Background
Methods
Indications for starting PN
1 | Infants aged 1 to 12 months: inability to achieve an adequate energy intakea for more than 3 days |
2 | In children older than 1 year: inability to achieve an adequate energy intakea for more than 5 days |
3 | Children not expected to meet an appropriate energy and nutrient intake for more than 7 days |
4 | Clinical condition leading to an absolute or relative contraindication to enteral nutritionb |
5 | In children older than 1 year: duration of PN of at least 5 days except in undernourished children |
PN Complications
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electrolytes abnormalities were defined as at least two consecutive results above or below the reference value for age and divergent from baseline levels, requiring a change of PN prescription or oral/iv supplementation; calcium and magnesium were corrected for the albumin level, serum sodium was corrected in the presence of hyperglycemia [12]. Patients were monitored for hypophospathemia throughout the duration of PN, which was considered a marker of refeeding syndrome (RS) in the first 10 days of PN in malnourished children or those who had lost a significant amount of weight prior to the start of PN [13].
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Hypoglycaemia was defined as a blood glucose level of less than 3.6 mmol/l (40 mg/dl) both in newborns and in children [14, 15]. Children were considered hyperglycaemic if their blood sugare rose above 7 mmol/L (126 mg/dl) [14]. In newborns plasma glucose concentrations above 8 mmol/l (150 mg/dL) were considered pathological in accordance with the guidelines of the American Society for Parenteral and Enteral Nutrition [14].
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Blood triglyceride concentrations were checked on a weekly basis 4 h after stopping the lipid infusion; levels > 200 mg/dl in newborns, > 250 mg/dl in infants and > 400 mg/dl in children were considered pathological [16].
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uNa was considered low if < 20 Meq/L.
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Acid-base disturbances as a consequence of respiratory failure, sepsis and metabolic disease were not considered to be related to PN.
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Hypercapnia secondary to respiratory failure was not recorded.
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300–800 microG/L were considered normal reference values for vitamin A in children older than 6 months of age. Serum concentrations below 200 microg/L were considered to indicate deficiency in premature infants [6].
Results
Population characteristics
Pre-existing diagnosis | No | Percentage |
---|---|---|
Cardiac disease | 90 | 29,7 |
Malignancy | 68 | 22,4 |
GI pathology | 41 | 13,5 |
Immune dysfunction | 20 | 6,6 |
No pre existing pathology | 17 | 5,6 |
Metabolic disorder | 16 | 5,3 |
Prematurity | 16 | 5,3 |
Neurological abnormality | 15 | 5,0 |
Syndrome | 7 | 2,3 |
Endocrine disorder | 3 | 1,0 |
Congenital bone diseases | 3 | 1,0 |
Lung disease | 3 | 1,0 |
Rheumatological disorder | 3 | 1,0 |
Indication | No | Percentage |
---|---|---|
Critical illness | 66 | 21.8 |
Pre-peri-post surgery nutritional support | 63 | 20.8 |
Bone marrow transplantation | 28 | 9.2 |
Feed intolerance | 25 | 8.2 |
NEC | 22 | 7.3 |
Intestinal resection in congenital malformation of the GI tract | 21 | 6.9 |
Mucositis due to chemotheraphy | 19 | 6.3 |
Other intestinal resections | 10 | 3.3 |
Condition associated with malabsorption | 9 | 3.0 |
Decompensation in patients with metabolic condition | 7 | 2.3 |
Organ transplant | 6 | 2.0 |
Post surgical ileus | 4 | 1.3 |
Autoimmune disorder associated with intestinal failure | 4 | 1.3 |
GI dysmotility | 4 | 1.3 |
Miscellaneus | 4 | 1.3 |
Post operative nutritional support | 3 | 1.0 |
Malnourishment | 3 | 1.0 |
Meconium aspiration | 2 | 0.7 |
Acute pancreatitis | 2 | 0.7 |
Heart cachexia | 1 | 0.3 |
Appropriatness of indications for prescribing PN
Current Audit | NCEPOD | |||
---|---|---|---|---|
Newborns | Infants/children | Newborns | Infants/children | |
No, Percentage | No, Percentage | No, Percentage | No, Percentage | |
Appropriate | 64, 95.5 | 214, 90.7 | 244, 92.4 | 62, 88.6 |
Indeterminate | 1, 1.5 | 12, 5,1 | 4, 1.5 | / |
Inappropriate | 2, 3.0 | 10, 4.2 | 16, 6.1 | 8, 11.4 |
Complications
Metabolic complication | No | Percentage among all patients |
---|---|---|
Hyperphophatemia | 111 | 36,6 |
Hypermagnesemia | 95 | 31,4 |
Hypercalcemia | 90 | 29,7 |
Hypophosphatemia | 84 | 27,7 |
Rise in urea | 74 | 24,4 |
Hypokalemia | 70 | 23,1 |
Hypophosphatemia in the first 10 days | 66 | 21,8 |
Hypernatremia | 36 | 11,9 |
Acidosis | 36 | 11,9 |
Hyponatremia | 35 | 11,6 |
Hyperkalemia | 32 | 10,6 |
Hyperglycemia | 32 | 10,6 |
Hypercarboxinemia | 27 | 8,9 |
Hypomagnesemia | 25 | 8,3 |
Hypertrigliceridemia | 21 | 6,9 |
Hypocalcemia | 19 | 6,3 |
Alcalosis | 19 | 6,3 |
Hypercloremia | 14 | 4,6 |
Hypocloremia | 13 | 4,3 |
Low urinary sodium | 12 | 4,0 |
Hypoglycemia | 9 | 3,0 |
Nutritional complication | No | Percentage among all patients with PN > 28 days |
---|---|---|
Vitamins | ||
High vitamin E | 15 | 27,3 |
High vitamin A | 14 | 25,5 |
High vitamin D | 1 | 1,8 |
Low vitamin D | 1 | 1,8 |
High folate | 7 | 12,7 |
High vitamin B12 | 1 | 1,8 |
Trace elements | ||
Low Zinc | 7 | 12,7 |
High Zinc | 1 | 1,8 |
Low selenium | 16 | 29,1 |
High selenium | 2 | 3,6 |
Low copper | 9 | 16,4 |
High copper | 5 | 9,1 |
Low iron | 4 | 7,3 |
High iron | 1 | 1,8 |
High Manganese | 1 | 1,8 |
Current Audit | NCEPOD | |||
---|---|---|---|---|
Newborns | Infants/children | Newborns | Infants/children | |
No, Percentage | No, Percentage | No, Percentage | No, Percentage | |
Metabolic complications | 50, 74.6 | 181, 76.7 | 63, 30.4% | 10, 14.3 |
CVC related complications | 11, 16.4 | 58, 24.6 | 56, 25.0 | / |