Parenteral nutrition compatibility and stability: Practical considerations

Parenteral nutrition (PN) is a complex preparation that contains multiple component products with the associated risk for incompatibilities and diminished stabilities when combined together as an admixture. Significant patient harm can result from prescribing, preparing, and administering PN without confirming compatibility and stability. Incompatibility or instability is rarely obvious to the unaided eye, so safe PN admixture relies on incorporating physicochemical properties of the included components into compatibility and stability decisions. Practices include applying active ingredient concentration limits to reduce risk for incompatibilities and instabilities. The purpose of the current article is to distill the wide-ranging information on PN compatibility and stability into a feasible blueprint that individual healthcare organizations can then use to design and implement practical initiatives. Compatibility and stability considerations can be incorporated into the routine tasks of PN prescribing, order reviewing, preparing, and administering. The focus of this review is on identifying potential physicochemical interactions that can be addressed at each step in the PN use process. Organizations should incorporate compatibility and stability considerations into the routine procedures and practices of all clinicians involved with PN therapy. Those clinicians in healthcare organizations and caregivers in the home should then be in a position to safely provide the appropriate PN admixtures in terms of compatibility and stability.

An Assessment of aluminum contamination in neonatal parenteral nutrition solutions based on measured versus labeled content

Aluminum can potentially cause toxicity in pediatrics and neonates receiving parenteral nutrition. Some PN solutions and ingredients in Saudi Arabia do not comply with US FDA regulations regarding aluminum exposure. This study aims to determine the aluminum concentration in samples of PN solutions and ingredients used to feed infants in Saudi Arabia. The aluminum in the samples was determined using inductively coupled plasma mass spectrometry. The concentration of metal contaminants in each sample was determined in triplicate. The aluminum content of 38 samples was investigated, 15 of which originated from components included in the prepared PN solutions. Among the 15 samples, the least measurable aluminum content was detected in potassium chloride solutions (0.81 mcg/L). In contrast, the greatest amount of aluminum was detected in potassium phosphate and calcium gluconate (141,64 mcg/L and 462.7 mcg/L), respectively. The results showed that the final PN solution (PNS) product contained more aluminum levels than the content ingredients; in addition, the study found a statistically significant relationship among 18 pediatric patients at KFMC who had intestinal failure and needed long-term parenteral nutrition. Specifically, their high aluminum levels, exceeding the normal range of 0.6 ng/ml, indicate that the current use of PN solutions will likely cause toxicity due to aluminum contamination in additives. Hence, reducing aluminum in PN solutions is imperative to ensure patient safety.

Iron overload in patients with Crohn's disease with short bowel syndrome who received long-term parenteral nutrition with trace elements

Crohn's disease patients often need regular home parenteral nutrition (HPN) for intestinal failure due to multiple intestinal resections. Trace elements are necessary for long-term HPN but the requirement volume of iron is undetermined. We describe three patients with Crohn's disease with short bowel syndrome (SBS) who had iron overload as a result of long-term HPN including iron. Serum ferritin level was significantly decreased through depleting intravenous iron administration in all cases. One patient needed regular insulin injection and phlebotomy for diabetes mellitus due to hemochromatosis, and intravenous iron administration had a significant impact on the patient's health. Long-term routine intravenous iron administration should be cautious in SBS patients to avoid the overload.

n-3 Polyunsaturated Fatty Acid Supplementation Affects Oxidative Stress Marker Levels in Patients with Type II Intestinal Failure: A Randomized Double Blind Trial

Type II intestinal failure (IF-II) is a condition in which the gastrointestinal tract is compromised. Liver complications may occur because of the pathology and/or prolonged use of parenteral nutrition (PN); oxidative stress has been implicated as one of the causes. Lipid emulsions containing n-3 polyunsaturated fatty acids (PUFAs) have been proposed for the treatment. We aimed to evaluate the effect of 7-day n-3 PUFA supplementation on oxidative stress in IF-II patients receiving PN. This was a randomized, controlled, double-blinded, pilot trial of adult patients with IF-II, receiving either conventional PN (control) or PN enriched with n-3 PUFAs (intervention). Twenty patients were included (14 men, 49 ± 16.9 years), with the ANCOVA analysis the glucose (p = 0.003), and direct bilirubin (p = 0.001) levels reduced; whereas the high-density lipoprotein cholesterol (HDL-C) increased (p = 0.017). In the random-effect linear regression analysis, a reduction (p < 0.0001) in the malondialdehyde (MDA) level was found in the intervention group when the covariables age, HDL-C level, and alanine aminotransferase activity were considered. After 1 week of PN supplementation with n-3 PUFAs, the marker levels of some oxidative stress, blood lipids, and hepatic biomarkers improved in patients with IF-II.

ESPEN practical guideline: Home parenteral nutrition

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion catheter and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

Home Parenteral Nutrition for Children: What Are the Factors Indicating Dependence and Mortality?

Parenteral nutrition (PN) in children with short bowel syndrome is crucial and lifesaving. Taking care of such patients requires interprofessional practice and multiple team resource management. Home PN (HPN) usage allows patients and families to live regular lives outside hospitals. We share our experiences for the last two decades and identify the risk factors for complications and mortality. A retrospective study of HPN patients was conducted between January 2000 and February 2022. Medical records of age, body weight, diagnosis, length of residual intestines, HPN period, central line attempts, complications, weaning, and survival were collected and analyzed. The patients were classified as HPN free, HPN dependent, and mortality groups. A total of 25 patients received HPN at our outpatient clinic, and one was excluded for the adult age of disease onset. There were 13 patients (54.1%) who were successfully weaned from HPN until the record-enroled date. The overall mortality rate was 20.8% (five patients). All mortality cases had prolonged cholestasis, Child Class B or C, and a positive Pediatric End-Stage Liver Disease (PELD) score. For HPN dependence, extended resection and multiple central line placement were two significant independent factors. Cholestasis, Child Class B or C, and positive PELD score were the most important risk factors for mortality. The central line-related complication rate was not different in all patient groups. The overall central line infection rate was 1.58 per 1000 catheter days. Caution should be addressed to prevent cholestasis and intestinal failure-associated liver disease during the HPN period, to prevent mortality. By understanding the risks of HPN dependence and mortality, preventive procedures could be addressed earlier.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

Setting impurity limits for endogenous substances: Recommendations for a harmonized procedure and an example using fatty acids

Endogenous substances, such as fatty, amino, and nucleic acids, are often purposefully used in parenterally pharmaceuticals, but may be present as impurities. Currently, no consensus guidance exists on setting impurity limits for these substances. Specific procedures are needed, as the amount and types of toxicity data available for endogenous substances are typically far less than those for other chemical impurities. Additionally, the parenteral route of administration of these substances is inherently non-physiological, resulting in potentially different or increased severity of toxicity. Risk Assessment Process Maps (RAPMAPs) are proposed as a model to facilitate the development of health-based exposure limits (HBELs) for endogenous substances. This yielded a framework that was applied to derive HBELs for several fatty acids commonly used in parenteral pharmaceuticals. This approach was used to derive HBELs with further vetting based on anticipated perturbations in physiological serum levels, impacts of dose-rate, and consideration of intermittent dosing. Parenteral HBELs of 100-500 mg/day were generated for several fatty acids, and a proposed class-based limit of 50 mg/day to be used in the absence of chemical-specific data. This default limit is consistent with the low toxicity of this chemical class and ICH Q3C value for Class 3 solvents.

Early calcium and phosphorus supplementation in VLBW infants to reduce metabolic bone disease of prematurity: a quality improvement initiative

Objective

To reduce the incidence of metabolic bone disease (MBD) among very low birthweight (VLBW) infants admitted to neonatal intensive care unit from baseline of 35% by 50% over 2 years by implementing a quality improvement (QI) initiative.

Methods

A multidisciplinary QI team used evidence-based interventions and the healthcare improvement model to reduce MBD rate in VLBW infants. The specific interventions included routine enteral supplementation of calcium and phosphorus using Human Milk Fortifier (HMF) to expressed breast milk by day 14 of life (Plan/Do/Study/Act (PDSA) cycle 1), parenteral and early enteral supplementation of calcium and phosphorus (PDSA cycles 2 and 3). We included VLBW infants admitted within the study period at birth and excluded babies with congenital malformations, skeletal disorders and those who died before 2 weeks of age. Compliance with adding HMF by day 14, compliance with adding calcium and phosphorus in total parenteral nutrition (TPN) from day 1 of life and compliance with starting HMF when the baby reached 100 mL/kg/day of feeds were used as process indicators. The incidence of MBD was used as an outcome indicator during the study. The incidence of MBD was tracked using the Statistical Process Control methodology.

Results

The baseline MBD rate in 2015 was 35%. After the first PDSA cycle, 20% developed MBD (p=0.02). The same was sustained for a period of 1 year with the rate of 22%. After the second and third PDSA cycles, there was a drop in the MBD rate to 17%, and sustained for 3 months with 21%.

Conclusion

Implementation of QI initiatives decreased the MBD rate from 35% to <20%. Early parenteral calcium and phosphorus supplementation in TPN and optimising enteral supplementation with multicomponent fortifiers appear to have significant reduction in the incidence of MBD.

Use of oral rehydration solution and intravenous fluid in home settings for adults with short bowel syndrome

Although both oral rehydration solutions (ORSs) and intravenous fluids (IVFs) were initially developed to treat severe dehydration from diarrhea due to cholera, they are the mainstays of treatment for patients with short bowel syndrome (SBS). Advances in medical care have provided an expansion of new concepts on existing ideas, including adaptations of ORSs, pharmaceutical introductions of new oral and enteral products, and supply chain limitations of intravenous products necessitating the development of novel clinical practices. The evaluation and understanding of a patient's hydration status, socioeconomic status, compliance to therapies, and, finally, the ability to obtain actual products all play an integral role in determining the best plan of care to manage fluid balance in the presence of SBS. Therefore, a multidisciplinary approach, including a dietitian, medical provider, pharmacist, and others, is crucial to create a collaborative and comprehensive look at a complicated patient to individualize treatment options. The purpose of this paper is to provide an overview of the historical and current use of ORSs and IVFs to maintain fluid balance and combat dehydration from SBS, describe the challenges patients and healthcare providers have been faced with, and provide recommendations for future research to overcome these barriers.

Fluid management in hospitalized pediatric patients

The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.

Behavior of Regular Insulin in a Parenteral Nutrition Admixture: Validation of an LC/MS-MS Assay and the In Vitro Evaluation of Insulin Glycation

Parenteral-nutrition (PN)-induced hyperglycemia increases morbidity and mortality and must be treated with insulin. Unfortunately, the addition of insulin to a ternary PN admixture leads to a rapid decrease in insulin content. Our study's objective was to determine the mechanistic basis of insulin's disappearance. The literature data suggested the presence of a glycation reaction; we therefore validated an LC-MS/MS assay for insulin and glycated insulin. In a 24-h stability study, 20 IU/L of insulin was added to a binary PN admixture at pH 3.6 or 6.3. When the samples were diluted before analysis with a near-neutral diluent, insulin was fully stable at pH 3.6, while a loss of around 50% was observed at pH 6.3. Its disappearance was shown to be inversely correlated with the appearance of monoglycated insulin (probably a Schiff base adduct). Monoglycated insulin might also undergo a back-reaction to form insulin after acidic dilution. Furthermore, a second monoglycated insulin species appeared in the PN admixture after more than 24 h at high temperature (40 °C) and a high insulin concentration (1000 IU/L). It was stable at acidic pH and might be an Amadori product. The impact of insulin glycation under non-forced conditions on insulin's bioactivity requires further investigation.

PN Administration in Critically Ill Children in Different Phases of the Stress Response

Nutritional support is an important part of the treatment of critical ill children and the phase of disease has to be taken into account. The metabolic stress response during acute critical illness is characterized by severe catabolism. So far, there is no evidence that the acute catabolic state can be prevented with nutritional support. The Pediatric ’Early versus Late Parenteral Nutrition’ (PEPaNIC) trial showed that withholding supplemental parenteral nutrition (PN) during the first week in critically ill children, when enteral nutrition was not sufficient, prevented infections and shortened the stay in the pediatric intensive care unit (PICU) and the hospital. A follow-up performed 2 and 4 years later showed that withholding parenteral nutrition (PN) also improved several domains of the neurocognitive outcome of the children. Current international guidelines recommend considering withholding parenteral macronutrients during the first week of pediatric critical illness, while providing micronutrients. These guidelines also recommend upper and lower levels of intake of macronutrients and micronutrients if PN is administered.

Advances in Trace Element Supplementation for Parenteral Nutrition

Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT^® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.

Particulates formed in online prepared substitution fluid- Effect of acetic acid cleaning on endotoxin retentive filters

INTRODUCTION

There is no standard for insoluble particulate matters in dialysate. We evaluated the insoluble particulate matters in online prepared substitution fluid.

METHODS

We evaluated particle diameters and constituent elements of particles in online prepared substitution fluid and the final endotoxin retentive filter (ETRF).

RESULTS

The measurement results with particles in the online prepared substitution fluid and particles attached to the final ETRF revealed that Ca-containing particles accounted for 11 particles and Si-containing particles accounted for 19 particles of 30 particles detected in the online prepared substitution fluid and the final ETRF.

CONCLUSION

We presume that insoluble particulates in online prepared substitution fluid were Ca and Mg precipitated from dialysate and Si precipitated from dialysis water. Even if two ETRFs were connected in series, these particles were formed in the final ETRF.

Parenteral nutrition compatibility and stability: A comprehensive review

Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Impact of nationwide essential trace element shortages: A before-after, single-center analysis of hospitalized adults receiving home parenteral nutrition therapy

BACKGROUND

Recent data on the prevalence of essential trace element (ETE) deficiencies in home parenteral nutrition (HPN) patients are scarce. We investigated whether ETE deficiencies are still an important issue for HPN patients and whether the prevalence of such deficiencies may be influenced by nationwide drug shortages.

METHODS

We conducted a single-institution, retrospective analysis from 2006 to 2015 of hospitalized HPN patients who continued PN during and in between hospitalizations. In subgroup analysis, patients were dichotomized as those with HPN duration <1 vs ≥1 year. Zinc (Zn), copper (Cu), and selenium (Se) levels were abstracted for patients over the study period. Prevalence of ETE deficiency was compared using chi-squared test for patients hospitalized during nonshortage vs shortage (2011-2014) periods.

RESULTS

Ninety-six patients were included in the analysis. Prevalence of ETE deficiency during nonshortage vs shortage periods was 48% vs 54% (Zn), 15% vs 21% (Cu), and 24% vs 48% (Se; P = .01), respectively. When comparing patients who received HPN <1 year vs ≥1 year, the prevalence of Se deficiency doubled during shortage in both subgroups (24% to 42% vs 26% to 49%); and Cu deficiency tripled during shortage period in the group receiving HPN ≥1 year (5% to 16%).

CONCLUSION

ETE deficiency is prevalent in hospitalized HPN patients and was exacerbated during nationwide shortages of parenteral supplements. Statistical significance may be limited by small sample size. Future studies are needed to determine optimal ETE supplementation strategies for minimizing the impacts of nationwide drug shortages on HPN patients.

Characterization of American teduglutide consumers from 2015 to 2020: A large database study

INTRODUCTION

Teduglutide, a glucagon-like peptide-2 analog, is a novel therapy for intestinal failure that reduces need for parenteral support, especially in patients without a functional terminal ileum or colon. It can also predispose patients to accelerated progression of gastrointestinal (GI) malignancy and fluid overload. We demographically and clinically characterized American patients prescribed teduglutide.

METHODS

The Explorys database is an aggregate of deidentified patient data from dozens of US healthcare systems. We used SNOMED classification to identify patients prescribed teduglutide from 2015 to 2019. Through the browse cohort feature we determined the demographics, postsurgical anatomy, comorbidities, and indication for teduglutide use among these patients.

RESULTS

Of approximately 72 million patients, 170 were prescribed teduglutide. A large majority were female (70.6%). Most common etiologies of short-bowel syndrome were intestinal obstruction (52.9%) and Crohn's disease (41.2%). Common postsurgical anatomy included total colectomy (41.2%) and ileostomy. Common incident symptoms included abdominal pain (41.2%) and nausea (23.5%). Thirty (17.6%) patients were prescribed teduglutide despite comorbid heart failure, and 5.9% despite prior GI malignancy. A total of 11.8% of patients had a history of benign GI neoplasms before starting teduglutide. A total of 5.9% of patients had posttreatment formation of colon polyps.

CONCLUSION

In a large American database, the teduglutide prescription is rare. Only a minority have postsurgical anatomy associated with the most robust response to teduglutide. Serious adverse events appear rare, but a substantial number of patients are at risk for adverse effects because of the presence of comorbid heart failure or GI neoplasm.

[Prescription of phosphorus, calcium and magnesium: choice of the millimole unit to establish the equivalence of doses between oral and injectable forms]

OBJECTIVES

Information available on the packaging of drugs indicated for patients electrolytes replenishment differs from one manufacturer to another. They relate, for example, the unit chosen to express elemental electrolyte concentration. These differences constitute a risk factor for medication errors. This article proposes a clinical decision support tool which defines dose equivalences between the oral and injectable formulation galenic forms for medications providing phosphorus, calcium and magnesium and a calculated replenishment ratio.

METHODS

The amounts of elemental electrolyte were determined from the information contained on the packaging and the summaries of product characteristics. Only the specialties of our hospital drug formulary were studied. For each element, the replenishment ratio was determined from published data.

RESULTS

Equivalence tables were created for the phosphorus, calcium and magnesium between oral and injectable formulation. A clinical decision support tool was developed from these data.

CONCLUSION

The use of this tool is a first way to reduce the risk of medication errors. It remains to determine the conditions for its dissemination and evaluation. This issue raises the questions of the exclusive use of the millimole unit on packaging and for prescription, and that of the integration of this type of tool into prescription software and decision support systems.

Back pain associated with centrally administered parenteral nutrition

Parenteral nutrition (PN) is well recognized for its ability to provide nutrition to patients without the ability to digest enterally; however, PN must also be seen as a medication with associated adverse drug events similar to any other pharmacological agent that is administered to patients. Here we present a case report of localized lower back pain with central PN infusion. The initial areas of concern were the intravenous lipid emulsion, peripherally inserted central catheter placement, osmolarity of the formula, and the additives. The patient's back pain was ultimately felt to be an adverse reaction to the multivitamin component of the infusion based on an elimination trial of the PN components.

Nutritional management in inpatients with aspiration pneumonia: a cohort medical claims database study

BACKGROUND/OBJECTIVES

This study aimed to describe real-world nutrition management patterns among inpatients hospitalized for aspiration pneumonia, using a medical claims database in Japan.

METHODS

Patients aged ≥65 years hospitalized for aspiration pneumonia treatment were identified in a medical claims database between January 2013 and December 2018, to evaluate nutrition management initiation and adjustment timing, factors associated with >7-days nil per os (NPO) status, prescribed nutrition doses, and types of parenteral nutrition solutions. Patients who received oral intake or enteral nutrition on the day of admission (Day 1) were excluded.

RESULTS

The analysis population included 72,315 inpatients. The median (first quartile, third quartile) initiation date of oral nutrition intake was Day 4 (3, 7) and 65.1% of patients received oral nutrition intake by Day 7. Factors associated with >7-day NPO included sex, BMI, treatment years, Barthel Index score, Japan Coma Scale score, and oxygen inhalation on the day of hospital admission. Amongst NPO patients on Day 7, only 5.3% were prescribed the recommended doses of ≥20 kcal/kg; 6.4% were prescribed ≥1.0 g/kg amino acids, and 5.7% were prescribed fat energy ratio at ≥15% of non-protein calories. Commonly prescribed parenteral nutrition solutions on Day 7 were carbohydrate/electrolyte solutions (52.8%) and peripheral parenteral nutrition solutions (49.0%).

CONCLUSION

Prescribed parenteral energy, amino acids, and fat during the NPO period were lower than the recommended doses in the majority of patients. Prescribing recommended doses of each of these component nutrients may be beneficial when managing parenteral nutrition of patients during NPO.

Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.

Supplementation of vitamins, trace elements and electrolytes in the PEPaNIC Randomised Controlled Trial: Composition and preparation of the prescription

BACKGROUND AND AIMS

Following the results of the paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial, the new ESPGHAN/ESPEN/ESPR/CSPEN and ESPNIC guidelines recommend to consider withholding parenteral macronutrients for 1 week, while providing micronutrients, in critically ill children if enteral nutrition is insufficient. Critically ill children are suspected to be vulnerable to micronutrient deficiencies due to inadequate enteral nutrition, increased body's demands and excessive losses. Hitherto, micronutrient requirements in PICU are estimated based on recommended daily intakes for healthy children and expert opinion. We aimed to provide an overview of the current practice of micronutrient administration and practical considerations in the three participating centres of the PEPaNIC study, and compare these therapies with the recommendations in the new ESPGHAN/ESPEN/ESPR/CSPEN guidelines.

METHODS

We describe the current composition and preparation of the prescribed parenteral micronutrients (consisting of vitamins, trace elements and electrolytes) in the three centres (Leuven, Rotterdam and Edmonton) that participated in the PEPaNIC RCT, and compare this per micronutrient with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines recommendations.

RESULTS

The three centres use a different micronutrient supplementation protocol during the first week of critical illness in children, with substantial differences regarding the amounts administered. Leuven administers commercial vitamins, trace elements and electrolytes in separate infusions both in 4 h. Rotterdam provides commercial vitamins and trace elements simultaneously via 8-h infusion and electrolytes continuously over 24 h. Lastly, Edmonton administers commercial vitamins and institutionally prepared trace elements solutions in 1 h and electrolytes on demand. Comparison with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines yields in differences between the recommendations and the administered amounts, which are most substantial for vitamins.

CONCLUSION

The practice of intravenous micronutrient administration differs substantially between the three PEPaNIC centres and in comparison with the current guideline recommendations. This deviation is at least partially explained by the inability to provide all recommended amounts with the currently available commercial products and by the lack of strong evidence supporting these recommendations.

Clinical Impact of Prescribed Doses of Nutrients for Patients Exclusively Receiving Parenteral Nutrition in Japanese Hospitals: A Retrospective Cohort Study

BACKGROUND

In patients receiving parenteral nutrition (PN), the association between nutrition achievement in accordance with nutrition guidelines and outcomes remains unclear. Our purpose was to assess the association between nutrition achievement and clinical outcomes, including in-hospital mortality, activity of daily living (ADL), and readmission.

METHODS

In this retrospective cohort study, data were extracted from an inpatient medical-claims database at 380 acute care hospitals. This study included patients who underwent central venous catheter insertion between January 2009 and December 2018. Patients were classified into 3 groups: (1) target-not-achieved; (2) target-partially-achieved; and (3) target-achieved. The target doses of energy, amino acids, and lipid were defined as ≥20 kcal/kg/day, ≥1.0 g/kg/day, and ≥2.5 g/day, respectively. To examine the effect of nutrition achievement on outcomes, a multivariable logistic regression analysis was performed.

RESULTS

A total of 54,687 patients were included; of these, 21,383 patients were in the target-not-achieved group, 29,610 patients were in the target-partially-achieved group, and 3694 patients were in the target-achieved group. The adjusted odds ratio (OR) (95% CI) for in-hospital mortality was 0.69 (0.66-0.72) in the target-partially-achieved group and 0.47 (0.43-0.52) in the target-achieved group with reference to the target-not-achieved group. The adjusted ORs for deteriorated ADL was 0.93 (0.85-1.01) in the target-partially-achieved group and 0.77 (0.65-0.92) in the target-achieved group with reference to the target-not-achieved group. Readmission was not associated with nutrition achievement.

CONCLUSION

In-hospital mortality was lower and deteriorated ADL was suppressed in patients whose PN management was in accordance with the nutrition guidelines.

ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations used as a source of energy and essential fatty acids in parenteral nutrition. Issues associated with ILE use are distinctly different from oral fat and arise from emulsion stability, dose, and infusion tolerance. Since 1975, soybean oil has been the consistent source oil used in ILE formulations in the US. Partly because of safety concerns with the soybean-based ILE and frequent and long-standing problems with product inventory shortages, new ILE products have become available. Gaps in ILE best practices create a risk for ILE safety errors in prescribing, compounding, and administration of these products. This paper provides information on appropriate indications, dosing, and methods to avoid potential errors with ILE products in the US. This paper (Part 1) will focus on ILE background, information, and recommendations for adult patients, whereas Part 2 of this series will focus on neonatal and pediatric patient-specific information.

Dosing errors in total parenteral nutrition prescriptions at a specialized cancer care hospital of Lahore: The role of clinical pharmacist

STUDY OBJECTIVE

To determine the role of pharmacist in identifying the frequency of errors in total parenteral nutrition prescriptions in cancer patients for the years 2015 and 2016. Total parenteral nutrition has a high potential for medical errors because of its complex composition, thus leading to severe complications. Pharmacist review of the prescriptions reduces the risk of inappropriate prescribing, preparation, and administration of parenteral nutrition.

METHODOLOGY

An observational study was performed by collecting data of total parenteral nutrition prescriptions of 71 patients for the last two years from Pharmacy Department of specialized cancer care hospital.

RESULTS

It was found that the frequency of dosing errors and incomplete prescriptions was higher in 2015 compared to 2016. Additionally, the frequency of macro and micronutrients dosing errors were higher in adults (23.4% and 66.2%) compared to pediatrics (14.6% and 46.6%). Furthermore, the frequency of illegible prescriptions was higher (5.03%) in year 2016 as compared to year 2015 (1.64%). Nevertheless, such dose interventions improved patient's weight (20%) and promoted enteral feeding (42.3%). Major complication was hypophosphatemia (39.4%) followed by hyperglycemia (10%) and catheter-induced infection, i.e. sepsis (4.2%).

CONCLUSION

In conclusion, data suggested that pharmacist played instrumental role in identifying and rectifying total parenteral nutrition dosing errors for both micronutrients and macronutrients-with higher frequency in 2015 compared to 2016, leading to improvements in total parenteral nutrition-related complications and switches to enteral feeding.

ESPEN guideline on home parenteral nutrition

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

Parenteral Nutrition-Associated Liver Disease

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-nowak a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-interview-nowak an interview with the author.

Use of Integrated Clinical Decision Support Tools to Manage Parenteral Nutrition Ordering: Experience From an Academic Medical Center

Parenteral nutrition (PN) is a complex therapy with numerous opportunities for error during the prescribing, preparation, and administration processes. Advances in technology, such as computerized provider order entry (CPOE), electronic health records (EHRs), and clinical decision support (CDS) have helped decrease the risks associated with PN therapy. These technologies can be utilized to guide prescribing, provide automated safety checks, and increase overall safety and accuracy in PN ordering, compounding, and administration. In recent years, increased awareness of the risks associated with PN therapy, in particular issues with ordering and transcription, have magnified the need for improved support of PN ordering within currently available systems. Additionally, drug shortages continue to impact key components of PN admixtures, further increasing the risks associated with this complex therapy. These concerns and risks present an opportunity for the development of new functionality, as well as improvements in and innovative utilization of available technology within systems supporting the PN use process. This discussion will highlight the risks associated with PN, examine the role of drug shortages on the safety of this therapy, describe the application of available technology to manage shortages, and report the experience of using commercially available CDS tools at one academic medical center. It will also include a discussion of the transition from paper orders to CPOE/EHR-based orders for PN and the transition from one commercially available electronic system to another at this particular institution.

Enteral and parenteral nutrition considerations in pediatric patients

PURPOSE

Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed.

SUMMARY

The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients.

CONCLUSION

The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.

Standardized and Individualized Parenteral Nutrition Mixtures in a Pediatric Home Parenteral Nutrition Population

OBJECTIVES

Studies evaluating efficacy or safety of standardized parenteral nutrition (PN) versus individualized PN are lacking. We aimed to assess effects on growth and safety of standardized PN compared with individualized PN in our Home PN group.

METHODS

Descriptive cohort study in Dutch children on Home PN, in which standardized PN was compared with individualized PN. Both groups received similar micronutrient-supplementation. Primary outcome was growth over 2 years, secondary outcomes were electrolyte disturbances and biochemical abnormalities. Additionally, patients were matched for age to control for potential confounding characteristics.

RESULTS

Fifty patients (50% girls, median age 6.5 years) were included, 16 (32%) received standardized PN mixtures. Age (11 vs 5 years), gestational age (39.2 vs 36.2 weeks) and PN duration (97 vs 39 months) were significantly higher in the group receiving standardized PN (P: ≤0.001; 0.027; 0.013 respectively). The standardized PN group showed an increase in weight-for-age (WFA), compared with a decrease in the individualized PN group (+0.38 SD vs -0.55 SD, P: 0.003). Electrolyte disturbances and biochemical abnormalities did not differ. After matching for age, resulting in comparable groups, no significant differences were demonstrated in WFA, height-for-age, or weight-for-height SD change.

CONCLUSIONS

In children with chronic IF, over 2,5 years of age, standardized PN mixtures show a comparable effect on weight, height, and weight for height when compared with individualized PN mixtures. Also, standardized PN mixtures (with added micronutrients) seem noninferior to individualized PN mixtures in terms of electrolyte disturbances and basic biochemical abnormalities. Larger studies are needed to confirm these conclusions.

TRIAL REGISTRATION

Academical Medical Center medical ethics committee number W18_079 #18.103.

Sodium glycerophosphate and prescribed calcium concentrations in pediatric parenteral nutrition: a retrospective observational study and economic evaluation

Background

The risk of precipitation limits calcium and phosphate concentrations that can be administered parenterally to pediatric patients. As an alternative to dipotassium phosphate, sodium glycerophosphate (NaGlyP) is claimed to reduce the risk of precipitation in solutions for parenteral administration.

Objectives

To determine the calcium concentrations, NaGlyP, and dipotassium phosphate prescribed in pediatric parenteral nutrition orders and the cost–benefit of the organic phosphate.

Methods

We retrospectively collected cross-sectional data for parenteral nutrition orders from September 2014 to August 2015 for pediatric patients including neonates and children aged <18 years who were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Calcium concentration, calcium concentration adjustments, and costs of phosphate used per bag were analyzed.

Results

Of 2,192 parenteral nutrition orders, NaGlyP was used in 2,128 (97.1%) with calcium concentrations in the range of 0.84–139.91 mmol/L, which were significantly higher than calcium concentrations used with dipotassium phosphate (0.00–12.21 mmol/L, P < 0.001). There was no report of visible precipitation. Median costs of NaGlyP and dipotassium phosphate used per unit bag were not significantly different (35.88 and 41.25 Thai baht [THB] or 1.04 and 1.20 USD per bag, respectively, P>0.99; (1 USD equivalent to 34.241 THB U.S. Federal Reserve Bank G5.A annual average rate 2015).

Conclusions

Higher calcium concentrations could be achieved without increasing the direct cost per unit bag significantly as a result of using NaGlyP, an alternative to dipotassium phosphate as a source of phosphate for patients who require high amounts of calcium in parenteral nutrition.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Quality and safety of parenteral nutrition for newborn and preterm infants as an on-ward preparation

BACKGROUND

For newborn and preterm infants, standardised and individual parenteral nutrition (PN) is used. PN preparation is at risk for contamination and dosing errors. The quality of PN is crucial for infants and has a direct impact on their health status and safety.

PURPOSE

The aim of this study is to evaluate the physicochemical and microbial quality of PN for newborn and preterm infants prepared on a neonatal ward.

METHODS

Sampling of various individual PN prepared by nurses on a neonatal ward was performed. Formulations included maximal four electrolytes, variable dextrose and amino acid concentrations. Depending on the sample volume, up to three quality analyses were performed: (1) test for bacterial endotoxins by kinetic-chromogenic method, (2) sterility according to the European and US Pharmacopoeia, and (3) quantification of electrolytes by capillary electrophoresis and of dextrose by ultraviolet detection after enzymatic reaction of hexokinase. The concentrations obtained were evaluated based on the US and Swiss Pharmacopoeia specifications for compounded preparations and compared to the widened pharmacy specifications.

RESULTS

The composition of 86% of the 110 analysed PN prepared by nurses on the neonatal ward corresponded to their medical prescription. 14% were out of the acceptable widened pharmacy ranges. We found no microbial contamination in the samples. All PN were free from endotoxins.

CONCLUSION

Component concentrations of PN prepared on wards by nurses differed frequently and significantly from their medical prescription, and the deviation can be critical depending on the component and its mode of action. The sample size is too small to evaluate the microbial contamination.

Medical Nutrition Terminology and Regulations in the United States and Europe-A Scoping Review: Report of the ISPOR Nutrition Economics Special Interest Group

BACKGROUND

The term medical nutrition (MN) refers to nutritional products used under medical supervision to manage disease- or condition-related dietary needs. Standardized MN definitions, aligned with regulatory definitions, are needed to facilitate outcomes research and economic evaluation of interventions with MN.

OBJECTIVES

Ascertain how MN terms are defined, relevant regulations are applied, and to what extent MN is valued.

METHODS

ISPOR's Nutrition Economics Special Interest Group conducted a scoping review of scientific literature on European and US MN terminology and regulations, published between January 2000 and August 2015, and pertinent professional and regulatory Web sites. Data were extracted, reviewed, and reconciled using two-person teams in a two-step process. The literature search was updated before manuscript completion.

RESULTS

Of the initial 1687 literature abstracts and 222 Web sites identified, 459 records were included in the analysis, of which 308 used MN terms and 100 provided definitions. More than 13 primary disease groups as per International Classification of Disease, Revision 10 categories were included. The most frequently mentioned and defined terms were enteral nutrition and malnutrition. Less than 5% of the records referenced any MN regulation. The health economic impact of MN was rarely and insufficiently (n = 19 [4.1%]) assessed, although an increase in economic analyses was observed.

CONCLUSIONS

MN terminology is not consistently defined, relevant European and US regulations are rarely cited, and economic evaluations are infrequently conducted. We recommend adopting consensus MN terms and definitions, for example, the European Society for Clinical Nutrition and Metabolism consensus guideline 2017, as a foundation for developing reliable and standardized medical nutrition economic methodologies.

Biological and Clinical Aspects of an Olive Oil-Based Lipid Emulsion-A Review

Intravenous lipid emulsions (ILEs) have been an integral component of parenteral nutrition for more than 50 years. Numerous formulations are available and are based on vegetable (soybean, olive, coconut) and animal (fish) oils. Therefore, each of these formulations has a unique fatty acid composition that offers both benefits and limitations. As clinical experience and our understanding of the effects of fatty acids on various physiological processes has grown, there is evidence to suggest that some ILEs may have benefits compared with others. Current evidence suggests that olive oil-based ILE may preserve immune, hepatobiliary, and endothelial cell function, and may reduce lipid peroxidation and plasma lipid levels. There is good evidence from a large randomized controlled study to support a benefit of olive oil-based ILE over soybean oil-based ILE on reducing infections in critically ill patients. At present there is limited evidence to demonstrate a benefit of olive oil-based ILE over other ILEs on glucose metabolism, and few data exist to demonstrate a benefit on clinical outcomes such as hospital or intensive care unit stay, duration of mechanical ventilation, or mortality. We review the current research and clinical evidence supporting the potential positive biological and clinical aspects of olive oil-based ILE and conclude that olive oil-based ILE is well tolerated and provides effective nutritional support to various PN-requiring patient populations. Olive oil-based ILE appears to support the innate immune system, is associated with fewer infections, induces less lipid peroxidation, and is not associated with increased hepatobiliary or lipid disturbances. These data would suggest that olive oil-based ILE is a valuable option in various PN-requiring patient populations.

Effectiveness of in-Line Filters to Completely Remove Particulate Contamination During a Pediatric Multidrug Infusion Protocol

The large number of drugs administered simultaneously to neonates and children in hospital results in the formation of particles that are potentially infused. We have investigated the ability of IV in-line filters to eliminate particulate matter from multidrug infusion lines and so prevent contamination. The impact on particle occurrence of the internal volume of the IV line below the in-line filter was then evaluated. The multidrug therapy given to children was reproduced with and without in-line filtration. Three combinations with a filter were tested to vary the internal volume (V) between the filter and the catheter egress. The catheter was then connected to a dynamic particle count to evaluate the particulate matter potentially administered to children during infusion. The introduction of in-line filters led to a significant reduction in overall particulate matter, from 416,974 [208,479-880,229] to 7,551 [1,985-11,287] particles (p < 0.001). Larger particles of ≥10 and 25 µm were also significantly reduced. Adding an extension set to the egress of the in-line filter (V = 1.7 mL) caused a significant increase in particulate contamination for both. This study showed that in-line filtration is an effective tool in preventing particle administration to patients. Their position in the infusion in-line is therefore important because of its impact on internal volume and drug particle formation.

Parenteral Protein Decision Support System Improves Protein Delivery in Preterm Infants: A Randomized Clinical Trial

BACKGROUND

Management of neonatal parenteral protein intake for preterm infants is challenging and requires daily modifications of the dose to account for the infant's postnatal age, birth weight, current weight, and the volume and protein concentration of concurrent enteral nutrition. The objective of this study was to create and evaluate the Parenteral Protein Calculator (PPC), a clinical decision support system to improve the accuracy of protein intake for preterm infants who require parenteral nutrition (PN).

MATERIALS AND METHODS

We integrated the PPC into the computerized provider order entry system and tested it in a randomized controlled trial (routine or PPC). Infants were eligible if they were ≤3 days old, had a birth weight ≤1500 g, and had no inborn error of metabolism. The primary outcome was the appropriate total protein intake, defined as target protein dose ±0.5 g/kg.

RESULTS

We randomly allocated 42 infants for 221 PN days in the control group and 211 in the PPC group. Total protein intake in the PPC group was more accurate as compared with the control group (appropriate protein dosing: odds ratio = 5.8; 95% CI, 2.7-12.4). Absolute deviation from protein target was 0.41 g/kg (0.24-0.58) lower in the PPC group.

CONCLUSION

The PPC improved appropriate protein dosing for premature infants receiving PN. Further studies are needed to test whether clinical decision support systems will reduce uremia and improve growth and to replicate similar findings in the cases of other PN nutrients.

Association between continuous peripheral i.v. infusion of 3% sodium chloride injection and phlebitis in adults

PURPOSE

One institution's experience with use of peripheral i.v. (PIV) catheters for prolonged infusions of 3% sodium chloride injection at rates up to 100 mL/hr is described.

METHODS

A prospective, observational, 13-month quality assurance project was conducted at an academic medical center to evaluate frequencies of patient and catheter phlebitis among adult inpatients who received both an infusion of 3% sodium chloride injection for a period of ≥4 hours through a dedicated PIV catheter and infusions of routine-care solutions (RCSs) through separate PIV catheters during the same hospital stay.

RESULTS

Sixty patients received PIV infusions through a total of 291 catheters during the study period. The majority of patients (78%) received infusions of 3% sodium chloride injection for intracranial hypertension, with 30% receiving such infusions in the intensive care unit. Phlebitis occurred in 28 patients (47%) during infusions of 3% sodium chloride and 26 patients (43%) during RCS infusions (p = 0.19). Catheter phlebitis occurred in 73 catheters (25%), with no significant difference in the frequencies of catheter phlebitis with infusion of 3% sodium chloride versus RCSs (30% [32 of 106 catheters]) versus 22% [41 of 185 catheters]), p = 0.16).

CONCLUSION

Patient and catheter phlebitis rates were not significantly different with infusions of 3% sodium chloride injection versus RCSs, suggesting that an osmolarity cutoff value of 900 mOsm/L for peripheral infusions of hypertonic saline solutions may not be warranted.

Influence of Dietitians in Preventing Parenteral Nutrition Prescription Errors in Children

BACKGROUND

The purpose of this study is to determine whether direct involvement by dietitians in parenteral nutrition (PN) ordering resulted in a reduction in PN prescriptions errors.

METHODS

A prospective audit of PN prescriptions was undertaken at a pediatric hospital over 50 weeks. Prescriptions for PN that had dietitian involvement (dietitian group) were compared with prescriptions in which dietitians were not directly involved (nondietitian group). The number of total prescriptions, the number of prescriptions with errors, and the types of errors from both groups were recorded. Errors were classified into "dietitian-preventable errors" and "nondietitian-preventable errors." Comparisons were made between prescriptions with and without errors, between dietitian-preventable and nondietitian-preventable errors, and between the dietitian and nondietitian groups per error type.

RESULTS

The total number of PN prescriptions was 725 (from 45 patients) and 471 (from 66 patients) for the dietitian and nondietitian groups, respectively. The nondietitian group was more likely than the dietitian group to prescribe PN incorrectly-18.0% (85 of 471) vs 12.4% (90 of 725; P = .007)-with the nondietitian group having 1.5-times more PN prescriptions with errors (risk ratio = 1.5, 95% CI: 1.1-1.9). The total number of prescription errors was 126 and 146 for the dietitian and nondietitian groups, respectively. The dietitian group was less likely than the nondietitian group to be associated with dietitian-preventable errors: 65.9% (83 of 126) vs 87.0% (127 of 146; risk ratio = 1.3, 95% CI: 1.1-1.5; P < .0001).

CONCLUSION

Dietitian input into prescription of PN reduced the number of prescriptions with errors.

Addition of Insulin to Parenteral Nutrition for Control of Hyperglycemia

Administration of parenteral nutrition (PN) may result in hyperglycemia in patients with preexisting diabetes or disease-related insulin resistance, and it can be associated with increased rates of complications. Treatment requires insulin therapy. Insulin can be administered subcutaneously, intravenously via a variable rate sliding scale, or by adding it directly to the PN. The last method is a potentially attractive technique for a number of reasons-it could deliver the insulin intravenously at a steady rate alongside carbohydrates, and in malnourished patients with little subcutaneous tissue, it may prevent the need for frequent insulin injections. Despite such potential advantages, the addition of insulin to PN remains controversial, largely with respect to the bioavailability of insulin in PN and resultant concerns of the risk of hypoglycemia. There is a paucity of long-term quality controlled studies to address this question. The available literature suggests that, at least in the short term, insulin addition to PN can achieve reasonable glycemic control with low rates of hypoglycemia, and the technique compares favorably with the use of long-acting insulin preparations. This literature review finds a wide range of values reported for insulin availability via PN, ranging from 44% to 95% depending on the type of PN container material used and the presence of added vitamins and trace elements. Few studies looking at glycemic control among patients receiving home PN were found, and larger prospective trials are needed to assess the efficacy and safety of this technique in this patient group.

Considerations for Fueling an Endurance Athlete With Home Parenteral Nutrition

The goal of clinicians managing nutrition support for patients with home parenteral nutrition (HPN) is to adapt nutrition needs to best serve the consumers, so they may have the best quality of life despite specialized nutrition needs. Some HPN consumers may desire to participate in endurance athletics, which will require special considerations. This review is intended to outline key nutrition differences in endurance athletes that a nutrition support team should consider when providing HPN.