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Phongpreecha T, Ghanem M, Reiss JD, Oskotsky TT, Mataraso SJ, De Francesco D, Reincke SM, Espinosa C, Chung P, Ng T, Costello JM, Sequoia JA, Razdan S, Xie F, Berson E, Kim Y, Seong D, Szeto MY, Myers F, Gu H, Feister J, Verscaj CP, Rose LA, Sin LWY, Oskotsky B, Roger J, Shu CH, Shome S, Yang LK, Tan Y, Levitte S, Wong RJ, Gaudillière B, Angst MS, Montine TJ, Kerner JA, Keller RL, Shaw GM, Sylvester KG, Fuerch J, Chock V, Gaskari S, Stevenson DK, Sirota M, Prince LS, Aghaeepour N. AI-guided precision parenteral nutrition for neonatal intensive care units. Nat Med 2025:10.1038/s41591-025-03601-1. [PMID: 40133525 DOI: 10.1038/s41591-025-03601-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 02/17/2025] [Indexed: 03/27/2025]
Abstract
One in ten neonates are admitted to neonatal intensive care units, highlighting the need for precise interventions. However, the application of artificial intelligence (AI) in guiding neonatal care remains underexplored. Total parenteral nutrition (TPN) is a life-saving treatment for preterm neonates; however, implementation of the therapy in its current form is subjective, error-prone and resource-consuming. Here, we developed TPN2.0-a data-driven approach that optimizes and standardizes TPN using information collected routinely in electronic health records. We assembled a decade of TPN compositions (79,790 orders; 5,913 patients) at Stanford to train TPN2.0. In addition to internal validation, we also validated our model in an external cohort (63,273 orders; 3,417 patients) from a second hospital. Our algorithm identified 15 TPN formulas that can enable a precision-medicine approach (Pearson's R = 0.94 compared to experts), increasing safety and potentially reducing cost. A blinded study (n = 192) revealed that physicians rated TPN2.0 higher than current best practice. In patients with high disagreement between the actual prescriptions and TPN2.0, standard prescriptions were associated with increased morbidities (for example, odds ratio = 3.33; P value = 0.0007 for necrotizing enterocolitis), while TPN2.0 recommendations were linked to reduced risk. Finally, we demonstrated that TPN2.0 employing a transformer architecture enabled guideline-adhering, physician-in-the-loop recommendations that allow collaboration between the care team and AI.
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Affiliation(s)
- Thanaphong Phongpreecha
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Marc Ghanem
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Jonathan D Reiss
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Tomiko T Oskotsky
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Samson J Mataraso
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Davide De Francesco
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - S Momsen Reincke
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Camilo Espinosa
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Philip Chung
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Taryn Ng
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Jean M Costello
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | | | - Sheila Razdan
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Keck School of Medicine of USC, Division of Neonatal and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Feng Xie
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Eloise Berson
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Yeasul Kim
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - David Seong
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - May Y Szeto
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Faith Myers
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Hannah Gu
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - John Feister
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Laura A Rose
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Lucas W Y Sin
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Boris Oskotsky
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | - Jacquelyn Roger
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | - Chi-Hung Shu
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Sayane Shome
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Liu K Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Yuqi Tan
- Department of Pathology, Stanford University, Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Steven Levitte
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Stanford, CA, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Brice Gaudillière
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Martin S Angst
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | | | - John A Kerner
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Karl G Sylvester
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Janene Fuerch
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Valerie Chock
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Shabnam Gaskari
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | | | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | - Nima Aghaeepour
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA.
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2
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Kindt A, Kraus Y, Rasp D, Foerster KM, Ahmidi N, Flemmer AW, Herber-Jonat S, Heinen F, Weigand H, Hankemeier T, Koletzko B, Krumsiek J, Babl J, Hilgendorff A. Improved Macro- and Micronutrient Supply for Favorable Growth and Metabolomic Profile with Standardized Parenteral Nutrition Solutions for Very Preterm Infants. Nutrients 2022; 14:3912. [PMID: 36235563 PMCID: PMC9572167 DOI: 10.3390/nu14193912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/09/2022] [Accepted: 09/10/2022] [Indexed: 11/16/2022] Open
Abstract
Very preterm infants are at high risk for suboptimal nutrition in the first weeks of life leading to insufficient weight gain and complications arising from metabolic imbalances such as insufficient bone mineral accretion. We investigated the use of a novel set of standardized parenteral nutrition (PN; MUC PREPARE) solutions regarding improving nutritional intake, accelerating termination of parenteral feeding, and positively affecting growth in comparison to individually prescribed and compounded PN solutions. We studied the effect of MUC PREPARE on macro- and micronutrient intake, metabolism, and growth in 58 very preterm infants and compared results to a historic reference group of 58 very preterm infants matched for clinical characteristics. Infants receiving MUC PREPARE demonstrated improved macro- and micronutrient intake resulting in balanced electrolyte levels and stable metabolomic profiles. Subsequently, improved energy supply was associated with up to 1.5 weeks earlier termination of parenteral feeding, while simultaneously reaching up to 1.9 times higher weight gain at day 28 in extremely immature infants (<27 GA weeks) as well as overall improved growth at 2 years of age for all infants. The use of the new standardized PN solution MUC PREPARE improved nutritional supply and short- and long-term growth and reduced PN duration in very preterm infants and is considered a superior therapeutic strategy.
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Affiliation(s)
- Alida Kindt
- Institute of Computational Biology, Helmholtz Zentrum München, 85764 Oberschleißheim, Germany
- Metabolomics and Analytics Center, Leiden Academic Centre for Drug Research, Leiden University, 2333 AL Leiden, The Netherlands
| | - Yvonne Kraus
- Center for Comprehensive Developmental Care (CDeCLMU), Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr von Hauner Children's Hospital, Munich University Hospital, Ludwig Maximilians University, 80336 Munich, Germany
- Comprehensive Pneumology Center, Helmholtz Zentrum München, Member of the German Lung Research Center (DZL), 81377 Munich, Germany
| | - David Rasp
- Metabolomics and Analytics Center, Leiden Academic Centre for Drug Research, Leiden University, 2333 AL Leiden, The Netherlands
| | - Kai M. Foerster
- Comprehensive Pneumology Center, Helmholtz Zentrum München, Member of the German Lung Research Center (DZL), 81377 Munich, Germany
- Department of Neonatology, Perinatal Center, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians University, 80337 Munich, Germany
| | - Narges Ahmidi
- Institute of Computational Biology, Helmholtz Zentrum München, 85764 Oberschleißheim, Germany
| | - Andreas W. Flemmer
- Department of Neonatology, Perinatal Center, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians University, 80337 Munich, Germany
| | - Susanne Herber-Jonat
- Department of Neonatology, Perinatal Center, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians University, 80337 Munich, Germany
| | - Florian Heinen
- Center for Comprehensive Developmental Care (CDeCLMU), Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr von Hauner Children's Hospital, Munich University Hospital, Ludwig Maximilians University, 80336 Munich, Germany
| | - Heike Weigand
- Center for Comprehensive Developmental Care (CDeCLMU), Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr von Hauner Children's Hospital, Munich University Hospital, Ludwig Maximilians University, 80336 Munich, Germany
| | - Thomas Hankemeier
- Metabolomics and Analytics Center, Leiden Academic Centre for Drug Research, Leiden University, 2333 AL Leiden, The Netherlands
| | - Berthold Koletzko
- Division of Metabolic and Nutritional Medicine, Department of Paediatrics, Dr. von Hauner Children’s Hospital University Hospital, Ludwig-Maximilians University, 81377 Munich, Germany
| | - Jan Krumsiek
- Institute of Computational Biology, Helmholtz Zentrum München, 85764 Oberschleißheim, Germany
- Institute for Computational Biomedicine, Englander Institute for Precision Medicine, Department of Physiology and Biophysics, Weill Cornell Medicine, New York, NY 10065, USA
| | - Juergen Babl
- Pharmacy of the University Hospital, Ludwig-Maximilians University, 81377 Munich, Germany
| | - Anne Hilgendorff
- Center for Comprehensive Developmental Care (CDeCLMU), Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr von Hauner Children's Hospital, Munich University Hospital, Ludwig Maximilians University, 80336 Munich, Germany
- Comprehensive Pneumology Center, Helmholtz Zentrum München, Member of the German Lung Research Center (DZL), 81377 Munich, Germany
- Department of Neonatology, Perinatal Center, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians University, 80337 Munich, Germany
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3
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Van den Broucke E, Deleenheer B, Meulemans A, Vanderstappen J, Pauwels N, Cosaert K, Spriet I, Van Veer H, Vangoitsenhoven R, Sabino J, Declercq P, Vanuytsel T, Quintens C. Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE). J Med Syst 2022; 46:56. [PMID: 35804275 DOI: 10.1007/s10916-022-01835-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
Parenteral nutrition (PN) is recommended in patients nutritionally at risk and unable to receive oral or enteral nutrition. A standardized electronic PN order format could enhance appropriate PN prescribing. We developed the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate PN using a Validated Electronic decision TREE), embedded in our electronic health record. We aimed to evaluate its validity and impact on physicians' prescribing behavior. A non-randomized before-after study was carried out in a tertiary care center. The OLIVE TREE comprises 120 individual items. A process validation was performed to determine interrater agreement between a pharmacist and the treating physician. To estimate the proportion of patients for whom the OLIVE TREE had an effective and potential impact on physicians' prescribing behavior, a proof of concept study was conducted. The proportion of patients for whom PN was averted and the proportion of decisions not in line with the recommendation were also calculated. The process validation in 20 patients resulted in an interrater agreement of 95.0%. The proof of concept in 73 patients resulted in an effective and potential impact on prescribing behavior in 50.7% and 79.5% of these patients, respectively. Initiation of PN was not averted and recommendations of the OLIVE TREE were overruled in 42.5% of the patients. Our newly developed OLIVE TREE has a good process validity. A substantial impact on prescribing behavior was observed, although initiation of PN was not avoided. In the next phase, the decision tree will be implemented hospital-wide.
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Affiliation(s)
- Evelyne Van den Broucke
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Barbara Deleenheer
- Pharmacy Division, UZ Leuven, Louvain, Belgium. .,Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.
| | - Ann Meulemans
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Department of Chronic diseases and Metabolism - Clinical and Experimental Endocrinology (CEE), KU Leuven, Louvain, Belgium
| | | | - Nelle Pauwels
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Leuven Intestinal Failure and Transplantation (LIFT), UZ Leuven, Louvain, Belgium
| | | | - Isabel Spriet
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Hans Van Veer
- Division of Thoracic Surgery, UZ Leuven, Louvain, Belgium.,Department of Chronic Diseases and Metabolism - Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) - Lung Transplant Unit, KU Leuven, Louvain, Belgium
| | - Roman Vangoitsenhoven
- Division of Endocrinology, UZ Leuven, Louvain, Belgium.,Department of Chronic diseases and Metabolism - Clinical and Experimental Endocrinology (CEE), KU Leuven, Louvain, Belgium
| | - João Sabino
- Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.,Division of Gastroenterology and Hepatology, UZ Leuven, Louvain, Belgium
| | - Peter Declercq
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
| | - Tim Vanuytsel
- Department of Chronic Diseases and Metabolism - Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Louvain, Belgium.,Leuven Intestinal Failure and Transplantation (LIFT), UZ Leuven, Louvain, Belgium.,Division of Gastroenterology and Hepatology, UZ Leuven, Louvain, Belgium
| | - Charlotte Quintens
- Pharmacy Division, UZ Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium
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4
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Falciglia GH, Sierra-Fernandez H, Freeman M, Healy D, Wicks JS, Robinson DT. Advancing Clinical Decision Support Systems for the Management of Neonatal Nutrition: Barriers to Implementation. RESEARCH AND REPORTS IN NEONATOLOGY 2022. [DOI: 10.2147/rrn.s355468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ambreen G, Kumar V, Ali SR, Jiwani U, Khowaja W, Hussain AS, Hussain K, Raza SS, Rizvi A, Ansari U, Ahmad K, Demas S, Ariff S. Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country. Arch Dis Child 2022; 107:381-386. [PMID: 34257078 DOI: 10.1136/archdischild-2021-321552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/21/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes. DESIGN This was a quality improvement initiative. Data were collected retrospectively before and after the intervention. SETTING A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan. PATIENTS All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018. INTERVENTIONS A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU. MAIN OUTCOME MEASURES We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay. RESULTS Neonates on SPN had greater rate of change in weight compared with IPN (β=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group. CONCLUSIONS We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.
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Affiliation(s)
- Gul Ambreen
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Vikram Kumar
- Neonatology, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Syed Rehan Ali
- Neonatology, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Uswa Jiwani
- Center of Excellence in Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Waqar Khowaja
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Ali Shabbir Hussain
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Kashif Hussain
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Shamim Raza
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Uzair Ansari
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Khalil Ahmad
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Simon Demas
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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Abstract
At birth preterm babies are unable to tolerate sufficient enteral nutrition to support growth and development. Parenteral nutrition provides a means to bridge the transition from placental transfer of nutrients to the establishment of enteral feeds. Despite preterm babies being one of the highest users of parenteral nutrition amongst all patient groups and that it has been in use in preterm infants for several decades, the evidence base for its use remains weak. There are several areas of uncertainty in practice, including the optimal and relative intakes of macronutrients and the optimal timing of initiation of parenteral nutrition after birth. High quality randomised controlled trials powered to detect differences in long term functional outcomes are needed to determine best practice in preterm parenteral nutrition practice.
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Affiliation(s)
- Sabita Uthaya
- Department of Neonatal Medicine, School of Public Health, Imperial College London, UK.
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7
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Royer M, Libessart M, Dubaele JM, Tourneux P, Marçon F. Controlling Risks in the Compounding Process of Individually Formulated Parenteral Nutrition: Use of the FMECA Method (Failure modes, effects, and Criticality Analysis). PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2020. [DOI: 10.1515/pthp-2019-0020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractParenteral nutrition (PN) in the neonatal intensive care unit (NICU) involves a succession of risky processes. The objective was to identify and prioritize the risks associated with PN in order to improve the quality of the pathway. A failure modes, effects, and criticality analysis (FMECA) was used to identify potential PN pathway failure modes. A multidisciplinary working group conducted a functional analysis of the processes, then listed the failure modes (FM). The FM criticality was assessed on a scale from 1 to 5 for occurrence (O), severity (S), and detection (D). The risk priority number (RPN), ranging from 1 to 125, was calculated. The FMECA identified 99 FM (prescription (n=28), preparation (n=48), and administration (n=23)). The median RPN was 12, with scores ranging from 3 to 48. 25 % of the scores had an RPN>21.75.Among them, 12 were associated with prescription FM, 5 were associated with FM related to preparation and 8 were associated with a FM linked to administration. It allowed us to prioritize areas of potential quality improvement for parenteral nutrition of the preterm infant. The results demonstrated the need for the presence of a clinical pharmacist in the NICU to ensure the quality of PN process.
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Affiliation(s)
- Mathilde Royer
- Pharmacy, Centre Hospitalier Universitaire d’AmiensHôpital Sud, Avenue rene laennec, Amiens, Hauts-de-France80054, France
| | - Maïté Libessart
- Pharmacy, Centre Hospitalier Universitaire d’AmiensHôpital Sud, Avenue rene laennec, Amiens, Hauts-de-France80054, France
| | - Jean-Marc Dubaele
- Pharmacy, Centre Hospitalier Universitaire d’AmiensHôpital Sud, Avenue rene laennec, Amiens, Hauts-de-France80054, France
| | - Pierre Tourneux
- Pediatric Urgent and Intensive Care, Centre Hospitalier Universitaire d’AmiensHôpital Sud, Avenue rene laennec, Amiens, Hauts-de-France80054, France
| | - Fréderic Marçon
- Pharmacy, Centre Hospitalier Universitaire d’AmiensHôpital Sud, Avenue rene laennec, Amiens, Hauts-de-France80054, France
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8
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Falciglia GH, Murthy K, Holl JL, Palac HL, Woods DM, Robinson DT. Low prevalence of clinical decision support to calculate caloric and fluid intake for infants in the neonatal intensive care unit. J Perinatol 2020; 40:497-503. [PMID: 31813935 PMCID: PMC7042157 DOI: 10.1038/s41372-019-0546-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/08/2019] [Accepted: 10/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown. METHODS Online surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children's Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar's test. RESULTS Clinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%, p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%, p < 0.001). DISCUSSION Most CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.
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Affiliation(s)
- Gustave H. Falciglia
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
| | - Karna Murthy
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA ,Children’s Hospital Neonatal Consortium, Kansas City, MO USA
| | - Jane L. Holl
- 0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA ,0000 0001 2299 3507grid.16753.36Center for Health Services & Outcomes Research, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | | | - Donna M. Woods
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0001 2299 3507grid.16753.36Center for Health Services & Outcomes Research, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | - Daniel T. Robinson
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
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Morgan C, Tan M. Attainment Targets for Protein Intake Using Standardised, Concentrated and Individualised Neonatal Parenteral Nutrition Regimens. Nutrients 2019; 11:E2167. [PMID: 31509953 PMCID: PMC6769713 DOI: 10.3390/nu11092167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/27/2023] Open
Abstract
Neonatal parenteral nutrition (NPN) regimens that are individualised (iNPN) or standardised concentrated NPN (scNPN) are both currently used in preterm clinical practice. Two recent trials (one iNPN and one scNPN) each compared standard (control) and high (intervention) parenteral protein and energy dosage regimens and provided data about actual protein intake. We hypothesised that scNPN regimens would achieve a higher percentage of the target parenteral protein intake than their corresponding iNPN regimens. We calculated the daily individual target parenteral protein intake and used the daily parenteral protein intake to calculate the target attainment for protein intake in each infant for the two control (iNPN: n = 59, scNPN: n = 76) and two intervention (iNPN: n = 65; scNPN: n = 74) groups. The median (IQR) target attainment of high-dose protein was 75% (66-85) versus 94% (87-97) on days 1-15 for iNPN and scNPN regimens respectively (p < 0.01). The median (IQR) target attainment of standard dose protein was 77% (67-85) versus 94% (91-96) on days 1-15 for iNPN and scNPN regimens, respectively (p < 0.01). This was associated with improved weight gain (p = 0.050; control groups only) and head growth (p < 0.001; intervention groups only). scNPN regimens have better target attainment for parenteral protein intakes than iNPN regimens.
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Affiliation(s)
- Colin Morgan
- Liverpool Women's Hospital, Liverpool L8 7SS, UK.
| | - Maw Tan
- Alder Hey Children's Hospital, Liverpool L14 5AB, UK
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10
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Riskin A, Picaud JC, Shamir R, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Standard versus individualized parenteral nutrition. Clin Nutr 2018; 37:2409-2417. [DOI: 10.1016/j.clnu.2018.06.955] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
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Falciglia GH, Murthy K, Holl JL, Palac HL, Oumarbaeva Y, Woods DM, Robinson DT. Energy and Protein Intake During the Transition from Parenteral to Enteral Nutrition in Infants of Very Low Birth Weight. J Pediatr 2018; 202:38-43.e1. [PMID: 30195557 DOI: 10.1016/j.jpeds.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/18/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the association between nutrition delivery practices and energy and protein intake during the transition from parenteral to enteral nutrition in infants of very low birth weight (VLBW). STUDY DESIGN This was a retrospective analysis of 115 infants who were VLBW from a regional neonatal intensive care unit. Changes in energy and protein intake were estimated during transition phase 1 (0% enteral); phase 2 (>0, ≤33.3% enteral); phase 3 (>33.3, ≤66.7% enteral); phase 4 (>66.7, <100% enteral); and phase 5 (100% enteral). Associations between energy and protein intake were determined for each phase for parenteral nutrition, intravenous lipids, central line, feeding fortification, fluid restriction, and excess non-nutritive fluid intake. RESULTS In phases 2 and 3, infants receiving feeding fortification received less protein than infants who were unfortified (-1.1 and -0.3 g/kg/d, respectively; P < .001). However, this negative association was not observed after adjusting for relevant nutrition delivery practices. Despite greater enteral protein intake during phases 2 and 3 (0.3 and 0.8 g/kg/d, respectively; P < .001), infants with early fortification received less parenteral protein than infants who were unfortified (-1.4 and -1.1 g/kg/d, respectively; P < .001). Similar patterns were observed for energy intake. Protein intake declined during phases 3 and 4. CONCLUSIONS Infants paradoxically received less protein and energy on days with early fortification, suggesting that clinicians may lack easily accessible data to detect the association between nutrition delivery practices and overall nutrition in infants who are VLBW.
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Affiliation(s)
- Gustave H Falciglia
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago.
| | - Karna Murthy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago; Children's Hospitals Neonatal Consortium, Kansas City, MO
| | - Jane L Holl
- Ann & Robert H. Lurie Children's Hospital of Chicago; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Hannah L Palac
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Yuliya Oumarbaeva
- Department of Pediatrics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Donna M Woods
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniel T Robinson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago
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Alrifai MW, Mulherin DP, Weinberg ST, Wang L, Lehmann CU. Parenteral Protein Decision Support System Improves Protein Delivery in Preterm Infants: A Randomized Clinical Trial. JPEN J Parenter Enteral Nutr 2018; 42:219-224. [PMID: 29505147 DOI: 10.1002/jpen.1034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/11/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Management of neonatal parenteral protein intake for preterm infants is challenging and requires daily modifications of the dose to account for the infant's postnatal age, birth weight, current weight, and the volume and protein concentration of concurrent enteral nutrition. The objective of this study was to create and evaluate the Parenteral Protein Calculator (PPC), a clinical decision support system to improve the accuracy of protein intake for preterm infants who require parenteral nutrition (PN). MATERIALS AND METHODS We integrated the PPC into the computerized provider order entry system and tested it in a randomized controlled trial (routine or PPC). Infants were eligible if they were ≤3 days old, had a birth weight ≤1500 g, and had no inborn error of metabolism. The primary outcome was the appropriate total protein intake, defined as target protein dose ±0.5 g/kg. RESULTS We randomly allocated 42 infants for 221 PN days in the control group and 211 in the PPC group. Total protein intake in the PPC group was more accurate as compared with the control group (appropriate protein dosing: odds ratio = 5.8; 95% CI, 2.7-12.4). Absolute deviation from protein target was 0.41 g/kg (0.24-0.58) lower in the PPC group. CONCLUSION The PPC improved appropriate protein dosing for premature infants receiving PN. Further studies are needed to test whether clinical decision support systems will reduce uremia and improve growth and to replicate similar findings in the cases of other PN nutrients.
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Affiliation(s)
- Mhd Wael Alrifai
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David P Mulherin
- HealthIT @VUMC, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stuart T Weinberg
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christoph U Lehmann
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Franco KA, O'Mara K. Impact of Computerized Provider Order Entry on Total Parenteral Nutrition in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2016; 21:339-345. [PMID: 27713674 DOI: 10.5863/1551-6776-21.4.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES: To determine if computerized provider order entry (CPOE) implementation impacts the time it takes for preterm neonates to reach their parenteral macronutrient goals. METHODS: Retrospective review of neonates <1750 g receiving parenteral nutrition (PN) before and after the implementation of CPOE. Primary outcome was the attainment of parenteral macronutrient goals. Secondary outcomes included time to attainment, the frequency of electrolyte abnormalities, and the incidence of required adjustments made to PN orders by verification pharmacists. RESULTS: Goal PN was achieved by 12/47 (25.5%) intervention vs. 2/44 (4.5%) control group infants (p < 0.05). This goal was attained in 10.8 ± 7.5 days in the intervention group and 10 ± 4.2 days in the control group (p = 0.90). Goal protein was reached by 74.5% of CPOE patients vs. 36.4% of controls, p < 0.05. Lipid goals were achieved by 98% vs. 100% (p = 0.33) of patients and were attained at an average of 1.5 ± 0.8 days vs. 2.0 ± 1.1 days (p < 0.05). Abnormal serum electrolyte values occurred more frequently in the control group (0.79 vs. 1.12/day PN). Adjustments by a verification pharmacist were required in 5.6% of CPOE compared with 30.4% of control group orders (p < 0.05). CONCLUSIONS: CPOE parenteral nutrition increased the proportion of preterm neonates attaining overall macronutrient goals. With CPOE, protein goals were reached by more patients and goal lipids were achieved faster. This system also decreased the number of pharmacist interventions during verification of PN orders and appeared to positively impact the incidence of serum electrolyte disturbances.
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Affiliation(s)
- Kyle A Franco
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Keliana O'Mara
- University of Florida Health Shands Hospital, Gainesville, Florida
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Uthaya S, Modi N. Practical preterm parenteral nutrition: systematic literature review and recommendations for practice. Early Hum Dev 2014; 90:747-53. [PMID: 25263586 DOI: 10.1016/j.earlhumdev.2014.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Current practice in relation to the prescribing, compounding and administration of parenteral nutrition for extremely preterm infants is inconsistent and based on largely historical evidence. Increasingly there are calls for more 'aggressive' nutritional interventions to prevent 'postnatal growth failure'. However the evidence base for these recommendations is weak, and there are no long-term studies examining the impact of such practices. Here we summarise the evidence for preterm parenteral nutrition interventions. We suggest principles to guide practice based on evidence from a systematic search and review of evidence to date, and recommend actions necessary to advance the understanding of this important aspect of preterm care.
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Affiliation(s)
- S Uthaya
- Imperial College London, UK; Chelsea Westminster Hospital NHS Foundation Trust, London, UK.
| | - N Modi
- Imperial College London, UK; Chelsea Westminster Hospital NHS Foundation Trust, London, UK.
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Gnigler M, Schlenz B, Kiechl-Kohlendorfer U, Rüdiger M, Navarro-Psihas S. Improved weight gain in very-low-birth-weight infants after the introduction of a self-created computer calculation program for individualized parenteral nutrition. Pediatr Neonatol 2014; 55:41-7. [PMID: 23911096 DOI: 10.1016/j.pedneo.2013.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 05/06/2013] [Accepted: 05/27/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although 90% of babies <1500 g (very-low-birth-weight or VLBW) are appropriate for gestational age (AGA) at birth, almost all are small for gestational age at 36 weeks of gestation, mainly due to nutritional deficiency in the first weeks of life. A computer calculation program (CCP) to calculate parenteral nutrition (PN) was introduced to improve nutritional intake in preterm infants. METHODS Somatometric data and composition of PN of VLBW infants were compared with two points of time measured over a period of 4 years. RESULTS Data from 56 patients born before the introduction of the CCP (2001-2002) and 59 patients born after the introduction of the CCP (2004-2005) were obtained. Although the number of AGA infants at birth did not differ, the computer-calculated group had significantly more AGA infants at the time of discharge from hospital (44% vs. 14%, p < 0.05). In this group, more protein and fat were administered in the first 5 days of life (7.3 g/kg vs. 4.5 g/kg, p < 0.05 and 5 g/kg vs. 0.5 g/kg, p < 0.05) and the duration of total PN was shorter (16 days vs. 24 days, p < 0.05). CONCLUSION Because the CCP contributes to a better weight gain in VLBW infants due to simplification of PN calculation, we suggest its use in the calculation of PN in VLBW infants.
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Affiliation(s)
- Maria Gnigler
- Department of Pediatrics II (Neonatology), Innsbruck Medical University, Innsbruck, Austria
| | - Bernhard Schlenz
- Department of Pediatrics II (Neonatology), Innsbruck Medical University, Innsbruck, Austria
| | | | - Mario Rüdiger
- Department of Neonatology and Pediatric Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Salvador Navarro-Psihas
- Department of Pediatrics II (Neonatology), Innsbruck Medical University, Innsbruck, Austria.
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Morgan C. Early amino acid administration in very preterm infants: Too little, too late or too much, too soon? Semin Fetal Neonatal Med 2013; 18:160-165. [PMID: 23490859 DOI: 10.1016/j.siny.2013.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Early postnatal growth failure is well described in very preterm infants. It reflects the nutritional deficits in protein and energy intake that accumulate in the first few weeks after birth. This coincides with the period of maximum parenteral nutrition (PN) dependency, so that protein intake is largely determined by intravenous amino acid (AA) administration. The contribution of PN manufacture, supply, formulation, prescribing and administration to the early postnatal nutritional deficit is discussed, focusing on total AA intake. The implications of postnatal deficits in AA and energy intake for growth are reviewed, with particular emphasis on early head/brain growth and long-term neurodevelopmental outcome. The rationale for maximising AA acid intake as soon as possible after birth is explained. This includes the benefits for very early postnatal nutritional intake and metabolic adaptation after birth. These benefits relate to total AA intake and so have to be interpreted with some caution, given the very limited evidence base surrounding the balance of individual AAs in neonatal PN formulations. This work mostly predates current nutritional recommendations and therefore may not provide a true reflection of individual AA utilisation in current clinical practice.
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Affiliation(s)
- Colin Morgan
- Neonatal Intensive Care Unit, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK.
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Raimbault M, Thibault M, Lebel D, Bussières JF. Automated compounding of parenteral nutrition for pediatric patients: characterization of workload and costs. J Pediatr Pharmacol Ther 2013; 17:389-94. [PMID: 23411509 DOI: 10.5863/1551-6776-17.4.389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Parenteral nutrition (PN) compounding in large hospital centers is now largely automated using volumetric pump systems. No study has examined the pharmacy workload and costs associated with this process. This study was designed to characterize these elements at our center and to identify areas for potential improvement. METHODS We retrospectively analyzed all PN orders compounded from May 19, 2007, to June 25, 2010. Patients were divided into groups according to the ward where PN was initiated. RESULTS The age and weight of patients at initiation of PN were similar throughout the study, except in neonatology, where initiation now occurs earlier in life (age 1.3 ± 2.7 days in 2010 vs. 3.4 ± 9.4 in 2007; p=0.003). An average of 894 orders per month were compounded. A total of 59% of orders were for neonatal patients. The average cost of source solutions per PN order increased from Can$23.27 in 2007 to Can$37.78 in 2010. Partially used source solutions discarded at the end of the day represented between 7.7% and 9.2% of total source solution cost. Amino acids in 3-L bags were responsible for the largest waste, with Can$953 to Can$1048 wasted monthly. CONCLUSIONS PN compounding at our center represents an important workload and increasing costs. A reduction in source solution waste, for example, by reducing the use of large source solution containers, would be beneficial.
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Affiliation(s)
- Mélina Raimbault
- Unité de Recherche en Pratique Pharmaceutique (Pharmacy Practice Research Unit), Montreal, Quebec, Canada ; Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
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Abstract
Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.
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Abstract
OBJECTIVES The aim of this study was to evaluate the efficacy, safety, flexibility, and ease of handling and use of the Ped3CB-A 300 mL, the first ready-to-use multichamber parenteral nutrition (PN) system, with optional lipid bag activation, specially designed for administration to preterm infants. MATERIALS AND METHODS In this prospective, open-label, multicenter, noncomparative, phase III clinical trial, preterm infants were treated with Ped3CB-A for 5 to 10 consecutive days. RESULTS A total of 113 preterm infants were enrolled in the study and 97 (birth weight 1382 ± 520 g; gestational age 31.2 ± 2.5 weeks; postnatal age administration 5.6 ± 6.1 days) were included in the per protocol analysis accounting for 854 perfusion days. Double-chamber bag activation was used for 32 perfusion days. Macronutrient, electrolyte, and mineral supplements were primarily administered through a Y-line or directly in the activated bag. In all, 199 additions (mainly sodium, 95%) were made to the Ped3CB-A bags on 197 infusion days (23.1%) in 43 infants (44.3%). More than 1 of these nutrients was added to the bag on only 1 perfusion day. Mean and maximum parenteral nutrient intakes were 2.8 ± 0.7 and 3.6 ± 0.8 g amino acids per kilogram per day, and 80 ± 20 and 104 ± 22 kcal · kg(-1) · day(-1). Mean weight gain represented 10.0, 21.5, and 22. 6 g · kg(-1) · day(-1) according to age at inclusion (0-3, 4-7, or >7 days of life). A visual analog scale was completed and produced positive results. No adverse events were attributable to the design of the Ped3CB-A system. CONCLUSIONS Ped3CB-A provides easy-to-use, well-balanced, and safe nutritional support. Nutritional intakes and weight gain were within the recent PN recommendations in preterm infants.
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Popescu M, Vialet R, Loundou A, Peyron F, Buès-Charbit M. Étude de la variabilité dans les reconstitutions de vancomycine intraveineuse en réanimation pédiatrique. ACTA ACUST UNITED AC 2011; 30:726-9. [DOI: 10.1016/j.annfar.2011.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 04/06/2011] [Indexed: 10/18/2022]
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SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care. BMC Pediatr 2011; 11:53. [PMID: 21663622 PMCID: PMC3141505 DOI: 10.1186/1471-2431-11-53] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/10/2011] [Indexed: 11/29/2022] Open
Abstract
Background Infants born <29 weeks gestation are at high risk of neurocognitive disability. Early postnatal growth failure, particularly head growth, is an important and potentially reversible risk factor for impaired neurodevelopmental outcome. Inadequate nutrition is a major factor in this postnatal growth failure, optimal protein and calorie (macronutrient) intakes are rarely achieved, especially in the first week. Infants <29 weeks are dependent on parenteral nutrition for the bulk of their nutrient needs for the first 2-3 weeks of life to allow gut adaptation to milk digestion. The prescription, formulation and administration of neonatal parenteral nutrition is critical to achieving optimal protein and calorie intake but has received little scientific evaluation. Current neonatal parenteral nutrition regimens often rely on individualised prescription to manage the labile, unpredictable biochemical and metabolic control characteristic of the early neonatal period. Individualised prescription frequently fails to translate into optimal macronutrient delivery. We have previously shown that a standardised, concentrated neonatal parenteral nutrition regimen can optimise macronutrient intake. Methods We propose a single centre, randomised controlled exploratory trial of two standardised, concentrated neonatal parenteral nutrition regimens comparing a standard macronutrient content (maximum protein 2.8 g/kg/day; lipid 2.8 g/kg/day, dextrose 10%) with a higher macronutrient content (maximum protein 3.8 g/kg/day; lipid 3.8 g/kg/day, dextrose 12%) over the first 28 days of life. 150 infants 24-28 completed weeks gestation and birthweight <1200 g will be recruited. The primary outcome will be head growth velocity in the first 28 days of life. Secondary outcomes will include a) auxological data between birth and 36 weeks corrected gestational age b) actual macronutrient intake in first 28 days c) biomarkers of biochemical and metabolic tolerance d) infection biomarkers and other intravascular line complications e) incidence of major complications of prematurity including mortality f) neurodevelopmental outcome at 2 years corrected gestational age Trial registration Current controlled trials: ISRCTN76597892; EudraCT Number: 2008-008899-14
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D'Apolito O, Pianese P, Salvia G, Campanozzi A, Pettoello-Mantovani M, Dello Russo A, Corso G. Plasma levels of conjugated bile acids in newborns after a short period of parenteral nutrition. JPEN J Parenter Enteral Nutr 2010; 34:538-541. [PMID: 20852182 DOI: 10.1177/0148607110374059] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2025]
Abstract
BACKGROUND Patients receiving parenteral nutrition (PN) frequently exhibit liver dysfunction. The authors previously reported that plant sterols of lipid emulsions added to the nutritional solution of newborns receiving PN accumulate in plasma and cell membranes and may contribute to the development of cholestasis. Conjugated bile acids (BA) have been shown to be useful markers of cholestasis. Plasma levels of several BA in newborns were quantified after administration of PN for less than 2 weeks. METHODS Plasma samples from 15 healthy control infants (CN), 22 patients who had received PN for 3-15 days (T1), and 9 patients scheduled to receive PN (T0) were analyzed. After a simple extraction procedure, plasma BA were analyzed by liquid chromatography-tandem mass spectrometry using a quantitative isotope dilution method. RESULTS The concentrations of BA did not differ significantly between controls and patients before PN (CN vs T0), with the exception of glycocholic acid (GCA; 2.30 ± 2.60 µM vs 7.29 ± 5.39 µM, respectively). There was a significant difference in several BA between controls and patients after PN (2.30 ± 2.60 µM vs 7.61 ± 6.46 µM for GCA, respectively; 4.02 ± 3.49 µM vs 11.88 ± 11.05 µM for taurocholic acid [TCA], respectively; and 4.81 ± 3.49 µM vs 13.58 ± 12.22 µM for taurochenodeoxycholic + taurodeoxycholic + tauroursodeoxycholic acids [TCDCA+TDCA+TUDCA], respectively). CONCLUSIONS In newborns receiving PN, a short period of PN is associated with an early increase of some conjugated BA. These results suggest that GCA, TCA, and TCDCA+TDCA+TUDCA levels could be used as early markers of PN-related cholestasis.
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Affiliation(s)
- Oceania D'Apolito
- Clinical Biochemistry, Department of Biomedical Sciences, University of Foggia, Italy
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