International survey of De-implementation of initiating parenteral nutrition early in Paediatric intensive care units

Abstract

Background: Initiating parenteral nutrition (PN) within 24 h in critically ill children is inferior to withholding PN during the first week, as was found in the PEPaNIC study. The aims of this study were to investigate deimplementation of early initiation of PN at PICUs worldwide, and to identify factors influencing de-implementation. Methods: A cross-sectional online survey was conducted (May-October 2017), consisting of 41 questions addressing current PN practices, the degree of de-implementation, and factors affecting de-implementation. Results: We analysed 81 responses from 39 countries. Of these 81 respondents, 53 (65%) were aware of the findings of the PEPaNIC study, and 43 (53%) have read the article. In these 43 PICUs, PN was completely withheld during the first week in 10 PICUs, of which 5 already withheld PN (12%), and 5 de-implemented early initiation of PN (12%). Partial de-implementation was reported by 17 (40%) and no de-implementation by 16 (37%). Higher deimplementation rates were observed when the interpreted level of evidence and grade of recommendation of PEPaNIC was high. Predominant reasons for retaining early initiation of PN were concerns on withholding amino acids, the safety in undernourished children and neonates, and the long-term consequences. Furthermore, the respondents were waiting for updated guidelines. Conclusions: One year after the publication of the PEPaNIC trial, only two-thirds of the respondents was aware of the study results. Within this group, early initiation of PN was de-implemented completely in 12% of the PICUs, while 40% asserted partial de-implementation. Increasing the awareness, addressing the intervention-specific questions and more frequently revising international guidelines might help to accelerate de-implementation of ineffective, unproven or harmful healthcare.

Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations

“…A summary of comparisons between our recommendations and those presented by ASPEN/SCCM is shown in Table 2. Table 2) which helps assist in the uptake and implementation of guidelines into practice [21]. Implementation of evidence into clinical practice remains problematic, in 2017 a European survey of 59 PICUs found that 69% of PICUs still had no local feeding guidelines [13].…”

Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score-matched observational study

“…Our finding of evidence of greater morbidity in survivors who received early PN is in keeping with evidence in critically ill adults, children and term neonates, which has led to calls for the de-implementation of early PN in these groups. 21 The mechanisms that explain the adverse outcomes in paediatric patients are equally likely to play a role in preterm infants. A secondary analysis of the PEPaNIC trial (The Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit), comparing early versus delayed PN in critically ill children and babies, found that it was the early administration of amino acids, but not glucose or lipids, that explained the harm from early PN.…”

Use of parenteral nutrition in term and late preterm infants: an Australian and New Zealand survey

“…The late PN group had lower odds of infection, shorter duration of mechanical ventilation, shorter duration of PICU and hospital stay (17) . When another worldwide survey was conducted by van Puffelen et al (18) , 1 year after the publication of the PEPaNIC trial (17) , only five units (12 %) reported changing their practice from early to late commencement of PN (18) . Although the short timeframe between the publication of the RCT and the survey may be the main reason for the low rate of change in clinical practice, concerns about the risk of hypoglycaemia and the perceived limited external validity of the PEPaNIC trial may also have prevented clinicians from changing their clinical practice (19)(20)(21)(22) .…”