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Cogle SV, Ayers P, Berger MM, Berlana D, Wischmeyer PE, Ybarra J, Zeraschi S, De Cloet J. Parenteral nutrition in the hospital setting/short-term parenteral nutrition. Am J Health Syst Pharm 2024; 81:S102-S111. [PMID: 38869256 PMCID: PMC11170504 DOI: 10.1093/ajhp/zxae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
PURPOSE This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely. SUMMARY Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries. CONCLUSION The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.
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Affiliation(s)
- Sarah V Cogle
- Department of Pharmacy, Clinical Programs, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, MS, USA
| | - Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Berlana
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus and Department of Pharmacology, Toxicology and Therapeutic Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Sarah Zeraschi
- Pharmacy Department and Nutrition and Intestinal Failure Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joeri De Cloet
- Pharmacy Department, Ghent University Hospital, Ghent, Belgium
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Cogle SV, Martindale RG, Ramos M, Roberti GJ, Roberts PR, Taylor K, Sacks GS. Multicenter Prospective Evaluation of Parenteral Nutrition Preparation Time and Resource Utilization: 3-Chamber Bags Compared With Hospital Pharmacy-Compounded Bags. JPEN J Parenter Enteral Nutr 2020; 45:1552-1558. [PMID: 33188572 DOI: 10.1002/jpen.2045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/16/2020] [Accepted: 11/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a complex and costly therapy that places significant demands on healthcare resources. Commercially manufactured 3-chamber bags (3CBs) offer potential time and cost advantages compared with hospital pharmacy-compounded bags (HCBs); however, no data are yet available from studies comparing these delivery systems in US hospitals. The primary aim of this study was to evaluate the PN preparation time and resource utilization required for 3CBs compared with HCBs in US hospitals. METHODS A prospective, multicenter, time and motion study was performed to evaluate the time from transcription to completion of PN preparation and costs for 3CBs compared with HCBs. The cost per bag included labor, PN products, medical consumables, and equipment. RESULTS One hundred thirty-six PN prescriptions were prepared during the study (66 prescriptions for 3CBs and 70 prescriptions for HCBs). The mean ± standard deviation total time required for transcription, review, validation, and preparation of PN was 5.5 ± 1.3 minutes for 3CBs vs 14.3 ± 6.2 minutes for HCBs (P < .001). The mean total cost per PN bag was $81.60 for 3CBs and $131.17 for HCBs (mean difference, -$49.57). CONCLUSION Commercial 3CBs reduced staff time by 62% and direct costs by 37% compared with HCBs. The results demonstrate that 3CBs offer potential cost-savings for hospitalized patients who require PN in US hospitals.
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Affiliation(s)
- Sarah V Cogle
- Department of Pharmacy Practice, Auburn University, Auburn, Alabama, USA.,Department of Pharmacy, East Alabama Medical Center, Opelika, Alabama, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Gregory J Roberti
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Pamela R Roberts
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Kaci Taylor
- Department of Pharmacy, OU Medical Center, Oklahoma City, Oklahoma, USA
| | - Gordon S Sacks
- Department of Pharmacy Practice, Auburn University, Auburn, Alabama, USA.,Medical Affairs, Fresenius Kabi, LLC, Lake Zurich, Illinois, USA
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Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, Moss M. An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 197:897-904. [PMID: 29241014 DOI: 10.1164/rccm.201706-1132oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages. OBJECTIVES To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS. METHODS Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location. MEASUREMENTS AND MAIN RESULTS Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056). CONCLUSIONS When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.
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Affiliation(s)
- Peter D Sottile
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - Tyree H Kiser
- 2 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado; and
| | - Ellen L Burnham
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - P Michael Ho
- 3 Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Marc Moss
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
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Prohaska CC, Sottile PD, Nordon-Craft A, Gallagher MD, Burnham EL, Clark BJ, Ho M, Kiser TH, Vandivier RW, Liu W, Schenkman M, Moss M. Patterns of utilization and effects of hospital-specific factors on physical, occupational, and speech therapy for critically ill patients with acute respiratory failure in the USA: results of a 5-year sample. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:175. [PMID: 31097017 PMCID: PMC6524324 DOI: 10.1186/s13054-019-2467-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/05/2019] [Indexed: 08/25/2024]
Abstract
Background Timely initiation of physical, occupational, and speech therapy in critically ill patients is crucial to reduce morbidity and improve outcomes. Over a 5-year time interval, we sought to determine the utilization of these rehabilitation therapies in the USA. Methods We performed a retrospective cohort study utilizing a large, national administrative database including ICU patients from 591 hospitals. Patients over 18 years of age with acute respiratory failure requiring invasive mechanical ventilation within the first 2 days of hospitalization and for a duration of at least 48 h were included. Results A total of 264,137 patients received invasive mechanical ventilation for a median of 4.0 [2.0–8.0] days. Overall, patients spent a median of 5.0 [3.0–10.0] days in the ICU and 10.0 [7.0–16.0] days in the hospital. During their hospitalization, 66.5%, 41.0%, and 33.2% (95% CI = 66.3–66.7%, 40.8–41.2%, 33.0–33.4%, respectively) received physical, occupational, and speech therapy. While on mechanical ventilation, 36.2%, 29.7%, and 29.9% (95% CI = 36.0–36.4%, 29.5–29.9%, 29.7–30.1%) received physical, occupational, and speech therapy. In patients receiving therapy, their first physical therapy session occurred on hospital day 5 [3.0–8.0] and hospital day 6 [4.0–10.0] for occupational and speech therapy. Of all patients, 28.6% (95% CI = 28.4–28.8%) did not receive physical, occupational, or speech therapy during their hospitalization. In a multivariate analysis, patients cared for in the Midwest and at teaching hospitals were more likely to receive physical, occupational, and speech therapy (all P < 0.05). Of patients with identical covariates receiving therapy, there was a median of 61%, 187%, and 70% greater odds of receiving physical, occupational, and speech therapy, respectively, at one randomly selected hospital compared with another (median odds ratio 1.61, 2.87, 1.70, respectively). Conclusions Physical, occupational, and speech therapy are not routinely delivered to critically ill patients, particularly while on mechanical ventilation in the USA. The utilization of these therapies varies according to insurance coverage, geography, and hospital teaching status, and at a hospital level. Electronic supplementary material The online version of this article (10.1186/s13054-019-2467-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clare C Prohaska
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Amy Nordon-Craft
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | | | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, 80045, USA
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Wenhui Liu
- VA Eastern Colorado Health Care System, Aurora, CO, 80045, USA
| | - Margaret Schenkman
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
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Lakdawalla DN, Mascarenhas M, Jena AB, Vanderpuye-Orgle J, LaVallee C, Linthicum MT, Snider JT. Impact of Oral Nutrition Supplements on Hospital Outcomes in Pediatric Patients. JPEN J Parenter Enteral Nutr 2014; 38:42S-9S. [DOI: 10.1177/0148607114549769] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Darius N. Lakdawalla
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | | | - Anupam B. Jena
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
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Kiser TH, Allen RR, Valuck RJ, Moss M, Vandivier RW. Outcomes Associated with Corticosteroid Dosage in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2014; 189:1052-64. [DOI: 10.1164/rccm.201401-0058oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Boullata JI, Gilbert K, Sacks G, Labossiere RJ, Crill C, Goday P, Kumpf VJ, Mattox TW, Plogsted S, Holcombe B. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr 2014; 38:334-77. [PMID: 24531708 DOI: 10.1177/0148607114521833] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation. METHOD A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?
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Composition of personalized and standard nutritional mixtures in patients on home parenteral nutrition. Eur J Clin Nutr 2014; 68:433-6. [DOI: 10.1038/ejcn.2014.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/20/2013] [Accepted: 01/01/2014] [Indexed: 11/08/2022]
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Colomb V. Commercially premixed 3-chamber bags for pediatric parenteral nutrition are available for hospitalized children. J Nutr 2013; 143:2071S-2076S. [PMID: 24108138 DOI: 10.3945/jn.113.176974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Hospitalized children are vulnerable to malnutrition during serious illness or recovery from injury and are at subsequent risk of increased morbidity and growth retardation. In cases in which enteral nutrition is not possible, parenteral nutrition (PN) can be used to ensure that patients at nutritional risk receive appropriate amounts of macro- and micronutrients. Nutritional needs cannot be met by 1 standard PN formulation in pediatric patients (term to 18 y) because of the wide range of needs according to age, weight, degree of maturity, and disease state. Preparation of individualized PN is associated with several limitations, including prescribing errors, stability issues, and risk of infection. These risks may be avoided by the availability of a range of pediatric PN formulations provided as commercial premixed 3-chamber bags (3-CBs). These 3-CBs were developed in conjunction with experienced neonatologists and pediatricians in accordance with international guidelines. A prospective study has previously shown the practical handling and ease of use of 2 formulations of these 3-CBs, 1 designed for term infants and toddlers up to 2 y of age and 1 for children and adolescents aged 2-18 y. The majority of pharmacists and nurses described the 3-CB as easy to use and favored it over individual bottles, bags compounded on the ward, ready-to-use compounded bags, and premixes prepared by the pharmacy and tailored to patient needs. These formulations offer a means of improving the quality of care in hospital pediatric units, particularly in the absence of a nutrition support team.
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