The arrival of all-in-one parenteral nutrition has signalled an important shift in practice in paediatrics but it is important to acknowledge that there will always be children outside the remit of standardisation
Rosan Meyer PhD
Department of Gastroenterology,
Great Ormond Street Hospital Foundation Trust,
Parenteral nutrition (PN) is a feeding mode suitable for infants and children who cannot be fully fed via the enteral route, that can transform the outlook for patients who do not have the ability to achieve nutritional requirements via this route.(1,2) In the past, individualised PN was thought to be the ‘gold standard’ for achieving optimal nutrient intake and patient safety. However, several studies have highlighted serious prescription and compounding errors, in addition to suboptimal delivery of nutrients and electrolytes to nutritionally very vulnerable children.(3–5) In 2007, the American Society for Parenteral and Enteral Nutrition (ASPEN) suggested a standardised process for PN management, which included the implementation of standardised PN formulations,(4) which are very much in line with the more recent paediatric recommendations by Fusch et al(6) for short-term PN. As a result, there has been a move towards standardisation of PN for both neonates and paediatrics.(6) This article is aimed at providing advice and factors that need to be considered for the implementation of standard PN.
Choice of AIO PN
Unlike adult PN, commercial paediatric standard solutions are relatively new and the variety is limited. This is related to the fact that infants and children continue to have the demand for growth and development and, as such, require varying amounts of nutrients at different stages of life.(7) It is therefore not possible to provide one standard solution for all ages, and a number of different standard solutions are required. Commercial standard PN falls within two broad categories: standard aqueous solution of amino acids and glucose that require lipids to be given separately, or AIO solutions, which combine both aqueous solutions and lipids.(7,8) However, many specialist paediatric centres have resorted to developing their own standard AIO PN, to cover the broad range of diagnoses. It is important to note that, in paediatrics, there will always be patients who fall outside of the remit of standard PN (for example, complex oncology patients, long-term home parenteral nutrition), which is in line with current ASPEN guidelines that recommend the availability of a mechanism for compounding individual PN for patients.
Advantages of AIO PN
The advantages association with using standard AIO PN include:4,(9–11)
● Cost saving during preparation, handling and delivery
● Better nutrient utilisation and assimilation
● Reduced costs of intravenous tubing, syringes and connectors
● Ease of administration
● Reduced rate of metabolic complications (for example, hyperglycaemia and electrolyte disorders)
● Further decreasing cost of monitoring.
Whether in-house or commercial standard AIO PN is used, there are several lessons to be learnt in the implementation of standard PN, as described by Meyer et al.(11) It is important to first identify the areas of improvement in PN practice and where current practice in your centre may pose a risk to patients. Although AIO standard PN has significant benefits, not all errors are addressed just by changing to this system of PN delivery. In the study by Meyer et al,(11) they did not only change to an AIO PN system with the option for individualised PN, but also changed to an electronic ordering system, a new labelling system, a new compounder and the method of delivery of the PN.
Keady et al(9) produced a fishbone diagram by which units may find it useful to assess their practice (Figure 1).
Other factors that need to be taken into account with the implementation of AIO PN are summarised in Table 1 and broadly cover:
● Patient population?
● Who prescribes the PN?
● How is the prescription done?
● Ward practicalities?
● Electrolyte and micronutrient imbalances?
In our experience, the implementation is dependent on a multidisciplinary approach where both the teaching as well as the attending should include all staff (doctors, nurses, dieticians, technicians) that are involved in the process of ordering and delivering PN. Meyer et al(11) used two teaching packs: one for nursing staff/other healthcare professionals and for physicians. The presentations were repeated in small groups for each medical specialty and were carried out by the parenteral nutrition dietitian, the pharmacist and a physician responsible for the specific specialty (Figure 2). Implementation occurred over one month with a follow-up review of prescriptions after six months.
Common perceived difficulties with AIO PN
Especially in centres that are used to having individual PN for each child, the initial phase of switching to AIO PN can be difficult, as it is often perceived to be “less flexible”. Electrolyte changes have been a particular challenge for Meyer et al,(11) where, in the initial phases, clinicians expressed the need to add electrolytes to the AIO PN at ward level. Muhlebach et al(12) discussed handling of AIO PN, recommending that acute electrolyte corrections should ideally not be done through standard PN, as this has the potential to introduce dosage errors, bacterial contamination, and may also impact on the stability of the PN. It is recommended that additional electrolytes are added in pharmacy in an aseptic environment and the acute corrections are carried out separately at ward level (that is, not via PN).
Another common perceived difficulty is that fluid delivery in AIO standard PN is linked to the adequacy of delivery of nutrients. Unlike individual PN, where the fluid in the PN matches the prescribed amount of both nutrients and fluid by the clinician, AIO PN comes in a standard volume (that is, 1.5l) and healthcare professionals provide only the volume from this bag that has been prescribed (for example, 850ml) to provide sufficient nutrients. It may therefore be the case that additional intravenous fluid is required. The practice of fluid and electrolyte management in AIO PN is therefore similar to enteral feeding standard solutions.
The arrival of AIO PN has signalled an important shift in practice in paediatrics. Research has indicated a benefit in the implementation of these standard PN bags for many children; however, it is important to acknowledge that there will always be children outside the remit of standard PN. The implementation is a step-wise process, involving the multidisciplinary team, that requires regular monitoring.
- All-in-One parenteral nutrition ( AIO PN) may reduce errors in children requiring PN.
- AIO PN has been shown to provide better nutrients and electrolytes in children.
- Although most children will be able to use AIO PN, there will always be those that require individual PN.
- When implementing AIO PN use the opportunity to review the process from prescription to delivery.
- Implementation requires teaching of all staff involved.
- Koletzko B 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.
- Shulman RJ, Phillips S. Parenteral nutrition in infants and children. J Pediatr Gastroenterol Nutr 2003;36(May):587–607.
- Brown CL, Garrison NA, Hutchison AA. Error reduction when prescribing neonatal parenteral nutrition. Am J Perinatol 2007;24(7):417–27.
- Kochevar M et al. ASPEN statement on parenteral nutrition standardization. JPEN J Parenter Enteral Nutr 2007;31(5):441–8.
- Steward JAD 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. /www.ncepod.org.uk/2010report1/downloads/PN_report.pdf (accessed 23 January 2014).
- Fusch C et al. Neonatology/paediatrics. Guidelines on parenteral nutrition, Chapter 13. Ger Med Sci 2009;7:Doc15.
- Colomb V. Commercially premixed 3-chamber bags for pediatric parenteral nutrition are available for hospitalized children. J Nutr 2013;143(12):2071S–6S.
- Rigo J et al. Benefits of a new pediatric triple-chamber bag for parenteral nutrition in preterm infants. J Pediatr Gastroenterol Nutr 2012;54(2):210–7.
- Keady S et al. Effect of a neonatal standard aquaous parenteral nutrition formulation on aceptic unit capacity planning. ESPEN Clin Nutr Metab 2010;5:e14–e17.
- Skouroliakou M et al. Physicochemical stability of parenteral nutrition supplied as all-in-one for neonates. JPEN J Parenter Enteral Nutr 2008;32(2):201–9.
- Meyer R et al. Developing and implementing all-in-one standard paediatric parenteral nutrition. Nutrients 2013;5(6):2006–18.
- Muhlebach S, Franken C, Stanga Z. Practical handling of AIO admixtures. Guidelines on Parenteral Nutrition, Chapter 10. Ger Med Sci 2009;7:Doc18.