Assessment Tools and Guidelines: Parenteral Nutrition Therapy

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Assessment Tools and Guidelines:

Parenteral Nutrition Therapy

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Assessment Tools and Guidelines:

DISCLAIMER—This pocket guide is designed to be a summary of information. Although it is detailed, it is not an exhaustive pharmaceutical review; the entries in this publication present selected facts about each product. McMahon Publishing and Hospira assume no liability for the use of this guide, and the accuracy of the information contained herein is not guaranteed. Readers are strongly urged to consult any relevant primary literature, the complete prescribing information available in the package insert of each drug, and appropriate clinical protocols. Copyright © 2008, McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form.

Parenteral Nutrition Therapy

Jay M. Mirtallo, MS, RPH, FASHP, BCNSP Specialty Practice Pharmacist Nutrition Support/Surgery Department of Pharmacy The Ohio State University Medical Center Columbus, Ohio

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Figures and Tables

Table of Contents

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Evaluation of Body Weight . . . . . . . . . . . . . . . . . . .7

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Table 1.

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Figure 1. Algorithm for the administration of nutrition support. . . . . . . . . . . . . . . . . . . . . . .8-9

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Figure 2. Health care organization nutrition consultation request form. . . . . . . . . . . .10

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Table 3.

Metabolic Derangements in Which PN Should Be Used With Caution . . . . . . . .14

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Nutrition Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Nutritional Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 PN Formulation Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Medication Compatibility With PN . . . . . . . . . . . . . . . . . . . . . .24 Glucose Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Guideline for Special Diseases . . . . . . . . . . . . . . . . . . . . . . . . .33

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Table 4.

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Pharmaceutical and Metabolic Equations in PN Therapy . . . . . . . . . . . . . . . . . . . .12

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Table 2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Macronutrients: PN Dosing Guidelines . . . . . . . . . . . . . . . . . . .16-17

Withholding and Withdrawing PN . . . . . . . . . . . . . . . . . . . . . .39 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Figure 3. Consequences of protein calorie overfeeding. . . . . . . . . . . . . . . . . . . . . . . .18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41-44

Table 5.

Micronutrients: PN Dosing Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . .20-21

Other Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Table 6.

FDA Requirements for Labeling Aluminum Content of PN Products . . . . . . . . . . . .22

Table 7.

ASPEN Safe Practice Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-29

Figure 4. PN formulation standard order format—renal failure. . . . . . . . . . . . . . . . . .30 Figure 5. PN formulation standard label format—renal failure. . . . . . . . . . . . . . . . . .31 Table 8.

ASPEN Recommendations on PN Standardization . . . . . . . . . . . . . . . . . . . . . . . .32

Table 9.

Y-Site Injection Compatibility of I.V. Medications With PN . . . . . . . . . . . . . . .34-38

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Introduction

Table 1. Evaluation of Body Weight

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alnutrition is associated with more frequent treatment complications and longer stays in the intensive care unit (ICU) and hospital, as well as increased costs of medical care. Patients at high risk for malnutrition should be identified and evaluated for specialized nutrition support (SNS).1 Determining the appropriate route of nutrition support for patients at risk for malnutrition is an important consideration when one is attempting to positively influence patient outcomes. In patients with a functioning gastrointestinal (GI) tract, enteral nutrition (EN) can improve outcomes.1 EN has been shown to improve nutritional status and reduce length of stay in the ICU and is associated with fewer infectious complications than parenteral nutrition (PN).2 The major limitation of EN is the need to gain enteral (postpyloric) access so that the nutrient infusion is tolerated and serious complications, such as aspiration pneumonia,are avoided.1 Techniques are available to facilitate access to the GI tract so that enteral tube feedings may be administered safely. For patients who have a nonfunctioning GI tract, PN is the available method of nutritional support.3 PN is essential for patients who are severely malnourished and have GI tract problems that are not expected to resolve within 7 days.1,4 When PN is considered, it should be noted that this method is complex and has been associated with a unique set of complications, some of which can be serious or even life-threatening.3 In addition, few published reports can be found that demonstrate a consistently favorable effect of PN on patient outcomes.4 This pocket guide discusses nutritional assessment,nutritional requirements, PN formulation design, medication

% of IBW =

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current weight x 100 IBW

80% to 90% = mild malnutrition 70% to 79% = moderate malnutrition 0% to 69% = severe malnutrition % of Usual Body Weight % of UBW =

current weight x 100 usual weight

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85% to 95% = mild malnutrition 75% to 84% = moderate malnutrition 0% to 74% = severe malnutrition

IBW, ideal body weight; UBW, usual body weight Adapted from references 4 and 8.

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% of Ideal Body Weight

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Nutrition assessment

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Decision to initiate SNS

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• Aggressive attempt to obtain enteral access • Feedings may be more appropriate distal to the pylorus for patients with high gastric residuals, critical illness, gastroparesis, or pancreatitis

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Yes

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Functional GI tract?

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ed Inconclusive

EN

EN trial

Obstruction, peritonitis, paralytic ileus, mesenteric ischemia, short-bowel syndrome, enterocutaneous fistula, malabsorption

Yes

EN tolerated?

No

No

PN only if EN contraindicated

PN

Status of GI function Nonfunctional

Continue PN

Yes

Continue EN

Aspiration, abdominal distention, diarrhea, high gastric residuals

Status of GI function

Functional

Transition to EN

Figure 1. Algorithm for the administration of nutrition support.

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EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; SNS, specialized nutrition support

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compatibility with PN, and guidelines for special diseases, as well as an overview of evidence-based guidelines published by the American Society for Parenteral and Enteral Nutrition (ASPEN).1,3 Also included in the review is a discussion of FDA regulations concerning aluminum contamination of PN,5 United States Pharmacopeia (USP) standards for sterile compounding,6 and recommendations on the use of insulin in PN.7

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The purpose of nutrition assessment is to identify the degree to which the current or future nutritional status of the patient will influence his or her outcome. The current nutritional status of the patient is determined by several factors, including the patient’s weight and how it compares with ideal and usual weights (Table 1,page 7); the duration of weight loss if it has occurred; visceral protein status; laboratory values indicative of fluid, electrolyte, and potential nutritional deficits; clinical condition; and whether the patient may be nourished by oral, enteral, or parenteral means.1,4,8 During PN, both pharmaceutical and metabolic calculations are used in the assessment of nutrition support. Equations used to assess clinical, nutritional, and metabolic status are provided in Table 2 (page 12).4,9-11 Figure 1 (pages 8-9) is a useful algorithm for determining the appropriate indications for PN. Clinicians should consider PN if a trial of enteral feedings has failed, if the enteral route is contraindicated, or if the GI tract has severely diminished function because of underlying disease or treatment and GI function is not expected to return within 7 days.1,4 Contraindications to PN include the following: a functional GI tract; an inability to achieve appropriate venous access; an unstable clinical condition; and terminal

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Nutrition Assessment

Figure 2. Health care organization nutrition consultation request form.

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Table 2. Pharmaceutical and Metabolic Equations In PN Therapy

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1. Predicting Energy Needs

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Using Harris-Benedict Equationa: For males: 66 + 13.75 (wt in kg) + 5 (ht in cm) – 6.8 (age in years) For females: 655 + 9.6 (wt in kg) + 1.8 (ht in cm) – 4.7 (age in years)

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2. Predicting the Degree of Metabolic Stress

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Catabolic index = 24-hour urine urea nitrogen [UUN] (g) – (0.5 dietary nitrogen intake + 3) Values 0-5 represent moderate stress and >5 represent severe stress. 3. Predicting the Degree of Malnutrition

I. Creatinine height index = 24 hr actual creatinine excreted in urine (mg) x 100 24 hr expected creatinine excreted in urine of normal adult of same height II. Body mass index (kg/m2) = weight (kg) / height (m2)

4. Measuring the Success of Nutrition Support

Nitrogen balance = (protein intake [g]/6.25) – (24-hour urine urea nitrogen [g] + 3-5 g) a Stress factors should not be applied.

PN, parenteral nutrition Based on references 4 and 9-11.

disease, critical illness, or metabolic derangement for which a favorable response to therapy is not feasible or the risk of complications is too high.4 In these conditions, the metabolic profile is such that exogenous nutrients are poorly used and frequently cause complications that require prolonged mechanical ventilation, intensive care, or hospitalization.4 Table 3 (page 14) lists some metabolic derangements that necessitate cautious use of PN until the patient’s condition improves.4 Applying the algorithm using the aforementioned concepts in a nutrition consultation form (Figure 2,page 10) can help improve appropriate use of PN in an institution. Such a form also provides documentation for the need for SNS,and, along with the nutrition assessment, includes a recommendation for route and dose of nutrients to be provided.

Nutritional Requirements

Over the past several years, there has been a continual refinement of PN, focusing on the delivery of the safest, most effective doses. Guidelines provide a framework for nutrient doses in a variety of disease states.1,3 In general, there has been a decline in recommended caloric doses, a liberalization of protein doses, especially for renal and liver failure, and more specific recommendations for fat doses (Table 4,pages 16-17).1,3,4,12 Two specific purposes for fat—nonprotein calories and prevention of essential fatty acid deficiency—are listed. Obesity is becoming more prevalent and needs to be considered in dosing of PN.The body mass index is used to classify patients with a value greater than 30 as obese and a value greater than 40 as severely obese.1 Overfeeding of calories and protein can have serious consequences in patients receiving PN and has led to the

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Table 3. Metabolic Derangements in Which PN Should Be Used With Caution

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Blood urea nitrogen >100 mg/dL

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Serum Cl >115 mEq/L

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Serum glucose >300 mg/dL

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Hyperglycemia

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Hyperchloremic metabolic acidosis

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Azotemia

Abnormality To Be Corrected

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Metabolic Derangement

Hyperosmolality

Serum osmolality >350 mOsm/kg

Hypochloremic metabolic alkalosis

Serum Cl