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Review of standard & individualised parenteral nutrition (PN) prescribing in neonates
  1. J E Marianczak,
  2. S Tomlin
  1. Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK

Abstract

Objectives Primarily, the review was carried out to look at the appropriateness of parenteral nutrition (PN) prescribing in neonates against ESPGHAN guidelines using both standard and individually manufactured bags.1 Secondly, to examine the cost effectiveness of using 48 h versus 24 h PN and to determine the uptake of standard bags as a percentage of the total PN usage.

Method This was a 3 month prospective data collection study carried out on a 16 cot NICU / 25 bed SCBU. Data was collected daily from the PN prescription, fluid and observation charts, and medical notes.

Results Twenty six patients were initiated on PN during the data collection period and received 233 days of PN.

The minimum amino acid intake of 1.5 g/kg/day was achieved on 92% of PN days with no difference between standard (n=8) and tailored bags (n=9) for those who did not meet the minimum requirements. The maximum amino acid intake was met on 95% of PN days. Of those who exceeded the amino acid intake 90% were on tailored bags.

All neonates met ESPGHAN standards for minimum and maximum glucose intake. Only 61% of neonates met the standard non-protein calorie intake of 60–75% acquisition from glucose. This calorie provision from glucose was met more frequently with standard bags (69%) than tailored bags (46%).

Lipid was started no-later than the third day of life in 93% of patients, with the minimum linoleic acid intake being achieved in 87% of neonates and the maximum not being exceeded in any patient. Of those who meet the minimum linoleic acid intake 77% were on standard bags and 80% were on tailored bags.

Prescribing of 48 h PN led to a saving of 66 PN days (28%) and a total cost saving for 3 months of £4253 (Standard £3109, tailored £1144). Standard bags were prescribed on 149/233 PN days accounting for 64% of total PN during the audit period.

Conclusion Standard bags appeared to be as effective at delivering appropriate nutrition as tailored bags. ESPGHAN guidelines were not met on all parameters and there is room for improvement on provision of nutrition to neonates. The main areas for consideration are earlier initiation of PN which could be improved by the use of electrolyte free standard bags, updating current prescriptions, review of calorie provision and auditing use of insulin versus carbohydrate reduction for hyperglycaemia. There are limited cost advantages of using standard bags versus individually tailored bags (similar price per bag), however they have significant benefits for improving patient safety (batch manufacture and end product tested standard bags) and enabling out of hours use of PN. Using 48 h bags had significant cost advantages so this should be encouraged for stable patients.

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