Procedures prior to and at PN commencement

• PN will be delivered to the ward from the pharmacy aseptic unit at the Royal Infirmary for a guaranteed 7pm start.
• PN must be prescribed by either a doctor or non-medical prescriber on the patient’s IV fluid prescription chart to include the following:

1. 1. Date
   2. “Parenteral nutrition (PN)” as the name of the fluid.
   3. “As per Pharmacy parenteral nutrition (PN) label/rate chart” as the infusion rate.
   4. Signature of prescriber and surname printed clearly in capital letters

See Appendix 1 for an example of a completed IV fluid prescription chart

Check that the pharmacy PN order prescription contains [the correct]:

• Patient given (first) name and surname
• CHI number
• PN weight (i.e. the ‘working’ weight of the patient)
• Ward
• PN weaning status
• Date of infusion
• Type of IV access
• Hours of PN supplied
• Prescriber signature
• Pharmacist signature
• Each daily row has been filled in with the indicative quantities requested per kg

[Note the Pharmacy PN Prescribing Code on the prescription is for pharmacy use only – please ignore]

See Appendix 2 for examples of PN order prescriptions (below and above 13kg)

• Check that a Prescription Details for Paediatric Parenteral Nutrition Sheet is supplied with the PN. This is for retention in the patient’s clinical notes and contains information against which the PN labels and order prescription are checked:
• Check the following information matches on each piece of documentation. L = Label, OP = Order Prescription, DS = Details Sheet.

Note 1: Elemental content of PN. Note the “per kg” column indicates the exact amounts supplied compared to the indicative amounts on the order prescription

Note 2: Flow rate is always a daily flow rate. Where there is a one hour taper to prevent hypoglycaemia or when a weaning chart is in place, the rate will be manually crossed out and reference made to a rate/weaning chart.

See Appendix 3 and Appendix 4 for examples of details sheet and label for all-in-one and 2-in-1 bags.

• On completing the checking process the nursing staff must enter the solution “Ref”
  number and sign the relevant line on the patient’s daily fluid prescription chart.

It should be noted that on average the LIPID rate will be approximately 10 times smaller than the aqueous rate

• To prevent incorrect infusion rates of the aqueous and lipid containers during PN set-up every PN bag will be supplied from pharmacy with a rate chart. The prescription, rates and child’s identity should be independently checked by two IV competent registered nurses.
• Clinical changes which affect the volume requirement of a patient must not be managed by increasing the infusion rates of the PN. The only exception is if a pharmacy rate chart has been supplied. Increases in fluid requirements should be provided using a separate prescribed infusion fluid the content of which is appropriate for the patient
• If fluid requirements decrease, the PN infusion rates may be reduced according to the written instructions of a prescriber. It should be noted that reducing or suddenly stopping PN, especially in neonates, infants or patients with significant malnutrition/re-feeding syndrome, may cause a rebound hypoglycaemia. Gradual tapering of the rate of the glucose-containing bag of PN is recommended.

Nothing must be added to PN prior to or during its infusion.

• PN must not mix directly in a patient’s IV line with any other drug or infusion fluid unless authorised by Pharmacy. This does not include solutions infusing simultaneously down a line with two or more lumens where the solutions only mix in the bloodstream.

Current Lloyds Pharmacy Clinical Homecare prescriptions for all Home PN (HPN) patients are located in Tantallon ward treatment room as well as in pharmacy. Patients using their own Homecare prescriptions as inpatients should only receive HPN via a hospital-supplied pump.

• The following critical sections of the Lloyds prescription must be cross-checked against the label on the PN container(s):

1. 1. Patient name
   2. Date of birth
   3. Bag code which is the unique identifier between bag and prescription.
   4. Daily volume to be infused (and infusion rate if stated)

It is not necessary to cross-check other aspects of the prescription and label if the above elements are all correct.

• PN must be prescribed – either by a doctor or a non-medical prescriber – on the patient’s IV fluid prescription chart including the following:
  1. Date
  2. “Parenteral nutrition (PN)” as the name of the fluid.
  3. “As per HPN label/prescription” as the infusion rate.
  4. Signature of prescriber and name printed clearly.

See Appendix 1 for an example of a completed IV fluid prescription chart

If satisfied that all the above points are correct, the PN solutions may be set up using appropriate aseptic techniques and infusion equipment.

Key points regarding parenteral nutrition

• Aseptic Non-Touch Technique (ANTT) should ALWAYS be used when accessing or caring for a child or young person’s Central Venous Access Device (CVAD).
• All PN solutions should be checked for presence of particles. If particles or cloudiness detected, the container must not be used.
• All PN solutions must be protected from light during their infusion to protect against degradation
  It should be noted that on average the LIPID rate will be approximately 10 times smaller than the aqueous rate.
• If following, commencement of infusion, PN becomes disconnected from the CVAD it should be discarded and prescribed IV maintenance fluids commenced.