Hang time parenteral nutrition bag (incl lipids)

[Chris van den Akker]

May I ask whether anyone has experience with a prolonged hanging time of a parenteral nutrition (PN) bag (incl lipids) of up to 48h?

 

We are probably changing our PN regimen into an all-in-one bag. Since the bag contains >400 mL, it would suffice for most premature infants for 2 days. One strategy could thus be to prolong hang time from 24h to 48h to cut PN costs by half.

A recent Australian study (attached) also suggests this would be a feasible approach: https://www.ncbi.nlm.nih.gov/pubmed/23320598

Since our pharmacy will do all additions to the bag in an aseptic environment, including connection and filling the line, I think it could be an attractive solution. Also there is an air-filled dripping chamber in the line, so there exists no continuous fluid-filled connection from the patient to the PN-bag. On the other hand, the line would be in place for 48h as well, so this could form a potential risk.

We must be sure it is a safe approach though…

What are your thoughts and experiences on this matter?

 

Thank you so much,

 

best wishes,

Chris van den Akker, neonatologist

Amsterdam UMC, the Netherlands

[Stefan Johansson]

This is indeed a valid question - I have also thought this myself, We also change every 24 hours BTW. Thanks for sharing that paper, was not aware of it. 

Would be great to bring this question into a research context (i.e. like large collaborative observational study, presumably with historical controls + some experimental "sham" work). I'd be in such an project

 

[Francesco Cardona]

Sounds like a promising approach if preparation is aseptic. I wonder how many neonatology wards get the same service as you do in the Netherlands!

[Rashmi]

Yes, NICU I work in UK, we do use the PN bags for 48hrs and each time they are changed aseptically.

[cmcdermott]

We change the aqueous portion every 48 hours (lipid every 24 as per manufacturer but that is potentially to change) and have been doing so for several years with no issues.  The practice is being recommended in the National Guidelines for Parenteral Nutrition in Neonatal and Paediatric settings.  There is no good evidence to suggest it is harmful and indeed the 24 hour change of infusions and administration sets   seems to be based purely on custom and practice.  We have made considerable savings too.  The bags have to be clearly marked with a label stating date and time they are hung to avoid prolonging hang times.  ESPGHAN guidelines suggested up to 72 hours but we decided to keep with 48 and try get everyone on board

Christine

[M C Fadous Khalife]

Effectively, never thought about that, The 24 hours were so obvious 

Thanks for sharing 

[piatkat]

On 6/26/2020 at 3:40 PM, Chris van den Akker said:

May I ask whether anyone has experience with a prolonged hanging time of a parenteral nutrition (PN) bag (incl lipids) of up to 48h?

 

We are probably changing our PN regimen into an all-in-one bag. Since the bag contains >400 mL, it would suffice for most premature infants for 2 days. One strategy could thus be to prolong hang time from 24h to 48h to cut PN costs by half.

A recent Australian study (attached) also suggests this would be a feasible approach: https://www.ncbi.nlm.nih.gov/pubmed/23320598

Since our pharmacy will do all additions to the bag in an aseptic environment, including connection and filling the line, I think it could be an attractive solution. Also there is an air-filled dripping chamber in the line, so there exists no continuous fluid-filled connection from the patient to the PN-bag. On the other hand, the line would be in place for 48h as well, so this could form a potential risk.

We must be sure it is a safe approach though…

What are your thoughts and experiences on this matter?

 

Thank you so much,

 

best wishes,

Chris van den Akker, neonatologist

Amsterdam UMC, the Netherlands

@Chris van den AkkerI've just found this thread! Seeing you had posted this question some time ago already, I wonder how did it go- have you changed your PN regimen? Please let us know what are your thoughts about it! Any suggestions for units trying to implement this model? 

[cmcdermott]

We will shortly be changing our standardised lipid infusions from syringes to bags which will have a 48hr hang time.  Several units in Ireland have already adapted to a 48hr (over several years) hang time for an aqueous bag and we have not noted any increase in infection.  Theoretically it should reduce the risk as you are breaking the central line only once every 48hrs as apposed to every day.  Despite initial concerns from the neonatal nurses they have embraced the change and are looking forward to changing the lipids to 48 hours as well.  The biggest risk is that when the lipids are infused as a separate infusion errors can occur when setting the infusion rates unless there are robust systems in place for checking, prompts on the pumps etc.  Unfortunately we have discovered that no one is manufacturing a light protected IV administration set in any colour other than shades of yellow which would help clearly distinguish each infusion. Therefore labelling the lines will be important both before and after the pump, two -person checks at each change of infusion and subsequent infusion rate changes, hourly checking set rate and volume infused and checks at each shift changeover.  Another suggestion following an error in the UK is to consider having dedicated pumps for Lipid infusions only.

[M C Fadous Khalife]

https://doi.org/10.1186/s12887-020-1958-9 Standardised neonatal parenteral nutrition formulations – Australasian neonatal parenteral nutrition consensus update 2017

I just found this publication in BMC pediatrics from 2017 and it seems obvious we must all shift to 48 hours for parenteral nutrition and consider it for lipids

 I remembered this discussion and I am sharing this article

It contains other interesting informations 

 

[Vicky Payne]

I have only come across this thread too! We (UK) have 48 hour hang times for vamin, and 24 hour lipid change. The lipids are infused on a separate syringe driver, and the vamin run through different fluid pump. We were looking into using orange light protecting giving sets for the lipid which a different colour to our standard giving sets for bags of fluid.

We have standard manufactured bags of PN in stock on the unit, and then we can also get special bespoke bags made via our aseptic pharmacy team if the patient needs fluid restriction or careful electrolyte management.  Our nurses change the fluids using aseptic non touch technique. 

I think the point about accessing lines less frequently is a good one @Chris van den Akker.

[M C Fadous Khalife]

I tried to change but I found that our smoflipid contains microg of Aluminium and we are not only limited by time but also we can't exceed an amount of ml because of Aluminium toxicity 

We had lipofundin before but it was no more available since the start of COVID-19