south west neonatal network guideline · guideline regional neonatal parenteral nutrition main...

South West Neonatal Network Guideline Regional Neonatal Parenteral Nutrition

Main Author(s): Zoe Price – Neonatal Pharmacist P. Cairns - Neonatologist C. Turner - Dietician H. Norris - Dietician P. Mannix - Neonatologist

Ratifying Committee: South West Neonatal Network Executive Board

Date Ratified: 9h July 2018,

Review Date: July 2019

Version: 01

KEYWORDS: Parenteral Nutrition, Nutrition, Feeding, Neonate

March 2018

South West Neonatal Network Guideline Regional Neonatal Parenteral Nutrition – 9

th July 2018

Website: www.swneonatalnetwork.co.uk Email: [email protected] Authors: Z. Price, P. Cairns, C. Turner, H. Norris, P. Mannix, R. Smart

1. BACKGROUND 2 2. SCOPE 2 3. INDICATIONS FOR USE2 2 4. PN AVAILABILITY 3 5. ADMINISTRATION 3 LINES 4 6. HOW TO START AND INCREASE TPN 5 INFANTS < 37/40 AND ALL INFANTS < 2.5KG 5 (NB. FOR UNITS THAT ONLY KEEP SW NEONATAL BAGS PN 1 & 2, THIS FLOWCHART CAN BE USED FOR ALL INFANTS

WHATEVER GESTATION OR WEIGHT) 5 INFANTS > 37/40 IF > 2.5KG 6 (NB. FOR UNITS THAT ONLY KEEP SW NEONATAL PN BAGS 1 & 2, THEN THE FLOWCHART FOR ‘INFANTS < 37/40

AND ALL INFANTS <2.5KG’ SHOULD BE USED) 6 6 7. MONITORING 7 8. MANAGING METABOLIC COMPLICATIONS 8 9. WEANING TPN 8 10. REFERENCES 9 APPENDIX ONE 10 THE MANAGEMENT OF METABOLIC COMPLICATIONS 10 APPENDIX TWO 14 REGIONAL STANDARDISED CONCENTRATED PN PRESCRIBING GUIDANCE SHEET 14 REGIONAL STANDARDISED CONCENTRATED PN PRESCRIBING GUIDANCE SHEET 15 REGIONAL STANDARDISED CONCENTRATED PN PRESCRIBING GUIDANCE SHEET 16 REGIONAL STANDARDISED CONCENTRATED PN PRESCRIBING GUIDANCE SHEET 17 APPENDIX THREE 18 LIPID SYRINGE RECIPE 18 PN BAG DETAILS, I.E. GLUCOSE CONCENTRATION AND OSMOLARITY DATA 18 APPENDIX FOUR 19 NEONATAL PARENTERAL NUTRITION PRESCRIPTION (PRETERM) 19 PRETERM INFANTS <37/40 CGA AND ALL INFANTS <2.5KG 19 DAYS 1 TO 6 19 (NB. FOR UNITS THAT ONLY KEEP SW NEONATAL BAGS PN 1 & 2, THIS PRESCRIPTION CAN BE USED FOR ALL INFANTS

WHATEVER GESTATION OR WEIGHT) 19 NEONATAL PARENTERAL NUTRITION PRESCRIPTION (PRETERM) 20 PRETERM INFANTS <37/40 CGA AND ALL INFANTS <2.5KG 20 DAY 7 ONWARDS 20 (NB. FOR UNITS THAT ONLY KEEP SW NEONATAL BAGS PN 1 & 2, THIS PRESCRIPTION CAN BE USED FOR ALL INFANTS

WHATEVER GESTATION OR WEIGHT) 20 APPENDIX FIVE 21 NEONATAL PARENTERAL NUTRITION PRESCRIPTION (TERM) 21 TERM INFANTS >37/40 CGA, IF >2.5KG 21 DAYS 1 TO 6 21 NEONATAL PARENTERAL NUTRITION PRESCRIPTION (TERM) 22 TERM INFANTS >37/40 CGA, IF >2.5KG 22 DAY 7 ONWARDS 22

http://www.swneonatalnetwork.co.uk/

mailto:[email protected]


th July 2018


1. Background

Preterm infants are born with an immature gut and are consequently unable to digest sufficient milk to meet their nutritional requirements for at least 10-14 days post birth. They also have limited nutrient stores, so are therefore at a high risk of accumulating significant nutrient deficits and consequential poor growth which is associated with poor neurodevelopmental outcome in later life.1

Parenteral Nutrition (PN) is an important aspect of neonatal care by which the infant’s specific nutritional requirements can be met intravenously. Evidence confirms that providing optimal nutrition early can minimise growth failure and associated neuro-cognitive effects1. PN is also essential for infants who may not tolerate enteral feeds such as those with congenital or acquired gut disorders. Standardised bags maximise nutrient delivery in line with BAPM recommendations2 and

minimise the risk of errors in prescribing and compounding. Using 48 hour bags reduces the

number of times lines are accessed and thus reduces line infection rates. Standardised PN

should always be used when administering PN3, apart from in exceptional cases.

The aim of this guideline is to provide clear, evidence based guidance and procedures for using PN on the neonatal unit. This is to ensure safe and optimum management of parenterally fed infants and minimise the risks associated with this form of nutrition support.

2. Scope

This guidelines applies to neonatal units that care for and manage patients on Parenteral Nutrition within the South west Neonatal Network, this includes the following hospitals.

Royal United Hospital Bath NHS Trust - Royal United Hospital Bath North Bristol NHS Trust - Southmead Hospital, Bristol University Hospitals Bristol NHS Foundation Trust - St Michaels Hospital, Bristol Royal Devon and Exeter NHS Foundation Trust - Royal Devon and Exeter Hospital Gloucestershire Hospitals NHS Foundation Trust - Gloucester Royal Hospital Plymouth Hospitals NHS Trust - Derriford Hospital, Plymouth Great Western Hospitals NHS Foundation Trust - Great Western Hospital, Swindon Taunton and Somerset NHS Foundation Trust - Musgrove Park Hospital, Taunton Royal Cornwall Hospitals NHS Trust - Royal Cornwall Hospital, Truro

3. Indications for use2 PN should be considered in the following infants:

All infants admitted to NICU < 1.25kg or < 30/40 weeks gestation

Infants > 30/40 weeks gestation or > 1.25kg who are not anticipated to be on > 100ml/kg/day enteral feeds within 5 days




th July 2018


Infants with intestinal disease precluding feeding e.g. necrotising enterocolitis (NEC), gastroschisis, intestinal atresia

If indicated from birth, PN should be started within the first 24 hours of life, ideally within 6 hours of

birth or from confirmation of line placement.

4. PN availability There are 3 types of PN bags available across the region:

SW Neonatal PN Bag 1 (minimal electrolytes)

SW Neonatal PN Bag 2 (preterm maintenance)

SW Neonatal PN Bag 3 (term maintenance) N.B. bag size and availability will vary between units

5. Administration PN should be removed from the fridge at least one hour prior to use. Aqueous PN bags should not run for longer than 48 hours and should be infused via a 0.2 micron filter. Lipid syringes should not run for longer than 24 hours and should be infused over 24 hours. The PN giving set and filters must be changed every 48 and 24 hours respectively for aqueous and lipid solutions.

Restarting PN after full enteral feeds or if not starting PN at time of birth: Start on day 3 of the appropriate PN flowchart

Is the Infant < 1.25kg or

< 30/40 weeks gestation?

Start PN within 6 hours of birth

(See ‘Preterm PN’ flowchart)

Will the infant achieve

>100ml/kg/day enteral

nutrition by day 5 of life

Start enteral nutrition

according to local protocol

Start PN as soon as possible

after birth

(See ‘Term PN’ flowchart)

Yes No

Yes No

New born infant:




th July 2018


Lines

PN should ideally be administered via a central venous catheter (for example, UVC or long line); peripheral venous catheters should be avoided for routine administration of PN where possible due to risk of extravasation injuries. This should be a short-term measure until central access is secured or PN is stopped.

If PN is to be administered via a peripheral venous cannula then lipid MUST also be administered

along the same line as the aqueous PN.

Ideally a line should be used solely for PN although this is not always possible in neonates due to difficulties in venous access. No medication should be given down the same line as the PN without checking compatibility. If in any doubt then assume that they are not compatible and contact pharmacy. Bolus medication may be given with a flush of sodium chloride 0.9% before and afterwards. Access to the line should be minimised to reduce risk of infection.




th July 2018


6. How to start and increase TPN

Infants < 37/40 and all infants < 2.5kg

(NB. For units that only keep SW Neonatal Bags PN 1 & 2, this flowchart can be used for all

infants whatever gestation or weight)




th July 2018


Infants > 37/40 if > 2.5kg

(NB. For units that only keep SW Neonatal PN Bags 1 & 2, then the flowchart for ‘Infants < 37/40 and

all infants <2.5kg’ should be used)




th July 2018


7. Monitoring Routine biochemical monitoring should take place in all infants on PN as it is crucial to prevent and

treat instabilities potentially caused by PN.

Any derangement from normal range should be discussed with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available, before prescribing. Below is a suggested schedule of monitoring however requirements may differ for individual infants and situations3.

First Week Stable PN

Daily Twice Weekly

Weekly Daily Twice Weekly

Weekly Monthly

Infusion Site-assess hourly

Fluid balance

Blood glucose*

Urine glucose

Urine electrolytes*

Electrolytes (Na, K, Cl)

Urea, creatinine

Calcium

Phosphate

Magnesium

Triglyceride*

LFTs, Alkaline Phosphatase

Albumin

Bilirubin

Conj. Bilirubin

Acid base balance

Full blood count

Trace elements*

Vitamin A, D, E*

Weight

Head Circumference

*see special considerations




th July 2018


*Special Considerations Blood Glucose

Measure blood glucose levels (BGL) 6-12 hourly whilst increasing PN and 12-24 hourly when on full PN and stable

Follow the unit guidelines for the management of hyperglycaemia. A BGL >11mmol/l is currently the classification of hyperglycaemia in a neonate.

Triglyceride monitoring

For infants <26/40 CGA, or those that are severely septic, then triglycerides should be monitored once they are receiving 10ml/kg/day lipid (1.5g/kg/day), and then again at 20ml/kg/day (3g/kg/day). From then on it should be routinely on a Sunday.

All other infants should have triglycerides measured weekly on a Sunday. More frequent monitoring may be required in certain circumstances, for example if an infant has

had previously high triglyceride levels, is septic, catabolic or critically ill, or has severe and unexplained thrombocytopenia.

Urinary Electrolytes Sodium is thought to be critical to growth and measuring urinary sodium can be a useful

indicator of whole body sodium status. Checking this regularly, particularly in surgical infants who are at higher risk of sodium

depletion, is important. There is no nationally agreed reference range but the surgical team at BRHC advise

supplementing sodium if the urinary sodium level is below 20mmol/L. There should be a urinary sodium to potassium ratio of approximately 2:1.

If an infant requires supplementation, urinary sodium should be checked weekly until it is above 20mmol/L.

Long term PN and Trace elements Infants receiving PN long term i.e. >3 weeks and have minimal or no enteral feeds should also

have the following monitored on a monthly basis. o Trace element status to include copper, manganese, selenium and zinc o Fat soluble vitamin status

Trace elements should also be monitored in infants with pre-existing imbalances or who have a reduced excretion of bile e.g. in cholestasis, renal failure or hepatic disease. This should happen irrespective of length of time on PN.

8. Managing Metabolic Complications See Appendix One for information regarding managing metabolic complications.

9. Weaning TPN 1. As enteral feeds increase, wean all glucose infusions (5% and 10%) to zero. 2. Once enteral feeds at 30ml/kg/day, wean lipid infusion down to 15ml/kg/day and then titrate

aqueous phase to total fluid allowance. 3. As enteral feeds increase to 60ml/kg/day, wean lipid infusion down to 10ml/kg/day and then

titrate aqueous phase to total fluid allowance.




th July 2018


4. As enteral feeds increase to 90ml/kg/day, wean lipid infusion down to zero (unless running peripherally, in which case keep lipid at 10ml/kg/day) and then titrate aqueous phase to total fluid allowance.

5. PN can be stopped once tolerating 120ml/kg/day enteral feeds, or continued at 30ml/kg/day and weaned until tolerating 150ml/kg/day enteral feeds.

When Enteral feeds reach Wean Lipid infusion to Titrate Aqueous phase to

30ml/kg/day 15ml/kg/day total fluid allowance

As Enteral feeds increase to Wean Lipid infusion to Titrate Aqueous phase to

60ml/kg/day 10ml/kg/day total fluid allowance

90ml/kg/day Zero* (unless peripheral) total fluid allowance

120ml/kg/day Zero* (unless peripheral) total fluid allowance

*Unless running peripherally, in which case keep at 10ml/kg/day

NOTE – some high risk infants may continue on a small amount of aqueous PN and lipid to support

growth

10. References

1. Franz A, Pohlandt F, et al. Intrauterine, early neonatal, and post discharge growth and neurodevelopmental outcome at 5.4 years in extremely preterm infants after intensive neonatal nutrition support. Pediatrics 2009; 123 (101-109)

2. ‘The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice’ British Association of Perinatal Medicine April 2016

3. ‘Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for neonates and children’ A report from the Chief Pharmacists Group Nov 2011

4. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26:1SA-138SA




th July 2018


Appendix One

The management of metabolic complications

Hyperglycaemia If blood glucose level (BGL) >11mmol/L, which has been confirmed with a capillary/venous sample (1

sample has to be peripheral in case of contamination from central fluids), then treat for

hyperglycaemia.

1) Ensure all additional glucose infusions are reduced to 5% glucose, including the diluent for drug infusions, if compatible

2) If still hyperglycaemic, decrease aqueous PN rate by 30ml/kg/day and supplement volume with 5% glucose

3) If still hyperglycaemic, consider insulin (see insulin guideline) (Ensure minimum glucose infusion rate is no less than 6mg/kg/min)

Hypoglycaemia 1) Increase the concentration of all additional glucose infusions in a step wise manner from 10% to

15% to 20%. Ensure all drug infusions are in 10% glucose if compatible. 2) If still hypoglycaemic, decrease aqueous PN by 30ml/kg/day and supplement with 20% glucose 3) If still hypoglycaemic, stop PN and replace fluid volume with glucose 20% with electrolytes,

where required

Hypernatremia 1) Assess fluid balance, weight and hydration status. 2) Ensure arterial line is kept patent with heparinised 0.45% sodium chloride (not 0.9%), where

available 3) For immediate action, consider changing aqueous PN to SW Neonatal PN Bag 1. If true sodium

over supplementation discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available

Hyponatraemia 1) Assess fluid balance, weight and hydration status.

Water overload must be considered before supplementation of sodium is prescribed. In these cases fluid restriction is usually required and can be achieved by reducing the supplementary glucose 10% infusion rate.

2) If it is felt there is a true sodium deficit and this is not being corrected by the current PN regimen (ensure aqueous PN is not sodium free) then sodium losses should be calculated and replaced by using the standard sodium concentrations in the table below, to supplement sodium.

3) Ensure arterial line is kept patent with heparinised 0.9% sodium chloride (not 0.45%), where available

There are 5 standard sodium concentrations made up in glucose 10%. For central use only These supplementary sodium infusions allow replacement of sodium in addition to the sodium prescribed in the PN.




th July 2018


Guidance for sodium replacement (exclude fluid overload before supplementing sodium)

Sodium level

(mmol/l) Supplementary sodium infusion required

132-135

Small

deficit

Add 10mmol Sodium Chloride (2ml of 30% Sodium Chloride) to 48ml

glucose 10% to make up 50ml infusion containing 0.2mmol/ml of Sodium

Chloride.

Infusion rate 0.1mmol/kg/hr (0.5ml/kg/hr) gives sodium supplementation

of 2.4mmol/kg/day

128-131

Medium

deficit



Chloride.


of 4.8mmol/kg/day

124-127

Large

deficit



Chloride.


of 7.2mmol/kg/day

<124

Very large

deficit



Chloride.


of 9.6mmol/kg/day

<120

Discuss

with

consultant


glucose 10% to make up 50ml infusion containing 1mmol/ml of Sodium

Chloride.


of 12mmol/kg/day

NB: glucose 5% can be used as the diluent in cases of hyperglycaemia




th July 2018


Hyperkalaemia 1) Ensure that the hyperkalaemia result is true, i.e. not haemolysed. 2) Stop any additional potassium infusions 3) For immediate action, consider changing aqueous PN to SW Neonatal PN Bag 1. If true potassium

over supplementation discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available

Hypokalaemia (<3mmol/L) 1) Ensure aqueous PN bag contains potassium 2) Replace deficit by using supplementary potassium infusion. Aim to correct over 24 hours.

For central use only 3) Magnesium levels should also be checked and corrected if required

Add 10mmol Potassium Chloride (5ml of 15% Potassium Chloride) to 45ml glucose 10% to make

up 50ml infusion containing 0.2mmol/ml of Potassium Chloride.

Infusion rate 0.1mmol/kg/hr (0.5ml/kg/hr) gives potassium supplementation of 2.4mmol/kg/day

Occasionally, larger potassium requirements are needed (eg stoma losses, diuretics). These should be met by using the standard solution above and increasing the RATE of infusion as described below.

Infusion rate 0.2mmol/kg/hr (1ml/kg/hr) gives potassium supplementation of 4.8mmol/kg/day

Infusion rate 0.3mmol/kg/hr (1.5ml/kg/hr) gives potassium supplementation of 7.2mmol/kg/day

NB: glucose 5% can be used as the diluent in cases of hyperglycaemia

Hypercalcaemia (corrected calcium >3mmol/l) 1) Check serum phosphate levels. Hypercalcaemia may be secondary to hypophosphataemia

particularly if the latter is severe or persistent. The treatment in these cases is to supplement phosphate.

2) If the phosphate level is within range then any infusion containing calcium may need to be stopped, including PN. NB: all SW Neonatal PN bags contain calcium

3) Discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available

Hypocalcaemia (corrected calcium <1.5mmol/l, or ionised calcium <1mmol/L) 1) Check acid-base balance as metabolic alkalosis decreases ionised calcium levels. 2) Magnesium levels should also be checked and corrected if required 3) Change to SW Neonatal PN Bag 2 (if not already prescribed, and suitable for the patient), as it

contains more calcium than the SW Neonatal PN Bags 1 and 3, and optimise rates if possible. 4) If serum calcium level is still low, then administer 2ml/kg calcium gluconate 10% (0.46mmol/kg)

intravenously over 10minutes. Do NOT administer down the same intravenous line as the PN. 5) If higher amounts of calcium are required, then discuss with Consultant, Neonatal Pharmacist and

Neonatal Dietitian, where available.

Hyperphosphataemia 1) Calcium levels should also be checked and corrected if required 2) If true hyperphosphataemia and immediate action is required then stop aqueous PN and change

to SW Neonatal PN Bag 1. 3) Discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available. Hypophosphataemia (<1.5mmol/L)




th July 2018


1) Potassium levels should be checked and corrected if required 2) Check acid-base balance as metabolic acidosis increases urinary excretion of phosphate 3) Change to SW Neonatal PN Bag 2 (if not already prescribed and suitable for the patient), as it

contains more phosphate than the SW Neonatal PN Bags 1 and 3, and optimise rates if possible. 4) Discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available. 5) If infant tolerating more than half enteral feeds then consider enteral phosphate

supplementation. Hypermagnesaemia 1) If immediate action is required then stop aqueous PN and change to SW Neonatal PN Bag 1.

2) Discuss with Consultant, Neonatal Pharmacist and Neonatal Dietitian, where available.

Hypomagnesaemia 1) Ensure potassium and calcium serum levels are within the normal range

2) Change to SW Neonatal PN Bag 2 or 3 (if not already prescribed, and suitable for the patient), as it contains more magnesium than SW Neonatal PN Bag 1, and optimise rates if possible.

3) Consider magnesium supplementation with 0.4mmol/kg magnesium sulphate intravenously over

10minutes.

Hyperlipidaemia (>2.8mmol/L) For infants <26/40 CGA, or those that are severely septic, then triglycerides should be monitored once they are receiving 10ml/kg/day lipid (1.5g/kg/day), and then again at 20ml/kg/day (3g/kg/day). From then on it should be routinely on a Sunday. All other infants should have triglycerides measured weekly on a Sunday.

More frequent monitoring may be required in certain circumstances, for example if an infant has had previously high triglyceride levels, is septic, catabolic or critically ill, or has severe and unexplained thrombocytopenia. If infant is severely septic consider stopping the lipid infusion and discuss with Consultant, Neonatal

Pharmacist and Neonatal Dietitian, where available.

Triglyceride level

(mmol/L)

Action required When to re-measure

triglyceride

< 2.8mmol/L None Weekly on a Sunday

2.9-3.5mmol/L Reduce lipid infusion by 5ml/kg/day In 3 days

3.64mmol/L Reduce lipid infusion by 10ml/kg/day In 2 days

>4mmol/L Reduce lipid infusion to 5ml/kg/day or

consider stopping

In 2 days

Once repeat triglyceride measurement is <2.8mmol/L increase lipid infusion rate by 5ml/kg/day and repeat measurement every 2 days until target lipid infusion rate is reached. If the level >2.8mmol/L on a repeated test then repeat according to the table above then reduce the rate.




th July 2018


Appendix Two Regional standardised concentrated PN prescribing guidance sheet

Flow rates SW Neonatal PN Bag 1

Aqueous bag

50 ml/kg/day 65 ml/kg/day 80 ml/kg/day

Lipid syringe


Contents per kg/day at above rates

Nitrogen 0.32 g 0.42 g 0.51 g

Protein 2 g 2.6g 3.2 g

Glucose 5.79 g 7.53 g 9.27 g

Glucose 4.02 mg/kg/min 5.23 mg/kg/min 6.43 mg/kg/min

Sodium 0 mmol 0 mmol 0 mmol

Potassium 0 mmol 0 mmol 0 mmol

Calcium 0.42 mmol 0.54 mmol 0.67 mmol

Phosphate 0 mmol 0 mmol 0 mmol

Magnesium 0.06 mmol 0.08 mmol 0.1 mmol

Chloride 0.41 mmol 0.54 mmol 0.66 mmol

Acetate 0 mmol 0 mmol 0 mmol

Peditrace® 0.5ml 0.65ml 0.8ml

Lipid 0.75 g 1.5 g 2.25 g

Vitlipid Infant® 1 ml 2 ml 3 ml

Solivito N® 0.25 ml 0.5 ml 0.75 ml

Non-nitrogen calories (kcal/kg/day) 31.7 kcal 47.1 kcal 62.6 kcal

Kcal/g protein 15.8 18.1 19.5

If additional fluid is required, prescribe glucose 10% to make up the volume (NB: Glucose 5% can be used as an alternative)

Note Aqueous PN bags can be connected to the patient for a maximum of 48 hours Lipid syringes can only be connected to the patient for a maximum of 24 hours




th July 2018


Regional standardised concentrated PN prescribing guidance sheet


Aqueous bag


Lipid syringe



Nitrogen 0.36 g 0.45 g 0.56 g

Protein 2.28 g 2.8g 3.5 g

Glucose 7.01 g 8.63 g 10.78 g


Sodium 2.6 mmol 3.2 mmol 4 mmol

Potassium 1.3 mmol 1.6 mmol 2 mmol


Phosphate 1.3 mmol 1.6 mmol 2 mmol



Acetate 1.3 mmol 1.6 mmol 2 mmol

Peditrace® 0.65ml 0.8ml 1ml

Lipid 1.5 g 2.25 g 3 g


Solivito N® 0.5 ml 0.75 ml 1 ml

Non-nitrogen calories (kcal/kg/day) 45 kcal 60 kcal 77.1 kcal

Kcal/g protein 19.8 21.4 22






th July 2018




Aqueous bag


Lipid syringe



Nitrogen 0.26 g 0.38 g 0.51 g

Protein 1.6 g 2.4 g 3.2 g

Glucose 4.63 g 6.95 g 9.27 g


Sodium 0 mmol 0 mmol 0 mmol

Potassium 0 mmol 0 mmol 0 mmol


Phosphate 0 mmol 0 mmol 0 mmol



Acetate 0 mmol 0 mmol 0 mmol

Peditrace® 0.4ml 0.6ml 0.8ml

Lipid 0.75 g 1.5 g 2.25 g


Solivito N® 0.25 ml 0.5 ml 0.75 ml

Non-nitrogen calories (kcal/kg/day) 27 kcal 44.8 kcal 62.6 kcal

Kcal/g protein 16.9 18.7 19.5






th July 2018




Aqueous bag

40 ml/kg/day 60 ml/kg/day 80 ml/kg/day 100 ml/kg/day

Lipid syringe

5 ml/kg/day 10 ml/kg/day 15 ml/kg/day 20 ml/kg/day


Nitrogen 0.18 g 0.27 g 0.36 g 0.45 g

Protein 1.13 g 1.69 g 2.25 g 2.81 g

Glucose 4.2 g 6.3 g 8.4 g 10.5 g

Glucose 2.92 mg/kg/min 4.37 mg/kg/min 5.83 mg/kg/min 7.29 mg/kg/min

Sodium 1.6 mmol 2.4 mmol 3.2 mmol 4 mmol

Potassium 0.8 mmol 1.2 mmol 1.6 mmol 2 mmol

Calcium 0.4 mmol 0.6 mmol 0.8 mmol 1 mmol

Phosphate 0.52 mmol 0.79 mmol 1.05 mmol 1.31 mmol

Magnesium 0.08 mmol 0.12 mmol 0.16 mmol 0.2 mmol

Chloride 1.09 mmol 1.64 mmol 2.18 mmol 2.73 mmol

Acetate 1.07 mmol 1.61 mmol 2.15 mmol 2.69 mmol

Peditrace® 0.4ml 0.6ml 0.8ml 1ml

Lipid 0.75 g 1.5 g 2.25 g 3 g

Vitlipid Infant® 1 ml 2 ml 3 ml 4 ml

Solivito N® 0.25 ml 0.5 ml 0.75 ml 1 ml

Non-nitrogen calories (kcal/kg/day)

25.3 kcal 42.2 kcal 59.1 kcal 76 kcal

Kcal/g protein 22.5 25 26.3 27






th July 2018


Appendix Three

Lipid Syringe Recipe

Ingredient Volume (ml)

SMOF lipid 30

Vitlipid Infant 8

Solivito N 2

Total volume in a 50ml syringe 40

PN bag details, i.e. glucose concentration and osmolarity data

Type of bag% Glucose

Concentration

Osmolarity of

aqueous phase

(mOsm/L)

Volume of

aqueous

phase

Osmolarity of

lipid

(mOsm/L)

Volume of

lipid phase

Aqueous and lipid

combined

osmolarity

(mOsm/L)

Shelf

life

(days)

Licensing

1002 40 270 5 920.67

1002 50 270 5 935.45

1002 60 270 10 897.43

1002 65 270 10 904.40

1002 80 270 15 886.42

1049 65 270 10 945.13

1049 80 270 15 926.00

1049 100 270 20 919.17

954 40 270 5 878.00

954 60 270 10 856.29

954 80 270 15 846.00

954 100 270 20 840.00

<900mOsm/L4

900-950mOsmol/L2

SW Neonatal Bag 1

SW Neonatal Bag 2

SW Neonatal Bag 3

In summary

11.6

10.8

10.5

60

60

89

Unlicensed

Unlicensed

Unlicensed




th July 2018


Appendix Four

Neonatal Parenteral Nutrition Prescription (Preterm)

Regional Standardised Concentrated PN bags

Preterm infants <37/40 CGA and all infants <2.5kg (Days 1 to 6)

(NB. For units that only keep SW Neonatal Bags PN 1 & 2, this prescription can be used for all infants

whatever gestation or weight)

†For infants restarting PN after a period of full enteral feeds, start on day 3 and then increase

DATE

Day of Week

Day of TPN 1 2 3† 4 5 6

Weight (kg)

Peripheral/Central Line

Bag Type + Volume

(ml/kg/day)

Circle bag type required

NB: Volumes cannot be

altered. These refer solely

to the volume of aqueous

phase and do not include

lipid.

SW

Neonatal PN

Bag 1

50

SW

Neonatal PN

Bag 1

65

SW

Neonatal PN

Bag 1

80

- - -

-

SW

Neonatal PN

Bag 2

65

SW

Neonatal PN

Bag 2

80

SW

Neonatal PN

Bag 2

100

SW

Neonatal PN

Bag 2

100

SW

Neonatal PN

Bag 2

100

Total Lipid/vits Volume

(ml/kg/day) 5 10 15 20 20 20

Peditrace (ml/kg/day) (NB: already in bag)

0.5 0.65 0.8 1 1 1

Doctor/NMP’s Signature

Pharmacist’s Signature

Addressograph Patient name:…………………………………... Unit Number:…………………………………... NHS Number:…………………………………... Date of Birth:…………………………………... Consultant:…………………………………...

- Maximum volumes of PN are supplied by default –

nursing staff titrate volume administered according to

patient requirements

- Prescribe 48 hour bags where possible




th July 2018


Neonatal Parenteral Nutrition Prescription (Preterm)


Preterm infants <37/40 CGA and all infants <2.5kg (Day 7 onwards)

(NB. For units that only keep SW Neonatal Bags PN 1 & 2, this prescription can be used for all infants

whatever gestation or weight)

For infants restarting PN after a period of full enteral feeds, start on day 3 and then increase

DATE

Day of Week

Day of TPN

Weight (kg)


Bag Type + Volume

(ml/kg/day)






lipid.

SW

Neonatal

PN

Bag 2

100

SW

Neonatal

PN

Bag 2

100

SW

Neonatal

PN

Bag 2

100

SW

Neonatal

PN

Bag 2

100

SW

Neonatal

PN

Bag 2

100

SW

Neonatal

PN

Bag 2

100

Total Lipid/vits Volume

(ml/kg/day) 20 20 20 20 20 20


1 1 1 1 1 1











th July 2018


Appendix Five

Neonatal Parenteral Nutrition Prescription (Term)


Term infants >37/40 CGA, if >2.5kg (Days 1 to 6)

†For infants restarting PN after a period of full enteral feeds, start on day 3 and then increase

DATE

Day of Week

Day of TPN 1 2 3† 4 5 6

Weight (kg)


Bag Type + Volume

(ml/kg/day)






lipid.

SW Neonatal

PN

Bag 1

40

SW Neonatal

PN

Bag 1

60

- - - -

SW Neonatal

PN

Bag 3

40

SW Neonatal

PN

Bag 3

60

SW Neonatal

PN

Bag 3

80

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

Total Lipid/vits Volume (ml/kg/day)

5 10 15 20 20 20


0.4 0.6 0.8 1 1 1











th July 2018


Neonatal Parenteral Nutrition Prescription (Term)


Term infants >37/40 CGA, if >2.5kg (Day 7 onwards)

For infants restarting PN after a period of full enteral feeds, start on day 3 and then increase

DATE

Day of Week

Day of TPN

Weight (kg)


Bag Type + Volume

(ml/kg/day)



altered. These refer solely to

the volume of aqueous


lipid.

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

SW Neonatal

PN

Bag 3

100

Total Lipid/vits Volume (ml/kg/day)

20 20 20 20 20 20


1 1 1 1 1 1










south west neonatal network guideline · guideline regional neonatal parenteral nutrition main...

Documents