Provision Of Parenteral Nutrition Research Articles

When parenteral nutrition is the answer: The case of pediatric intestinal rehabilitation.

In pediatric patients with intestinal failure, parenteral nutrition is lifesaving but also has several associated risks. The goals of intestinal rehabilitation include promoting growth, minimizing complications associated with intestinal failure, and reaching enteral autonomy, if possible. Pediatric intestinal rehabilitation programs are interdisciplinary teams that strive to provide optimal care for children dependent on parenteral nutrition. The provision of parenteral nutrition requires close monitoring of patients' growth, nutrition concerns, clinical status, and laboratory parameters. Recent advances in the field of intestinal rehabilitation include new lipid emulsions, considerations regarding enteral feeding, advances in micronutrient provision, and central venous catheter preservation techniques. Challenges in the field remain, including improving overall quality of life with home parenteral nutrition administration and preventing recently recognized complications such as chronic intestinal inflammation.

Vascular rehabilitation in children with chronic intestinal failure reduces the risk of central-line associated bloodstream infections and catheter replacements

Background & AimsChildren with chronic intestinal failure (IF) require a long-term central venous catheter (CVC) for provision of parenteral nutrition. Vascular, mechanical and infectious complications such as central line-associated bloodstream infections (CLABSI) may lead to progressive loss of venous access sites. Handling and management of CVCs therefore play an important role. Our vascular rehabilitation concept (VRC) is a core component of our intestinal rehabilitation program (IRP) and consists of an education program, optimization of skin care, catheter fixation and lock solution, and the use of hybrid technique for catheter placement.Aim of this study is to analyse the effectiveness of our VRC on CLABSI rates and need for CVC replacements. MethodsRetrospective analysis of all children treated in our IRP that were followed up between 2018 and 2023. ResultsA total of 117 children with chronic IF could be included for analysis of 248864 catheter days (CD). 91 patients were referred from other hospitals (127117 CD before and 89359 CD after entry into our IRP). Children receiving primary care at our IRP (32388 CD) showed a significantly lower CLABSI and line replacement rate than patients referred from external centers (p<0.001). After entering our IRP, CLABSI rates and need for CVC replacements per 1000 CD decreased significantly in referred patients: 1.17 to 0.26 and 1.75 to 0.59, respectively (p<0.001). ConclusionManagement of paediatric chronic IF patients by an IRP with a vascular rehabilitation concept significantly lowers the rate of CLABSI episodes and the need for catheter replacements.

Improving dietetic practice and reducing risk in the provision of parenteral nutrition for patients at tallaght university hospital

Improving dietetic practice and reducing risk in the provision of parenteral nutrition for patients at tallaght university hospital

The provision of parenteral nutrition during the Covid-19 pandemic: A district general hospital experience.

The provision of parenteral nutrition during the Covid-19 pandemic: A district general hospital experience.

Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition.

Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population. An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded. The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided. Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.

Safety in parenteral nutrition compounding.

Parenteral nutrition (PN) compounding is a complex process that requires knowledge and training to ensure the safety and efficacy of this form of nutrition support therapy. Unfortunately, errors and lack of adherence to safe PN compounding recommendations and sterile compounding requirements have resulted in patient injury and death. These lapses in the safe provision of PN have been the result of various factors, including a lack of understanding of PN compatibility, stability, and sterility requirements, as well as drug product shortages and order entry errors. This review will describe the current challenges with the education and training regarding PN compounding, compatibility and stability of PN admixtures, simultaneous administration of nonnutrient medications with PN admixtures, and specific challenges with special populations such as neonates, pediatrics, and those receiving home care.

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system.

Parenteral nutrition (PN)-related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database. A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death. 12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors. This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.

The provision of parenteral nutrition for patients with COVID-19 on the intensive care unit: experience at a district general hospital

Up to 10% of COVID-19 patients require respiratory and hemodynamic support in the ICU and are at an increased risk of malnutrition (1). Where enteral nutrition is impossible, contraindicated, or insufficient then parenteral nutrition (PN) is warranted, and considered safe in the critically ill cohort (2, 3). We report the characteristics and outcomes for ventilated patients with COVID-19 who received PN on ICU.

Evaluation the Role of Nutrition Support Team for Monitoring the Types, Complication, Nutrients and Drugs Provision in the Parenteral Nutrition

Parenteral nutrition (PN) is a form of administering nutrients, include water, macro and micronutrients and is one of widely used mode of therapy used in patients who are unable to tolerate oral or enteral feeding. Therefore, the success of nutritional therapy depends chiefly on nutrition support teams. The aim of the present work to evaluation the provision of parenteral nutrition in the Benghazi medical center. A total of 86 patients were involved in the study and numbers of questions were answered from nutrition support team at the hospital. The result revealed that PPN (IV drip) most common used and mixture of dextrose and sodium chloride were highly provision in the hospital. Furthermore the Doctors at the ward were shown have fully responsibility for provided PN but there were neglected role of dietitian and pharmacist. Patients monitoring were not carried out routinely. Most drug delivered by PN found NSAIDs and insulin. Dextrose and sodium chlorides commonly used in the hospital for delivery medication. The present study also demonstrated that, PN did not fulfill the patients requirement and there were no patients monitoring. PN found to be used most frequently in some condition were where in real need such as pulmonary disease, GIT disorder and renal disease. Furthermore, TPN provided for the admitted patients include in emergencies, therapeutic and for unconscious patients. There were reported a number of complication in patient received PN due to lack of monitoring and prolong replacements of PN drainage. PPN (Iv drips) were the most common uses at the hospital and longer duration was proved which might led to patients burden in the hospital. Furthermore, due to the uses of PPN for longer times this could contribute for patients malnutrition. Our data suggested that, comprehensive nutrition support team and provision of intervention programs in order to increased quality and reduced patients burden and also the result of our study needed to be validated in large sample to know the real role of dietitian and pharmacist for ordered of drugs and nutrients and nutrients drug interactions. Keywords: Nutrients, Provision, TPN, PN, complication, medications.

Early supplemental parenteral nutrition is associated with reduced mortality in critically ill surgical patients with high nutritional risk

Adequate nutritional provision is important for critically ill patients to improve clinical outcomes. Starting enteral nutrition (EN) as early as possible is recommended and preferred to parenteral nutrition (PN). However, patients who undergo emergency abdominal operations may have alterations in their intra-abdominal environment and gastrointestinal motility leading to limitation in starting an enteral diet. Therefore, our study was designed to evaluate the benefit of early supplemental PN to achieve adequate calorie and protein supply in critically ill patients undergoing surgery who are not eligible for early EN. We reviewed the medical records of 317 patients who underwent emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The nutritional data of the patients were collected for 7 days in maximum, starting on the day of intensive care unit (ICU) admission. The patients were divided by low or high malnutrition risk using the modified Nutrition Risk in Critically ill (mNUTRIC) score and body mass index. The low- and high-risk groups were subdivided into the following two categories: those who received PN within 48h ("early") and those who did not ("usual"). Data regarding the baseline characteristics, initial severity of illness, morbidity, and mortality rates were also obtained. The average calorie and protein supply per day were calculated in these groups. Patients in all groups showed no significant differences in baseline characteristics, initial status, and infectious complications. In terms of outcomes, patients with low malnutrition risk had no significant difference in mortality. However, among patients with high malnutrition risk, the "Early" group had lower rates of 30-day mortality (7.6% vs. 26.7%, p=0.006) and in-hospital mortality (13.6% vs. 28.9%, p=0.048) than those of the "Usual" group. Kaplan-Meier survival curves for 30-day mortality in these groups also showed a statistically significant difference (p=0.001). The caloric adequacy of the "Early" group and the "Usual" group were 0.88±0.34 and 0.6±0.29, respectively. Amounts of protein received were 0.94±0.39g/kg in the "Early" group and 0.47±0.34g/kg in the "Usual" group, respectively. There was no significant difference in infectious complications between both groups. Mortality in patients with high malnutrition risk who received early PN supply within 48h after emergency surgery for cIAI was lower than those who did not receive PN earlier. PN may be necessary to fulfill the caloric and protein requirements for critically ill patients who cannot achieve their nutritional requirements to the fullest with EN alone.

The incidence of osteopenia of prematurity in preterm infants without phosphate supplementation: A prospective, observational study.

To meet their requirements for bone mineralization, it is recommended that preterm infants receive nutritional support containing calcium and phosphate. There are no clear data on the incidence of osteopenia of prematurity (OFP) in preterm infants without phosphate supplementation.This study aimed to investigate the incidence of OFP in preterm infants without phosphate supplementation and its relationship with the duration of parenteral nutrition (PN).This was a prospective and observational study.This study included 30 infants aged <32 gestational weeks and weighed <1500 g at birth. All infants received PN according to a standard protocol, beginning on day 1 with calcium, without phosphate. Starting from the first day of life, all infants received human milk without fortifiers. Oral vitamin D (400 IU/d) was administered when enteral nutrition reached 100 mL/kg/d.The diagnosis of OFP was based on radiographs that were taken of both wrists. Serum alkaline phosphatase (ALP) was measured 3 times: at the start of PN (ALP 1), at the end of PN (ALP 2), and at discharge or the expected due date (ALP 3). Radiographs were obtained on the same day as ALP 3. The duration of PN was analyzed in the presence of OFP using receiver operating characteristic curve analysis.Among the 30 infants, 13 (43%) were diagnosed with OFP. The duration of PN was significantly longer in the OFP group than in the group without OFP (16 vs 12 days; P < .05). The provision of PN for >15 days significantly increased the risk of OFP (odds ratio, 5.40; 95% confidence interval, 1.12–26.04; P = .035).We found a high incidence of OFP in preterm infants without phosphate supplementation. An association was found between the duration of PN and the incidence of OFP. Further research is needed to prevent the development of osteopenia in preterm infants.

Parenteral nutrition in critical illness: total, supplemental or never?

The current review summarizes recent evolutions in knowledge and discusses the concept of whom and when parenteral nutrition should be considered in critically ill patients as a total form of nutrition, in a supplemental form, or never. Recent developments in our understanding of the application of parenteral nutrition in critical care include the phases of illness, avoidance of overfeeding and the population in whom parenteral nutrition may be appropriate for. Importantly, one of the greatest lessons of recent times may be who not to provide parenteral nutrition to; however, a blanket approach of increased risk with parenteral nutrition is too simple for the modern context. When providing total or supplemental parenteral nutrition, avoidance of overfeeding with total calories and/or glucose alone is critical, as is consideration to the phase of illness the patient is in, the population in whom it is to be applied, premorbid nutrition status and the setting (including adequacy of line management and expertise in parenteral nutrition provision). The appropriateness of parenteral nutrition should be considered in those where death is imminent or who are well nourished, likely to commence oral and/or enteral nutrition imminently and have a short-stay in intensive care, or are in a high-risk setting.

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

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 &lt; 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.

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

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 (&gt;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

P43 Concentrated standardised PN to optimise nutrition in preterm infants

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 &lt;28 weeks gestation or &lt;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

Single centre experience of post-operative parenteral nutrition provision in patients undergoing cytoreductive surgery & heated intraperitoneal chemotherapy

Single centre experience of post-operative parenteral nutrition provision in patients undergoing cytoreductive surgery & heated intraperitoneal chemotherapy

SUN-PO260: Central Venous Catheters Infections Related to Parenteral Nutrition Provision

SUN-PO260: Central Venous Catheters Infections Related to Parenteral Nutrition Provision

P1.53: Are Femoral Tunnelled Central Venous Catheters safe to use for HPN?

Background: Patients with Intestinal Failure (IF) require reliable intravenous access for provision of Parenteral Nutrition. Venous access for Home Parenteral Nutrition (HPN) patients with Type 3 IF can be compromised due to thrombosis of deep veins. Preferred choice of veins for central venous catheter are the supra cardiac veins. Femoral tunnelled CVC are avoided due to concerns of catheter related blood stream infection (CRBSI) and are considered as a last resort when all other thoracic CVC access is exhausted. We assess the outcomes of tunnelled femoral catheters in our cohort of HPN patients. Methods: We did a retrospective analysis of a prospectively collected data of all HPN patients and venous access from January 2013 to December 2018 managed at a National HPN Unit. The details of venous access, complications of CVC, sex and details of stoma extracted from database. Results: In a cohort of 9 HPN patients with tunnelled femoral CVC, 6 were females and 3 were males leading to a total of 8418 days. A total 3 episodes of CRBSI were recorded in 1 patient. All of the 3 episodes (methicillin – sensitive Staphylococcus aureus (MSSA), Escherichia Coli and CNS) were successfully salvaged. The average no of days for femoral CVC was 935 days. The rate of CRBSI was 0.35 per 1000 catheter days. 8 patients had stoma or open abdominal wound. There were no episodes of ipsilateral femoral DVT. The CVC was replaced for 2 patients due to fracture of CVC. Conclusion: Tunnelled femoral CVC CRBSI rate (0.35)is comparable to thoracic veins CVC CRBSI rate(0.31) in our unit. Furthermore femoral access could be considered as a reliable access to provide HPN. It may be considered as an option if more than 2 thoracic deep veins are occluded to prevent complete occlusion of SVC. We feel tunnelled femoral CVC is a safe option to consider for HPN

Parenteral Provision of Micronutrients to Adult Patients: An Expert Consensus Paper.

Micronutrients, an umbrella term used to collectively describe vitamins and trace elements, are essential components of nutrition. Those requiring alternative forms of nutrition support are dependent on the prescribed nutrition regimen for their micronutrient provision. The purpose of this paper is to assist clinicians to bridge the gap between the available guidelines' recommendations and their practical application in the provision of micronutrients via the parenteral route to adult patients. Based on the available evidenced-based literature and existing guidelines, a panel of multidisciplinary healthcare professionals with significant experience in the provision of parenteral nutrition (PN) and intravenous micronutrients developed this international consensus paper. The paper addresses 14 clinically relevant questions regarding the importance and use of micronutrients in various clinical conditions. Practical orientation on how micronutrients should be prescribed, administered, and monitored is provided. Micronutrients are a critical component to nutrition provision and PN provided without them pose a considerable risk to nutrition status. Obstacles to their daily provision-including voluntary omission, partial provision, and supply issues-must be overcome to allow safe and responsible nutrition practice.

An audit of parenteral nutrition provision on the cardiac and general intensive care units at Southampton general hospital

An audit of parenteral nutrition provision on the cardiac and general intensive care units at Southampton general hospital