Parenteral nutrition with standard solutions in paediatric intensive care patients

doi:10.1016/j.clnu.2004.11.004

Clinical Nutrition

Volume 24, Issue 2, April 2005, Pages 274-280

https://doi.org/10.1016/j.clnu.2004.11.004 Get rights and content

Summary

Background: Paediatric intensive care patients often require parenteral nutrition (PN). Only very few standard mixtures are available for infants and children. Individual PN solutions need to be compounded manually on the ward, if preparation by the hospital pharmacy is not feasible. Since manual compounding is associated with a greater risk of compounding errors and microbial contamination, the use of standard solutions might be a preferable alternative.

Methods: We evaluated the use of standard solutions on the paediatric intensive care unit of the von Hauner Children's Hospital at the University of Munich over a period of 8 months. PN solutions were either prescribed individually or as standard solutions. We evaluated the frequency of standard solution prescriptions and their modification, compared nutrient intakes with standard vs. individual PN solutions as well as the occurrence of laboratory anomalies.

Results: Standard PN solutions were prescribed in 68% of cases, individual PN solutions in 32%. Modifications of standard PN solutions were performed in 54%. The intake of a number of macronutrients and electrolytes was similar with individual and standard PN, but calcium and phosphate intakes were lower with individual total PN. Electrolyte imbalances occurred slightly more often with individual PN than with standard PN (34% vs. 26%, respectively).

Conclusion: Standard PN solutions were used in the majority of patients on a paediatric intensive care unit. We did not detect indications for inadequacy of standard solutions in the majority of patients reviewed.

Introduction

Parenteral nutrition (PN) is often required in seriously ill paediatric patients because of their large caloric and substrate needs and their high susceptibility to clinically relevant consequences of suboptimal nutrient supplies. While a wide variety of standard solutions for PN is available today for adult patients, only very few standard mixtures are available for infants and children.1, 2 Rather, individualized prescriptions and compounding of PN solutions are mostly used in this age group. In larger hospitals, individually prescribed PN solutions tend to be prepared in the hospital pharmacy on a daily basis under strict aseptical conditions by trained pharmaceutical staff with semi-automated compounding devices, but in a number of cases PN solutions need to be prepared on the ward by the nursing staff, usually under laminar air flow units. Severe disadvantages of manual compounding are the greater risk of compounding errors³ and of microbial contamination.⁴ Standard PN solutions might be a preferable alternative if their use is feasible in paediatric practice, but only very limited information has been published on their use. Therefore, we evaluated the use of standard solutions in our clinical practice.

Section snippets

Patients and methods

This observational study monitored the PN practice over a period of 8 months (from 2002/02 until 2002/10) on the paediatric intensive care unit of the von Hauner Children's Hospital at the University of Munich, a large tertiary referral centre. Patient charts were reviewed, but the practice of the attending staff was not influenced. PN solutions were either prescribed individually or as standard solutions, according to the choice of the attending physician.

All prescriptions were made with a

Results

During the 8 month period, a total of 337 prescriptions for PN solutions were made for 46 children (age 3 months to 18 years) treated in the ICU, with 171 prescriptions for partial and 166 prescriptions for total PN. Standard PN solutions were prescribed in 68% of cases (226 prescriptions), individual PN solutions in 32% (111 prescriptions). The distribution of standard vs. individual PN solution was similar in partial and total PN. In partial PN standard PN solutions were used in 69% of cases

Discussion

Standard PN solutions were used in about $\frac{2}{3}$ of the PN prescriptions in a paediatric ICU with a modification in about half of the prescriptions. The intake of a number of macronutrients and electrolytes was similar with individual and standard PN, but calcium and phosphate intakes were lower with individual PN, and a number of patients received no phosphate at all. Hyperphosphatemia was present in only one case receiving no phosphate, whereas we assume the omission of phosphate in individual

Acknowledgment

Dr. Kathrin Krohn was financially supported in part by an unconditional grant from the Schweisfurth Foundation, Munich, Germany. We are indebted to Stephan Hiedl for his support.

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Supplementation of vitamins, trace elements and electrolytes in the PEPaNIC Randomised Controlled Trial: Composition and preparation of the prescription
2021, Clinical Nutrition ESPEN
Following the results of the paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial, the new ESPGHAN/ESPEN/ESPR/CSPEN and ESPNIC guidelines recommend to consider withholding parenteral macronutrients for 1 week, while providing micronutrients, in critically ill children if enteral nutrition is insufficient. Critically ill children are suspected to be vulnerable to micronutrient deficiencies due to inadequate enteral nutrition, increased body's demands and excessive losses. Hitherto, micronutrient requirements in PICU are estimated based on recommended daily intakes for healthy children and expert opinion. We aimed to provide an overview of the current practice of micronutrient administration and practical considerations in the three participating centres of the PEPaNIC study, and compare these therapies with the recommendations in the new ESPGHAN/ESPEN/ESPR/CSPEN guidelines.
We describe the current composition and preparation of the prescribed parenteral micronutrients (consisting of vitamins, trace elements and electrolytes) in the three centres (Leuven, Rotterdam and Edmonton) that participated in the PEPaNIC RCT, and compare this per micronutrient with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines recommendations.
The three centres use a different micronutrient supplementation protocol during the first week of critical illness in children, with substantial differences regarding the amounts administered. Leuven administers commercial vitamins, trace elements and electrolytes in separate infusions both in 4 h. Rotterdam provides commercial vitamins and trace elements simultaneously via 8-h infusion and electrolytes continuously over 24 h. Lastly, Edmonton administers commercial vitamins and institutionally prepared trace elements solutions in 1 h and electrolytes on demand. Comparison with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines yields in differences between the recommendations and the administered amounts, which are most substantial for vitamins.
The practice of intravenous micronutrient administration differs substantially between the three PEPaNIC centres and in comparison with the current guideline recommendations. This deviation is at least partially explained by the inability to provide all recommended amounts with the currently available commercial products and by the lack of strong evidence supporting these recommendations.
ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Standard versus individualized parenteral nutrition
2018, Clinical Nutrition
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Furthermore, in a study that evaluated the use of standard PN solutions in a pediatric intensive care unit, it was found that standard PN orders could be used in the majority of the patients. These solutions were usually nutritionally adequate and the intake of most macronutrients and electrolytes was similar to those from individually prescribed PN [9]. In fact, calcium and phosphate intakes were better with standard PN compared to the individualized PN, and electrolyte imbalances occurred less frequently [9].
Physicochemical stable standard all-in-one parenteral nutrition admixtures for infants and children in accordance with the ESPGHAN/ESPEN guidelines
2018, Nutrition
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Nutritional needs in children vary according to their weight and age. PN for pediatric patients is hence often prescribed individually and compounded day by day in the hospital pharmacy or on the ward by the nursing staff [1]. Lipid emulsions are often administered separately in Y-site to the other macronutrients.
Because there are almost no standard all-in-one parenteral nutrition admixtures available for infants and children, the aim was to develop standard two-compartment parenteral nutrition bags for different weight categories based on the ESPGHAN/ESPEN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Clinical Nutrition and Metabolism) guidelines. The 1 g/kg/d lipid version for the 3 to 10 kg weight category (PED1) was assessed for short- and long-term physicochemical stability with the ability to add additional electrolytes (PED1+E).
The lipid compartment A and the all-in-one admixture of A + B + vitamins + trace elements were assessed physically by visual inspection, Sudan red test, pH measurement, and lipid droplet size distribution. Chemical stability for compartment A was evaluated by quantitative analyses of non-esterified fatty acids and peroxide content. The glucose–amino acid–electrolyte compartment B was evaluated physically by visual inspection, measuring particle contamination and pH. Chemical stability was assessed by discoloration, quantitative analyses of glucose, and the amino acids L-cysteine, L-tyrosine, and L-tryptophan.
No phase separation or coalescence occurred, and the mean droplet size diameter did not exceed 0.5 µm. Peroxide content and non-esterified fatty acids concentration of compartment A remained well below the limit of acceptation. No precipitation was detected for compartment B; only a slight yellow discoloration was noted at 80 d. Concentrations of glucose, L-tyrosine, and L-tryptophan remained stable; only L-cysteine decreased significantly from its initial concentration.
The two-compartment PED1 and PED1+E admixtures are stable up to 80 d 2° to 8°C + 24 h room temperature (RT) with an additional 7 d 2° to 8°C + 48 h RT after mixing and addition of vitamins and trace elements.
Safety of parenteral nutrition in newborns: Results from a nationwide prospective cohort study
2018, Clinical Nutrition
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Advantages of standardized or pharmaceutical industrial formulations include promotion of safer administration, consistent adherence to guidelines, better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings [8,9]. Several studies have demonstrated that standardized formulations are more appropriate in the management of preterm neonates than individualized [10,11]. Surveys conducted in industrialized countries show that nutritional management in neonatal departments are often not in accordance with the existing guidelines [12,13].
Limited or delayed availability of parenteral nutrition (PN) solutions, as well as difficulties in ordering are often identified as reasons for non-compliance with international guidelines in newborns. This study aims at assessing the modality of use and safety of premixed standardized PN solutions in a nationwide prospective cohort of newborns treated in clinical practice.
Two premixed fixed formulations with respective osmolarity of 715 and 790 mOsm/L specifically designed for neonates were made available throughout the country for clinical use from birth onwards. Descriptive data and modality of use were prospectively collected in a case report form, whereas all related and unrelated adverse events were recorded on a separate adverse event form.
A total of 14,167 infants were prospectively included and 16,640 parenteral nutrition periods were analyzed. Mean age was 33 weeks of gestation, and mean weight was 2086 g. The majority of infants (81%) started the parenteral nutrition the first day of life or the day after. The route of parenteral nutrition delivery was peripheral in 47% of the parenteral nutrition periods. During the whole study, a total of 72 adverse events occurring in 68 infants were reported. Of these adverse events, 59 (0.37% of the nutrition periods), among which 19 serious adverse events, were reported as related to the parenteral nutrition solutions. The events related to parenteral nutrition solutions were general disorders and administration site conditions (n = 42 including 9 cases of cutaneous necrosis), and nutrition and metabolism disorders (n = 17). There was no case of thrombophlebitis. Six of the 19 serious events related to the parenteral nutrition solutions (32%) were due to the misuse of the infusion bag.
These data support the concept that ready-to-use parenteral nutrition formulations can safely provide parenteral nutrition from birth onwards. They further support that parenteral solutions with an osmolarity up to 800 mOsm/L are well-tolerated when infused on a peripheral vein. Considering the potential risk of errors and misuses, this study also highlights the need for nutrition practice care guidelines for neonates and for regular campaigns providing information and strategies for a safe use of parenteral nutrition solutions.
Should pediatric parenteral nutrition be individualized?
2014, Revista Paulista de Pediatria
As formulações da nutrição parenteral (NP) são comumente individualiza‐ das, visto que a padronização destas parece inadequada para a população pediátrica. O objetivo do estudo foi avaliar o estado nutricional e os motivos para individualização da NP dos pacientes pediátricos em uso de NP internados em um hospital terciário de Campinas‐SP.
Estudo longitudinal conduzido com pacientes acompanhados por até 67 dias de uso de NP. Para a classificação do estado nutricional, foram utilizados os critérios propos‐ tos pela World Health Organization (WHO) (2006) e WHO (2007). As dosagens sanguíneas analisadas foram: sódio, potássio, cálcio iônico, cloreto, magnésio, fósforo inorgânico e triglicerídeo (TGL). Foram considerados motivos indubitáveis para individualização da NP quando esses elementos apresentavam redução expressiva dos níveis sanguíneos (potás‐ sio < 3 mEq/L; sódio < 125 mEq/L; magnésio < 1 mEq/L; fósforo < 1,5 mEq/L; cálcio iônico < 1 mmol/L; cloreto < 90 mEq/L) ou qualquer valor superior aos de referência.
Foram estudados 12 pacientes (49 individualizações) com idade de 1 mês a 15 anos. A maioria dos pacientes foi classificada como desnutrida. Observou‐se que 74/254 (29,2%) dos exames demandaram NP individualizada por motivos indubitáveis.
O estado nutricional dos pacientes foi considerado crítico, na maioria dos casos. Desta forma, a individualização realizada no início da NP para a adequação ener‐ gética proteica foi essencial. Além disto, a NP individualizada foi indispensável em, no mínimo, 29,2% das NP, para correção das alterações encontradas nos exames bioquími‐ cos.
Parenteral nutrition (PN) formulations are commonly individualized, since their standardization seem inadequate for the pediatric population. This study aimed to evaluate the nutritional state and the reasons for PN individualization in pediatric patients using PN hospitalized in a tertiary hospital in Campinas, São Paulo.
This longitudinal study comprised patients using PN followed by up to 67 days.
Nutritional status was classified according to the criteria established by the World Health Organization (WHO) (2006) and WHO (2007). The levels of the following elements on blood were analyzed: sodium, potassium, ionized calcium, chloride, magnesium, inorganic phosphorus and triglycerides (TGL). Among the criteria for individualization, were considered undeniable: significant reduction in blood levels of potassium (<3 mEq/L), sodium (<125 mEq/)L, magnesium (<1 mEq/L), phosphorus (<1.5 mEq/L), ionic calcium (<1 mmol) and chloride (<90 mEq/L) or any value above the references.
Twelve pediatric patients aged 1 month to 15 years were studied (49 individualizations). Most patients were classified as malnourished. It was observed that 74/254 (29.2%) of examinations demanded individualized PN by indubitable reasons.
The nutritional state of patients was considered critical in most cases. Thus, the individualization performed in the beginning of PN for energy protein adequacy was indispensable. In addition, the individualized PN was indispensable in at least 29.2% of PN for correction of alterations found in biochemical parameters.
Paediatric multichambered industrial bags: Feasibility study in home parenteral nutrition
2013, Nutrition Clinique et Metabolisme
Évaluer les possibilités de substitution des poches pédiatriques « à la carte », par des prémélanges industriels, pour des enfants en nutrition parentérale à domicile (NPD).
Une étude rétrospective des formulations de patients est effectuée au regard de trois critères successifs : ratio calories non protéiques par volume, rapport calorico-azoté et concentration en électrolytes. Puis, comparaison avec les produits industriels disponibles sur le marché français.
Les formulations de 29 poches nutritives industrielles ont été comparées aux prescriptions de 37 enfants en NPD. Les pourcentages de patients pour lesquels une poche industrielle est envisageable décroissent au cours de l’analyse : 84 % après application du premier critère, 41 % au deuxième critère, puis 22 % au dernier critère. Pour ces patients, le nombre maximum de possibilités de substitution baisse également au cours de l’étude (de 12 à 1 poches). Le problème du faible volume des prémélanges industriels retenus apparaît lorsque l’on envisage l’administration de 2 à 9 poches par jour au patient.
La diversité et la complexité des prescriptions pédiatriques de nutrition parentérale rendent l’utilisation des formules industrielles difficilement envisageable en l’état, tant d’un point de vue qualitatif qu’organisationnel. La fabrication « à la carte » reste pour l’instant la plus adaptée aux enfants en nutrition parentérale pédiatrique à domicile.
Evaluate the substitution of tailor-made parenteral nutrition admixtures by industrial premixed bags for children in home parenteral nutrition.
A retrospective study of patients’ formulations was carried out under three successive criteria: ratio of non-protein calories per volume, calorie to nitrogen ratio, electrolyte concentration. Then a comparison with industrial products available on the French market was done.
Formulations of 29 industrial multichambered bags were compared with 37 pediatric prescriptions of home parenteral nutrition. The percentages of patients for whom the use of an industrial bag was possible decreased during the analysis: 84% patients after application of the first criterion, 41% after the second test and 22% after the last criterion. For these patients, the maximum number of substitution possibilities also declined during the study (12 to 1 bags). The problem with the small volume of selected industrial premixed bags appears when considering the administration of 2 to 9 bags by day to the patient.
The diversity and complexity of pediatric parenteral nutrition formulas makes the use of industrial admixtures difficult for qualitative and organizational reasons. So far, a tailor-made admixture remains the most child-friendly pediatric parenteral nutrition at home.

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ORIGINAL ARTICLEParenteral nutrition with standard solutions in paediatric intensive care patients