8.6 () Parenteral Nutrition Flashcards
Per nutrition guidelines, what is the stepwise approach to fulfilling nutrient/energy requirements in all cancer patients (outside of the dying/terminal phase?)
Proceeding to next step only if prior inadequate:
1. Oral dietary counselling and supplementation
2. Enteral tube feeding
3. Supplemental or Total parenteral nutrition
What evidence is there for PN in the terminal phase?
No evidence for improved QOL or duration of survival
Focus on alleviating hunger (uncommon) and thirst (treat symptomatic xerostomia)
What are 6 important considerations when deciding for or against parenteral nutrition (assuming patient meets conditions to start)
- food intake
- severity of nutritional impairment
- potential benefit
- risks and burdens
- aggressiveness/expected course of disease
- patient/caregiver preferences
FS:
SIPP
Benefit and harm
How does “starvation” differ from “cachexia”
Starvation is an inadequate food supply in the absence of metabolic stressors (can be treated by resupply of nutrition)
(e.g. GI obstruction in an otherwise metabolically normal person)
FS: Anorexia cachexia is driven by abnormal intake + abnormal metabolism
3 medical risks and 3 burdens of parenteral nutrition
Risks:
- Metabolic derangements (lytes, glucose, lipids)
- Bacteremia and sepsis
- VTE
- Occlusion of access device
Burdens:
- Time consuming
- Technically challenging
- Interfere with activity and social interactions
- Costly and will need caregiver support
4 clear indications for PN
- Severe small bowel defect (e.g. short bowel, peritoneal carcinomatosis)
- Survival at least a few weeks
- Patient consents
- PN safely possible
FS: according to uptodate - there is no clear indication for PN. Can be considered in patients with limited oral intake + prog > 3m + end point + on bridging tx. For example - pts prior to major bowel surgery, head and neck/esophageal cancer pts going through systemic treatment, mucositis during stem cell transplant
Name 6 nutrition requirements (ie components) in PN
- Energy (20-30kcal/kg of BW)
- Water (30-40ml/kg of BW)
- Electrolytes (Na, K, Ca, Mg, Po)
- Macronutrient (amino acid, glucose, fat)
- Trace elements (iron, zinc, copper, etc.)
- Vitamins (ADEK, B, C, biotic, folic acid)
Which vein is needed for PN
Central vein
What is refeeding syndrome?
How does it show up on bloodwork?
2 ways to avoid?
Metabolic disturbance when refeeding severely malnourished patients - leading to low K, Mg, Po4
Drop of PO4 levels < 0.5 mmol/L within 4 days of initiating feeds
Start PN slowly and increase over 3-4 days to targeted goal
Combine with high dose thiamine for first 10 days
Name 4 risk factors of refeeding syndrome
Low BMI (< 18)*
Weight loss (grade 3 or above)*
Little intake in last 5-10 days*
Low K, PO4, Mg*
ETOH
Meds: insulin, diuretics, chemo*
FS: SIPP
When to stop TPN
Lack of meeting pre-negotiated goals (strength, activity, QOL, length of life, allowing for cancer tx)
Risks/burdens > benefits
Last days and weeks of life
FS:
End points = no benefit, harm, last days
