Post-guideline Group Research Articles

Nutrition Practice Guidelines and Neonatal Outcomes in Elbw Infants.

Early nutritional intervention, both parenteral and enteral, is becoming a standard of care for the extremely low birth weight infant (ELBW) in many neonatal intensive care units (NICU) across the country. However, there are no published or widely accepted guidelines regarding nutrition support strategies for this population. Most NICU's have developed their own guidelines and nutritional practices vary widely. In an effort to standardize our practice, we implemented nutrition support guidelines for ELBW infants, initiating both total parenteral nutrition (TPN) and minimal enteral feedings (MEFs) within the first 24 hours of life whenever possible. Objectives: 1) Evaluate the adherence to the nutritional guidelines and 2) Compare pre- and post-guideline outcomes. Materials and Methods: The study was conducted at a Level III NICU from January 2002 until February 2003. Charts of 70 infants born ≤1250gms were reviewed as part of a quality assurance project to monitor adherence to the newly established guidelines. Another 23 charts of ELBW infants who were admitted and cared for in the NICU prior to the initiation of the nutritional guidelines were reviewed as a control group. Student t-tests were used to compare selected clinical outcomes between infants started on early nutrition support (≤24 hours of life) versus those who were started later. Results: 61.4% and 52.9% of eligible infants were started on TPN and MEF's, respectively within 24 hours of life. The average time to start TPN was 21.9 hours after the adoption of the guidelines as opposed to 64.4 hours prior to guideline implementation (p<0.01). In the post-guideline group, MEF's were initiated at mean 27.3 hours of age versus 80.3 hours in the pre-guideline group (p<0.01). Those who were started on early TPN and MEF's reached full enteral feedings significantly sooner (mean:12.8 and 13.3 days vs. 45.8 and 45.8 days, respectively; p<0.01). Early nutrition support also resulted in earlier regain of birth weight (mean day 12.7 vs. 16.0 for early vs. late TPN; p<0.01 and mean day 13.8 vs. 16.0; p<0.04 for early vs. late MEF's). While not statistically significant, infants who received earlier nutrition support showed trends toward greater overall weight gains in weeks 2–3 and 3–4 of life and a lower incidence of elevated serum blood glucose for infants who received earlier nutrition support. Conclusions: The implementation of early Nutrition support guidelines influenced the timeliness of initiating nutrition support in our unit. Early initiation of TPN and MEF's in ELBW infants produces a more rapid regain of initial weight loss, improves weight gain and, enhances earlier achievement of full enteral feedings.

Effect of prescribing guidelines on the use of neuromuscular blocking agents

The effect of prescribing guidelines on the use of neuromuscular blocking agents (NMBs) was studied. Voluntary guidelines on the appropriate prescribing of formulary NMBs in the operating rooms at a university hospital were approved in January 1993. Patients who underwent inpatient surgery with neuromuscular blockade during a preguideline period (March 1, 1992, through May 31, 1992) or a postguideline period (March 1, 1993, through May 31, 1993) were randomly selected (n = 200 per group) and compared to determine the relative appropriateness, effectiveness, safety, and cost of NMB use. The preguideline and post-guideline groups were demographically similar. There were significantly more instances of appropriate NMB use after than before the guidelines were established. Neuromuscular blockade was maintained inall patients. The overall rates of NMB-associated adverse events were 5.5% and 7.5% for the preguideline and postguideline groups, respectively. The acquisition cost of NMBs and drugs used to treat NMB-associated adverse events for the preguideline patients was $4261, versus $2978 for the postguideline patients. Extrapolated to the estimated 10,000 operations per year requiring neuromuscular blockade at the institution, the total cost was $213,000 before guideline introduction and $149,000 afterward, for a guideline-associated cost reduction of $64,000. Prescribing guidelines reduced expenditures for NMBs without affecting clinical outcomes.