T PN Protocol

Parenteral Nutrition Guidelines (Adults)
Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005) Page 1
Contents
Contents ............................................................................................................................... 2 Introduction.......................................................................................................................... 3 Composition of Group ......................................................................................................... 4 Roles of Individual Team Members ................................................................................. 4 Roles of Ward Staff......................................................................................................... 5 Indications for Parenteral Nutrition .................................................................................... 6 Starting and Continuing Parenteral Nutrition .................................................................... 7 Overview......................................................................................................................... 7 Intravenous Access ............................................................................................................. 9 Obtaining Intravenous Access......................................................................................... 9 Management of Line Problems ..................................................................................... 11 Prescribing Parenteral Nutrition ....................................................................................... 12 Who can prescribe PN? ................................................................................................ 12 What should be prescribed before PN starts? ............................................................... 12 Recommended Composition of PN ............................................................................... 12 Prescription of PN12 Nursing Care of Patients on PN ........................................................................................ 14 Medical Monitoring of Patient while on PN ...................................................................... 15 Stopping Parenteral Nutrition ........................................................................................... 16 When? .......................................................................................................................... 16 How? ............................................................................................................................ 16 Appendix 1: Contacts for Team...........................................................................................17 Appendix 2: Monitoring - Medical..................................................................................... 18 Appendix 3: Monitoring - Nursing .................................................................................... 19 Appendix 4: Re-feeding Guidelines .................................................................................. 20 Appendix 5: Post CVC Insertion Management Chart ...................................................... 21 Appendix 6: Procedure for suspected parenteral line infection..................................... 22 Appendix 7: Management of Catheter Occlusion ............................................................ 25 Appendix 8: Troubleshooting Guidelines ........................................................................ 27 Continued...................................................................................................................28-29 Appendix 9: Out of Hours PN............................................................................................ 30
Introduction
In light of Clinical Governance, these guidelines on parenteral nutrition for adults have been put together to eliminate inconsistent and erratic practices throughout the Oxford Radcliffe Hospitals NHS Trust in relation to patient selection, duration of treatment, monitoring of results and documentation.
Where a fully operational Nutrition Support Team (NST) is in place, reduced parenteral nutrition (PN) related complications (line and metabolic), decreased morbidity, improved nutrient intake, improved clinical outcomes, reduced costs and decreased length of stay have been demonstrated (BAPEN 1994).
This is intended to be a working document to help achieve these goals, and by standardising practice facilitate the audit process.
Note: Feedback on this document, and the processes supported by it, are encouraged. Please direct any comments to the Nutrition Support Team. E-mail: fiona.henderson@orh.nhs.uk
Reference Silk DBA (1994) Organisation of Nutritional Support in Hospitals. BAPEN. ISBN 1 899467 00 9.
Acknowledgements Thank you to the Nutrition Support Team at Middlemore Hospital, Auckland, New Zealand for their contribution towards producing these guidelines. Thank you to Carole Glencorse (Senior Dietitian) and Liz Creswell (Clinical Nurse Specialist) who were instrumental in compiling Version 1 of these guidelines Thank you also to Sarah Cripps, Clinical Pharmacist, for her input in relation to the refeeding guidelines.
Composition of Group
Roles of Individual Team Members (JR2 site)
Optimal care for patients with nutritional problems is enhanced by a multidisciplinary team approach that acknowledges the skills and training of the individuals and professions involved. To refer patients for PN please contact the nutrition registrar on bleep 4084. For other queries please refer to the contact list (Appendix 1). Medical The clinicians on the Nutrition Support Team oversee the referrals and will liase with the patients supervising consultant as required. They will also discuss biochemical and other data with the team and will assist with ethical decisions surrounding the administration of PN. Dietetic The dietitian in the NST has the overall responsibility for the nutritional assessment and calculation of nutrients and electrolyte requirements of the patient based on age, sex and clinical condition. The dietitian assesses patients for risk of re-feeding syndrome and is also responsible for the nutritional monitoring of patients requiring PN. They will also advise on alternative feeding routes and manage the transition of patients from parenteral to enteral nutrition. Pharmacy The pharmacist will be responsible for optimising the composition of PN based on knowledge of products available and prescribing and ordering on a daily basis. They will also advise on supplementary electrolytes and drugs as necessary. Nursing The nurses in the team will support and educate the ward nursing staff with specific PN and line related problems. They will also take responsibility for training patients for home PN. Line Insertion Service The line insertion team are responsible for the insertion and removal of peripherally inserted central catheters (PICC's) and tunnelled central lines.
Other Personnel Other Clinicians and support staff will be approached on an as-needed basis: Microbiologyto advise on episodes of catheter sepsis and the treatment of this. Radiology responsible for insertion of central lines where radiological guidance is required.
Roles of Ward Staff Ward staff who are actively caring for patients will play a crucial role in the identification of patients who require nutritional support, the subsequent initiation and management of PN, and monitoring of ongoing needs. It is intended that the process of providing nutritional expertise be inclusive (rather than exclusive) and educational.
Nutritional support is best carried out as a multidisciplinary activity. All members provide their own expertise, and help to provide the best care for the individual patient.
Indications for Parenteral Nutrition
The basic indication for using Parenteral Nutrition is a requirement for nutrition when the gastrointestinal tract is either not working, not available, or not appropriate. PN may be useful for (but is not limited to) the following situations: Non functioning gut e.g. Paralytic ileus Malnourished patients in whom the use of the intestine is not anticipated for >7 days after major abdominal surgery. Patients with specific conditions severely affecting the gastrointestinal tract (such as severe mucositis following systemic chemotherapy, upper gastrointestinal strictures or fistulae, severe acute pancreatitis where jejunal feeding is contra-indicated). In those patients with major resections of the small intestine (short bowel syndrome) before compensatory adaptation occurs. Patients in the Intensive Care Unit (ICU) with systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS).
The duration of PN in most of the described categories depends on the return of normal gut function. Provision of PN for less than 7 days is usually not clinically indicated as the risks outweigh the benefits, but it is accepted that sometimes this will occur as a consequence of early identification and intervention in at-risk patients. All patients referred for PN should have also been referred to the ward dietitian for a full nutritional assessment.
Longer-term PN may be required in a small number of patients for various reasons: Extreme short bowel syndrome of any aetiology. Other causes of prolonged intestinal failure (atresia, radiation enteritis, some inflammatory or motility disorders).
Key Point: If you have a patient with pre-existing malnutrition who will be unable to have a normal nutritional intake for more than 7 days, discuss the patient with the Nutrition Support Team or the ward dietitian.
Starting and Continuing Parenteral Nutrition
Overview The identification and selection of patients who require Parenteral Nutrition, and the subsequent provision and monitoring of this treatment, consists of a number of overlapping phases. These are described here as an overview in the following sections. Screening Where there is concern with regard to a patients nutrition they should have been referred to the ward dietitian for a full assessment. A member of the patients clinical team should then direct any PN referrals to the NST through the nutrition registrar (Bleep 4084). Assessment Once referred to the Nutrition Support Team, the patient will be formally assessed. This may take place on more than one occasion if appropriate. Recommendations will be made and documented in the patient's notes. Enrolment Once the NST have assessed the patient and agreed on the need for PN, a referral will be made to the Line Insertion Service (LIS) for venous access. For short term PN (7-10 days) this will be a Peripherally Inserted Venous Catheter (PICC), and a tunnelled central line will be used where the anticipated duration of PN is longer or peripheral access is limited. Short-term Central Venous Catheters (CVC's) may be used to administer PN if they have been insitu for <5 days and have a dedicated lumen available for PN. Otherwise a replacement line will be placed. Please advise the LIS if the patient requires additional fluids or intravenous drug administration, and has limited peripheral access a double or triple lumen line may then be inserted as clinically indicated. Initiation of PN Prior to initiating PN, baseline biochemistry should be checked and fluid and electrolyte abnormalities corrected. In those at risk of developing re-feeding syndrome, additional intravenous vitamins may be required (Appendix 4). Referrals made after 11.00a.m. Will be deferred until the next working day (on a Friday, this will mean Monday). This is because PN must be ordered by 11.00a.m. daily. PN will not be available out-of-hours (evenings and weekends) because malnutrition is the culmination of a gradual process and cannot be considered an emergency. Out of hours PN may in fact increase the risks of complications, including sepsis and metabolic disturbances (in particular, re-feeding syndrome, Appendix 4).
In exceptional circumstances, PN can be requested via the Gastro-Medical Spr or on-call dietitian on public holidays (Appendix 9). Medical staff must make referrals and the patient must have suitable venous access and baseline biochemistry (Appendix 2). Early monitoring phase During the first week of PN (and subsequently if the patient is unstable with respect to fluid and electrolyte or metabolic issues) the patient will be monitored intensively. This will consist of Nutrition Support Team consultations, a minimum set of mandatory ward observations, and appropriate blood and other laboratory tests (Appendices 2&3). The aim is to optimise nutritional support while remaining aware of the other therapeutic strategies in the patients overall care plan. It may be necessary to modify either nutritional support or overall patient care to obtain the best patient outcomes. Communication between the clinical team and the Nutrition Support Team will be maintained during this process. Stable patient phase Once the patient becomes stable whilst on PN, a less intensive monitoring process will be required (Appendices 2&3). Re-introduction of diet At a certain point, diet will usually be introduced in a graded fashion. Liaison with the ward dietitian and NST will allow appropriate reduction or cessation of PN. Cessation of PN PN will usually be stopped when oral nutritional intake is deemed adequate by the NST. As a general rule of thumb cessation of PN is determined on a variety of factors and is a multi-disciplinary decision. Occasionally PN needs to be stopped for other reasons (acute operations, major metabolic disorders) and advice on the optimal manner of stopping PN is provided elsewhere in this manual (Page 16). After routine cessation of PN, the Nutrition Support Team may maintain contact with the patient in order to audit clinical outcome and performance.
Intravenous Access
Obtaining Intravenous Access There is a balance between convenience and safety with intravenous access for PN. The NST and Line Insertion Service (LIS) will assess the patient and advise on the most appropriate route. As a general guide:
Peripheral Cannulae (Venflons! ). Should not routinely be used for the administration of PN and are only to be used in the short term for the administration of re-feed PN where indicated by the team in the patients notes. Peripheral parenteral nutrition is not without its complications primarily the development of peripheral vein thrombophlebitis (PVT). This can be reduced by considering the following: If there is already a cannula insitu this can be used for PN providing Visual Infusion Phlebitis Score (VIPS) = <1
Otherwise, Cannula size & material:- 19-23 gauge polyurethane cannula Vein size & site:- ideally a large vein, performing cannulation away from the joint. (n.b the patient may have a PICC inserted for PN so please try to reserve veins in the antecubital fossa for this purpose). Change when VIPS = " 1
PICC lines (peripherally-inserted central catheters) will be used for medium to longterm venous access Requirements for patient selection: normal venous anatomy antecubital vein recent full blood count (requirements as follows)
If a PICC line is not indicated, a tunnelled, cuffed CVC (central venous catheter) will be inserted via the subclavian (or jugular) vein. Requirements for patient selection: recent full blood count -platelets must be >100 (lower than this and the LIS will discuss with the individual practitioner) -normal Hb -normal WCC (WCC>10 or neutropenia may preclude) normal clotting screen (to include PT and APPT), with INR<1.5 regardless of a normal clotting screen, avoid administration of SC Heparin for 12 hours, SC Fragmin for 24 hours and IV Heparin for 4 hours prior to line insertion non-dependent on Oxygen (will require discussion with LIS) consent prescription for Midazolam (1-10mg IV)
intravenous access
A dedicated single-lumen line is the safest route of PN administration. There is a greater risk of infection the more times a line is manipulated. Obviously, aseptic technique should be used. Nothing else should be given through this lumen, nor should blood be sampled from the line under normal circumstances. If a multi-lumen line must be used for clinical reasons, one lumen should be dedicated for PN use only. Again, nothing else should be given through this lumen, nor should blood be sampled from this. For post-insertion line care refer to Appendix 5.
Management of Line Problems Need to Stop PN Suddenly or Unexpectedly? One of the potential problems if PN is stopped suddenly or unexpectedly is rebound hypoglycaemia, which may be severe and dangerous. Because of the high glucose and amino acid load in PN, pancreatic hormones (especially insulin) are produced in moderateto-high quantities. If the nutrient load is suddenly stopped, the hormones are still produced and active for some timethis can produce a hypoglycaemic state. To minimise this effect, if PN needs to be stopped suddenly or unexpectedly an infusion of 5% dextrose should be initiated at 100 ml/hr for five (5) hours. Beyond this time, and in patients with large fluid losses or requirements, IVI should be administered as clinically indicated. (Planned cessation of PN would normally take place when the patient is tolerating oral diet and fluids. In this situation, 5% dextrose is not required). When PN is being administered over periods of <24 hours, down-ramping (reducing the hourly infusion rate by at least 50% for the last hour of feeding) should occur, again to prevent rebound hypoglycaemia occurring. Central Venous Line Infection? Failure to recognise central line infection, and remove the catheter promptly if proven, may prove to be life threatening to the patient. Central line infection usually presents in one of two ways, either entry site infection (redness, tenderness, or pus) or unexplained fever. The procedure for suspected central line infection is outlined in Appendix 6. Loss of Line? If the access line is lost for any reason (blockage, leakage, inadvertent removal of line) the patient should be started on a replacement IVI until the NST are able to assess the patient. Generally, the line will be repaired or replaced on the next working day. For problems with catheter occlusion see Appendix 7 and refer to Appendix 8 for a trouble-shooting guide.
Prescribing Parenteral Nutrition
The PN Prescription On a daily basis (Monday-Friday) the NST will formulate the PN prescription and agree this with the nutritional SpR. The clinician with overall responsibility for that patient will be kept informed of any changes in the PN prescription. What should be prescribed before PN starts? Many patients requiring PN will have fluid and electrolyte imbalances, as well as a degree of protein/energy malnutrition (by definition). To minimise subsequent problems, correctable abnormalities should be addressed in the following manner. Optimisation of fluid and electrolyte status is essential before starting PN. For those patients identified as being at risk of refeeding syndrome, give additional thiamine as per protocol (Appendix 4). The clinical team in charge of the patient are responsible for optimising fluid and electrolyte status, and prescribing the above vitamins. Recommended Composition of PN Patients nutritional requirements are based on standard dietetic equations. JRH Standard PN bags are used where appropriate. If patients have special requirements or if nutritional/electrolyte requirements cannot be met with a standard bag then individualised or scratch bags are prescribed. Starting PN Once any biochemical abnormalities have been corrected, it is usual to start with fullstrength PN from day one. In those patients at-risk of re-feeding syndrome then a starter regimen may be used, where the first bag of PN contains less calories and Nitrogen. It is necessary to give a single dose of thiamine (Pabrinex 1 pair of ampoules mixed together Appendix 4) 30 minutes prior to commencing the PN for each day that a re-feed bag is used. (See also Pg 9 re. IV access for refeeding syndrome)
Nitrogen Protein in PN is provided in the form of amino acids. Individual nitrogen requirements are calculated by the NST dietitian based on the clinical condition of the patient. Carbohydrate and Lipid The NST dietitian taking into consideration the patients underlying clinical condition, age, sex, bodyweight and activity level will calculate energy requirements. The energy in PN is described as non-protein calories (i.e. the figure shown on the bag excludes the energy provided from amino acids). Total energy intake is best given as a mixture of glucose and lipid, usually in a ratio of 60:40 or 50:50. This may be varied if clinically important glucose intolerance develops, or if there is a requirement for a lipid free PN bag. Volume The overall aim is to provide all fluid volume requirements via the PN, including losses from wounds, drains, stomas and fistulae etc. However, if these losses are large or highly variable, they should be replaced and managed separately. In exceptional cases, where venous access is a problem, a side arm of additional fluid for drug administration/hydration may be provided. This should be discussed with the NST. Electrolytes These are modified according to clinical requirements, and with particular regard to extrarenal losses. NB Electrolytes are reviewed daily (Appendix 2) and modified as necessary. It is the responsibility of the medical team to check the electrolyte content of the PN (written in the medical notes and nursing Kardex) prior to prescribing additional electrolytes. Vitamins, Minerals and Trace Elements These are added routinely on a daily basis. Extra Zinc or Selenium may be required in patients with large gastrointestinal losses. Patients on long-term PN will have routine micronutrient screening undertaken. Other medications No drug additions will routinely be made to the PN. Consideration of possible administration techniques will be given to patients who require IV medication but have limited vascular access - this should be discussed with the NST.
Nursing Care of Patients on PN
The ward Nursing Staff looking will perform the following tasks after patients on PN. These procedures will be audited. Daily weight (before starting PN and daily thereafter). 4 - 6 hourly temperature and blood pressure. (Also observe for clinical evidence of infection, general well being, etc.) Accurate fluid balance chart and summary (to maintain accurate fluid balance and homeostasis). Bag change will be at 20:00 hrs each day. Capillary glucose monitoring (BMs) 6 hourly for first 24 hours, then BD or OD when stable (glucose between 410 mmols/L). Return to 6 hourly BMs when PN being weaned off. Daily assessment for CVC/PICC site infection or leakage. 72 hour dressing change minimum for CVC, more frequent if loose, soiled or wet. Dressing change weekly for PICC's. Weekly bung change. Twice weekly 24-hour urine collections (Sunday and Wednesday) for Nitrogen balance and electrolytes. Documentation: Bag and prescription/formulation checked by at least one IV assessed nurse. Record on fluid balance chart. Sign for on drug chart. Document dressing and bung change in the nursing notes.
Storage of PN on Ward Bags not yet connected to the patient must be stored in a refrigerator (at between 2C and 8C). Bags stored in a refrigerator must be kept well away from any freezer compartment to prevent ice crystal formation in the PN. Bags that have been refrigerated should be removed at least 1-2 hours before being hung and infused, to allow the solution to reach room temperature. Bags connected to the patient should be protected from light (which breaks down some components of PN) using the coloured protective cover.
As a Reminder: If your patient moves ward or unexpectedly stops PN please inform Baxter on Ext: 35843 and the PN Team on Ext. 21653.
Medical Monitoring of Patients on PN

It is the responsibility of the medical staff in each clinical team to ensure that PN bloods are done. The NST will arrange full micronutrient screening on long-term PN or "at-risk" patients. Biochemical monitoring will be audited. Baseline: the tests outlined in the table below should be requested prior to referring patients for PN and any abnormalities corrected. PN will not be started when there are metabolic disturbances due to the associated risks. New/Unstable patient: daily monitoring as outlined below. Stable patient: as outlined below.
Results should be monitored by clinical team, but will also be reviewed by the Nutrition Support Team when prescribing PN. N.B. The clinical team retains overall responsibility for the patient.
Baseline Blood Biochemistry Urea and Creatinine Na K Bicarbonate Chloride LFTs: Bilirubin Alk Phos AST or ALT Albumin Calcium Magnesium Phosphate Zinc Copper CRP Full blood count Coagulation APTT INR Lipids Cholesterol Triglycerides Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes New Patient or Unstable Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Sun Monthly Sun, Tues, Thurs Sun, Tues, Thurs Sun Sun Sun Sun Stable patient Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Every 2 weeks Every 3 months Sun, Tues, Thurs Sun Sun Sun Sun Sun
As a Reminder: Clinical team responsibilities are also documented on a Photostat sheet that will be kept in the patients medical notessee Appendix 2. Responsibilities of the nursing staff are on a sheet kept with the nursing notes.
Stopping Parenteral Nutrition

When? Patients will be started on an enteral or oral diet when thought appropriate by NST. PN will be weaned off or discontinued in those patients who are able to tolerate and absorb oral/enteral feeding. At this point, nursing staff or the patient should maintain accurate Food Record Charts, in addition to the existing fluid balance charts. All patients being weaned off PN need to be referred to the ward dietitian.
In other instances e.g. the decision for palliative care, it may be appropriate to withdraw PN. This decision will usually be made by the NST in association with the clinical team and relatives/patient.
How? PN will usually be stopped when oral nutritional intake is deemed adequate by the NST. As a general rule of thumb cessation of PN is determined on a variety of factors and is a multi-disciplinary decision. Clinical observation by nursing staff will identify the rare patient who has problems after cessation and any concerns should be reported to the NST. Some PN is weaned off over 48 hrs.
Occasionally PN needs to be stopped for other reasons such as acute operations, major metabolic disorders or problems with equipment. If PN needs to stop suddenly or unexpectedly an infusion of 5% dextrose should be initiated at 100 ml/hr for five (5) hours. Beyond this time or where patients have ongoing large fluid losses or requirements, additional IV fluids and electrolytes should be administered as clinically indicated.
Line Removal? The Line Insertion Service and Nutrition Support Team will advise on the timing of, and arrange for removal of tunnelled central lines. PICCs and other short-term devices may be removed at ward level by nursing staff with the appropriate training.
Appendix 1: Contacts for Team - JR2
Referrals for PN should be made directly to the PN registrar on Bleep 4084. However if this not possible you can discuss a referral with any member of the team
Person Simon Travis Bruce George
Role Consultant Gastroenterologist Consultant Colorectal Surgeon PN Senior Registrar
Preferred contact Ext 51073 or Radiopage 07693248364 Ext. 20794 or Bleep 1899 Bleep 4084 Ext. 21653 or Bleep 1749 Ext. 21703 or Bleep 1702 Ext. 21836 Ext 21653 or Bleep 1945 Ext 21653 or Bleep 1953 Ext 21653 or Bleep 1530 Ext. 21653 or Bleep 1797 Ext 40378 or Bleep 1972
Helen Hamilton Marion OConnor
Senior Nurse Manager PN/LIS Senior Dietitian Senior Pharmacist
Fiona Henderson Ginny Mountford Nicola York Cathy Hartley-Jones Gill Siuda
Clinical Nurse Specialist PN Clinical Nurse Specialist PN Clinical Nurse Specialist LIS Clinical nurse Specialist LIS Clinical Nurse Specialist EN (Enteral Nutrition)
Appendix 2: Monitoring - Medical

It is the responsibility of the medical staff in each clinical team to ensure that PN bloods are done. The NST will arrange full micronutrient screening on long-term PN or "at-risk" patients. Biochemical monitoring will be audited. Baseline: the tests outlined in the table below should be requested prior to referring patients for PN and any abnormalities corrected. PN will not be started when there are metabolic disturbances due to the associated risks. New/Unstable patient: daily monitoring as outlined below. Stable patient: as outlined below.
Results should be monitored by clinical team, but will also be reviewed by Nutrition Support Team when prescribing PN. N.B. The clinical team retains overall responsibility for the patient.
Baseline Blood Biochemistry Urea and Creatinine Na K Bicarbonate Chloride LFTs: Bilirubin Alk Phos AST or ALT Albumin Calcium Magnesium Phosphate Zinc Copper CRP Full blood count Coagulation APTT INR Lipids Cholesterol Triglycerides Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes New Patient or Unstable Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Daily Sun Monthly Sun, Tues, Thurs Sun, Tues, Thurs Sun Sun Sun Sun Stable patient Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Sun, Tues, Thurs Every 2 weeks Every 3 months Sun, Tues, Thurs Sun Sun Sun Sun Sun
As a Reminder: Clinical team responsibilities are also documented on a Photostat sheet that will be kept in the patients medical notes. Responsibilities of the nursing staff are on the reverse side of the same sheet.
Appendix 3: Monitoring - Nursing

The ward Nursing Staff looking will perform the following tasks after patients on IVN. These procedures will be audited. Daily weight (before starting PN and daily thereafter). 4 - 6 hourly temperature and blood pressure. (Also observe for clinical evidence of infection, general well being, etc.) Accurate fluid balance chart and summary (to maintain accurate fluid balance and homeostasis). Bag change will be at 20:00 hrs each day. Capillary glucose monitoring (BMs) 6 hourly for first 24 hours, then BD or OD when stable (glucose between 410 mmols/L). Return to 4 hourly when PN being weaned off. Twice weekly 24-hour urine collections (Sunday and Wednesday) for Nitrogen balance and electrolytes. Daily assessment for CVC/PICC site infection or leakage. 72 hour dressing change minimum for CVC, more frequent if loose, soiled or wet. Dressing change weekly for PICC's. Weekly bung change. Documentation: Bag and prescription checked by at least one IV assessed nurse. Record on fluid balance chart. Sign for on drug chart. Document dressing and bung change in nursing kardex.
Storage of PN on Ward Bags not yet connected to the patient must be stored in a refrigerator (at between 2C and 8C). Bags stored in a refrigerator must be kept well away from any freezer compartment to prevent ice crystal formation in the PN. Bags that have been refrigerated should be removed at least 2 hours before being hung and infused, to allow the solution to reach room temperature. Bags connected to the patient should be protected from light (which breaks down some components of PN) using the coloured protective cover.
As a Reminder: If your patient moves ward or unexpectedly stops PN please inform Baxter on Ext: 35840 and the PN Team on Ext. 21653.
Appendix 4: Re-feeding Guidelines

Defined as severe fluid and electrolyte shifts and related metabolic implications in malnourished patients undergoing refeeding. Signs are hypophosphataemia, hypokalaemia, hypomagnesaemia, altered glucose metabolism, fluid balance abnormalities, and vitamin deficiency.
If all biochemistry is normal (K, Ca, P, Mg), start feeding
At risk patient
Check biochemistry (K, Ca, P, Mg)
If K<2.5mmol/L} If P<0.3mmol/L} correct levels (see below) If Mg<0.5mmol/L}
Dose of IV Thiamine (at least 30 minutes before feeding starts). Re-check biochemistry. Start feeding @ 20kcal/kg*
Monitor K, P, Ca, and Mg for the first 2 weeks, and act on as indicated.
*20 kcal/kg for the first 24hrs, then increase gradually within the first week to full feeding, with careful monitoring and replenishing of electrolytes as required The PN team will advise on the regimen and rate, but the clinical team has responsibility for correcting fluid and electrolyte imbalances prior to starting PN. N.B. Re-check calcium, magnesium and phosphate before commencing PN. Replacement treatment Low phosphorous (serum <0.3mmol/l) Addiphos: 40mmol (20ml vial) in 500ml 5% dextrose over 6 hours. Shake bag well Oral phosphate causes diarrhoea (One vial of Addiphos contains: Phosphate 40mmol, potassium 30mmol, and sodium 30mmol) Low magnesium (<0.5mmol/l) Magnesium sulphate 50%: 5g (50% MgSO4) in 500ml 5% dextrose over 6 -12 hours Oral magnesium is poorly absorbed due to GI side effects of large doses Low potassium (<2.5mmol) IV fluids containing potassium e.g. 40mmol K in 1000ml N.Saline over 8 hours. Repeat as necessary. Or Sando K (12mmol/tablet): 2 tds for 48hours. Repeat as necessary. Thiamine Pabrinex: 1 pair of ampoules (equivalent to 250mg thiamine) in 50 - 100ml 5% dextrose over 30 minutes
CENTRAL LINE MANAGEMENT This chart is for guidance only If in doubt about catheter care SEEK EXPERT HELP LINE FLUSHING PAIN
1. MILD LOCAL SITE PAIN CONSIDER CAUSE ANALGESIA MONITOR OR LARGER WHEN USING LINE ONLY USE 10ML SYRINGE REFER TO LOCAL DRESSING PROTOCOL 2. LOCAL SITE REDNESS MONITOR CONSIDER REACTION TO SITE DRESSING CONSIDER BEGINNING OF INFECTION CONSIDER TRAUMA BY LINE MOVEMENT AND TAPE SECURELY FLUSH WITH 0.9% SODIUM CHLORIDE 10 ML SOLUTION PRE-DRUG ADMIN PUSH, PAUSE, POSITIVE PRESSURE METHOD DISCARD FIRST 5ML ASPIRATED (UNLESS BLOOD GIVE TREATMENT REGIME AS PRESCRIBED CULTURES) ENSURE LINE APPROPRIATELY FLUSHED AFTER ASPIRATION SEE LINE FLUSHING LINE ASPIRATION INDICATED: LINE CULTURES POOR PERIPHERAL ACCESS ASSESSMENT LINE PATENCY INFLAMMATION MONITOR 1. NO SIGNS ALWAYS MAINTAIN STRICT ASEPTIC CONDITIONS
SITE DRESSING SITE INFLAMMATION
SITE BLEEDING
LINE ASPIRATION
CHANGE EXIT/ENTRY
1. SMALL LOCALISED
SITE AFTER 24 HRS
BLEEDING THIS IS EXPECTED POST
ALWAYS MAINTAIN STRICT ASEPTIC CONDITIONS WHEN USING LINE ONLY USE 10ML SYRINGE OR LARGER
(SOONER IF HEAVILY BLOOD STAINED OR
INSERTION MONITOR FOR SWELLING
WET) 2. MODERATE LOCAL SITE PAIN CONSIDER CAUSE REVIEW ANALGESIA MONITOR
EXCESS BLEEDING
CLEAN SITE
2. HEAVY LOCALISED BLEED
WITH CHLORHEXIDINE
COVER ORIGINAL DRESSING WITH EXTRA PADS AND TAPE
0.5% IN 70% IMS (HYDREX 3. LOCAL SITE AND SHOULDER TIP PAIN AS ABOVE PLUS CONSIDER PNEUMOTHORAX/LINE MISPLACEMENT 4. PAIN AND RESPIRATORY PAIN AS ABOVE PLUS INFORM MEDICAL TEAM CONSIDER O2 AND SATS MONITOR TREAT AS PER PNEUMOTHORAX ? CHEST X-RAY 5. LOCAL AND SHOULDER TIP PAIN AND NECK SWELLING STOP INFUSION CONSIDER LINE POSITION, RE X-RAY CONSIDER THROMBOSIS 5. AS ABOVE + INFUSION LEAK OR HIGH GRADE PYREXIA STOP INFUSION CONSIDER LINE REMOVAL 3. LOCAL SITE REDNESS AND PAIN/ITCHING AS ABOVE PLUS CONSIDER SITE SWAB MONITOR FOR PYREXIA
FIRMLY CHANGE DRESSING 1 HR LATER
SOLUTION)
MONITOR FOR SWELLING
CONTINUE TO DRESS EXIT/ENTRY SITES
3. HEAVY BLEED AND
EVERY 3/7 UNLESS WET/DIRTY
SITE SWELLING AS ABOVE PLUS
INFORM MEDICAL / INSERTION TEAM
CONSIDER PRESSURE DRESSING
REMOVE ENTRY SITE
SUTURES IN 7 DAYS REMOVE EXIT SITE
4. SITE SWELLING AND NECK SWELLING
4. AS ABOVE + SITE EXUDATE + PYREXIA CONSIDER BLOOD CULTURES (PERIPHERAL AND CENTRAL) CONSIDER ANTIBIOTICS
FLUSH WITH 10MLS 0.9% SODIUM CHLORIDE AND WITH 5 MLS HEPARINISED SALINE 10U/ML
IF LINE DOES NOT BLEED BACK SEEK EXPERT HELP CONSIDER LINE MALPOSITION FIBRIN SHEATH FORMATION
Appendix 5: Post CVC Insertion Management Chart
SUTURES NOT BEFORE 21 DAYS
AS ABOVE PLUS CHECK CLOTTING/PLATELETS
Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
IF LINE BLOCKED SEEK EXPERT HELP CONSIDER FLUSH WITH 5000iu UROKINASE IN 2ML 0.9% SODIUM CHLORIDE IN EVENT OF LINE SPLIT/TEAR STOP INFUSION CLAMP LINE ABOVE SPLIT/TEAR SEEK EXPERT HELP
5. CONSIDER ARTERIAL BLEED
Page 21
Appendix 6: Procedure for suspected PN line infection
1. Suspect a line infection when there are clinical signs of sepsis (such as fever, rigors, elevated white cell count, elevated CRP)
2. Do not assume that because a patient has a feeding line that this is necessarily the likely source of sepsis: take a history examine the patient (look for signs of endocarditis, pneumonia, cholangitis, deep vein thrombosis, superficial phlebitis at venflon sites, and the line insertion site) dipstix the urine send an MSU if leukocyte esterase and/or nitrites positive, or symptoms refer to urinary tract chest X-ray blood cultures through the line (call the nutrition nurse specialist, Bleep 1945) take peripheral blood cultures (1 set, add 10ml blood to each of the 2 bottles) check FBC, CRP, LFTs if ALP is elevated, arrange abdominal ultrasound
3. Make a decision about antibiotics on the clinical picture
(a) Low grade infection (history of several days, temperature <38C, normotensive, no clear source) Do not start antibiotics until cultures return Do not give PN that night or use the central line Contact PN team on next working day Liase with microbiologists when culture results available
(b) Severe infection, line source possible (temperature >38C, hypotensive, no clues to other source) Start *Cefuroxime 1.5g I.V. (not through central line), continue tds (bd in severe renal impairment) Give single dose of intravenous Gentamicin (5mg/kg over 20 min) If MRSA colonised, also start Vancomycin 1g IV (not via central line), otherwise give as in (c) below Do not give PN that night or use the central line for any other purpose Contact PN team on next working day Liase with microbiologists on next working day
(c) Severe infection, line source probable (temperature >38C, hypotensive, history of previous line sepsis or signs of entry site sepsis) Start Vancomycin 1g through central line. Infuse no faster than 10mg/min. Check level before 3rd to 5th dose, or if renal impairment, before 2nd dose (target<10mg/L). Refer to Medicines Information leaflet 2(4) in the Therapeutics section of the ORH website Start *Cefuroxime 1.5g I.V. and continue tds (bd in severe renal impairment) Do not give PN that night Contact PN team on next working day Liase with microbiologists on next working day
(d) Entry site infection (erythema, swelling, tracking at skin entry site of feeding line) Gently express any pus from the tunnel, swab and send for culture Start *Flucloxacillin 500mg qds (oral if >50cm functioning small intestine, otherwise IV) Draw around area of redness Daily dressing changes Liase with the microbiologists/PN team on the next working day
DO NOT REMOVE THE CENTRAL FEEDING LINE
4. Make a management plan in conjunction with the PN team and microbiologists when results are available For low-grade line infections (Coagulase Negative Staphylococcal bacteraemia), 2 weeks of antibiotics via the central line may be successful and line removal avoided. Exit site infections will usually respond to oral/I.V. *Flucloxacillin which should be given for 2 weeks For more severe infections, including tunnel infection or bacteraemia due to Staph aureus, Candida sp. or Pseudomonas sp., line removal should be performed by the PN/LIS, with reinsertion arranged at an interval of at least 48 hours to allow antibiotics to take effect. Patients with Staph aureus or Candida sp. infections should be assessed particularly carefully for sites of seeding including echocardiography, and for Candida sepsis, fundoscopy
*If a patient is allergic to B lactams, discuss with microbiology/ID before giving.
Drs Travis and Bowler, 04.09.01
Appendix 7: Management of Catheter Occlusion

Minimising the risk of catheter occlusion The risk of central venous catheter (CVC) occlusion may be minimised in several ways:
Immediately flushing with 10ml normal saline once an infusion has finished. Using push-pause positive pressure flushing technique to increase intralumenal turbulence and prevent blood flashback within catheter tip Use of positive pressure claves to prevent blood flashback within catheter tip (available from PN and LIS department) Insertion of a Groshong#-valved catheter Instillation of 50 units Heparin in 5 ml (Hepsal) if not using catheter for more than 6 hours
Urokinase If a CVC does become partially or completely occluded, Urokinase may be used to unblock the line. Qualified staff that have completed the PN assessment may perform this procedure. Any queries may be referred to the PN and Vascular Access department. 1. 2. 3. Ensure medical personnel prescribe Urokinase on drug chart and order from pharmacy. Dilute 10,000 units Urokinase in 4ml water for injections (equal to 5000 units in 2ml) and ensure solution has fully dissolved. Using strict aseptic technique as described in ORH PN Handbook, slowly instil 5000 units Urokinase (in 2ml water for injections) into each blocked lumen of the CVC. If this is the first attempt at unblocking the line, leave for 2 hours. Subsequent attempts should remain insitu for 4-12 hours. Once dwell time is complete, try to withdraw Urokinase from the CVC. This may not be possible in catheters with Persistent Withdrawal Occlusion (see below). If it is not possible to withdraw the Urokinase, the solution may be safely flushed into the central system. If this has not been effective, repeat the procedure with remaining 5000 units Urokinase. If it is not possible to unblock the line in this way, please contact the PN or Line Insertion Team.
4.
5. 6.
Persistent Withdrawal Occlusion Persistent Withdrawal Occlusion (PWO) occasionally occurs when a catheter may be flushed but not aspirated. This is usually due to the formation of a fibrin sheath at the end of the catheter, which occludes the tip when negative pressure is applied during aspiration. Although the CVC may be flushed with ease, it is potentially dangerous if PWO is left untreated.
If PWO is identified in a patient with a CVC, the following measures should be taken:
1. 2. 3.
Verify tip position with a chest x-ray. Tip should be in the lower 1/3 of the superior vena cava. If tip is not in the correct position, liase with the Vascular Access team. Instil 5000 units Urokinase in 2ml water for injections as described above. Repeat if first attempt unsuccessful. Arrange linogram with fibrin sheath disruption.
If all these tests are normal, contact the Consultant Radiologist who performed the linogram for advice.
Appendix 8: Troubleshooting Guide
Problem My patients PN bag didnt turn up today
Solution Check in medical notes that it was actually ordered Check other ward areas to see if accidentally delivered there. If still missing, Contact cancer pharmacist on-call (via switchboard) Run maintenance IV fluids e.g. 5% Dextrose or NaCl +/- K+. (Team/on-call HO will need to chart). Document in the patients notes.
My patients PN isnt charted on the drug card I cant find my patients prescription to check against the PN bag
Call on-call House Officer to prescribe Check patients notes for composition
Pre-ordered bags may have prescription details on previous days script Original Prescriptions kept in pharmacy. Try bleeping on call pharmacist Do not put up PN bag without a prescription!
D/W on-call HO if composition ok with current electrolytes then you may be able to use bag if not happy to use bag then administer maintenance IV fluids e.g. 5% Dextrose or NaCl +/- K+. (Team/on-call HO will need to chart). My patients bag has turned up but there is no giving set Document in the patients notes. Spare giving sets can be obtained from the PN nurses ext 21653 (during office hours) and can be found in the PN Boxes on wards 5A, 6F, 5F, 5C/D and SEU (out of office hours)
The prescription/formulation doesnt match the bag delivered
Ensure you are checking the correct patients and days prescription. If there is a rate discrepancy run the PN as stated on PN bag. Call cancer pharmacist on-call for advice
D/W Dr if electrolyte composition is safe the Dr should alter the prescription, and sign that s/he has done so. Document in the patients notes
My patients PN bag/giving set is leaking
Discard the bag and giving sets (Do not re-plumb the bag) Contact the doctor on-call to arrange for alternative IVI and electrolytes to be given Inform the NST as soon as possible. Fill in an Incident Form. Keep giving set to one side if leaking so it can be returned to Baxter for examination
The PN has been removed from the fridge but has not been hung up.
The PN can be used as long as the maximum time the bag is out of the fridge does not exceed 48 hours (i.e. time left out of fridge and infusion time) and the bag is within the use by date. If the bag is not going to be used, as long as the seals have not been broken, the PN should be returned to the fridge as soon as possible. Label the bag to outline when it was out of the fridge and for how long.
The volume of PN fluid in the bag is insufficient for the fluid losses calculated from the fluid balance charts.
Contact the junior doctors and start additional fluids via a peripheral line. If venous access is poor, liase with the PN team for alternative solutions.
The patient is on PN but their K level is <3.0mmol/L.
Give additional K through a separate peripheral line (e.g. 40mmol K in 1000ml N.Saline over 8 hours). (Do not add anything to the PN bag) Liase with the PN team. BMs > 11mmol/L for 3 recordings in 48 hours start sliding scale insulin. Single BM >17, start sliding scale insulin. If the patient has septicaemia and a line infection is suspected (all other underlying causes having been considered), omit PN until source of infection confirmed. See Appendix 6. Provide peripheral IVI and electrolytes. If PN is resumed and the patient re-spikes a temperature/ has a rigor, discontinue PN and re-start IVI and electrolytes. Follow sepsis guidelines. Appendix 6.
My patients BMs are high. I think my patient may have a line infection.
My patients CVC/PICC access is red/hot/swollen or my patient has a temperature > 38C
The contents of the PN bag are discoloured/have separated (note lipid-free bags will be yellow in colour)
Do not give the PN. Contact the PN pharmacist for advice on the next working day. Contact the HO to prescribe alternative IV fluids and electrolytes. Repair kits for Hickman lines are located in the PN Office on Level 5 C/D corridor, or on 5E (JR2 site) If you are unable to access a kit or repair the line, clamp below the damaged area Contact the HO to obtain alternative peripheral access and prescribe IV fluids Advise the LIS as soon as possible
My patients line is cracked/damaged
Different problem? No obvious solution? Call the PN Team on 21653.

Appendix 9: Out of Hours PN (public holidays)
PN will not be available out-of-hours (evenings and weekends) because malnutrition is the culmination of a gradual process and cannot be considered an emergency. Out of hours PN may in fact increase the risks of complications, including sepsis and metabolic disturbances. The approach advised is as follows: 1. TPN is never an emergency 2. It is most dangerous when started at weekends when the urgency of malnutrition is (finally) recognised: such patients are invariably at high risk of re-feeding syndrome, which is potentially fatal 3. The best nutritional care that doctors, dietitians and pharmacists can give is to ensure vitamin and electrolyte replacement in preparation for TPN to start safely on Monday 4. Doctors should measure K, Mg, phosphate and calcium 5. They should give iv Pabrinex daily and follow re-feeding guidelines (Re-feeding Guidelines Appendix 4) to replace K, Mg, phos and ca 6. All electrolytes should be monitored daily, including Saturday and Sunday 7. The PN team should be contacted through the link Gastro SpR on Monday morning (bleep 4084) so that the patient's nutritional need can be assessed and PN started as appropriate on Mon evening 8. This applies to requests after 11am on Fri, and on Sat and Sunday

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Parenteral Nutrition Guidelines (Adults)

Indications for Parenteral Nutrition

Starting and Continuing Parenteral Nutrition

Prescribing Parenteral Nutrition

Nursing Care of Patients on PN

Medical Monitoring of Patients on PN

Stopping Parenteral Nutrition

Appendix 1: Contacts for Team - JR2

Person Simon Travis Bruce George

Role Consultant Gastroenterologist Consultant Colorectal Surgeon PN Senior Registrar

Helen Hamilton Marion OConnor

Senior Nurse Manager PN/LIS Senior Dietitian Senior Pharmacist

Appendix 2: Monitoring - Medical

Appendix 3: Monitoring - Nursing

Appendix 4: Re-feeding Guidelines

If all biochemistry is normal (K, Ca, P, Mg), start feeding

Check biochemistry (K, Ca, P, Mg)

If K<2.5mmol/L} If P<0.3mmol/L} correct levels (see below) If Mg<0.5mmol/L}

SITE DRESSING SITE INFLAMMATION

SITE AFTER 24 HRS

BLEEDING THIS IS EXPECTED POST

(SOONER IF HEAVILY BLOOD STAINED OR

INSERTION MONITOR FOR SWELLING

2. HEAVY LOCALISED BLEED

COVER ORIGINAL DRESSING WITH EXTRA PADS AND TAPE

FIRMLY CHANGE DRESSING 1 HR LATER

MONITOR FOR SWELLING

CONTINUE TO DRESS EXIT/ENTRY SITES

3. HEAVY BLEED AND

EVERY 3/7 UNLESS WET/DIRTY

SITE SWELLING AS ABOVE PLUS

INFORM MEDICAL / INSERTION TEAM

CONSIDER PRESSURE DRESSING

REMOVE ENTRY SITE

SUTURES IN 7 DAYS REMOVE EXIT SITE

4. SITE SWELLING AND NECK SWELLING

Appendix 5: Post CVC Insertion Management Chart

SUTURES NOT BEFORE 21 DAYS

AS ABOVE PLUS CHECK CLOTTING/PLATELETS

5. CONSIDER ARTERIAL BLEED

Appendix 6: Procedure for suspected PN line infection

3. Make a decision about antibiotics on the clinical picture

DO NOT REMOVE THE CENTRAL FEEDING LINE

*If a patient is allergic to B lactams, discuss with microbiology/ID before giving.

Drs Travis and Bowler, 04.09.01

Appendix 7: Management of Catheter Occlusion

Appendix 8: Troubleshooting Guide

Problem My patients PN bag didnt turn up today

The prescription/formulation doesnt match the bag delivered

My patients PN bag/giving set is leaking

The patient is on PN but their K level is <3.0mmol/L.

My patients CVC/PICC access is red/hot/swollen or my patient has a temperature > 38C

My patients line is cracked/damaged

Different problem? No obvious solution? Call the PN Team on 21653.

Appendix 9: Out of Hours PN (public holidays)

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