clinical guideline for total parenteral ......clinical guideline template page 2 of 25 1....

Clinical Guideline Template

of 25

CLINICAL GUIDELINE FOR TOTAL PARENTERAL NUTRITION IN PAEDIATRIC PATIENTS FROM 4 WEEKS TO 16 YEARS

Summary

1. NO

YES

Refer to paediatric dietitian, providing information on diagnosis,

history of presenting complaint, indication for PN & anthropometry

Take baseline blood test, weight, height/length, head circumference (if <2yrs) Day prior to initiation or by 10am in morning

If taking bloods in the morning mark as urgent

Continuation Follow guideline for frequency of

monitoring (see 2.3) Take bloods night before

prescribing or urgently in the morning as above

Pharmacist and doctor check blood results prior to prescribing

Tailor prescription to outcome of monitoring (e.g. fluid status, blood sugars), enteral intake, complications

Initiation Pharmacist and doctor check

baseline blood results Paediatric dietitian conducts initial

nutritional assessment Discuss blood results with BCH Prescribe 1 day at a time days 1-3

(up to 3 days if starting on Friday) Daily blood monitoring (see 2.3) Monitor physical status as per 2.3,

including fluid in/output and blood/urine sugars

Pharmacist sends prescription to PTSU by 1pm (Mon-Fri)

PTSU make PN (Mon-Fri) and send to PN fridge (top of pharmacy ramp) by 6pm

Doctor prescribe PN on fluid chart

Inadequate enteral intake or enteral route contraindicated and need for PN > 72 hours

Inform ward pharmacist, paediatric dietician and nurse as soon as practical

See Appendix 4 for information on MDT roles and

responsibilities

Baseline assessment Paediatric consultant* decision to initiate PN following

discussion with nutrition team at Bristol Children’s Hospital (BCH) (see appendix 3 for proforma)

Document reason for PN, desired outcome, expected duration and other nutrition/fluid/electrolytes via other routes in notes

Provide information to child/family Insert suitable IV access (see 2.5.1)

*Should be a joint paediatric/surgical consultant opinion if surgical patient. Liaison with BCH to be carried out by paediatric consultant


of 25

1. Aim/Purpose of this Guideline 1.1. This guideline should be used on the paediatric wards to initiate PN. It should not be used for neonates (under 4 weeks of age). 1.2. This guidance is based on procedures used at Bristol Children’s Hospital. The information is guidance only, and nutrition should be tailored to a patient’s individual needs taking into account hydration status and the access available.

2. The Guidance 2.1. Introduction Parenteral nutrition (PN) is the administration of nutrition directly into the bloodstream, and is usually indicated when sufficient nutrition cannot be given either orally or enterally to meet the patient’s requirements to correct malnutrition or to maintain appropriate growth. Parenteral nutrition can lead to many complications and should only be used where there is no alternative method of feeding. Risks involved in the use of PN include:

Fluid overload or dehydration Venous catheter complications – line sepsis, thrombosis, thrombophlebitis,

extravasation, line breakage Metabolic disturbances – hypo- or hyper-glycaemia, hypertriglyceridaemia Electrolyte disturbances Liver disease associated with PN Refeeding syndrome

2.2. Initiation of PN The decision to initiate PN should be made by a paediatric consultant following discussion with the nutrition team at Bristol Children’s Hospital (BCH) via the paediatric gastroenterologist on service who can triage from there if needed. They can either be reached via trust switchboard (0117) 923 0000 or mobile 07789 876406. The template in Appendix 3 may be used to guide these discussions. Where the patient is under the care of a surgical team the decision to initiate PN should be made jointly with surgical and paediatric consultants. A plan for PN should be made prior to initiation and documented in the medical notes, including:

Expected duration and desired outcome of PN What IV access is available or will be available for the administration of PN Other oral/enteral/parenteral nutrition or fluids to be given alongside PN or

whether the patient is nil-by-mouth PN will not be initiated at the weekends due to the inability to check stability of formulations and reduced access to specialist advice both at RCHT and BCH, except in exceptional circumstances where a delay until the next working day would cause significant harm to the child. The decision to initiate PN at weekends must be made by the paediatric consultant (see section 2.8 for out of hours prescribing).

2.3. Monitoring Monitoring is an essential component of safe and effective PN therapy, and should follow the following table (based on the BCH guidance). Any derangements from the normal range should be discussed with the consultant or ward pharmacist. If there are any major concerns the patient must be discussed with Bristol Children’s Hospital’s nutrition team. Blood samples should ideally be taken from a different line to the PN. This reduces the risk of incorrect electrolyte levels and line infections.


of 25

Additional notes Prior to

initiation First week Stable PN

Daily Twice weekly

Weekly Daily Twice weekly

Weekly Monthly

Infusion site Monitor CVC exit site and dressing for redness, tenderness, swelling, leakage or inflammation

Fluid balance Must include oral/enteral and intravenous input (including IV flushes and medications) and urine/vomit/aspirates/stoma/drain output/bowel output using ward fluid balance charts

Mouth care If NBM or poor oral intake, monitor for signs of thrush and mouth ulcers Glucose

monitoring Urinary dipsticks daily whilst PN running for first week. If urinary glucose cannot be measured use blood glucose (treat >11mmol/L as significant) Persistent hyperglycaemia may require adjustment of carbohydrate content – seek advice from BCH

Only if glucose dose recently increased

Sodium Potassium

Urea, Creatinine Urine sodium &

potassium

Calcium Phosphate Magnesium Triglyceride Check weekly, or more frequently if lipid dose > 3g/kg/day, history of high

triglyceride levels, sepsis, in the catabolic or critically ill or unexplained thrombocytopenia. Preferably take directly prior to hanging infusion

ALT/AST Alk Phos

GGT Only if repeat if LFTs abnormal Only if repeat if LFTs abnormal Albumin Bilirubin

Acid base balance FBC Do not order more than once weekly as part of routine PN monitoring – patients

are vulnerable to anaemia secondary to repeated venesection

Ferritin After 1 month, then every 3 months Trace elements Including copper, selenium, manganese, zinc. Check CRP at same time After 1 month, then every 3 months Vitamins ADE After 1 month, then every 3 months

Weight Plotted on a centile chart at suitable intervals Height/length

Head circumference Only if < 2 yrs old


of 25

2.4 Prescribing Paediatric PN is prescribed using a spreadsheet based programme, which allows provision of bespoke PN provided as an aqueous bag, containing amino acid and carbohydrate (provided in a silver light-proof cover), and a lipid bag or syringe (provided in a black light-proof cover). A different system is used for neonates and is outside the scope of this guideline. In some circumstances it may be possible to use an “all-in-one” bag, which requires completion of an adult PN prescription. The ward pharmacist can advise on which prescription will be used following liaison with the adult nutrition team. Prior to PN prescribing:

The patient must have been discussed with BCH’s nutrition team via consultant to consultant telephone call

A full set of baseline bloods as per 2.3 must be available, and any electrolyte imbalances corrected before starting PN

The patient’s weight must be known. Actual weight should be used for prescribing unless the patient is grossly oedematous or thought to be acutely dehydrated, in which best estimate of body weight should be used, which will be the last actual weight that was taken when the patient was oedematous, for example.

The patient’s calorific requirements should have been assessed by a paediatric dietitian. As a minimum, the BCH nutrition team can give an estimate of nutrition requirements, but this must be followed by an accurate assessment as soon as practical.

The PN prescription must be completed by a senior paediatrician (registrar or above) looking after the patient and a pharmacist. It is recommended that initially PN is prescribed one day at a time. An exception to this is over the weekend where it may be necessary to prescribe 3 days (4 days if over a bank holiday period). Once prescribed two copies of the prescription should be printed and signed. One copy will be sent to pharmacy technical services and one copy should be stored in the patient’s nursing folder with the fluid chart. Once prescribed on the electronic system, PN should be prescribed on EPMA (using the drug “TPN”) to alert all health professionals that the patient is receiving PN and on the fluid chart to enable nurses to administer. It will be necessary to prescribe the aqueous phase and lipid phase separately on the fluid chart where bespoke PN in being used. Guidance on the recommended nutritional content can be found in appendix 1. However, this is just a guide and the PN should be adjusted as required based on a patient’s individual requirements. During ongoing PN support the patients calorific requirements must be assessed by a paediatric dietitian weekly or as clinically indicated (i.e. if patient’s clinical condition changes e.g. sepsis) to ensure patients calorie requirements are being met by the current PN regime.


of 25

2.4.1 Allergies The lipid component of PN often contains allergens that are unsuitable for patients allergic to fish, egg, soya or peanut protein. In these patients modifications to the recipe may be required. This will need to be discussed with the pharmacist and nutrition team.

Product Type of Allergy Fish Egg Soya Peanut

protein Methylhydroxy-

benzoate SMOFLipid X X X X

Intralipid X X X Solivito N X

X = CONTRAINDICATED 2.4.2 Compounding, delivery and storage All PN requests are processed by the pharmacy technical services unit at RCH. Prescriptions must be received by the unit by 1pm for delivery to the refrigerator at the top of the pharmacy ramp by 5pm. Wards can collect PN from the fridge once it is needed either by collecting the key from pharmacy before 6pm or by obtaining the key from switch board out of hours. Prior to hanging, PN must be left to stand for 1 hour to minimize the risk of hypothermia. 2.4.3 Patients at risk of refeeding syndrome Any patient who has experienced recent starvation is at risk. However presence of the following risk factors increases the chances of developing refeeding syndrome:

High risk Very high risk BMI < 80% median BMI (0.4th-2nd

centile) < 70% median BMI (< 0.4th centile)

5-10% weight loss >10% weight loss Minimal or no feeding (<50%

estimated requirements) prior to admission for > 3 days

Heightened risk if in combination with concurrent illness

Low serum levels of potassium, phosphate or magnesium

Chronic malabsorption e.g. significant diarrhea or vomiting in the last week

Neutropenia Bradycardia or prolonged QT interval If a patient is at risk of refeeding syndrome the patient must be discussed with the nutrition team at BCH. General principles of management are listed below.

Ensure hypophosphataemia is corrected before initiating PN Initiate fluid volume at 50% of 24 hour maintenance requirements and

increase by 25% per day Aim over the first 2-3 days to maintain the same weight or lose weight Give carbohydrate over 24 hours Replace potassium slowly


of 25

Give at least 0.5mmol/kg phosphate and increase up to 1mmol/kg if required for low phosphate levels

Limit initial nitrogen intake to avoid hyperammonaemia and/or metabolic acidosis and ensure protein/total calorie ratio is balance. 0.08-0.16g/kg nitrogen initially may be sufficient. Increase dose slowly.

Monitor weight daily and for signs of oedema. If oedematous, review IV fluids.

Initiate Pabrinex (IV vitamin B) at least 30mins prior to starting feeding. This should be continued for 3-5 days. Doses given once daily:

o < 6 years 1.25mL o 6-10 years 2mL o 10-14 years 3mL o > 14 years 5mL Dose volume above should be taken from each ampoule and given by infusion (see product literature)

If electrolyte levels fall but no clinical signs of refeeding then replace electrolytes but do not decrease calorie intake.

Further information can be found in the Bristol Children’s Hospital guideline “Refeeding syndrome – management of paediatric inpatients”, accessed via the link on the Child Health intranet page “Paediatric Policies and Guidelines”

2.5 Administration 2.5.1 Venous access PN should run through a central venous catheter (CVC) wherever possible as many of the PN formulations used cannot be given peripherally. The line tip position should be confirmed by x-ray in theatre as being in the superior vena cava or inferior vena cava or outside of the right atrium before PN is infused as per ESPGHAN guidance. Ideally there should be a dedicated nutrition line or lumen (if multi-lumen line). For care of the CVC please refer to separate guideline. If no central access is available please discuss with a pharmacist or Bristol nutrition team to discuss options. Suitable CVCs

CVCs may have single, double or triple-lumen. Single lines are more common in long-term PN

Percutaneously inserted central catheters (PICCs) and tunneled catheters (e.g. Hickman lines) for long-term PN

Femoral or temporary central lines are not recommended for central PN but may be used for short term use while plans are made to place a definitive central venous line. Care should be taken to ascertain where the tip of a femoral line is located, as the line must be regarded as peripheral unless the tip is in the superior/inferior vena cava/outside of right atrium. Femoral lines should only be used for a maximum of 7 days.

Subcutaneous implantable ports are only suitable for short term PN (i.e. up to 7 days)

Accessing the line and blood sampling


of 25

Blood samples should ideally be taken from a different line to the PN. This reduces the risk of incorrect electrolyte levels and reduces the risk of line infections. Where a multi-lumen line is in use accessing a lumen other than that used to administer PN is not considered to be using the PN line.

NOTE Syringes of 10mL or greater should be used to access a CVC as the high flush pressure generated by syringes smaller than 10mL can rupture the line.

Please see separate CVC guideline for management of complications associated with CVCs.

2.5.2 Practicalities of administration

As PN is administered Centrally, administration must only be carried out by nurses who have completed CVC training

If the PN administration set is disconnected from the patient at any time the PN and giving set must be discarded. A PN infusion should never be restarted if disconnected.

Appropriate giving sets for the PN are provided with the PN – other giving sets may not be appropriate and therefore should not be used unless checked for suitability with a pharmacist or the nutrition team.

Other fluids and medications should be given through a different line. Using the PN line to give medication increases the risk of infection. There is also a risk that the medication/fluids may interact with the PN resulting in blocked lines or harm to the patient.

It is acknowledged that in exceptional circumstances that the PN line may be the only access available (e.g. in autistic children who cannot tolerate a cannula). In these cases the following guidance must be followed:

o Medication or blood products must not be administered through a y-site with PN as there is a high risk of instability. Additional information on compatibilities of medication with PN can be found on MEDUSA or the ward pharmacist can provide information.

o If there are no other options for venous access and medication has to go through the PN line, PN should be paused (NOT disconnected), the line flushed well and then the drug given, followed by another flush.

o NOTE Products containing calcium, phosphate or sodium bicarbonate should never be given through the same line as PN while the PN is running as there is a high risk of incompatibility with the PN

o Where the PN line is used for medication a DATIX must be completed

No additions must be made to the PN at ward level – this may affect stability and will increase infection risk.

It is not recommended to hang PN for longer the 24 hours Nursing checks of PN during administration

Care of the central line should be carried out as per the separate CVC guideline

Additional care is required to ensure that PN is administered at the correct rate – giving PN too quickly can cause significant harm to the patient. The following checks should be carried out when putting up a new bag of PN and at handover of each shift:


of 25

FOR TAILORED PN (where separate bags are provided for the aqueous feed and lipid)

o Identify which bag contains the aqueous phase and which contains the lipid. The lipid will be white/cream in colour and will be covered with a black light proof bag. The aqueous phase will be transparent and cover with a silver light-proof bag.

o Ensure the each bag is running at the correct rate. This should be checked against the fluid chart AND the electronically generated PN prescription which will be filed in the nursing folder.

o As part of this check it should be confirmed that the correct giving set is going through the right pump.

FOR STANDARD BAG PN (single bag containing both lipid and aqueous phase)

o Ensure the bag is running at the correct rate. This should be checked against the fluid chart AND the pre-printed PN prescription which will be filed in the nursing folder.

2.6 Continuation of PN Once the patient is stable, monitoring can continue as per 2.3 Liaison with the Bristol nutrition team should occur weekly and more

frequently if the patient’s condition changes (e.g. complications develop) 2.7 Stopping/weaning PN

PN can usually be safely discontinued when the patient reaches two-thirds of their target oral/enteral intake – this must be discussed with a dietitian to ensure calorific intake is not compromised

Cyclical PN, where PN is given over <24 hours each day, is not recommended until the patient has been on PN for at least 1 week. The sudden discontinuation of a high glucose infusion increase the risk of hypoglycaemia, so blood glucose should be checked 30-60minutes after the end of the infusion until results are stable. Hypoglycaemia should be treated as per Trust protocol

2.8 Provision of parenteral nutrition to paediatric patients at weekends 2.8.1 Initiation of PN is rarely a clinical emergency, and prior to requesting PN every effort

should be made to liaise with the ward dietitian and/or Bristol Children’s Hospital Nutrition Support Team (NST) Monday to Friday to explore whether other feeding routes have been exhausted and how PN will be managed for the specific patient.

2.8.2 On the rare occasions that PN needs to start outside of usual operational times pre-filled PN bags can be used to provide basic nitrogen, carbohydrate, lipid and electrolytes. These bags are limited as they may not be tailored to the age or weight of the patient and do not contain vitamins or trace elements, which are highly desirable if the patient receives no enteral nutrition. Tailored bags cannot be made out of hours as there is no access to stability data. This section provides information on the appropriate use of pre-filled bags in this situation.


of 25

Yes No

Start

Baseline Assessment

Paediatric consultant decision to initiate PN – (with input from Consultant Surgeon if surgical patient)

Document reason for PN, desired outcome, expected duration and other nutrition/fluid/electrolytes via other routes in notes – PN should only be commenced out of hours in exceptional circumstances as specialist advice from Bristol Children’s Hospital not easily accessed at weekends (see 2.2)

Insert suitable IV access and take baseline bloods and anthropometrics as per 2.3-2.5

Decision to Start PN

Once done contact the on-call pharmacist who will liaise with technical

services pharmacist regarding supply for

either same day if time appropriate or next day.

Manage Fluids and Review

Starting out of hours PN Consider refeeding risk Calculate desired maintenance fluid

volume and available volume for PN Insert suitable IV access (see 2.5) Select PN product by access, weight

and available fluid volume (see next page)

Prescribe recommended volume of PN for weight and day of PN, unless available fluid volume is less (prescribe that instead)

Monitor bloods as per 2.3 Top-up electrolytes and/or fluids as

needed Liaise with ward pharmacist on next

working day to arrange PN.


of 25

Bag Selection for Out of Hours Use:

And SMOFLipid 20% Day 4:

12.5ml/kg#

# Note if patient at high/very high risk of refeeding and electrolyte levels are falling do not increase dose until electrolytes are replaced and are in the normal range

Patient Weight <10kg

CENTRAL LINE Babiven

Maintenance (If more fluid required) Day 1: 50ml/kg Day 2: 75ml/kg# Day 3+:

100ml/kg# AND

SMOFLipid 20% Day 1: 5ml/kg Day 2: 7.5ml/kg# Day 3+:

10ml/kg#

CENTRAL LINE ONLY

Babiven Concentrated

(Preferred bag to use) Day 1: 40ml/kg Day 2: 60ml/kg# Day 3+:70ml/kg#

AND SMOFLipid 20% Day 1: 5ml/kg Day 2: 7.5ml/kg# Day 3+:

10ml/kg#

10kg – 30kg

CENTRAL LINE Kabiven 9g Day 1: 40ml/kg Day 2+:

55ml/kg#

> 30kg

CENTRAL LINE Kabiven 9g Day 1+: 40ml/kg

<5kg

Babiven Concentrated Day 4: 80ml/kg#


of 25

2.8.3 Whilst the patient is receiving PN they must be monitored in accordance with

Paediatric Parenteral Nutrition guideline section 2.3 (monitoring), or as per additional monitoring required for patients at high or very high risk of refeeding syndrome (see 2.4.3)

2.8.4 Check carefully what volume of PN should be prescribed per kilogram, it may be less than the maintenance requirements of the patient. Some patients will need additional IV fluids or electrolytes due to the fixed-content of pre-filled PN bags.

2.8.5 PN should be prescribed on the blue paediatric IV fluid chart AND the blue and white PN prescription chart which can be supplied by the on-call pharmacist.

3. Monitoring compliance and effectiveness Element to be monitored

Safe administration of PN in paediatric patients

Lead Lead paediatric pharmacists (Sabrina Tierney & Jackie Pope) Paediatric consultant with specialist interest in gastroenterology Dr

M Thorpe Tool DATIX reports Frequency Annually Reporting arrangements

Paediatric governance committee

Acting on recommendations and Lead(s)

Paediatric governance committee

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 1 month. A lead member of the paediatric team will be identified to take each change forward where appropriate.

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 6.

.


of 25

Appendix 1 Recommended nutritional content of PN to meet estimated average requirements (EAR) These values are provided as a basic guide, and will vary according to the child’s clinical condition. Exact requirements should be confirmed with Bristol Children’s Hospital. Further information can be found in the Bristol Royal Hospital for Children’s clinical guideline “Total Parenteral Nutrition”. Energy This is a guide only – actual energy requirements should be provided by a dietitian on an individual basis as soon as possible.

Nutrient Unit 0-1 years 1-7 years 7-12 years 12-18 years Energy Kcal/kg/day 90-100 75-90 60-75 30-60

Protein (prescribed as grams of nitrogen) Some conditions e.g. sepsis, surgery may mean higher protein requirements are required. Conditions like renal disease and hepatic failure may lead to lower protein requirements. This should be discussed with BCH (see also BCH guideline).

Nutrient Unit 1month – 3 years

3-5 years 6-12 years Adolescent

Nitrogen g/kg/day 0.14-0.4 0.16-0.32 (max 0.48)

0.16-0.32 (max 0.48)

0.16 (max 0.32)*

*based on lean body weight

1 g N = 6.25g protein

Carbohydrate (prescribed as glucose)

Nutrient Unit Weight Day of PN

1 2 3 4 onwards

Glucose g/kg/day

<3kg 10 14 16 18 3-10kg 8 12 14 16-18 10-15kg 6 8 10 12-14 15-20kg 4 6 8 10-12 20-30kg 4 6 8 <12 >30kg 3 5 8 <10

Please also see section on refeeding syndrome Lipid Infants max lipid dose: 3-4g/kg/day Older children max lipid dose: 2-3g/kg/day There is no need to gradually increased lipid dose. However, gradual increments of 0.5-1g/kg/day can may it easier to monitor for hypertriglyceridaemia. If using doses of >3g/kg/day in infants patients should be monitored for signs of “fat overload syndrome”, which can present with coagulopathies, hepatomegaly, elevated


of 25

liver enzymes, hyperbilirubinaemia, respiratory distress and thrombocytopenia. Lipid dose should be adjusted if marked hyperlipidaemia occurs (>2.8mml/L in infants or >4.5mmol/L in older children). Management of high triglyceride level:

Check whether the line was flushed prior to the sample being taken Repeat triglyceride level if biochemistry has commented that the sample is

lipaemic Consider repeating triglyceride level after a period of 4 hours off lipids (if

clinically suitable for the patient) Excess provision of carbohydrate may be associated with increased production

of triglycerides – discuss with BCH if this is being considered Discuss with BCH if repeat triglyceride is markedly elevated

Fluid Maintenance fluid requirement may be calculated using the rule of thumb: However, when calculating the fluid volume for PN consideration should be given to:

Oral/enteral fluid intake Intake from medications Losses e.g. insensible, urine, from stoma Current fluid balance

Electrolytes and minerals Take into account that some drugs contain significant amounts of cations (e.g. iv antibiotics), or mineral salts

Electrolyte Unit 1-6 months 7-12 months

1-13 years 14-18 years

Sodium mmol/kg/day 2-3 2-3 1-3 1-3 Potassium mmol/kg/day 1-3 1-3 1-3 1-3 Calcium mmol/kg/day 0.8 0.5 0.2 0.8

Phosphorous* mmol/kg/day 0.5 0.5 0.2 0.5 Magnesium mmol/kg/day 0.2 0.2 0.1 0.2

*Calcium to phosphate ratio in PN should be 1.3-1.7

Neonates and infants, up to 180mL/kg/day <10kg 100mL/kg/day 10-20kg 1000mL + 50mL/kg/day for each kg>10kg >20kg 1500mL + 20mL/kg/day for each kg > 20kg


of 25

Vitamins and trace elements Nutrient Estimated requirement per

day (per kg or total Product used and

dose Infants

(per kg or total dose where indicated)

Children ( total dose or per kg

where indicated) Trace

elements Selenium 1-3 µg 1-3 µg/kg Peditrace® up to

40kg 1mL/kg, up to 15mL/day

Additrace® for >

40kg 10mL per day

Zinc <3mth 250 µg >3mth 100 µg

50 µg/kg/day (max 5mg)

Manganese Up to 1 µg Up to 1 µg/kg Copper 20 µg 20 µg/kg Iodine 1 µg total 1 µg total

Soluble vitamins

Ascorbic acid 15-25 mg 80 mg

Solivito N® 1mL/kg, up to 10mL per day

Thiamine 0.35-0.5mg 1.2mg Riboflavin 0.15-0.2mg 1.4mg Pyridoxine 0.15-0.2mg 1mg

Niacin 4.0-6.8mg 17mg B12 0.3 µg 1 µg

Pantothenic acid 1.0-2.0mg 5mg Biotin 5.0-8.0 µg 20 µg

Folic acid 56 µg 140 µg Fat soluble

vitamins Vitamin A 150-300 µgRE

(retinol equivalents) 150 µgRE Vitlipid N® infant up

to 11 years <2.5kg 4mL/kg, >2.5kg

10mL per day total Vitlipid N® adult for >11years 10mL per

day total

Vitamin D 0.8 µg(32IU)/kg

10 µg (400IU)

Vitamin E 2.8-3.5mg/kg 7mg Vitamin K 10 µg/kg 200 µg

Iron is not routinely added to PN for children < 40kg and iron deficiency anaemia may develop after prolonged PN. Please discuss with nutrition team regarding adding iron to PN is anaemia develops.


of 25

APPENDIX 2 – Off the shelf PN recipes available at RCH Please note, not all constituents listed for each bag Nutriflex Lipid PERI – not for out of hours use Per 1000mL Nitrogen (g) 4.6 Glucose (g) 64 Lipid (g) 40 Total calories (kcal) 764 Non-protein kcal/N ratio 140:1 Sodium (mmol) 40 Potassium (mmol) 24 Magnesium (mmol) 2.4 Calcium (mmol) 2.4 Phosphate (mmol) 6 Nutriflex Lipid Plus – not for out of hours use VIA CENTRAL LINE ONLY Per 1000mL Nitrogen (g) 5.4 Glucose (g) 120 Lipid (g) 40 Total calories (kcal) 1012 Non-protein kcal/N ratio 158:1 Sodium (mmol) 40 Potassium (mmol) 28 Magnesium (mmol) 3.2 Calcium (mmol) 3.2 Phosphate (mmol) 12 Nutriflex Lipid Special – not for out of hours use VIA CENTRAL LINE ONLY Per 1000mL Nitrogen (g) 8 Glucose (g) 144 Lipid (g) 40 Total calories (kcal) 1180 Non-protein kcal/N ratio 120:1 Sodium (mmol) 54 Potassium (mmol) 38 Magnesium (mmol) 4.2 Calcium (mmol) 4.2 Phosphate (mmol) 16


of 25

Babiven Products

Content Amount per 100ml Maintenance Concentrated

Total Energy (kcal) 54 81.8 Nitrogen (g) 0.37 0.6 Glucose (g) 11.1 16.8

Sodium (mmol) 2.22 3.4 Potassium (mmol) 1.5 2.3 Phosphate (mmol) 1.11 1.7 Magnesium (mmol) 0.15 0.2

Calcium (mmol) 1.11 1.7 Chloride (mmol) 1.5 2.3 Acetate (mmol) 1.5 2.3

Kabiven 9g

Content Amount per 100ml Total Energy (kcal) 70.83

Nitrogen (g) 0.38 Glucose (g) 6.75

Sodium (mmol) 2.21 Potassium (mmol) 1.67 Phosphate (mmol) 0.75 Magnesium (mmol) 0.28

Calcium (mmol) 0.14 Chloride (mmol) 3.25 Acetate (mmol) 2.71


of 25

Content Amount per 1000ml Sodium Chloride

0.9%

Sodium Chloride

0.45%

Sodium Chloride

0.45% with glucose 5%

Sodium Chloride


Sodium Chloride


& potassium chloride 10mmol*

Sodium Chloride


& potassium chloride 20mmol*

Plasma-lyte 148

Plasma-lyte 148 with

glucose 5%

Total Energy (kcal)

0 0 200 400 200 200 0 200

Glucose (g) 0 0 50 100 50 50 0 50

Sodium (mmol)

150 75 75 75 75 75 140 140

Potassium (mmol)

0 0 0 0 20 40 5 5

Magnesium (mmol)

0 0 0 0 0 0 1.5 1.5

Chloride (mmol)

150 75 75 75 95 115 98 98

Acetate (mmol

0 0 0 0 0 0 27 27


of 25

Appendix 3 - CONSULTANT TO CONSULTANT DISCUSSION FOR PN INTITIATION To be used for information only – not to be filed in patient’s notes

Baseline bloods Sodium mmol/L

Potassium mmol/L Urea mmol/L

Creatinine µmol/L Calcium (corr) mmol/L Phosphate mmol/L

ALT Iu/L Alk Phos iu/L

GGT iu/L Albumin g/L Bilirubin µmol/L

WCC 109/L Hb g/L Plt 109/L

RBC 1012/L Haematocrit L/L

MCV fL MCH pg

MCHC g/L Neutrophils 109/L

Lymphocytes 109/L CRP mg/L

Inset patient details

Allergies (including food allergies)

Weight (kg) Height/Length (cm)

Age

Indication for PN (include details of any co-morbidities)

Nutritional intake prior to decision to start PN (including IV fluids e.g. dextrose, enteral feeding regime, recent weight loss etc)

IV access:

State of hydration (i.e. dehydrated, oedematous, fluid restricted)


of 25

OUTCOME


of 25

Appendix 4. Multidisciplinary Team, Roles and Responsibilities once referral has been accepted for local management

Paediatric Dietitian

To conduct initial nutritional assessment:

o Nutritional requirements, including fluid

o Anthropometric measurements: o Current nutritional intake

(potential to maximise) o Period of time since full

requirements met o Assessment of relevant

biochemistry o History of allergies

To report back to the Paediatric

Team with full nutritional assessment and notification that PN

may be required

Suggest aim of TPN

Advise regarding re-feeding risk

Liaise with Nutrition Team Dietitian throughout treatment planning and

monitoring

Nutrition Support Team

The nutrition support team can advise re generic principles of safe PN administration

To include: o Availability and suitability of formulations o Nutrition team Dietitian can discuss

appropriate TPN formulations with paediatric dietitians and pharmacy to meet nutritional requirements.

o Nutrition team pharmacist and technician ensure that parenteral nutritional solutions are stable and compounded appropriately

o Prevention and management of complications

o Audit PN usage and service

Line care o Advice on line care can be provided by

the paediatric oncology outreach nurses and deputy ward managers of the CLIC unit.

o For PN specific line care enquiries the nutrition team at Bristol Children’s Hospital should be contacted (see main guideline for contact details)

Paediatric Pharmacist

The paediatric pharmacist o Advise medical staff on optimal

fluid and electrolytes treatment prior to commencement of PN

o Advises on parenteral nutrition composition and compatibilities

o Checks PN against allergens o Inputs requirements into

electronic pn prescription o Makes safe additions to

standard parenteral feeds or tailor-makes feeds according to the patient’s individual requirements

o Assists with monitoring of parenteral feeding

o Advises on drug-nutrient and nutrient-nutrient interactions


of 25

Appendix 5. Governance Information

Document Title CLINICAL GUIDELINE FOR TOTAL PARENTERAL NUTRITION IN PAEDIATRIC PATIENTS FROM 4 WEEKS TO 16 YEARS

Date Issued/Approved: 3/11/17

Date Valid From: 10/11/17

Date Valid To: 10/11/20

Directorate / Department responsible (author/owner):

Sabrina Tierney, Lead paediatric pharmacist Matt Greening – Deputy Head of Technical Services

Contact details: 01872 252590

Brief summary of contents Guideline covering the actions required when initiating and maintaining a paediatric patient on parenteral nutrition

Suggested Keywords: PN, parenteral nutrition, nutrition

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: n/a

This document replaces (exact title of previous version):

New Document

Approval route (names of committees)/consultation:

Paediatric Guidelines Committee MPC

Divisional Manager confirming approval processes

Karen Jarvill CSCS

Name and Post Title of additional signatories

‘Not Required’

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name:

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Child Health


of 25

Links to key external standards Governance Team can advise

Related Documents:

UHBristol Clinical Guideline: Total Parenteral Nutrition (PN) April 2016 UHBristol Clinical Guideline: Refeeding syndrome – management of paediatric inpatients March 2016

Training Need Identified? No

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

July 2017 V1.0 Initial Issue Sabrina Tierney, Lead paediatric pharmacist

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.


of 25

Appendix 6. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

CLINICAL GUIDELINE FOR TOTAL PARENTERAL NUTRITION IN PAEDIATRIC PATIENTS

Directorate and service area: CHILD HEALTH

Is this a new or existing Policy? NEW

Name of individual completing assessment: Sabrina Tierney

Telephone: 01872 252590

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

Safe administration and management of paediatric patients requiring parenteral nutrition

2. Policy Objectives*

To provide clear guidance on the initiation of PN and to ensure appropriate monitoring of patients

3. Policy – intended Outcomes*

Standardised safe practice

4. *How will you measure the

outcome?

Review of DATIX

5. Who is intended to benefit from the

policy?

Children and families. Medical staff.

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups

What was the outcome of the consultation?


of 25

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age X

Sex (male, female, trans-gender / gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical impairment, sensory Impairment, mental health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

x

9. If you are not recommending a Full Impact assessment please explain why. Not required

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


of 25

Signature of policy developer / lead manager / director

Date of completion and submission

Names and signatures of members carrying out the Screening Assessment

1. 2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site. Signed __ _____________ Date ________________