Newsletter of the Parenteral and Enteral Nutrition Group of the British Dietetic Association

ISSUE 28 2006

PEN Group information website: www.peng.org.uk BAPEN Clinical nutrition website: www.bapen.org.uk

INSIDE…

PEN Group Summer Meeting 2006, NPSA Patient Safety Alert and more…

Coming soon...

BAPEN Conference 2006 Brighton

PEN GroupSummerMeeting

2006 London

Current controversies in nutrition support

PEN Group Committee August 2006

Dear members

Welcome to this Autumn issue of Penlines. It has been a busy few months since the last issue with

the publication of the long awaited NICE guidelines for Nutrition Support and the ESPEN enteral

nutrition guidelines providing us with some food for thought. Both documents received some

attention at the PEN Group Summer Meeting this year. The Group was delighted to have such good

support for the Summer Meeting, held again this year in London. Given the current climate with

many Trusts in serious financial difficulty, it was great to see the meeting so well supported.

Well done to Carole Anne McAtear and Sarah Whittington and all the committee for their

contribution to making the event so successful. Inside this issue we have a summary report on the

meeting. For further information see the Group’s website where all speakers presentations will be

posted. Also in this issue we have a very informative report on a forthcoming patient safety alert

from the NPSA that will have a big impact on all nutrition support dietitians.

If you have any comments or feedback on the newsletter’s content or any reports or articles that you

would like to communicate with our readers, just send me an email (note contact details below).

Happy reading.

Dr Paula Murphy

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Dr Paula MurphyNutrition and Dietetics Dept.Plymouth Hospitals NHS TrustDerrifordPlymouth PL6 8DH

Email: paula.murphy@phnt.swest.nhs.uk

Closing date for next edition31 February 2007

Address for correspondence:

The PEN Group would like to thank Nutricia Clinical Care for their financial support in sponsorship and distribution of PENlines,

and Fox Design Consultants (www.foxdc.co.uk) for their help with design and publication. Thanks also to Merck who kindly supplied the tube feeding

product images for the NPSA Alert article on pages 6 and 7.

Note The views expressed in PENlines are those of the individuals concerned and not necessarily the official views of the BDA. Items in PENlines are

for the guidance of the PEN Group members of the BDA: before using any information, members are advised to seek the advice of manufacturers.

ACKNOWLEDGEMENTS

Name Position Email

Pete Turner CHAIR of PEN Peter.Turner@rlbuht.nhs.ukBAPEN council

Vera Todorovic Membership Secretary of PEN vera.todorovic@dbh.nhs.ukBAPEN council judy.beeston@dbh.nhs.uk

Jo Prickett Treasurer Joanna.pricket@nbt.nhs.uk

Carole Anne McAtear BDA Liason caroleanne.mcatear@sgh.scot.nhs.ukMeetings Organiser

Catriona McMaster Education catriona.mcmaster@sgh.scot.nhs.ukWebsite monitor

Alex Leckie Website monitor alex.leckie@rothgen.nhs.uk

Sarah Whittingham Meetings Organiser Sarah.Whittingham@sebt.n-i.nhs.uk

Paula Murphy Award Co-ordinator paula.murphy@phnt.swest.nhs.ukPENlines Editor

Ailsa Kennedy Clinical Update ailsa@geoffholdgate.wanadoo.co.uk

Clare Soulsby Clinical Update c.t.soulsby@qmul.ac.uk

Penlines 28 3

The PEN Group organises an ongoing programme of training andpublications designed to support all members of the BDA involved in treating clinical nutrition. For those of you who join the PEN Group there are also a wide variety of additional benefits.

For an annual sum of £25 you are entitled to:

• Subsidised rates at PEN Group meetings and The Clinical Update Course

• Subsidised rate for the Pocket Guide to Clinical Nutrition and free complete handbookcontaining 4 new updated sections for 2006/2007 members

• 2 clinical meetings per year (one at BAPEN)

• Automatic membership of BAPEN, plus dietetic representation at BAPEN

• 2 copies a year of PENlines including abstracts from meetings and clinical reviews

• PEN Group website www.peng.org.uk

• PEN Group Award £1000 for an outstanding abstract to be presented at BAPEN

• CPD opportunity to serve on the committee or work with them on individual projects.

To join...simply complete the slip below and send to: Judy Beeston, Dietetic Department,Bassetlaw Hospital, Worksop, S81 OBD, by 1st November 2006.

Calling AllNorthern IrelandDietitians! How to get your voice heard !!!

As the Chair of the NI Board of the BDA(NIBBDA) I want to ensure that anyconsultation responses made by theNIBBDA include the expertise of localdietitians. We have therefore beendeveloping a Specialist Groups’ map forNI to identify key contacts who cancascade information within theirSpeciality e.g. Chairs of regional groupsor BDA Specialist Groups.

WE NEED YOU!It would be incredibly helpful if wecould establish a key contact for PENGroup in NI as well as an email networkso that information could be shared andexpert opinion provided to the NIBBDA.

Q Do you want to be consulted about relevant DHSSPSNI documents and the NIBBDA responses?

Q Would you be interested in joining an email network?

Q Would you be willing to be the key contact person for NI?

Q It would be incredibly helpful if we could establish a key contact for PEN Group in NI as well as an email network so that information could be shared and expert opinion provided to the NIBBDA.

Q Do you want to be consulted about relevant DHSSPSNI documents and the NIBBDA responses?

Q Would you be interested in joining an email network?

Q Would you be willing to be the key contact person for NI?

If you answered YES to any of thesequestions please make contact with mevia the NIBBDA email address:northernirelandboard@bda.uk.com

I look forward to hearing from you!

Elizabeth McKnightNI Constituency Council Member

Why be a PEN Groupmember?

PEN Group Membership ApplicationPlease enclose a cheque or postal order for £25,made payable to PEN Group

Name

Current work address

E mail address

Job Title/Role

Current PENG registration number (if existing member)

✃

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This year’s Summer Meeting was held inLondon House and proved to be verysuccessful with a total of 130 delegatesover 2 days. A wide range of topics werecovered including energy requirements,NICE guidelines for Nutrition Support ,parenteral nutrition, ethics of feeding,intestinal failure, drug nutrientinteractions and the forthcomingpatient safety alert soon to be releasedby the NPSA. The evaluation revealedthat the majority (93%) of delegatesenjoyed the days and plan to makesome change to practice as a result ofattending. Alex Leckie and myself havesummarised the sessions on each daybelow. Full presentations will beavailable on the PENG website.

Day 1by Dr Paula MurphyTeam LeaderNutrition Support DerrifordHospital, Plymouth

Dr Liz Weekeschaired themorning session. Lizis the PracticeDevelopment andClinical ResearchLead at Guy’s andSt.Thomas NHS TrustLondon. Both Liz and ClareSoulsby were responsible for updating the‘estimation of nutritional requirements’section of the PENG handbook andconsequently Liz was invited to speak onthis topic. Her session entitled‘Introduction to current controversies inthe estimation of energy requirements’examined the methods of measuringenergy expenditure and their limitations.Liz emphasised the importance ofexamining the literature on energyrequirements in individual patient groupsand checking its applicability to your own

patients. There are considerable gaps inthe literature in this particular area.Dietitians need to be more activelyinvolved in research and auditprojects to reduce the gaps in ourknowledge.

The second session of the morningwas a debate where Pete Turner andClare Soulsby discussed the ability andneed to estimate energy requirements inthe critically ill. Pete, a Specialist CriticalCare Dietitian in the Royal LiverpoolUniversity NHS Trust, argued against themotion while Clare, Chief Dietitian at theRoyal London Hospital, argued in favour.Pete suggested that it is impossible tocalculate requirements accurately withthe huge variation in results obtainedfrom existing methodology. We cannotequate energy expenditure with energyrequirements in this patient group.

Instead we should be monitoring keyparameters closely and adjusting as

appropriate. Clare discussed howrequirements are calculated inthe critically ill andacknowledged a potential forerror of –15% to 100%, howeverthis can be reduced by

experience and knowledge andappreciation of the literature. Clare

went on to describe the benefits offeeding and the consequences ofunderfeeding. The debate stimulatedmuch discussion but was restricted due totime constraints. An example of how thesame literature can be interpreteddifferently.

Following the intensive care debateRachel Donnelly and Rachel Barrett bothSpecialist Oncology Dietitians at Guy’sand St Thomas’ NHS Trust examinednutritional requirements in cancerpatients. They described the process ofcancer cachexia and the metabolic

alterations that occur comparing andcontrasting it with the alterations thatoccur in starvation. This was followed byan interactive case study enablingaudience participation which kept theaudience attention until lunchtime.

After refuelling the brain cells, CaroleAnne McAtear took the chair for theafternoon session. Alan Torrance, ChiefDietetic Manager at Newcastle UponTyne guided us through the influence ofnutrition on acid base balance. Alan wasfollowed by Rebecca White. Rebecca isthe Lead Pharmacist in Nutrition andSurgery at the John Radcliffe Hospital inOxford and is clearly passionate abouther subject. She discussed the impact ofvarious drugs on nutrient intake andnutrient metabolism and the influence ofnutrition on drug pharmacokinetics. Shereminded us of the BAPEN publicationsfor clinical staff and patient use allaccessible from the BAPEN website.

Sarah Illingworth of LondonMetropolitan University was the nextspeaker. Sarah has been involved in theBDA prescribing group and provided anoverview of the current legislation surrounding medicines managementand how dietitians can effectively usethis to improve patient care.

PENGroupSummerMeeting 2006

Beyond the Clinical Update

‘Current controversies in nutrition support’Report by Paula Murphy (day 1) and Alex Leckie (day 2) August 2006

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After a short but much needed coffeebreak the next speaker was Kirstine Farrer.Kirstine is a Consultant Dietitian in intestinal failure at Hope Hospital, Salford.Hope Hospital is one of 2 intestinal failureunits in the UK. Kirstine described the mainclinical responsibilities of the dietitianworking in the multidisciplinary team.Clearly with 50% of new admissionsrequiring home PN following their in-patient stay, the dietitian has a key role toplay in assessment and monitoring.

The afternoon concluded with NikkiStewart, Senior Dietitian at North Herts and Stevenage PCT. Nikki gave a usefulrevision of the principles of PN and the roleof some key vitamins. It was a long butthoroughly enjoyable and informative day.

Day 2 by Alex LeckieSenior Nutrition Support DietitianRotherham General Hospital

The second day of the PEN Group SummerMeeting was entitled ‘NICEly does it’. Thiswas very well attended andincorporated a widevariety of nutritionsupport relatedtopics and recentlypublished guidelinesin this area (such asNICE/ESPEN/NPSA)and how these impacton our practice asdietitians. The presentationsallowed for interesting debate and sharingof information amongst the audience.

The morning sessions were chaired by Professor Marinos Elia and addressed thenow familiar NICE guidelines for NutritionSupport starting with an overview of the‘NICE experience’ from Christine Baldwin.She explained how the guideline came

about, the professionals involved in thedevelopment group and the ever presentproblems with availability of evidence fornutrition support. Some of the implicationsof the guidelines and how we as dietitiansneed to use these guidelines as anopportunity for improving the profile ofnutrition were also discussed. Still on the‘NICE’ theme, our second presentation fromSusan Murray followed on from how theguidelines came about to how these can beimplemented and the tools that areavailable to help us with this. Susanhighlighted some of the common reasonswhy guidelines are not implemented suchas ‘forgetting’ or ‘not agreeing’ with theguidelines and how promotion and teamworking are two potential solutions tothese. There was discussion around thedisparities between recent guidelines thathave been published and it wasemphasised that we need to look at theprocess behind the development ofguidelines and bear in mind that these areonly ‘guidelines’. The delegates discussedways of implementation and felt that moreinformation would be welcome from NICEon this issue.

Jo Prickett presented the NICE RefeedingGuidelines focusing on the management ofpatients that are at high risk of refeedingsyndrome and looking at how we canminimise this in clinical practice. Theseguidelines do differ from the current onesin the PEN Group ‘Pocket Guide to ClinicalNutrition’ and suggest commencing at alower rate of feeding with appropriatemonitoring of biochemistry and

supplementation of vitamins andminerals. The full guidelines are

included in the NICE document andit is planned for the Pocket Guideones to be updated.

Professor Marinos Elia looked atthe cost of disease related

malnutrition and covered the basisof health economics, reminding us that

resources within the health service arelimited and demands large thereforechoices have to be made. We have toconsider the efficacy and effectiveness oftreatments.

After lunch (which was very NICE!) PeteTurner chaired the afternoon session whichfocused on some practical aspects ofnutritional support. Dr Simon Gabe

touched on the very emotive issue of ethicsof feeding patients and reminded us ofsome of the more infamous ethical casesthat have been in the media in recentyears. Two important points that came outof the presentation were that there is nolegal difference between withholding andwithdrawing treatment. If in doubt, a trial oftreatment could be recommended such asfor patients suffering from dementia,particularly when there is debate aroundartificially feeding these patients.

Ann Ashworth gave us a comprehensiveoverview of the NPSA Alert ‘Preventingwrong route errors with oral/enteralmedicines, feeds and flushes’ which is dueout in final format later this year. This iscovered in more detail in this issue ofPENLines. Ailsa Brotherton presented asummary of a paper she has produced onthe impact of PEG feeding on quality of lifeand reminded us that we cannot generaliseabout the impact of PEG feeding onpatients and their carers. She found thatthere was a wide range of experiences and perspectives.

Last but not least, Carole Anne McAtearrounded off the day with a summary ofguidelines that have been producedrelating to enteral feeding access routesincluding the BSG/NICE/SIGN/ESPENguidelines. Details of how to access theseguidelines are available in the presentation,which with all the presentations will beavailable on the PEN Group website under‘Events Diary’.

All in all this was a very informative, busyand interesting day and reminded us thatthere are several guidelines out there tohelp us in our everyday practice as clinical dietitians.

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The National Patient Safety Agency(NPSA) is a Special Health Authoritycreated to co-ordinate the efforts of allthose involved in healthcare, and moreimportantly to learn from patient safetyincidents occurring in the NHS(www.npsa.nhs.uk).

The NPSA is about to launch a PatientSafety Alert which is likely to affectpatients receiving enteral feeding and theircarers (including Dietitians). This Alerthas been drafted following a widestakeholder consultation, which included arange of health care professionals(Nutrition Nurses, Pharmacists and aDietetic representative from PENG).Manufacturers of enteral feedingequipment, such as giving sets andsyringes, were also involved.

Why is this Alert needed?Patients with dysphagia often take theirmedicines in a liquid form via their feedingtube. Accidentally, these medicines havebeen given intravenously (IV) whenpatients have both IV lines and enteralfeeding tubes in place. Published reports ofthese instances describe that patients haveeither died or have become very unwell.It is believed that there are about 30instances per month in England and Wales.

Why do these ‘wrong routeerrors’ occur?Nursing staff use IV syringes to bothmeasure and give liquid medicinesenterally, due to their availability at wardlevel. An IV syringe has a ‘male luer’ending, which is compatible with the drugport of the enteral giving set (female luer)and the side port of feeding tubes (whichmay have a syringe adaptor ‘lid’).

What do the different syringes fit with?

This bit… Fits with… Covered by Standard? So that…

A Cap/spike of Feed reservoir ‘preferably a screw fitting or Feed reservoirthe giving set a means different from… system and giving set are

used for parenteral administration’ incompatible with(BS EN 1615:2000) IV system

B Drug (or side) Male IV syringes No Medicines are port of given using male giving set IV syringes

C End of Patients Giving set connector shall be: The female luergiving set feeding tube • Either a designated step end of the giving

(NG/PEG etc) design OR set should be(D) • Female 6% luer, slip or lock OR impossible to

• Alternative system which connect to an IVdoes not connect with (female luer) linefemale luer (BS EN 1615:2000) in the patient

D Patients The giving set Enteral feeding…connector Opposite of IV feeding tube (C) shall be: system(NG/PEG etc) • A male 6% luer OR

• Shall be designed to mate with the connector provided on the giving set (BS EN 1615:2000)

E Side ports of Lots of syringe No Different types feeding tubes ends depending of syringes can (NG/PEG etc) on design be used, such as

IV or catheter tip

F Syringe adaptor ‘lid’

Preventing wrong route errors with oral/enteral medicines, feeds and flushes Report by Ann Ashworth

Syringe Definition? Which fits with?

Oral syringe Type provided by Community Pharmacist with It does NOT have a luer tip,children’s medicines to give directly by mouth. so is incompatible with the Looks like a male luer but has a non-luer tip. current drug ports on giving

sets. It may fit into the side port of the feeding tube, with the syringe adaptor in place.

Enteral Depends on manufacturer e.g. Medicina range Syringes with female luer lock syringe has female luer lock (female conical component ends will fit directly onto male

with a 6% taper, collar has screw fitting so can luer feeding tubes. BUT theylock onto male end). Baxa has a range of Enteral won’t fit into current drug syringes, some due to be withdrawn as they are ports on giving sets at present.compatible with IV.

May be purple, although not yet specified as a standard requirement.

Catheter tip Also known as bladder tip. Long (about 2 inches) Catheter tips will fit onto the tip on end with taper. end of feeding tubes (easier

with funnel adaptor) and some side ports of feeding tubes if the design is compatible (see diagram).Will not fit onto drug port.

Male luer tip Male conical component with a 6% taper. Current drug ports of giving– ‘slip’ or ‘lock’ Dimensions specified by International standards. sets and side ports of feeding

‘Slip’ is the plain one,‘lock’ is the one with a tubes (with syringe adaptorscrew collar around the outside of the tip, which in place, depending on can be locked into place. design).

What goes into what? From feed reservoir to patient:

Ann is a Nutrition Support

Specialist Dietitian at

Torbay Hospital, Torquay

and acted as the PEN Group

Representative on NPSA

Stakeholder Consultation.

Product images © Merck 2006

What does the NPSA Alert say? In brief, the NPSA alert is likely to include the following:1 Only oral, enteral or catheter tip syringes must be used to administer oral/enteral

medicines, feeds and f lushes to patients.2 (Side) ports on nasogastric and enteral feeding catheters (enteral feeding tubes) must be

male luer, catheter tip or other non-female luer in design.3 Administration (giving sets) and extension sets must not contain any in-line female

luer ports.4 Use of three way taps not recommended.5 Adaptors that convert oral/enteral syringes to connect with other medical devices must

not be used.6 Devices designed for uses other than enteral should only be used in exceptional

circumstances following a risk assessment.7 Only oral/enteral devices that are clearly labelled and easily identified should be used.8 All Healthcare organisations should include procedures in their training programmes.9 All Healthcare organisations should conduct annual audits.

Date of implementation to be confirmed.

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What does this mean?

• Nursing staff and patients on Home EnteralFeeding can no longer use male luersyringes for medications or flushing via side ports.

• Until the manufacturers change the givingset and feeding tube design, medicines and flushes will have to be given via the end of the feeding tube (e.g. using acatheter tip syringe plus funnel adaptor ifrequired. But, catheter tip syringes are notrecommended for measuring medicines,so an alternative would have to be foundOR using an ‘enteral’ female luer syringe).

• Repeated access to the end of the feedingtube will cause multiple breaks to thesystem. If the end of the giving set is notproperly capped off, it could be dropped on the patients bed/floor/wound etc. Intheory, this may present a microbiologicalrisk to the patient, as the end of the givingset could ‘pick up’ bacteria.

• The design of the syringes used may need to be addressed – 50ml syringes are advised by BAPEN at present(Administering drugs via enteral feedingtubes; www.bapen.org.uk).

• Purple could be effective to identify theenteral system, but is not yet a standard.

• Patients and carers need consistent advice – impractical to have one system in hospital and a completely different one inthe community.

• Any existing enteral feeding policy whichcovers syringes/single use will probablyneed to be re-written.

What next?

• Obtain the full NPSA document, oncereleased. Read the further information onthe action points.

• Determine which equipment/practice doesnot comply in your Trust.

• Form a multidisciplinary group, includingrepresentatives from: pharmacy, nursing,clinical governance, drugs and therapeutics,to agree a new policy. If for example,syringes cannot be changed due to costissues, this will need to be risk assessed andagreed by the Trust.

• Training programme.

• Audit.

And finally…The ONLY time a male IV syringe can beused is to inflate the retention balloon of alow profile device. This is because the valvedesign can only allow this type of syringe. Itwas also felt that if medications were given in error into the balloon, there would be lowrisk of harm.

See the NPSA website for furtherinformation. References are available fromthe author on request.

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The British Standards Institution document BS EN 1615:2000 defines and describes theconnectors A, C and D. The side ports (B and E/F) are not standardized which appears tohave caused the problem. However, the NPSA are also aware of other connectors beingused, e.g. in Paediatric ICU, IV lines have been used as extension sets. Many dietitians willalso be aware of the use of three way taps attached to the end of feeding tubes to givemedications and flushes. Necessity is the mother of invention and if an unfamiliar feedingtube has been used which does not have the standard ends, nursing staff have had to find asolution to the connector problem.

Male luer syringes may be used for aspirating stomach contents to check the position of theNG tube using an adaptor on the guide wire.

A

B

C

F

DE

White cap

Drip chamber

Tubing to pump

Tubing to pump

Orangeadaptor

Clearplasticcover

Drug port

Giving Set

Flushing withCatheter Tip Syringe

Flushing with Luer Tip Syringe

Skirt

Peg tube

Skirt

Peg tube

Side Port

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Diary Dates

BAPEN Date: 1-2 November 2006Venue: Hilton Metropole, Brighton

Further information visit:www.bapen.org.uk

Nutrition Society Winter Meeting hosted by the MRC-Human NutritionResearch Cambridge jointly with theNeonatal Society, supported by the RoyalSociety of Medicine

‘Nutrition in early life – new horizons in anew century’. An international conference tocelebrate the centenary of the birth of Dr ElsieWiddowson

Date: 11 – 13 December 2006Venue: Churchill College, Cambridge

Registration deadline: 23rd October 2006

Please see www.nutritionsociety.org for fullprogramme and registration information orcontact the Meetings Administrator,Liz Costin (e-mail: e.costin@nutsoc.org.uk;telephone 01442 825 568)

Pen Group Clinical Update Date: 4-8 June 2007Venue: Queen Margaret College, Edinburgh

Further information visit:www.peng.org.uk

ESPENDate: 8-11 September 2007Venue: Prague, Czech Republic

Further information visit:www.espen.org

BDA ConferenceDate: 20-21 June 2007Venue: Hastings Europe Hotel, Belfast

Further information visit:www.bda.uk.com

News from Industry

FORTIJUCE – New great tasteAs part of an on-going commitment toproduct development Nutricia Clinical Carehas reformulated Fortijuce to give it a greatnew taste and viscosity.

Extensive product development and tastetesting with patients has led to the creation ofnew flavour variants which includeStrawberry, Lemon, Apple, Orange,Blackcurrant, Forest Fruits, andTropical. These are available nowand are packaged in the newbottle presentation.

Importantly, the new Fortijuce hasa similar nutritional profileproviding 300kcals (1.5kcals/ml)and 8g of protein per 200ml bottle.

NEW FORTISIP RANGE STARTER PACKFollowing on from the success of the FortisipSample Service, Nutricia Clinical Care has nowlaunched the new Fortisip Range Starter Pack(which contains a range of Fortisip Bottle,Fortijuce and Fortifresh as well as a patientinformation leaflet), available through localpharmacies on prescription. The new packallows patients to receive their samplesthrough just a single, simple prescription andsaves valuable time for the health careprofessional. Providing patients with a widerchoice of samples will allow them to choose a supplement they like, helping toensure compliance and efficacy of nutritional support.

Patients can further benefit from theselaunches with a new patient dedicatedwebsite (www.forti.org.uk) providing support information and recipes to aid patient compliance.

FLOCARE – Committed to patient safetyNutricia Clinical Care is committed to ensuringpatients receive the highest standards ofsafety from their enteral feeding system.

That's why Flocare is the only purple colourcoded enteral feeding system currentlyavailable for clear distinction from IV systemsand why it is also the UKs first totally DEHP-Free enteral feeding system.

For more information on any of the aboveplease contact your local Nutricia Clinical Carerepresentative or contact Clinical NutritionDirect. Tel: 01225 751098 or email:cndirect@nutricia.co.uk

MEDICAL PRESS RELEASEAbbott Nutrition has announced thatTWOCAL HN has received approval from the Advisory Committee on BorderlineSubstances (ACBS).

TwoCal HN is now ACBS approved for use as asole source of nutrition or as a nutritionalsupplement for use under medical or dieteticsupervision for the following: disease relatedmalnutrition, short bowel syndrome,intractable malabsorption, inflammatorybowel disease, haemodialysis and continuousambulatory peritoneal dialysis, bowel fistulae,dysphagia, following total gastrectomy and forpre-operative patients who are malnourished.

TwoCal HN is a complete, balanced liquid feedwith fructo-oligosaccharides (FOS), providing2.0 kcal/ml and 8.4g of protein per 100ml. It isvanilla flavour and is presented in 237 ml cans.TwoCal HN is also clinically gluten and lactose free.

For further information, please contact yourlocal Abbott Nutrition representative orAbbott Nutritional Services on 0800 252882

FRESENIUS KABI IS ON THE MOVEThe development of the Fresenius Kabi newbusiness home, Cestrian Court, is nearingcompletion, which will see the Fresenius Kabiteam, including Calea, move from the threeseparate buildings currently operated from toone central office, bringing all employeestogether under one roof.

The decision for this move was more than justabout building a new headquarters. It wasabout providing an even better service tocustomers, whilst shaping Fresenius Kabi’sposition in the industry and being a goodneighbour in the local environment.

The new offices are seen as a workingshowroom that the company is extremelyproud to welcome customers into.Demonstrating its commitment to excellencein service is central to Fresenius Kabi’s strategy and is one of the company’s key differentiators against competitors. The newbuilding and the Fresenius Kabi team’scontinued dedication and passion willcontinue this wonderful trend.

Our new contact details from September 18th 2006:Fresenius Kabi Limited Cestrian Court, Eastgate Way, Manor Park,Runcorn, Cheshire WA7 1NT, UK Tel: 01928 533533 Fax: 01928 533534www.fresenius-kabi.co.uk