interests. The decision-maker, in consultation with professional colleagues and other people interested in the person’s welfare should consider a number of factors including: • Patient’s past and present wishes and feelings, beliefs and values • Clinical judgement around effectiveness of treatment • Views of relatives and others close to the patient, including any attorney or court- appointed deputy who does not have decision-making authority for this decision In difficult clinical situations it is recommended that a second opinion should be sought from another senior clinician or a clinical ethics committee ‘Clinical Resource Efficiency Support Team’ (CREST) 2004.
6.2.6. Advanced Decisions, Lasting Power of Attorney Court Appointed Deputies and IMCAs Some patients may have made an advanced decision to refuse artificial nutritional support (ANS), including PN. If this decision is valid and applicable healthcare professionals are legally obliged to respect it. Where the effect of an advanced decision to refuse ANS is likely to lead to the patient’s death there are special rules that apply. For further guidance see Health Board policy HD014: Policy on Advance Decisions. A patient may have also indicated their preferences which, whilst not legally binding, must be considered when making a decision in the person’s best interests.
Some patients may have granted a Lasting Power of Attorney to a specific person who they wish to have the authority to make decisions on their behalf in the event of their losing decision-making capacity. There are different types of Lasting Power of Attorney which provide different levels of decision-making authority and the person can also limit the attorney’s authority to make specific decisions. If patients are assessed as lacking capacity, then the decision-maker must ask the person and/or others close to the patient if someone has been granted a Lasting Power of Attorney. If the decision about ANS falls within the attorney’s authority the attorney would be the decision-maker.
In circumstances where a person lacks capacity and it is likely that they will lack capacity for future decisions the Court of Protection has the power to appoint a deputy to make those decisions for the person. The scope and duration of a deputy’s powers are defined by the Court but, as with attorneys, if the decision about ANS falls within their authority the deputy would be the decision-maker. Deputies cannot make decisions to refuse a treatment considered to be life-sustaining as this would require the authority of the court.
If there is no-one appropriate for the decision-maker to consult with about a decision in respect of ANS and the treatment is considered a ‘serious medical treatment’ (MCA Code of Practice, paragraph 10.42) then an Independent Mental Capacity Advocate must be instructed to represent and support the person. Further guidance and support in respect of the Mental
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HYWEL DDA LOCAL HEALTH BOARD Capacity Act can be found in Health Board policy HD018: Guidance on the Mental Capacity Act.
6.3. Withdrawing PN Parenteral Nutrition is considered a treatment. If it is providing no benefit (e.g. if the patient is dying) then it may be discontinued. Where the patient lacks the capacity to consent to such a decision the safeguards provided by the Mental Capacity Act must be followed as part of the consideration of withdrawal of feeding.
In ethical terms there is no legal difference between starting and withdrawing treatment. In emotional terms it is more difficult to withdraw a treatment once begun than not to start it at all. For this reason there can sometimes be a reluctance to commence PN for fear it will be difficult to stop. In such circumstances it may be appropriate to start treatment for a time or period, with the provision that the outcome will be reviewed at the end of a specific time period or earlier if needed, to be stopped, changed or continued as appropriate (CREST 2004).
7. DEFINITION OF PARENTERAL NUTRITION Parenteral nutrition (PN) involves the provision of an artificially prepared solution containing amino acids, glucose, lipids, electrolytes, trace elements and vitamins that are needed to maintain health. Nutrients are delivered directly into the circulatory system via a dedicated venous catheter.
7.1. Total parenteral nutrition (TPN) TPN is the provision of parenteral nutrition as a sole source of nutrition
7.2. Supplementary Parenteral nutrition (SPN) SPN is the provision of PN given in conjunction with enteral nutrition to meet patient’s daily nutritional requirements.
8. INDICATIONS OF PARENTERAL NUTRITION • Failure of gut function to a degree that definitely prevents adequate gastrointestinal absorption of nutrients • 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
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HYWEL DDA LOCAL HEALTH BOARD • Patients with reasonable gut function who cannot eat and when enteral tube feeding is impossible or impractical for reasons of tube access (NICE, 2006)
Short Term Long Term • Surgical complications such as • Short bowel syndrome of any anastomotic leak, intestinal obstruction, aetiology (i.e. small intestine adhesions or fistulation <200cm) • Patients with severe pancreatitis if there is • Intestinal failure gastric outlet obstruction secondary to • Motility disorders such as duodenal stenosis or complex fistulation scleroderma and chronic idiopathic • Patients with multi-organ failure, severe intestinal pseudo-obstruction sepsis or burns where nutritional syndromes requirements cannot be met by enteral • Chronic radiation enteritis nutrition alone • Failure of gut motility despite the use of prokinetics • Short bowel syndrome, high output stoma or evidence of malabsorption where nutritional requirements cannot be met by enteral nutrition alone • Patients with swallowing difficulties – mechanical or neurological, oesophageal or stomach problems such as obstructions awaiting enteral access, stenting or surgery • Incurable cancer patients in hypophagic / obstructions, if there is an acceptable performance status if they are expected to die from starvation / under nutrition prior to tumour spread • Oral mucositis that prevents enteral access being established
9. CONTRAINDICATIONS • Patients who are able to absorb adequate nutrition via the enteral route • Well nourished or mildly undernourished patients in preoperative period who are consuming adequate enteral nutrition
9.1. Precautions of use • Patients with pre-existing malnutrition who will be at high risk of refeeding syndrome (Further information on refeeding syndrome is available in appendix 2) • PN may not be appropriate for patients with advanced cancer who have been unresponsive to treatment
9.1.1. Allergies, hypersensitivity and restrictions • Vegetarian / vegan: PN is suitable for most vegetarians but the lipid may contain eggs vegans may therefore insist on lipid free products. • Egg allergy: Normal lipid products should not be administered to patients with an egg allergy without close supervision. Lipid free products may have to be used.
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HYWEL DDA LOCAL HEALTH BOARD • Soya protein allergy: lipids based on soybean oil do not contain soya protein so can be used with caution in patients with soybean allergy.
Refer to section 11.4.3 for further advice on lipids
10. ROUTES OF ACCESS The type of central line used will depend upon the length of time PN is required and the condition of the patient’s veins. A planned approach to central line access is required in patients who are likely to require longer periods of PN to minimise the need for repeated insertion of short term catheters.
The type of access required will depend on a number of factors including the length of time PN is required, the availability of suitable veins and staff expertise. Establishing and maintaining suitable access to the circulation is essential for the successful management of PN.
A number of veins are suitable to provide central access for parenteral nutrition: • Subclavian Vein The subclavian route is often the preferred route for long-term parenteral nutrition i.e. lasting over thirty days (NICE, 2006). In practice jugular vein is used instead of subclavian. However as there is an associated risk of pneumothorax during the insertion procedure the jugular route is often used in preference for short term administration. There is a lower risk of infection with this route and dressings can be safely secured over the line reducing movement and increasing patient comfort (Masoorli et al., 2002).
• Jugular Veins Accessing the jugular veins for central access is associated with a lower risk of complication during the insertion procedure; there is an increased risk of infection post insertion due to the position of the exit site on the neck. Dressing application is difficult requiring more frequent replacement due to neck movement and hair growth in men. Catheter position also often makes head movement uncomfortable for the patient as a pulling sensation is felt.
• Basilic and Cephalic veins Accessing the basilic or cephalic veins carries a much lower complication rate during insertion and infection risk post insertion. Dressing application is easy. However in the acutely ill patient these veins may be difficult to access due to previous cannulations, the need for repeated blood tests or oedema.
• Femoral vein Wherever possible the femoral route should be avoided for PN. Use of the femoral vein carries a high risk of infection and thrombosis (Hamilton., 2006). There is also a much higher demand for nursing management for skin hygiene due to the risk of contamination from urine and faeces. Dressing application may also be an issue particularly in patients who are mobile or incontinent as frequent dressing changes may be required.
10.1. Types of Lines 10.1.1. Peripheral cannula Although easy to insert the use of a peripheral cannula for PN places restrictions on the type of feeding solution that can be used, as not all products are suitable for peripheral administration.
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HYWEL DDA LOCAL HEALTH BOARD There is an associated risk of developing thrombophlebitis with a peripheral cannula therefore it is advisable to change the site of the cannula every 24- 48 hours according to patient need and availability of veins. For the administration of PN peripheral access should only be used for short term therapy (up to 14 days) as the patient may at risk of phlebitis, infiltration and extravasation (Campbell et al., 2011).
10.1.2. Non tunnelled central venous catheters Short term venous central catheters are non-tunnelled, 20 – 30 cm long polyurethane (PUR) catheters inserted in a central vein (subclavian vein, internar jugular vein, innominate vein, axillary vein or femoral vein): they may have a single lumen or multiple lumens, and they should be used only in hospitalized patients (Ryder, 2006).
Medium term central catheters are non-tunnelled central venous devices: they include PICCs (peripherally inserted central catheters) and Hohn catheters. PICCs are non-tunnelled central catheters inserted through a peripheral vein of the arm (basilica or brachial or cephalic vein); they are 50 – 60 cm long and usually made of silicone or 2nd- 3rd generation PUR. Both PICCs and Hohn catheters can be used for prolonged PN, up to 3-6 months. (Ryder., 2006).
With regards to PN in the hospitalized patient, there is no clear data showing significant advantages of PICCs vs. centrally inserted central venous catheters (CVC). Some evidence suggests that PICC may be preferable because associated with fewer mechanical complications at insertion, lower costs of insertion, and a lower rate of infection (Timmis., 1998) it is accepted that placement in the antecubital fossa or at midarm carries the important advantage of removing the exit site of the catheter away from endotracheal, oral and nasal secretions (Pratt., 2007).
10.1.3. Tunnelled Lines Long term (> 3 months) requires a long term venous access device, such as a tunnelled central catheter (Hickman, Broviac, Groshong, etc.) or a totally implanted port. The choice between a tunnelled catheter vs. a port depends on many factors, mainly related to patient’s compliance, experience of the nursing staff, and frequency of venous access. According to CDC Guidelines (CDC., 2002) totally implantable access devices should be reserved for patients who require long-term, intermittent vascular access, while for patients requiring long term frequent or continuous access (which is the case of PN), a tunnelled CVC is preferable (Class C recommendation according to CDC).
NB: PN must be delivered through a dedicated lumen (proximal port) and clearly labelled. If a lumen has been previously used for other substances, flush with saline before using for PN. Care bundles for Central lines should be used in the care of patients with PN via central lines.
11. STARTING PARENTERAL NUTRITION Where possible, patients should be informed of the potential risks and benefits of PN before the treatment begins. Refer to section 6.0 for further information on gaining consent to treatment. 11.1. Assessment Careful assessment of all patients referred for PN is essential in order to understand their nutritional requirements and how they might best be met. A full clinical assessment must include the following: • Patient details and reason for referral • Clinical history • History of nutrient intake and body weight changes
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HYWEL DDA LOCAL HEALTH BOARD • History of gastrointestinal function • Laboratory results • Risk of re-feeding syndrome • Potential length of treatment
11.2. Referral and prescription A multidisciplinary approach to PN improves patient care and reduces complications as recommended in NICE guideline 32. The referral process within Hywel Dda is based on completion of a specific PN referral form (appendix 4) which requires clinical, dietetic and pharmacy input.
If PN is considered as an appropriate route for nutrition, a senior or middle grade clinician responsible for the patients care must document the request in the medical notes, including the indication for PN, likely duration and route of administration.
The dietitian will complete the PN request form and make recommendations for the PN regime to enable appropriate prescription form (appendix 5) to be completed by the clinician after consultation with the ward pharmacist. The prescription should be written on the IV section of the prescription chart.
11.3. Patients admitted who are on Home Parenteral Nutrition (HPN) If a patient on HPN is admitted to any hospital within Hywel Dda LHB, the centre managing their HPN should be contacted for advice about the prescription and line care.
11.4. Composition of PN All-in-one 3 chamber parenteral bags will be used within the Health Board. These contain a combination of an amino acids solution, fat emulsion, glucose solution and water. Fat soluble vitamins, trace elements, minerals and electrolytes additions will be made under aseptic conditions. Further modification of PN bags, such as adding extra electrolytes is only available in special circumstances. Further information on the range of bags available and their composition is available in the appendix 7 and 8 .
11.4.1. Nitrogen The Nitrogen solution used will contain a mixture of essential and non essential amino acids. Requirements are based on a number of factors including body weight and clinical condition.
Glutamine is not present in most commercially available amino acid solutions due to its instability. However it can be added to a PN bag prior to administration.
11.4.2. Carbohydrate PN formulation contains carbohydrate in the form of glucose only. The maximum amount of glucose should not exceed 7mg/kg/minute. Other glucose sources such as glucose in IV fluids need to be considered when deciding on the final prescription.
During critical illness patients demonstrate increased gluconeogenesis and glycogenolysis together with suppressed insulin levels and insulin resistance, all of which can lead to increased glucose levels. Exogenous insulin therapy is likely to be required in this patient group to control blood glucose levels.
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HYWEL DDA LOCAL HEALTH BOARD 11.4.3. Lipid Traditional lipid emulsions are commonly long-chain triglycerides from soybean and/or safflower oils. They contain essential fatty acids to maintain cell membrane integrity and immune function. These lipid emulsions are rich in pro-inflammatory omega-6 fatty acids. Some trials have shown lower complication rates in patients receiving fewer of these fatty acids. Omega-3 fatty acids have an anti-inflammatory effect and there is a growing body of evidence looking at the benefit of using omega-3 based lipid emulsions in PN. Omega 3 containing lipid emulsions may be considered in critical care patients and any patients showing lipid related complications.
A minimum of 0.5g fat/kg/day is required to prevent essential fatty acid deficiency and should not exceed 2g fat/kg/day to prevent lipid associated complications (Pullicino & Elia., 2001). In cases of egg allergy where a lipid free PN solution is used, sunflower oil should be rubbed into the patient’s skin to prevent essential fatty acid deficiency.
11.4.4. Fluid Baseline fluid requirements are 30-35mls/kg/day. Additional fluid will be required to compensate for losses e.g. increased body temperature, large drain outputs etc. Caution is needed regarding the amount of additional salt administered in Intra Venous (IV) fluids to avoid fluid retention leading to odema. Further advice is provided in the GIFTASUP guidelines.
11.5. Storage PN bags must be stored in the medication refrigerator (between 2*c and 8*c). Bags stored in the refrigerator must be kept well away from any freezer compartment to prevent ice crystal formation within the PN bag. Each bag must be removed from the refrigerator 1-2hours prior to infusion to allow the solution to reach room temperature away from direct sunlight.
11.6. Administration • PN should be introduced progressively and closely monitored, usually starting at no more than 50% of estimated needs for the first 24-48hrs (NICE., 2006) • The integrity of each PN bag must be checked prior to administration to ensure there are no leaks in the bag. If a leak is identified the bag must not be used as the risk of microbial contamination is high. • All PN bags must be covered by a light protective bag during infusion to reduce vitamin degradation. • PN solution must be administered using a volumetric pump fitted with occlusion and air- in-line alarms. This will reduce the risk of continued administration when there is a potential embolus in the line (air/precipitate). • All PN bags must be discarded 24 hours after the infusion has commenced and a new PN bag started even if solution remains in the bag. • Under no circumstances can additions of any kind be made to the PN bag on the ward. • Any unused PN bags should be returned to pharmacy as soon as possible • A gradual change from continuous to cyclical feeding should be made with patients who have received PN for more than 2 weeks. 11.7. Rate of administration Rate of administration of PN will be recommended by the dietitian. The patient’s risk of refeeding syndrome, glycaemic control and fluid balance will all be incorporated in the decision.
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HYWEL DDA LOCAL HEALTH BOARD Rate of infusion should not exceed 2.6ml/kg body weight/hour in central bags and 3.7ml/kg body weight/hour in peripheral bags.
11.8. Undesired effects of PN Common Uncommon Very rare >1/100, <1/10 >1/1000, <1/100 <1/10000 Blood & lymphatic Haemolysis, disorder reticulocytosis Respiratory, thoracic & Tachypoena mediastinal disorders Gastrointestinal Abdominal pain, disorders nausea, vomiting Immune system Hypersensitivity disorders reactions e.g anaphylactic reaction, skin rash, urticaria Investigations Increase in plasma levels of liver enzymes Nervous system Headache disorders Reproductive system Priapism and breast disorders Vascular disorders Thrombophlebitis Hypotension, hypertension General disorders & Rise in body Chills, tirdness administration site temperature conditions
11.8.1. Overdose of PN Symptoms such as nausea, vomiting and sweating have been observed during amino acid infusion at rates exceeding the recommended maximum rate. Additionally, overdose might cause fluid overload, electrolyte imbalances, hyperglycaemia and hyperosmolality. If symptoms of overdose occur, the infusion should be slowed down or discontinued.
11.8.2. Fat overload syndrome An impaired capacity to eliminate fat may lead to fat overload syndrome. It is characterized by hyperlipidaemia, fever, hepatosplenomegaly, anaemia, leucopenia, thrombocytopenia, coagulopathies and coma. It may occur as a result of overdose in the amount of lipid given or exceeding the infusion rate. It can also occur at recommended infusion rates due to a sudden change in the patient’s clinical condition resulting in severe renal or hepatic impairment.
11.8.3. Allergic reaction In the case of an allergic reaction, PN should be stopped immediately until the cause is identified. 12. CONNECTING AND DISCONNECTING PN INFUSION Nurses should be IV trained and competent to set up and disconnect PN. Staff must attend the Health Board PN Study Day. Guidelines for connecting and disconnecting a PN infusion are available in appendix 9 and 10.
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HYWEL DDA LOCAL HEALTH BOARD 13. FLUSHING A CENTERAL LINE FOR PN • Flush lumen before starting and on completion of PN with 20mls of sterile normal saline. • Flush using rapid push/pause technique on Hickman lines, draw back and flush for central lines. This creates turbulence within the lumen decreasing the risk of occlusion. • If feed is stopped for any reason the lumen must be flushed immediately. • Syringe size must be 10mls or larger. Smaller syringes increase the pressure exerted upon the catheter potentially leading to venous damage or rupture of the lumen.
14. GIVING MEDICATION No medication may be given through a lumen required for PN. The line must be labelled. Do not disconnect PN to give medication.
15. OUT OF HOURS PN Malnutrition is a culmination of a gradual process and cannot be considered as an emergency. Out of hours PN in fact increases the risks of complications including sepsis and metabolic disturbances. There is rarely, if ever, an indication to start PN out of normal working hours (NCEPOD., 2011).
The best nutritional care out of hours is to ensure appropriate fluids and vitamin and electrolyte replacement in preparation for PN to start safely and at the earliest opportunity.
New patients: The approach advised is as follows: • Consider the patients risk of refeeding syndrome (Refer to appendix) • Check U&E’s including magnesium, phosphate and calcium and correct as indicated • Give IV thiamine (Pabrinex) • Ensure IV fluids in situ • Monitor blood glucose levels frequently • Refer to Dietitian / Ward Pharmacist on the next working day
Existing patients: In the event of the need to replace an existing bag due to leakage or similar damage, a limited range of bags are located in the main pharmacy refrigerator. These can only be obtained via the on-call pharmacist.
16. MONITORING In view of potential risks associated with PN regular review and monitoring of PN patients is essential. The aim is both to prevent and recognise complications as early as possible in order to limit their consequences. Both clinical and laboratory review are needed on a daily basis during the early phases of PN. In the longer term when the patent is more stable biochemical monitoring can become less frequent. 16.1. Clinical monitoring
Parameter Frequency Rationale
Fluid balance Daily Early identification of under / over hydration
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HYWEL DDA LOCAL HEALTH BOARD Weight Daily if concerns regarding To assess ongoing fluid balance, otherwise nutritional status weekly reducing to monthly Temperature / blood pressure 4 hourly To detect signs of infection / line malposition Line entry and dressing sites Daily To detect signs of infection / inflammation or thrombohlebitis Gastrointestinal function Daily To assess continued need for PN
16.2. Laboratory monitoring Parameter Frequency Rationale Interpretation Sodium, potassium, urea, Baseline Assessment of renal Interpret with creatinine Daily until stable function, fluid status, knowledge of fluid Then 1 or 2 times a week and Na and K status balance and medication Urinary sodium may be helpful if patient hyponatraemic, or in complex cases with gastrointestinal fluid loss Glucose Baseline (send to lab) Glucose intolerance is Good glycaemic common control is necessary 4 hourly random BM’s initially Daily once stable
If diabetic – refer to ward guidelines Magnesium, phosphate Baseline Depletion is common Low concentrations Daily if risk of refeeding and under recognised indicate poor status syndrome High risk of depletion Three times a week until in refeeding syndrome stable Then weekly Liver function tests including Baseline Abnormalities Complex. May be due International Normalised Ratio Twice weekly until stable common during to sepsis, other (INR) Then weekly parenteral nutrition disease or nutritional intake Calcium, albumin Baseline Hypocalcaemia or Correct measured Then weekly hypercalcaemia may serum calcium occur concentration for albumin Hypocalcaemia may be secondary to Mg deficiency Low albumin reflects disease not protein status
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HYWEL DDA LOCAL HEALTH BOARD Full blood count and MCV Baseline Anaemia due to iron or Effects of sepsis may 1 or 2 times a week until folate deficiency is be important stable common Then weekly
C-reactive protein Baseline Assists interpretation To assess the Then 2 or 3 times a week of protein, trace presence of an acute until stable element and vitamin phase reaction (APR). results The trend of results is important
The following tests should be requested on an individual patient bas is - discuss with lab as necessary. May not be indicated for short term PN or in acute illness Parameter Frequency Rationale Interpretation
Folate, B12 Baseline Folate deficiency is Serum folate/B12 Then every 2–4 weeks common sufficient, with full Always check if blood count terminal ileum missing Iron, ferritin Baseline Iron deficiency Iron status difficult if (if FBC not informative) Then every 3–6 months common in long-term APR (Fe ↓, ferritin ↑) parenteral nutrition The following on an individual patient basis for those on long -term or home PN (Discussion with lab needed) Parameter Frequency Rationale Interpretation Zinc, copper Baseline Deficiency common, People most at risk Then every 2–4 weeks, especially when when anabolic depending on results increased losses APR causes Zn ↓ and Cu ↑ Selenium Baseline if risk of Se deficiency likely in APR causes Se ↓ depletion severe illness and Long-term status Further testing sepsis, or long-term better assessed by dependent on baseline nutrition support glutathione peroxidase Manganese Every 3–6 months if on Excess provision to be Red blood cell or home parenteral avoided, more likely if whole blood better nutrition liver disease measure of excess than plasma 25-OH Vit D 6 monthly if on long- Low if housebound Requires normal term support kidney function for effect
16.3. Other Monitoring: Parameter Frequency Rationale Interpretation
b Bone densitometry On starting home Metabolic bone Together with lab parenteral nutrition disease diagnosis tests for metabolic Then every 2 years bone disease
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HYWEL DDA LOCAL HEALTH BOARD 16.3.1. Albumin Hypoalbuminaemia is not a marker of malnutrition and in itself is never an indication for PN (Austin & Scott.,). Albumin levels drop within 6hours of an acute injury, decreasing by up to 50% in severe cases due to trans-capillary escape rate and reduced return via a lymphatic system. It has been shown that PN does not improve serum albumin over 10days (Gogos et al., 1990) and a failure to rise during a period of nutritional support should not be considered to reflect inadequacy of the nutrition provided (BMJ, 2001).
17. COMPLICATIONS PN can cause a range of complications. All staff dealing with PN must therefore understand PN related complications and recognise the problem as soon as possible.
17.1. Metabolic complications Complication Cause Action Salt and water • Excessive provision of salt • Accurate fluid balance charts imbalance and water • Daily weights • Excessive fluid losses from • Monitor pulse, blood pressure, high output stomas, fistula respiration and signs of oedema or drains • Review additional sources of fluid • Monitor urine sodium levels Hyperglycaemia • Poorly controlled diabetes • Careful monitoring • insulin resistance secondary • Ensure Glucose requirements to sepsis not exceeded • excessive provision of • Consider timing of current glucose medication if diabetic • Consider use of sliding scale • Refer patient to diabetes specialist team Hypoglycaemia • Sudden cessation of rapidly • Avoid sudden cessation infused glucose/PN solution of glucose / PN solutions, • Inadequate provision of taper infusion down prior glucose to disconnection • Excessive use insulin • Review current medications Refeeding syndrome • Excessive provision of • Identify at risk patients glucose in patients with pre- • Refer to Hywel Dda guidelines existing malnutrition on Adult patients identified as at risk of re-feeding syndrome Derranged LFTS / • Infection / sepsis • Rule out other causes Hepatic stenosis / • Portal Bacterial translocation • Review total calorie intake and Cholestasis • Biliary obstruction ensure not excessive • Unrecognised previous liver • Consider cyclical feeding disease • Consider alternative lipid • New liver disease formulations • Drug reaction • Consider frequency of • Excessive provision of lipids lipid administration / glucose • Consider introduction of enteral nutrition If Jaundice continues despite above measures, PN should be stopped for 3-4 days. It is also possible to consider oral urosodeoxycholic acid, although further studies are required
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HYWEL DDA LOCAL HEALTH BOARD in this field Hypertriglyceridaemia • Excessive provision of lipids • Ensure fat requirements not exceeded • Consider reduction in lipi d provision • Consider frequency of lipid administration
17.2. Catheter related complications
Complication Cause Action
Catheter related Contamination of line Stop PN sepsis Contact medical team Peripheral / central line blood cultures NEWS score chart Exit swab site swab Consider other sources of infection Establish peripheral IV access Catheter occlusion • Mechanical obstruction – Management depends on cause closed clamp, kink in line or Check for kinks line tip against vein wall Try changing position of patient or • Pharmacological elevate arm incompatibility – IV nutrition incompatibility, instability, drug-drug precipitate, drug- nutrient precipitate • Deposition – lipid • Thrombosis Catheter damage Too much force applied and Clamp line immediately above catheter splits – often during high damaged portion, as there is a risk of pressure flushing to clear blockage air embolism Inform medical team to obtain alternative peripheral access Thrombosis Central venous clot Stop PN Contact medical team immediately to consider Venogram Extravasation Line placement / erosion through Stop PN vein wall Inform medical team Establish alternative IV access Peripheral vein Hyperosmolar PN Stop PN thrombophlebitis Contact medical team Establish alternative IV access 18. DISCONTINUING PN Withdrawal of PN should be planned and stepwise with a daily review of patient’s progress (NICE, 2006). Prematurely stopping PN may lead to further nutritional depletion in patients with pre-existing malnutrition. Establishing another route of feeding is important prior to discontinuing PN. • PN can be discontinued when adequate oral and/or enteral support is established. • If the patient is taking food and fluids, then accurate food charts should be kept to ensure the patient is eating at least half their meals or tolerating a minimum of 500mls of nutritious fluids per day prior to stopping PN (Austin & Stroud., 2008).
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HYWEL DDA LOCAL HEALTH BOARD • In other instances e.g. the decision for palliative care, it may be appropriate to withdraw PN. This decision must be made in association with the clinical team and patient / relatives.
PN should not be stopped abruptly due to the risks of rebound hypoglycaemia. Rates of PN should be reduced to at least 50% for a short period of time before stopping and blood glucose levels monitored after cessation.
18.1. Unplanned stops in PN There are some occasions when reducing the rate of administration is not possible. The most common reasons include: • Suspected line sepsis • Failed IV access e.g. line has become blocked, fallen out or been pulled out • Peripheral vein thrombophlebitis • Significant intervention e.g. surgery • Iv access required for other therapy • Significant change in the patients fluid balance or electrolytes e.g. acute fluid overload or acute renal failure
In any case where PN is disconnected for any length of time, disconnect and discard the PN bag. Blood glucose levels should be monitored for rebound hypoglycaemia and any drugs to control blood glucose, especially insulin, will need urgent review.
18.1.1. Recommencing PN after an unplanned break • In the even of any interruptions of PN, previous bags must never be reconnected once it has been disconnected due to increased microbial risks. • If the break is less than 4days and the patient was already receiving PN at the full rate for several days before the interruption occurred and was clinically stable on the regimen, then the patient can go straight back on their previous regimen. • If the interruption is longer than 4 days, the PN was never fully established at full rate, or the patient was clinically unstable on the regimen given, recommencement may need to be at 25-50% and gradually increased (Austin & Stroud, 2007).
19. LONG TERM PN Hywel Dda LHB is currently unable to provide a homecare package for patient’s being discharged on PN. Should a patient require discharge home on PN or if it is anticipated that they will need home PN in the near future, they will need to be referred to an adult Home Parental Nutrition (HPN) Team at one of the following centres: Cardiff or Wrexham. Once referred, the centre will fill in an Individualised Patient Commissioning (ICP) request form, which will allow that centre to apply for funding from the Health Commission Wales. Following training the patient is discharged back into the local area and they will then be followed up by M.D.T. clinics held by the HPN centres.
20. RESPONSIBILITY All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. Optimal care for patients with nutritional problems is enhanced by a M.D.T approach that acknowledges the skills and training of the individuals and professions involved. Best practice suggests a multi-disciplinary nutrition support team should be responsible for managing PN or for advising the Consultant team with respect to PN.
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HYWEL DDA LOCAL HEALTH BOARD Nutrition Steering Group : Responsible for the oversight of all aspects of nutritional and hydration care within the Health Board. This includes ensuring appropriate policies and procedures are in place and compliance monitored.
Doctors : Consider PN in those patients who are unable to maintain nutrition via the oral / enteral route. Hold responsibility for prescribing PN, should it be indicated, as well as the ongoing clinical and laboratory monitoring. Senior Doctors with relevant PN expertise support the training and education of staff in relation to clinical aspects of PN.
Nursing staff : Ward nurses have a responsibility to screen patients for nutrition risk using a Health board agreed screening tool on admission and weekly thereafter. Highlight any patients with pre existing malnutrition or those patients deemed at high risk of malnutrition to the medical team and make referral for patients at high nutritional risk to dietetics. Follow prescribed feeding and electrolyte replacement regimes, highlighting any problems on a day to day level.
Clinical Nutrition Nurse Specialist: Troubleshoot any line-relate problems whilst the IV line is being used for PN. Support training and education with respect to best practice in nursing care for patients on PN.
Dietitian: Responsible for ensuring each patient receives adequate and appropriate nutritional support. Educate and train staff on PN, highlight at risk patients, formulate feeding regimens and monitor nutritional status.
Ward Pharmacist : Responsible for checking that the indication for PN is appropriate and checking the accuracy of the PN prescription. Support training and education in relation to prescribing of PN and drug – nutrient interactions
Aseptic Pharmacist: Responsible for checking that the PN regimen prepared is chemically and physically stable and is appropriate to the route of administration. The aseptic pharmacist is responsible for checking that the electrolyte content is clinically appropriate and within the limits of stability for the regimen.
Chemical Pathologist: Advise on treatment of altered blood biochemistry and appropriate investigations. Support training and education in relation to monitoring and responding to biochemical changes related to PN.
Clinical biochemist: Advise on interpretation of altered blood biochemistry and appropriate investigations.
Infection control team and Microbiology: Investigate any PN line infections that do occur and provide advice to minimise their future occurrence. Support training and education in relation to line care.
21. TRAINING Training will be overseen and co-ordinated via the Nutrition and Hydration steering group, practice development leads and Learning and development department Health Board wide. A log of all staff trained / made aware of the guideline will be kept within each locality of the Health Board.
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HYWEL DDA LOCAL HEALTH BOARD 22. IMPLEMENTATION An implementation plan will be overseen and co-ordinated via the Nutrition and Hydration Steering group. Monitoring of this guideline will be through clinical audit.
23. FURTHER INFORMATION • Audit Commission briefing: A spoonful of sugar. Medicines management in NHs Hospitals (2001) • British Pharmaceutical Nutrition Group (BPNG). Position statement on the use of multi- chamber parenteral nutrition bags for use in adult patients • European Society for Parenteral and Enteral Nutrition (ESPEN) – Guidelines on Parenteral Nutrition • British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP), 2011. • Hywel Dda Nutrition Web page – available via the LHB intranet • National Institute of Clinical Excellence (NICE): Clinical Guideline 32 – Nutritional Support in Adults (2006) • National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – A mixed bag. An enquiry into the care of hospital patients receiving parenteral nutrition (2010) • National Patient Safety Alert (NPSA). Promoting safer use of injectable medicines (2007) • Royal College Physicians (RCP). Oral Feeding Difficulties & Dilemmas 2010 • Royal College of Nursing (RCN). Standards for infusion therapy (2010)
24. CLINICAL POLICIES 209: Hywel Dda Adult Refeeding Syndrome Guidelines Hywel Dda Adult Enteral Feeding Policy 215: Interim Policy For the Insertion of CVP Lines HD018: Guidance on the Mental Capacity Act 4306: Policy & Procedures for Instructing the Independent Mental Capacity Advocate (IMCA) service
25. REVIEW This guideline will be reviewed in two years time. Earlier review may be required in response to any relevant changes in national guidance.
26. REFERENCES Austin P & Stroud M. (2007) Prescribing Adult Intravenous Nutrition. Pharmaceutical press.
Ayliffe G. et al. (2000) Control of Hospital Infection: A practical handbook (4 th edition). Hodder Arnold Campbell C (2011) Peripheral vascular access devices: Care and maintenance. British Journal of cardiac nursing. Volume 6 (3). Department of Health (DOH):London. High quality care for all (2008). Dimond B (2002) Legal aspects of consent. Salisbury, Quay books. Hamilton, H. (2006). Complications associated with venous access devices: Part one. Nursing Standard, 20(26):43-50.
Masoorli, S. (2002). Getting a line on CVAD: Central vascular access devices. Nursing. 32(4)36-45.
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HYWEL DDA LOCAL HEALTH BOARD National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – A mixed bag. An enquiry into the care of hospital patients receiving parenteral nutrition (2010)
National Institute for Clinical Excellence (2006) Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. NICE. London. http://www.nice.org.uk/CG32
NMC (2008) The code: standards of conduct, performance and ethics for nurses and midwives.
Pratt et al (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 65S, S1–S64.
Ryder M. Evidence-Based Practice in the Management of Vascular Access Devices for Home Parenteral Nutrition Therapy. JPEN 2006, 30:S82–S93. Timmis L. PICC of the bunch. Peripherally inserted central catheter. Nurs Times 1998;94:70- 73 Todd (1998). “Peripherally inserted central catheters”. Professional Nurse. 13(5) 297-302 (111). Rowley JS (2001) Aseptic no touch technique. Nursing times 97: 7 Yebenes J et al (2008). Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect handling. Critical care medicine Vol 36, issue 9.
27. APPENDIX 1: ENTERAL & PARENTERAL ALGORITHM Patient unable to meet nutritional needs through oral route alone
Yes No
Is the patient’s GI tract accessible
& functioning? Do you anticipate that intestinal absorptive No function will meet all nutritional needs?
Yes Yes Is the oesophagus &/- stomach absent?
No Is the GI tract obstructed? Yes
No
Is there impaired gastric emptying?
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Yes No Are methods to After consideration of risk v improve gut function benefit, is trial of NG tube No (e.g prokinetics) feeding +/- oral nutrition successful? appropriate? Gastrostomy +/- No Yes oral nutrition
Is feeding likely to be short No term (eg <4weeks)?
Jejunal feeding +/- Yes oral nutrition NG tube feeding +/- oral nutrition
Is adequate nutrient intake
achieved & tolerated? No Consider parenteral Yes nutrition +/- enteral / oral nutrition Review of indications for route, risks, benefits & goals of nutritional support at regular intervals depending on the Stop parenteral nutrition if / patient, care setting & duration of when adequate oral +/- nutrition support. Intervals between enteral nutrition support monitoring may increase as the meets nutritional needs & Review need to maintains nutritional status. patient is stabilised on nutrition continue nutrition support Stop enteral tube feeding if / 28. APPENDIX 2: REFEEDING SYNDROMEsupport when oral intake meet Refeeding syndrome (RFS) is severe fluid and electrolyte shifts associatedadequate with nutritional initiating needs & nutritional support in malnourished patients and the metabolic implications,maintain which nutritional occur status as a result of this (Solomon and Kirby 1990). Potential consequences of RFS include: • Cardiac failure, pulmonary oedema and dysrhythmias • Acute circulatory fluid overload or circulatory fluid depletion • Hypophosphataemia • Hypokalaemia • Hypomagnesaemia and occasionally hypocalcaemia • Hyperglycaemia
IDENTIFICATION OF PATIENTS AT RISK OF REFEEDING SYNDROME (NICE, 2006) At Risk: Those who have one or more of the following: !!! Very little or no food intake for more than 5 days especially if already undernourished !!! BMI < 20kg/m 2 * !!! Unintentional weight loss > 5% within the last 3-6 months*
High Risk: Patient has one or more of the following: !!! BMI < 16kg/m 2* !!! Unintentional weight loss > 15% within the previous 3-6 months* !!! Very little or no nutritional intake for > 10 days
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HYWEL DDA LOCAL HEALTH BOARD !!! Low levels of potassium, phosphate or magnesium prior to feeding
Or patient has two or more of the following: !!! BMI < 18.5kg/m 2* !!! Unintentional weight loss > 10% within the previous 3-6 months* !!! Those with very little or no intake for > 5 days !!! A history of alcohol or drug abuse or some drugs including insulin, antacids or diuretics and patients on chemotherapy.
Extremely high risk: Patient has one or more of the following: !!! BMI < 14kg/m 2* !!! Negligible intake for > 15 days !!! Pre-feeding hypokalemia, hypophosphataemia or hypomagnesaemia
Other considerations !!! Refeeding syndrome can occur in patients receiving oral, enteral or parenteral nutrition. It is less likely to occur in those fed orally (although it is possible) since starvation is usually accompanied by a reduction in appetite !!! There have been reported cases of re-feeding syndrome occurring in patients with chronic vomiting (hyperemesis gravidarum), prolonged diarrhoea, gastrointestinal obstruction, malabsorption diseases, and poorly controlled diabetes !!! Refeeding problems can also occur in overweight patients who have eaten nothing for prolonged periods. Particular caution needed in bariatric surgical patients who have developed complications resulting in a significant period of starvation. !!! Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels. The combined effect of rehydration and refeeding can cause significant changes in biochemistry within hours to very low levels. (PENG, 2011) STARTING NUTRITION FOR PATIENTS AT RISK OF REFEEDING SYNDROME
At risk patients Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before increasing to full requirements if clinical and biochemical monitoring reveals no abnormalities. Meet full requirements for fluid, electrolytes, vitamins, minerals and trace elements from day 1 of feeding
High risk and extremely high Risk patients Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days. Any increase in feed should be dependent on trends in biochemistry. Using only 5kcal/kg/day in extremely high risk patients, monitoring cardiac rhythm in this group and any others who have or develop cardiac arrhythmias is recommended Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary Provide immediately before and during the first 10 days of feeding: oral thiamine, vitamin B- co strong (or full dose daily intravenous vitamin B preparation if necessary) Provide a balanced multivitamin/trace element supplement once a day
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HYWEL DDA LOCAL HEALTH BOARD Please refer to Adult Refeeding guidelines (Guideline 209) on the Hywel dda intranet for more detailed information on RFS. Starter regimens are available in the appendix of this guideline for safe management of at risk patients requiring enteral feeding out of hours.
29. APPENDIX 3: ADULT PARENTERAL NUTRITION REFERRAL PROCESS
Decision made for PN Referral form completed by clinical team and left in medical notes Medical team / Nursing staff to contact Dietitian for full assessment
Nutritional assessment completed by Dietitian highlighting / discussing concerns with clinical team. Referral form and nutritional assessment to be filed within dietetic records. Once PN regimen decided, Dietitian to contact Pharmacy and complete pharmacy request form
Pharmacy to check prescription request, informing Dietitian / clinical team of any concerns
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Clinical team to ensure appropriate prescription written on IV section of the prescription chart
Pharmacy to label PN bag with patient information and inform ward staff when the bags are available on the ward
Any changes to the PN prescription need to be highlighted to clinical team and pharmacy and change of regimen form completed
30. APPENDIX 4: ADULT PARENTERAL NUTRITION REFERRAL FORM
DATE: …………………………………….
WARD: …………………………………... ADDRESSOGRAPH CONSULTANT: ………………………….
RELEVANT PMH: ……………………...
…………………………………………….. INDICATION FOR PARENTERAL NUTRITION: Intestinal obstruction [ ] Inflammatory bowel disease [ ] Intestinal failure [ ] Severe pancreatitis [ ] Short bowel [ ] Inadequate enteral nutrition [ ] Radiation enteritis [ ] Oral mucositis [ ] Surgical complications e.g. anastomotic leak, adhesions, fistulation [ ]
Has enteral nutrition been considered: Y [ ] N [ ]
ROUTE OF ADMINISTRATION: Central Line [ ] Peripheral Line [ ] Dedicated cannula available for PN? Y [ ] N [ ] Date line inserted: …………………………………
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HYWEL DDA LOCAL HEALTH BOARD LIKELY DURATION OF PN: 5-14 days [ ] 14-28 days [ ] >28days [ ]
ASSESSMENT Weight: ……………..Kg Estimated / actual weight: …………….. Odema present Y [ ] N [ ] Ascities present Y [ ] N [ ]
Need for fluid restriction: Y [ ] N [ ] if yes, volume of restriction: ………mls Date of last bloods: …………………………. Has the patient consent been obtained to start PN: Yes [ ] No [ ]
Signature: ……………………………… Name: ……………………….. Designation: ……………………………. Date: …………………………. Once completed Please contact the ward Dietitian for a full assessment
NUTRITIONAL ASSESSMENT – to be completed by Dietitian
Nutrition Screening tool score: ………... Duration of restricted oral nutritional intake: …………………………….. If ascites / odema present est dry weight: …………….Kg % weight loss: …………….. BMI:…….Kg/m 2 Re-feeding syndrome risk: No risk [ ] At Risk [ ] High risk [ ]
GI losses: Diarrhoea / fistula out put / drain out put / NG out put Estimated fluid losses: ……………………………………………………. Estimated electrolyte losses (mmol\l): Na………. K+ ………. Mg ………. Po 4- ………. Blood Glucose levels (mmol/l):……………………………………………………………….. Is the patient Diabetic? Y [ ] N [ ] If yes, what medication are they receiving for their diabetes? ………………………………………………………………………………………………….. Current Fluid intake: …………………………………………………………………………..
CALCULATED REQUIREMENTS:
Energy (Kcals)
Nitrogen (g)
Fluid (mls)
Potassium (mmol)
Sodium (mmol)
Magnesium (mmol)
Phosphate (mmol)
Calcium (mmol)
GOR (g)
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OTHER NUTRITIONAL INTAKE: e.g. IV fluids, sedation
…………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….
31. APPENDIX 5: ADULT PARENTERAL NUTRITION PHARMACY REQUEST FORM
DATE: …………………………………….
WARD: …………………………………... ADDRESSOGRAPH CONSULTANT: ………………………….
RELEVANT PMH: ……………………...
……………………………………………..
NAME OF RESPONSIBLE DIETITIAN: …………………………BLEEP:………
LIKELY DURATION OF PN: 5-14 days [ ] 14-28 days [ ] >28days [ ]
ROUTE OF ADMINISTRATION: Central Line [ ] Peripheral Line [ ]
RECOMMENDED PN BAG: ………………………………………………………..
GLUTAMINE RECOMMENDED: Y [ ] N [ ] OTHER ADDITIONS:……………………………………………………………………………………………… ……………………………………………………………………………………………………………..
RECOMMENDED REGIMEN:
Day 1: Volume: ……………….. Rate: ……………… Duration: ………………
Day 2: Volume: ……………….. Rate: ……………… Duration: ………………
Day 3: Volume: ……………….. Rate: ……………… Duration: ………………
TARGET REGIMEN:
Volume: ……………….. Rate: ……………… Duration: ………………
Pharmacist signature: ……………………………………………………. 32. APPENDIX 6: ADULT PARENTERAL NUTRITION PHARMACY CHANGE OF REGIMEN FORM
DATE: …………………………………….
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HYWEL DDA LOCAL HEALTH BOARD WARD: …………………………………...
CONSULTANT: ………………………….
NAME OF RESONSIBLE DIETITIAN: ……………………………BLEEP:………….
CURRENT PN REGIMEN: …………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….
CHANGE OF REGIMEN:
NAME OF BAG: ………………………………………………………………………
VOLUME: ……………….. RATE: ……………… DURATION: …………………
DATE EFFECTIVE FROM: …………………………………………………………
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33. APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS
Product Kabiven Kabiven11gN Kabiven Kabiven Kabiven Kabiven 8gN 14gN 5gN 7gN 9gN Administration Central Peripheral
Volume (mls) 1560 2073 2586 1460 1940 2420 Amino acids 51 68 85 34 45 57 (g) Nitrogen (g) 8.1 10.8 13.5 5.4 7.2 9 Fat (g) 60 80 100 51 68 85 Glucose (g) 150 200 250 97 130 162 Calories (Kcals) Total 1400 1900 2300 1000 1400 1700 Non-protein 1200 1600 2000 900 1200 1500 Lipid 600 800 1000 510 680 850 CHO 600 800 1000 390 520 650
Electrolytes (mmols)
Sodium 48 64 80 32 43 53 Potassium 36 48 60 24 32 40 Magnesium 6 8 10 4 5.3 6.7 Calcium 3 4 5 2 2.7 3.3 Phosphate 15 20 25 11 14 18 Chloride 70 93 116 47 62 78 Acetate 58 78 97 39 52 65 Maximum infusion rate 2.6ML/KG BODY WEIGHT/HOUR 3.7ML/KG BODY WEIGHT/HOUR
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34. APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS
Drug name Additrace Solivito Vitlipid Pabrinex (per 10 ml vial) (per 10ml vial) (per 10ml vial) (vial 1&2) Route Intra venous(IV) I.V I.V I.V Contents A - - 330units - B1 Thiamine - 3.1mg - 250mg B2 Riboflavine - 4.9mg - 4mg B3 Niacin - - - 160mg B5 Pantothenic - 16.5mg - - acid B6 Pyridoxine - 4.9mg - 50mg B7 Biotin - 60mcg - - (Vitamin H) B8 Inositol - - - - B9 Folic Acid - 400mcg - - B12 - 5mcg - - C - 100mg - 500mg D - - 5mcg - E - - 9.1mg - K - - 150mcg - Zinc 100micromol - - - Copper 20 micromol - - - Selenium 0.4 micromol - - - Manganese 5 micromol - - - Iron 20micromol - - - Molybdenum 0.2 micromol - - - Chromium 0.2 micromol - - - Iodine 1 micromol - - - Fluoride 50 micromol - - - Calcium - - - - Phosphorus - - - - Magnesium - - - - Potassium - - - -
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HYWEL DDA LOCAL HEALTH BOARD 35. APPENDIX 9: GUIDELINE FOR CONNECTING A PARENTERAL NUTRITION INFUSION
• Nurses should be IV trained and competent to set up and disconnect parenteral nutrition
Equipment required Bag of parenteral nutrition (PN) labelled for the patient Patient prescription chart Basic wound dressing pack Sterile gloves Sterile giving set Needle-free connector (if it is due to be changed) Drawing up needle 10 ml 0.9% Sodium chloride for injection Alcohol hand gel 70% alcohol or alcohol/ chlorhexidine wipes 70% alcohol spray for hard surfaces Sharps bin
Procedure Ration ale Connecting a PN infusion PN readily supports bacterial growth therefore it is an using aseptic technique independent risk factor for sepsis. In order to reduce the risk of sepsis, all PN regimens (central and peripheral) need to be administered using aseptic technique (Pratt et al, 2007). Aseptic technique prevents contamination by ensuring only sterile items come into contact with the connection to the patient (Ayliffe et al, 2000).
Equipment required as Preparation will prevent interruption to aseptic technique and listed above. connection process. The environment in which the procedure is carried out must be visibly clean, free of dust and soilage before an aseptic is commenced (DOH, 2008) Check patient identity, To ensure the patient understands the procedure and gives explain procedure, gain his/her valid consent (NMC, 2008) verbal consent Ensure Transfer to treatment room to conduct procedure in clean, patient is comfortable uncluttered environment, free of interruptions
Decontaminate dressi ng Cleaning physically removes a high proportion of micro- trolley first with detergent organism and protein material using detergent and water solution and dry carefully (Ayliffe et al, 2000) with paper towels. Prior to Decontaminate the dressing trolley before and after each use for aseptic technique. use HYWEL DDA LOCAL HEALTH BOARD Collect the equipment To check no equipment is out of date or damaged To reduce needed, check packaging the time sterile field is exposed to potential contaminants. for expiry date and damage and place on bottom shelf of a clean trolley. Check prescription against To ensure the correct solution (script dose and time) is PN bag contents and patient administered to the correct patient via the correct route identity as per Health Board IV policy Social hand wash with To remove dirt and transient organisms. liquid soap Hand mediated transmission is a major contributing factor to Effective hand washing infection. Handwashing is the single most important requires three stages: procedure for preventing hospital acquired infection. Preparation: requires Effective hand decontamination results in significant wetting reductions in the carriage of potential pathogens on the hands before applying liquid hands and decreases the incidence of preventable hospital soap. acquired infections Ensure hands are dry - damp hands Washing & Rinsing: the transfer bacteria more readily than dry. hand washing solution must come into contact with all surfaces of the hand and the hands must be rubbed together vigorously for 10-15 seconds paying particular attention to the tips of the fingers, the thumbs and the area between the fingers Hands should be rinsed thoroughly. Drying: with good quality paper towels If an infusion has just To close the system to the patient finished (i.e. the patient is receiving PN infusion over 24 hours without a break) switch off the pump, close roller clamp on the giving set and close the clamp of the PN lumen on the intra- venous catheter Snap port off PN bag Port is not sterile and needs to be decontaminated. infusion port, Decontaminate the infusion port with disinfection wipe for 5 -10 seconds with a vigorous back and forth motion, and allow to air dry.
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HYWEL DDA LOCAL HEALTH BOARD Wash hands and put on To help prevent risk of transmission of micro-organisms apron (refer to Infection Control Guidelines)
Open the dressing pack – Touching only the edges ensures that the centre of the pack unfold the sterile field remains sterile touching corners and edges only- and place on trolley Open onto the centre of the To maintain sterility of items. sterile towel: • Giving set • Sterile gloves • Replacement needle-free connector if required (e.g . change once No smaller than a 10mL syringe to be used (smaller syringes weekly, or more exert greater pressure, which might cause catheter fracture) frequently if cracked Todd, 1998 or damaged as according to manufacturer’s instructions) • Drawing up needle • 10mL syringe Place the sterile towel To provide a sterile environment. Touching only the edges underneath the intra- ensures that the centre of the pack remains sterile. venous catheter, unfold touching corners and edges only Clean hands with alcohol To eliminate contamination from handling outer surface of hand gel: packaging. Only 1 squirt of the hand gel is required. The hand gel solution must come into contact with all surfaces of the hand. Hands must be rubbed together vigorously paying particular attention to the tips of the fingers, the thumbs and the area between the fingers and until the solution has evaporated and the hands are dry (approximately 15 seconds). Put on sterile gloves To eliminate any micro-organisms from hands. Gloves provide a barrier that minimises passage of micro-organisms (Rowley, 2001)
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HYWEL DDA LOCAL HEALTH BOARD Draw up the flush – place The use of a drawing up needle protects the tip of the drawing up needle on to syringe and hence the needle-free connector, from syringe and draw up 10mLs contamination. of 0.9% sodium chloride for Sterile 0.9% sodium chloride for injection should be used to injection. Expel air and flush the catheter lumen (Pratt et al, 2007) remove drawing up needle (See Sharps policy) (discard in sharps bin) If a previous giving set is To maintain a non touch aseptic technique attached to the intra-venous catheter (i.e. no break between PN infusions) using gauze from the pack to hold the line and to allow a non touch technique, detach the previous giving set Take the disinfection wipe Contamination of the catheter hub is an important contributor and open out holding edges to intra-luminal microbial colonisation of catheters (Pratt et and use untouched surfaces al, 2007) to clean hub. Only the wipe surface is in contact with the hub. Decontaminate the hub / access connector70% alcohol wipes (Pratt et al, 2007) for 5 -10 seconds with a vigorous back and forth A sterile barrier that has become wet is considered motion, and allow to dry . contaminated
Place the intra-venous catheter end on a dry part of the sterile towel
Attach syringe to connector and flush
Clamp intra-venous catheter The catheter should be clamped while the final 0.5mls of the while flushing the last mL of flush is being injected, to maintain a positive pressure to help fluid prevent blood entering the catheter after flushing, which might lead to thrombus formation (Todd, 1998) Ensure to then release the pressure on the syringe plunger before twisting off to remove. This allows the valve of the needle-free connector to return to the “closed” (i.e. non recessed) position
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HYWEL DDA LOCAL HEALTH BOARD * If a replacement needle- A needle free connector can be used for up to 100 free connector is required: activations and over a period of 96 hours; replace when Using gauze from the pack either limit is reached. to hold in each hand, use a non touch technique to detach the previous needle- As above, ensure clamp on intra-venous catheter is closed, free connector and discard. to ensure a closed system and prevent air entering the Wipe with a disinfection system and risk of air embolism. Interruptions to the closed wipe (as above) and allow system should be kept to a minimum to decrease risk of to dry . Attach the new contamination needle-free connector
Ensure the needle free When using / changing a needle-free device ensure that all device is intact and flush components of the system are secured, to minimise breaks with housing (i.e. not and leaks in the system (Pratt et al, 2007) recessed). If the valve has Needle-free IV access devices reduce risk of needle stick been incorrectly accessed injury, and with correct handling and disinfection before with a needle, appears handling, reduce transmission of blood borne pathogens and recessed or cracked or contamination of the fluid pathway (Yebenes et al, 2008) damaged in any way, replace immediately
Close roller clamp on the Removing the cover off the giving set spike just before giving set. Remove insertion will reduce the risk of contamination protective cover off the giving set spike and insert into PN bag infusion port, taking care that the other end of the giving set does not move off the sterile field Half fill the chamber of the Carefully prime the giving set to remove all air from the line giving set. before administration. Air must not be allowed to enter the Carefully prime the line catheter due to risk of air embolism Attach th e giving set to All PN admixtures should be administered via dedicated the intra-venous catheter intravenous catheters, through an electronic volumetric Set the volumetric pump pump /controller with an occlusion and air in line alarm volume to be infused and (NCCAC, 2006). rate according to the It is an MHRA directive that all staff receive documented prescription training in the use of any medical device they use (Dimond, Un-clamp the PN lumen of 2002) the catheter and commence the infusion (proximal port)
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HYWEL DDA LOCAL HEALTH BOARD Remove gloves, clear away Gloves provide an ideal climate for micro-organism growth. rubbish Gloves must be disposed of as clinical waste and hands Social hand wash with liquid decontaminated by washing with liquid soap and water after soap the gloves have been removed (Pratt et al, 2007) Sign the prescription, record To follow national and Trust documentation guidelines fluid volume on fluid chart and document in nursing notes
If the intra-venous catheter To dedicate one lumen for PN use only Decreasing has more than one lumen, manipulation and use of the PN lumen decreases risk of label one lumen ‘for PN use contamination and catheter related infection ONLY’. (Do not use for taking routine bloods, only for central blood culture if required). Monitor for complications Nurses are accountable for knowledge and monitoring of as per PN guidelines below intra-venous catheter and PN related complications as per Health Board Guidelines
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HYWEL DDA LOCAL HEALTH BOARD 36. APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A PARENTERAL NUTRITION INFUSION
Use the following guideline when disconnecting / discontinuing a parenteral nutrition infusion. (If a new PN bag is to be attached (i.e. a 24 hour infusion without a break) or the needle-free connector is due to be changed please refer to the above guideline ‘Connecting a Parenteral Nutrition Infusion’).
• Nurses should be IV trained and competent to set up and disconnect parenteral nutrition
Equipment required Basic wound dressing pack Sterile gloves 10 ml syringe Drawing up needle 10 ml 0.9% Sodium chloride for injection Alcohol hand gel 70% alcohol wipes 70%alcohol hard surface wipes Sharps bin
Procedure Rationale Disconnecting a PN infusion using PN is a particularly good media for micro- aseptic technique organisms and readily supports bacterial growth, therefore PN is an independent risk factor for sepsis. In order to reduce the risk of sepsis, all PN regimens (central and peripheral) need to be administered using aseptic technique (Pratt et al, 2007). Aseptic technique prevents contamination by ensuring only sterile items come into contact with the connection to the patient.
Gather equipment required as listed Preparation will prevent interruption to aseptic above technique and disconnection process. The environment in which the procedure is carried out is as clean and safe as possible. Check patient identity, explain To inform the patient about the procedure and procedure, gain verbal consent / acting gain consent to proceed. Transfer to treatment in patient’s best interests Ensure room to conduct procedure in clean, patient is comfortable uncluttered environment, free of interruptions
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HYWEL DDA LOCAL HEALTH BOARD Social hand wash with liquid soap To remove dirt and transient organisms. Ensure hands are dry - damp hands transfer bacteria more readily than dry Switch off the pump, close roller clamp on To close the system to the patient the giving set and close the clamp of the PN lumen on the intra-venous catheter Clean the trolley . If visibly dirty clean To remove dirt and transient organisms trolley first with soap and water. Clean the trolley with alcohol spray Collect the equipment needed, check To check no equipment is out of date or packaging for expiry date and damage damaged and place on bottom shelf of a clean To reduce the time sterile field is exposed to trolley. potential contaminants. Wash hands and put on apron To help prevent contamination Open the dressing pack – unfold the Touching only the edges ensures that the sterile field touching corners and edges centre of the pack remains sterile only- and place on trolley Open onto the centre of the sterile towel: To maintain sterility of items. • Sterile gloves • Drawing up needle No smaller than a 10mL syringe to be used • 10mL syringe (smaller syringes exert greater pressure, which • Disinfection wipe might cause catheter fracture)
Take a second disinfection wipe and Ready for use in aseptic technique clean the 0.9% sodium chloride ampoule , snap it open and place on the edge of the trolley OR alternatively pour into sterile galipot / tray of infusion pack Place the sterile towel under neath the To provide a sterile environment. Touching intra-venous catheter , unfold touching only the edges ensures that the centre of the corners and edges only pack remains sterile Clean hands with alcohol hand gel To eliminate contamination from handling Only 1 squirt of the hand gel is required. The outer surface of packaging hand gel solution must come into contact with all surfaces of the hand. Hands must be rubbed together vigorously paying particular attention to the tips of the fingers, the thumbs and the area between the fingers, and until the solution has evaporated and the hands are dry (approximately 15 seconds). Put on sterile gloves To eliminate any micro-organisms from hands. Gloves provide a barrier that minimises passage of micro-organisms (Rowley, 2001)
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HYWEL DDA LOCAL HEALTH BOARD Draw up the flush – place drawing up The use of a drawing up needle protects the needle on to syringe and draw up 10mLs tip of the syringe and hence the needle-less of 0.9% sodium chloride for injection. connector, from contamination Expel air and remove drawing up needle (discard in sharps bin) Using gauze from the pack to hold the line To maintain a non touch aseptic technique and to allow a non touch technique, (A needle-free connector should be in place. detach the previous giving set from the See “ Connecting a Parenteral Nutrition catheter hub / needle-free connector Infusion” for guidance on changing the connector) Take the disinfection wipe from the sterile To disinfect the hub / needle-free connector field and open out holding edges and use untouched surfaces to clean hub. Only the wipe surface is in contact with the hub. A sterile barrier that has become wet is Allow to air dry . Place the intra-venous considered contaminated catheter end on a dry part of the sterile towel Attach syringe to connector and flush
Clamp intra-venous catheter while flushing The catheter should be clamped while the final the last ml of fluid 0.5mls of the flush is being injected, to maintain a positive pressure to help prevent blood entering the catheter after flushing, which might lead to thrombus formation Ensure to then release the pressure on the syringe plunger before twisting off to remove. This allows the valve of the needle-free connector to return to the “closed” (i.e. non recessed) position
Remove gloves, clear away rubbish Gloves provide an ideal climate for Social hand wash with liquid soap microorganism growth. Safe disposal of clinical waste prevents spread of infection Document on the fluid balance chart To follow national and Trust documentation guidelines Monitor for complications as per PN Nurses are accountable for knowledge and and central venous catheter guidelines monitoring of intra-venous catheter and PN related complications as per Health Board guidelines
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HYWEL DDA LOCAL HEALTH BOARD Patient Details/Addressograph: 9.4 Parenteral feeding
Patient Problem: Nursing Intervention: Patient Objective/outcome:
Patient has a poor dietary intake and Anxiety Reduction To meet the patient’s nutritional and is unable to provide nutritional Feeding fluid requirements as per requirements enterally, requires patient’s stated wishes parenteral feeding through a (tick all Nutrition Therapy that apply) Nutrition Management To prevent and identify Fluid Management potential complications to Peripheral line ensure safe feeding Central line PLEASE COMPLETE DAILY Plan of care - Please tick all that apply Review Date 36.1.1.1. 36.1.1.2. Explain all procedures, care and treatment to patient
Maintain privacy, dignity and comfort throughout.
Take appropriate measures to prevent cross-infection e.g. hand washing, when changing the administration set Peripheral parenteral feeding (Less than 14 days) Assist with the insertion of the peripherally inserted central catheter Ensure that this is used only for parenteral feeding Note any signs of infection, inflammation or thrombophlebitis and inform Dr 36.2. Central parenteral feeding (more than 14 days) Ensure a dedicated centrally placed central venous catheter. (A dedicated free lumen in a multi-lumen centrally placed catheter maybe used but needs to be appropriately labelled to avoid confusion) 36.3. Central/peripheral parenteral feeding Refer to Dietitian for nutritional assessment prior to commencing feeding DATE OF REFERRAL ______Order Parenteral nutrition as requested by dietitian from pharmacy Ask Dr to review Intravenous fluids. Ensure that aseptic technique is used when changing/handling peripheral/central line Monitor catheter entry site daily for signs of infection/inflammation. If noticed consult medical team Record temperature and blood pressure and inform Dr of any abnormalities Complete All Wales fluid balance charts daily and monitor and
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HYWEL DDA LOCAL HEALTH BOARD record actual volume of feed delivered in 24 hours Monitor blood glucose regular - 4 hourly for first 24 hours, then twice a day when stable. Return to 6hrly monitoring when weaning off Parenteral feeding Record patient’s bowel function Note if patient is experiencing nausea and give prescribed anti- emetic and monitor effectiveness Ensure oral hygiene assessment undertaken and provide appropriate assistance Contact Dietitian if planning to/weaning to enteral feed or oral diet Note any psycho-social effects of parenteral feeding e.g. effects on body image, loss associated with inability to enjoy eating and join in with the associated social aspects of eating. Connected parenteral nutrition bag is to be protected from light using coloured protective cover Ensure parenteral nutrition bags that are not connected are stored in fridge, but removed 1-2 hours before hanging. Care to be evaluated at the end of each shift - document variations to care plan Care plan discussed with patient
Additional Care Required:
Initials:
Review date:
Reference : BAPEN (2012) Hospital food as treatment. www.bapen.org.uk Hywel Dda Health Board (2012) Enteral Feeding Policy Hywel Dda Health Board (2009) Policy for consent to examination and treatment (008) Johnson M, Bulechek G, McCloskey J, Dochterman, Maas M & Moorhead (2001) Nursing diagnoses, outcomes and interventions. NANDA, NOC & NIC Linkages. Mosby, USA. Doughety L & Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th Edition. Blackwell Science, London. Chapter 8. NICE (2006) Clinical Guideline 32 – Nutrition support in Adults. NICE
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Database No: 338 Page 45 of 46 Version 0.2 Adult Parenteral Nutrition Guidelines
HYWEL DDA LOCAL HEALTH BOARD
Database No: 338 Page 46 of 46 Version 0.2 Adult Parenteral Nutrition Guidelines