Evelina Children’s Hospital Pharmacy Department Review of Standard and Individualised Parenteral Nutrition (PN) Prescribing in Neonates Marianczak JE, Tomlin S, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Introduction Neonatal PN can provide sufficient nutrients parenterally not only to maintain body tissues but also to sustain growth. There is evidence to suggest that nutrition provided at this age determines various outcomes later in life, including both physical growth and intellectual development1. The National Patient Safety Agency (NPSA) Alert ‘Promoting Safer Use of Injectable Medicines’ released in March 2007 recommended implementing a ‘Purchasing for safety’ policy to promote procurement of injectable medicines with inherent safety features2. Babiven Maintenance bags were introduced onto the Neonatal Unit in 2008 and have the following advantages over individually manufactured bags: They are batch produced and undergo end product testing (EPT) for quality control. They are devised in line with guidance from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the Fresenius Kabi (FK) working group for neonatal PN Additions of electrolytes, trace elements and vitamins can be made They are available for out of hours use Standard bags are considered first line for all neonates due to the advantages above Objectives To review the appropriateness of PN prescribing in neonates in a large tertiary neonatal unit against ESPGHAN guidelines1 using both standard and individually manufactured bags. To examine the cost effectiveness of using 48 hour versus 24 hour PN To determine the uptake of standard bags as a percentage of the total PN usage Method This was a 2 month prospective data collection study from 1st August 2009 until 30th September 2009, carried out on a 16 cot NICU and 25 bed SCBU at the Evelina Children’s Hospital, London Data was collected from the PN prescription, fluid and observation charts and the medical and nursing notes Results The total number of neonates initiated on PN during the data collection period was 26 They received a total of 233 days of PN which was an average of 9 PN days per patient Standard bags accounted for 64% of total PN during the audit period Graph 1. Displays the actual spend on PN for each different PN bag (24 hr total spend = £8,016 for 101 days = £79.37 per day / 48 hr total spend = £6,270 for 132 days = £47.50 per day) and the predicted spend if all non-essential 24 hour bags were ordered as 48 hour bags – giving a cost saving over 2 months of £2,622 or £16K per annum Discussion Amino Acid Amino acid supply on the first postnatal day was not received by 83% of neonates mainly due to the lack of availability of suitable standard bags containing no electrolytes. Of those not achieving the minimum amino acid there was no difference between standard (n = 8) and individualised (n = 9) PN. Of those who exceeded the usual maximum amino acid, 90% were on individualised PN, showing clinicians optimise nutrition when individualised bags are used. Glucose All neonates met the ESPGHAN standards for minimum and maximum glucose intake. Only 61% of patients received 60 – 75% of their non-protein calories from glucose. This calorie provision from glucose was met more frequently with standard bags (69%) than with individualised PN (46%). Thus standardisation increases compliance with guidance, although it is accepted that there are still many questions about the ratio measuring. Lipid Lipid was only started after the third day of life in 7% of patients indicating good practice with both standard and individualised PN. The minimum linoleic acid intake was achieved in 87% of neonates and the maximum was not exceeded in any patient. Of those who met the minimum linoleic acid intake, 77% were on standard bags and 80% were on individualised PN showing no difference in lipid provision between the different bags Lipid was reduced or stopped when triglyceride levels exceeded 2.8mmol / l for all patients however it was noted that lipid was frequently being stopped at triglyceride levels less than this Conclusion Standard bags appear to be as effective at delivering nutrition as individually manufactured bags and increase compliance with international guidance. ESPGHAN guidelines were not met on all parameters and there is room for improvement on provision of nutrition to neonates Amino Acid Standards Aim Achieved For pre-term infants amino acid supply should start on the first postnatal day 100 % 17 % The minimum amino acid intake for pre-term and term infants is 1.5g/kg per day 92 % The maximum amino acid intake for pre-term infants is 4g/kg per day and for term infants is usually 3g/kg per day 95 % Glucose Standards Aim Achieved For preterm infants the glucose infusion should be started with 4 – 8 mg/kg/min 100 % Glucose administration to full term neonates and children up to 2 years of age should not exceed 18g/kg/day (13mg/kg/min) Glucose intake should usually cover 60 – 75 % of non-protein calories 61 % Recommendations Electrolyte free standard bags could improve earlier initiation of PN End product tested standard bags significantly improve the clinical application and safety of provision of neonatal PN. Encourage utilisation of 48 hour PN bags for all stable patients during week and weekends Improve provision of nutrition on the neonatal unit by: Updating current prescription charts for minimum and maximum amino acid requirement and lipid monitoring parameters Audit use of insulin versus reduction in carbohydrate for hyperglycaemia Provide education for junior medical staff on monitoring and prescribing Lipid Standards Aim Achieved Lipid emulsions should be started no later than on the third day of life 100 % 93 % For preterm infants the minimum linoleic acid intake is 0.25g/kg/day and for term infants is 0.1g/kg/day 87% Maximum parenteral lipid intake should be limited to 3-4g/kg/day in infants Reduction of the dosage of lipid emulsions should be considered if serum or plasma triglyceride concentrations during infusion exceed 250mg/dl (2.8mmol/l) References Koletzko B, Goulet O, Hunt J et al, Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical nutrition and Metabolism (ESPEN). Journal of Paediatric Gastroenterology and Nutrition, 2005; 41: S1-S4. Promoting Safer Use of Injectable Medicines, National Patient Safety Agency Alert, March 2007. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59812