Download Is there a referral criteria?

The management of high output stoma? – (link to the dietary advice: patients with
high output)
The management of an enterocutaneous fistula?
Please see link to the leaflet ‘A Guide to the management of enterocutaneous
fistulae’
Abnormal liver function in PN
It is very common for patients receiving Parenteral Nutrition (PN) to develop
abnormal liver function tests (LFTs). PN is often recommended for some of the
sickest patients in hospital and therefore the development of abnormal LFTs is
usually multifactorial. Baker & Nightingale (2004) found that 34% of patients already
had pre-existing liver disease and the presence of sepsis in 24% of patients was
likely to be a major contributory factor. There are several factors which can
contribute to the development of abnormal LFT and they can be divided into two
main aspects: Patient related or parenteral nutrition related.
Patient related includes:
Sepsis and inflammation
Underlying disease
Bacterial overgrowth/translocation
Lack of enteral stimulation
Bile acid secretion/composition
Medication
All of the above factors need to be regularly reviewed and addressed in order to
prevent and treat abnormal liver function in those receiving PN. It is usual that once
sepsis is identified and treated that abnormalities in liver function resolve.
PN related include:
Excess glucose provision
Excess lipid provision
Previous reports have demonstrated that providing excess glucose and/or lipid can
result in abnormal liver function. Providing excessive glucose often results in
steatosis whereby an excess of lipid can lead to cholestasis. Therefore it is essential
that an adequate assessment of energy requirements is completed to prevent
overfeeding from either of these macronutrients (Gabe & Culkin 2010).
References
Baker ML, Nightingale JMD. (2004) Abnormal liver function tests and parenteral nutrition. Clin Nutr;
23:864–5
Gabe SM & Culkin A. (2010) Abnormal liver function tests in the parenteral nutrition fed patient.
Frontline Gastroenterology; 1:98
What type of vascular catheter is best for home parenteral nutrition?
There are some general points to consider when selecting vascular access devices
for individuals requiring home parenteral nutrition. These include
The size of the device – to reduce the risk of thrombosis, the smallest size catheter
to deliver the hourly flow rate required should be selected.
The number of lumens – unless other long term intravenous therapies are needed, a
single lumen catheter is preferred.
Who will be caring for the device – if the patient is going to care for their device they
need to be able to access it easily. For this reason a tunnelled cuffed catheter (often
referred to as a “Hickman line”) which exits the body on the chest wall is usually
used. For patients not able to care for their own catheter, or those who only need to
be at home on parenteral nutrition for a short period of time, a peripherally inserted
central catheter (PICC) may be suitable.
External catheter or implanted device (port) – External catheters (for example
“Hickman type”) are relatively easy to insert and remove, and infections within them
can often be treated without having to remove the device. The insertion of an
implanted device (port) is a more invasive procedure and infections within them are
not easily treated which requires removal and re-insertion. They are not used very
frequently for patients on home parenteral nutrition, possibly due to this factor.
How to monitor patients on PN
It is essential that patients receiving PN are monitored closely as they are more
prone to experience metabolic complications compared to those receiving enteral
nutrition. Careful monitoring will help to minimise the likelihood of complications
arising. The following parameters will require monitoring:
Basic clinical signs (temperature, pulse, respiratory rate, blood pressure)
Overall nutritional intake (oral, enteral and parenteral nutrition and fluids)

Gastrointestinal function

Body composition (weight, height, BMI, triceps skinfold thickness & mid arm
muscle circumference, handgrip)

Fluid balance

Biochemistry

Blood glucose

Urinalysis
Based on the monitoring assessment the nutrition team will confirm the
appropriateness of the PN prescription and alter accordingly. In addition the nutrition
team will adjust the flow rate depending on the clinical condition of the patient.
Additional intravenous fluids and/or electrolytes may be recommended to meet
requirements. Biochemical monitoring of patients receiving parenteral nutrition is
very important in order to minimise fluid and electrolyte abnormalities which may
result from the administration of parenteral nutrition.


The administration of PN can result in metabolic complications which if left untreated
can be life threatening. These include deficiency or excess of the components of PN
e.g. electrolytes, glucose, lipid, fluid, vitamins and trace elements. Avoiding
metabolic complications is essential in providing safe PN and is an important role of
the nutrition team. The NCEPOD report (2010) found that 39.3% of patients on PN
developed metabolic complications the commonest of which were
hypophosphataemia and hypokalaemia. In addition it was thought that nearly half of
these complications were avoidable. Furthermore 15.5% were managed
inappropriately after identification. These findings support the requirement for a
thorough assessment by the nutrition team who are familiar with PN and regular
monitoring to minimise the risk of metabolic complications. The parameters detailed
in table 1 & 2 should be monitored in all patients receiving PN to minimise the risk of
metabolic complications and to aid the nutrition team in decision making.
Table 1: Monitoring required for patients on PN
Rationale
Frequency
Action
Fluid balance
To monitor hydration
Hourly
Measure daily inputs and outputs. Observe for
thirst, lethargy, low urine output, ankle oedema
or breathlessness. Used in conjunction with
daily weight
Weight
To monitor hydration status
Daily
Weigh on same scales, in similar clothes at
same time of day. 1kg=1 litre of fluid
Gastrointestinal
function
To assess suitability to return
to enteral nutrition
Daily
May reduce provision of PN to prevent
overfeeding
Temperature
To detect signs of infection
4 hourly
Monitor 4 hourly. If >380C complete septic
screen
CVC entry site
To detect signs of infection
Daily
Observe site for discharge, pain or swelling and
if present swab site for culture
CVC dressing
To detect signs of infection
Daily
Ensure changed weekly or at any time it
becomes loose or soiled
Urinalysis
To detect for metabolic or
infective complications
Daily
If positive for nitrates and/or leukocytes, please
send a MSU. If positive for glucose or ketones,
please inform the nutrition team
Clinical condition
To observe for changes which
may affect nutritional
requirements
Daily
Changes in clinical condition may require the
PN to be altered in order to prevent under or
overfeeding
Food intake chart
To facilitate transition
between parenteral to enteral
nutrition
Daily
May reduce provision of PN to prevent
overfeeding
Anthropometrics
Assessment of body
composition
Baseline and then
monthly
Measurements of tricep skinfold thickness &
mid arm muscle circumference can be used to
assess changes in muscle and fat mass.
Grip Strength
Assessment of functional
capacity
Baseline and then
monthly
Serial measurements can be used to monitor
progress
Table 2: Laboratory monitoring for patients on parenteral nutrition
Parameter
Frequency
Rationale
Interpretation
FBC
1-2x weekly till stable
then weekly
Anaemia due to
iron/folate deficiency
common
APR causes ↓Fe & ↑ ferritin. Iron status difficult
to interpret
WCC
Daily until stable then
twice weekly
Assessment of APR
May not be elevated in severely malnourished
patients
Folate B12
Baseline then every 1-2
weeks
Deficiency common
Serum folate/ B12 sufficient with FBC
Sodium
Daily until stable then
twice weekly
To detect metabolic
abnormalities &
hydration status
Interpret with knowledge of fluid balance .Urine
Na may be helpful in complex cases with
gastrointestinal fluid loss
Potassium
Daily if risk of refeeding
then twice weekly
To detect metabolic
abnormalities and risk of
refeeding
Interpret with knowledge of fluid balance and
renal function
Urea
Daily until stable then
twice weekly
Assessment of renal
function & hydration
Prevent dehydration and fluid overload. May be
elevated during APR
Creatinine
Daily until stable then
twice weekly
Assessment of renal
function
Reliable marker of glomerular function
Glucose
6 hourly capillary blood
glucose for first 48 hours
unless otherwise
requested. If stable
<10mmol and not diabetic
(on insulin or oral diabetic
medication) change to
daily urine dipstick for
glucose
To detect hyper or
hypoglycaemia. Risk of
refeeding
Good glycaemic control is necessary to
minimise risk of infection Hypoglycaemia can
result from sudden feeding cessation of PN or
refeeding.
Magnesium
Daily if risk of refeeding
then twice weekly
To detect metabolic
abnormalities and risk of
refeeding
Interpret with knowledge of fluid balance and
intestinal losses
Corrected
Calcium
Daily if risk of refeeding
then twice weekly
To detect metabolic
abnormalities and risk of
refeeding
Hypocalcaemia may be secondary to Mg
deficiency
Phosphate
Daily if risk of refeeding
then twice weekly
To detect metabolic
abnormalities and risk of
refeeding
Interpret with knowledge of fluid balance and
renal function
LFTs
Baseline then twice
weekly
Abnormalities common
during PN
Complex. May be due to sepsis, other disease,
medications or overfeeding
Albumin
Baseline then twice
weekly
Assessment of APR
Low albumin reflects disease not protein
status. Use in conjunction with CRP & WCC
CRP
Baseline then twice
weekly until stable
Assessment of APR
Reflection of disease severity. Accurate
interpretation of trace element & vitamin status
Zinc Copper
Selenium
Baseline Then every 2-4
weeks, depending on
results
Deficiency common,
especially when
increased losses and
severe illness
APR causes ↓Zn, ↓Se & ↑Cu. Preferable for
CRP to be <20 for interpretation of result
Urine sodium
Baseline Then twice
weekly
Sensitive indicator of
hydration status (or
sodium deficiency)
Value <20mmol/L suggests dehydration Can
be inaccurate in renal failure
25-OH Vitamin
D
3-6 monthly
Low if house bound
Requires normal kidney function for effect
APR = acute phase response
http://www.ncepod.org.uk/2010report1/downloads/PN_report.pdf
How to manage patients with CVC sepsis
How do I refer a patient to the Intestinal Failure Unit? If you are a clinician
wanting to refer a patient please complete the referral form found on the ‘How to
Refer’ Page and either email it to our co-ordinator on [email protected] or by
fax on 0208 235 4009.
If you are a patient wanting to be referred please ask your doctor to complete the
form and return it to us by email, fax or post – marking it for the attention of Seema
Patel, I/F Co-ordinator
Is there a referral criteria? – Yes there is a referral criteria. Please see the ‘How to
Refer’ page.