Parenteral Nutrition to Neonates, Infants and Children - The Administration of

Publication: 15/03/2013  
Next review: 17/12/2023  
Clinical Guideline
CURRENT 
ID: 3270 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The Administration of Parenteral Nutrition to Neonates, Infants and Children

Appendices

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. 

All patients having PN should have the following ward observations throughout their stay (unless long-term and stable). These should be documented on the paediatric advanced warning score (PAWS) charts.

Temperature:- 4 HOURLY

Heart rate: - 4 HOURLY

Blood pressure (BP):- DAILY (more often if BP abnormal or if the patient takes antihypertensive medication)

Weight:- TWICE WEEKLY  (Mon & Thurs) or as advised by the dietitian

Fluid balance: - DAILY.
This should include input and output. Poor documentation of fluid balance will affect and delay clinical decisions.

INPUT should include type (PN, IV maintenance fluid, replacement fluid) route (oral, enteral feeding tube & IV) and amount given on an hourly basis. Apart from on PICU, IV drug volumes will usually be given as ‘extra’ to the total fluid allowance for PN patients.
OUTPUT should include stool volumes, stool frequency and stool type (appendix 8); vomits, aspirates, stoma losses, urine output.

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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

Type of venous access

Definition

Maximum glucose concentration for PN 13

Central Venous Catheter

A venous catheter that terminates in the great veins near the heart or in the heart, with one or more lumens for infusion, blood withdrawal and monitoring functions.
Check X-RAY for tip position.

Non tunnelled lines

  • Central insertion direct into central vein e.g. right internal jugular, femoral or umbilical venous catheters (UVCs)
  • Peripheral insertion into central vein (PICC) e.g. neonatal long line

Tunnelled

  • Broviac/Hickman 
  • Portacath
  • Tunnelled PICCs (e.g. radiologically placed)

20%
In a PICU setting where patients are fluid restricted, glucose concentrations of up to 30% may be possible - assess on an individual patient basis, in consultation with the intensivist. This can also apply to other fluid restricted patients on other wards e.g. VOD post stem cell transplantation, renal and liver patients in discussion with the clinical team

Short long line* (Mid lines)

A peripherally inserted venous catheter, typically 8-20cm long, inserted near the antecubital fossa and terminating in the peripheral vasculature in the upper arm.
e.g. some PICC lines.
Ensure X-RAY checked for tip position

12.5%

Peripheral line

A venous cannula, inserted into a peripheral vein or scalp vein

10%
Not recommended for PN, however, acceptable for short periods (up to 48 hours) if CVC not possible.

*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:

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:

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d. Phlebitis

See section 4.8 Site inspection of the following guideline:

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e. Extravasation

See the following guidelines:

           

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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.

Alaris order code

MFX 2275e

72323e-0006

MFX 1827

MFX 1825

Description

“Y” extension set 3 way

SE primary infusion set (with in line vamin filter & smart site port below filter)

Stand alone vamin  filter

Stand alone lipid filter

Filter Size

Line with 0.22 micron Endotoxin Retentive Filter

Line with 0.22 micron Endotoxin Retentive
Filter

0.22 micron Endotoxin Retentive Filter

1.2 micron
Lipid Filter 

Filling Volume

0.7 mL

20 mL

0.85 mL

0.7 mL

Maximum flow rate

150 mL/hr

100 mL/hr for neonates
999.9 mL/hr for children

720 mL/hr

2700 mL/hr

Duration between changing filters

 72  hours

24 hours

72 hours

24 hours*

What ward should use this

Neonates
 (with SE infusion set 72504e-0006)

All Paediatric wards

All Paediatric wards  that don’t use 72323e-0006

All wards (including neonates)

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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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Contact list

Speciality

Contact Name

Contact number

LGI and SJUH Neonatal

Jennifer Jackson (pharmacist)
Kim Mak (pharmacist)

80-1773
80-5382

Oncology/Haematology

Evelyn Ward (dietitian)
Lisa Henry (dietitian)

07789174355
80 -2425

Children’s Cardiology

Teresa Brooks (pharmacist)
(Mon-Wed)
Alix Dunlop-Jones (dietitian)

80-2735

80-3176

Children’s surgery, medicine, Intensive Care, Gastroenterology, Renal, Children’s cardiology on  Thurs & Friday

Ask your ward pharmacist for who is covering that day, or bleep 80-1310

Natalia Iglesias (pharmacist) (Tues-Thurs) Sarah Zeraschi (pharmacist)
Gemma Wiltshaw (pharmacist)
Penny Chu (pharmacist)

 

 

80-1310

 

Children’s Liver

Kirsten Tremlett (dietitian)
(Mon, Tues, Thurs and Fri)
Penny North - Lewis (pharmacist)

80-2533

80-1108

Provenance

Record: 3270
Objective:
  • To ensure that careful and early consideration is given to the need for PN in neonates and once the decision to commence PN is made that it is started without undue delay.
  • To fulfil the requirement of the NCEPOD (National Confidential Enquiry into Patient Outcome and Death) report ‘A mixed bag’, that patients receiving PN are under the care of a nutrition team.
  • To ensure that all aspects of the patient’s PN management are explained, discussed and agreed with the patient/carer, the ward or departmental staff and with the patient’s family.
  • To promote a system that enables an effective and efficient referral pathway.
  • To liaise with the patient’s primary consultant and team in an advisory capacity on clinical issues affecting the patient’s nutritional management.
  • To promote enteral nutrition when the gut is accessible or functioning.
  • To monitor the patient closely, to avoid metabolic complications.
  • To monitor the need for continued nutritional support and managing changes appropriate to the patient’s condition.
  • To undertake regular audit of PN practice which should include the complications of PN.
  • To ensure that a central record is maintained of who PN has been supplied to and the duration of their time on PN.
  • To comply with the report from the paediatric chief pharmacists group (November 2011) entitled ‘Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children’. Recommendation 15 states the following: - ‘The hospital Executive Group must ensure there are agreed guidelines in place for the provision of PN based on and referenced to published evidence and/or guidelines which are ratified by their Clinical Governance Committee who agree any significant deviations’.
  • To comply with the report from the paediatric chief pharmacists group (November 2011) entitled ‘Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children’. Recommendation 6 states the following: - ‘The hospital Executive Group must ensure that staff are trained to meet a local set of competencies that relate to their role in the provision of PN. Hospitals must hold training records, which demonstrate this competence of those individuals, involved in the process.’ (see appendices 1, 2 and 3).
Clinical condition:

Parenteral Nutrition. Intestinal failure

Target patient group: Neonates, infants and children within LTH who receive, or are considered for parenteral nutrition
Target professional group(s): Secondary Care Doctors
Allied Health Professionals
Secondary Care Nurses
Adapted from:

Evidence base

References

  1. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral Nutrition. Clinical Nutrition 37 (2018) 2306-2429
  2. Reilly, H. Parenteral nutrition: an overview of current practice. British Journal of Nursing, Vol 7, No. 8, 1998
  3. NCEPOD recommendation number 1: ‘Careful and early consideration should be given to the need for PN.’
  4. NCEPOD recommendation number 2: ‘Once the decision to commence PN is made it should be started without undue delay.’
  5. Neonatal Parenteral Nutrition. NICE guideline Published: 26 February 2020 www.nice.org.uk/guidance/ng154
  6. The Provision of Parenteral Nutrition within Neonatal Services: A Framework for Practice - BAPM Guidance December 2015
  7. EJHP-P. Volume 11, 2005/5 ‘Paediatric parenteral nutrition: New European guidelines’ Koletzko et al.
  8. Leeds Teaching Hospitals CVC guidelines
  9. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 9 - ‘The hospital Executive Group must ensure all decisions to initiate PN are made by a senior clinician.’
  10. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 24 - ‘The Hospital Executive Group must have agreed written guidelines for biochemical monitoring which take account of length of time on PN, prematurity, co-morbidities and other medicines.’
  11. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 25 - ‘The Hospital Executive Group must ensure that clinical guidelines for biochemical monitoring identify who is responsible for reviewing results and taking appropriate action when abnormal values are observed.
  12. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 11 - ‘The Hospital Executive Group should ensure the clinician accountable for deciding on nutrient needs and PN formulation also signs the prescription.’
  13. ‘ Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. Patient Safety Alert, September 2017. NHS/PSA/W/2017/005
  14. Royal College of Nursing, Standards for infusion therapy. The RCN IV Therapy Forum. Third edition, January 2010.
  15. NCEPOD recommendation number 9: ‘CVC insertion should be clearly documented.’
  16. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 20 - ‘ The Chief Pharmacist must agree locally the maximum concentration of glucose that can be infused in peripheral veins and must ensure the PAU labels all PN solutions which contain glucose solutions in excess of this ‘to be given by central line only. ’
  17. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 19 - ‘ The Chief Pharmacist must ensure that the hospital’s medicines policy mandates the use of standard PN solutions in preference to individualised PN solutions whenever it is clinically appropriate.’
  18. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 27 - ‘ The hospital  Executive Group must ensure that there are arrangements for the provision of PN when the PAU is closed and that ward based preparation or additional manipulation of PN components does not occur.’
  19. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 28- ‘The hospital Executive Group must ensure that PN is quality assured to the same standards regardless of scale or whether it is prepared under a Section 10 exemption or prepared under a Manufacturers Specials Licence.’
  20. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 26 - ‘ The hospital Executive Group must ensure additions to PN solutions (aqueous or lipid phase) contained in infusion bags and/or syringes are only made in a PAU.’
  21. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 45 - ‘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.’
  22. ‘Use of Filters During the Preparation and Administration of Parenteral Nutrition: Position Paper and Guidelines Prepared by a British Pharmaceutical Nutrition Group Working Party.’ Kathryn Bethune et al. Nutrition 17:403-408, 2001.
  23. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. Recommendation 49- ‘The Chief Pharmacist should use the annual risk assessment of their PN service to help identify local training needs.’

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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