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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.