Long Term Monitoring
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1. This document outlines the long term monitoring of a 23-year old woman who underwent a colectomy for ulcerative colitis and subsequent ischaemic bowel issues requiring multiple surgeries and a jejunostomy. 2. She was discharged on home parenteral nutrition (HPN) with monitoring including regular clinic visits, blood tests, and anthropometric measurements based on ESPEN and other guidelines. 3. Monitoring aims to assess nutrition status and detect deficiencies or toxicities from long term HPN, with the goal of correcting abnormalities and optimizing the patient's health and quality of life. Frequency of monitoring may be reduced once stable in some centers without increasing complication rates.
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Long Term Monitoring
- 1. Long term monitoring Dr Simon Gabe Consultant Gastroenterologist St Mark’s Hospital
- 2. Patient 23 year old lady 1/4/14 Colectomy for UC 3 - 7/4/14 Ischaemic bowel 4 laparotomies Jejunostomy at 35 cm 23/5/14 Weight 39kg (height 162 cm) BMI 14.9kg/m2 (Usual weight in health 51 kg, BMI 19.5 kg/m2)
- 3. Discharged on HPN HPN prescription Volume 3.0L Nitrogen 11g Non-protein 1540kcal Lipid (x2/week) 1000kcal Na 250mmol K 40mmol Ca 4mmol Mg 12mmol Phosphate 15mmol Additrace daily Cernevit alt days Observations at discharge Weight 40kg BMI 15.3kg/m2 MAMC 18.2cm (5th-10th centile) Stoma 2.5L/day Urine 800ml/day Alk Phos 205 IU/L ALT 189 IU/L Bil 30 IU/L Urinary Na 45 mmol/l
- 4. How often do you monitor? Weekly 2 weekly Monthly 3 monthly 6 monthly Initial clinic visits Long term clinic visits Monthly 3 monthly 6 monthly Yearly
- 5. What do others do? ESPEN-HAN working group Questionnaire: 42 centres in 8 countries Wengler et al, 2008 Clin Nutr;25:693
- 6. Blood tests: what do they measure? 0 20 40 60 80 100 Haematology LFTs U&E, creatinine Ca, Mg, PO4 Glucose Lipids Albumin Trace elements Vitamins A, D, E, B12, folate % centres Wengler et al, 2008 Clin Nutr;25:693
- 7. Clinic visit (4 weeks after discharge) 2-3L/day stomal output 1L fluid orally/day Antidiarrhoeal & antisecretory drugs Weight 42 kg BMI 16 kg/m2 MAMC 19.7 cm (25th-50th centile) Alk Phos 236iu/l () GGT 82 iu/l () ALT 150 iu/l (⇔) Bil 25 iu/l () Urinary Na 26mmol/l Observations Lab results What would you do?
- 8. What would you measure every time? Haem & biochem • FBC • U&E, LFT, Ca, Mg, PO4 • CRP, ESR Micronutrients • Ferritin, zinc • Selenium • Copper, manganese Vitamins • B12, folate • A, E, D Urine sodium
- 9. Scottish HPN Managed Clinical Network Frequency of HPN monitoring & consequence for complication rates 141 HPN clinic assessments for 53 patients 16 (30%) were seen every 100d as per guideline 60% reviews were within 100d of previous appointment Duration of HPN treatment inversely correlated with frequency of review Complication rates not increased in HPN patients reviewed less often Hallam et al, 2010 Nutrition doi:10.1016/j.nut.2009.11.0262010 Nutr 1-7
- 10. Scottish HPN managed clinical network Frequency of HPN Monitoring Hallam et al, 2010 Nutrition doi:10.1016 Nutr 1-7 No difference in complication rates between patients reviewed within the recommended time periods and those reviewed less often
- 11. Frequency Measure All visits Biochemistry & anthropometry 6 monthly Trace elements & vitamins Yearly Bone mineral density Clin Nutr 2009, 28, 467-479 ESPEN guidelines on parenteral nutrition HPN in adult patients
- 12. NICE recommendations Initially Once stable Long term Anthropometry Daily Weekly Monthly FBC, Na, K, Urea, Cr Baseline Daily x1-2/week Glucose Baseline Daily Weekly Mg, Phosphate Baseline x3/week Daily if refeeding Weekly LFT Baseline x2/week Weekly Ca, albumin Baseline Weekly Weekly CRP Baseline x2-3/week Zinc, copper Baseline 2-4 weekly 2-4 weekly Selenium Baseline Depends on results Iron, ferritin Baseline 3-6 monthly 3-6 monthly B12, folate Baseline 2-4 weekly 2-4 weekly Manganese 3-6 monthly Vitamin D 6 monthly Bone density Baseline 2 yearly
- 14. What do we do? History Medical illness & QoL Incl drug history Fluid & nutrition: oral & parenteral Thirst, SOB, oedema, urine frequency, diet CVC & homecare issues Examination CVC Exit site, integrity, (tip position) Anthropometrics Weight, BMI MAC, TSF, MAMC, grip strength Investigations Haem & biochem FBC, ESR, U&E, LFT, Ca, Mg, PO4, CRP Micronutri ents Ferritin, Zn, Se, Cu, Mn Vitamins A, E, D, B12, folate Urine sodium
- 15. St Mark’s Initially Once stable Long term Anthropometry (weight) Baseline Daily x2/week 3-4 monthly FBC, Na, K, Urea, Cr Baseline Daily x2/week 3-4 monthly Glucose Baseline Daily x2/week 3-4 monthly Mg, Phosphate Baseline Daily x2/week 3-4 monthly LFT Baseline x2/week x2/week 3-4 monthly Ca, albumin Baseline Weekly x2/week 3-4 monthly CRP Baseline x2/week x2/week 3-4 monthly Iron, ferritin Baseline 3-6 monthly 3-6 monthly 3-4 monthly B12, folate Baseline 2-4 weekly 2-4 weekly 3-4 monthly Vitamin D Baseline 2-4 weekly 3-4 monthly Vitamin A, E yearly Zinc, copper Baseline 3 monthly 6 monthly Selenium Baseline 3 monthly yearly Manganese yearly Bone density Baseline 2 yearly
- 16. Suggestions for monitoring micronutrient deficiency & toxicity Ensure complete nutrition daily (diet & parenteral) Verify adherence to nutrition prescription Routinely assess micronutrient status in long term PN patients Correlate findings with medical history & physical examination Supplement suspected/proven deficiencies and then reassess Monitor for subsequent toxicity after prolonged supplementation Monitor for subsequent deficiency after prolonged omission Monitor laboratory, clinical & physical response to nutrition interventions Guideline Micronutrients in Parenteral Nutrition: Too Little or Too Much? The Past, Present & Recommendations for Future Covers Fe, Zn, Cu, Se, manganese, chromium, iodine, boron, silicon & fluoride, carnitine, choline, vitamins C, D, E, K Buchman et al 2009 Gastroenterology 137, 5, S1-134
- 17. Howard et al, 2007 JPEN;31:388 Normal iron & mildly increased Zn for HPN patients
- 18. Howard et al, 2007 JPEN;31:388 Significantly raised copper & manganese in HPN patients
- 19. Howard et al, 2007 JPEN;31:388 Significantly raised chromium & normal selenium in HPN patients
- 20. What do we do? History Medical illness & QoL Incl drug history Fluid & nutrition: oral & parenteral Thirst, SOB, oedema, urine frequency, diet CVC & homecare issues Examination CVC Exit site, integrity, (tip position) Anthropometrics Weight, BMI MAC, TSF, MAMC, grip strength Investigations Haem & biochem FBC, ESR, U&E, LFT, Ca, Mg, PO4, CRP Micronutri ents Ferritin, Zn, Se, Cu, Mn Vitamins A, E, D, B12, folate Urine sodium