South West Midlands Neonatal Network Parenteral Nutrition Guideline. May 2017

Transcription

1 South West Milans Neonatal Network Parenteral Nutrition Guieline May 2017 Prouce for SWMNN by Dr Gemma Holer, Consultant Neonatologist, CH, Dr Gill Preston, Clinical Fellow, CH, Louise Whitticase, Lea Pharmacist, CH, Sara Clarke, Senior Specialist Neonatal Dietitian, SWMNN with contributions from SWMNN Nutrition Group.

2 1. Introuction Growth failure on the neonatal unit is associate with longer term growth failure an/or neurological eficit. Parenteral nutrition (PN) is an important component of neonatal care where gastrointestinal immaturity or isease prevents these nutritional nees being met by the enteral route. The National Confiential Enquiry into Patient Outcome an Death (NCEPOD) enquiry publishe in inicate that only 24% of neonates inclue in the survey were juge to have parenteral nutrition care that was consiere goo practice. The components of this guieline have been written to try an ensure that the local practices meet the NCEPOD efinitions of goo practice in relation to parenteral nutrition care. The British Association of Perinatal Meicine (BAPM) publishe The Provision of Parenteral Nutrition within Neonatal Services A Framework for Practice in April 2016 with the aim of escribing best practice for the aministration of neonatal PN. The paucity of evience is acknowlege within this ocument an many of the recommenations are base on expert evaluation of the limite evience. Neonatal parenteral nutrition typically comprises of 2 components, vamin an lipi, which are esigne to run simultaneously as separate infusions. The vamin component (containing carbohyrate, protein, electrolytes +/-trace elements) has been carefully formulate as stanar bags esigne for use in units across the Southern West Milans Newborn Network (SWMNN). There are 2 ifferent lipi preparations formulate as stanar syringes, containing lipi an vitamins, esigne for the SWMNN. These utilise Intralipi 20% an SMOFlipi. Intralipi 20% is erive from soya beans an is primarily mae up of omega-6 polyunsaturate fatty acis, which are pro-inflammatory an can result in the prouction of free raicals, which in turn can cause oxiative amage to cells. It also contains phytosterols which are irectly hepatotoxic. It is thought that it is these properties of the lipi that contribute to parenteral nutrition associate liver isease (PNALD). SMOFlipi is a blen of soybean oil, meium chain triglyceries, olive oil an fish oils. Fish oil contains primarily omega-3 polyunsaturate fatty acis, which are anti-inflammatory an potentially hepatoprotective, an no phytosterols. SMOFlipi has been shown to be safe to use in preterm infants, but currently there is no evience to suggest any benefits of its routine use over Intralipi 20% 6,7 in non-cholestatic infants (irect bilirubin <50 µmol/l). There is a recent stuy showing that the use of SMOFlipi improves the liver function tests in those with cholestasis, but oes not prevent the evelopment of PNALD. SMOFlipi shoul only be consiere in babies with a irect bilirubin >50 µmol/l an rising tren. Cycling -infusing the total aily ose of lipi over 20 hours, rather than 24 hours, in cholestatic infants may be consiere hepatoprotective.

3 Inications for Use all babies 30 weeks gestation an all babies 1000g shoul be commence on PN as soon as possible after birth but certainly within 24 hours of birth/ amission babies who are 1001g 1500g shoul commence PN if it is anticipate that they will not achieve enteral fees of at least 100mls/kg/ay by ay 5 of life all babies receiving conservative treatment for Necrotising Enterocolitis all babies who have unergone surgery for a congenital abnormality or acquire gut anomaly shoul receive PN whilst establishing enteral fees all babies likely to be faste for more than any 5 ay perio for any meical or surgical reason Moe of Delivery Peripheral PN It is recommene that all PN is run centrally. In the absence of central access Start Up Vamin (electrolyte free an comprising 10% glucose an amino acis) may be run peripherally, for example on ay of birth or when central access is temporarily unavailable in a baby alreay establishe on PN. There is some evience to suggest running lipi peripherally in aition to the Vamin component may prolong the life of the peripheral cannula. 9 Central PN Central access shoul be sought as soon as possible All Parenteral Nutrition (glucose >10% ) shoul be aministere centrally via an umbilical venous catheter (UVC), percutaneous long line or surgically inserte central venous catheter in view of the high concentration of glucose an calcium. Due to the increasing reports of PN extravasation when aministere via a UVC, prolonge infusion via a UVC is not recommene 10 PN must always be infuse via a eicate lumen. The only exceptions are a continuous vancomycin infusion, or soium or potassium chlorie infusions which may be aministere simultaneously with the PN proviing they o not excee a maximum concentration 200mmol/L- incluing amounts provie by amino aci, trace element solutions an lipi emulsions. In exceptional circumstances where the baby has a single lumen line but requires aitional infusions/ rugs an obtaining aitional access is impossible, iscuss with your unit pharmacist. Note that calcium, magnesium an phosphate containing fluis must never be aministere simultaneously with PN. PN Preparations The SWMNN PN formulations have been evelope to provie aequate nutrition at the maximum prescription rate (see appenix). Vamin Bags There are 4 types of stanar vamin bags specifically formulate for Southern West Milans Newborn Network (SWMNN). A bag may be infuse for a maximum of 48hours. Please see appenix 1 an 2 for compositions.

4 Start Up Use as initial infusion flui for up to 24 hours of life. Can also be given peripherally if central access is temporarily unavailable in a baby alreay establishe on PN, or by either route if electrolyte free PN is require. Maintenance 12 - initial maintenance PN to be infuse for at least 48 hours; when glucose tolerance establishe move to Maintenance 15 (see below). Prolonge use may be require in infants with glucose intolerance or aciosis (contains acetate). Please note this oes not provie aequate nutrition for long term growth. Maintenance 15 - stanar maintenance PN for all preterm infants. Term Baby for use in preterm infants over 2.5kg an/or infants born from 37 weeks onwars. If Parenteral Nutrition is being commence after a baby has previously tolerate enteral fees they o not require a start up bag an shoul commence on the appropriate maintenance bag of vamin. They can start at maximum volume of lipi. For infants likely to require PN for longer than 14 ays- consier orering bags with Peitrace (a mixture of trace elements. The aition of these reuce frige life to 7 ays) to ensure recommene micronutrient intakes are met. Discuss with Nutrition Lea, Pharmacist or Dietitian. Lipi Types Intralipi 20% This is commercially available in bags with a 24 month manufacturer expiry. Intralipi syringes formulate for SWMNN contain intralipi 20% with ae fat an water soluble vitamins. These syringes have a 7 ay expiry from the ate of manufacture. Intralipi syringes, with ae vitamins, shoul be use in preference to bags whenever possible. A syringe may be infuse for a maximum of 24 hours. Where it is necessary to infuse an intralipi bag, this shoul be irectly from the bag via a syringe pump; intralipi 20% shoul never be withrawn from the bag into a syringe at war level. SMOFlipi SMOFlipi syringes formulate for SWMNN contain SMOFlipi with ae fat an water soluble vitamins. These syringes also have a 7 ay expiry from the ate of manufacture. A syringe may be infuse for a maximum of 24 hours. To prevent wastage, in the event of excess stock, SMOFlipi syringes may be prescribe for any baby requiring lipi. Note the slight ifference in ose when prescribing an intralipi / SMOFlipi syringe or intralipi 20% bag ue to ae vitamin component in the syringes g fat/kg/ Intralipi syringe ose (inc vitamins) SMOFlipi syringe ose (inc vitamins) Intralipi 20% bag ose (no vitamins) 1 st ay PN 2g 12mls/kg/ay 12mls/kg/ay 10mls/kg/ay 2 n ay PN 3g 18mls/kg/ay 18mls/kg/ay 15mls/kg/ay 3 r ay PN 3.4g 20mls/kg/ay 20mls/kg/ay 17mls/kg/ay

5 The total volume in an intralipi / SMOFlipi syringe is 50mls. In a baby weighing more than 2.5kg, where the lipi infusion rate excees 2.1mls/hr, prescribe only one syringe per 24 hour perio to prevent excessive vitamin aministration. An intralipi 20% bag shoul be prescribe to aminister the remaining lipi requirement for the 24 hour perio. If you are in any oubt which is the most suitable choice of PN, please iscuss with the unit Nutrition Lea/ Pharmacist or the Dietitian if available. Prescribing an Aministration All maintenance PN shoul be prescribe on a eicate prescription chart (see example in appenix). Birth weight shoul be use for the calculations of PN until birth weight is regaine. Thereafter, the most recent weight or working weight as appropriate shoul be use. SWMNN maintenance PN elivere at maximum rate will provie ml/kg/ay (epenant on Vamin bag) this may not provie aequate flui, particularly in the first week of life. It may be necessary to provie extra flui, which can be given alongsie the parenteral nutrition as clinically necessary (see Moe of Delivery). Prior to aministering any infusion of parenteral nutrition, 2 registere practitioners shoul inepenently ensure that: The prescription is legal an clinically correct The type of vamin bag an lipi obtaine are the same as that prescribe The prouct will not expire for at least 24 hours (note if vamin expiry <48 hours bag will nee replacing sooner than usual) The vamin bag has reache room temperature. (During warming small gas bubbles form, which then issipate when the bags reach room temperature. Whilst they are reportely not large enough to cause any harm to the patient they may set off pump alarms. In aition patients may get col shock from infusion of chille flui) The calculate infusion rates are correct an o not excee maximum allowe The batch number for both the vamin bag an lipi syringe/bag are ocumente in the baby s paperwork as per unit policy. An inepenent log (separate to the baby s notes) is mae of the prouct/ batch number to be aministere to baby (see appenix.) A eicate lumen of a central line is available an esignate for PN (see moe of elivery) PN infusions are aministere via a rate controlle syringe pump Vamin is aministere via a 0.2 micron filter. It is not manatory to filter lipi solutions. Refer to unit policy. Weaning PN Enteral fees shoul be commence as soon as possible an increase as per SWMNN Enteral Feeing Guieline. To ensure the provision of aequate nutrition uring the introuction of enteral fees the volume of parenteral nutrition elivere shoul not be reuce until the baby is receiving a total volume of 180mls/kg/ay (Enteral an Parenteral )(unless flui restricte). Once this volume is reache the vamin an lipi components of the parenteral nutrition shoul be weane in proportion to ensure the ratio of calorie provision by fat an carbohyrate remains appropriate.

6 For every 1ml/hr increase in enteral fees maintenance 15 Vamin shoul be reuce by 0.85ml/hr an Lipi syringe by 0.15ml/hr an maintenance 12 Vamin an Term baby shoul be reuce by 0.83ml/hr an Lipi syringe by 0.17ml/hr Example calculation: 1100g baby on Maintenance 15 + Lipi syringe an increasing enteral fees of MEBM Total fluis 180ml/kg/ay = 198ml/ay = 8.25ml/hr x 24 hours EN = 80ml/kg/ay = 7.3ml 2 hourly PN 100ml/kg/ay Calculate total PN hourly rate = 100 x 1.1=110ml/ay = 4.58ml/hr Maintenance 15 Vamin rate = 0.85 x 4.58ml/hr = 3.90ml/hr Lipi syringe rate =0.15 x 4.58ml/hr = 0.69ml/hr For etaile tables showing PN /EN volume intakes an nutritional intake as enteral fees increase an PN ecreases see appenix 4a-e Enteral vitamins (if require) shoul be commence when the lipi infusion is running at less than 10mls/kg/ay (see SWMNN vitamin an mineral guieline) Monitoring an Review All babies who are receiving parenteral nutrition shoul: Be reviewe by the local Nutrition Team weekly (ieally comprising as a minimum of a octor, ietician, pharmacist an nurse). Be weighe at least three times a week an plotte on a neonatal an infant close monitoring growth chart. Have length an hea circumference measure weekly an plotte on a neonatal an infant close monitoring growth chart. NB: In the event an infant is too unstable to be weighe for perios of over 5 consecutive ays consier aopting the working weight as the calculate weight for age from the appropriate growth chart, assuming the the infant is following their previous centile line. This will ensure aequate parenteral nutrition is aministere accoring to infant s likely weight. Reinstate routine weighing once infant is stable enough to tolerate the proceure. Have aily U+Es an glucose monitoring for the first 7 ays. Clinical jugement shoul etermine further monitoring of these parameters in the subsequent weeks. Liver function tests, incluing split bilirubin/bone profile shoul be one weekly for the uration of PN. Have nutrition bloos performe 4 weekly. Stop the lipi infusion 4 hours prior to taking the bloos These inclue: Triglyceries Fat soluble vitamins A D E Zinc

7 Copper Manganese Selenium B12 an folate Ferritin Note that ferritin an copper levels may be elevate in the presence of infection, an vitamin A, zinc an selenium may be lowere. Orering of PN Orering proceures nee to be etermine locally. Storage Vamin bags an lipi syringes shoul be refrigerate immeiately after elivery. Intact Intralipi 20% bags can be store at room temperature. Vamin an the lipi syringes shoul be refrigerate between 2 8 o C. The temperature of the frige shoul be checke aily an ocumente accoring to local policy. Review, Monitoring, an Revision Arrangements Regular auit shoul be conucte to ensure all the aspects of PN aministration are being ahere to Appenix 1 Nutritional Composition of PN bags Appenix 2 Exapmle of PN log Appenix 3 Example of PN prescription sheet Appenix 4a-e Combine nutritional intake enteral an parenteral 9. References 1. Tsang RC, Uauy R, Koletzko B, Zlotkin SH. Nutrition of the Infant: Scientific Basis an Practical Guielines. 2 n En Digital Eucational Publishing ISBN- 13: ESPGHAN 2012 Enteral Nutrient Supply for Perterm Infants: Commentary from European Society for Paeiatric Gastroenterology, Hepatology an Nutrition Committee on Nutrition. J Peiatr Gastroenterol Nutr. Vol 50; Koletzko, Berthol, Goulet, Olivier et al. Guielines on Peiatric Parenteral Nutrition of the European Society of Paeiatric Gastroenterology, Hepatology an Nutrition (ESPGHAN) an the European Society for Clinical Nutrition an Metabolism (ESPEN) supporte by the European Society of Paeiatric Research. J Peiatr Gastroenterol Nutr Vol 41 sup 2 pps1-s87 4. NCEPOD Report: Parenteral Nutrition: A Mixe Bag (2010) 5. e Meijer VE, Gura KM, Meisel JA, Le HD et al. Parenteral Fish Oil Monotherapy in the Management of Patients with Parenteral Nutrition Associate Liver isease. Arch Surg 2012; 145(6):

8 6. Develieger H, Jochum F Allegaert K. Short term Use of Parenteral Nutrition with a lipi emulsion containing a mixture of soybean oil, olive oil, meium chain triglycerie an fish oil: a ranomise ouble blini stuy in preterm infants. J Parenter Enter Nutr : Rowan M, N Ascenzo R, D Eqiio S, Angelini L et al. Parenteral nutrition of preterm infants with a lipi emulsion containing 10% fish oil; effect on plasma lipis an long chain polyunsaturate fatty acis. J Peiatr 2011 Jul;159(1): 33-38e 8. corresponence from ITH Pharma, Quality Department. 2 n Fe Pineault M, Chessex P, Pieboeuf B et al. Beneficial effect of coinfusing a lipi emulsion on venous patency. J Parenter Enteral Nutr 1989;13(6): Haase R, Hein M, Thale V et al. Umbilical venous catheters-analysis of malpositioning over a 10 year perio. Z Gerburtshilfe neonatal 2011; 215(1): 18-22

9 Composition (ml) Start up Maintenance 12 Maintenance 15 Term baby Maintenance 12 + peitrace Maintenance 15 + peitrace Term baby + peitrace Vaminolact Glucose 50% WFI Calcium gluconate 10% Potassium phosphate 13.6% (1mmol/ml PO4 an K) NaAc 30% (2.2mmol/ml Na an Ac) MgSO4 50% (2mmol/ml) ZnSO4 100micromol/ml Soium glycerophosphate 21.6% (2mmol/ml Na an 1mmol/ml PO4) Soium selenite 0.2micromol/ml Soium chlorie 30% Potassium chlorie 15% Peitrace Total volume Stability 90 ays 90 ays 90 ays 90 ays 7 ays 7 ays 7 ays

10 Composition (ml) Start up Maintenance 12 Maintenance 15 Term baby Maintenance 12 + peitrace Maintenance 15 + peitrace Term baby + peitrace Per volume (ml)/kg Nitrogen (g) Protein(g) Glucose (g) Nitrogen calories (Kcal) Non-nitrogen calories (Kcal) Total calories (Kcal) Soium (mmol) Potassium (mmol) Calcium (mmol) Magnesium (mmol) Phosphate (mmol) Acetate (mmol) Chlorie (mmol) Zinc (micromol) Selenium (nanomol) Copper (micromol) Manganese (nmol) Fluorie (micromol) Ioie (nmol) Max Peitrace in Neo 12 =0.8ml/kg/ay peitrace lt by vaminolact amount*

11 NEONATAL PARENTERAL NUTRITION RECORD SHEET Check expiry ate of the PN bag that you are using alongsie others of the same type in the frige use the one with the shortest expiry ate. If any maintenance 12 / 15 or Term baby + Peitrace is ue to expire within the next 3 ays, please use in place of maintenance 12 / 15 or Term baby in babies on these corresponing bags where possible. Check expiry ates of all intralipi syringes, an use the one with the shortest expiry ate first. If there are no intralipi syringes, use SMOFlipi syringe Only use intralipi 20% bags if there are no lipi syringes that are in ate. PLEASE ENSURE RECORDS ARE IN CHRONOLOGICAL ORDER WHERE POSSIBLE Date Given Baby s Hospital No. Baby Surname Nutrition prouct utilise* Batch No. Expiry Name of nurse (Please print) If bag not use, please specify here (incluing reason) * Please specify type of prouct from this list: Start-up Vamin maintenance 12 maintenance 15 Term baby maintenance 12 + Peitrace maintenance 15 + Peitrace Term baby. + Peitrace Intralipi syringe SMOFLipi syringe Intralipi 20% bag

12 NEONATAL PARENTERAL NUTRITION PRESCRIPTION CHART PRETERM MAINTENANCE 12 Working weight: Solution formula (Aqueous volume = 400mL) Water f or Injection **Aminister via CENTRAL LINE only** Use a single central line lumen ONLY for PN Date recore: Details from nutrition roun: Vaminolact Soium Chlorie, 30% 0.16 Calcium Gluconate, 10% Soium Gly cerophosphate, 21.6% 6 Preferre PN bag to Lipi type to Date of roun: Registration No. NHS No. Sex War change to: be use: Glucose, 50% 96 Magnesium Sulf ate, 50% 0.4 Surname First Name Potassium Chlorie, 15% 3.2 Zinc Sulf ate 100micromol/ml 0.16 Age D.O.B. Consultant Soium Selenite 0.2micromol/ml 0.5 Nutrition an electrolyte summary Lipi syringe (see guielines if using intralipi 20% bag) Potassium ihy rogen Phosphate 13.6% 1.6 Soium Acetate 30% ml/kg 40 ml/kg 60 ml/kg 80 ml/kg 100 ml/kg Protein (g) Day 1 (with Start-up Vamin) 12 ml/kg/ay 2 g/kg/ay 20 Kcal/kg/ay Glucose (g) Soium (mmol) Total Calories (Kcal) Day 2 18 ml/kg/ay 3 g/kg/ay 30 Kcal/kg/ay Potassium (mmol) Calcium (mmol) Day 3 onwars 20 ml/kg/ay 3.4 g/kg/ay 34 Kcal/kg/ay Magnesium (mmol) Phosphate (mmol) Acetate (mmol) WEANING - VAMIN Decrease ml/hr = Total volume to ecrease/hr x 0.83 LIPID Total volume to ecrease/hr x 0.17 Chlorie (mmol) Zinc (μmol) Date Total flui volume before Enteral Fee Weaning volume (ml/hr) Signature Selenium (nmol) weaning Amount increase Frequency Vamin Lipi Copper (μmol) Manganese (nmol) Fluorie (μmol) Ioie (nmol) Date Nutrition type PRETERM MAINTENANCE 12 (run for 48 hours) LIPID TYPE (for first 24hrs) Please circle VOLUME (ml/kg/ay) RATE (ml/hr) ROUTE Prescriber s Signature Print Name Batch No. Expiry CHECK BY Start time Volume at start Pharmacist Clinical Check INTRALIPID SYRINGE SMOFLIPID SYRINGE INTRALIPID 20% BAG LIPID TYPE (for next 24hrs) Please circle INTRALIPID SYRINGE SMOFLIPID SYRINGE PRETERM MAINTENANCE 12 (run for 48 hours) LIPID TYPE (for first 24hrs) Please circle INTRALIPID SYRINGE SMOFLIPID SYRINGE INTRALIPID 20% BAG INTRALIPID 20% BAG LIPID TYPE (for next 24hrs) Please circle INTRALIPID SYRINGE SMOFLIPID SYRINGE INTRALIPID 20% BAG

13 volume Appenix 4a.. Table showing contribution to nutritional intake from Maintenance 12 PN & MEBM Parenteral Nutrition - Maintenance 12 vamin lipi syringe Enteral Nutrition MEBM Combine Parenteral an Enteral Nutrition energy protein soium volume energy protein soium volume energy protein soium kcal/kg/ ml/kg/ ml/kg/ ml/kg/ kcal/kg/ g/kg/ mmol/kg/ ml/kg/ kcal/kg g/kg/ mmol/kg/ ml/kg/ g/kg/ mmol/k g/ a BMF

14 Appenix 4b.. Table showing contribution to nutritional intake from Maintenance 12 PN & Nutriprem 1 Parenteral Nutrition - Maintenance 12 Enteral Nutrition Nutriprem 1 volume vamin lipi syringe Combine Parenteral an Enteral Nutrition energy protein soium volume energy protein soium volume energy protein soium ml/kg/ kcal/kg ml/kg/ ml/kg/ kcal/kg ml/kg/ ml/kg/ g/kg/ mmol/k kcal/kg g/kg/ mmol/k g/kg/ mmol/k / / g/ g/ g/

15 Parenteral Nutrition - Maintenance 15 volume Appenix 4c.. Table showing contribution to nutritional intake from Maintenance 15 PN & MEBM /Infant Formula vamin lipi syringe Enteral Nutrition MEBM Combine Parenteral an Enteral Nutrition energy protein soium volume energy protein soium volume energy protein soium ml/kg/ ml/kg/ ml/kg/ kcal/kg/ g/kg/ mmol/kg/ ml/kg/ kcal/kg g/kg/ mmol/kg/ ml/kg/ kcal/kg/ g/kg/ mmol/kg/ a BMF

16 Appenix 4. Table showing contribution to nutritional intake from Maintenance 15 PN & Nutriprem 1 Parenteral Nutrition - Maintenance 15 Enteral Nutrition Nutriprem 1 volume vamin lipi syringe Combine Parenteral an Enteral Nutrition energy protein soium volume energy protein soium volume energy protein soium ml/kg/ ml/kg/ ml/kg/ kcal/kg/ g/kg/ mmol/kg / ml/kg/ kcal/kg g/kg/ mmol/kg / ml/kg/ kcal/kg/ g/kg/ mmol/kg /

17 Parenteral Nutrition - Term Baby volume Appenix 4e.. Table showing contribution to nutritional intake from Term Baby PN & MEBM /Infant Formula vamin lipi syringe Enteral Nutrition MEBM/Term formula Combine Parenteral an Enteral Nutrition energy protein soium volume energy protein soium volume energy protein soium ml/kg/ ml/kg/ ml/kg/ kcal/kg/ g/kg/ mmol/kg / ml/kg/ kcal/kg/ g/kg/ mmol/kg / ml/kg/ kcal/kg/ g/kg/ mmol/kg/