LOCAL OPERATING PROCEDURE

CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 17/7/14 PARENTERAL NUTRITIAN (PN) - ADULT

1. DEFINITIONS:

CVAD – Central Venous Access Devices include any catheter that is placed so that the distal tip sits in a major or central vein. This is usually the Superior Vena Cava (SVC) although the Inferior Vena Cava may also be used, as is the case for femoral catheters. Catheters that belong to this group include short term central venous catheters (CVC) and peripherally inserted central catheters (PICC) as well as longer term tunnelled catheters (eg. Hickman Catheter), and implanted venous ports (eg. Port-a- Cath or PAS-Port).

IV- intravenous

Medical Team – This term is used throughout this document to refer to the medical team responsible for the patient.

Medical Officer- MO

PICC – Peripherally Inserted Central Catheters (see CVAD)

PN – Parenteral Nutrition (PN) refers to the provision of nutrients by the intravenous route, thus bypassing the gastrointestinal tract.

Rebound hypoglycaemia – Because of the high glucose and amino acid load in PN, pancreatic hormones (especially insulin) are produced in moderate-to-high quantities. If the nutrient load is suddenly stopped, the hormones are still produced and active for some time. This can produce a hypoglycaemic state.

Refeeding Syndrome – Refeeding syndrome is the term used to describe the adverse metabolic effects and clinical complications that can arise when a starved or seriously malnourished individual commences refeeding (see Appendix 1).

2. INDICATIONS: The indication for using PN is a requirement for nutrition when the gastrointestinal tract is not functional, it cannot be accessed, or the patient cannot be adequately nourished by the enteral means. PN may be useful for (but is not limited to) the following situations:  Bowel obstruction or paralytic ileus with failure of enteral feeding;

 Severe exacerbation of inflammatory bowel disease;

 Gastrointestinal fistulae;

 Severe acute pancreatitis where jejunal feeding is contra-indicated;

 Enteric anastomosis or imminent bowel resection;

 Ischaemic bowel;

 Short bowel syndrome before compensatory adaptation occurs;

 Inability to establish full enteral feeding.

PN is not without risks (catheter insertion complications, infection, sepsis, fluid and electrolyte abnormalities and metabolic complications) and financial cost; hence its use should be reserved to where clearly indicated. The duration of PN depends on the return of normal gut function.

Where possible, combining PN with low-level enteral or oral feeding maintains gut function and prevents bacterial overgrowth.

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CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 17/7/14 PARENTERAL NUTRITIAN (PN) – ADULT cont’d

3. ROLES: Due to the complexity of the solution and the complications that can be associated with its delivery, patients are to have regular review by the primary medical team, dietitian, and pharmacy.

Medical team will identify patients who require PN, organise IV access, and prescribe PN, micronutrients and electrolytes according to the protocol. The primary medical team or Anaesthetic Registrar (when an inpatient in ACC) are responsible for optimising fluid and electrolyte status on a daily basis.

Dietitian is consulted for any patient being considered for PN and will complete a nutritional assessment and recommend the amount of PN to be delivered which is documented in the patient’s notes. When a dietitian is unavailable the afterhours starting regimen will be followed-see below.

Pharmacy- Supply of PN bags only.

Nursing staff- See section below (Nursing Care of Patients on PN)

4. BASELINE INVESTIGATIONS The medical team is responsible for arranging biochemistry investigations. Prior to initiating PN, the following baseline biochemistry should be checked and fluid and electrolyte abnormalities managed as required. In those at risk of developing Refeeding Syndrome, particular care should be taken in managing suboptimal electrolyte levels (in particular phosphate, potassium and magnesium).

Test Baseline Critically ill Stable Pt EUC and CMP Yes Daily 3 x weekly LFTs, Albumin Yes 3 x weekly Weekly FBC Yes 3 x weekly Weekly Triglycerides Yes Weekly Monthly INR, PT, aPTT Yes As required As required Iron studies Yes Monthly Monthly Manganese, Copper If malnourished Monthly Monthly Selenium, Zinc Yes Monthly Monthly 25’OH Vitamin D Monthly Monthly Vitamin A, E If severely 6 monthly malnourished/ malabsorption Vitamin B12, Folate Yes 3 monthly 3 monthly Weight Yes 2 x weekly 2 x weekly Fluid Balance Yes Daily Daily Capillary Glucose QID QID QID/BD Temperature QID QID QID Pulse QID QID QID BP QID QID QID

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CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 17/7/14 PARENTERAL NUTRITIAN (PN) – ADULT cont’d

5. PRESCRIBING PN As with all IV fluids for administration, PN needs to be charted daily by a medical officer on the Intravenous Fluid order chart. The PN in use is Olimel N9, supplied in 2000mL bags.

Many patients requiring PN will have fluid and electrolyte imbalances as well as a degree of protein/ energy malnutrition. The micronutrients, Cernevit, and Trace Elements are included in Olimel N9 PN and therefore do not need to be charted separately. Thiamine is considered for malnutrition and Zinc or Selenium may be required in patients with large gastrointestinal losses. Replacement will be determined by biochemistry screening results.

Micronutrient levels must be monitored in long-term PN patients to prevent overload or deficiencies.

If a patient experiences hyperglycemia, insulin therapy should be prescribed on the diabetic management chart.

6. ADMINISTRATION OF PN AND MICRONUTIENTS Ensure electrolytes have been checked and replaced prior to commencing PN. The aim of PN is to provide all nutritional requirements, however if additional fluids or medications are required these should be given separately.

No medications or fluids are infused through the PN line

PN is delivered via a general AGUILA infusion set through an AGUILA infusion pump at the prescribed rate (no ramp up). The daily set up of PN, lines and fluids is a sterile procedure due to higher risk of CVAD infection when PN is being infused through the CVAD.

Administration of Micronutrients Vitamin K (phytomenadione) - 10mg IV weekly. Vitamin K 10mg is delivered as a slow intravenous bolus over at least 30 seconds.

Thiamine- 100mg IV slowly over 10-15 minutes to be given 30 minutes prior to commencement of PN, then daily for five days.

7. SUPPLY OF PN

Pharmacy supplies the PN formulation which includes the micronutrients Cernevit and Trace elements to wards on request and must be stored in the fridge. Due to the short expiry of the PN bags containing micronutrients, they will not be stored on imprest. After hours and on weekends (when pharmacy is closed) please contact the oncall pharmacist to arrange supply.

8. STARTING PN

For patients at risk of refeeding syndrome or of low body mass index, a slower commencement regimen may be required. The medical team or dietitian will advise if this is the case and recommend an appropriate starting and increase regimen (see Appendix 1, Refeeding Syndrome).

PN solution should be commenced at a maximum of 30mls/hr and maintained at that rate until medical team or dietitian r/v and orders an increase in rate. Refer to Appendix 2 if dietitian away for extended period.

Electrolytes: are reviewed daily and prescribed as necessary. It is the responsibility of the Medical team to check the electrolyte content of the PN prior to prescribing additional electrolytes.

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CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 17/7/14 PARENTERAL NUTRITIAN (PN) – ADULT cont’d

Medical monitoring: It is the responsibility of the medical staff in each clinical team to ensure that PN, IV prescriptions and PN bloods are ordered and reviewed daily. Investigations should be conducted as per the table below, or more frequently if required.

Blood sampling for pathology: Blood samples should be sourced via venepuncture whenever possible. Due to the increased risk of infection associated with increased CVAD handling, blood sampling from the CVAD should be avoided, unless there is no available venous access for venepuncture.

In the case of PICC access, the opposite limb should be used for venepuncture. When sampling from a CVAD, turn off the infusion prior to sample, discard the first sample (except when taken for MC&S) and sample from the proximal lumen, so as to avoid sample infusion-related contamination. Refer to RHW Local Operating Procedure: Central Venous Access Devices.

9. NURSING CARE OF PATIENTS ON PN The ward Nursing Staff will perform the following for patients on PN:

Observations • Weight at baseline then twice weekly (Mon- Thurs). • 4 hourly temperature, respiratory and heart rate and blood pressure. (Also observe for clinical evidence of infection, general wellbeing, etc.) • Accurate fluid balance chart and summary (to maintain accurate fluid balance and homeostasis). • Capillary blood glucose monitoring (use opposite limb to site of infusion): baseline, then 6 hourly • May do 12 hourly BGLs once stable on target rate of PN (i.e. glucose between 4-10 mmol/L without requirement of insulin) and return to 4 hourly when PN is being weaned

Nursing care Adherance to “5 Moments” handwashing principles when handling, accessing, connecting lines and attending dressing care to prevent infection of line - Refer to RHW Local Operating Procedure Central Venous Access Devices. The set-up of the Bag of TPN and connection of line is an aseptic procedure.

Bags and lines are to hang for no longer than 24 hours, regardless of how much solution is left in bag. Bag and line change will be at 16:00 hrs each day. See Administration of PN Place date of change on line.

All medications are delivered as per the RHW medications policy and procedure manual

Delivery of micronutrients as prescribed

Storage of PN on ward Bags must be stored in the medication fridge.

Bags connected to the patient should be protected from light using the coloured protective cover.

10. CESSATION OF PN The rate is halved for the first hour then ceased. One further BGL is needed and if within normal range (4-10 mmol/L) no further BGLs need to be taken.

Patients will be started on an enteral or oral diet when thought appropriate by the medical team and or dietitian.

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5. LOCAL OPERATING PROCEDURE

CLINICAL POLICIES, PROCEDURES & GUIDELINES

Approved by Quality & Patient Safety Committee 17/7/14

PARENTERAL NUTRITIAN (PN) – ADULT cont’d

The dietitian will advise on weaning /ceasing PN in those patients who are able to tolerate and absorb adequate oral/enteral feeding.

TPN should not be ceased until patient is managing 75% of their energy/protein requirement orally and/ or enterally as assessed by Dietitian.

A food chart in addition to the fluid balance chart completed by nursing or the patient may be ordered to ascertain food intake.

In some cases it may be appropriate to withdraw PN e.g. palliative care, acute operations, metabolic disorders, line infections.

Advise pharmacy when PN is ceased.

Ceasing PN Suddenly or Unexpectedly One of the potential problems if PN is stopped suddenly or unexpectedly is rebound hypoglycaemia, which may be severe and dangerous.

To minimise this effect, if PN needs to be stopped suddenly or unexpectedly an infusion of 5% dextrose should be initiated at 100 ml/hr for 5 hours. Beyond this time, and in patients with large fluid losses or requirements, intravenous fluids should be administered as clinically indicated. (NB. When the patient is tolerating oral diet and fluids this is not necessary).

When PN is being administered over periods of <24 hours, 'down-ramping' (reducing the hourly infusion rate by at least 50% for the last hour of feeding) should occur, again to prevent rebound hypoglycaemia.

Insulin Infusions -patients requiring insulin infusions will be cared for in ACC. Consult Anaesthetic Reg after hours or Physician in hours for management.

Care must be taken with patients on insulin infusions to ensure optimal glycaemic control when weaning/ceasing PN.

Line Removal -Refer to RHW Clinical Procedures Manual: Central Venous Access Devices

REVISION & APPROVAL HISTORY Reviewed and endorsed Therapeutic & Drug Utilisation Committee 10/6/14 Approved Quality & Patient Safety Committee 18/8/11 Reviewed Therapeutic & Drug Utilisation Committee 16/8/11 Approved Quality Council 15/12/03 FOR REVIEW : 17 JULY 2015

…./Appendices

APPENDIX 1: Refeeding Syndrome What is Refeeding Syndrome? Refeeding syndrome is the term used to describe the adverse metabolic effects and clinical complications that may arise when a starved or seriously malnourished individual commences refeeding by any route. When the malnourished patient is fed carbohydrate, anabolism leads to intracellular influx of anabolic ions in response to insulin. The resulting electrolyte shifts can lead to dangerously low plasma levels of these ions. Signs of refeeding syndrome include: • Severe hypophosphataemia, hypokalaemia or hypomagnesaemia; • Vitamin deficiencies (most notably, thiamin depletion); • Glucose intolerance; • Fluid balance disturbances.

The risk of refeeding syndrome is increased in patients who are on PN as the rapidly administered parenteral carbohydrate speeds the metabolic effects.

Who is at risk? Any malnourished patient is at risk, specifically if any one of the following is present: • Severe underweight (BMI < 17) • Severe recent weight loss (> 10% in less than 4 months) • Chronic alcoholism • Unfed, or on intravenous hydration only, for >7-10 days with evidence of stress and depletion.

Precautions to be taken 1. Identify at-risk patients. All patients should be assessed for risk of refeeding syndrome by the medical team or dietitian prior to commencing PN.

2. Treat electrolyte abnormalities. Electrolyte levels (in particular phosphate, potassium and magnesium) must be assessed at baseline and any abnormalities corrected.

3. Provide vitamin supplementation. Thiamine should be provided prior to commencement of refeeding, and daily thereafter. A multivitamin (Cernevit) must also be provided daily, as per standard PN guidelines.

4. Deliver energy and fluids slowly. PN should be commenced at no more than half the goal rate and increased gradually. The dietitian will provide recommendations on starting rates for patients at risk of refeeding syndrome.

After hours (Dietitian unavailable) PN solution should be commenced at a maximum of 30mls/hr and maintained at that rate until a Dietitian assessment can be conducted. If there is no dietitian available for an extended period of time please refer to Appendix 2.

5. Monitor the patient. Fluid balance should be carefully documented so as to avoid fluid overload. Biochemistry should be monitored intensively during the first week of feeding and any abnormalities corrected (specifically phosphate, potassium and magnesium).

REFERENCES: ASPEN Board of Directors and the Clinical Guidelines Task Force (2002). Guidelines for Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. Journal of Parenteral and Enteral Nutrition, 26 (Supplement), 1SA-6SA. AuSPEN (1999) Guidelines for intravenous trace elements and vitamins Oxford Radcliffe Hospitals NHS Trust (2004). Parenteral Nutrition Guidelines (Adults), version 2.7 RHW Local Operating Procedure Central Venous Access Devices POWH Clinical Policy and Procedure; Parenteral Nutrition

APPENDIX 2

Procedure to follow if dietitian away

Commence feed at 30ml/hr and hold for 24 hours. Increase rate at 10-20ml/hr per 24 hours depending on the patient’s condition and requirements.

*Assess whether patient at risk of refeeding syndrome (refer to Appendix 1). If so, rate should be increased very slowly to goal rate i.e. only +10ml/hr each 24 hours, provided electrolytes remaining normal.

The following table provides an outline of goal rates based on body weight of patient, using Schofield equation for energy prediction and injury factor 1.2-1.3, activity factor 1.2 (bed rest).

Pt weight (kg) Goal rate (ml/hr) Calories/day Protein g/day 50 60 1728 58 60 65 1872 62 70 70 2016 67 80 75 2160 72 90 80 2304 77

Risk rating: Extreme risk Review period: 12 months