The Administration of Parenteral Nutrition to Neonates, Infants and Children

• Summary
• Aims
• Background
• Diagnosis
  • Referral criteria
  • Referral pathway
  • PN referrals at weekends and bank holidays
• Treatment/management
  • Biochemistry
  • Patient observations
• Before starting PN
  • Venous access for PN
    1. PN infusion rates
    2. Infection
    3. Occlusion
    4. Phlebitis
    5. Extravasation
• Management with PN
  1. PN infusions
     • Standard PN bags
     • Storage
     • Vitamins and trace elements
     • Filters
  2. Commencing and changing a PN infusion
     • CVC and short long line (midline) dressings
     • Flushing lines
     • Removal of CVCs
• Refeeding problems
• Stopping PN
• Contact list

Appendices

• Appendix 1: Competencies (PN pharmacists)
• Appendix 2: Competencies (Dietitians)
• Appendix 3: Competencies (Nurses)
• Appendix 4: Eligibility criteria and biochemical monitoring
• Appendix 5: Cycling PN
• Appendix 6: Referral form for PN
• Appendix 7: Intestinal Failure referral form
• Appendix 8: How to record stools (for ward nurses)
• Appendix 9: PN products used at LTH
• Appendix 10: Filters set up for PN
• Appendix 11: LTH PN process

Summary

Guideline for the Administration of Parenteral Nutrition (PN) to neonates, infants and children. This document provides guidance regarding indications, mechanism of referral, venous access, monitoring and complications of PN.

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Aims

• To enable the provision of a high quality PN service to patients who have a compromised nutritional status, and where oral or enteral feeding is not a viable or complete option.
• To foster a co-ordinated, multi-disciplinary approach to PN support.
• To act as a source of information and advice on the management of PN.

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Background

In 2010, the NCEPOD report entitled ‘A mixed bag’, was published, which was the first national review examining the care of hospital patients receiving PN. The review aim was to examine the ‘assessment, administration, catheter care and monitoring of patients receiving PN’ in order to identify factors in need of improvement. One key recommendation from the review was that all NHS Trusts must have dedicated guidelines detailing indications, goals, precautions and essential monitoring for all patients receiving PN. The publication of the joint 2011 report on ‘Improving Practice and reducing risk in the provision of parenteral nutrition for neonates and children’ has also prompted the writing of this guideline.

Parenteral Nutrition (PN) is the administration of nutrition directly into the bloodstream. PN is used to treat infants and children who cannot be fully fed by the enteral or oral route, for example in severe intestinal failure, post chemotherapy, in necrotising enterocolitis or in failure to thrive. Intestinal failure occurs when the gastrointestinal tract is unable to ingest, digest and absorb sufficient macronutrients and/or water and electrolytes to maintain health and growth¹.

Enteral feeding should always be the route of choice as it is safer in terms of mechanical, septic and metabolic complications².

The time when PN should be initiated will depend both on individual circumstances and the age and size of the infant or child. In the small preterm infant, starvation for just one day may be detrimental and where it is clear that enteral feeds will not be tolerated soon, PN must be instituted shortly after birth. Evidence now exists that in extremely low birth weight (ELBW) neonates, PN should be started as soon after birth as is possible so that full nutritional value can be achieved early in postnatal life’^3-6.

In older children and in adolescence, longer periods of inadequate nutrition up to about seven days may be tolerated, depending on age, nutritional status, and the disease, surgery or medical intervention⁷.

PN can also be used in a community setting, known as home parenteral nutrition (HPN).

PN is a complex process, requiring accurate assessment of the patient’s nutritional requirements, placement of an appropriate feeding line, care of the line, accurate calculation and administration of calorific requirements and the monitoring of electrolytes and blood chemistry. It has the potential for many serious metabolic and non-metabolic complications. The metabolic complications include hyperglycaemia, electrolyte and fluid imbalances. The non-metabolic complications are related to the central venous catheter (CVC) and the administration of PN and these include CVC sepsis, occlusion and misplacement, cardiac tamponade, extravasation and thromboembolisation⁸.

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Diagnosis

Referral criteria

The following indications are the most common indications for PN at LTH. The list is not exhaustive and other indications can be discussed with the nutrition team. See the eligibility criteria for each patient group in appendix 4 entitled ‘Eligibility criteria and biochemical monitoring’. For neonatal patients see LTHT neonatal parenteral nutrition guideline (http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=6643) and for patients on PICU see Guidelines for the Prescribing and Administration of Parenteral Nutrition (PN) for Children on Paediatric Intensive Care (PICU) (http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=6711)

The risks associated with PN use are likely to outweigh the potential benefits unless PN is provided for at least 5 days.

Neonatal and Neonatal Surgery

• Prematurity
• Intra uterine growth retardation (IUGR)
• Congenital abnormalities e.g. gastroschisis, Hirschsprung’s disease
• Necrotising entrocolitis (NEC)

Infants and children

• Bowel obstruction (functional or mechanical)
• Failure to thrive
• Actual / anticipated prolonged ileus
• Organ transplant
• Gastro intestinal surgery e.g. appendectomy, malrotation, volvulus
• Intestinal atresia
• Intractable vomiting
• Intractable diarrhoea / high stoma output
• Crohn’s disease
• Anorexia
• Oncology/haematology e.g. mucositis, bone marrow transplant (BMT), radiation and severe graft versus host disease
• Paediatric Intensive care unit (PICU) e.g. sepsis, trauma, ventilation
• Intestinal failure
• Short bowel

(Diagram courtesy of Julie Steele LTH dietitian)

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Referral pathway

The decision to initiate PN must be made by a senior clinician⁹. A referral form for PN (appendix 6) must be completed by a doctor and approved by a PN pharmacist/dietitian before PN will be made. (Please see the contact list section later in this guideline.) The original referral form must be sent to the lead nutrition pharmacist and it will be uploaded on PPM+ as per the NCEPOD recommendation that ‘All hospitals should keep a central record of where and to whom PN has been supplied.’

All referrals for PN must be received in pharmacy aseptics by 1pm on weekdays.

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PN referrals at weekends and bank holidays

Three days of PN should be prescribed on Fridays for over the weekend (but changes to these prescriptions are still possible over the weekend if deemed absolutely necessary. These changes should be formalised by 11am in consultation with an appropriate practitioner and the weekend PN pharmacist). Over four day bank holiday weekends, individual PN prescribing may differ in certain clinical areas based on patient numbers and the clinical status of patients; this will be arranged locally with pharmacy aseptics and the individual PN prescribers in advance of the bank holiday weekend. Pharmacy aseptics in certain circumstances might accommodate new referrals for PN at weekends or bank holidays for patients over 6 months of age. The decision needs to be made by a consultant in discussion with the PN pharmacist. For patients under 6 months of age, contact pharmacy aseptics before 10am.

Once PN has commenced the nutrition pharmacist/dietitian will review the patient daily. Any changes to the nutrition treatment plan should be documented on PPM+ and discussed with the medical team.

Any complicated/potentially long term PN patients should be referred to the nutrition team to be reviewed on the Tuesday morning ward round (see appendix 7 for the Intestinal Failure referral form). If HPN is likely to be required this needs to be discussed with the Children’s Nutrition Team at the earliest opportunity and an official referral made. Considerable preparation is required for the organisation of HPN.

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Treatment/management

Biochemistry

To ensure that PN is prescribed safely and appropriately it is necessary to monitor blood biochemistry very closely. Biochemical monitoring should also take into account the length of time on PN, prematurity, co-morbidities and other medicines¹⁰. The clinical team is responsible for reviewing the results and taking appropriate action where abnormal values are observed¹¹. The person who signs the prescription as the ‘prescriber’ is accountable for both the nutrient content and the electrolytes and minerals that have been prescribed on the PN prescription¹². It is essential for all patients on PN to be monitored very carefully, so that adverse events are detected early. Before commencing PN certain baseline bloods must be taken; these should include the following: -

• Urea and electrolytes (U&Es)
• Liver function tests (LFTs)
• Adjusted calcium (Ca (adj))
• Phosphate (PO4)
• Magnesium (Mg)
• Blood glucose (BMs)
• FBC (at the consultant’s discretion)

Appendix 4 gives a general outline on how often biochemical monitoring is required.

If blood glucose ≥10 mmol/L, treatment with insulin may be necessary. The clinical team should follow local protocols for hyperglycaemia or can contact the children’s nutrition team for advice.

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Patient observations

On the ward, the following observations should be performed. It is essential that input and outputs are accurately recorded to ensure that effective clinical decisions can be made. Following the Patient Safety Alert from September 2017¹³, pump and fluid infusion checks should be done hourly. 

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Before starting PN

Venous access for PN

A dedicated CVC should be placed (or a lumen dedicated for PN) and its position confirmed before PN is initiated. The insertion of the CVC should be clearly documented in the patient’s casenotes¹⁵. If a multi lumen catheter is used, you must identify, designate and label one port for the use of PN if at all possible (CVAD 8 epic2 Class D/GPP). In patients with a single lumen CVC it may be necessary to use the CVC for administration of other intravenous drugs/fluids/blood products using a double needleless port ("Smartsite") extension set (also known as a “Y connector”) to avoid breaking the line. Once PN is disconnected it cannot then be reconnected. It is important to ensure that adequate maintenance fluids are prescribed if the PN has to be disconnected for any reason.

In general, drugs should not infuse down the same line as PN. In some situations, this is impossible; therefore if a drug is not compatible with PN, then the PN must be stopped, CVC flushed, drug administered, flushed and PN recommenced. The rationale for deviations should be documented in the patient’s medical notes.

See Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2281

*Short long lines are very similar in appearance to peripherally inserted central venous catheters (PICCs) and should be dressed, accessed, secured and routinely observed in the same manner. It is important to remember however, that the tip is positioned in a peripheral vein where the blood flow is 5-10 times slower than that achieved at the tip of a CVC. This means that the precautions regarding the use of medications with extremes of pH or osmolality in peripheral cannulas still need to be considered. It is essential that the maximum concentration for the peripheral administration of potassium does not exceed 40mmol/L.

The following catheters should not be used for the administration of PN:

• Arterial catheters

Caution should be exercised in using the following for PN administration:

• Vas-caths

Where there is any doubt, the advice of the nutrition pharmacist and the clinical team managing the patient should be sought.

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a. PN infusion rates

The route and rate for PN administration is printed on both the aqueous ‘vamin’ bag and lipid syringe/bag labels or standard bags¹⁶. The printed ‘details of parenteral nutrition’ prescription sheet that accompanies the PN also has copies of the PN labels printed on the reverse. The infusion rates do not appear on the original neonatal PN prescription chart. It is very important to infuse PN at the prescribed rate and also to ensure that the correct rate is inputted into the correct channel of the pump. A Patient Safety Alert (September 2017)¹³ on “Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies” showed that there had been some incidents where the vamin and lipid rates were incorrectly inputted into the channels of the pump, resulting in the vamin infusing at the lipid rate and vice versa. This resulted in severe harm to babies through pulmonary collapse, intraventricular haemorrhage or organ damage, and where intensive intervention and treatment were needed. Therefore at LTHT, smart pumps have been introduced to the Children’s’ Hospital. Pump library has been reviewed and incorporates both lipid and aqueous PN components in order to introduce an additional check prompt, and hard and soft rate limits based on weight ranges. Also two nurses are required to check PN and pumps before PN is started.

In certain clinical situations, primarily on NNU and PICU, the PN infusion rates may need to be altered. This is usually due to changes in overall fluid volumes, changes in enteral feed volumes or the addition of further continuous drug infusions, which means that the rates of both vamin and lipid or standard bag may need to be reduced. If the overall fluid volume increases or other infusion rates decrease, the vamin, lipid or standard bag rates should NEVER be increased, as doing so would increase the hourly rates of electrolytes such as potassium, which could lead to devastating consequences. Recommendation 23 of the report from the paediatric chief pharmacists group (November 2011) ‘Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children’ states ‘ The hospital Executive Group must ensure clinicians record any change in infusion rate, from that originally stated on the label of the PN solution, on the patient’s prescription chart’. To be compliant with this recommendation, nurses should seek the approval of the PN pharmacist (during normal working hours) or the duty doctor before reducing either the vamin, lipid or stadard bag rate. This change in rate should then be annotated on the hourly infusion chart and an entry should made on the nursing notes twice daily, explaining why the prescribed rate of PN was altered.

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b. Infection

See the following guidelines:

• Guideline for the management of suspected central venous catheter infection for infants (excluding neonates on the intensive care unit (NICU)) and children receiving parenteral nutrition. http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2165

• Guideline for the management of Neonatal Long Line sepsis http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=654

Patients with intestinal failure often suffer from bacterial overgrowth, where they may present with a distended abdomen, wind, abdominal pain and diarrhoea. The children’s nutrition team usually prescribe ‘cyclical antimicrobials’ to manage these problems. See guideline “Small Intestinal Bacterial Overgrowth in children” for the antimicrobial treatment options, based on anecdotal evidence and experience at LTH and also Rifaximin: Amber Drug Guidance for the treatment of Small Bowel Bacterial Overgrowth in Children http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=3449

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c. Occlusion

See section 4.11.2 Occlusion of the following guideline:

• Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children
  http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2281

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d. Phlebitis

See section 4.8 Site inspection of the following guideline:

• Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children,
  http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2281

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e. Extravasation

See the following guidelines:

• Extravasation Injury - the Prevention and Treatment of Neonatal Extravasation Injury http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=554

• Guideline for the Insertion and Management of Peripheral Venous Cannulae in Adults, Paediatrics and Neonates
  http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1778

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Management with PN

a. PN infusions

Standard PN bags

Babiven® start up is a standard neonatal PN bag that is stored on the neonatal unit and is used for any neonate ≤ 1.25 who requires PN¹⁷. This is used for day 1 of life, if the infant is born after 1pm they will miss the pharmacy aseptic service for that day¹⁸. PN will be made the following day for that infant. PN patients at LTH will preferably have a standard bag of PN, however if not suitable individualised PN will be provided. All the PN bags are made in the pharmacy aseptics department¹⁹ and, if ordered before 1pm are delivered to the ward usually by 6pm that evening, seven days a week. Additions to PN solutions are only made in the pharmacy aseptic unit and under no circumstances should any additions to PN solutions be made at ward level²⁰.

The PN products used at LTH can be found in appendix 9.

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Storage

PN is an intravenous medicine and should be treated accordingly in line with the LTHT Medicines Code. PN bags delivered from the LTH pharmacy aseptic unit are at room temperature and can be infused straight away. If for any reason, the PN is not suitable or not required, ensure that the PN is stored in the locked ward medication fridge until required. If there is a problem or query with the PN bag or prescription and the PN is not used, then store it overnight in a locked medication fridge and follow up any concerns with the nutrition pharmacist the next day. For ‘pre-homecare’ and HPN patients who have been admitted to hospital, it is safe to use their own PN supply. As these patient groups usually receive a week’s supply of PN at a time, their PN will be refrigerated and so must be taken out of the fridge four hours before infusing, to allow it to reach room temperature. A ‘PN pre - compounded administration record chart’ should be placed in the nursing kardex to record the administration of ‘pre homecare’ or HPN (http://www.leedsformulary.nhs.uk/docs/RxParenteralNutritionPreCompounded(paed).
pdf?UNLID=86540223520201014144422)

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Vitamins and trace elements

Recommendation 45 states that ‘The Hospital Executive Group must ensure there are written guidelines for the alternative administration of vitamins or other micro-nutrients contained within the lipid phase of PN, when lipid administration is interrupted.’ At LTH, there is never a situation where trace elements or water soluble vitamins are omitted from PN. In hypertriglyceridaemia (TG >4mmol/L), lipid is occasionally not provided, which means that fat soluble vitamins are omitted from PN. Lipid is usually reintroduced at perhaps a lower amount within 24-48 hours. At LTH, we do not feel that this short period of time without fat soluble vitamins is detrimental or that it leads to any complications, nor do we routinely check fat soluble vitamin levels in short term PN patients²¹. The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines state ‘routine monitoring is not recommended because of lack of evidence on adequate benefits. Optimal doses and conditions of infusion for vitamins in infants and children have not been established.’

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Filters¹⁴

Every patient who receives PN can have adverse effects resulting from particulate contamination from raw materials and administration sets, inadvertently introduced bacterial contamination and precipitates. In-line filters are recommended for all patients receiving PN ²²and in accordance with ‘improving practice and reducing risk in the provision of parenteral nutrition for neonates and children’ recommendation 55 - ‘The Hospital Executive Group should ensure that in-line filters are used in accordance with published BPNG guidance.

At LTH, the following filters should be used:-

• 0.22 micron for ‘vamin’
• 1.2 micron for lipid and standard bags. This filter can also be used to filter both vamin and lipid bags at the same time.

See appendix 10 for pictorial guidance on how to attach filters correctly for PN.

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b. Commencing and changing a PN infusion

CVC and short long line (midline) dressings

For CVCs and midlines, the dressing of choice is a sterile, transparent, semi-permeable polyurethane dressing (epic2 CVAD 19 Class D). This type of dressing can remain in place for a maximum of 7 days, providing it remains secure and appears clean.

All CVCs should have a clean exit site at all times and the dressing should be intact.

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Flushing lines

The catheter should be flushed before and after use. There is no need to stop a PN infusion merely to flush the catheter.

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Removal of CVCs

CVCs should be removed at the earliest opportunity if no longer required, once weight gain has been observed on enteral/oral feeding alone. CVCs must be removed by competent staff. Non-tunnelled CVCs may be removed in ward areas by competent staff. Due to the difficulty of freeing the cuff, tunnelled catheters should be removed by someone who has demonstrated competency in a controlled environment. A protocol for the removal of non-tunneled CVCs can be found in the http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2281

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Refeeding problems

Refeeding syndrome is a potentially fatal complication of the nutritional management of severely malnourished patients. It encompasses a number of complications that can occur in the early stages of refeeding, irrespective of the modality of nutritional support. It is associated with life threatening acute micronutrient abnormalities including hypophosphataemia, hypokalaemia, hypomagnesaemia and occasionally hypocalcaemia. It may also result in acute circulatory fluid overload, fluid depletion and hyperglycaemia and can lead to significant morbidity and death but the incidence is uncertain. See guideline Refeeding Syndrome http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=4323

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Stopping PN

The anticipated endpoint of treatment with PN should be stated at the time of referral if at all possible. The decision to discontinue PN should be made jointly by the clinical team and the nutrition team/dietitian and documented in the medical notes. It is safe to stop PN abruptly as long as the patient is tolerating adequate enteral/oral feeds and that it is felt that they will be able to maintain their weight and normal homeostasis without PN.

In many patients enteral nutrition and PN may run concurrently and will be titrated against each other as gastrointestinal function returns. As a general rule, PN will be stopped once successful enteral feeding is established (or is likely to be so within the next 72 hours if there are vascular access problems).

If the decision to withdraw active treatment is taken by the referring clinical team, then continuation of PN is almost universally inappropriate, although there may be occasions such as ‘end of life pathway’ where PN is continued, following discussions between the family and the clinical team

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