Portable bedside microcomputer system for management of parenteral nutrition in all age groups

Algorithm for Calculating the Protein Intake in Enteral and Parenteral Nutrition in Premature Infants

INTRODUCTION

Calculating the exact nutritional balance especially for the premature infant has always been a challenge for the daily practice of the clinician.

PURPOSE

we intend to establish a simplified formula and mathematical algorithms to calculate the necessary amino acids and proteins for the nutrition of the premature newborn, covering most of the international recommendations and also to give to the neonatal intensive care physician the opportunity of their rapid customization for each case.

METHODS

following an extensive literature revision we have established the protein intake recommendations, indications and contraindications for enteral and parenteral nutrition in premature infants, by age of gestation, birth weight and postnatal age. Then, these recommendations were translated into simplified mathematical equations and we have proceeded to develop logical algorithms to enable the rapid choice of the best equation that fits each individual case with all its peculiarities, at a defined time.

RESULTS

for all three premature categories, we have identified intervals for enteral and parenteral nutrition, which were translated into mathematical formulas and management regulations and then transposed into logic algorithms.

CONCLUSIONS

although mathematically one can use a simplified calculation, for a rapid appreciation, the clinician is still required to go through these algorithms daily and sometimes several times a day. Moreover, to optimize protein intake, we have to calculate the protein / energy ratio and the non-protein calories / gram of protein ratio. This involves extending the calculation for the carbohydrates, fats and calories-practically the entire nutrition.

Early amino acid administration in very preterm infants: Too little, too late or too much, too soon?

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.

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

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

[Electronic protocol for structurated data collection of pediatric patients in nutritional therapy using SINPE(c) (Integrated System of Electronic Protocols)]

OBJECTIVES

To develop a clinical database for pediatric patients in nutrition therapy, to computerize the database turning it into an electronic protocol, to make the multicentric use of the database possible.

METHOD

The database was developed based on medical literature search, using textbooks and scientific studies about pediatric nutrition therapy. It was initially organized in one master protocol and after that divided into two specific protocols, one for patient's admission and other one for evolution. The database computerization was performed using a software developed in the C# (C sharp) language, by the electronic laboratory for clinical research at the Hospital of Clinics from Federal University of Paraná.

RESULTS

The electronic protocol allows data collection of clinical, laboratorial and radiological parameters. The final version includes 6694 parameters, 392 distributed in Admission and 6302 in Evolution.

CONCLUSION

the creation of a database for pediatric patients in nutrition therapy was possible, the computerization of this database was reliable, there is the possibility of integration between different medical centers for development of multicentric studies, the application of the electronic protocol in the mentioned group of patients was reliable.

Clinical decision support systems for neonatal care

BACKGROUND

Clinical decision support systems (CDSS) are computer-based information systems used to integrate clinical and patient information to provide support for decision-making in patient care. They may be useful in aiding the diagnostic process, the generation of alerts and reminders, therapy critiquing/planning, information retrieval, and image recognition and interpretation. CDSS for use in adult patients have been evaluated using randomised control trials and their results analysed in systematic reviews. There is as yet no systematic review on CDSS use in neonatal medicine.

OBJECTIVES

To examine whether the use of clinical decision support systems has an effect on 1. the mortality and morbidity of newborn infants and 2. the performance of physicians treating them

SEARCH STRATEGY

The standard search method of the Cochrane Neonatal Review Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (from 1966 to August 2004), EMBASE (1980-2004), CINAHL (1982 to August 2004) and AMED (1985 to August 2004).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which compared the effects of CDSS versus no CDSS in the care of newborn infants. Trials which compared CDSS against other CDSS were also considered. The eligible interventions were CDSS for computerised physician order entry, computerised physiological monitoring, diagnostic systems and prognostic systems.

DATA COLLECTION AND ANALYSIS

Studies were assessed for eligibility using a standard pro forma. Methodological quality was assessed independently by the different investigators.

MAIN RESULTS

Two studies fitting the selection criteria were found for computer aided prescribing and one study for computer aided physiological monitoring.Computer-aided prescribing: one study (Cade 1997) examined the effects of computerised prescribing of parenteral nutrition ordering. No significant effects on short-term outcomes were found and longer term outcomes were not studied. The second study (Balaguer 2001) investigated the effects of a database program in aiding the calculation of neonatal drug dosages. It was found that the time taken for calculation was significantly reduced and there was a significant reduction in the number of calculation errors.Computer-aided physiological monitoring: one eligible study (Cunningham 1998) was found which examined the effects of computerised cot side physiological trend monitoring and display. There were no significant effects on mortality, volume of colloid infused, frequency of blood gases sampling (samples per day) or severe (Papile Grade 4) intraventricular haemorrhage. Published data did not permit us to analyse effects on long-term neurodevelopmental outcome.

AUTHORS' CONCLUSIONS

There are very limited data from randomised trials on which to assess the effects of clinical decision support systems in neonatal care. Further evaluation of CDSS using randomised controlled trials is warranted.

A survey of neonatal parenteral nutrition design practices in North Carolina

BACKGROUND

Parenteral nutrition is an important component of postnatal hospital care for very-low-birth-weight infants (VLBW; birth weight < or =1500 g). Designing and preparing parenteral nutrition for VLBW infants is a complicated process requiring many nutrition decisions and mathematical computations, a process most medical centers have developed independently. The goal of this project was to examine the nutrition design practices and resources of regional neonatal intensive care units (NICUs).

METHODS

In depth interviews were conducted with neonatal nutrition health-care providers at eight medium to large NICUs in North Carolina to describe the patient population, the nutrition support staff, nutrition decision-making procedures and resources, the design of parenteral nutrition, and problems with parenteral nutrition design and preparation.

RESULTS

The eight centers reported an average of 182 VLBW infant admissions and prepared 4810 parenteral nutrition orders per year. Five centers employed experienced neonatal nutrition staff to offer decision support. Six centers used paper parenteral nutrition order forms, all of which provided some decision guidance such as a recommended ordering dose range. Self-reported medical mistakes included incorrect parenteral nutrition additive dilutions and incorrect supplementation of parenteral nutrition additives.

CONCLUSIONS

Most NICUs offered nutrition resource personnel and used paper parenteral nutrition order forms, which offered a wide range of decision guidance. About half the reported medical errors could be addressed using electronic parenteral nutrition design; however, a broader, more general approach to the entire design and administration system would reduce more errors. Last, as development of electronic neonatal nutrition resources in the clinical arena progresses, standards for recording neonatal nutrition content, and evaluating the effect of decision support need to be identified.

Use of computers in long-term/home parenteral nutrition--a missed opportunity?

Desk-top microcomputers and total parenteral nutrition grew up together, and in their early days there was considerable progress in both camps. Since that time, the power of computing devices has increased dramatically, as has their ability to share information both between individual systems and worldwide through facilities such as the Internet and e-mail. Although there are some signs of continuing progress, to date there appears to be little evidence in peer-reviewed journals that this increased power is being utilized or that the vision of the pioneers in this area has been realized.

How often do parenteral nutrition prescriptions for the newborn need to be individualized?

BACKGROUND

Parenteral nutrition is commonly given in the newborn period to premature infants or those with gastrointestinal disorders. Computer-assisted prescribing is widely used, with prescriptions for each patient being varied on a daily basis. It has previously been suggested that 'individualization' of feeds may have little clinical benefit whilst increasing pharmacy workload and costs. However, the scope for use of standard feed solutions as an alternative remains uncertain.

METHODS

To assess the potential for using standardized pre-mixed feeds we prospectively reviewed 148 computer assisted prescriptions for newborn infants in order to establish how often the prescribing clinician adhered to the computer protocol, and the reason for modification when this occurred.

RESULTS

Only one-fifth of feeds were based strictly on the computer recommendation with no, or minimal, modification. However, many of the deviations in the other four-fifths of feed prescriptions reflected a routine use of higher carbohydrate, sodium and phosphate intakes implying that a higher proportion of feeds could be 'standardized' if the computer regimens were modified to reflect current nutritional practices on the unit.

CONCLUSIONS

This study suggests that the introduction of standard PN feeds could considerably reduce the use of computer assisted individualized PN prescriptions on the neonatal unit. The practical implications of such a system for pharmacy and the potential cost benefits deserve further investigation.

A computerized aid in ventilating neonates

A computer program for ventilating neonates using a volume controlled ventilator is presented. The program proposes directions for changes of ventilator settings decided from the actual arterial blood gas samples and ventilator settings. The program deals with up to six babies at the same time and contains a continuous evaluation of the last six values of pCO2 and pO2 resulting in statements and warnings in potentially harmful situations. The program is consistent with the written instructions of the department. The ventilator treatment of 30 premature babies is evaluated retrospectively using the program, showing a total agreement of 37.5%, lowest among the babies who died in respiratory insufficiency. The advantage of the use of the program is discussed.

A program for parenteral and combined parenteral and enteral nutrition of neonates and children in an intensive care unit

A computer program for parenteral and combined parenteral and enteral nutrition of children in intensive care unit is described. It acts as a guide for the prescribing physician by using informative messages, food composition tables and alarms when mistakes or uncommon prescription values are input from the keyboard.

The nutrition team in a children's hospital

This paper discusses the reasons for a paediatric nutritional care team, the members involved, and their role within the team. The methods used for nutritional assessment are described and the cost effectiveness of the nutrition team's involvement is discussed.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.