PPN Usage ReviewPPN Usage Review

Tenet MetroWest Medical CenterNatick CampusRenee Brunelle RD

June 12,2002

A.S.P.E.N. Indications for A.S.P.E.N. Indications for Parenteral Nutrition (PN)Parenteral Nutrition (PN)

-- Peritonitis– Intestinal

Hemorrhage– Intestinal

Obstruction – Intractable

Vomiting– TPN not feasable

– Paralytic Ileus– Severe Pancreatitis– Stool Output

>1L/day– High Output Fistula– Short Bowel

Syndrome

PPN is Contraindicated if the PPN is Contraindicated if the Patient:Patient:

• Requires prolonged nutrition support• Is hemodynamically unstable• Is in renal or cardiac failure• Has increased fluid or electrolyte requirements• Has poor venous access• Is considered “comfort measures only”• Patient is well-nourished with hypocaloric

oral/enteral intake <7days

Risks of PPNRisks of PPN

• Thrombophlebitis• Fluid Overload• Electrolyte Imbalances• Glucose Intolerance• Line Infection

Study GuidelinesStudy Guidelines

• 6-Month restrospective study of PN usage• Male and female admits to MWMC Natick• N=97 Aged 34-95• Excluded: 17 TPN patients; TCU, 6 North,

and 4 South• Appropriateness was based on A.S.P.E.N.

guidelines and PPN use of five days or more ( PPN over 20 days was also counted)

Study GuidelinesStudy Guidelines• Did the patient have gut function?• Was enteral feeding attempted?

– If no, why?• How many days on PPN?• Patient’s prognosis?• Was nutrition consulted?• Were nutrition’s recs taken?• Metabolic/physical complications?

ResultsResults

• Of n=80, 63 patients had gut function• Enteral nutrition was attempted with 10 pts• Of the 70 that EN was not attempted:

– 8 Ileus/SBO -3 PO -1 Ascites– 9 N/V/D -4 Family -7 Unknown– 6 Pancreatitis -2 Esoph CA– 17 GIB/Abd pain -13 Asp risk

ComplicationsComplications

• Metabolic– Hyperglycemia (n=5)

– Hypernatremia (n=5)

– Hyperkalemia (n=5)

– Hyponatremia (n=4)

• Physical– CHF (n=1)

– Candida (n=2)

– Phlebitis (n=1)

– Sepsis of unknown source (n=1)

ResultsResults

• Of n=80, PPN use was appropriate by ASPEN criteria for diagnosis in 54 patients

• Of these patients 28 were not appropriate because PPN was used <5days

• 17 pts were on PPN >7 days (3 = >20 days)• 4 pts were CMO. 5 pts had poor prognosis• 26 of all patients were appropriate (32%)• 54 of all patients were not appropriate (68%)

ResultsResults

• Metabolic complications were 36%• Physical complications were 8%• Rate of nutrition consults 23%• Cost of preventable PPN:

– 54 patients (188 days) x 2 L (avg use) x $13.60/L = $5,114 in 6 months

• This does not consider the cost of line placement, pharmacist’s time, and inventory carrying cost

Prevention of Inappropriate UsePrevention of Inappropriate Use

• Education of Physicians on PPN guidelines

• Automatic RD consult when PN ordered

• Use of post-pyloric nasogastric feeding for patients with aspiration risk

ReferencesReferences

• A.S.P.E.N. Board of Directors: Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 17 (4):1SA-52SA,1993

• Stokes MA, Hill GL: Peripheral parenteral nutrition: A preliminary report on its efficacy and safety. JPEN 17(2);145-147.1993

• Trujillo EB, Young LS, Chertow GM: Metabolic and monetary costs of avoidable parenteral nutrition use. JPEN23(2):109-113.1999