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LRI Children’s Hospital Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline (Part 2 of 3) Staff relevant to: Medical, nursing, pharmacy, dietetic staff Team approval date: October 2019 Version: V 2 Revision due: April 2023 (6 month extension given following Chair’s approval) Written by: David Harris, Dr Hemant Bhavsar, Dr Anne Willmott, R. Zseli, Kristian Bravin Trust Ref: C43/2018 Acknowledgement: This document is based on the extensive review by Ghazala Javid and the Paediatric Gastroenterology Team over the last 15 years Contents Section 3: Monitoring ........................................................................................................... 3 Biochemical Monitoring ..................................................................................................... 4 Adjustments based on Blood Results ................................................................................ 5 Physical Assessment ......................................................................................................... 5 Section 4: Troubleshooting .................................................................................................... 5 Refeeding syndrome ......................................................................................................... 5 Refeeding Syndrome Prevention ....................................................................................... 6 Prophylactic vitamins ......................................................................................................... 8 Metabolic complications .................................................................................................... 9 Hypoglycaemia ............................................................................................................. 10 Hyperglycaemia ............................................................................................................ 10 Hypertriglyceridemia ..................................................................................................... 10 Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline Trust Ref: C43/2018 Page 1 of 22 V: 2 Approved by Children’s Clinical Practice Group : October 2019 Next Review: April 2023 6 month extension given following Chair’s approval NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library Metabolic acidosis ......................................................................................................... 11 Cholestasis ................................................................................................................... 11 In acute sepsis, significant acidosis, liver derangement ................................................ 12 Line Infection Prophylaxis (inc Taurolock) and Treatment ............................................. 12 Chylothorax ................................................................................................................... 13 Failure to thrive whilst on PN......................................................................................... 14 Section 5 - Administration Issues ...................................................................................... 14 Unavailability of PN ....................................................................................................... 14 Increased fluid requirements ......................................................................................... 14 Line Failure ................................................................................................................... 15 Medication incompatibilities .......................................................................................... 15 Preterm and term infants .................................................................................................. 15 Children ............................................................................................................................ 16 Appendix 1 – Information Sheet for Weaning TPN ............................................................ 21 INFORMATION SHEET FOR WEANING TPN .................................................................... 21 Rates to be prescribed on the drug chart for each 24 hour period ................................ 21 Appendix 2 - How to calculate reduced infusion rates of paediatric TPN........................... 22 1. Introduction and who Guideline applies to Parenteral nutrition (PN) is nutrition that is delivered to the circulation without using the gut. It is complex and expensive. A multidisciplinary approach to the management of these patients is needed to optimise therapy and reduce complications. Close liaison between the patient’s clinical team and the ward Dietician or Paediatric Gastroenterologist on service is vital to achieve optimum care. This guideline applies to all Health Professionals who administer PN to Neonates, Infants, Children and Young People cared for in UHL Childrens Hospital, including those aged 16-25 on Ward 27 (Teenage, Young Adult Cancer Unit) or in EMCHC. Young adults aged 16-18 years who are being cared for on all other UHL wards requiring PN should be referred to the Leicester Intestinal Failure team (LIFT) Related documents: • Adults - please see Policy for the Administration of Parenteral Nutrition via a Central Venous Catheter in Adults B22/2015 • NNU Neonates - please see Neonatal Parenteral Nutrition Guidelines C28/2018 UHL Parenteral Nutrition in Children - Initiation – referral, ordering, prescribing and administration Trust ref: C42/2018 Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline Trust Ref: C43/2018 Page 2 of 22 V: 2 Approved by Children’s Clinical Practice Group : October 2019 Next Review: April 2023 6 month extension given following Chair’s approval NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library UHL Parenteral Nutrition in Children - Supporting Information Trust ref: C44/2018 UHL Procedure for Administering Parenteral Nutrition in Babies, Children and Young People Trust ref: C45/2018 Guideline to identify and manage paediatric inpatients who are at risk of refeeding syndrome. Trust ref: B19/2019 2. Guideline Standards and Procedures When considering using TPN for your patient there are a few questions to answer to demonstrate the benefits outweigh the risks of treatment There are 3 Children’s Hospital Parenteral Nutrition guidelines available (see above related documents): • Part 1 Initiation – referral, ordering, prescribing and administration o Indication Will TPN be beneficial? o Vascular Access Is a central line present or planned? o Nutritional requirements Is there enough volume available? • Part 2 - Ongoing care – Monitoring, troubleshooting and weaning o Monitoring Are these assessments feasible? o Troubleshooting What can go wrong? • Part 3 - Information – Appendices of forms and basis for advice Section 3: Monitoring All monitoring of the patient is the responsibility of the doctors on the clinical team looking after the patient. Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline Trust Ref: C43/2018 Page 3 of 22 V: 2 Approved by Children’s Clinical Practice Group : October 2019 Next Review: April 2023 6 month extension given following Chair’s approval NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library Biochemical Monitoring Monitoring is necessary to identify those patients with, or at risk of, electrolyte disturbances. Parameters Baseline on day 1 Week 1 Week 2, 3 and 4 commencing TPN Sodium, All to be done daily All to be done daily All to be done daily if unstable, potassium, urea, otherwise all parameters to be creatinine done thrice weekly for week 2. Blood glucose On week 3 all parameters checked once a week if stable Triglycerides Triglycerides are to be measured daily Measurement of random urine Calcium while increasing sodium and potassium is (albumin also lipids recommended to explain the done routinely), cause/s of hypo/hypernatraemia phosphate, or hypo/hyperkalaemia magnesium LFTs Fe, Zn, Se, Cu, Ferritin, Iron, zinc, selenium, Cr, Mo, copper, chromium and molybdenum monthly Check zinc sooner if poor weight gain against expected FBC To be done daily To be done daily To be done daily if unstable, otherwise to be done three times a week for week 2 Clotting screen To be done daily Do on day 3 and 5 Do once a week, unless unstable Urinalysis To be done daily To be done twice a Weekly for week 2 then as week needed by electrolyte requirements Weight To be done daily To be done twice a To be done twice a week for < 1- week for < 1year year old patients , unless old patients , unless unstable unstable Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline Trust Ref: C43/2018 Page 4 of 22 V: 2 Approved by Children’s Clinical Practice Group : October 2019 Next Review: April 2023 6 month extension given following Chair’s approval NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library
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