Dietitian’s Role in Dietitian’s Role in HPNHPN

Kirstine Farrer, Kirstine Farrer,

Consultant Dietitian – Intestinal Consultant Dietitian – Intestinal FailureFailure

Intestinal Failure Unit, Hope Intestinal Failure Unit, Hope Hospital, Salford, ManchesterHospital, Salford, Manchesterkirstine.farrer@srht.nhs.ukkirstine.farrer@srht.nhs.uk

Home Parenteral NutritionHome Parenteral Nutrition

• Nutritional &/or water/electrolyte Nutritional &/or water/electrolyte imbalance that cannot be corrected imbalance that cannot be corrected by enteral feeding by enteral feeding

• Acute (type 2) or chronic (type 3) Acute (type 2) or chronic (type 3) intestinal failureintestinal failure

• PN feasible at homePN feasible at home PatientPatient FamilyFamily Healthcare professionalsHealthcare professionals

HPN - indicationsHPN - indications

Type 2 Intestinal Failure – short term Type 2 Intestinal Failure – short term Pending Pending

spontaneous recovery (e.g. some fistulas)spontaneous recovery (e.g. some fistulas) intestinal reconstructive surgeryintestinal reconstructive surgery death (some cancer patients)death (some cancer patients)

Type 3 Intestinal Failure - long termType 3 Intestinal Failure - long term Pending Pending

intestinal adaptation?intestinal adaptation? small bowel transplantation?small bowel transplantation?

IF AetiologyIF AetiologyAdmitted patients (1999-2006)Admitted patients (1999-2006)

0

5

10

15

20

25

30

35

40%

pa

tie

nts

Hope

St Mark's

All Treated Patients All Treated Patients Regional Data (2005/6)Regional Data (2005/6)

0

20

40

60

80

100

120

No

. p

atie

nts

Hope

St Mark's

HPN centresHPN centres Hope 132Hope 132

St Mark’s 105St Mark’s 105

Royal Victoria, BelfastRoyal Victoria, Belfast

Cardiff/Swansea/Cardiff/Swansea/

WrexhamWrexham

OxfordOxford

Cambridge (SB Tx)Cambridge (SB Tx)

Royal LondonRoyal London

SouthamptonSouthampton

BristolBristol

Dudley (DGH)Dudley (DGH)

LeicesterLeicester

LiverpoolLiverpool

NewcastleNewcastle

NottinghamNottingham

SheffieldSheffield

LeedsLeeds

The Patients’ Views The Patients’ Views (PINNT)(PINNT)

Mean Distance for Routine check: 84 Mean Distance for Routine check: 84 (240) & for emergencies:71(400)(240) & for emergencies:71(400)

Average cost/trip: £16.48 (£230)Average cost/trip: £16.48 (£230) Accompanied: >50%Accompanied: >50% Local care out of Hours: 63%Local care out of Hours: 63% Dissatisfied: 30%Dissatisfied: 30% Would like service nearer home – Would like service nearer home –

78%78%

OutcomeOutcomeNew patientsNew patients

HopeHope St Mark’sSt Mark’s

UKUK WalesWales %% UKUK WalesWales %%

DischargeDischarged homed home

HPNHPN 2424 33 5555 2424 00 4343

S/c S/c fluidsfluids 00 00 00 33 00 55

Artificial Artificial enteralenteral 44 00 99 33 00 55

Oral Oral alonealone 1212 11 2727 2222 11 4242

DiedDied 44 00 99 00 00 00

Transfer (hospital)Transfer (hospital) 00 00 00 33 00 55

Demographic DetailsDemographic Details

132 HPN patients at Hope132 HPN patients at Hope mean 50 years (range 18-78 years)mean 50 years (range 18-78 years) 79 female79 female Mean length of time on HPN 5.4 Mean length of time on HPN 5.4

years (range 0 -25years)years (range 0 -25years) Mean No of nights on HPN=5Mean No of nights on HPN=5

The two most common types of The two most common types of short bowelshort bowel

Jejuno-colic Jejuno-colic anastomosisanastomosis

Ileum and some of Ileum and some of jejunum resected jejunum resected leaving jejuno-colic leaving jejuno-colic anastomosisanastomosis

JejunostomyJejunostomy Colon, ileum and some Colon, ileum and some

of jejunum resected, of jejunum resected, leaving a jejunostomyleaving a jejunostomyJejunocolic anastomosis Jejunostomy

Fistuloclysis/Distal Feeding – a new HETF Fistuloclysis/Distal Feeding – a new HETF indication?indication?

Multidisciplinary teamMultidisciplinary team

•MDT ward rounds involving patients as a team player

Multidisciplinary Team for Multidisciplinary Team for HPN Clinic – the patient’s HPN Clinic – the patient’s journeyjourney

DietitianDietitian Nurses Nurses (Psychologist) (Psychologist) PharmacistPharmacist BiochemistBiochemist Clinical DirectorClinical Director Surgical and Medical RegistrarsSurgical and Medical Registrars

Nutritional RequirementsNutritional Requirements

Nitrogen 0.17-0.2gN/kg/dayNitrogen 0.17-0.2gN/kg/day 150-350g Glucose / day150-350g Glucose / day <1g fat /kg lipid / day<1g fat /kg lipid / day Fat soluble vitamins 1-2/ weekFat soluble vitamins 1-2/ week Water soluble vitamins Water soluble vitamins MineralsMinerals

HPN – dietetic monitoringHPN – dietetic monitoring

WeightWeight

HeightHeight

BMIBMI

MACMAC

TSFTSF

MAMCMAMC

CommenCommentsts

Nutritional Status of HPN Nutritional Status of HPN PatientsPatients

Weight Median 60kg (Range 41-94kg)Weight Median 60kg (Range 41-94kg)

BMI Median 22.5 (Range 15-30)BMI Median 22.5 (Range 15-30)

TSF Median 11mm (Range 2.8-22)TSF Median 11mm (Range 2.8-22)

MAC Median 27cm (Range 18-42cm) MAC Median 27cm (Range 18-42cm)

MAMC Median 23.6cm (Range 17.2-34)MAMC Median 23.6cm (Range 17.2-34)

Oral IntakeOral Intake

Actively encouraged – Actively encouraged – psychological and physiological psychological and physiological reasonsreasons

Improves QOL / social interactionImproves QOL / social interaction Decreases biliary sludge and Decreases biliary sludge and

promotes intestinal adaptation - promotes intestinal adaptation - may result in a reduction of HPN.may result in a reduction of HPN.

Biochemistry MonitoringBiochemistry Monitoring

3/123/12 FBC, bone, liver profilesFBC, bone, liver profiles Cu, Zn, Se, Vitamin D statusCu, Zn, Se, Vitamin D status CRP, ESRCRP, ESR FerritinFerritin Coagulation ScreenCoagulation Screen

Incidence of HPN related Incidence of HPN related MBD MBD

Incidence is unknown but reports range Incidence is unknown but reports range from 40-100%.from 40-100%. Analysis has shown a reduced bone Analysis has shown a reduced bone

formation rate in most patientsformation rate in most patients

No clear answer- most likely to be a No clear answer- most likely to be a combination of causescombination of causes

General and lifestyle factors- age, General and lifestyle factors- age, menopause, alcohol and tobaccomenopause, alcohol and tobacco

Other drugs- corticosteriods, heparin, Other drugs- corticosteriods, heparin, tinzaparin.tinzaparin.

Underlying disease-Underlying disease- Malabsorption of Ca, Mg and Vit D in Malabsorption of Ca, Mg and Vit D in

IBDIBD

Summary of Clinical TrialsSummary of Clinical Trials

Pironi et al (2002)- Bone Mineral Density, 165 Pironi et al (2002)- Bone Mineral Density, 165 patients, MBD seen in 84% of pts, 35% had bone patients, MBD seen in 84% of pts, 35% had bone pain and 10% had fractures.symptoms. No pain and 10% had fractures.symptoms. No difference seen between primary diseases. Age of difference seen between primary diseases. Age of starting TPN and BMI main factors to predict starting TPN and BMI main factors to predict morbidity. morbidity.

The studies suggest anywhere from immediately The studies suggest anywhere from immediately up to three yearsup to three years

Shaffer et al- 52 pts- review of bone scans in HPN Shaffer et al- 52 pts- review of bone scans in HPN pts.pts.

Average significant reduction of bone mass was ~ Average significant reduction of bone mass was ~ 2years.2years.

Guidelines recommend baseline scan and then Guidelines recommend baseline scan and then yearly. (ASPEN)yearly. (ASPEN)

Parenteral Nutrition + Liver DiseaseParenteral Nutrition + Liver Disease

Shaffer and Lumen (2002) Shaffer and Lumen (2002)

Retrospective Study of 107 case notes. Median Retrospective Study of 107 case notes. Median duration of HPN was 40 months. The main duration of HPN was 40 months. The main underlying diagnoses were Crohns Disease (40%) underlying diagnoses were Crohns Disease (40%) and ischaemic bowel (28%). and ischaemic bowel (28%).

Derranged LFTs were defined as 1.5 times above Derranged LFTs were defined as 1.5 times above the reference range, at least 6 months after the reference range, at least 6 months after initiation of HPN. Persistently abnormal LFTs initiation of HPN. Persistently abnormal LFTs were present in 39% adult patients on long-term were present in 39% adult patients on long-term HPN. HPN.

• Clinical Nutrition 2002; 21(4): 337-43.

Parenteral Lipid and Hepatic Parenteral Lipid and Hepatic DysfunctionDysfunction

Lipid emulsion >1g/kg Lipid emulsion >1g/kg increased hepatic increased hepatic

dysfunction (retrospective).dysfunction (retrospective).11

MCT/LCT emulsions rather than LCT alone MCT/LCT emulsions rather than LCT alone

more efficient oxidative metabolism more efficient oxidative metabolism

reduce hepatic dysfunction?reduce hepatic dysfunction?22

(In practice, only (In practice, only lower lower

serum bilirubin).serum bilirubin).33

Olive oil-based lipid emulsion (case report: Olive oil-based lipid emulsion (case report:

improvement in LFTs possibly due to improvement in LFTs possibly due to

vitamin E content?).vitamin E content?).441. Ann Intern Med 2000; 132: 525-32 2. JPEN 1991; 15: 601-33. Clin Nutrition 1998; 17: 23-94. Clin Nutr 2004; 23: 1418-25

Preventing & Treating Preventing & Treating TPN-associated Liver DiseaseTPN-associated Liver Disease

Encourage oral intake!Encourage oral intake!

Avoid Dextrose Overfeeding (<40kcal/kg/d)Avoid Dextrose Overfeeding (<40kcal/kg/d)

Reduce Fat Calories (<1g/kg/d)Reduce Fat Calories (<1g/kg/d)

Cyclical PNCyclical PN

CholineCholine

Liver/Small Bowel TransplantLiver/Small Bowel Transplant

? Total intravenous calorie intake

JPEN 2002; 26(5): S43-8.

HPN – case studyHPN – case study

35 year old male – Mr W35 year old male – Mr W Admitted to IFU in May 2002Admitted to IFU in May 2002 Diagnosis – mesenteric volvulusDiagnosis – mesenteric volvulus Remaining small bowel – 30cm of Remaining small bowel – 30cm of

jejunum and 10cm of ileum, jejunum and 10cm of ileum, brought out as a jejunostomy and brought out as a jejunostomy and mucous fistulamucous fistula

HPN Case StudyHPN Case Study

Social history – engineer, married, Social history – engineer, married, wife just had a baby and interests wife just had a baby and interests include running marathons!include running marathons!

Physical examination – thin and Physical examination – thin and jaundicedjaundiced

Alk phos 160, ALT 480 and bilirubin Alk phos 160, ALT 480 and bilirubin 7676

Otherwise haemodynamically stableOtherwise haemodynamically stable

Dietetic AssessmentDietetic Assessment Weight 56.6kg (Weight history – 63kg)Weight 56.6kg (Weight history – 63kg) BMI 19.6BMI 19.6 MAC 26cmMAC 26cm TSF 10.6mmTSF 10.6mm MAMC 22.7cmMAMC 22.7cm Nutritional Requirements – 2100kcals and Nutritional Requirements – 2100kcals and

11gN11gN

Not eating – “too scared” increased his Not eating – “too scared” increased his outputoutput

Dietetic PlanDietetic Plan

Low fibre dietLow fibre diet Glucose-saline drink 1litre /dayGlucose-saline drink 1litre /day Restrict hypotonic fluidsRestrict hypotonic fluids Commence on PPN until line Commence on PPN until line

cultures come back clear (3L, cultures come back clear (3L, 1800kcals and 9gN)1800kcals and 9gN)

PLANPLAN

HPN training and home, trained quickly, HPN training and home, trained quickly, home by 24home by 24thth July. July.

Drugs on discharge – loperamide 6mg Drugs on discharge – loperamide 6mg qds,qds,

codeine PO 60mg qds and omeprazole codeine PO 60mg qds and omeprazole 80mg bd80mg bd

Reconstructive surgery at a later date to Reconstructive surgery at a later date to close jejunostomyclose jejunostomy

HPN px on dischargeHPN px on discharge

2/7 fat 3.5L bag2/7 fat 3.5L bag 2200kcals, 11gN, 244mmol Na, 2200kcals, 11gN, 244mmol Na,

50mmol K, 9mmol Ca 11mmol Mg, 50mmol K, 9mmol Ca 11mmol Mg, 27.7mmol PO, additrace and 27.7mmol PO, additrace and cernevitcernevit

5/7 glucose bags – 3.5L5/7 glucose bags – 3.5L 2200kcals, 13gN, + same 2200kcals, 13gN, + same

electrolytes + additrace electrolytes + additrace

HPN – dietetic monitoringHPN – dietetic monitoring19.5.0219.5.02 20.8.0220.8.02 19.11.019.11.0

2216.1.0316.1.03 2.12.032.12.03

WeightWeight 56.656.6 54.454.4 6060 6767 70.870.8

HeightHeight 1.721.72 1.721.72 1.721.72 1.721.72 1.721.72

BMIBMI 19.619.6 18.418.4 20.320.3 2323 23.823.8

MACMAC 2626 25.525.5 27.527.5 2929 30.530.5

TSFTSF 10.610.6 1010 13.813.8 15.815.8 15.815.8

MAMCMAMC 22.722.7 22.422.4 23.223.2 2424 25.525.5

CommenCommentsts

7/7 7/7 PNPN

IncreasIncrease kcals e kcals + N+ N

SurgerSurgeryy

25/1125/11

5/7 5/7 PNPN

2/7 2/7 PNPN

‘ No man is really an accomplished physician or surgeon who has not made dietetic principles and practice an important part of his professional education’

SIR HENRY THOMPSON, F.R.C.S, 1897