Essentials for Home Initiation of Parenteral Nutrition Carol Ireton-Jones, PhD, RD, LD, CNSD Mary Snyder, RPh
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Essentials for Home Initiation of Parenteral Nutrition
Carol Ireton-Jones, PhD, RD, LD, CNSD
Mary Snyder, RPh
1. Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance.
2. Carry the Evaluation Packet you received on registration with you to EVERY session.
3. If you’re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable.
4. Pharmacists and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go.
5. FOR CE: At your last session, total the hours and sign your Statement of Continuing Education Certificate form.
– Keep the PINK copy for your records. Place the YELLOW and WHITE copies in your Evaluation packet
– Make sure an evaluation form from each session you attended is completed and in your Evaluation packet
– Put your name on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center
Top 5 Things to Know for CE:
Objectives
Review admission criteria for initiation of parenteral nutrition (PN) in the home setting
Discuss causes and treatment of refeeding syndrome
List 5 specific monitoring parameters/interventions for the patient who initiates PN in the home.
Parenteral Nutrition Indications
When a person cannot or will not take adequate
nutrition orally
and has a non-functional GI tract
In home care, patient preference may play a role as well as reimbursement.
ASPEN/SCCM Guidelines for the Use of Parenteral and Enteral Nutrition In Adults
(JPEN 2009)
Critical Care Provide nutrition support if patient
unable to meet needs orally for 5-10 days (B)
Enteral is the preferred route of feeding (B)
Parenteral should be reserved for those unable to tolerate enteral feeding (C)
Home Nutrition Support Home specialized nutrition support (HSNS) should be used
in patients who cannot meet nutrient needs orally and who are able to receive therapy outside of an acute care facility (B).
When HSNS is required, home enteral nutrition (HEN) is preferred route when feasible (B).
When HSNS is indicated, HPN should be used when the GI tract is not functional or HEN/oral intake insufficient to meet nutritional needs (B).
ASPEN Guidelines for the Use of Parenteral and Enteral Nutrition In Adults
(JPEN 2002)
Diagnoses associated with Home PN
Oncologic diagnoses or treatments that effect ability to intake or absorb nutrients Chemotherapy
induced N/V Radiation enteritis Inflammation of the
GI tract – oral to intestine
Obstruction due to tumor
Gastrointestinal disorders Pancreatitis Severe Diarrhea Intractable
Vomiting Recovery post GI
surgery Malabsorption
Diagnoses associated with Home PN
Other Complications of Gastric by-pass surgery Hyperemesis gravidarum Congenital disorders Celiac disease (exacerbation of
symptoms)
Home initiation – W4 Why, who, what, why not?
Why – for patients who need PN but who should or may bypass the hospital for PN initiation
Who – when a patient has a non-functional GI tract and requires PN to maintain or replete nutritional status
What – start low and go slow – in general use low dextrose and slow progression
Why not? – an unstable, cachextic patient is not a candidate for home initiation
Patient examples:
Chronic pancreatitis patient, unable to maintain adequate nutrition through j-tube feeding
Hyperemesis patient already receiving anti-emetic and fluid therapy via PICC line
Cancer patient currently receiving IV chemo through central access
Home Initiation of PN Goal
#1 PATIENT SAFETY! Identification of at risk patients who
are not appropriate for home PN initiation
Comprehensive nutrition and home assessment to identify individual patient needs
Home initiation criteria
Hemodynamically stable? Baseline labs? Cardiovascular status? CHF? Kidney function?
Diabetes or glucose abnormalities? Acute pancreatitis? Uncontrolled diabetes? Medications that cause glucose fluctuations?
Age? Very young? Very old?
Initiating TPN at Home, Nutrition in Clinical Practice, 1999 Crocker, et al
Home initiation criteria
Central venous access? PICC – confirmed by chest x-ray? Port – tip placement confirmed?
Catheter clear No signs or symptoms of catheter infection
Support system Caregiver Home care provider Nursing – first dose?
Initiating TPN at Home, Nutrition in Clinical Practice, 1999 Crocker, et al
When is initiation of PN in the home not indicated?
Prescribing MD has not seen the patient
Specific conditions that require very close patient monitoring Renal failure Severe liver disease Fluid imbalance/intolerance (ex. high output ostomy,
cardiac failure) Uncontrolled Diabetes No IV access Inadequate home environment
At significant risk for Refeeding Syndrome
Significant Respiratory Dysfunction
Slide courtesy of Coram Specialty Infusion
Home Assessment Criteria Electricity Refrigeration Telephone Water General cleanliness Safety issues Patient/Carepartner ability to provide
care Fuhrman, T in Handbook of Home Nutrition Support, 2007
Nutrition Assessment – Critical Care
Traditional nutrition assessment tools (albumin, prealbumin, and anthropometry) are not validated in critical care. Before initiation of feedings, assessment should include evaluation of weight loss and previous nutrient intake prior to admission, level of disease severity, comorbid conditions, and function of the GI tract. (E)
ASPEN and SCCM Guidelines, JPEN, 2009
Nutrition Assessment
Previous nutrient intake or nutrition support – how recent?
Weight loss – how much? What period of time?
Disease severity/patient stability Function of the GI Tract Baseline Lab Data Home Environment/Safety
Nutrition Assessment - Lab Values
Serum protein status albumin, pre-albumin, transferrin
Lab parameters for evaluating PN initiation CMP Mg, Phos BUN/Cr Liver function tests Chol/TG
Refeeding Syndrome- At Risk Patient Profiles
Anorexia nervosa Chronic
malnutrition Chronic alcoholism Prolonged fasting Bariatric surgery
Dunn et al, NCP 2003
Oncology patients NPO 7-10 days
with stress Prolonged IV
hydration <80% IBW 5-10% weight loss
over preceding 1-2 months
Slide courtesy of Coram Specialty Infusion
Nutrition assessment: Body Weight Assessment
Height Actual and Usual Body Weight % of Usual Body Weight = Actual Body Weight X 100 Usual Body Weight % Weight Loss = Usual - Actual Body Weight X 100 Usual Body Weight
Energy Equations
Macronutrient Requirements
Based on a patient-specific nutrition assessment that determines nutrition needs Protein
0.8 - 1.5 grams/Kg body weight Fat
20 - 30% of total kcals Carbohydrate – balance of kcals Fluids
30 - 35 ml/Kg body weight (+ extraneous losses)
Refeeding Syndrome and Home initiation of
Parenteral Nutrition (NCP, 2006)
119 patients initiated on PN at home;41 M/78F 56% digestive dxs (malabsoprion, HG, pancreatitis, fistulas) 44% oncologic dxs (GI, lung, ovarian, brain)
Checklist to identify pts at risk for Refeeding Syndrome (RS) 66 patients “at risk” for RS
Of those, 20 had abnormal baseline labs indicating actual RS 14 required rehydration prior to HPN initiation 6 started with dextrose <50% of goal with K, Phos, Mg
maximized
113/119 started at home on PN did not develop RS Cost savings of $4500/pt achieved due to hospital avoidance
The Secret to Success……
Start Low… Go Slow
Malnutrition did not start over night and cannot be cured overnight!
Developing the PN formula
Individualization and Team work is key Macronutrients:
Dextrose (3.4 kcal/gm) Amino Acids Lipids
Fluids/electrolytes Ca/phos concerns
Vitamins/Trace Additives
What is low/slow?
Initiate with fluids and electrolytes only (and MVI/trace)
Initiate with 25-50% dextrose goal, 50% fat goal and full protein (and MVI/trace)
What is low/slow?
Advance over 5 - 7 days After 3 days, increase dextrose/lipid by
50% After 3-4 days, increase to goal
macronutrients Infusion time
Start at 24 hours for first 3 days (negotiable)
Decrease infusion time as tolerated and as macronutrients
Vitamins (adult) Daily Requirements* MVI –12 (10 ml)** MVI-13 (10ml)+
Vitamin A (IU) 4000 -5000 3300 3300 Vitamin D (IU) 400 200 200 Vitamin E (IU) 12 - 15 10 10 Ascorbic Acid (mg) 45 100 200 Niacin (mg) 12 - 20 40 40 Riboflavin (mg) 1.1 - 1.8 3.6 3.6 Thiamine (mg) 1.0 - 1.5 3.0 6.0 Pyridoxine (mg) 1.6 - 2.0 6.0 6.0 Pantothenic Acid (mg) 5 - 10 15 15 Folic Acid (mcg) 400 400 600 Biotin (mcg) 150 - 300 60 60 Cyanocobalamin (mcg) 3 5 5 Vitamin K (mcg) N/A 0 150
*NAG/AMA recommended daily guidelines **Consider supplementing MVI-12 with Vitamin K 5 - 10mg IM/IV weekly and Iron Dextran 35 - 50 mg IM/IVs
+required as of 2003
Electrolytes
Recommended daily requirements* Sodium 1 - 2mEq/kg/day Potassium 1 - 2mEq/kg/day Calcium 10 - 15mEq/d Magnesium 8 - 12 mEq/d Phosphate 15 - 30mM/d Acetate 80 - 120mEq/d (balance) Chloride 100 - 180mEq/d (balance)
Consider abnormal losses (fistulas, diarrhea, etc.)
Trace Elements
Daily MTE-5 MTE-5C Requirements** (3 ml) (1 ml)
*Zinc (mg) 2.5 - 4.0 3 5 *Copper (mg) 0.5 - 1.5 1.2 1 *Manganese (mg) 0.15 - 0.8 0.3 0.5 *Chromium (mcg) 10 - 15 12 10 *Selenium (mcg) --- 60 60
*Available as single entity products **AMA recommended daily guidelines
Special Considerations - Refeeding Syndrome
Occurs with overly aggressive reintroduction of nutrition (any route)
Characterized by intracellular shift of electrolytes (K, Mg, Phos)
Symptoms may include altered state of consciousness, muscle cramps, hyperglycemia, sudden drop in serum K, Mg, Phos, arrhythmia, respiratory failure, cardiac arrest
Slide courtesy of Coram Specialty Infusion
Avoiding Refeeding Syndrome
Careful patient evaluation Correct electrolytes Limit initial dextrose dose Thiamine repletion if indicated Avoid fluid volume excess Maximize K+, PO4
=, Mg++ Begin as continuous infusion Monitor labs after initiation (protocol – 24
hours, 48 hours)
Slide courtesy of Coram Specialty Infusion
Additives
Medications Insulin H2 blockers Heparin Additional vitamins
Steps to Success
Patient Selection Nutrition Assessment/Goals Start Low, Go Slow
Increase dextrose, kcals over 1-2 weeks Progress to cyclic infusion gradually over
1-2 weeks
Monitor progress to nutrition goals
Home Initiation Case Study 52 y/o F Dx: chronic pancreatitis CC: inability to eat adequately due to pain w/intake
Wt: 93.7 lbs/Ht: 65 inches UBW: 125#
Meds: Norco with eating, fentanyl patch, phenergan, lansoprazole, desvenlafaxine, pancrelipase tablets. Also,
multi-vitamin, methinonie, omega-3 fish oil
Lethargic, rarely out of bed, sleeps 12 hrs plus but requires Meds for sleep
Oral diet as tolerated plus j-tube feedings over night
Home Initiation Case Study Nutrition Assessment:
78% of ideal body weight Limited food tolerance (oral and j-tube feedings) due to pain and sxs; usual intake ~450 kcal/day with 20 gm protein Baseline labs – alb and pre-alb – wnl; hgb/hct – low – labs ~3 weeks prior
Recommendations: Initiate PN to provide majority of nutrients and fluids Continue PO and j-tube feedings as tolerated to provide ~25% of total kcals Initiate PN at home
Home Initiation Case Study Steps to Success: Home infusion provider selected and contacted –
reimbursement confirmed PICC line placed in out patient procedure Baseline labs drawn – glucose 128 mg/dL; creat 0.43
mg/dl – all others wnl PN Formulation determined by RD – confirmed by RPh
Initial infusion – 235 ml D70 600 ml AA 10%
100 ml 20% lipid +MVI–12(no Vit K)/MTE-5/electrolytes 1400 ml total fluid volume Infused over 12 hours
Home Initiation Case Study Steps to Success: Education: Nurse provided teaching to patient and care
partner (husband); and follow up on subsequent visits Follow up:
Labs drawn 6 days later – glucose slightly elevated, creat unchanged
Patient feeling well and tolerating PN Labs at Day 12 – all labs wnl PN increased to final 200 gm dextrose/75 gm AA/150
ml lipid infused over 10 hours Continued on HPN for 7 months; weaned over 1 month
as po intake increased. (J tube removed after 2 months on PN) Final weight:118 lbs
It’s Your Turn: Appropriate for Home Initiation?
45 yo female/Dx: Cervical CA & Weight loss Ht: 5’8” Wt: 205# UBW 230# (3 mos ago) Symptoms & Physical Findings: Generalized weakness, <500kcal/d oral clear liquids after development of an ileofistula following surgery for Cervical CA Other Factors: Patient does not want to lose further work time as she is at a new job/dependent on maintaining ins. Baseline blood work results within normal range Central line placement coordinated in an outpatient
facility
It’s Your Turn: Appropriate for Home Initiation?
25 yo female/Dx: s/p Gastric by-pass (Roux-en-Y) 4 months prior Ht: 5’4” Wt: 167# UBW 250#
Symptoms & Physical Findings: Generalized weakness, N/V daily, hair loss, very little food intake due to taste changes and N/V;
Other Factors: Patient unable to return to work since GBP, lives alone; non-compliant with follow up visits to GBP physician.
Presents to new FP who refers for home initiation of PN.
It’s Your Turn: Appropriate for Home Initiation?
70 yo male/Dx: s/p GI Surgery discharged from hospital 4 days prior; seen at GI surgeons office – on PN in hospital
Ht: 5’11” Wt: 150# UBW 165# (6 mos ago weighed 180#)
Symptoms & Physical Findings: Generalized weakness, unable to take oral nutrition due to pain
Referred for Home initiation: Baseline blood work results indicate dehydration and low
normal phos and K Central line placement coordinated in an outpatient
facility
Successful Home Initiation of PN
Review risk factors Coordinate care plan
Patient Care partner Home care provider Physician
References Parrish CR The Refeeding Syndrome in 2009: Prevention is the
Key to Treatment. The Journal of Supportive Oncology 2009:7(1):20-21.
Newton AF, DeLegge MH. Home Initiation of Parenteral Nutrition. Nutrition in Clinical Practice, 2007;22 (1): 57-64.
Siepler, J. Principles and Strategies for Monitoring Home Parenteral Nutrition; Nutr Clin Pract, 2007; 22(3): 340 – 350.
Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition. 2005 Feb;21(2):156-60.
References Soo I, Gramlich L. Use of parenteral nutrition in patients with
advanced cancer. Appl Physiol Nutr Metab. 2008 Feb;33(1):102-6.
Orrevall Y, Tishelman C, Permert J, Cederholm T. The use of articfical nutirtion among cancer patients enrolled in palliative home care services. Palliat Med. 2009 Sep;23(6):556-64.
Seres D, Sacks GS, Pedersen CA, Canada TW, Johnson D, Kumpf V, Guenter P, Petersen C, Mirtallo J. parenteral nutrition safe practices: results of the 2003 American Society for Parenteral and Enteral Nutrition Survey. JPEN J Parenter Enteral Nutr. 2006 May-Jun;30(3):259-65.
August DA, Thorn D, Fisher RL, Welchek CM. Home parenteral nutrition for patients with inoperable malignant bowel obstruction. JPEN J Parenter Enteral Nutr. 1991 May-Jun;15(3):323-7.
References DiBaise JK, Scolapio JS. Home parenteral and enteral nutirtion.
Gastroenterol Clin North Am. 2007 Mar;36(1):123-44, vii. Review.
Scolapio JS, Picco MF, Tarrosa VB. Enteral versus parenteral nutirtion: the patient’s perspective. JPEN J Parenter Enteral Nutr. 2002 Jul-Aug;26(4):248-50.
Newton A. Refeeding Syndorme and Home initiation of Parenteral Nutiriton. Nutirtion in Clinical Practice, April 2006.
Crocker KS, Riccardi C, DiIeso M. Initiating Total Parenteral Nutirtion at home. Nutr Clin Prac 1999;14:124-129.
Fish JA, Stieger E, Seidner D. Initiating Total Parenteral Nutrition in the Hospital. Nutr Clin Prac 1999;14:129-130.
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