Download Adult Parenteral Nutrition Guidelines

HYWEL DDA LOCAL HEALTH BOARD
RESTRICTED NOT YET APPROVED
Adult Parenteral Nutrition Guidelines
338
Policy Number:
Version
No:
Date Of
Review:
Reviewer
Name:
0.2
April 2013
Rachel Lewis &
Linda Morgan
Brief Summary
of Document:
To be read in
conjunction with:
Standards For
Healthcare
Services No/s
Supercedes:
Completed
Action:
Approved
by:
7,8,11,13,14,15,16,
18, 19
Date
Approved:
Clinical Policy
Review Group
New Review
Date:
April 2015
Guidance to support the safe and appropriate administration of Parenteral
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
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
Classification:
Clinical
Category:
Policy
Freedom Of
Information
Status
Authorised by:
Caroline
Oakley
Job Title
Director of
Nursing
Signature:
Open
HYWEL DDA LOCAL HEALTH BOARD
Rachel Lewis
Linda Morgan
Nutrition and
Dept
Dietetics
Responsible
Officer/Author:
Contact Details:
Tel No
Scope
01267 227067
Job
Title:
Clinical Lead Dietitian
Clinical Nutrition Nurse Specialist
Base
Glangwili Hospital
E-mail:
[email protected]
[email protected]
ORGANISATION
WIDE

DIRECTORATE

Administrative/
Estates

Allied Health
Professionals

Ancillary

Maintenance


Scientific &
Professional

Other

Staff Group
Medical & Dental

Nursing
DEPARTMENT
ONLY


COUNTY ONLY
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
group
Nutrition support Clinical
focus group
Nutrition and Hydration
Steering group
CONSULTATION
Group(s)
Committee(s)
KEY
(in accordance with the
Schedule of Delegation)
A = Approval
Required
NAME OF COMMITTEE
FR = Final
Ratification
Clinical Policy Review Group
22nd April
2013
Please enter any keywords to be
used in the policy search system
to enable staff to locate this policy
Database No:
338
Date(s)
Date(s)
RATIFYING AUTHORITY
Date Equality Impact
Assessment
Undertaken
July 2012
July 2012
Date Approval
Obtained
COMMENTS/
POINTS TO NOTE
FR
Group
completing
Equality impact
assessment
Rachel Lewis
Linda Morgan
Jackie Hooper
Parenteral Nutrition, Enteral feeding, Nutrition Support,
Refeeding syndrome
Page 2 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Document Implementation Plan
How Will This Policy Be
Implemented?
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).
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
What (if any)
Training/Financial
Implications are
Associated with this
document?
Training needs will be identified by the relevant professional leads;
meeting the training needs will depend on the specific need.
Financial: This policy supports the appropriate use of PN and therefore
there is unlikely to be an increased cost associated with implementing
this policy. Optimal PN provision and related care may reduce costs by
ensuring PN is only used in appropriate circumstances, reducing line
infections and optimising nutritional care
Action
What are the Action
Plan/Timescales for
implementing this policy?
Database No:
By Whom
Approved guideline sent for signing
Rachel Lewis
Signed guideline made active on
intranet
Active guideline advertised via global email
Awareness sessions across the health
board
Cascade of guideline through locality
nutrition groups
Post graduate teaching sessions in
each locality
Promotion of guideline via nutrition
steering groups
Policy
Coordinator
338
Page 3 of 46
Adult Parenteral Nutrition Guidelines
By When
Dietetics
Dietetics
Dietetics
Dietetics
Dietetics
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Contents
1.
2.
3.
4.
5.
6.
INTRODUCTION................................................................................................................. 6
POLICY STATEMENT ........................................................................................................ 6
SCOPE ............................................................................................................................... 6
AIM ..................................................................................................................................... 6
OBJECTIVE ........................................................................................................................ 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
Database No:
338
Page 4 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
30.
31.
32.
33.
34.
35.
36.
APPENDIX 4: ADULT PARENTERAL NUTRITION REFERRAL FORM ..................... 29
APPENDIX 5: ADULT PARENTERAL NUTRITION PHARMACY REQUEST FORM .. 31
APPENDIX 6: ADULT PARENTERAL NUTRITION PHARMACY CHANGE OF
REGIMEN FORM ......................................................................................................... 31
APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS ................................... 33
APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS
…………………………………………………………………………………………………...34
APPENDIX 9: GUIDELINE FOR CONNECTING A PARENTERAL NUTRITION
INFUSION ..................................................................................................................... 35
APPENDIX 10: GUIDELIENE FOR DISCONNECTIONG AND FLUSHING AFTER A
PARENTERAL NUTRITION INFUSION ....................................................................... 41
Database No:
338
Page 5 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
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
Database No:
338
Page 6 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 rescreened 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.
Database No:
338
Page 7 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Database No:
338
Page 8 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 courtappointed 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
Database No:
338
Page 9 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Database No:
338
Page 10 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
• Surgical complications such as
anastomotic leak, intestinal obstruction,
adhesions or fistulation
• Patients with severe pancreatitis if there is
gastric outlet obstruction secondary to
duodenal stenosis or complex fistulation
• Patients with multi-organ failure, severe
sepsis or burns where nutritional
requirements cannot be met by enteral
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
Long Term
• Short bowel syndrome of any
aetiology (i.e. small intestine
<200cm)
• Intestinal failure
• Motility disorders such as
scleroderma and chronic idiopathic
intestinal pseudo-obstruction
syndromes
• Chronic radiation enteritis
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.
Database No:
338
Page 11 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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.
Database No:
338
Page 12 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Database No:
338
Page 13 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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.
Database No:
338
Page 14 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 airin-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.
Database No:
338
Page 15 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
>1/100, <1/10
Blood & lymphatic
disorder
Respiratory, thoracic &
mediastinal disorders
Gastrointestinal
disorders
Immune system
disorders
Investigations
Uncommon
>1/1000, <1/100
Very rare
<1/10000
Haemolysis,
reticulocytosis
Tachypoena
Abdominal pain,
nausea, vomiting
Hypersensitivity
reactions e.g
anaphylactic
reaction, skin rash,
urticaria
Increase in plasma
levels of liver
enzymes
Headache
Nervous system
disorders
Reproductive system
and breast disorders
Vascular disorders
Priapism
Thrombophlebitis
General disorders &
administration site
conditions
Rise in body
temperature
Hypotension,
hypertension
Chills, tirdness
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.
Database No:
338
Page 16 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Database No:
338
Page 17 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Weight
Temperature / blood pressure
Daily if concerns regarding
fluid balance, otherwise
weekly reducing to monthly
4 hourly
Line entry and dressing sites
Daily
Gastrointestinal function
Daily
16.2. Laboratory monitoring
Parameter
Frequency
To assess ongoing
nutritional status
To detect signs of infection /
line malposition
To detect signs of infection /
inflammation or thrombohlebitis
To assess continued need for PN
Rationale
Interpretation
Sodium, potassium, urea,
creatinine
Baseline
Daily until stable
Then 1 or 2 times a week
Assessment of renal
function, fluid status,
and Na and K status
Glucose
Baseline (send to lab)
Glucose intolerance is
common
Interpret with
knowledge of fluid
balance and
medication
Urinary sodium may
be helpful if patient
hyponatraemic, or in
complex cases with
gastrointestinal fluid
loss
Good glycaemic
control is necessary
4 hourly random BM’s
initially
Daily once stable
Magnesium, phosphate
Liver function tests including
International Normalised Ratio
(INR)
Calcium, albumin
Database No:
If diabetic – refer to ward
guidelines
Baseline
Daily if risk of refeeding
syndrome
Three times a week until
stable
Then weekly
Baseline
Twice weekly until stable
Then weekly
Baseline
Then weekly
338
Depletion is common
and under recognised
High risk of depletion
in refeeding syndrome
Low concentrations
indicate poor status
Abnormalities
common during
parenteral nutrition
Complex. May be due
to sepsis, other
disease or nutritional
intake
Correct measured
serum calcium
concentration for
albumin
Hypocalcaemia may
be secondary to Mg
deficiency
Low albumin reflects
disease not protein
status
Hypocalcaemia or
hypercalcaemia may
occur
Page 18 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Full blood count and MCV
Baseline
1 or 2 times a week until
stable
Then weekly
Anaemia due to iron or Effects of sepsis may
folate deficiency is
be important
common
C-reactive protein
Baseline
Then 2 or 3 times a week
until stable
Assists interpretation
of protein, trace
element and vitamin
results
To assess the
presence of an acute
phase reaction (APR).
The trend of results is
important
The following tests should be requested on an individual patient basis - discuss with lab as
necessary. May not be indicated for short term PN or in acute illness
Parameter
Frequency
Folate, B12
Baseline
Then every 2–4 weeks
Rationale
Interpretation
Folate deficiency is
Serum folate/B12
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 longLow if housebound
Requires normal
term support
kidney function for
effect
16.3. Other Monitoring:
Parameter
Frequency
b
On starting home
parenteral nutrition
Then every 2 years
Bone densitometry
Database No:
338
Rationale
Interpretation
Metabolic bone
disease diagnosis
Together with lab
tests for metabolic
bone disease
Page 19 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Salt and water
imbalance
Cause
Excessive provision of salt
and water
• Excessive fluid losses from
high output stomas, fistula
or drains
•
Hyperglycaemia
•
•
Hypoglycaemia
•
Poorly controlled diabetes
insulin resistance secondary
to sepsis
• excessive provision of
glucose
•
•
•
Refeeding syndrome
Derranged LFTS /
Hepatic stenosis /
Cholestasis
•
•
•
•
•
•
•
Database No:
Action
338
Sudden cessation of rapidly
infused glucose/PN solution
Inadequate provision of
glucose
Excessive use insulin
Excessive provision of
glucose in patients with preexisting malnutrition
Infection / sepsis
Portal Bacterial translocation
Biliary obstruction
Unrecognised previous liver
disease
New liver disease
Drug reaction
Excessive provision of lipids
/ glucose
Accurate fluid balance charts
Daily weights
Monitor pulse, blood pressure,
respiration and signs of oedema
• Review additional sources of
fluid
• Monitor urine sodium levels
• Careful monitoring
• Ensure Glucose requirements
not exceeded
• Consider timing of current
medication if diabetic
• Consider use of sliding scale
• Refer patient to diabetes
specialist team
• Avoid sudden cessation
of glucose / PN solutions,
taper infusion down prior
to disconnection
• Review current medications
• Identify at risk patients
• Refer to Hywel Dda guidelines
on Adult patients identified as
at risk of re-feeding syndrome
• Rule out other causes
• Review total calorie intake and
ensure not excessive
• Consider cyclical feeding
• Consider alternative lipid
formulations
• Consider frequency of
lipid administration
• 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
Page 20 of 46
Adult Parenteral Nutrition Guidelines
•
•
•
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Hypertriglyceridaemia
•
Excessive provision of lipids
in this field
• Ensure fat requirements not
exceeded
• Consider reduction in lipid provision
• Consider frequency of lipid
administration
17.2. Catheter related complications
Complication
Cause
Action
Catheter related
sepsis
Contamination of line
Catheter occlusion
Mechanical obstruction –
closed clamp, kink in line or
line tip against vein wall
• Pharmacological
incompatibility – IV nutrition
incompatibility, instability,
drug-drug precipitate, drugnutrient precipitate
• Deposition – lipid
• Thrombosis
Too much force applied and
catheter splits – often during high
pressure flushing to clear blockage
Stop PN
Contact medical team
Peripheral / central line blood cultures
NEWS score chart
Exit swab site swab
Consider other sources of infection
Establish peripheral IV access
Management depends on cause
Check for kinks
Try changing position of patient or
elevate arm
Catheter damage
•
Thrombosis
Central venous clot
Extravasation
Line placement / erosion through
vein wall
Peripheral vein
thrombophlebitis
Hyperosmolar PN
Clamp line immediately above
damaged portion, as there is a risk of
air embolism
Inform medical team to obtain
alternative peripheral access
Stop PN
Contact medical team immediately to
consider Venogram
Stop PN
Inform medical team
Establish alternative IV access
Stop PN
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).
Database No:
338
Page 21 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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.
Database No:
338
Page 22 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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.
Database No:
338
Page 23 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 multichamber 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 (4th 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.
Database No:
338
Page 24 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 HealthcareAssociated 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;94:7073
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
Do you anticipate that
intestinal absorptive
function will meet all
nutritional needs?
Yes
No
Is the patient’s GI tract accessible
& functioning?
No
Yes
Is the oesophagus &/stomach absent?
No
Is the GI tract obstructed?
Yes
No
Is there impaired gastric
emptying?
Database No:
338
Page 25 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Yes
No
Are methods to
improve gut function
(e.g prokinetics)
successful?
No
After consideration of risk v
benefit, is trial of NG tube
feeding +/- oral nutrition
appropriate?
No
Gastrostomy +/oral nutrition
Yes
Is feeding likely to be short
term (eg <4weeks)?
Jejunal feeding +/oral nutrition
No
Yes
NG tube feeding +/- oral
nutrition
Is adequate nutrient intake
achieved & tolerated?
No
Yes
Consider parenteral
nutrition +/- enteral /
oral nutrition
Review of indications for route, risks,
benefits & goals of nutritional support
Stop parenteral nutrition if /
at regular intervals depending on the
when adequate oral +/patient, care setting & duration of
enteral nutrition support
nutrition support. Intervals between
meets nutritional needs &
monitoring may increase as the
Review need to
maintains nutritional status.
patient is stabilised on nutrition
continue nutrition
Stop enteral tube feeding if /
support
support
28. APPENDIX 2: REFEEDING SYNDROME
when oral intake meet
Refeeding syndrome (RFS) is severe fluid and electrolyte shifts associated
with
initiatingneeds &
adequate
nutritional
nutritional support in malnourished patients and the metabolic implications,
which
occurstatus
as a
maintain nutritional
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/m2 *
! Unintentional weight loss > 5% within the last 3-6 months*
High Risk: Patient has one or more of the following:
! BMI < 16kg/m2*
! Unintentional weight loss > 15% within the previous 3-6 months*
! Very little or no nutritional intake for > 10 days
Database No:
338
Page 26 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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/m2*
! 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/m2*
! 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
Database No:
338
Page 27 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Database No:
338
Page 28 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
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: …………………………………
Database No:
338
Page 29 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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/m2
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 ………. Po4- ……….
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)
Database No:
338
Page 30 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
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 [ ]
ROUTE OF ADMINISTRATION:
>28days [ ]
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: …………………………………….
ADDRESSOGRAPH
Database No:
338
Page 31 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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: …………………………………………………………
Database No:
338
Page 32 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
33. APPENDIX 7: COMPOSITION OF COMPOUNDED PN BAGS
Product
Kabiven
8gN
Kabiven11gN
Kabiven
14gN
Central
Kabiven
5gN
Kabiven
Kabiven
7gN
9gN
Peripheral
1560
51
2073
68
2586
85
1460
34
1940
45
2420
57
8.1
60
150
10.8
80
200
13.5
100
250
5.4
51
97
7.2
68
130
9
85
162
1400
1200
600
600
1900
1600
800
800
2300
2000
1000
1000
1000
900
510
390
1400
1200
680
520
1700
1500
850
650
64
48
8
4
20
93
78
80
60
10
5
25
116
97
32
24
4
2
11
47
39
43
32
5.3
2.7
14
62
52
53
40
6.7
3.3
18
78
65
Administration
Volume (mls)
Amino acids
(g)
Nitrogen (g)
Fat (g)
Glucose (g)
Calories (Kcals)
Total
Non-protein
Lipid
CHO
Electrolytes (mmols)
Sodium
Potassium
Magnesium
Calcium
Phosphate
Chloride
Acetate
Maximum
infusion rate
48
36
6
3
15
70
58
2.6ML/KG BODY WEIGHT/HOUR
3.7ML/KG BODY WEIGHT/HOUR
HYWEL DDA LOCAL HEALTH BOARD
34. APPENDIX 8: COMPOSITION OF VITAMINS, MINERALS AND TRACE ELEMENTS
Drug name
Route
Contents
A
B1 Thiamine
B2 Riboflavine
B3 Niacin
B5 Pantothenic
acid
B6 Pyridoxine
B7 Biotin
(Vitamin H)
B8 Inositol
B9 Folic Acid
B12
C
D
E
K
Zinc
Copper
Selenium
Manganese
Iron
Molybdenum
Chromium
Iodine
Fluoride
Calcium
Phosphorus
Magnesium
Potassium
Database No:
Additrace
(per 10 ml vial)
Intra venous(IV)
Solivito
Vitlipid
Pabrinex
(per 10ml vial) (per 10ml vial) (vial 1&2)
I.V
I.V
I.V
-
3.1mg
4.9mg
16.5mg
330units
-
250mg
4mg
160mg
-
-
4.9mg
60mcg
-
50mg
-
100micromol
20 micromol
0.4 micromol
5 micromol
20micromol
0.2 micromol
0.2 micromol
1 micromol
50 micromol
-
400mcg
5mcg
100mg
-
5mcg
9.1mg
150mcg
-
500mg
-
338
Page 34 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
Rationale
Connecting a PN infusion
using aseptic technique
PN readily supports bacterial growth therefore it 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 (Ayliffe et al, 2000).
Equipment required as
listed above.
Preparation will prevent interruption to aseptic technique and
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,
explain procedure, gain
verbal consent Ensure
patient is comfortable
To ensure the patient understands the procedure and gives
his/her valid consent (NMC, 2008)
Transfer to treatment room to conduct procedure in clean,
uncluttered environment, free of interruptions
Decontaminate dressing
trolley first with detergent
solution and dry carefully
with paper towels. Prior to
use for aseptic technique.
Cleaning physically removes a high proportion of microorganism and protein material using detergent and water
(Ayliffe et al, 2000)
Decontaminate the dressing trolley before and after each
use
HYWEL DDA LOCAL HEALTH BOARD
Collect the equipment
needed, check packaging
for expiry date and
damage and place on
bottom shelf of a clean
trolley.
To check no equipment is out of date or damaged To reduce
the time sterile field is exposed to potential contaminants.
Check prescription against
PN bag contents and patient
identity as per Health Board
IV policy
To ensure the correct solution (script dose and time) is
administered to the correct patient via the correct route
Social hand wash with
liquid soap
Effective hand washing
requires three stages:
Preparation: requires
wetting
hands before applying liquid
soap.
Washing & Rinsing: the
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
To remove dirt and transient organisms.
Hand mediated transmission is a major contributing factor to
infection. Handwashing is the single most important
procedure for preventing hospital acquired infection.
Effective hand decontamination results in significant
reductions in the carriage of potential pathogens on the
hands and decreases the incidence of preventable hospital
acquired infections Ensure hands are dry - damp hands
transfer bacteria more readily than dry.
If an infusion has just
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 intravenous catheter
To close the system to the patient
Snap port off PN bag
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.
Port is not sterile and needs to be decontaminated.
Database No:
Page 36 of 46
Adult Parenteral Nutrition Guidelines
338
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Wash hands and put on
apron
To help prevent risk of transmission of micro-organisms
(refer to Infection Control Guidelines)
Open the dressing pack –
unfold the sterile field
touching corners and edges
only- and place on trolley
Touching only the edges ensures that the centre of the pack
remains sterile
Open onto the centre of the
sterile towel:
• Giving set
• Sterile gloves
• Replacement
needle-free
connector if required
(e.g. change once
weekly, or more
frequently if cracked
or damaged as
according to
manufacturer’s
instructions)
• Drawing up needle
• 10mL syringe
To maintain sterility of items.
No smaller than a 10mL syringe to be used (smaller syringes
exert greater pressure, which might cause catheter fracture)
Todd, 1998
Place the sterile towel
underneath the intravenous catheter, unfold
touching corners and edges
only
To provide a sterile environment. Touching only the edges
ensures that the centre of the pack remains sterile.
Clean hands with alcohol
hand gel:
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).
To eliminate contamination from handling outer surface of
packaging.
Put on sterile gloves
To eliminate any micro-organisms from hands. Gloves
provide a barrier that minimises passage of micro-organisms
(Rowley, 2001)
Database No:
338
Page 37 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Draw up the flush – place
drawing up needle on to
syringe and draw up 10mLs
of 0.9% sodium chloride for
injection. Expel air and
remove drawing up needle
(discard in sharps bin)
The use of a drawing up needle protects the tip of the
syringe and hence the needle-free connector, from
contamination.
Sterile 0.9% sodium chloride for injection should be used to
flush the catheter lumen (Pratt et al, 2007)
(See Sharps policy)
If a previous giving set is
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
To maintain a non touch aseptic technique
Take the disinfection wipe
and open out holding edges
and use untouched surfaces
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
motion, and allow to dry.
Contamination of the catheter hub is an important contributor
to intra-luminal microbial colonisation of catheters (Pratt et
al, 2007)
A sterile barrier that has become wet is considered
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
while flushing the last mL of
fluid
The catheter should be clamped while the final 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 (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
Database No:
Page 38 of 46
Adult Parenteral Nutrition Guidelines
338
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
* If a replacement needlefree connector is required:
Using gauze from the pack
to hold in each hand, use a
non touch technique to
detach the previous needlefree connector and discard.
Wipe with a disinfection
wipe (as above) and allow
to dry. Attach the new
needle-free connector
A needle free connector can be used for up to 100
activations and over a period of 96 hours; replace when
either limit is reached.
Ensure the needle free
device is intact and flush
with housing (i.e. not
recessed). If the valve has
been incorrectly accessed
with a needle, appears
recessed or cracked or
damaged in any way,
replace immediately
When using / changing a needle-free device ensure that all
components of the system are secured, to minimise breaks
and leaks in the system (Pratt et al, 2007)
Needle-free IV access devices reduce risk of needle stick
injury, and with correct handling and disinfection before
handling, reduce transmission of blood borne pathogens and
contamination of the fluid pathway (Yebenes et al, 2008)
Close roller clamp on the
giving set. Remove
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
Removing the cover off the giving set spike just before
insertion will reduce the risk of contamination
Half fill the chamber of the
giving set.
Carefully prime the line
Carefully prime the giving set to remove all air from the line
before administration. Air must not be allowed to enter the
catheter due to risk of air embolism
Attach the giving set to
the intra-venous catheter
Set the volumetric pump
volume to be infused and
rate according to the
prescription
Un-clamp the PN lumen of
the catheter and commence
the infusion (proximal port)
All PN admixtures should be administered via dedicated
intravenous catheters, through an electronic volumetric
pump /controller with an occlusion and air in line alarm
(NCCAC, 2006).
It is an MHRA directive that all staff receive documented
training in the use of any medical device they use (Dimond,
2002)
Database No:
Page 39 of 46
Adult Parenteral Nutrition Guidelines
338
As above, ensure clamp on intra-venous catheter is closed,
to ensure a closed system and prevent air entering the
system and risk of air embolism. Interruptions to the closed
system should be kept to a minimum to decrease risk of
contamination
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Remove gloves, clear away
rubbish
Social hand wash with liquid
soap
Gloves provide an ideal climate for micro-organism growth.
Gloves must be disposed of as clinical waste and hands
decontaminated by washing with liquid soap and water after
the gloves have been removed (Pratt et al, 2007)
Sign the prescription, record
fluid volume on fluid chart
and document in nursing
notes
To follow national and Trust documentation guidelines
If the intra-venous catheter
has more than one lumen,
label one lumen ‘for PN use
ONLY’. (Do not use for
taking routine bloods, only
for central blood culture if
required).
To dedicate one lumen for PN use only Decreasing
manipulation and use of the PN lumen decreases risk of
contamination and catheter related infection
Monitor for complications
as per PN guidelines below
Nurses are accountable for knowledge and monitoring of
intra-venous catheter and PN related complications as per
Health Board Guidelines
Database No:
Page 40 of 46
Adult Parenteral Nutrition Guidelines
338
Version
0.2
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
aseptic technique
PN is a particularly good media for microorganisms 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
above
Preparation will prevent interruption to aseptic
technique and disconnection process.
The environment in which the procedure is
carried out is as clean and safe as possible.
Check patient identity, explain
procedure, gain verbal consent / acting
in patient’s best interests Ensure
patient is comfortable
To inform the patient about the procedure and
gain consent to proceed. Transfer to treatment
room to conduct procedure in clean,
uncluttered environment, free of interruptions
Database No:
338
Page 41 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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
the giving set and close the clamp of the
PN lumen on the intra-venous catheter
To close the system to the patient
Clean the trolley. If visibly dirty clean
trolley first with soap and water. Clean the
trolley with alcohol spray
To remove dirt and transient organisms
Collect the equipment needed, check
packaging for expiry date and damage
and place on bottom shelf of a clean
trolley.
To check no equipment is out of date or
damaged
To reduce the time sterile field is exposed to
potential contaminants.
Wash hands and put on apron
To help prevent contamination
Open the dressing pack – unfold the
sterile field touching corners and edges
only- and place on trolley
Touching only the edges ensures that the
centre of the pack remains sterile
Open onto the centre of the sterile towel:
• Sterile gloves
• Drawing up needle
• 10mL syringe
• Disinfection wipe
To maintain sterility of items.
Take a second disinfection wipe and
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
Ready for use in aseptic technique
Place the sterile towel underneath the
intra-venous catheter, unfold touching
corners and edges only
To provide a sterile environment. Touching
only the edges ensures that the centre of the
pack remains sterile
Clean hands with alcohol hand gel
To eliminate contamination from handling
outer surface of 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
Database No:
No smaller than a 10mL syringe to be used
(smaller syringes exert greater pressure, which
might cause catheter fracture)
To eliminate any micro-organisms from hands.
Gloves provide a barrier that minimises
passage of micro-organisms (Rowley, 2001)
338
Page 42 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Draw up the flush – place drawing up
needle on to syringe and draw up 10mLs
of 0.9% sodium chloride for injection.
Expel air and remove drawing up needle
(discard in sharps bin)
The use of a drawing up needle protects the
tip of the syringe and hence the needle-less
connector, from contamination
Using gauze from the pack to hold the line
and to allow a non touch technique,
detach the previous giving set from the
catheter hub / needle-free connector
To maintain a non touch aseptic technique
(A needle-free connector should be in place.
See “ Connecting a Parenteral Nutrition
Infusion” for guidance on changing the
connector)
Take the disinfection wipe from the sterile
field and open out holding edges and use
untouched surfaces to clean hub. Only the
wipe surface is in contact with the hub.
Allow to air dry. Place the intra-venous
catheter end on a dry part of the sterile
towel
To disinfect the hub / needle-free connector
A sterile barrier that has become wet is
considered contaminated
Attach syringe to connector and flush
Clamp intra-venous catheter while flushing
the last ml of fluid
The catheter should be clamped while the final
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
Social hand wash with liquid soap
Gloves provide an ideal climate for
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
and central venous catheter guidelines
Nurses are accountable for knowledge and
monitoring of intra-venous catheter and PN
related complications as per Health Board
guidelines
Database No:
338
Page 43 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Patient Details/Addressograph:
9.4 Parenteral feeding
Patient Problem:
Nursing Intervention:
Patient has a poor dietary intake and
is unable to provide nutritional
requirements enterally, requires
parenteral feeding through a (tick all
that apply)
Peripheral line
Central line
Anxiety Reduction
Feeding
Nutrition Therapy
Nutrition Management
Fluid Management
Patient Objective/outcome:
To meet the patient’s nutritional and
fluid requirements as per
patient’s stated wishes
To prevent and identify
potential complications to
ensure safe feeding
PLEASE COMPLETE DAILY
Plan of care - Please tick all that apply
Date
36.1.1.1.
36.1.1.2.
Review
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
Database No:
338
Page 44 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2
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 antiemetic 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
Signature List
Date
Job title
Database No:
Print name
338
Signature
Page 45 of 46
Adult Parenteral Nutrition Guidelines
Initials
Version
0.2
HYWEL DDA LOCAL HEALTH BOARD
Database No:
338
Page 46 of 46
Adult Parenteral Nutrition Guidelines
Version
0.2