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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
Page 1
ParenteralNutritionGuidelines
Adults)
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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
Page 2
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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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
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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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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
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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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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
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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
Ext. 21653 or Bleep 1749
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
Ext 21653 or Bleep 1953
Nicola York Clinical Nurse Specialist -
LIS
Ext 21653 or Bleep 1530
Cathy Hartley-Jones Clinical nurse Specialist
LIS
Ext. 21653 or Bleep 1797
Gill Siuda Clinical Nurse Specialist
EN (Enteral Nutrition)
Ext 40378 or Bleep 1972
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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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Parenteral Nutrition Guidelines Version 2.7 August 2004 (revision date August 2005)
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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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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