Parenteral Nutrition in the Acute Setting

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Parenteral Nutrition in the Acute Setting

• Nikki Stewart
• Chief Dietitian
• North Herts. and Stevenage PCT

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PN

• The administration of nutrients via the
  intravenous route
• Usually with a dedicated central or peripheral
  line

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Parenteral Nutrition

• Parenteral nutrition is generally started in
  order to prevent or minimise the adverse effects
  of malnutrition in patients who would other wise
  have no significant intake
• The length of time that a patient can tolerate
  complete or near starvation without harm is
  variable and unknown

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Advantages of Parenteral Nutrition

• Meet calculated nutritional requirements in first
  24 hours
• The feed can be tailored to meet estimated
  requirements
• High tech

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Disadvantages

• Invasive
• Unphysiological - gut atrophy, bacterial
  translocation
• Cost - economic and clinical
• Risk of line insertion, subsequent infection and
  thrombophlebitus
• Risk of fluid and electrolyte imbalance

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PN

• In patients with a failure in gut
  function(e.g.obstruction, fistula, ileus,
  dysmotility, severe malabsorption), to a degree
  that will definitely prevent gastro intestinal
  absorption of nutrients
• And
• The consequent intestinal failure has persisted
  for many days( e.g.gt5 days) or is likely to
  persist for many days ( e.g.5 days or longer)
  before significant improvement

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Long Term Indication for PN in Adults (BAPEN
and NICE)

• Extreme short bowel syndrome
• Inflammatory bowel disease
• Radiation enteritis
• Motility disorders (Scleroderma)
• Chronic malabsorption

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Short Term Indication for Parenteral Nutrition

• Prolonged NBM following major excisional surgery
• Multi - organ failure where nutritional
  requirements cannot be met by enteral route
• Severe pancreatitis
• Mucositis following chemotherapy
• High output or enterocutaneuos fistula
• Intractable vomiting

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Other Requests for Parenteral Nutrition

• Veterans affairs study ( NEJ Med 1991) -
  complications associated with parenteral
  nutrition are least when used in severely
  malnourished patients for more than 5 days.
• Heyland et al JAMA 1998 (meta -analysis) studies
  published after 1989 suggest PN associated with
  increased mortality rates and no effect on
  complication rates. This could reflect the
  nutrient content of the feeds that predisposed
  patients to hyperglycaemia and infection.

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Other Request for Parenteral Nutrition

• Mcfie BJS 2000 - when enteral route not working
  parenteral route preferred to starvation in
  catabolism , as patients left for gt14 days have a
  poor outcome.

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Parenteral Nutrition

• The decision to start parenteral nutrition is
  never an emergency.
• Catheter insertions should be planned and
  performed in aseptic conditions.

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Audit

• In critical care looking at requests for PN
  from 27/02/02 31/05/02
• 29 patients were started on parenteral nutrition
• 6 patients started on Thursday
• 9 patients started on a Friday
• 3 patients started at a weekend

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Day PN was started
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Audit

• 4 /9 started on Friday were fed for less than 4
  days, 3 of these died 3 days later
• In that time 133 bags were prescribed
• 11 bags ( 8.3) were wasted, 9 of which were for
  patients who died at the weekend

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Outcome

• Plan for feeding all patients in critical care
  (including PN) discussed and agreed on a Friday.
• Where ambiguous, plan if not for PN clearly
  documented.
• For re-audit but anecdotally..

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NICE and Vitamins

• The addition of vitamins and trace elements are
  always required must be made under the
  appropriate pharmaceutically controlled
  conditions (NICE 2006)
• The common characteristics of these groups were
  a high oxidative tress and micronutrient
  depletion Heyland et al 2004

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Revision on Thiamin

• Occurs most commonly as the coenzyme thiamine
  diphosphate (TDP)

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Revision on Thiamin

• Coenzyme in many reactions in carbohydrate
  metabolism such as in the TDP dependent pyruvate
  dehydrogenase reaction to generate acetyl-CoA.
  (Key source of energy for mitochondrial
  oxidation and precursor compound in lipid
  metabolism)
• In the Krebs cycle TDP is a cofactor for
  oxidative decarboxylation of alpha ketoglutarate
  to succinyl CoA

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Revision on Vitamin B6

• Pyridoxal phosphate dependant enzymes catalyse a
  number of important reactions in amino acid and
  glycogen metabolism
• Transaminase to yield keto acids - the main
  route of oxidative metabolism of most amino
  acids, and provides a pathway for non essential
  amino acids, whose oxo acids are common metabolic
  intermediates

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Revision of Vitamin B6

• Decarboxylation to yield amines ( e.g.histamines)
• The process to synthesis niacin from tryptophan
  involving kynureninase
• Bender 1989 European Journal of Clinical
  Nutrition 10 20 of the healthy population
  demonstrate signs of inadequate vitamin B6
  intake. Plasma concentration also decreases with
  age

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Role of Vitamin B6

• Animal studies suggest 6 days are needed to
  return to normal enzyme activity

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Revision of Vitamin C

• Anti oxidant
• Cofactor in hydroxylation reactions, deficiency
  results in impaired collagen synthesis
• Carnitine biosynthesis from lysine. Carnitine
  is central to the role transporting long chain
  fatty acids in to mitochondria for oxidation and
  the supply of energy

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Revision of Vitamin C

• Surgical stress has a marked effect on blood
  ascorbate levels (Schorah et al 1986 Annals of
  Clinical Biochemistry)

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Trace Elements

• Selenium Vitamin E, Vitamin C function
  synergistically to regenerate both water and fat
  soluble antioxidants
• Providing a combination of endogenous antioxidant
  micronutrients improves clinical outcome more so
  than individual provision.
• Heyland 2005, Intensive Care Medicine

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Case Report -Scolapio JPEN 2005

• 53 year old female with short bowel syndrome who
  developed urticaria after administration of
  cyclical PN
• 16 days after starting PPN noticed small hives
  and itching on arm which disappeared after 1 hour
  of stopping PN
• After eliminating individually drugs and drugs,
  established that it was related to the vitamin
  preparation

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Case Report

• The reaction was related to the duration of the
  PN (day16 onwards)
• The rate of the PN infusion (182ml/hr)
• Thought to be related to the fact that a certain
  amount of allergen is required to trigger a
  reaction
• Oral preparation successfully used (stomach and
  100cm of small intestine)

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Any Questions