









Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
Total Parenteral Nutrition (TPN) is the delivery of nutrients sufficient to meet metabolic requirements. ... Both CPN and PPN require one line or port.
Typology: Lecture notes
1 / 17
This page cannot be seen from the preview
Don't miss anything!
To establish guidelines that will promote safe and effective use of parenteral nutrition (PN). Our goal is to enhance the nutritional status of our patients and by doing so, drive improved clinical outcomes. These guidelines include initiation, follow-up, monitoring and modification of parenteral nutrition. Optimal care for patients requiring parenteral nutrition will be delivered by our multidisciplinary team approach. It is intended that the process of providing nutritional expertise be inclusive and educational.
Central Parenteral Nutrition (CPN) is the delivery of nutrients via a central vein.
Total Parenteral Nutrition (TPN) is the delivery of nutrients sufficient to meet metabolic requirements.
Peripheral Parenteral Nutrition (PPN) is the delivery of nutrients via a peripheral vein.
II. Parenteral Nutrition Team Members
Clinical staff that is actively caring for patients will play a crucial role in the identification of patients who require nutritional support and the subsequent initiation and management of parenteral nutrition needs.
Ordering PN should be made directly through our electronic ordering system, Eclipsys. The physician ordering parenteral nutrition must be certified in parenteral nutrition competency, or be supervised by a parenteral nutrition team member that is certified. Parenteral nutrition teams shall be comprised of an Attending Physician certified in the management of parenteral nutrition, a registered dietitian, and a house officer.
Physician: Attending Physicians, Fellows, Residents, and Interns A physician who has been credentialed in the delivery of parenteral nutrition will initiate parenteral nutrition orders. Dietitian: Registered dietitians will work closely with the entire team to assure safe and effective delivery of parenteral nutrition. Surgical Service / Interventional Radiology Service: Both the Surgical Service and the Interventional Radiology Service will assist in the management of venous access. Nursing: The bedside nurse will communicate across the service continuum and facilitate delivery of parenteral nutrition. Pharmacy: The pharmacist will be responsible for optimizing the composition of parenteral nutrition, based on their knowledge of product availability. They will also advise on supplementary electrolytes and drugs as necessary. Infection Control: The infection control team will monitor and advise on episodes of catheter related infectious events.
V. Initiation and Monitoring of Parenteral Nutrition
1. Overview The identification and selection of patients requiring Parenteral Nutrition, and the subsequent implementation and monitoring of this treatment, consists of a number of overlapping phases. These phases will be carried out by a multi-disciplinary team and are described below. 2. Screening When there is concern regarding a patient’s nutritional status, and the potential need for parenteral nutrition, they should be referred to the ward or ICU dietitian for a full assessment. This may take place on one or more occasions if appropriate. Recommendations will be made and documented in the patient's chart. If parenteral nutrition is indicated, a physician certified in the management of parenteral nutrition will place the order. 3. Enrollment Once the multi-disciplinary team has assessed the patient and agreed on the need for PN, venous access will be acquired. The surgical service and interventional radiology will be available to assist in this process. When choosing the mode of venous access (peripheral, non-tunneled, tunneled, or implanted port) consider the likely duration of treatment, and limitations of that form of venous access. If the patient requires additional fluids or intravenous drug administration, and has limited peripheral access, a double or triple lumen line may then be inserted as clinically indicated. The appropriate venous access should be chosen early. Both CPN and PPN require one line or port dedicated exclusively for the infusion of PN (except in pediatrics when no other access is possible). Malnutrition is the culmination of a gradual process and cannot be considered an “emergency”. Never use dialysis access for PN administration. 4. Initiation of PN a) Prior to initiating PN, baseline laboratory values should be checked ( section X. ) and fluid and electrolyte abnormalities corrected. In those at risk of developing re-feeding syndrome, additional intravenous supplementation may be required. Adults and children (>12 yrs old) are at risk for refeeding syndrome when the serum potassium (K) < 3. mmol/L, phosphorus (P) < 2.7 mg/dL, and magnesium (Mg) < 1.6 mg/dL. Neonates and children < 12 yrs may be at risk when serum P < 4.5 mg/dL, in addition to K <3. mmol/L, and Mg < 1.6 mg/dL. Adult individuals at risk should receive a dose of IV Thiamine before the initiation of PN. The ‘at risk’ pediatric population requires adequate supplementation of group B vitamins before the initiation of PN. Remember to check and correct fluid and electrolyte abnormalities, after supplementing thiamine or other group B vitamins, and prior to starting PN. Dietitians will provide their expert opinion and insight during the order writing process.
b) All PN is to be ordered or reordered daily, according to age appropriate order form. Parenteral nutrition orders should be submitted before 1:00 pm. Orders submitted after 1:00 pm will not be compounded. Customized PN will not be available on off hours (a pre-mixed PN solution (Clinimix) is available for older pediatric and adult patients).
5. Early Monitoring Phase For the first week after initiation of PN the patient will be monitored very closely. This includes immediate and Q6 hourly inspection of the parenteral nutrition line site for the first 24 hours after placement, along with an assessment of fluids and laboratory values ( section X.) in an ongoing manner. All neonates and pediatric patients up to the age of 6 years , and any other individual that is limited in their ability to reliably express themselves , shall have their parenteral nutrition line site checked Q shift or more frequently, as indicated. If there is any evidence of line infiltration, the attending physician, in discussion with the surgical and/or interventional radiology service, shall consider immediately removing and replacing the line. If the patient suffers notable metabolic disturbances, with respect to fluid and electrolyte or metabolic parameters, the patient will be monitored intensively. This will consist of a daily assessment by the medical team and the dietitian, and the appropriate laboratory tests (section X.). It may be necessary to modify either nutritional support or overall patient care to obtain the best patient outcomes. Communication between the members of the clinical team and the Parenteral Nutrition Team will be maintained during this process. 6. Stable Patient Phase Once the patient becomes stable on PN, a less intensive monitoring process will be required (section X.). 7. Refeeding Syndrome Refeeding syndrome is defined as severe fluid and electrolyte shifts and related metabolic disturbances in malnourished patients undergoing refeeding. Signs are hypophosphatemia, hypokalemia, hypomagnesemia, altered glucose metabolism, fluid balance abnormalities, and vitamin deficiency. **(Appendix 2)
VI. Intravenous Access (Appendix 3: for extensive line management details)
1. Obtaining Intravenous Access
anticipated delay of PN is less than one hour, blood glucose monitoring is not necessary during this interruption.
2. Line Infection
a) Failure to recognize a line infection, and remove the catheter promptly, may prove to be life threatening to the patient. Line infection may presents in several ways, including entry site infection (erythema, induration, or pus), unexplained fever or bacteremia.
b) If any member of the hospital team has a concern regarding the management of the central line, they are required to discuss their concern with a senior member of their team and the surgical or interventional radiology services. If the concern regarding the management of the central line is not satisfactorily resolved, a member of the PN committee should be contacted. Central line management concerns may include, but are not limited to: fever, site dressing, site bleeding, site pain, site inflammation, line flushing and line aspiration.
3. Loss of Line
a) If the access line is lost for any reason the patient should be started on a replacement IV infusion until another line is placed. Generally, the line will be modified or replaced as soon as possible. For problems with catheter occlusion see Appendix 3.
b) The risk of venous catheter occlusion may be minimized in several ways:
VIII. Prescribing Parenteral Nutrition
Many patients requiring PN will have fluid and electrolyte imbalances before starting parenteral nutrition, and by definition a degree of protein/energy malnutrition. Optimization of fluid and electrolyte status is essential before starting PN. For adults at risk of refeeding syndrome, additional thiamine should be administered; pediatric patients at risk, should receive adequate provision of group B vitamins.
The clinical team in charge of the patient is responsible for optimizing the fluid and electrolyte status. The PN prescription will be reviewed, on a daily basis, by the clinician responsible for the patient, with the dietitian’s input.
1. Recommended Composition of PN A patients’ nutritional requirements are based on standardized equations. Individual patients have unique nutritional and electrolyte needs; therefore, individualized PN formulations are prescribed.
The PN solution is provided as a 2 in 1 solution (dextrose – amimo acids) with additives (electrolytes, vitamins, & trace elements) and a lipid emulsion infused separately as an IV piggyback. The infusion of a PN solution and lipid emulsion should be completed within 24 hours.
2. Starting PN After the following electrolyte abnormalities (K, P, Mg) have been corrected, it is standard to start with full strength PN from day one in adults. In the neonatal and pediatric patients and in those patients at-risk of refeeding syndrome, a starter regimen is generally used. It is necessary to give a single dose of thiamine at least 30 minutes prior to commencing the daily PN (for 3-7 days) for those adults at high risk of refeeding syndrome.
a) Energy Substrates: The certified clinician (along with the dietitian) will calculate the patient’s energy requirements -provided as carbohydrates, lipids, and amino acids. These requirements are based on the patient’s underlying clinical condition, age, sex, body weight and activity level. This may be varied if clinically significant glucose intolerance develops, or if there is a requirement for a lipid free PN regimen.
1. Carbohydrate Carbohydrates are the primary fuel source. If refeeding syndrome is a consideration, PN should be initiated with a starter regimen. 2. Lipid Intravenous fat emulsion (IVFE) is used to provide energy and is a source of essential fatty acids. 3. Protein PN protein is provided in the form of amino acids. The total protein requirements are calculated by the certified clinician along with the dietitian and are based on the clinical condition of the patient.
Documentation:
X. Medical Monitoring of Patients on PN
1. It is the responsibility of the medical staff on each clinical team to ensure that PN blood draws are done. 2. The clinical team will arrange full metabolic screening on long-term PN or "at-risk" patients. 3. Baseline: the tests outlined in the table below should be obtained prior to initiating PN; and all the electrolyte (K, P, Mg) abnormalities corrected 4. New/Unstable patient: daily monitoring as outlined below. Stable patient: as outlined below. 5. Results should be monitored by the clinical team, but will also be reviewed by PN team when prescribing PN. 6. The clinical team retains overall responsibility for the patient.
Table. Suggested Monitoring for PN
Parameter Baseline Critically Ill Patients Stable Patients
Basic Metabolic Panel Yes Daily Twice weekly BUN, Creatinine Yes Daily Twice weekly Calcium Yes Daily Twice weekly Phosphorus Yes Daily Twice weekly Magnesium Yes Daily Twice weekly Liver Function Tests
Yes Yes
Daily Weekly
Twice weekly Weekly CBC with differential Yes Daily Weekly PT, PTT Yes Weekly Weekly Serum triglycerides Yes Weekly Weekly Albumin Yes Daily Weekly Prealbumin (except neonates) Yes Weekly Weekly C-reactive protein (adults only) Yes Weekly Weekly Glucose – adults
Yes Yes Yes
Q6 hours (until controlled) Q6 hours or as needed Q 6 hours
Daily (if controlled) Daily (if controlled) Q 6 hours Weight
Yes Yes
Daily Twice daily
3 times per week Daily Intake and output Daily Daily Daily Nitrogen balance As needed As needed As needed
Appendix 1: PN Contacts
Person Role Preferred contact
Lisa Musillo PN Committee Member Dietitian
Ext: 2- Pager: (516) 651– Kathy Hill PN Committee Member Dietitian
Ext: 2- Pager: (516) 651– Laurie Haufler PN Committee Member Nursing
Ext: 2- Pager: (516) 651– Linda Maksym PN Committee Member Infection Control
Ext: 2- Pager: (516) 651– Paul Mustacchia PN Committee Chairman Gastroenterologist
Ext: 2- Pager: (516) 651– Sofia Rubinstein PN Committee Member Nephrologist
Ext: 2- Pager: (516) 651– Peter Ciminera PN Committee Member Pediatric Intensivist
Ext: 2- Pager: (516) 651– Ammukutty Paulose PN Committee Member Neonatologist
Ext: 2- Pager: (516) 651– Faina Iskhakova PN Committee Member Pharm D
Ext: 2- Pager: (516) 651– Kaleem Rizvon Gastroenterologist Ext: 2- Pager: (516) 651– Richard Batista Surgeon Ext: 2- Pager: (516) 651- Krishnaiyer Subramani Gastroenterologist Ext: 2- Pager: (516) 651– Ali Karakurum Gastroenterologist Ext: 2- Pager: (516) 651–
Appendix 2: Refeeding Guidelines
Refeeding syndrome is defined as severe fluid and electrolyte shifts and related metabolic implications in malnourished patients undergoing refeeding. Signs are hypophosphatemia, hypokalemia, hypomagnesemia, altered glucose metabolism, fluid balance abnormalities, and vitamin deficiency.
If the following electrolytes are normal (K, P, Mg), start feeding
At risk patient
Check electrolytes (K, Ca, P, Mg)
Dose IV Thiamine (at least 30 minutes before feeding start) for adults Provide adequate group B vitamins in the pediatric population Re-check electrolytes Start feeding at 50 – 75% of estimated calorie requirements*
If K < 3.3 mmol/L If P < 2.7 mg/dL (children > 12 years old – adults) correct levels & P < 4.5 mg/dL (neonates – 12 years old) (see below) If Mg < 1.6 mg/dl
Monitor K, P, Ca, and Mg for the first 2 weeks, and act as indicated.
Start at *50 – 75% of estimated calorie requirements for the first 24hrs, then increase gradually within the first week to full feeding, with careful monitoring and supplementation of electrolytes as required. The clinical team has the responsibility for correcting fluid and electrolyte imbalances prior to starting PN , the PN team will be available to advise on the regimen and rate.
V. Site Inspection and Documentation A. Daily (or more frequent in pediatrics) inspection and palpation of the site must be performed and documented by Nursing. Aseptic technique is used. B. The site should be assessed for the presence of erythema, induration and purulent drainage and so noted in the progress notes by Nursing.
VI. Site Rotation/Administration Set Rotation A. Central venous catheters, including PICCs , tunneled, non-tunneled and implanted devices
VII. Femoral Insertion Sites A. The use of multi-lumen catheters should be avoided. B. If replacement at a non-femoral site becomes possible, the line should be relocated as soon as possible if prolonged central line placement is required.
VIII. Changes over a Guide Wire A. Do not use guidewire exchanges routinely for central non-tunneled catheters B. Use a guidewire exchange to replace a malfunctioning non-tunneled catheter only if no evidence of infection is present.
IX. Suspected Infection A. Lines should be removed and the site changed if the patient appears to be septic and no other source is evident. C. If sepsis is suspected or the central line is removed due to evidence of local infection (induration, purulent drainage), the distal 2 inches of the catheter should be aseptically cut and sent to microbiology for semi-quantitative analysis.