HPE HPE 85 – Spring 2017 - Page 44

Practical therapeutics Non-clinical issues The NHS has a reduced capacity for manufacturing, lack of appropriate facilities and skilled staff and lack of capital investment has led to the use of external suppliers or ‘outsourcing’. Aseptic manufacture is a complex and high-risk process where compounding errors and microbial contamination have led to patient harm and, in a few cases, death. The use of a standardised approach to PN in the context of short-term PN has been recommended by the Chief Pharmacists’ group 7,8 to improve risk management of the PN process. 42 The current debate in neonatal PN Many preterm infants exhibit growth failure during their stay in the ICU due to inadequate nutrition. A deficit in calories leads to neurodevelopmental impairment due to poor brain growth. The ultimate goal therefore is not only to prevent growth failure but also to avoid inappropriate body composition with the associated adverse metabolic effects such as insulin resistance due to gain in adipose rather than lean tissue. 1,2 The first debate involves the two large-scale trials that have been published in the last few years with very different approaches to PN in neonates and, in particular, premature infants. The aim for both trials was to promote growth and, in particular, head circumference. The NEON trial 3 of preterm infants of <31 weeks gestation proposed a peripheral PN with low calorie provision as an adjunct to rapid enteral feed progression. Patients either received a low or high protein intake. The results found poorer brain growth among the cohort with high protein PN. Conversely, the SCAMP trial 9 in premature infants <29 weeks’ gestation used concentrated central PN with a more generous calorie provision and higher protein content based on previous trial data and found early brain growth that was still evident at 36 weeks’ corrected gestational age. The other topic of debate involves the multi-centre PEPaNic trial 10 in critically ill children in intensive care. This was an unblinded trial of delayed PN (starting eight days post-admission) versus supplemental PN initiated on day 1 of admission to PICU. The main outcome was fewer new infections (p<0.001); in particular, airway and bloodstream infections (p<0.002) in the late group, and reduced stay in the PICU. The trial authors recommended delayed PN to all hospitalpharmacyeurope.com Key points • Parenteral nutrition (PN) should only be initiated when normal metabolic and nutritional needs are not met by enteral feeding in patients with adequate intestinal function. • The neonatal brain is sensitive to periods of malnutrition and metabolic insult during this period of rapid growth. • Early introduction of amino acids with glucose on day one of life has been found to be safe in premature infants and will decrease protein catabolism and enhances net protein accretion. • Lipid emulsions are an important component of a balanced PN regimen.They provide high energy needs without carbohydrate overload, improve the net nitrogen balance and prevent essential fatty acids deficiency. • Aseptic manufacture is a complex and high- risk process that risks compounding errors and microbial contamination. The use of standardised PN in the short term is recommended by the Chief Pharmacists group. patient groups including neonates; but premature infants were excluded from the trial and only a small proportion of term neonates (15%) were enrolled. These patients were predominantly cardiac patients with the lowest weight specified in the paper of 4.5kg. There were no standard protocols for calorie provision or enteral feeding across the three centres although the authors state that this did not have any effect on the results. )=єԔѡєɽݕɔ)͍ɝɽ% T䁑܁ͼ)ЁɕٔA8Q́́ѡ)фձЁѼɅєѼ)Ʌѥ)%Ё́ݽѠѥѡЁѡ٥)͔ȁхA8͔́ݥѠ)Ʌ͕ɽɥ̰䁽)ݡɔչݕɕՔѼ)ѥЁյ̸Iѥ́ѕ)Ѽ͕́ɥٕİȰ)Qɽѡɵ)Aɵ́ɔЁѡЁѡ)ձѤ͍ѕɥ)ɕѕɴѕɴ̸Qɽ٥)٥ȁɽɥє́՜)ѡɅ䰁՜ѵ́ȁձѤ)ɝɕ̰՜ѥѥ́)䁹܁ɽ٥ѕɽ)Ёɕ͍ɥ́ȁѠA8)ȁ̸Q䁍ͼ䁅)ѕɅɽѡٕЁ)ѥѕɹѥե̸)́ݼɵ́٥ѕѼ)ѥєѡMA8MA!8(ԁե́ȁɥɕѕɅ)ɥѥāѡͽɵЁȁѡ)єԀՉѥ(ܤ$Ѽɽ٥Ʌѥ٥)х䰁եх䁽ѡՉɅѕ̰)ɽ٥ЁѼѡ͕́)ѡєե) ͥ)ɽɥєɥѥѡɕɔ)Ё́ɅչЁȁɽ٥ѡ)ՉɅѕ́ɕեɕЁѥɅ)ɽѠٕиQ͔)ͽɍ́ɱA8ех)䁡ٔЁѕɴɽѠ)Ѡ)Iɕ(ā-魼Ё쁙ȁѡAɕѕɅ9ɥѥ)ե́]ɭɽĸե́Aɥ)AɕѕɅ9ɥѥѡɽM䁽)Aɥɽѕɽ䰁!ѽ䁅9ɥѥ(MA!8ѡɽM䁙ȁ )9ɥѥ5хʹMA8Mѕѡ)ɽM䁽AɥI͕ɍMAH()Aȁɽѕɽ9ȀġMȤLNJLܸ(ȁ]ѡѽ@Ё]́A8ɽɥє)A8()AɕѕȁѕɅ9ȀӊLܸ(́Uѡ儁LЁ9ɥѥمՅѥ)ѥͅѥѕ聄Ʌ镐Չ)ɽɥɕ)Ʌٕ́ͥѥɕѕɴɕѕɅ)ɥѥ( 9ȀϊLԸ(Ё]́@ЁL@8եM)ɥѥ́ݥѠѕѥɔЁɥͬ)ɕѕɅɥѥͽѕٕȁ͕͔)A8()AɕѕȁѕɅ9ȀLܸ(ԁ ձф)$ЁMA8ե)ɕѕɅɥѥɑɥɑȁɕ٥ܰ)չͥ)A8()AɕѕȁѕɅ9ȀӊLܸ(؁՝L1()܁I,5᥵մѽɅѕ)͵ɥ䁙ȁɥɅɅѥɕѕɅ)ɥѥɥѥ̸)A8(AɕѕȁѕɅ)9ȀߊLĸ(܁5ͽЁAɕѕɅɥѥȁѕ)ɕ聄ᕐɍ́ (L(Aɥ AɵЁɽ%ɽ٥)ɅѥɕՍɥͬѡɽ٥ͥ)ɕѕɅɥѥȁѕ́ɕĸ)ܹɵ̹е̽ͥɥͬ)ɕؤ͕ɥܤ(5ɝ ЁAѹхɽѠɕѕɴ)Ʌ镐ɽɕѕɅɥѥ)Ց丁Aɥ̀ÊL(ٕPЁɱٕ́єɕѕɅɥѥ)ɥѥ䁥ɕ8(5РȤNJLȸ(ā ɥѥ͠ͽѥAɥх5Q)ɽ٥ͥɕѕɅɥѥݥѡх)͕٥̃LɅݽɬȁAɅѥظ)ܹɜՉѥ̽յ̽ե̼)AɕѕɅ9ɥѥɥع(͕ɥܤ