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reflects outdated and suboptimal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