P21 Introduction of standardised parenteral nutrition for use in preterm neonates in a neonatal intensive care unit at a large tertiary hospital
Authors: Whiteley Sarah , Mak Kimberly , Forster Christopher 
Published: April 2022

Aim

Following the publication of the updated NICE guidelines1 recommending the use of standardised parenteral nutrition (PN) in preterm and term babies, alongside the known associated risks to patient safety with increased manipulations,2 and the need to reduce workload pressures in the aseptic department, the decision was made to introduce standardised PN, Numeta G13 and G16 produced by Baxter, for all babies in the neonatal unit.

When initially introduced, 85% of babies weighing less than 1kg were changed to a bespoke PN. Of the babies who required a switch, 75% had hyponatraemia and/or hypophosphatemia and 45% were switched due to hyperglycaemia. Insulin usage in this cohort had increased from 33% to 76%. An earlier study trialling standard additions of sodium glycerophosphate had reduced the switch rate due to electrolyte imbalance. The aim of this prospective study was to trial an alternative building regimen to reduce the number of patients requiring a switch to bespoke PN due to hyperglycaemia.

Method

Standardised PN was routinely titrated by 20ml/kg/day, starting at 60ml/kg/day, up to 120ml/kg/day, with extra glucose 5% to provide enough fluid for hydration. For this prospective study, any neonate weighing less than 1.5kg was commenced on a slower build starting with 40ml/kg/day and building by 20ml/kg/day up to 120ml/kg/day. Glucose 5% was continued to be used as the ‘top-up’ fluid of choice. This equated to a more gradual build of glucose over the initial 5 day period. Hyperglycaemia was managed using the Trust’s ‘Management of Hyperglycaemia in the Neonate’ guideline.3 22 patients were included in the study and their insulin requirements and requirement to switch to a bespoke PN were recorded.

Results

Insulin usage in this cohort decreased from 75% to 45%. Although higher than the usage prior to the introduction of standardised PN, this is likely explained by the introduction of a standardised hyperglycaemia guideline3 which resulted in babies not receiving restricted glucose amounts in their PN by day 5 (16g/kg/day compared to an average of 9g/kg/day previously). More than 90% of babies in this cohort remained on standardised PN, compared to 15% when first introduced.

Conclusion

Following the introduction of standard additions of sodium glycerophosphate and the slower titration regimen for babies weighing less than 1.5kg, most babies were now tolerating standardised PN and it was deemed a suitable regimen for this cohort. NICE recommended nutritional support1 was reached by day 5 of PN. The introduction of a hyperglycaemia management guideline also standardised the use of insulin in this cohort, resulting in glucose reduction in PN being required less frequently.

Reference

National Institute of Health and Care Excellence. Neonatal Parenteral Nutrition: NICE Guideline [NG154], 2020. Available at: https://www.nice.org.uk/guidance/ng154

Beaney AM. Quality assurance of aseptics preparation services: standards part A. Fifth Edition. 2016. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20standards/Quality%20Assurance%20of%20Aseptic%20Preparation%20Services%20%28QAAPS%29/rps---qaaps-standards-document.pdf

Management of Hyperglycaemia in the Neonate. 2020. Local Trust guideline – reference available upon request.