P40 Appropriateness of parenteral nutrition prescribing in paediatric intensive care patients

Background & Aim Nutritional support is vitally important in the management of critically unwell children, however there is a lack of evidence-based guidelines, which results in a wide range of practice across different paediatric intensive care units (PICU).¹ The aim of this study was to assess the appropriateness of Parenteral Nutrition (PN) prescribing in a large, tertiary site PICU (23 beds).

Objectives

• Identify whether PN is initiated for an appropriate indication

• Identify whether PN is administered for an appropriate duration

• Identify whether the macronutrient content of PN is prescribed in accordance with The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines²

Method Prospective data was collected from January-March 2023, data was retrieved from the daily PN order forms. All patients admitted who received PN were included in the study. The patient’s reason for admission, indication for PN, date of admission, date PN was initiated, and macronutrient content were recorded. Patients were divided into three groups; group 1: cardiac-surgical, group 2: cardiac non-surgical and group 3: non-cardiac patients. For analysis, patients who were mechanically ventilated were categorised as acute phase of critical illness and those not ventilated were categorised as stable phase. Data was analysed using Microsoft Excel (Version 1808). Data was compared with the ESPGHAN guidelines on paediatric PN.²

Results 102 prescriptions were identified for 14 patients, of which 5 were cardiac-surgical patients, 4 cardiac non-surgical and 5 non-cardiac. 92.8% of (13/14) patients had an approved indication for PN. 21.4% (3/14) of patients received PN for 5 days or less. Only 1 patient received PN within 24 hours of admission, however they were on PN prior to admission.

For group 1; 9.4% (8/85) of prescriptions had daily calories within target range for their phase of critical illness, 28.2% (24/85) had carbohydrates within range, 100% (85/85) had protein within range, 91.8% (78/85) met minimum lipid requirements and 36.5% (31/85) received the recommended ratio of non-protein calories per gram of nitrogen.

For group 2; 13.8% (4/29) of prescriptions had daily calories within target range, 0% (0/29) had carbohydrates within range, 93% (27/29) had protein within range, 86% (25/29) met minimum lipid requirements and 48% (14/29) received the recommended ratio of non-protein calories per gram of nitrogen.

For group 3; 12.5% (5/40) of prescriptions had daily calories within target range, 2.5% (1/40) had carbohydrates within range, 100% (40/40) had protein within range, 87.5% (35/40) met minimum lipid requirements and 15% (6/40) received the recommended ratio of non-protein calories per gram of nitrogen.

Conclusion This study confirms that PN prescribing on PICU deviates from current national guidance. Patients were prescribed PN for appropriate indications, however some patients were prescribed PN for a duration less than recommended. The majority of patients received more calories than recommended for their phase of critical illness, and this appears to be the result of prescribing and administering more carbohydrates than recommended by ESPGHAN.¹ Most protein and lipid quantities were prescribed within range, however the majority of patients received higher than recommended non-protein calories per gram of nitrogen.

References

1. Tume LN, Vall FV, Joosten K, et al. Nutritional support for children during critical illness: European Society of Paediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations, Intensive Care Medicine 2020;46:411–425.

2. Jooston K, Embleton N, Yan W, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on paediatric parenteral nutrition: energy. Clinical Nutrition 2018;37:2309–2314.