‘PN provides liquid nutrients, including carbohydrates, proteins, fats, vitamins, minerals and electrolytes intravenously. It is a sterile liquid chemical formula that is put directly into the bloodstream through an intravenous catheter’
Abnormal bowel function Abnormal bowel function – which can occur due to surgical adhesions or abnormalities in bowel motility – means that food has difficulty moving through the intestines. As such, this can result in a variety of symptoms that prevent adequate food intake.
Short bowel syndrome Patients may either have this from birth or may have had surgery that has removed a significant amount of small intestine. In such cases, there isn’t enough bowel to absorb a sufficient amount of nutrients.
How PN is delivered
PN is delivered through a thin, flexible catheter that has been inserted into a vein. The two main catheter options for delivering PN are:
• A tunneled catheter, such as a Hickman catheter. This type of catheter has a segment of tube outside the skin and another portion tunneled under the skin before it enters the vein.
• An implanted catheter, on the other hand, is inserted completely beneath the skin and needs to be accessed with a needle in order to infuse the PN.
The catheter placement procedure is carried out after the patient has received heavy sedation or anesthesia. The catheter is then inserted into a large vein, which leads to the heart.
Once the procedure is completed, the surgical team uses laboratory testing to monitor the patient’s response to the PN. They also evaluate the fluid balance and catheter site on a regular basis, checking constantly that the patient is able to switch to tube feeding or normal, oral feeding.
Follow-up examinations are carried out to assess the patient’s nutrition plan. Depending on the reason for the PN being required, the care team
may be able to assist the patient in decreasing the amount of PN that they require and, in some cases, help to wean them off it completely.
Solutions for total parenteral nutrition may be customized to individual patient requirements, or standardized solutions may be used.
Types of PN
Prepared solutions Prepared solutions for PN usually consist of water and electrolytes; glucose, amino acids and lipids; essential vitamins, minerals and trace elements are added or given separately. Lipid emulsions used to be given separately, but it is increasingly common for a ‘three-in- one’ solution of glucose, proteins, and lipids to be administered.
Added components On some occasions, individual nutrient components of PN are added to adjust the body contents of it more precisely. Additional nutrients can either be infused individually, or can be injected into a bag of nutrient solution or intravenous fluids, which is given to the patient. If components are administered individually, this can often pose more problems that if they are administered as pre-mixed solutions. That’s because the latter are usually already balanced with regard to their ability to infuse peripherally.
Risks
One common and serious complication of PN is catheter infection, while other potential short- term complications include blood clots, fluid and mineral imbalances, and problems with blood sugar metabolism. On a long-term basis, there may be complications caused by too much or too little of trace elements, such as iron or zinc. Liver disease may also develop. Careful monitoring by healthcare professionals can obviously help to prevent or treat these complications.
• Watch for weight loss: this is not only visible to the eye, but can also be detected by the fact that a patient’s clothes seem to be more loose fitting than normal.
• Does the patient seem to have dry, cracked lips? Or is their mouth pale looking?
• Do they seem to have difficulty speaking due to a dry mouth? • Are they complaining about having false teeth that no longer fit? • Does the patient appear weak or disorientated? • Does their skin appear to be ‘breaking down? Does it seem loose or does it look/feel drier than usual?
The necessary steps to take
The first step is to identify those who you may suspect of being at nutritional risk or potentially at risk, and who may benefit from appropriate nutritional intervention. The most commonly used screening tool is the Malnutrition Universal Screening Tool (MUST), which detects over-nutrition as well as under-nutrition.
Management of malnutrition
In most cases, malnutrition is a treatable condition that can be managed using first-line dietary advice to optimise food intake and oral nutritional supplements (ONS), where necessary.
Dietary advice to optimise oral intake (‘food first’) • Everyday foods such as cheese and full-fat milk should be added to the diet to increase energy and protein content without increasing the volume of food consumed. Further guidance and advice can be obtained from local dietitians.
• Small, frequent meals and snacks, with food and fluids which are high in energy and protein.
Oral nutritional supplements (ONS) to optimise oral intake ONS are typically used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements. They not only increase total energy and protein intake, but also the intake of micronutrients.
ONS come in a range of styles (milk, juice, yogurt, dessert), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre-containing, low volume), energy densities (1-2.4kcal/ml) and flavours. They provide energy along with other essential macronutrients and micronutrients.
Most ONS provide 300kcal, 12g of protein and a full range of vitamins and minerals per serving.
SCOTTISH PHARMACIST - 45
Malnutrition in the elderly
At any one point in time there may be more than three million people in the UK, who are either malnourished or at risk of malnutrition: a situation which costs the UK in excess of £13bn a year. Ninety-three per cent of these people are based in the community and most are elderly.
As such, it’s vital that community pharmacy staff recognise the benefits that their interventions can have on the nutritional status of their patients. Elderly people, particularly those who are housebound or have limited mobility, often don’t have a social support network in place to assist with tasks such as food shopping and cooking. They also tend to be affected by health issues, restricted diets and budget concerns.
How to spot malnutrition
Unfortunately, the signs of malnutrition can be difficult to detect in the elderly, particularly in those who don’t seem ‘at risk’. Nevertheless, uncovering problems at an early stage can help to prevent complications later, so it’s a good idea to make yourself and your staff aware of the signs so that malnutrition can be detected.
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