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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)

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ParenteralNutritionGuidelines

Adults)


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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


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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 OxfordRadcliffe 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: [email protected]

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 re-

feeding guidelines.


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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 otherdata 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 parenteralto 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.


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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 beinclusive(ratherthan exclusive) andeducational.

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.


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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 daysis usually not clinically indicated as the

risks outweigh the benefits, but it is accepted that sometimes this will occur as aconsequence 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.


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Starting and Continuing Parenteral Nutrition

Overview

The identification and selection of patients who require Parenteral Nutrition, and thesubsequent 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 linewill 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


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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.


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Intravenous Access

Obtaining Intravenous Access

There is a balance between convenience and safety with intravenous access for PN. TheNST 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 theadministration of PN and are only to be used in theshort 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 thefollowing:

If there is already a cannula insitu this can be used for PN providing Visual

Infusion Phlebitis Score (VIPS) =


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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


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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 moderate-

to-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 dietand fluids. In this situation, 5% dextrose is not required).

When PN is being administered over periods of


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Prescribing Parenteral Nutrition

The PN Prescription

On a daily basis (Monday-Friday) the NST will formulate the PN prescription and agreethis 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 StandardPN 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 full-

strength PN from day one.

In those patients at-risk of re-feeding syndromethen 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)


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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 LipidThe 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 fistulaeetc. 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 extra-renal 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.


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Nursing Care of Patients on PN

The ward Nursing Staff looking will perform the following tasks after patientson 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 hungand 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.


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Stopping Parenteral Nutrition

When?

Patients will be started on an enteral or oral diet when thought appropriate by NST. PNwill 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

unexpectedlyan 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.


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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 Role Preferred contact

Simon Travis Consultant

Gastroenterologist

Ext 51073 or Radiopage

07693248364

Bruce George Consultant Colorectal

Surgeon

Ext. 20794 or Bleep 1899

PN Senior Registrar Bleep 4084

Helen Hamilton Senior Nurse Manager -

PN/LIS


Marion OConnor Senior Dietitian Ext. 21703 or Bleep 1702

Senior Pharmacist Ext. 21836

Fiona Henderson Clinical Nurse Specialist -

PN

Ext 21653 or Bleep 1945

Ginny Mountford Clinical Nurse Specialist -

PN


Nicola York Clinical Nurse Specialist -

LIS


Cathy Hartley-Jones Clinical nurse Specialist

LIS


Gill Siuda Clinical Nurse Specialist

EN (Enteral Nutrition)



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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 startedwhen 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 New Patientor Unstable

Stable patient

Blood BiochemistryUrea and Creatinine Yes Daily Sun, Tues, ThursNa Yes Daily Sun, Tues, ThursK Yes Daily Sun, Tues, ThursBicarbonate Yes Daily Sun, Tues, ThursChloride Yes Daily Sun, Tues, Thurs

LFTs: Bilirubin Yes Daily Sun, Tues, ThursAlk Phos Yes Daily Sun, Tues, ThursAST or ALT Yes Daily Sun, Tues, Thurs

Albumin Yes Daily Sun, Tues, ThursCalcium Yes Daily Sun, Tues, ThursMagnesium Yes Daily Sun, Tues, ThursPhosphate Yes Daily Sun, Tues, ThursZinc Yes Sun Every 2 weeksCopper Yes Monthly Every 3 monthsCRP Yes Sun, Tues, Thurs Sun, Tues, Thurs

Full blood count Yes Sun, Tues, Thurs Sun

Coagulation

APTT Yes Sun SunINR Yes Sun Sun

LipidsCholesterol Yes Sun SunTriglycerides Yes 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 .


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Appendix 3: Monitoring - Nursing

The ward Nursing Staff looking will perform the following tasks after patientson 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 andinfused, 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.


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Appendix 5: Post CVC Insertion Management Chart

SITEBLEEDING

PAIN

SITEINFLAMMATION

LI

NEFLUSHING

LINEASPIRAT

ION

SITEDRESSING

CENTRALLINEM

ANAGEMENT

Thischartisforguidanceonly

Ifindoubtaboutcathetercare

SEEKEXPERTHELP

C

HANGEEXIT/ENTRY

SITE

AFTER24HRS

(SOONERIFHEAVILY

BLOODSTAINEDOR

WET)

1.SMALLLOCALISED

BLEEDING

THISISEXPECTED

POST

INSERTION

MONITORFORSW

ELLING

EXCESSBLEED

ING

1.MILDLOCALSITEPAIN

CONSIDERCAUSE

ANALGESIA

MONITOR

1.NOSIGNS

INFLAMMATION

MONITOR

REFERTOLOCAL

DRESSINGPROTOCOL

ALWAYSMAINTAINSTRICT

ASEPTICCONDITIONS

W

HENUSINGLINE

ONLY

USE10MLSYRINGE

ORLARGER

ALWAYSMAINTAINSTRICT

ASEPTICCONDITIONS

WHENUSINGLINE

ONLYUSE10MLSYRINGE

ORLARGER

CLEANSITE

WITH

CHLORHEXIDINE

0.5%IN70%IMS

(HYDREX

SOLUTION)

2.HEAVYLOCALISEDBLEED

COVERORIGINALD

RESSING

WITHEXTRAPADSANDTAPE

FIRMLYCHANGEDR

ESSING1

HRLATER

MONITORFORSW

ELLING

2.MODERATELOCAL

SITEPAIN

CONSIDERCAUSE

REVIEWANALGESIA

MONITOR

2.LOCALSITEREDNESS

MONITOR

CONSIDERREACTIONTOSITE

DRESSING

CONSIDERBEGINNINGOF

INFECTION

CONSIDERTRAUMABYLINE

MOVEMENT

ANDTAPESECURELY

FLUSHWITH0.9%

S

ODIUM

CHLORIDE

10MLSOLUTION

PRE-DRUGADMIN

PUSH,PAUSE,

POSITIVEPRESSURE

METHOD

LINEASPIRATIONINDICATED:

LINECULTUR

ES

POORPERIPHERAL

ACCESS

ASSESSMENTLINEPATENCY

C

ONTINUETODRESS

EXIT/ENTRYSITES

EVERY3/7UNLESS

WET/DIRTY

3.HEAVYBLEED

AND

SITESWELLIN

G

ASABOVEPLU

S

INFORMMEDIC

AL/

INSERTIONTE

AM

CONSIDERPRESSURE

DRESSING

3.LOCALSITEAND

SHOULDERTIPPAIN

ASABOVEPLUS

CONSIDER

PNEUMOTHORAX/LINE

MISPLACEMENT

3.LOCALSITEREDNESSAND

PAIN/ITCHING

ASABOVEPLUSCONSIDERSITE

SWABMONITORFORPYREXIA

G

IVETREATMENT

REGIMEAS

PRESCRIBED

DISCARDFIRST

5ML

ASPIRATED(UNLESSBLOOD

CULTURES)ENSU

RELINE

APPROPRIATELYFLUSHED

AFTERASPIRAT

ION

SEELINEFLUSHING

R

EMOVEENTRYSITE

SUTURESIN7DAYS

REMOVEEXITSITE

SUTURESNOT

BEFORE21DAYS

4.SITESWELLING

AND

NECKSWELL

ING

ASABOVEPLUSC

HECK

CLOTTING/PLATELETS

4.PAINAND

RESPIRATORYPAIN

ASABOVEPLUS

INFORMMEDICALTEAM

CONSIDERO2ANDSATS

MONITOR

TREATASPER

PNEUMOTHORAX

?CHESTX-RAY

4.ASABOVE+SITEEXUDATE

+PYREXIA

CONSIDERBLOODCULTURES

(PERIPHERALANDCENTRAL)

CONSIDERANTIBIOTICS

INEVENTOFL

INE

SPLIT/TEARST

OP

INFUSIONCLAMPLINE

ABOVESPLIT/TE

AR

SEEKEXPERTHE

LP

FLUSHWITH10MLS

0.9%

SODIUMCHLORIDE

ANDWITH5MLS

HE

PARINISEDSALINE

10U/ML

5.CONSIDE

R

ARTERIALBLEED

5.LOCALANDSHOULDER

TIPPAINANDNECK

SWELLING

STOPINFUSIONCONSIDER

LINEPOSITION,REX-RAY

CONSIDERTHROMBOSIS

5.ASABOVE+INFUSION

LEAKORHIGHGRADE

PYREXIA

STOPINFUSION

CONSIDERLINEREMOVAL

IFL

INEBLOCKED

SEEK

EXPE

RTHELP

CONSIDER

F

LUSHWITH5000iu

URO

KINASEIN2ML0.9%

S

ODIUM

CHLORIDE

IFLINEDOESNOTBLE

EDBACK

SEEKEXPERTHELP

CONSIDERLINEMAL

POSITION

FIBRINSHEATHFOR

MATION


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Appendix 6: Procedure for suspected PN line infection

1. Suspect a line infection whenthere are clinical signs of sepsis (such as fever, rigors,

elevated white cell count, elevated CRP)

2. Do not assumethat 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 antibioticson the clinical picture

(a) Low grade infection(history of several days, temperature


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(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 (notvia 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 (target50cm 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


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4. Make a management plan in conjunctionwith 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, Candidasp. orPseudomonas 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 aureusor 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


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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. 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.

2. Instil 5000 units Urokinase in 2ml water for injections as described above. Repeat if

first attempt unsuccessful.

3. Arrange linogram with fibrin sheath disruption.

If all these tests are normal, contact the Consultant Radiologist who performed the

linogram for advice.


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Page 27

Appendix 8: Troubleshooting Guide

Problem Solution

My patients PN bag

didnt turn up today

Check in medical notes that it was

actually ordered

Check other ward areas to see ifaccidentally delivered there. If still

missing,

Contact cancer pharmacist on-call (viaswitchboard)

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

Call on-call House Officer to prescribe

I cant find my patients prescription

to check against the PN bag

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 withcurrent 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).

Document in the patients notes.

My patients bag has turned up but there

is no giving set

Spare giving sets can be obtained fromthe 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)


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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 PNas stated on PN bag.

Call cancer pharmacist on-call for advice

D/W Dr if electrolyte composition is safethe 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 foralternative IVI and electrolytes to be

given

Inform the NST as soon as possible.

Fill in an Incident Form. Keep giving setto 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 themaximum 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 longas 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 outof 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 startadditional fluids via a peripheral line.

If venous access is poor, liase with the PNteam for alternative solutions.


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The patient is on PN but their K level is

11mmol/L for 3 recordings in 48hours start sliding scale insulin.

Single BM >17, start sliding scale insulin.

I think my patient may have a line

infection.

If the patient has septicaemia and a lineinfection 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.

My patients CVC/PICC access

is red/hot/swollen

or my patient has a temperature > 38C

Follow sepsis guidelines. Appendix 6.

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 PNpharmacist for advice on the next working

day.

Contact the HO to prescribe alternativeIV fluids and electrolytes.

My patients line is cracked/damaged 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 repairthe 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

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


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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 hoursPN 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 onMonday

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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