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Nutrition Support In The Home Care Patient PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Nutrition Support in the Home Care Patient".

This medical PowerPoint presentation talks about nutrition support as an essential component of home care for patients who require assistance with maintaining adequate nutrition. The goal of nutrition support is to provide the patient with the necessary nutrients to maintain or improve their health and quality of life.

This presentation discusses some considerations for nutrition support in home care patients.

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Published on : Mar 28, 2023 | Views : 663 | Downloads : 2

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Slide 2-

Objectives 2 Identify three roles of the home care dietitian Describe two basic criteria needed for Home Enteral Nutrition (HEN) Medicare coverage Describe two basic criteria needed for Home Parenteral Nutrition (HPN) Medicare coverage Identify three considerations when planning a HEN regimen Identify three common complications in the HPN patient
Slide 3-

Home Care Dietitian Role 3 Intake Coordination Review all HPN and HEN referrals for completeness, safety & stability Coordinate discharge plans Support reimbursement issues and concerns Obtaining Medicare qualification criteria Assist providing clinical data for commercial insurance authorization
Slide 4-

Home Care Dietitian Role 4 Clinical Perform nutrition assessments as ordered by prescriber In-home visits for new and long-term HPN patients Ongoing care for HPN and HEN patients Providing patient education prn Ongoing coordination of clinical care with all team members: MD, RN/home agency, pharmacist Resource for patients as issues arise
Slide 5-

Home Care Dietitian Role 5 Sales & Nutrition Program Management Joint sales calls with Account Managers: Case Managers/Discharge Planners, MD offices, fairs/seminars Strategic market planning Ongoing nutrition support education for staff, external audiences Quality Improvement activities; Outcomes collection and reporting, CNW
Slide 6-

Medicare Enteral Nutrition Coverage
Slide 7-

Must meet two basic criteria Permanence: Length of Need => 90 days Non-function or disease of the structures that normally permit food to reach the small bowel Dysphagia- Neurological, Functional Obstructions, Fistulas Malabsorption Gastroparesis or Dumping Syndrome Medicare HEN Coverage
Slide 8-

Medicare EN Coverage
Slide 9-

Medicare EN Coverage
Slide 10-

Psychological Disorders End stage disease with anorexia or nausea Failure to thrive Dementia Dehydration Poor appetite Alzheimer’s/memory issues – forgetting to eat Aphasia Conditions with No Medicare EN Coverage
Slide 11-

Enteral nutrition is warranted if the patient cannot “maintain weight and strength commensurate with overall health status” with oral intake Acceptable: “for pleasure only” Sips Bites Small amounts Calorie counts with intake <50% of estimated needs What if the Patient Can Eat?
Slide 12-

Pump-assisted feeding Failure to tolerate gravity/bolus feedings due to: Reflux Aspiration Severe diarrhea Dumping syndrome Administration rate < 100 cc/hour Blood glucose fluctuations Circulatory overload Patient receiving > 2000 kcal or <750 kcal/day More than three NG tubes, or one G/JT every three months Additional Documentation is Required
Slide 13-

Medicare Home Parenteral Nutrition Coverage
Slide 14-

“Parenteral nutrition is covered for a patient with permanent severe pathology of the alimentary (GI) tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient’s general condition.” The patient must have: A condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients OR A disease of the stomach or intestine which is a motility disorder and impairs the ability of nutrients to be transported through the GI system There must be objective evidence supporting the diagnosis Meet definition of permanence >=90 days Medicare TPN Coverage
Slide 15-

Recent massive small bowel (sb) resection leaving 5 feet (152 cm) or less of sb beyond the ligament of Treitz Need: Operative report or other test indicating amount of bowel remaining and resection 3 months prior to PN initiation H & P/progress notes/Discharge Summary with diagnosis Documentation of LON >= 90 days 20-35 kcal/kg/day Criteria A - Massive Small Bowel Resection
Slide 16-

Short bowel syndrome where enteral intake >2.5-3L/day, gastrointestinal fluid and electrolyte losses exceed 50% of enteral intake, and urine output is less than 1 liter per day Need: Operative/Diagnostic Reports H & P/progress notes/Discharge Summary with diagnosis Detailed record of Intake/Outputs Documentation of LON >= 90 days 20-35 kcal/kg/day Criteria B - Short Bowel Syndrome
Slide 17-

Criteria C – Bowel Rest 17 Bowel rest required for at least three months for pancreatitis, severe exacerbation of regional enteritis, or fistula where distal TF is not possible Need: Diagnostic tests: Xrays, CT scans, US, Fistulograms Evidence of pancreatitis with lipase/amylase levels Fistula location and outputs H & P/progress notes/Discharge Summary with diagnosis and documented need for NPO Documentation of LON=>90 days 20-35 kcal/kg/day
Slide 18-

Criteria D – Bowel Obstruction 18 Complete mechanical small bowel obstruction where surgery is not an option Need: Diagnostic test or operative report confirming obstruction H & P/progress notes/Discharge Summary with diagnosis, that patient is not surgical candidate & feeding distal to obstruction is not possible Documentation of LON=>90 days 20-35 kcal/kg/day
Slide 19-

Criteria E – Severe Malabsorption 19 Significant malnutrition with very severe fat malabsorption as evidenced by a standard 72-hour fecal fat test Need: 72 hr. fecal fat study with >50 gms fat enteral intake, and fecal fat exceeding 50% of enteral intake 10% weight loss over three months, Nutrition Assessment Serum albumin <3.4 gm/dL H & P/progress notes/Discharge Summary with diagnosis and LON=>90 days 20-35 kcal/kg/day
Slide 20-

Criteria F – Severe Motility Disturbance 20 Significant malnutrition with severe motility disturbance of the small intestine and/or stomach which is unresponsive to prokinetic medication Need: Small bowel motility study/Scintigraphic or Radiographic report H & P/progress notes/Discharge Summary with diagnosis 10% weight loss over three months, Nutrition Assessment Serum albumin <3.4 gm/dL Documentation of LON=>90 days 20-35 kcal/kg/day
Slide 21-

Criteria G/H – Other Qualifying Conditions & Failed Tube Trial 21 Significant malnutrition with clinical condition unresponsive to altering the manner of delivery of nutrients: Unable to maintain weight despite modifying enteral diet’s nutrient composition & utilizing pharmacologic means to treat the etiology of the malabsorption Need: H & P/progress notes/Discharge Summary with qualifying diagnosis Diagnostic tests/Operative report/Nutrition Assessment Medication records 10% weight loss over three months, Serum albumin <3.4 gm/dL Documentation of LON=>90 days 20-35 kcal/kg/day
Slide 22-

Criteria G/H – Other Qualifying Conditions & Failed Tube Trial 22 Need: Documentation of Failed TF Trial, or why trial not medically feasible Documentation reflecting diet or TF adjustments to enhance tolerance
Slide 23-

Criteria G/H – Other Qualifying Conditions & Failed Tube Trial 23 AND….Need one of the following Qualifying Conditions: Moderate fat malabsorption Small bowel motility disturbance unresponsive to prokinetic medications > 5 feet sb remaining beyond the ligament of Treitz Short bowel syndrome with GI losses <50% Mild or moderate exacerbation of regional enteritis Partial sb obstruction where surgery is not an option
Slide 24-

Conditions with No Medicare HPN Coverage 24 Swallowing disorders Temporary defects in gastric emptying Psychiatric disorders impairing food intake Metabolic disorders inducing anorexia, such as cancer Physical disorders impairing food intake, such as dyspnea Renal failure and/or dialysis (IDPN) Side effects of medication
Slide 25-

When Additional Documentation is Required 25 Caloric intake <20 or >35 kcals/kg/day Protein intake <0.8 or >1.5 gms/kg/day Dextrose concentration <10% Lipids>150 units/month (1 unit=10 gms) – 1,500 gms/month HPN infusion <7 days/week Need for special nutrients
Slide 26-

Case Study #1 26 67 yo Female with PMH colon cancer, s/p chemo, pancreatic insufficiency (on Creon), depression, now diagnosed with tongue cancer presenting with anorexia & odynophagia Ht: 62 in/157.5 cm; Wt: 97 lbs./44.1 kg Usual BW: 120 lbs./54.5 kg last weighed 2 ½ months ago 81% UBW = 19% wt loss Albumin drawn last week=2.9 gm/dL Would this patient qualify for HPN under Medicare? What type of nutrition support is most appropriate for her?
Slide 27-

Case Study #2 27 68 yo Male with PMH adenocarcinoma s/p jejunal resection, c/w ECF with drain, >1 L output/day. Surgeon wants NPO and HPN for 2-4 months to heal fistula; pt too malnourished to undergo another surgery Ht: 72 in/183 cm; Wt: 173 lbs./78.6 kg; 30 lb. wt loss since prior to diagnosis 4 months ago. Last Albumin=2.0 gm/dL Would this patient qualify for HPN under Medicare?
Slide 28-

Home Enteral Nutrition
Slide 29-

Clinical Indications for HEN 29 Mechanical GI tract dysfunction Motility disorders Malabsorptive syndromes (IBD, SBS, Pancreatitis) Malignancies of the head & neck, digestive system Neurologic conditions (CHI, CVA, ALS) Hyperemesis gravidarum Failure to Thrive Inborn Errors of Metabolism
Slide 30-

Candidates for Home Nutrition Support 30 Safe home environment Patient and/or caregiver physically able Clinically and medical stable Appropriate feeding access Reimbursement available
Slide 31-

Reimbursement for HEN & HPN 31 Medicare Medicaid – varies by state and policy Self-Pay Private or Commercial Coverage of formula, supplies varies by employer contract May need a pre-authorization Required documents may vary Many use Medicare qualification criteria
Slide 32-

Developing the HEN & HPN Plan 32 -Team Approach is best practice Involves MD, RD, RN, Pharmacist, Case Manager, Social Worker, Patient and Caregiver -Explain risks & benefits -Assess patient and caregiver’s ability to perform home nutrition support therapy-related tasks
Slide 33-

Routes of Administration 33 Determined by: Expected length of therapy, long term if >6 weeks Risk of pulmonary aspiration Anatomical issues ie obstructions, fistulas Feeding tolerance history Diagnosis
Slide 34-

Routes of Administration 34 Gastric Feedings: nasogastric (NG), gastrostomy tube (surgically-placed GT or endoscopically placed=PEG) Bolus/syringe, gravity or pump GT buttons – low profile/skin level, extension set Jejunal Feedings: nasojejunal (not often seen in home care), Jejunostomy tube (surgically placed JT or endoscopically placed PEG/J), G/JT buttons Pump or gravity only
Slide 35-

Methods of Administration 35 Bolus/Syringe: inexpensive, no electricity, not tied to pump, easiest instruction, portable, inexact delivery, fastest (<1/2 hr.), increased risk for vomiting/aspiration Gravity Bag: inexpensive, no electricity, use bedside pole or hook, easy instruction, portable, inexact delivery, given over mins. (15-45 mins.) Pump: expensive, electricity needed, tied to pump (backpack), most education required, reduced labor (set up and go), exact delivery, reduced risk of gi intolerance & aspiration. Continuous, cyclic, intermittent
Slide 36-

Formula Selection 36 Polymeric: available in 1.0, 1.2, 1.5, 2.0 kcal/cc,Higher Fiber, High Protein, Prebiotics (support beneficial bacteria, enhances fluid/electrolyte absorption) Blenderized: Compleat, Liquid Hope/Nourish, Real Food Blends, Kate Farms Issues: Increased cost Insurance coverage Pump issues – viscosity, Infinity only?, Dilution needed? Decreased hang time 4 hrs vs. 8 hrs. open system
Slide 37-

Formula Selection 37 Diabetic/Glucose Intolerance – higher fat/lower carb/with fiber First minimize overfeeding with polymeric/standard Maximize medications Consider diabetic formula if above fails Glucerna, Diabetisource AC Malabsorption – hydrolyzed proteins to peptides, AA No routine use in malabsorption, diarrhea intolerance First examine medications, clinical state, infusion rate/method
Slide 38-

Formula Selection 38 Immune Modulating – omega 3’s/arginine/nucleotides (Impact), omega 3’s/arginine/glutamine (Pivot) surgical, trauma, critical care; head & neck cancer Impact rarely used in home care; Pivot occasionally Pulmonary Failure– 55% kcals fat (PUFA, MCT) COPD, respiratory failure/vent, cystic fibrosis Rarely used in home care Nutren Pulmonary, Pulmocare
Slide 39-

Formula Selection 39 Hepatic Failure – high BCAA:aromatic aa No evidence to support its use Nutrihep Never used in home care Renal Failure – fluid restricted, protein/electrolytes/vits/minerals optimized Designed for dialysis, acute or chronic RF Nepro, Novasource Renal Seen in home care most often in dialysis patients
Slide 40-

Developing the HEN Plan 40
Slide 41-

Developing the HEN Plan 41 Establish feeding access Define short & long-term goals Identify best formula Keep TF regimen simple Round to nearest ½ can if possible Minimize modulars/powders Include realistic water flushes/total additional water needs Begin planning ASAP for discharge Check into insurance coverage Identify who will write HEN orders
Slide 42-

HEN Administration Method 42 Consider pt’s lifestyle & activities/schedules Choose lowest tech method of administration Trial gravity drip or bolus syringe for gastric feeds Trial cycling for jejunostomy feedings Ambulatory pump/backpack if unable to cycle, active lifestyle
Slide 43-

Creating HEN Order 43 Components: Formula, MOA, Access Route, water Flushes: amount before/after feeds, can give every 1-8 hrs. Provide total additional water goal (po/tube) Give progression if needed No residual checks used in home care, only s/s gi tolerance If at risk for Refeeding Syndrome, get lab draw orders arranged
Slide 44-

Refeeding Syndrome: Seen in EN & PN 44 Aggressive PN (especially dextrose) stimulates insulin release intracellular shift of electrolytes and minerals potential for severe hypophosphatemia, hypomagnesemia and hypokalemia Physical symptoms: fatigue, lethargy, muscle weakness, edema, cardiac arrhythmia, respiratory and cardiac failure, aspiration and death
Slide 45-

Identifying Refeeding Syndrome Risk 45 www.nice.org.uk/guidance/cg32/evidence/full-guideline-194889853; accessed 3/25/16.
Slide 46-

Preventing Refeeding Syndrome 46 Correct electrolytes prior to any dextrose administration Take several days to increase to goal, while closely monitoring labs (K, Mg, Phos), I/O’s and weight “Safe Start” ~25-50% estimated needs on Day 1 Dextrose 100-150 g/day or <2 mg/kg/min Protein: < 1.5 gm/kg/day Additional Thiamine (100 mg) Advance PN formula only if electrolytes and clinical status stable, over 3-5 days Fluids: ~1000 ml/day
Slide 47-

HEN Monitoring 47 Weight Hydration Tolerance: nausea, vomiting, diarrhea, constipation, cramping, reflux, abd distention Osmolality, caloric density, MOA, tube placement, absorptive capacity Labs as indicated (Refeeding Syndrome, fingerstick Glucose) Access device function & site care Achievement of goals – short and long-term Readiness to transition to oral
Slide 48-

HEN Complications 48 Mechanical: tube position, clogging, accidental removal Causes - Inadequate/improper flush, med/nutrient interaction Intervention – use only warm tap water, give meds separately & flush afterward, declog with pancreatic enzymes Overfeeding/Underfeeding/Non-compliance Formula Contamination: clean can top, change bag every 24 hrs, wash syringes, hang time (4 hrs. reconstituted or diluted; 8-12 hrs. ready to use)
Slide 49-

HEN Complications 49 Metabolic Dehydration – thirst, skin turgor, UOP changes, BMP Hyperglycemia – monitor Glucose Refeeding Syndrome – BMP, Mg, Phos, & monitor hydration Gastrointestinal Nausea/emesis – meds, illness, too rapid MOA, caloric density, reflux/GERD, constipation Diarrhea – meds/antibiotics, illness, too rapid MOA, caloric density Constipation – check water intake, med changes, add/remove fiber Aspiration – keep HOB>30-45 degrees Vitamin/Mineral Deficiencies
Slide 50-

Patient/Caregiver Education 50 Goal: Enable independence, provide safe/effective home therapy Start teaching inpatient, continue on discharge Teach with supplies & equipment needed at home Provide written reference material Have patient demonstrate competency
Slide 51-

HEN Teaching Checklist 51 Explains rationale for HEN, therapy goals States tube type States site & tube care Describes clean technique States feeding schedule Demonstrates administration of water and feeding
Slide 52-

HEN Teaching Checklist 52 States/demonstrates medication administration States technique for self monitoring and identify potential complications: Weight, measure I/O if needed, temperature, Glucose levels States proper formula storage States whom to contact with questions or in emergency
Slide 53-

HEN Case Study 53 66 yr old Female s/p CVA with Dysphagia, s/p aspiration pneumonia, pleasure feeds only. PMH: DM, osteoarthritis, hyperlipidemia. Had PEG placed yesterday, RD consulted for HEN regimen, daughter caregiver. Meds: Metformin, Motrin, Simvastatin, Doxycycline Ht: 65 in./165.1 cm. Wt: 145 lbs./65.9 kg. Usual BW: 148 lbs. Est Needs: 1650 kcals (25 kcals/kg); 66-79 gms pro (1-1.2 gms/kg); 1650cc water (1cc/kg) TF Regimen Goal: 6 c/day Jevity 1.2 @ 2 c. tid via bolus/syringe via GT with 60cc water flush before, 120cc after each feed, 60cc flush after meds. Provides: 1710 kcals, 79 gms pro, 1685cc water
Slide 54-

HEN Case Study 54 TF Progression: Start with 3c/day given 1 c. tid via bolus/syringe, increase day 2 to 1 ½ c. tid, Day 3 increase to Goal 2 c. tid with flushes as per goal. Pt tolerating TF without nausea, vomiting, stools becoming more frequent/liquid 1-3x/day. Daughter & pt given feeding demonstration at hospital. Gluc ranging 130-160 mg/dL Discharged to home: Pt received delivery and RN visit with teaching completed. One week later home care staff receives call that pt having frequent diarrhea and asks for TF formula change. Home care RD consulted, learns that antibiotic therapy just completed. Confirms pt is receiving adequate water flushes, suggests yogurt orally. Daughter/RD makes MD aware of diarrhea, MD orders stool culture for C Diff, which comes back negative. MD orders Lomotil. Two weeks later f/u reveals pt back to 1-2 liquidy BMs/day while on Jevity 1.2.
Slide 55-

Home Parenteral Nutrition
Slide 56-

HPN Indications 56 GI tract not functioning GI tract cannot be accessed Whose nutritional needs cannot be met with enteral alone When need for PN is > 2 weeks and hospitalization no longer required Covered by insurance In 2002 - estimated 39,000 people in US on HPN Average Treatment Length – 108 days
Slide 57-

HPN Indications 57 Dysfunctional GI tract SBO Paralytic ileus High Output Fistula (>200 ml) Malabsorption Syndromes Short Bowel Syndrome Radiation Enteritis Crohn’s colitis requiring bowel rest Mesenteric ischemia Intractable vomiting Intractable/high volume diarrhea Uncontrolled anastomotic leak
Slide 58-

HPN Contraindications 58 Need is <7-14 days without evidence of severe malnutrition Functioning GI tract Comfort measures only Terminal illness/End stage of life Insufficient PO intake
Slide 59-

Venous Access Devices 59
Slide 60-

PN Components 60
Slide 61-

PN Components: AA 61 Crystalline amino acids Structural component for cells/tissues 4 kcal/gm 15-20% of total calories Estimated needs: 0.8-2.5 gm/kg Essential/ Nonessential AA
Slide 62-

PN Components: Lipids 62 Concentrated, isotonic source of energy Aids in glycemic control Linoleic and linolenic acids cannot be synthesized in body (essential FA) Prevention of EFAD; providing 4-8% total kcal as fat
Slide 63-

PN Components: Lipids 63 LCT: soybean/safflower oil IVFE 10%: 11 kcal/gm, 1.1 kcal/ml IVFE 20% (2 kcal/ml), 30% (3 kcal/ml): 10 kcal/gm SMOF 20%: Soybean/MCT/Olive oil/Fish oil 12 hour hang time CDC recommendation (2-in-1) 24 hour hang time (3-in-1) Should not exceed 0.11 g/kg/hr Max: 30% total kcal or no more than 1 gm/kg (critical care), <2.5 gm/kg/day other Egg allergy-lecithin content* Fish allergy-SMOF* *test dose: 1ml/minute x 30 mins
Slide 64-

PN Components: Lipids 64 Why not use Soybean-based oils? Omega 6 Fatty Acids=pro-inflammatory Phytosterols impair bile drainage Direct effect of lipids on hepatocytes Why use Fish-based oil emulsions? Omega 3 Fatty Acids=reductions in phytosterols and pro-inflammatory mediators
Slide 65-

PN Components: Lipids 65
Slide 66-

PN Components: Alternative Lipids 66 FDA approved in the US: Clinolipid-not yet available Olive Oil (Immunoneutral) + Soy Oil (Baxter) Omegaven Fish Oil (Only available in the U.S. for compassionate use and research for patients with PNALD) Requires special FDA and institutional approval
Slide 67-

PN Components: Dextrose 67 Primary energy source Protein sparing/reduces N2 excretion Minimum for neurological function = 130 g/d 3.4 kcal/gm Dextrose based PN with little or no fat implicated in steatosis Excess CHO - deposit in liver-steatosis Maximum glucose infusion for hospital patient= <5 mg/kg/min Stable hospitalized or home may tolerate >5mg/kg/min
Slide 68-

PN Components: Fluids 68 Needs constantly changing ~1 to 1.5L to support urine output ~500-1000 ml for insensible losses Replace emesis, ostomy, drain output Fever Consider status of CHF, ARF/CRF Consider other sources: IVF, oral, tube feeding 30-40 ml/kg
Slide 69-

Daily Adult Electrolyte Requirements 69
Slide 70-

PN Component: Vitamins 70 Available commercial products 12 or 13 Vitamin K or without Current available MVIs MVI 12 (Hospira) Infuvite adult (Baxter) Cernevit-12 (Baxter) Thiamine 100 mg/day should be added During PN MVI shortages Refeeding Syndrome ETOH abuse has been established
Slide 71-

PN Component: Vitamins 71
Slide 72-

PN Component: Trace Elements 72
Slide 73-

PN Component: Trace Elements 73 Excreted via Urine Chromium Selenium Zinc (also via skin & intestine) Copper (20%) Excreted via biliary tract Copper (80%) Manganese Consider holding/decreasing Copper and Manganese when Bilirubin elevated after checking levels, then monitor levels
Slide 74-

PN Component: Trace Elements 74 All Contaminants: Zinc, copper, manganese, chromium, selenium and aluminum Manganese At risk population – long-term PN patients May lead to manganese deposition in the basal ganglia and neurological symptoms Aluminum At risk population – long-term PN patients and neonate/pediatric patients on PN > 10 days Safe limit is 5 mcg/kg/day Products of most concern are calcium and phosphate salts
Slide 75-

PN Compatible Medications 75 Insulin –Regular human insulin only Octreotide 300 mcg/d H2 Blockers Famotidine 40 mg/d Cimetidine 1200 mg/d Ranitidine 150 mg/d Heparin 1 unit/ml Corticosteroids
Slide 76-

TNA Stability 76
Slide 77-

Glucose Control Issues 77 Hyperglycemia Start with 0.05-0.1 units insulin/gm of dextrose in PN or 0.15-0.2 units insulin/gm of dextrose Add ½ or 2/3 of total amount of sliding scale insulin needed over previous 24 hours to next day’s PN Check BS on PN, not during taper up or down Glycemic Goal: 140-180 mg/dL Hypoglycemia Can occur from abrupt d/c of PN or excessive insulin Avoid by running D10 or 25-50 ml D50-inpatient Avoid by tapering rate down by 1 or 2 hours Check BS 30-45 mins after PN disconnected, monitor for s/s
Slide 78-

HPN Monitoring 78 Lab Draws CMP, Mg, Phos, Trigs, CBC after 1st bag infused if home start, after changes to assess tolerance/needs Usually done weekly until stable, then transition to every 2 weeks or monthly Nutrition Assessments Before home starts, after lab draws to assess tolerance/needs Involve patient, caregiver, RN, Pharmacist, MD Assessments should include weight changes, hydration status, gi symptoms, all intakes/outputs, med changes, labs, compliance Micronutrient draws: Vitamin D, Zinc, Manganese, as per physical assessment, intake history findings. Long-term draw every 6-12 months or prn
Slide 79-

Essential Fatty Acid Deficiency 79 EFAD Determined by triene:tetraene ratio Check annually or if deficiency suspected Can occur 1-3 weeks of lipid-free PN 1-2% daily energy from linoleic acid and 0.3% from linolenic acid 500 ml 10% IVFE or 250 ml 20% IVFE twice/week or 500 ml 20% IVFE once/week Topical EFA application
Slide 80-

80
Slide 81-

Hypertriglyceridemia 81 Goal =<400 mg/dL; < 500 mg/dL for liver-failure patients (non-fasting) Hold lipids when labs exceed these levels Can occur with overfeeding of dextrose IVFE should be <30% total kcal or < 1 gm/kg/day (may prevent PNALD) May impair immune response, alter pulmonary hemodynamics or increase risk for pancreatitis
Slide 82-

Preventing Refeeding Syndrome 82 Correct electrolytes prior to any dextrose administration Take several days to increase to goal, while closely monitoring labs (K, Mg, Phos), I/O’s and weight “Safe Start” ~25-50% estimated needs on Day 1 Dextrose 100-150 g/day or <2 mg/kg/min Protein: < 1.5 gm/kg/day Additional Thiamine (100 mg) Advance PN formula only if electrolytes and clinical status stable, over 3-5 days Fluids: ~1000 ml/day
Slide 83-

Hepatobiliary Complications 83 PN-associated Cholestasis Impaired bile secretion or frank biliary obstruction (pediatrics) Elevated Alk Phos, GGT, Direct Bili >2 mg/dL with or without Jaundice; ~ 3 weeks on PN Gallbladder Stasis Results in sludge or gallstones Lack of EN stimulation and decreased CCK release Impaired bile flow and GB contractility Steatosis (hepatic fat accumulation) Predominant in adults Elevated AST after~ 2 weeks of PN May be due to overfeeding Avoid “fat free” PN
Slide 84-

Hepatobiliary Complications 84 Strategies to manage PN-associated complications Avoid overfeeding Decrease dextrose to < 7gm/kg/day Decrease IVFE to <1 gm/kg/day, give only 3-5 days/week Cycle PN (8-12 hrs) may reduce serum LFTs and bilirubin Reduce by 2 hrs/day (BS abnormalities, fluid issues) or 4 hrs/day Encourage PO and/or TF, even if small amounts or slow rate Hold/decrease Manganese and Copper when Direct Bili >2 mg/dL after checking levels, then monitor levels
Slide 85-

Metabolic Bone Disease-Causes 85 Limited Ca in TNA due to incompatibility with phosphorus Higher urinary Ca losses with: Higher Ca in PN Inadequate phosphorus in PN Higher protein in PN – limit to 1 gm/kg/day if stable Chronic metabolic acidosis associated with hypercalciuria and MBD Vitamin D Deficiency and toxicity result in bone disease Excess Vitamin D suppresses PTH and promotes bone resorption
Slide 86-

Metabolic Bone Disease-Causes 86 Aluminum Toxicity Magnesium Deficiency Results in hypophosphatemia due to increased phosphorus excretion Due to diuretics Copper Deficiency
Slide 87-

HPN Case Study 87 GU is a 58 yo F with Crohn’s Disease referred by MD to start PN at home 30 lbs. weight loss d/t diarrhea 4-5x/day x 3 months Ht: 5’2” Wt: 36.4 kg (80 lbs.) IBW: 49.6 kg Usual Wt: 49.6 kg (110 lbs.) Initial Labs: K=2.7* (sent to ER for K-rider, redraw 3.7); Mg=1.2*, Phos=2.1* PN initiated with higher electrolyte levels on 2/15, labs drawn 2/18: K=2.3*, Mg=1.0*, Phos=2.7, sent to ER 2/19 for K & Mg riders, redraw K=3.6, Mg=1.7 (low). Weight increased to 93 lbs. (up 13 lbs.) *=critically low lab value
Slide 88-

HPN Case Study 88 PN dispensed on 2/20 with higher amounts of K and Mg Blood draw 2/23 K=4.1, then on 2/28 K=5.8, Phos=3.0, Mg=1.9. Weight up to 98 lbs. (total gain 18 lbs.) with fluid retention Weight on 3/1=87 lbs. (down 11 lbs.)
Slide 89-

HPN Case Study 89 Did this patient exhibit Refeeding Syndrome? What went wrong? How could she have avoided another ER visit?
Slide 90-

HPN Case Study - Answers 90 Yes, she exhibited Refeeding Syndrome Oral meds included Lasix, K-dur, Pepcid and Lomotil Never give dextrose unless you have documented normal levels of K, Mg and Phos Always redraw electrolytes after supplementation, with the goal of normalizing them prior to giving dextrose Ideally, draw labs on Day 2, after first full bag of PN infused
Slide 91-

Conclusions 91 Knowledge of therapy complexity Providing HEN and HPN requires a multidisciplinary approach Communication is key Patient safety depends on clinicians knowledge base Dietitian is an indispensible team asset
Slide 92-

References 92 Brantley SL, Mills, ME. Overview of enteral nutrition. IN: Mueller CM, ed., The ASPEN Adult Nutrition Support Core Curriculum, 2nd ed., Silver Spring MD ASPEN 2013:170-184 Medicare Parenteral Nutrition Determination. Centers for Medicare and Medicaid Services website. https://www.cms.gov/medicare-coverage-database/indexes/lcd-alphabetical-index.aspx?DocType=Active&bc=AgIAAAAAAAAAAA%3d%3d&. Accessed August 15, 2016 Cresci G, et al. Enteral Formulations. Bankhead RR, Fang JC. Enteral Access Devices. IN: Mueller CM, ed.,The ASPEN Adult Nutrition Support Core Curriculum, 2nd ed., Silver Spring MD APEN 2013 Malone AM, et al. Complications of Enteral Nutrition. IN: Mueller CM, ed., The ASPEN Adult Nutrition Support Core Curriculum, 2nd ed., Silver Spring MD ASPEN 2013 Bankhead R, et al. Enteral Nutrition Practice Recommendations. JPEN. 2009;33:122-167 www.nice.org.uk/guidance/cg32/evidence/full-guideline-194889853; accessed 3/25/16 Winkler M, Hagan E, Albina J. Home Nutrition Support. IN: Mueller CM, ed., The ASPEN Adult Nutrition Support Core Curriculum, 2nd ed., Silver Spring MD ASPEN 2013:639-655 Krzywda E, et al. Parenteral Access Devices. IN:Gottschlich MM, ed., The ASPEN Nutrition Support Core Curriculum. American Society for Parenteral and Enteral Nutrition 2007
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References 93 Kumpf VJ, et al. Complications of Parenteral Nutrition. IN: Gottschlich MM, ed., The ASPEN Nutrition Support Core Curriculum. American Society for Parenteral and Enteral Nutrition 2007 Mirtallo J, et al; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. J Parenter Enteral Nutr. 2004;28(suppl):39SA-70SA. Erratum 2006;30:177 11. Driscoll D. Lipid Injectable Emulsions. 2006 NCP 21:381-386