scholarly journals P013 Developing standardised neonatal parenteral nutrition across a network

2019 ◽  
Vol 104 (7) ◽  
pp. e2.16-e2
Author(s):  
Louise Whitticase ◽  
Gemma Holder ◽  
Gillian Preston ◽  
Sara Clarke
Keyword(s):  
Patient Outcome ◽  
Parenteral Nutrition ◽  
European Society ◽  
Capacity Planning ◽  
Extremely Low Birth Weight ◽  
British Association ◽  
List Type ◽  
Confidential Enquiry ◽  
Neurodevelopmental Outcomes ◽  
Perinatal Medicine

Background and aimParenteral Nutrition (PN) forms the mainstay of nutritional support for extremely low birth weight (ELBW) infants immediately after birth to promote optimal growth and neurodevelopmental outcomes. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published in 2010 indicated that only 24% of neonates received parenteral nutrition that was considered good practice1. NCEPOD, alongside the Paediatric Chief Pharmacists Group Report, highlighted issues with prescribing and administration of PN linked to unnecessary variation in practice between hospitals.1 2 This encourages use of standardised PN with associated guidelines for use and administration. The aim was to be able to provide nutritionally complete PN for preterm and sick term babies in a ready to use formulation, 24 hours a day, 7 days a week without access to an onsite aseptic service and for the nutrition a baby receives to be consistent across the network regardless of which hospital they are in.MethodsThere is a robust network neonatal nutrition group, comprising neonatologists, pharmacists, dietitians and nutrition nurses. The remit of the group was initially to audit their current practice and agree the new standardized formulations and develop guidelines for use. These were based on European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and British Association of Perinatal Medicine (BAPM) guidelines and expert opinion.3 4 Advice on stability and compounding was sought from commercial experts. Assistance to award a contract to supply the network was sought from a group purchasing organisation to ensure capacity planning and cost effectiveness.ResultsConsensus on four concentrated formulations was agreed by the network group and all six units within the network are now successfully using these.ConclusionThis has been a lengthy process but it was possible to establish agreement of a structured set of standard bags that would deliver nutritionally complete PN to the cohort of babies in our network. Re-audit is now underway in house to compare to previous practice and we hope to shortly roll this audit out across the network. Future aspirations are to devise a system to manage stock control across the entire network, work towards reaching national consensus, work with commercial partners to obtain extended expiry with peditrace addition and to work in partnership with commercial companies to formulate licensed products.ReferencesStewart J, Mason G, Smith N, et al. A mixed bag; an enquiry into the care of hospital patients receiving parenteral nutrition. National Confidential Enquiry into Patient Outcome and Death, 2010.Paediatric Chief Pharmacists Group. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children, 2011.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), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41(Suppl 2):S1–87.British Association of Perinatal Medicine (BAPM). The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice, 2016.

scholarly journals P36 Numeta G13% preterm neonatal parenteral nutrition solution – a licensed all-in-one triple chamber, ready to use and terminally sterilised parenteral nutrition for preterm newborn infants

2020 ◽  
Vol 105 (9) ◽  
pp. e25-e25
Author(s):  
Mar Moreno ◽  
Kenny McCormick ◽  
Lindsey Macfarlane ◽  
Alexandra Scrivens
Keyword(s):  
Patient Safety ◽  
Parenteral Nutrition ◽  
Standard Deviation Score ◽  
British Association ◽  
List Type ◽  
Central Administration ◽  
Nursing Time ◽  
Perinatal Medicine ◽  
Improvement Project ◽  
Safety Alert

AimsWe aim to evaluate the efficacy and safety of Numeta G13%E preterm neonatal parenteral nutrition (PN) in our neonatal population.In September 2017 a National Patient Safety Alert (NPSA) highlighted the risk of harm to babies when lipid was mistakenly run at the rate intended for the aqueous component resulting in significant lipid overdose.Although we have worked to implement many of the alert’s recommendations, we feel we can avoid this risk further by using an all-in-one PN solution.1Numeta meets current nutritional guidelines as per British Association of Perinatal Medicine (BAPM) but this project allows comparison of outcomes important to both patient and service between those achieved with our current regimen and those with the all-in-one regimen.2MethodsWe carried out a quality improvement project from April 2018 to April 2019. We collected data from 330 babies in our neonatal unit during six months before (154 babies) and after (176 babies) the adoption of the all-in-one solution.Our previous PN regimen consisted of a ‘menu’ of aqueous bags (starter, maintenance, ‘light’ and bespoke) and a separate lipid solution. All of them were suitable for peripheral or central administration. Numeta came with similar choices: starter, maintenance -for central administration only- and ‘lite’ and Numeta peripheral, suitable for peripheral administration. Bespoke bags were also available if clinically indicated. We set out our desired outcomes and measured parameters accordingly:Patient outcomesMetabolic stability: electrolyte, glucose, bilirubin and lipid measurements summarised by the need to change from standard PN regimen and/or requirement for insulin.Fluid balance summarised by the lowest weight during the first two weeks of life and time taken to regain birth weight.Growth summarised by change of standard deviation score of weight and head circumference between birth and discharge or transfer back to local hospital.Liver tolerance of lipid solutions summarised by incidence of cholestasis (>25 μmol/l conjugated fraction of serum bilirubin)Days and type of PNSepsisService outcomesNursing time taken to prepare PNCostWastageAccess to productResultsAlthough we finished collecting the data in April 2019, we are still in the process of analysing it and evaluating the final results. There have been no cases of lipid overdose and our neonates (including the preterm ones) have so far tolerated well the new parenteral nutrition solution. Average nursing time preparing Numeta went down from 18.5 minutes to 8 minutes and comparison of cost came in favour of Numeta. PN wastage was higher with Numeta (4.7% Maintenance, 10% ‘light’, peripheral 50%) especially in the first month during the transition phase. There was no significant increase of bespoke bags when Numeta was introduced.ConclusionsIn summary, so far we have not identified significant clinical differences between the first six months of the project -using our old standardised nutrition regimen- and the last months -on the new all-in-one solution. We have continued with Numeta preterm solution on the basis of assumed safety.ReferencesRisk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. NHS improvement patient safety alert September 2017.The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. British Association of Perinatal Medicine (BAPM) April 2016 www.bapm.org

scholarly journals P12 Evaluation of energy and protein intake in neonates using SCAMP regimen

2020 ◽  
Vol 105 (9) ◽  
pp. e12.1-e12
Author(s):  
Sian Gaze ◽  
Chidubem Okoye ◽  
Graham Davies
Keyword(s):  
Parenteral Nutrition ◽  
Energy Intake ◽  
European Society ◽  
Protein Intake ◽  
Neonatal Unit ◽  
Study Patient ◽  
Target Range ◽  
Cardiac Anomaly ◽  
List Type ◽  
Congenital Cardiac Anomaly

AimsOur neonatal unit recently updated their parenteral and enteral feeding guideline and started using a standardised parenteral nutrition regimen (SCAMP).1The aim of this study was to observe the amount of energy and protein that was being delivered to patients using the SCAMP regimen and to evaluate whether it met the recommendations made by ESGPHAN in terms of energy and protein intake.2MethodsA data collection form was designed using Excel. Patients were identified using BadgerNet digital software. All required patient parameters were recorded from Badgernet. Data was anonymised and the Excel spreadsheet was password protected. A single investigator collected data over a 28 day period in October/November 2018. Only patients on the SCAMP regimen were included in the study. Patient data was collected from first day of SCAMP regimen until baby was discharged, or ceased parenteral nutrition.Results22 patients were identified for inclusion in the study. Of these, 17/22 (77%) weighed < 1 kg.Majority of babies (20/22; 91%) were aged < 31 weeks corrected gestational age when SCAMP was initiated.Majority of babies were on the SCAMP regimen due to prematurity; 4/22 (18%) had a surgical condition, that required PN to be initiated.1 patient had a complex congenital cardiac anomaly.Average length of time babies remained on SCAMP was 19 days (range 5–28 days).Majority of babies were enterally fed using breastmilk. Some babies were on alternative formula feeds.Mean amount of energy delivered to each patient was calculated. The amount of energy delivered increased daily over the first week, and by day 10 of life had reached the target range (110–135 kcal/kg/day). Recommended energy intake was then maintained for the rest of the 28–day study period.Target amount of protein intake varied for babies weighing <1 kg and >1 kg. For babies <1 kg, a gradual increase occurred over the first 5 days of life. Recommended protein intake was met between days 5–10 of life, then there was a gradual decline.For babies weighing between 1–1.8 kg, the recommended protein intake was achieved within 24–48 hours. Higher than recommended amounts of protein were being delivered between days 5–10 of life. Mean protein intake remained within ESPGHAN recommendations (3.5–4 g/kg/day) during weeks 3 and 4 of life.The results are encouraging and demonstrate that neonates are managing to achieve the recommended amounts of energy intake from day 10 of life.LimitationsThis study focused solely on energy and protein intake – it did not include observations of growth. Future studies should consider looking at more patient-focused outcomes.ConclusionsSCAMP regimen is delivering the recommended amounts of energy for babies on the neonatal unit – target levels are achieved by day 10 of life.Future work should focus on observing growth in babies on SCAMPEarlier introduction of breast–milk fortifier may be helpful to increase protein intake in babies < 1 kg – potential benefits need to be evaluated against risk of adverse effects.ReferencesMorgan C, Herwitker S, Badhawi I, et al. SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care. BMC Pediatrics 2011;11:53.Koletzo 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), supported by the European society of paediatric research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 (Suppl 2):S1–87.

scholarly journals P17 Introducing concentrated preterm stock parenteral nutrition and the impact on bespoke compounding

2020 ◽  
Vol 105 (9) ◽  
pp. e14.2-e15
Author(s):  
Suzannah Hibberd ◽  
Amy Hill
Keyword(s):  
Parenteral Nutrition ◽  
Neonatal Unit ◽  
List Type ◽  
High Demand ◽  
Perinatal Medicine ◽  
Group A ◽  
Preterm Babies ◽  
Collection Period ◽  
Group B ◽  
The Impact

BackgroundIt is widely recommended that stock parenteral nutrition (PN) bags are used where possible to reduce the risks associated with bespoke PN compounding.1 A review was undertaken within a level three neonatal unit which identified that a large proportion of compounded bags were made due to the need to provide full nutrition in a smaller volume. A preterm concentrated aqueous PN bag was developed which, when run with stock lipid syringes, meets the nutritional requirements of preterm babies in a total volume of 100 ml/kg/day.2AimThe aim of this work is to evaluate the impact of the introduction of a preterm concentrated stock bag on the need for bespoke PN in preterm babies.MethodThe new concentrated PN bag was transitioned into use from November 2017. Data regarding the number of preterm patients admitted and the type of PN they received was collected from January to October 2017, (Group A), this was then repeated for all preterm patients admitted from August 2018 to May 19, (Group B), after the preterm concentrated bag was fully introduced. Preterm babies were classified as babies that were born < 34 weeks gestation as the concentrated bag was formulated with these patients in mind.ResultsGroup A, (n=143), had 1045 bags supplied over the collection period. 47% of the PN bags supplied were bespoke PN bags, largely due to the need to provide PN in a smaller volume than the 130 ml/kg/day that the preterm stock bags available at that time. Group B, (n=118), had a total of 965 bags supplied, 16% of these bags were bespoke PN. The reasons behind requiring bespoke bags included the need for manganese free bags, requiring a reduction in glucose and a high electrolyte requirement in patients especially those with stomas. This has resulted in an overall reduction in spend on preterm PN of 34% and a reduction in compounded PN spend of 69%.ConclusionThis work has highlighted several benefits of introducing preterm concentrated PN bags. Firstly having concentrated preterm stock bags available on the ward has meant that a larger proportion of babies are maintained on stock PN without recourse to compounded PN. Secondly this has preserved the compounding capacity of our technical services unit so when a patient requires a bespoke bag that facility is available. Also, capacity for the compounding service has been preserved across the hospital minimising the need to outsource compounding. Finally the neonatal unit has seen a reduction in overall PN costs in this patient group. The introduction of this bag has been instrumental in reducing the need to outsource PN bags to commercial compounding units during periods of high demand, meeting national recommendations on the management of aseptic compounding capacity.3ReferencesA Report from the Paediatric Chief Pharmacists Group: Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children. November 2011.British Association of Perinatal Medicine. The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice. April 2016.Specialist Pharmacy Service/NHS England. National Pharmaceutical Supply Group (NPSG) Communication: Making best use of restricted aseptic compounding capacity. September 2018.

scholarly journals P43 Concentrated standardised PN to optimise nutrition in preterm infants

2020 ◽  
Vol 105 (9) ◽  
pp. e29.1-e29
Author(s):  
Zoe Price
Keyword(s):  
Parenteral Nutrition ◽  
Preterm Infants ◽  
Growth Parameters ◽  
Average Energy ◽  
List Type ◽  
Perinatal Medicine ◽  
Nitrogen Intake ◽  
Hospital Patients ◽  
Nitrogen Ratio ◽  
Full Benefit

BackgroundIn 2010, the NCEPOD1 report demonstrated a lack of good nutritional care for preterm infants. Since that time various approaches have evolved including standardisation of PN,2 concentrated standardised PN3 and publication of a national framework from BAPM.4 The delivery of nutrition to preterm infants on our unit has been continuously monitored, evaluated and adapted.AimsThe aim of this audit was to evaluate whether reformulating our PN recipes would improve nutritional intake and thus growth parameters over the first 14 days after birth.MethodsData was collected from our EPMA system and analysed retrospectively from all infants born at our unit <28 weeks gestation or <1Kg from 16/4/2016 to 15/4/2017 (audit 1) and from 1/6/2018 to 31/5/2019 (audit 2).ResultsData from a total of 33 patients was analysed using Excel™. The mean gestation and weight were similar for both audit cycles. Audit 1: gestation 26.5 weeks, weight 0.75 kg; audit 2: gestation 26.7 weeks, weight 0.74 kg. The average time from birth to PN was less in audit 2 (12 hrs 8 mins vs 13 hrs 12 mins), however the time from PN being prescribed to being administered took over 3 times longer (5 hrs 1 min vs 1 hr 30 mins). No patient received PN within 6 hours of birth in audit 2 compared to 20% in audit 1. The average nitrogen intake was higher in audit 2 than audit 1 (0.41 g/kg/day vs 0.36 g/kg/day) and the highest protein intake increased from 0.55 g/kg/day to 0.69 g/kg/day respectively; the average energy intake decreased from 73.5 kcal/kg/day in audit 1 to 68 kcal/kg/day in audit 2. The non-nitrogen energy to nitrogen ratio was lower in audit 2 versus audit 1 (165.3 kcal/g nitrogen vs 204.7 kcal/g nitrogen). There was no change in the percentage of patients requiring insulin: 40%. More patients had started receiving lipid infusion in the first 2 days after birth in audit 2 compared to audit 1 (94% compared to 33%). Both audits had 2 patients that had still not reached their birth weight by day 14, however the patients in audit 2 gained on average 9.12 g/kg/day compared to 4.96 g/kg/day in audit 1.ConclusionReformulating the PN resulted in higher nitrogen intakes and higher weight gain by day 14, although the full benefit may not have been achieved due to the lower kcal intake and non-nitrogen energy to nitrogen ratio. The time from birth to PN and the time taken to administer PN once prescribed were longer so work needs to be done on addressing these issues and reducing barriers to nutrition. The total nitrogen intake with PN and EN also needs to be reviewed to prevent excessive nitrogen intake which may result if enteral feeds increase and the rate of PN is maintained.ReferencesStewart JAD, Mason DG, Smith N, Protopapa K, Mason N, on behalf of CEPOD. 2010. A mixed bag; an enquiry into the care of hospital patients receiving parenteral. https://www.ncepod.org.uk/2010report1/downloads/PN_report.pdf Accessed 03/07/2019Paediatric Chief Pharmacists Group. Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children. 2011Morgan C, Radbone L, Birch J. 2016 The Neonatal Parenteral Nutrition (PN) QIPP Toolkit https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/documents/documents/national-toolkit-for-standardising-pn Accessed 03/07/2019British Association of Perinatal Medicine. The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. 2016. https://www.bapm.org/sites/default/files/files/Parenteral%20Nutrition%20April%202016.pdf Accessed 03/07/2019

Is intravenous fish oil associated with the neurodevelopment of extremely low birth weight preterm infants on parenteral nutrition?

2021 ◽  
Author(s):  
Chiara Biagetti ◽  
Alessio Correani ◽  
Rita D’Ascenzo ◽  
Enrica Ferretti ◽  
Cecilia Proietti ◽  
...  
Keyword(s):  
Birth Weight ◽  
Low Birth Weight ◽  
Parenteral Nutrition ◽  
Fish Oil ◽  
Preterm Infants ◽  
Extremely Low Birth Weight

scholarly journals Early oxygen levels contribute to brain injury in extremely preterm infants

2021 ◽  
Author(s):  
Krista Rantakari ◽  
Olli-Pekka Rinta-Koski ◽  
Marjo Metsäranta ◽  
Jaakko Hollmén ◽  
Simo Särkkä ◽  
...  
Keyword(s):  
Preterm Infants ◽  
Brain Structures ◽  
High Oxygen ◽  
List Type ◽  
Neurodevelopmental Outcomes ◽  
Oxygen Levels ◽  
Arterial Blood ◽  
Extremely Preterm ◽  
Extremely Preterm Infants

Abstract Background Extremely low gestational age newborns (ELGANs) are at risk of neurodevelopmental impairments that may originate in early NICU care. We hypothesized that early oxygen saturations (SpO2), arterial pO2 levels, and supplemental oxygen (FiO2) would associate with later neuroanatomic changes. Methods SpO2, arterial blood gases, and FiO2 from 73 ELGANs (GA 26.4 ± 1.2; BW 867 ± 179 g) during the first 3 postnatal days were correlated with later white matter injury (WM, MRI, n = 69), secondary cortical somatosensory processing in magnetoencephalography (MEG-SII, n = 39), Hempel neurological examination (n = 66), and developmental quotients of Griffiths Mental Developmental Scales (GMDS, n = 58). Results The ELGANs with later WM abnormalities exhibited lower SpO2 and pO2 levels, and higher FiO2 need during the first 3 days than those with normal WM. They also had higher pCO2 values. The infants with abnormal MEG-SII showed opposite findings, i.e., displayed higher SpO2 and pO2 levels and lower FiO2 need, than those with better outcomes. Severe WM changes and abnormal MEG-SII were correlated with adverse neurodevelopment. Conclusions Low oxygen levels and high FiO2 need during the NICU care associate with WM abnormalities, whereas higher oxygen levels correlate with abnormal MEG-SII. The results may indicate certain brain structures being more vulnerable to hypoxia and others to hyperoxia, thus emphasizing the role of strict saturation targets. Impact This study indicates that both abnormally low and high oxygen levels during early NICU care are harmful for later neurodevelopmental outcomes in preterm neonates. Specific brain structures seem to be vulnerable to low and others to high oxygen levels. The findings may have clinical implications as oxygen is one of the most common therapies given in NICUs. The results emphasize the role of strict saturation targets during the early postnatal period in preterm infants.

scholarly journals Association of Breast Surgeons at the British Association of Surgical Oncology (ABS AT BASO)

2006 ◽  
Vol 9 (S1) ◽  
pp. 28-33
Author(s):  
Keyword(s):  
Clinical Trials ◽  
Ductal Carcinoma ◽  
Randomised Trial ◽  
Surgical Oncology ◽  
British Association ◽  
List Type ◽  
Current Contact ◽  
Trial Testing ◽  
Er Positive

This section provides current contact details and a summary of recent or ongoing clinical trials being coordinated by Association of Breast Surgeons at the British Association of Surgical Oncology (ABS at BASO). Clinical trials include: BASO DCIS II TRIAL: Randomised trial testing observation (no radiotherapy) against radiotherapy in women with low-risk completely excised ER positive ductal carcinoma in situ (DCIS) of the breast on adjuvant endocrine therapy.Neoadjuvant trial of preoperative exemestane or letrozole ± celecoxib in the treatment of ER positive postmenopausal early breast cancer.

scholarly journals Influence of PCO2 Control on Clinical and Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants

Neonatology ◽  
2018 ◽  
Vol 113 (3) ◽  
pp. 221-230 ◽  
Author(s):  
Ulrich H. Thome ◽  
Jens Dreyhaupt ◽  
Orsolya Genzel-Boroviczeny ◽  
Bettina Bohnhorst ◽  
Manuel Schmid ◽  
...  
Keyword(s):  
Birth Weight ◽  
Low Birth Weight ◽  
Extremely Low Birth Weight ◽  
Low Birth Weight Infants ◽  
Neurodevelopmental Outcomes
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