Total Parenteral Nutrition Flashcards
How common is malnutrition
Malnutrition is a common clinical and public health problem, affecting all ages and all care settings
Age UK – 1 in 10 people > 65 are malnourished
Malnutrition affects 29% adults on admission to hospital
The cost of malnutrition in England was estimated to be £19.6 billion per year, or more than 15% of the total public expenditure on health and social care
Define malnutrition
Malnutrition - state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome (NICE CG32) .
Malnutrition is both a cause and a consequence of ill health. Increases a patient’s vulnerability to disease.
How do we treat malnutrition
Methods to improve or maintain nutritional intake are known as nutrition support
These methods can improve outcomes, but decisions on the most effective and safe methods are complex
What are the 6 types of nutritional support
Normal Diet
Softened diet
Intravenous fluids - hydration
Oral nutrition support – for example, fortified food, additional snacks and/or sip feeds
Enteral tube feeding – the delivery of a nutritionally complete feed directly into the gut via a tube
Total Parenteral Nutrition(TPN) - the delivery of nutrition intravenously
What are the consiquesnses of malnutrition
Weakness and loss of muscle mass Apathy and depression Reduced immune response Poor wound healing Increased morbidity and mortality
When is artificial nutritional support indicated
Patients who can’t meet their requirements by eating and drinking ‘normally’
Usual normal feeding aim:
Energy: 25-35 kcal/kg/day
Protein 0.8-1.5g kg/day
Fluid: 30-35 ml/kg/day
Adequate electrolytes, minerals, micronutrients and fibre
Note that this may vary depending on clinical circumstance e.g. refeeding syndrome
What are oral nutritional supports
Sip feeds Milk-based Ready to drink e.g. Fortisip Powdered supplements e.g. Complan Fruit juice based e.g. Fortijuice Semi-solid feeds High protein supplements Energy supplements
What are the rules around prescribing oral ntritional support
BNF borderline substances
Prescribed in certain circumstances
Most patients – not required long-term
Some can also be purchased but patient should be under healthcare professional supervision
When would we use an enteral tube feed
Most malnourished people have a functioning GI tract capable of absorbing nutrients
If inadequate or unsafe oral intake and functioning/accessible GI tract – enteral tube feeding
Enteral tubes cab be placed through nose or through abdominal wall
Nasogastric tube (NG) or nasojejunal (NJ) - fine bore tube
Access for up to 6 weeks
Percutaneous endoscopic gastrostomy (PEG) or Percutaneous endoscopic jejunostomy (PEJ)
Access for over 6 weeks
WHat are the benefits of enterak nutrition
More physiological – closely mimics normal feeding Less risk of infection Maintain GI tract Costs less Easier for home patients Patient ease Calorie control Safer and cheaper than TPN
When is enteral nutrition indicated
Eating & swallowing difficulties (dysphagia) - facial injury or surgery, neurological impairment, post-radiotherapy
Severe intestinal malabsorption e.g. Crohn’s disease, major GI surgery
Increased nutritional requirements e.g. severe burns
Eating disorders - anorexia nervosa
Self neglect – intentional/non-intentional
Chronic vomiting diarrhoea
What are some problems with enteral nutrition
Diarrhoea Regurgitation Taste and patient acceptability Abdominal distension Blocked feeding tubing Problems with the pump Placement of an external Dislocation of tubes esp. NG
How do we administer drugs via enteral feeding tubes
Use liquid preparation where available
Give each drug separately
Flush with >20ml water, before and after each drug
Not for m/r, e/c, cytotoxic
Crushed tablets may block tube – check resources
Which drugs can interact with enteral feeds
Directly with the feed: Ciprofloxacin Aluminium-containing antacids (Other metal salts such as calcium) Theophylline Phenytoin
When would total parenteral nutrition be used
Only when enteral route is not an option as GI tract is
Non-functional
Inaccessible
Perforated
Cannot take anything by mouth or via GI tract e.g. dysphagic post stroke, trauma, surgery
“Gut failure” - unable to digest and absorb food
The GI tract may be unavailable or unable to absorb nutrients
May be short or long-term
what are the indications for tpn
“Short-term” – acute intestinal failure Awaiting feeding tubes Bowel obstruction Following major excisional surgery ICU patients with multi-organ system failure Minority of patients with inflammatory bowel disease (IBD) Severe pancreatitis Pre-term neonates
Long-term TPN – chronic intestinal failure
Radiation enteritis
Crohn’s disease following multiple resections
Motility disorders e.g. scleroderma
Bowel Infarction
Cancer surgery
How are tpns administered
Generally infused over 24 hours
“Central administration” – into major vein due to high osmolality
Peripherally Inserted Central Catheter (PICC)
Hickman Line
A “Central Line” into major vein:
Intrajugular
Subclavian
What different benefits can diferent parenteral nutritions provide
Dedicated nutritional ward round – multidisciplinary
Build calories up slowly
Nutritionally complete - composition may vary day-to-day e.g. vitamins
All-in-one mixtures - Can add additions to bags
“Off the shelf” e.g. Kabiven, Oliclinomel
Tailor made bags (“scratch regimens”)
Made up from individual ingredients in Aseptic Pharmacy Departments/Suppliers
What can be found in PN bags
Macronutrients: Nitrogen (Protein) Glucose (Carbohydrate) Fat (Lipid) (not in all bags) Fluid Micronutrients: Vitamins Minerals – electrolytes and trace elements
Desvribe some complications arising from tpn
Air embolism/Insertion problems
Catheter blockage
Line Infections
Metabolic problems e.g. hypo/hyper-glycaemia, impaired liver function
Bone Disease
Refeeding syndrome - Severe electrolyte and fluid shifts (intracellular) associated with metabolic abnormalities in malnourished patients undergoing refeeding
How do we monitor patients on tpn
Clinical History Fluid balance Weight Nutritional intake GI function including nausea, vomiting, bowels, abdominal distension Nutritional status Temperature Line site or tube site
Which blood tests do we use to monitor patients on tpn
Bloods:
Urea and electrolytes –including sodium, potassium
Renal function
Glucose
Liver function tests including albumin, INR
Full blood count including folate and B12
Magnesium, phosphate, calcium
Selenium and zinc
Other vitamin levels
What is the role of the pharmacist surrounding tpn
Clinical Drug interactions Compatibilities Nutritional MDT +/- prescribing Risk assessment – potassium content, route and rate of delivery, checking bloods and picking up refeeding Technical Compounding Formulation Stability
