Nutrition: parenteral

Parenteral nutrition (PN) is the administration of nutrition directly into the bloodstream. It is the method of providing nutrition to children who have intestinal failure.

Parenteral nutrition may either provide the child’s full nutritional requirements or more frequently just part, when it is not possible to give the full requirements enterally.

Parenteral nutrition is invasive, has associated risks and should only be used when there is no alternative method of feeding available. 

Assessment for PN

PN may be required for these conditions:

  • prematurity
  • necrotising enterocolitis
  • acute pancreatitis (enteral feeds are usually recommended)
  • intestinal failure secondary to:
    • short bowel syndrome
    • protracted diarrhoea 
    • chronic intestinal pseudo-obstruction
    • post-operative abdominal surgery
    • radiation/cytotoxic therapy
  • hyper-catabolism:
    • extensive burns
    • severe trauma

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No patient should have PN unless a request form is completed (see Appendix 1).

PN needs to be requested by 10.30am for a tailormade bespoke bag to be provided. PN is compounded by pharmacy staff in a laminar airflow cabinet under clean room conditions. The solutions are prepared individually for each child depending on weight, height, clinical condition and the intravenous route available. 

Feeding regimens are built up over two to four days during which time the protein, fat and carbohydrate content are increased.

In certain circumstances, a standard bag will be used, e.g. when PN is initiated after 10.30am on a weekday or if ordered at the weekend or when the number of PN bags needed exceeds pharmacy capacity. Standard bags do not contain vitamins and minerals unless requested during working hours.

Administering PN

PN can be administered in a number of ways: 

Continuous PN

This is a 24-hour continuous treatment, where the non-fat bag (Solution A) is infused over 24 hours but the lipid (Solution B) is infused for 20 hours. This is switched off for four hours prior to blood sampling to allow for clearance of the fat emulsion from the plasma.

Cyclical PN

This is when parenteral nutrition is infused for less than 24 hours. Cyclical PN can be used when the child is on a stable regimen and can tolerate a reduced infusion time (see completion of infusion). This should be tried as soon as possible in infants and older children when clinically appropriate.  

Constituents of PN

Solution A (i.e. amino acid solution)

  • amino acids:

    • Vaminolact® for children under 15kg
    • Vamin 18 EF® for children over one year, who are fluid restricted or > 15kg

  • glucose and electrolytes

  • zinc, copper, selenium, manganese, fluoride, iodine and chloride:

    • Peditrace® for children under 15kg
    • Additrace® for those over 15kg
  • Solivito N®: water-soluble vitamins if a non lipid containing regimen

Solution B (ie lipid)

  • lipid emulsions:

    • Intralipid® 20 per cent
    • SMOF® 20 per cent
  • Vitlipid N infant®: fat-soluble vitamins
  • Solivito N®: water-soluble vitamins if a lipid containing regime

Management

To help maintain the safety of the child, all aspects of the management of PN must be performed by suitably trained nursing staff. Unless it is contra-indicated, prior to requesting PN, medical staff should liaise with their ward dietitian to ensure that the child has had an appropriate trial of enteral feeding. 

The multi-disciplinary Nutrition Support team (NST) does a twice weekly ward round of all children receiving parenteral nutrition in the hospital. They are available to discuss any aspects of parenteral nutrition.

Contact numbers for the Nutrition support team (NST)

Position  Contact number 

Senior Pharmacist: Clinical Nutrition

Bleep 0311/Ext 1180

Specialist Nutrition Pharmacist

Bleep 0377/Ext 5340

Specialist Nutrition Pharmacist Bleep 0731/Ext 5340
Specialist Nutrition Pharmacist  Ext 5340 
Consultant Paediatric Gastroenterologist  Ext 8384
Gastroenterology Registrar Bleep 0661
Clinical Nurse Specialist (CNS) Nutrition Bleep 0921/Ext 8304
CNS Nutrition  Bleep 1027 
CNS Nutrition  Bleep 0360
Senior Biochemist Ext 5278
Duty biochemist  Bleep 0589
At night and outside office hours:
On-call pharmacist

Bleep 0714
Clinical site practitioner (CSP) Ext 8169/Bleep 0313 

Inform the child and family

Ensure that the family are informed of the following: (Rationales 1, 2 and 3)

  • the reason for the PN

  • what it will involve

  • the likely duration of the PN

  • the potential side effects of PN

  • the likely impact on the child and family

The ward play specialist should be informed to enable them to work with the child (Rationale 4). Family will be given the leaflet Short Term Parenteral Nutrition by ward staff. See short-term parenteral nutrition website for further info. 

Preparation: baseline parameters

Immediately prior to starting PN, the child’s weight, height and head circumference (<2yrs) should be recorded and dated in their health care records (Rationales 5 and 6).

The child’s height and weight must also be plotted on their centile chart (Rationale 7).

The child must be weighed completely unclothed and according to the clinical guidelines Weight, measuring a child and Height: measuring a child (Rationale 8).

The urinary electrolytes (sodium and potassium) should be recorded (Rationale 9).

Nutrition blood samples should be taken according to the relevant monitoring form. These samples should include copper, zinc, selenium, (see Appendix 2) (Rationale 10)

The child should be assessed to see if there is a risk of refeeding syndrome. Refeeding syndrome is the metabolic and physiological consequences of the depletion, repletion, and compartmental shifts of phosphate, potassium, magnesium, glucose metabolism, vitamin deficiency and fluid restriction. Refeeding syndrome can occur after initiation of nutrition support via the oral, enteral or parenteral route.  It is more likely to occur in malnourished patients who have lost more than 10% of their body weight over the previous 2 months. Patients can become at risk after more than 72 hours without nutrition.  In this situation, more frequent electrolyte monitoring and a slower introduction of the PN infused is recommended. (Rationale 11)

Preparation: venous access

Central venous access for the administration of PN must be arranged (Rationale 12).

PN should be administered via a central venous catheter (CVC) (Rationale 13).

A dedicated nutrition line should be used i.e. a single-lumen CVC (Rationale 14).

A peripherally inserted central catheter (PICCI) is also suitable

A subcutaneous implantable port is only suitable for short term PN (Rationale 15).

PN should not be administered via a peripheral cannula (Rationale 16)

A glucose concentration of 12.5 per cent or above should only be administered through a CVC (Rationale 17).

The specialist pharmacists must be informed immediately if a CVC is removed or replaced with a peripherally sited cannula (Rationale 18).

The intravenous device should be cared for according to the relevant clinical practice guidelines (Rationale 14)

The child’s doctor or an independent prescriber must prescribe PN. 

A 'Request to start PN’ form must be fully completed prior to the production and dispensing of the PN (Appendix 1). 

The doctor should liaise with the ward dietitian about the nutritional aims of treatment and requirements of the child. These should be recorded in the medical notes (Rationale 19).

The prescription is required in the PN pharmacy by 10.30am (Rationale 20).

The doctor should contact the pharmacist on-call if PN is required out of hours (Rationale 21).

Pharmacy will arrange for the delivery of the PN. It will normally be delivered by 6pm (Rationale 22 and 23).

Solutions to be administered over a weekend will be delivered on Friday afternoon (Rationale 24).

PN must be stored in the ward drug or PN fridge (Rationale 25).

When PN is delivered to the clinical area it should be 

The temperature of the fridge should be recorded daily (Rationale 26).

Preparation: infusion

Negotiate the time to commence PN with the child and family (Rationales 28, 29 and 30).

Remove PN from the fridge at least one hour prior to use (for small bags) and for at least four hours for larger bags (Rationales 38, 39 and 40).

Negotiate the time to commence PN with the child and family (Rationales 27, 28).

Remove PN from the fridge at least one hour prior to use (for small bags) and for at least four hours for larger bags (Rationale 29).

The PN should be prepared in the ward treatment room with restricted access. The PN should only be prepared at the bedside if the child is unable to leave their cubicle, eg immobility, infectious precautions, protective precautions (Rationales 14, 30, 31 and 32).

It is best practice to prepare PN on an individual basis, i.e. immediately prior to connection, not in advance (Rationale 32)

New PN solutions are supplied every 24 hours. A new administration set and filter must always be used. These are always supplied with the new solutions.

PN must be administered via an appropriate administration set incorporating a filter. These are connected to the PN solution by pharmacy. A 1.2mm filter will be added by pharmacy if the administration set does not have an integral filter (Rationale 33).

All disposable items must have luer lock connections (Rationale 34).

PN must not be decanted into a syringe (Rationale 35).

Check the PN solution for leakage and precipitate (Rationales 14, 25 and 36).

Check the following match when comparing the child’s intravenous prescription chart against the PN solution and the pharmacy therapy sheet, according to the Trust's medicine administration policy (Rationales 19, 37 and 38):

• first name and family name
• date of birth
• hospital number
• ward name
• day of infusion
• route of administration
• glucose concentration 
• volume to be infused
• duration of infusion
• rate of infusion - if cyclical PN, the prescriber should always prescribe a wind down on the IV prescription chart

If there are discrepancies between the child’s prescription and the pharmacy therapy sheet (Rationale 39):

• The discrepancies must be resolved with the on-call pharmacist and/or the medical staff. If the child is unstable, the prescriber may have changed the rate on the prescription chart.
• If the PN is not given, an incident form must be completed via Datix (Rationale 40).

Great Ormond Street Hospital has standard pumps, which are used only for the infusion of PN. This equipment may not be the same for use in a home PN patient (Rationale 41).

Syringe pumps should not be used (Rationale 42).

A thorough hand wash must be performed before and after the procedure. Standard (universal) precautions must be adopted

The PN should be prepared using an aseptic non-touch technique (Rationale 14).

The administration set and filter should be primed with the PN solution with the lipid solution first, followed by the amino acid solution mixing at the point of entry to the access device (Rationales 42, 43 and 44).

Vitamins are usually added to the lipid bag but when lipid is not prescribed, only water-soluble vitamins will be added by pharmacy to the amino acid solution. If this is the case, the amino acid solution must be covered and protected from light (Rationale 45).

If the child is requiring additional IV therapy, eg antibiotics, an administration set should be connected below the filter (Rationale 46).

Do not add any other drugs or solutions to the prepared PN solution (Rationales 14, 25).

Connect infusion

The windows and doors should be shut and fans should be switched off (Rationale 14)

Immediately prior to starting PN, the following observations of the child should be recorded (Rationale 47):

• temperature
• heart rate
• respiratory rate
• blood pressure

The prescription and child’s identity should be checked by two registered nurses in line with the medicine administration policy before connection (Rationale 48).

Using an aseptic non-touch technique (Rationale 14)

• Prepare and assess the child’s CVC according to the relevant clinical procedure guidelines (Rationales 15 and 49).Central venous access devices (long term) - Clinical guidelines - Health professionals - Great Ormond Street Hospital
• Attach the administration set to the patient (Rationale 50).
The infusion pump should have the following correctly set (Rationales 51 and 52):
• rate
• volume to be infused
• pressure alarms

The level of the pump should be positioned within 30cm of the heart and the pressure alarm set, according to the instructions attached to the infusion device (Rationales 53 and 54).

The infusion pump must be secured onto the infusion stand and whenever possible run off mains electricity. If the battery runs out completely, it must be sent to Biomedical engineering.

Check (Rationales 55 and 56):

• all connections in the system are tight
• all the relevant clamps are open

All equipment must be disposed of according to the waste management policy (Rationale 57).

The accessing of the intravenous therapy device and the beginning of PN infusion must be documented in the child’s health care records. Any difficulties encountered must also be recorded (Rationale 58).

Managing infusion: general

The NST should be contacted if there are any concerns about a child receiving PN (Rationale 59)

The NST reviews children receiving PN on Tuesdays between 2.30-4.30pm and Wednesday 10.00-11.00am (Rationale 60).

The team may be contacted for multi-disciplinary discussions of children receiving PN (Rationales 6 and 61).

Do not add any other drug or solution to the prepared PN solution (Rationales 14 and 25)

Disconnection or manipulation of the PN system should not occur (Rationale 61).

If there is an accidental disconnection:

• discard the PN
• do not re-spike bag of PN
• flush and heparinise the CVC as prescribed
• seek medical advice

Interruption of the PN should be avoided whenever possible (Rationale 19).

It is recommended that IV medications should not be administered via the PN administration set. If the child requires multiple infusions/or antibiotics these should be filtered via a multiple lumen extension set or Y-connections should be connected to the child’s CVC before connecting the PN line. The pharmacy must be contacted for advice when it is thought to be unavoidable (Rationales 62 and 63).

The intravenous device should be cared for according to the relevant clinical procedure guidelines (Rationale 14).

If the filter blocks during the administration of the PN solution or there is a problem with the administration set (Rationale 64):

• stop the infusion and give appropriate IV fluids if required
• inform the child’s doctor
• inform the PN pharmacist, or if out of hours, the on-call pharmacist
• return the administration set to Pharmacy, Pharmacy will inform the ward of the batch number of the giving set (Rationale 65)

Managing infusion: monitoring 

The frequency of all the following observations depends on the clinical condition of the child and any underlying disease processes (Rationale 66)

The following should be monitored and recorded hourly (Rationales 67 and 68):

• infusion pump pressure
• infusion rate
• fluid volume infused

All lines and connections should be checked hourly for leakage and kinking (Rationales 69,70 and 71).
Accurate recordings of the child’s intake (oral and intravenous) and output should be made on the fluid intake chart (Rationale 72).

The following observations should be recorded at least every four hours until PN is fully established (Rationale 73):

• heart rate
• temperature
• respiratory rate
• blood pressure

The child’s urine should be analysed daily on the ward, at the same time, for glucose and ketones (Rationales 74 and 75).

Blood sugar should be monitored and recorded:

• every four hours until stable or as glucose monitoring policy for neonates (Reference 8)
• whenever the glucose concentration is increased (Rationale 74)
• when receiving cyclical PN, at 30 minutes after stopping PN and as clinically indicated (Rationale 76)

Blood samples for electrolytes and liver function tests should be marked as urgent if the results are needed on the same day.

Blood should be taken from the line four hours after stopping the lipid infusion (Rationales 77, 78 and 79).

The child’s urine electrolytes should initially be monitored once weekly (unless on diuretic treatment), then when required (Rationale 80).

Nutritional bloods should be monitored monthly. These include zinc, copper, selenium, vitamins A and E, and ferritin (see Appendix 2) (Rationale 77).

The child must be weighed while completely undressed, daily for the first five days, then at least twice weekly on the same scales and at the same time every day. This should be recorded and dated appropriately on the child’s weight chart (Rationales 73, 81, 82 and 83). 

See clinical guideline Weight: measuring a child.

Depending on the condition of the child, this may subsequently change to weekly. This is the minimum frequency. 

A monthly weight must be recorded on the child’s centile chart.

The child must be weighed once or even twice daily if acutely unwell (Rationale 84).

The height of the child should be measured accurately using appropriate equipment, recorded in the medical notes and dated appropriately every month. This should be plotted on the child’s centile chart Height: measuring a child (Rationale 81).

Management of complications

Sepsis

• Treat line infection and continue PN via the CVC (Rationale 85)

Cholestatic liver disease

• Consider ursodeoxycholic acid at 10mg/kg TDS (Rationale 86). 
• Consider reducing the lipids from daily to three times per week (Rationale 87)
• Consider changing lipid source to SMOF® if not already receiving or an alternative licenced mixed lipid solution if available - discuss with the NST (Rationale 88)
• Consider cyclical PN (Rationale 89).

Completion of infusion: continuous PN

The new solutions and the administration sets should be changed without delay according to the child’s prescription (Rationale 14, 90 and 91)

The total volume of PN infused must be recorded on the child’s fluid balance chart (Rationale 58).

When disconnecting the PN, the ‘infusion rate’ and the ‘volume to be infused’ must be cleared on the infusion pump. The ‘volume infused’ recorded on the infusion pump is cleared in the morning when a new fluid chart is commenced. The infusion rate and volume to be infused must be reset when reconnecting (Rationale 90).

Disconnection of infusion and reconnection of the new infusion should be done according to the guidelines for the specific intravenous therapy device being used (Rationale 91).

The disconnection and reconnection must be recorded in the child’s health care records (Rationale 58).

All used equipment should be disposed of according to the waste management policy (Rationale 91).

Completion of infusion: cyclical PN

This should be tried as soon as the infant or child is stable on their nutrition regimen and gaining weight appropriately (Rationale 92). Cyclical PN prevents liver complications related to PN.  During the last hour of the infusion, the infusion rate the non-fat bag (Solution A) must be reduced in stages to prevent rebound hypoglycaemia, especially in infants (Rationale 76).

It may not be possible to achieve cyclical PN in infants particularly those born preterm. 
The general principal is to approximately halve the infusion rate for 30 minutes, then halve the rate again (ie give approximately 25% original rate) for 30 minutes for a total of one hour.

NB: the wind down rates must be less than the original rate especially in young infants.

For infants < four months of age, wind down rates of:

• 10ml/hour for 30 minutes = 5ml
• 6ml/hour for 30 minutes = 3ml then stop 
• Total volume for wind down = 8ml

Infants > 4months of age and < 1 year:

• 20ml/hour for 30 minutes = 10ml
• 10ml/hour for 30 minutes = 5ml
• Total volume for the wind down = 15ml

For older children: 

• 40ml/hour for 30 minutes = 20ml
• 20ml/hour for 30 minutes = 10ml
• Total volume for the wind down = 30ml
• 60ml/hour for 30 minutes = 30ml
• 30ml/hour for 30 minutes = 15ml 
• Total volume for the wind down = 45ml

Example 1

• 4kg infant is prescribed 130ml/kg/day PN

PN volumes are:

• non-fat bag 120ml/kg/day over 24 hours
• lipids 10ml/kg/day over 20 hours

To infuse over 22 hours: 

• Final non-fat bag volume = 480ml – 8ml wind down volume for an infant = 472ml
• lipids 10ml/kg/day over 20 hours - unchanged

Rates including wind down:

• 472mls over 21 hours = 22.5ml/hour over 21 hours then 
• 10ml/hour for 30 minutes = 5ml then 
• 6ml/hour for 30 minutes = 3ml then stop

Prescribe the wind down rates on the intravenous fluid chart.

When first starting a cyclical regimen, or when increasing the number of hours off the PN infusion, the child’s blood glucose level must be monitored within 30 minutes of stopping PN and then as clinically indicated (Rationale 76 and 93).

The total volume of PN infused must be recorded on the child’s fluid balance chart (Rationale 58).

When disconnecting the PN, the ‘infusion rate’ and the ‘volume to be infused’ must be cleared on the infusion pump. The ‘volume infused’ recorded on the infusion pump is cleared in the morning when a new fluid chart is commenced. The infusion rate and volume to be infused must be reset when reconnecting (Rationale 90).

Disconnection of the infusion and reconnection of the new infusion must be done according to the guidelines for the specific intravenous therapy device being used (Rationale 91).

The disconnection and reconnection must be recorded in the child’s health care records (Rationale 58).

All used equipment should be disposed of according to the waste management policy (Rationale 91).

Completion of treatment

The specialist pharmacists must be informed when PN is no longer required. The child’s doctor must do this (Rationales 18 and 19). 

When finishing treatment, the volume of PN to be infused should be decreased as the child’s enteral intake increases (Rationale 94).

The child’s height and weight should be recorded at the end of treatment (Rationale 81).

The child’s height, weight and enteral intake should continue to be monitored by the ward dietitian (Rationales 81 and 95)

The intravenous access device should be removed when it is no longer required (Rationale 14).

Going home on PN

The child should be referred to the intestinal rehabilitation gastroenterology team and the nutrition nurses should be contacted to discuss arrangements with the child's parents/carers (Rationale 96).

Rationale

Rationale 1: To obtain informed consent. 
Rationale 2: To promote safe delivery of PN. 
Rationale 3: To maximise the effectiveness of the PN. 
Rationale 4: To enable psychological preparation. 
Rationale 5: To enable accuracy of PN formulation. 
Rationale 6: To determine the subsequent effectiveness of the PN. 
Rationale 7: To monitor their growth. 
Rationale 8: To obtain an accurate measurement. 
Rationale 9: To monitor the subsequent effectiveness of the PN. 
Rationale 10: To assess the nutritional status of the child.
Rationale 11: To ensure safe delivery of the PN
Rationale 12: To enable the PN to be infused. 
Rationale 13: To minimise the risks of extravasation. 
Rationale 14: To minimise the risk of infection.
Rationale 15: Infusion ports are associated with an increased risk of extravasation and infection. 
Rationale 16: Due to the risk of extravasation. 
Rationale 17: A glucose concentration above 12.5 per cent is hypertonic and acidic. This can cause phlebitis and lead to extravasation. 
Rationale 18: In order to avoid wastage of tailor made bespoke bags.
Rationale 19: To ensure the nutritional requirements of the child are met. 
Rationale 20: To ensure the child receives tailor made PN that day. 
Rationale 21: It is the responsibility of the doctor to organise the PN. 
Rationale 22: To avoid a delay in the treatment. 
Rationale 23: To maintain the child’s treatment cycle. 
Rationale 24: PN pharmacy is closed at the weekend. 
Rationale 25: To maintain the microbiological and physical stability of the product. 
Rationale 26: To provide a record for quality assurance. 
Rationale 27: To promote a partnership in care. 
Rationale 28: To ensure the child is present on the ward. 
Rationale 29: PN should be at room temperature as infusing a solution that is too cold causing hypothermia and minimising the appearance of champagne bubbles
Rationale 30: To provide ease of access to required resources. 
Rationale 31: To promote effective time management 
Rationale 32: To reduce the risk of mistakes.  
Rationale 33: To remove particles produced during the manufacture of PN. 
Rationale 34: To minimise the risk of accidental disconnection, which could result in embolism, haemorrhage and infection 
Rationale 35: To avoid contamination of the PN. 
Rationale 36: To ensure the PN is fit for use. 
Rationale 37: To ensure the correct product is prepared for the correct patient. 
Rationale 38: To ensure the prescription is correct. 
Rationale 39: Discrepancies may be due to changes in the child’s clinical condition. 
Rationale 40: To minimise risk. 
Rationale 41: To ensure accuracy of infusion. 
Rationale 42: To prevent air embolism. 
Rationale 43: To ensure the administration set is patent. 
Rationale 44: To prevent precipitation. 
Rationale 45: Some water-soluble vitamins are light sensitive, particularly vitamin B2. 
Rationale 46: To minimise the risk of infection by reducing the number of times the CVC is accessed. 
Rationale 47: To establish the baseline for subsequent observations. 
Rationale 48: To reduce the risk of a drug error. 
Rationale 49: To assess patency and position of the CVC. 
Rationale 50: To enable treatment to commence. 
Rationale 51: To maintain patient safety. 
Rationale 52: To promote the effective use of the medical device. 
Rationale 53: To maintain gravity thus avoiding siphonage. 
Rationale 54: To ensure the pressure alarm functions correctly. 
Rationale 55: To prevent accidental disconnection. 
Rationale 56: To facilitate flow of PN. 
Rationale 57: Safe practice as detailed in hospital policy. 
Rationale 58: To maintain an accurate record. 
Rationale 59: To enable issues to be resolved. 
Rationale 60: To review current PN regimens and promote the most effective use of PN. 
Rationale 61: To ensure the safety of the child. 
Rationale 62: To prevent potential drug interactions. 
Rationale 63: To prevent potential absorption of the drug into the filter. 
Rationale 64: To obtain a standard PN solution from pharmacy. 
Rationale 65: To enable investigation of the filter or administration set. 
Rationale 66: To meet the needs of the child. 
Rationale 67: To ensure accuracy of infusion pump. 
Rationale 68: To contribute to assessment of patency of CVC. 
Rationale 69: To enable the early detection of extravasation and phlebitis. 
Rationale 70: To reduce risk of haemorrhage. 
Rationale 71: To minimise risk of embolism. 
Rationale 72: To monitor fluid intake to help prevent dehydration or fluid overload. 
Rationale 73: To observe for fluid overload. 
Rationale 74: To monitor tolerance to glucose in PN. 
Rationale 75: It can be an early indicator of sepsis. 
Rationale 76: To check for rebound hypoglycaemia. 
Rationale 77: To guide the maintenance of normal blood chemistry by altering the constituents of the PN solution. 
Rationale 78: To allow for alteration of PN solution. 
Rationale 79: To allow for clearance of fat emulsion from the plasma
Rationale 80: To monitor total body sodium and potassium. 
Rationale 81: To measure the effectiveness of treatment. 
Rationale 82: To enable accuracy of PN formulation. 
Rationale 83: To ensure consistency of recording. 
Rationale 84: To observe for fluid overload or dehydration. 
Rationale 85: To ensure adequate nutrition during sepsis. 
Rationale 86: To improve biliary flow. 
Rationale 87: To allow for lipid metabolism and clearance between lipid containing PN. 
Rationale 88: To reduce the omega six content of the lipid emulsion. 
Rationale 89: To promote clearance of lipid. 
Rationale 90: To minimise the risk of error on reconnection. 
Rationale 91: Safe practice as detailed in hospital policy. 
Rationale 92: To reduce liver complications related to PN
Rationale 93: To ensure tolerance to a cyclical regimen. 
Rationale 94: To prevent fluid overload. 
Rationale 95: To re-establish enteral nutrition. 
Rationale 96: To ensure appropriate referral is completed and the home care company can be informed. 

References

Reference 1: 
JPEN (2002) Guidelines for the use of parenteral and enteral nutrition in adults and paediatric patients. Journal of Parenteral and Enteral Nutrition 26:1: 1SA-138SA. 

Reference 2: 
Department of Health (2003) Winning Ways: Working together to reduce healthcare associated infection. London, Department of Health.

Reference 3: 

Scales K (2008) Intravenous therapy: a guide to good practice. Br J Nurs 17 (19): S4-S12.Reference 4: Bravery K (2008) Paediatric intravenous therapy in practice Dougherty L and Lamb J In: Intravenous therapy in nursing practice. Oxford, Blackwell Publishing

Reference 5:

Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox MH (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65 Suppl 1: S1-64.

Reference 6:

Improving Practice and reducing risk in the provision of parenteral nutrition for neonates and children. A report from the Paediatric Chief Pharmacists group 2011. 

Reference 7:

A Mixed Bag: An enquiry into the care of hospital patients receiving parenteral nutrition. NCEPOD

Reference 8: 

Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R, Parenteral Nutrition Guidelines Working Group, European Society for Clinical Nutrition and Metabolism, European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society of Paediatric Research (ESPR) (2005) 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 41 Suppl 2: S1-87.

Reference 9:

Wales PW, Allen N, Worthington P, George D, Compher C, Teitelbaum D. American Society for Parenteral and Enteral Nutrition. ASPEN Clinical Guidelines: Support of Pediatric Patients With Intestinal Failure at Risk of Parenteral Nutrition-Associated Liver Disease. JPEN J Parenter Enteral Nutr 2014 38: 538. 

Reference 10 :

Seida JC, Mager DR, Hartling L, Vandermeer B,  Turner JM Parenteral ω-3 Fatty Acid Lipid Emulsions for Children With Intestinal Failure and Other Conditions: A Systematic Review. JPEN J Parenter Enteral Nutr 2013 37 44.

Reference 11:

Pichler J, Horn V, MacDonald S, Hill S. Intestinal failure-associated liver disease in hospitalized children. Arch Dis Child 2012; 97:3 211-4. 

Reference 12:

Pichler J, Simchowitz V, MacDonald S, Hill S. Comparison of liver function with two new/mixed intravenous lipid emulsions in children with intestinal failure. EJCN 25th June 2014, doi: 10.1038/ejcn 2014.118 

Document control information

Lead Author(s)

Venetia Simchowitz, Senior Specialist Pharmacist: Clinical Nutrition, Pharmacy

Additional Author(s)

Dr Susan Hill, Consultant Paediatric Gastroenterologist
Anna Hughes, Advanced Nurse Practitioner Gastroenterology
Sarah Macdonald, Principal Dietitian, Dietetic Department

Document owner(s)

Venetia Simchowitz, Senior Specialist Pharmacist: Clinical Nutrition, Pharmacy

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
31 January 2001
Date approved: 
03 June 2015
Review schedule: 
Three years
Next review: 
03 June 2018
Document version: 
4.0
Previous version: 
3.1