ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

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.

Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition"

BACKGROUND

The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN).

METHODS

The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience.

RESULTS

The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation.

CONCLUSIONS

This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

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.

Microbial Contamination of Neonatal Injectable Lipid Emulsions at 12 and 24 Hours' Infusion Time With Evaluation of Infection Control Measures

OBJECTIVES

This study aimed to assess the microbial contamination rate of injectable lipid emulsion (ILE) repackaged syringes at 12 and 24 hours of their infusion time. Probable risk factors associated with contamination of the ILEs were also assessed. In addition, the antimicrobial resistance pattern of the bacterial isolates was also determined.

METHODS

Samples of ILE were collected from 152 repackaged syringes and their infusion lines after 12 hours and 24 hours of infusion time (73 and 79 samples, respectively). Samples were cultured, the isolates were identified, and the antimicrobial resistance pattern of the bacterial isolates was identified. A checklist was completed throughout the study to observe the compliance to infection control measures by pharmacists (who prepare) and nurses (who administer) the ILE infusions. Results of septic neonatal cultures were taken from records.

RESULTS

Microbial contamination was found in 15.8% of ILE samples. The 2 most common pathogens found among positive samples were Klebsiella pneumoniae (29.2%) and Candida albicans (20.8%). Microbial contamination of repackaged syringes increased from 9.6% at 12 hours to 21.5% at 24 hours. This difference was found to be statistically significant (p = 0.044). A similar trend of predominance of those 2 pathogens, in both ILE and neonatal cultures, was observed. There was a statistically significant better performance of infection control measures of pharmacists rather than nurses. The K pneumoniae isolates (n = 7) showed antibiotic resistance in the following pattern: gentamicin (71.4%), cefazolin (85.7%), and cefoxitin (85.7%).

CONCLUSIONS

The rate of ILE contamination was less at 12 hours' than at 24 hours' infusion time. However, contamination rates at 12 hours were unacceptably high. Klebisella pneumoniae and C albicans were the most common pathogens isolated from ILE. Compliance with infection control measures was significantly worse among nurses compared with pharmacists.

[Neonates treated with individualized parenteral nutrition who are candidates to receive standardized parenteral nutrition]

Introduction

Objetive: to quantify the number of neonates treated with individualized parenteral nutrition (IPN) who were candidates to receive standardized parenteral nutrition (SPN), and to calculate their treatment duration. Material and methods: this was a prospective, observational, descriptive cohort study. Inclusion criteria were: neonates with indication of parenteral nutrition (PN) and individualized prescription. Exclusion criteria included: patients who had not started diuresis, with specific nutritional needs, altered acid-base balance, and/or contraindication to receive SPN. Included variables were patient-related (gender, weight, weeks of gestation, and days of life) and treatment-related regarding IPN composition. Setting the volume of PN as the conversion criterion, theoretical contributions were calculated with the SPN. The criterion for a patient to be a candidate to receive SPN was that all the theoretical contributions calculated were within the reference requirements range. Results: a total of 33 neonates (9 women) received IPN with 94 prescriptions. The median weight of the patients included in the study was 2.14 (IQR, 0.9) kg, and they were born at 35 (IQR, 3) weeks of gestation. PN began between 0 and 4 days of life. In all, 71 % (22/31) of the patients in 54.1 % of their (46/85) prescriptions were candidates to receive SPN via central administration for 1 to 8 days, whereas no patient was candidate to receive SPN via peripheral administration. Conclusions: in our center, 71 % of neonates treated with central administration of IPN are candidates to receive SPN, thus promoting the normalization of nutritional support in this population.

Extemporaneous Compounding: Selective Pharmacists with Separate Skill

Extemporaneous compounding takes place in community and hospital pharmacies. There are usually specialist compounding pharmacies in major towns and cities, but any pharmacy may undertake compounding as long as they have appropriate facilities according to state-based legislation (e.g. allocated clean bench, specific compounding equipment). Although development is a continuous process, companies are customizing features to meet the majority of patient needs, but the very nature of the process cannot meet all patient needs. The risk-benefit ratio of using traditionally compounded medicines is favorable for patients who require specialized medications that are not commercially available, as they would otherwise not have access to suitable treatment. However, if an FDA-approved drug is commercially available, the use of an unapproved compounded drug confers additional risk with no commensurate benefit. Published reports of independent testing by the FDA, state agencies, and others consistently show that compounded drugs fail to meet specifications at a considerably higher rate than FDA-approved drugs. Compounded sterile preparations pose the additional risk of microbial contamination to patients. In the last 11 years, three separate meningitis outbreaks have been traced to purportedly 'sterile' steroid injections contaminated with fungus or bacteria, which were made by compounding pharmacies. The 2012 outbreak has resulted in intense scrutiny of pharmacy compounding practices and increased recognition of the need to ensure that compounding is limited to appropriate circumstances.

Central line-associated bloodstream infections in neonates

Newborn infants, including premature infants, are high-risk patients susceptible to various microorganisms. Catheter-related bloodstream infections are the most common type of nosocomial infections in this population. Regular education and training of medical staffs are most important as a preventive strategy for central line-associated bloodstream infections (CLABSIs). Bundle approaches and the use of checklists during the insertion and maintenance of central catheters are effective measures to reduce the incidence of CLABSIs. Chlorhexidine, commonly used as a skin disinfectant before catheter insertion and dressing replacement, is not approved for infants <2 months of age, but is usually used in many neonatal intensive care units due to the lack of alternatives. Chlorhexidine-impregnated dressing and bathing, recommended for adults, cannot be applied to newborns. Appropriate replacement intervals for dressing and administration sets are similar to those recommended for adults. Umbilical catheters should not be used longer than 5 days for the umbilical arterial catheter and 14 days for the umbilical venous catheter. It is most important to regularly educate, train and give feedback to the medical staffs about the various preventive measures required at each stage from before insertion to removal of the catheter. Continuous efforts are needed to develop effective and safe infection control strategies for neonates and young infants.

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings

OBJECTIVE

To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings.

METHODS

Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method.

RESULTS

Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes.

CONCLUSIONS

The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors.

Evaluating Sterility of Single Dose Vials on an Automated Compounding Device

Background: Current guidelines for sterile compounding require that single dose vials of pharmaceuticals must be discarded after 6 hours when accessed in an ISO Class 5 environment. At this time, no studies have evaluated the sterility of single dose vials at any time after opening. Objective: The purpose of this study is to evaluate the sterility of single dose vials attached to an automated compounding device for up to 24 hours and accessed and maintained within a cleanroom environment. Methods: This is a prospective, observational study evaluating the sterility of 32 pooled samples of manufactured single dose injectable drugs attached to an automated compounding device for up to 24 hours and maintained within an ISO Class 5 environment in an ISO Class 7 buffer area. Each pooled sample was comprised of the remaining contents of 10 single dose vial additives that were used for total parenteral nutrition (TPN) and attached to the compounder within the previous 24 hours. Samples were evaluated using membrane filtration sterility testing and incubated for 14 days per USP <71> requirements. Results: The results revealed zero failed sterility samples. Single dose vials remained attached to the compounder for an average of 23.8 hours (±0.1 hours). The average volume per sample was 879 mL (±105.1 mL). Manipulation of vials during the compounding process included an average of 20.4 manipulations (±1.4). Conclusions: Single dose injectable drugs attached to an automated compounding device within an ISO Class 5 cleanroom environment may remain sterile for up to 24 hours. Future studies are needed with a larger sample size and under continued dynamic working conditions to provide further evidence to extend the beyond use date within USP <797>.

Incorrect aseptic techniques in medicine preparation and recommendations for safer practices: a systematic review

Objective

Many patient deaths have been reported because of administration of contaminated intravenous medicines due to incorrect aseptic techniques. Our aim was to review the literature for (1) incorrect practices in aseptic drug preparation and administration and (2) recommendations for safer practices in hospitals.

Methods

A systematic literature search was conducted in PubMed covering 2007-2015. Studies were included if they concerned aseptic medicine preparation and administration in hospitals by different healthcare professionals, assessed incorrect practices and made recommendations for safer aseptic preparation and administration.

Results

26 studies were included of which 19 were original articles. 12 of the studies concerned description of incorrect practices that led to contamination. The studies reported 11 incorrect practices that increased the risk of contamination of parenteral medicines. The most reported incorrect practices were multiple use of phials and syringes (2/12 studies) and lack of overall disinfection during the aseptic preparation and administration (3/12 studies). 22 practices were recommended to avoid contamination, which were classified into six categories: equipment and medicines (7); disinfection (6); working environment (3); storing (3); catheter care (2) and quality of prepared medicines (1). The results indicate that pharmacists prepared syringes with less contamination than nurses because of the pharmacist's aseptic skills and environmental aspects in pharmacy units.

Conclusions

The review discusses many appropriate and enhanced practices in aseptic drug preparation and administration. As the change for the better in contamination rates of administered medicines seems to be challenging to achieve in hospitals, better and possibly international procedures for safe parenteral practices need to be developed.

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

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?

Microbial Growth in Neonatal Intravenous Fat Emulsion Administered Over 12 Versus 24 Hours

OBJECTIVES

To determine whether an extended infusion time (24 hours) of intravenous fat emulsion is associated with an increase in microbial growth, versus a shorter infusion time (12 hours).

METHODS

Samples were collected from intravenous fat emulsions (n=132), from intravenous fat emulsions prepared in the current 24-hour infusion method (n=55), and from intravenous fat emulsions prepared in the twice-daily (12-hour infusion) method (n=55). In addition, samples were collected from pharmacy (n=22) to test for possible contamination.

RESULTS

No growth was observed in either arm of the study.

CONCLUSIONS

Current Kern Medical Center policy of preparation and administration of neonatal intensive care unit intravenous fat emulsion is safe and effective in regard to microbial growth.

Pharmacy compounding primer for physicians: prescriber beware

Since the development of federal standards for drug approval, the practice of medicine has historically involved the compounding of medications based on a physician's determination that a US FDA-approved product either did not exist, or could not be used for medical reasons. Today, prescriptions for non-FDA-approved compounded drugs may be driven by fanciful and largely unregulated pharmacy advertisements to physicians and patients and/or payer reimbursement policies, thus placing prescribers in the backseat for clinical decision making. This article outlines essential differences between FDA-approved drugs and compounded drugs and reasserts the primary medical role of physicians for determining what medical circumstances may necessitate treatment with non-FDA-approved products. In addition, liability concerns when prescribing non-FDA-approved drugs are discussed. While representing a US perspective, underlying principles apply globally in the setting of magistral and extemporaneous formulations produced outside national regulatory frameworks.

Risk of parenteral nutrition in neonates--an overview

Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.