0:04 thank you for joining for part 1 of the
0:07 smart pn video series parenteral
0:09 nutrition appropriateness the general approach
0:09 approach
0:11 I'm Angela Bingham I'm an associate
0:13 professor of clinical pharmacy at the
0:17 Philadelphia College of Pharmacy as we
0:19 begin it is important to recognize that
0:21 parenteral nutrition is one of the most
0:23 notable achievements of modern medicine
0:26 for patients across all age groups and
0:28 the healthcare continuum parenteral
0:29 nutrition has offered a life-sustaining
0:32 option when impaired gastrointestinal
0:34 function prevents adequate oral or
0:37 entral nutrition however we must also
0:40 recognize that parenteral nutrition must
0:42 be directed to appropriate patients
0:44 because it is an expensive form of
0:46 nutrition support and may result in
0:51 adverse events Aspen's parenteral
0:53 nutrition appropriateness task force
0:54 originally sought to identify
0:57 evidence-based indications for proneural
0:59 nutrition therapy however it quickly
1:02 became evident that the strength of the
1:03 literature would not support this
1:06 approach parenteral nutrition research
1:08 primarily represented the lower levels
1:10 of the hierarchy of evidence with narrow
1:13 cohorts rather than robust well-designed
1:16 randomized controlled trials systematic
1:18 reviews and meta-analyses that would
1:21 support grade-level recommendations
1:23 additionally much of the proneural
1:25 nutrition data is old and in many cases
1:27 reflects outdated and suboptimal
1:29 clinical practices for areas of
1:31 management such as class emic control
1:34 over feeding and central line care in
1:36 the past parenteral nutrition
1:38 administration may have appeared to
1:40 contribute to unfavorable clinical
1:42 outcomes due to these practices that
1:46 have improved over time for example the
1:47 initiation of care bundles for the
1:49 insertion and maintenance of central
1:51 venous access devices has reduced
1:54 infection rates also in the literature
1:57 there is sparse data for newer products
2:03 competency and outcomes in the absence
2:05 of high-quality grade-level evidence the
2:07 Aspen consensus recommendations were
2:08 developed by a multidisciplinary Task
2:11 Force of health care professionals these
2:13 consensus recommendations were designed for
2:13 for
2:15 provide guidance to clinicians to
2:18 identify best practices reduce
2:20 variations in practice enhance patient
2:23 safety and provide guidance for clinical
2:25 decisions in the day-to-day dilemmas or
2:28 quandary zuv patient care these
2:30 recommendations are not intended to
2:32 supersede the judgment of the healthcare
2:37 professional the win is parenteral
2:38 nutrition appropriate consensus
2:40 recommendations address proneural
2:42 nutrition based on clinical factors
2:46 rather than specific diagnosis they
2:48 examine parenteral nutrition use in all
2:50 phases of the lifespan and across the
2:53 healthcare continuum one of the goals
2:55 was to inform decisions of additional
2:58 stakeholders such as policy makers and
3:00 third-party payers by giving them a
3:02 sense of the role of proneural nutrition
3:04 and today's healthcare environment as a
3:06 thread woven throughout the
3:08 recommendations interprofessional
3:10 collaboration is essential to safe and
3:12 efficacious use of proneural nutrition
3:14 there should be collaboration that
3:16 crosses professional and departmental
3:21 boundaries in the consensus
3:23 recommendations there are 15 questions
3:24 that address appropriate use of
3:26 proneural nutrition and for overall
3:29 categories identifying candidates for
3:31 proneural nutrition use of proneural
3:33 nutrition in a variety of clinical
3:36 situations promoting optimal proneural
3:39 Nutrition outcomes and research the
3:42 research section is critical to inform
3:45 our future recommendations due to time
3:47 constraints our discussion will focus on
3:49 identifying candidates for parenteral
3:51 nutrition but I invite you to review the
3:54 other areas in the document this will be
3:55 a high-level overview of the
4:00 recommendations we will consider a few
4:01 questions regarding the identification
4:04 of candidates for proneural nutrition as
4:06 I review each statement consider how you
4:08 would handle these situations in
4:10 clinical practice and then we will
4:13 review the consensus recommendations as
4:15 parenteral nutrition ever routinely
4:17 indicated for a specific medical
4:21 diagnosis or disease state is proneural
4:23 nutrition ever the preferred route for
4:27 nutrition what clinical
4:29 determine the feasibility of ntral
4:34 nutrition when enteral nutrition is not
4:35 feasible what is the reasonable
4:37 timeframe for initiating parenteral
4:42 nutrition in practice there's been a
4:44 movement away from medical diagnosis as
4:46 the driver for proneural Nutrition use
4:49 in fact proneural nutrition use is not
4:51 based solely on medical diagnosis or
4:53 disease State there should be a
4:56 comprehensive evaluation and approach
4:58 used to identify the patients who will
5:00 likely benefit from proneural nutrition
5:03 while historically proneural nutrition
5:05 was considered standard of care for many
5:07 gastrointestinal diseases we know that
5:09 parenteral nutrition does not treat any
5:11 specific disease or medical condition
5:14 other than malnutrition clinical
5:15 practice guidelines support the use of
5:18 intro nutrition as the preferred route
5:20 of nutrient delivery when feasible to
5:24 improve clinical outcomes instead our
5:25 focus should be on the clinical factors
5:27 to determine the need for proneural
5:30 nutrition this includes consideration of
5:32 baseline health status and the
5:34 anticipated duration of proneural
5:37 nutrition need before initiating
5:38 proneural nutrition there should be a
5:41 full evaluation of the feasibility of
5:43 using entral nutrition parenteral
5:45 nutrition is reserved for clinical
5:47 situations when ntral nutrition is not
5:50 an option the functional capabilities of
5:52 the gastrointestinal tract is a key
5:55 consideration as you make the
5:57 determination of feeding readiness you
5:58 will inherently account for the
6:01 diagnosis you will evaluate the baseline
6:04 nutrition status are they malnourished
6:06 with a low fat store or malnourished
6:10 with extremely high fat stores
6:12 consideration of the metabolic status of
6:15 the patient and non nutritional aspects
6:17 such as end-of-life considerations in
6:20 many cases parenteral and initial
6:21 nutrition will become necessary either
6:24 together or sequentially along the
6:28 continuum we have established that
6:31 inchul nutrition is always preferred but
6:33 there must be ongoing consideration of
6:35 the clinical scenario to determine if
6:38 enteral nutrition use creates risk there
6:40 are some conditions that are likely to
6:41 require pronoun nutrition
6:44 across the lifecycle related to failed
6:47 or inadequate intro feeding however each
6:49 patient situation must be assessed to
6:52 evaluate intestinal failure versus
6:54 intestinal insufficiency and the level
6:56 of dependence on foreign oil nutrition
6:59 parenteral nutrition dependence can vary
7:01 over time with changes in clinical
7:03 status ordering exacerbations or
7:05 remissions of the underlying
7:08 gastrointestinal condition
7:11 impaired absorption or loss of nutrients
7:13 requiring Ferno nutrition may be seen in
7:15 short bowel syndrome high output
7:18 intestinal fistulas and other conditions
7:21 impacting absorptive capacity mechanical
7:23 bowel obstructions that cannot be
7:25 addressed by medical surgical or
7:27 interventional treatment will require
7:30 parenteral nutrition motility disorders
7:32 from pseudo obstruction or prolonged
7:34 ileus may warrant parenteral nutrition
7:37 if there is failure to tolerate adequate
7:40 oral intake or ntral nutrition in some
7:42 conditions there may be the need to
7:44 restrict oral or intro intake for bowel
7:47 rest we will explore bowel rest further
7:49 lastly there may be an inability to
7:52 achieve or maintain internal access due
7:54 to a variety of clinical circumstances
7:58 including hemodynamic instability active
8:00 gastrointestinal bleeding and severe
8:05 neutropenia fever in some cases there
8:07 may be the need to restrict oral or
8:09 intro intake for bowel rest warranting
8:12 the use of proneural nutrition the
8:14 examples provided within the consensus
8:16 recommendations are listed for your
8:20 review of note advances in practice such
8:21 as improvements in intro access
8:24 specialized intro formulas and protocols
8:26 for intro nutrition administration have
8:28 led to a broader definition of
8:31 functional gut patients with medical
8:33 conditions once thought to require bowel
8:36 rest may receive oral or intro nutrition
8:39 in many cases as one example in severe
8:42 acute pancreatitis enteral nutrition has
8:44 been associated with favorable outcomes
8:46 there's a better risk to benefit ratio
8:48 with intial nutrition compared with
8:49 parenteral nutrition
8:52 however when intro nutrition tolerance
8:54 cannot be achieved proneural nutrition
8:55 should be can
8:59 sidered to determine when ntral
9:01 nutrition is not feasible there must be
9:03 evaluation of clinical factors from
9:05 history physical examination and
9:08 diagnostic evaluations these factors
9:10 allow us to assess the functional status
9:12 of the gastrointestinal tract as
9:15 examples of information found during
9:18 this evaluation if a history is
9:20 suggestive of intractable vomiting or
9:22 diarrhea enteral nutrition may not be an
9:25 option the physical exam may provide
9:26 information about their hemodynamic
9:29 stability from blood pressure assessment
9:30 or abdominal distension may be
9:34 suggestive of bowel obstruction or ileus
9:36 diagnostic tests like abdominal imaging
9:38 can help determine gastrointestinal
9:41 functional impairment of abnormalities
9:43 such as obstruction or perforation or
9:47 seen if there have been multiple failed
9:49 enteral nutrition attempts failure to
9:51 achieve and maintain intro access
9:54 ongoing intolerance of intial nutrition
9:56 perhaps from intractable diarrhea
9:58 despite interventions and
10:00 contraindications to enter access
10:02 parenteral nutrition will need to be considered
10:03 considered
10:06 however as clinicians we must
10:08 re-evaluate gastrointestinal function
10:13 often as a reference the consensus
10:15 recommendations provide a table that
10:17 details absolute and relative
10:20 contraindications to enter all access in
10:23 recent years there have been new and
10:25 innovative techniques for placing and
10:28 securing intro access devices accessing
10:30 the small intestine and visualizing
10:33 intro access device placement less
10:35 invasively that have helped promote a
10:39 broader use of Intel nutrition in
10:41 considering parenteral nutrition
10:43 appropriateness we must consider the
10:46 timeframe for initiating therapy for
10:48 well-nourished stable adult patients who
10:50 have been unable to receive at least 50%
10:53 of estimated requirements by oral or
10:55 ntral nutrition parenteral nutrition
10:59 should be initiated after seven days for
11:01 nutritionally at-risk patients who are
11:03 unlikely to achieve their goal oral or
11:05 intial nutrition parenteral nutrition
11:07 should be initiated within three to five days
11:08 days
11:10 the recommendations to find
11:12 nutritionally at risk as involuntary
11:15 weight loss of 10% of usual body weight
11:19 within six months or 5% within one month
11:21 involuntary loss of ten pounds within
11:25 six months body mass index less than
11:27 eighteen point five kilograms per meter
11:30 squared increased metabolic requirements
11:33 altered diet or inadequate nutrition
11:36 intake including not receiving nutrition
11:39 for more than seven days for patients
11:41 with baseline moderate or severe
11:43 malnutrition in whom oral or intial
11:45 nutrition is not possible or sufficient
11:47 parenteral nutrition should be started
11:51 as soon as feasible in the setting of
11:53 severe metabolic instability the
11:55 initiation of proneural nutrition should
11:56 be delayed until the patient's condition
12:04 in the neonatal population parenteral
12:05 nutrition should be initiated promptly
12:08 after birth and very low weight infants
12:11 who weigh less than 1500 grams
12:13 unfortunately there is insufficient data
12:15 to suggest a specific timeframe for
12:17 parenteral nutrition initiation and more
12:20 mature preterm infants were critically
12:27 ill term neonates as some key takeaways
12:30 recognize that parenteral nutrition is a
12:32 high alert medication that requires
12:34 standardized policies and procedures to
12:35 reduce the risk of clinical
12:38 complications after all the goal for
12:40 parental Nutrition use is to promote
12:43 clinical benefits while minimizing the
12:45 potential risk associated with therapy
12:48 clinical assessment should be used to
12:49 identify candidates for proneural
12:52 nutrition as well as situations in which
12:54 per neural nutrition is not likely to be
12:57 of benefit judicious selection of
12:59 candidates for Ferno nutrition is
13:00 essential because when used
13:02 appropriately proneural nutrition can be
13:04 a life-sustaining option for our
13:08 patients for additional information
13:10 regarding proneural nutrition appropriateness
13:10 appropriateness
13:13 please review Aspen's consensus
13:18 recommendations this presentation is
13:21 brought to you by aspen with educational
