St Mark's IF with AuSPEN 30 - 31 October 2015

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

13. Other NICE recommendations

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