Comparing Aluminum Concentrations in Adult and Pediatric Parenteral Nutrition Solutions: Multichamber-Bag versus Compounded Parenteral Nutrition.

Aluminum contamination in parenteral nutrition (PN) solutions can lead to neurotoxicity, reduced bone mass, and liver toxicity, especially in pediatric patients. Ingredients commonly used in PN compounding, such as vitamins, trace elements, calcium, and phosphate salts, contain significant amounts of aluminum. This study aimed to compare aluminum concentrations in multichamber-bag (MCB) and compounded PN for adults and pediatrics. A prospective study assessed aluminum concentrations in various types of MCB and compared them with compounded PN formulations with similar compositions. The types of MCB included Lipoflex® (without electrolytes), Omegaflex®, Finomel®, Smofkabiven® (with and without electrolytes), Olimel®, Clinimix®, and Numeta®. Overall, 80 aluminum determinations were included: 36 for MCBs and 44 for compounded PN. MCBs showed significantly lower aluminum concentrations than compounded PN: 11.37 (SD 6.16) vs. 21.45 (8.08) µg/L, respectively. Similar results were observed for adult (n = 40) and pediatric (n = 40) PN formulations (12.97 (7.74) vs. 20.78 (10.28) µg/L, and 9.38 (2.23) vs. 22.01 (5.82) µg/L, respectively). Significant differences were also found between MCBs depending on the manufacturing company. These findings suggest that MCBs PN offer a safer option for reducing aluminum contamination in PN. Harmonizing regulations concerning aluminum concentrations in PN solutions could help mitigate differences between PN formulations.

Compatibility studies of selected multichamber bag parenteral nutrition with fluconazole.

OBJECTIVE: Fluconazole (FLZ) is a drug widely used in the treatment of fungal infections including the treatment of immunocompromised patients, HIV-infected patients, and cancer patients. Critically ill patients often require the administration of drugs with parenteral nutrition (PN). The safety of this combination should be defined before the drug and PN are administered in one infusion line. This study aimed to determine the compatibility of FLZ with six selected multichamber bag parenteral nutrition. METHODS: FLZ solution for infusion was combined with PNs in appropriate proportions, considering most clinical situations resulting from different possible administration rates of the preparations. Samples were visually assessed, and pH, osmolality, turbidity, particle size (dynamic light scattering and light obscuration methods), and zeta potential were measured. These measurements were made immediately after combining the solutions and after 4 h of storage at 23 ± 1°C. RESULTS: FLZ combined with PNs did not cause changes observed visually. The turbidity of the samples was <0.4 NTU. The average particle size of the lipid emulsion was below 300 nm, and the PFAT5 parameter was ≤0.02%. The absolute value of the zeta potential of the PN + FLZ samples was higher for 5 out of 6 PN than the corresponding value for PN immediately after activation. Changes in pH and osmolality during 4 h of sample observations were within acceptable limits. CONCLUSION: Compatibility of the FLZ with six multichamber bag PN was confirmed. Hence, those preparations can be administered to patients in one infusion line using the Y-site.

Stability of individualized neonatal parenteral nutrition admixtures with fish oil and high calcium content.

Introduction: Introduction: the stability of total parenteral nutrition admixtures for neonates (TPNAn) has been questioned in relation to the interaction between calcium and fish oil emulsions. Aim: the aim of this study was to check the stability (particle size < 1 µm) of different individualized TPNAn prepared with fish-oil emulsion and containing calcium at concentrations ranging from 10 to 20 mmol/L. Methods: admixtures analyzed: twelve different formulations with SMOFlipid® 20 % (conserved for 24 h and for 96 h), three formulations with Lipoplus® 20 % (conserved for 96 h) and three formulations with SMOFlipid® 20 % with Multi-12K1® Pediatric (conserved for 96 h). Two bags were compounded for each formulation and conservation period. Measurements on each admixture bag: particle standardized diameter by laser diffraction technique and pH by a calibrated pH-meter. Data analysis with mixed linear regression models. Results: maximum particle size was < 0.8 µm for all investigated admixtures. Lipid concentration of 5 g/L and sodium and potassium concentration of 100 mmol/L slightly increased the proportion of particles > 0.6 µm. Ninety six hours storage also increased the percentage of particles > 0.6 µm (+0.143 ± 0.07; p = 0.038) but did not influence other parameters. No association with calcium composition was observed. Amino acid content was inversely correlated with pH (-0.83; p < 0.0001). Conclusions: the studied individualized parenteral nutrition admixtures for newborns that contain fish oil emulsions and meet cation requirements are stable for at least 96 hours.

Introducción: Introducción: existe controversia sobre la estabilidad de las mezclas de nutrición parenteral total para recién nacidos (TPNAn) con emulsiones de omega-3 y alto contenido en calcio. Objetivo: estudiar la estabilidad (tamaño de partículas < 1 µm) de diferentes TPNAn individualizadas preparados con una emulsión lipídica que contiene w3 y concentraciones de calcio entre 10 y 20 mmol/L. Métodos: se analizaron doce formulaciones diferentes con SMOFlipid® 20 % (conservadas durante 24 h y por 96 h), tres formulaciones con Lipoplus® 20 % (conservadas durante 96 h) y tres formulaciones con SMOFlipid® 20 % con Multi-12K1® Pediatric (conservadas durante 96 h). Se prepararon dos bolsas por cada formulación y período de conservación. Se midieron el diámetro de partícula estandarizado mediante técnica de difracción láser y el pH con un pH-metro calibrado. Análisis de datos con modelos de regresión lineal mixta. Resultados: el tamaño máximo de partícula fue < 0,8 µm para todas las mezclas investigadas. La concentración de lípidos de 5 g/L y la concentración de sodio y potasio de 100 mmol/L aumentaron ligeramente la proporción de partículas > 0,6 µm. El almacenamiento de noventa y seis horas también aumentó el porcentaje de partículas > 0,6 µm (+0,143 ± 0,07; p = 0,038) pero no influyó en otros parámetros. No se observó asociación con la concentración de calcio. El contenido de aminoácidos se correlacionó inversamente con el pH (-0,83; p < 0,0001). Conclusiones: las TPNAn individualizadas estudiadas con emulsiones de omega-3 que incluyen los requerimientos de cationes son estables durante al menos 96 horas.

Unexpected Serum and Urine Aluminum Concentrations in Pediatric Patients on Home Parenteral Nutrition.

The intravenous supply of aluminum (Al) present in parenteral nutrition solutions poses a high risk of the absorption of this element, which can result in metabolic bone disease, anemia, and neurological complications. The aim of this study is to determine the impact of long-term parenteral nutrition (PN) in children on serum Al concentration and its urinary excretion compared to healthy children. We evaluated serum Al concentrations and its urinary excretion in patients enrolled in the Polish home parenteral nutrition (HPN) program between 2004 and 2022. The study group included 83 patients and the control group consisted of 121 healthy children. In children whose PN was started in the neonatal period, we found higher serum Al concentrations and higher urinary Al excretion than in other subjects whose PN was started later. Only 12% of the children on chronic parenteral nutrition had serum Al concentrations of less than 5 µg/L. Healthy children in the control group had higher serum Al concentrations than those in the parenteral nutrition group, which may indicate the influence of one's environment and diet on Al serum levels.

Aluminum blood concentration in adult patients: effect of multichamber-bag versus hospital-compounded parenteral nutrition.

Introduction: Background: the administration of aluminum-contaminated parenteral nutrition (PN) leads to an accumulation of aluminum. The aim of this study was to assess blood aluminum concentrations (BACs) of inpatients receiving multichamber-bag (MCB) PN compared to those receiving compounded PN. Methods: available BACs were retrospectively gathered from patient charts of adult inpatients receiving PN from 2015 to 2020, and compared depending on the type of PN administered. Long-term PN patients, defined as ≥ 20 days of PN, receiving at least > 10 days of compounded PN, were compared to long-term patients receiving only MCB. Results: a total of 160 BACs were available from 110 patients. No differences were found according to type of PN (mean BAC: 3.11 ± 2.75 for MCB versus 3.58 ± 2.08 µg/L for compounded PN). Baseline total bilirubin, surgery and days with PN were related to higher BACs (coefficient: 0.30 [95 % CI, 0.18-0.42], 1.29 [95 % CI, 0.52-2.07], and 0.06 [95 % CI: 0.01-0.11], respectively). Regarding long-term PN, patients receiving only MCB (n = 21) showed lower BACs compared to the compounded PN (n = 17) [2.99 ± 1.55 versus 4.35 ± 2.17 µg/L, respectively; p < 0.05]. Conclusions: although there were no differences in BAC according to type of PN administered, in long-term PN, MCB PN was associated with lower BACs as compared to compounded PN.

Introducción: Antecedentes: la administración de nutrición parenteral (NP) contaminada con aluminio conduce a su acumulación. El objetivo de este estudio fue evaluar las concentraciones de aluminio en sangre (CAS) en pacientes hospitalizados que recibieron NP elaboradas en el hospital o bolsas tricamerales. Métodos: se recogieron retrospectivamente las CAS disponibles de los pacientes hospitalizados con NP durante el período entre 2015 y 2020, comparándose los valores en función del tipo de NP administrada. Se comparan igualmente los valores de pacientes de larga duración, definida como ≥ 20 días de NP, que recibieron al menos > 10 días de NP elaborada frente aquellos de larga duración que recibieron solo NP tricameral. Resultados: se incluyeron un total de 160 CAS de 110 pacientes. No se encontraron diferencias con respecto al tipo de NP (CAS media: 3,11 ± 2,75 para la tricameral frente a 3,58 ± 2,08 µg/L para la elaborada). La bilirrubina total basal, la cirugía y los días con NP se relacionaron con un mayor valor de CAS (coeficiente: 0,30 [IC 95 %: 0,18-0,42], 1,29 [IC 95 %: 0,52-2,07] y 0,06 [IC 95 %: 0,01-0,11], respectivamente). En la NP a largo plazo, los pacientes que recibieron solo NP tricameral (n = 21) mostraron una CAS menor en comparación con el grupo que recibió al menos 10 NP elaboradas (n = 17) [2,99 ± 1,55 versus 4,35 ± 2,17 µg/L, respectivamente; p < 0,05]. Conclusiones: aunque no hubo diferencias de CAS con respecto al tipo de NP administrada, en la NP a largo plazo, la administración de NP tricameral se asoció con CAS menores en comparación con la NP elaborada.

Peripheral parenteral nutrition in surgery - a systematic review and meta-analysis.

BACKGROUND: Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery. METHODS: A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN. RESULTS: The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites. CONCLUSION: PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.

Existence of advanced glycation / lipoxidation end-products in parenteral nutrition solutions and effects of infusion conditions on their levels

Abstract Infusion solutions must be stable from the production stage until the infusion stage. Some infusion fluids contain degradation products, known as advanced glycation end products (AGEs); however, it is unknown whether AGEs exist in parenteral nutrition solutions. We aimed to investigate this question and test the effect of infusion conditions on AGE formation in parenteral nutrition solution. Nine parenteral nutrition solutions were supplied by the pharmacy with which we collaborated. To simulate the infusion conditions, the solutions were held in a patient room with standard lighting and temperature for 24 hours. Samples were taken at the beginning (group A) and the end (24th hour, group B) of the infusion period. The degradation products were 3-deoxyglucosone, pentosidine, N-carboxymethyl lysine, and 4-hydroxynonenal, which we investigated by high-performance liquid chromatography-mass spectrometry (LC-MS) and Q-TOF LC/MS methods. Two of four degradation products, 4-hydroxynonenal and N-carboxymethyl lysine, were detected in all samples, and Group B had higher levels of both compounds compared to Group A, who showed that the quantities of these compounds increased in room conditions over time. The increase was significant for 4-hydroxynonenal (p=0.03), but not for N-carboxymethyl lysine (p=0.23). Moreover, we detected in the parenteral nutrition solutions a compound that could have been 4-hydroxy-2-butynal or furanone

Pitfalls of iron supplementation in parenteral nutrition admixtures for children with intestinal failure.

BACKGROUND: Pediatric patients with intestinal failure are at increased risk for iron deficiency. Supplementation is not routinely included in parenteral nutrition solutions. There is currently limited research related to the safety of iron supplementation in parenteral nutrition and for intravenous forms used in patients with intestinal failure. Current American Society for Parenteral and Enteral Nutrition and ESPGHAN guidelines promote the use of enteral iron, acknowledging the risks of using iron supplementation within parenteral nutrition admixtures. METHODS: We review a patient case and the current available literature related to iron in parenteral nutrition. RESULTS: Five major concerns are identified: peroxidation reactions, incompatibility, hypersensitivity, infection risk, and iron overload. CONCLUSION: We propose an argument against the preferential use of iron supplementation within parenteral nutrition in children with intestinal failure when enteral supplementation or intermittent parenteral infusion may be sufficient.

The use of standardized commercially available parenteral nutrition as a bridge to customized compounded bag in the acute hospital setting is safe and feasible.

BACKGROUND & AIMS: The use of standardized commercially available parenteral nutrition (SCAPN) as a starter bag to bridge to customized compounded PN offers the advantage of starting PN on the same day of consult, avoiding delays in nutrition delivery. We aim to evaluate the safety and feasibility of using SCAPN as a bridge to compounded PN in the acute hospital setting. METHODS: Retrospective review of patients on PN from Aug 2018 to Sep 2019 was performed. SMOFKABIVEN® Peripheral 800 kcal in 1206 ml was used. Electrolyte replacements on the day and the day after PN commencement were compared between SCAPN and compounded PN. Results were reported as means (95% confidence intervals). P value < 0.05 was considered statistically significant. RESULTS: 135 (78.5%) patients received SCAPN while 37 (21.5%) received compounded PN on the first day of PN. Baseline characteristics of both groups were almost similar with higher BMI in the SCAPN. Baseline serum potassium 4.0 (3.9, 4.1) vs 4.0 (3.8, 4.1), p = 0.46; phosphate 1.1 (1.0, 1.1) vs 1.1 (1.0, 1.3), p = 0.40 and magnesium 0.8 (0.8, 0.9) vs 0.9 (0.9, 1.0), p < 0.05 for SCAPN and compounded PN respectively. Follow-up serum potassium was 3.9 (3.8, 3.9) vs 3.9 (3.8, 4.1), p = 0.36; phosphate 0.9 (0.9, 0.9) vs 1.1 (1.0, 1.2), p < 0.05 and magnesium 0.9 (0.9, 0.9) vs 0.9 (0.9, 1.0), p = 0.18. Baseline calories and protein were lower in SCAPN group. Electrolyte replacements were similar in both groups at baseline and follow up. CONCLUSION: Using our in-house protocol, the use of a SCAPN as a bridge to customized compounded PN is safe and feasible.

High particle counts in neonatal parenteral nutrition solutions with added cysteine: Relationship to crystal formation and effect of filtration on cysteine content.

BACKGROUND: Parenteral nutrition(PN) solutions containing calcium gluconate and cysteine have elevated particle counts when analyzed using laser light obscuration (LO) as recommended by the United States Pharmacopeia. It is unclear whether increased particle formation in these solutions results in decreased availability of cysteine to neonatal patients due to filtration. OBJECTIVE: The purpose of this study was to measure cysteine concentrations in neonatal PN solutions before and after filtration as well as analyze precipitates on filters. METHODS: Solutions of PN containing amino acids with and without cysteine that were compounded with calcium chloride or calcium gluconate plus potassium phosphate were analyzed using LO. Concentrations of cysteine were measured before and after filtration. The effect on particle formation of magnesium sulfate (MgSO4 ) and D70 was also evaluated. RESULTS: Multiple additives including the specific calcium or D70 additive, cysteine, and MgSO4 influenced particle formation of particles detected using LO. There was no significant decrease in cysteine concentration because of filtering and there was no difference in the amount of calcium on filters of various solutions after filtration regardless of LO particle counts. Scanning electron micrographic (SEM) analysis found no significant differences in crystal composition. Light microscopic and SEM examination did not show evidence of high particle counts on filters. CONCLUSION: The increased particle counts detected in neonatal PN solutions containing cysteine added at the time of compounding does not appear to result in increased precipitate or crystal formation. It is not associated witha decrease in cysteine delivery to patients.

Bacterial contamination of lightproof covers for high-calorie infusion solutions in wards.

Deterioration of drugs due to light exposure is one of the major concerns, especially regarding protection of high-calorie infusion solutions, lightproof covers are used in hospitals. In the absence of any set standards regarding their usage, they are often reused. This study aimed to investigate bacterial contamination of lightproof covers used in hospital wards. For this, lightproof covers which had been used or stored in wards were collected and bacterial cultures were carried out from them. Examination of the cultures revealed that bacteria were present in the used lightproof covers. The bacterial species detected in the used lightproof covers were Bacillus species Coagulase-negative Staphylococci (CNS) and Methicillin-resistant Staphylococcus aureus (MRSA). Bacillus species and CNS were also detected in lightproof covers stored in wards, whereas MRSA was not detected. Intestinal bacteria were detected in only one lightproof cover. However, no bacteria were detected from either inside or outside of the unused lightproof covers that were stored in the drugs department. After allowing the unused lightproof covers stored in the drugs department to stand for 24 h, Bacillus species and CNS were detected in only one of the covers, whereas no bacteria was detected in other covers. These results indicate that there is a risk of bacterial contamination in the reuse of lightproof covers and that they should either be disposed off properly after usage or hand, finger disinfectants should be used while handling them to prevent any possible contamination.

Determination of aluminum concentrations of parenteral nutrition solutions by HPLC.

Aluminum (Al) contamination of parenteral nutrition (PN) solutions has been known for over 30 years. In particular, vascular intake of Al leads to its accumulation in tissues. In this study, 8 all-in-one PN solutions the aluminum concentration was analyzed by high-performance liquid chromatography. The mean Al concentration of the glucose solutions of the PN solutions combinations was 16.36 ± 8.31 µg/L, the mean Al concentration of the amino acid solutions was 4.96 ± 3.73 µg/L, and the mean Al concentration of the lipid solutions was 9.09 ± 11.23 µg/L. The Al concentration of the PN5 glucose and PN2 lipid solutions were above 25 µg/L, which is the limit set by the Food and Drug Administration (FDA). No studies in the literature have examined the Al concentrations of all-in-one PN solutions via HPLC. In two of the analyzed solutions, the Al concentration was found to be higher than the limit set by the FDA.

Compatibility of intravenous metronidazole with some all-in-one parenteral nutrition regimens.

OBJECTIVES: Supplementation of parenteral nutrition (PN) admixtures with other parenteral drugs may be desired especially in the case of polypharmacy and limited vascular access. Metronidazole (MTZ) is administered in surgical and critically ill patients often requiring concomitant nutritional therapy in the form of parenteral nutrition. The aim of the study was to evaluate the possibility of the concomitant administration of MTZ with PN admixtures from one container. METHODS: MTZ (1500 mg) was combined with six different PN admixtures and stored for 7 days before the simulation of administration. The mean droplet size (MDS) of the lipid emulsion, zeta potential, color, and pH of the tested samples were determined every 24 h. The content of MTZ was determined by the high-performance liquid chromatography method within the same time frames. RESULTS: PN admixtures supplemented with MTZ were characterized by a pH range from 6.19 to 6.38 and zeta potential range from -21.6 mV to -8.8 mV. For all samples the pharmacopeial criteria for intravenously administered emulsions were met: The visual inspection showed no sign of emulsion destabilization or precipitation, and the MDS was <500 nm. The MTZ content remained >90% of the initial value throughout the whole study period. CONCLUSIONS: Results showed the physicochemical compatibility and stability of PN admixtures supplemented with MTZ at the dose of 1500 mg. Such formulations can be stored at a temperature of 5°C for up to 7 d before administration to the patient.

Inquérito Brasileiro Sobre Terapia de Nutrição Domiciliar: panorama atual / Brazilian Survey on Home Nutrition Therapy: current overview / Encuesta brasileña sobre terapia nutricional domiciliaria: panorama actual

Objetivo: descrever como a terapêutica nutricional domiciliar é realizada no Programa Melhor em casa do Ministério da Saúde e na Saúde suplementar. Método: Estudo transversal, com dados secundários, onde foram selecionados os perfis de profissionais atuantes em atenção domiciliaria no Brasil. A coleta de dados ocorreu de março a junho de 2018, depois de submetido e aprovado pelo Comitê de Ética e Pesquisa. Resultados: Dos 289 brasileiros, 74% eram profissionais atuantes na Assistência domiciliaria. O tipo de Terapia Nutricional realizada foi 67% enteral exclusiva seguida de 33% terapia mista. A prescrição realizada de dieta exclusiva artesanal foi de 9% e de dieta enteral mista 55%. A maioria recebe dieta por gravidade intermitente, seguida de administração em "bolus", gravitacional contínua e controle do gotejamento através da bomba de infusão. Conclusão: Os achados nos dão uma visão panorâmica da terapia nutricional enteral domiciliar no Brasil. A aumento da terapia nutricional domiciliaria se faz necessária especialmente pelo aumento da população idosa e consequentemente de maior presença das doenças crônicas que podem levar a incapacidade, dependência, maior tempo de hospitalização e custos para o sistema de saúde. É fundamental a presença da equipe interdisciplinar, de boas práticas e do acompanhamento das famílias nos domicílios.

Objective: To learn how home nutritional therapy is carried out in the Ministry of Health's Better Home Program and in Supplementary Health. Method: Cross-sectional study, with secondary data, in which the profiles of professionals working in home care in Brazil were selected. Data collection took place from March to June 2018, after being submitted and approved by the Ethics and Research Committee. Results: Of the 289 Brazilians, 74% were professionals working in home care. The type of nutritional therapy performed was 67% exclusive enteral followed by 33% mixed therapy. The prescription of an exclusive handmade diet was 9% and a mixed enteral diet 55%. Most receive intermittent gravity diet, followed by bolus administration, continuous gravitational and drip control through the infusion pump. Conclusion: The findings give us a panoramic view of home enteral nutritional therapy in Brazil. The increase in home nutritional therapy is necessary especially because of the increase in the elderly population and, consequently, the greater presence of chronic diseases that can lead to disability, dependence, longer hospitalization and costs for the health system. The presence of an interdisciplinary team, good practices and monitoring of families at home is essential.

Objetivo: Conocer cómo se lleva a cabo la terapia nutricional domiciliaria en el Programa Mejor Hogar del Ministerio de Salud y en Salud Complementaria. Método: Estudio transversal, con datos secundarios, en el que se seleccionaron los perfiles de los profesionales que trabajan en la atención domiciliaria en Brasil. La recolección de datos tuvo lugar de marzo a junio de 2018, luego de ser presentados y aprobados por el Comité de Ética e Investigación. Resultados: De los 289 brasileños, el 74% eran profesionales que trabajaban en la atención domiciliaria. El tipo de terapia nutricional realizada fue 67% enteral exclusiva seguida de 33% terapia mixta. La prescripción de una dieta exclusiva artesanal fue del 9% y una dieta enteral mixta del 55%. La mayoría recibe una dieta de gravedad intermitente, seguida de administración de bolo, control gravitacional continuo y de goteo a través de la bomba de infusión. Conclusión: Los hallazgos nos brindan una visión panorámica de la terapia nutricional enteral domiciliaria en Brasil. El aumento de la terapia nutricional domiciliaria es necesario sobre todo por el aumento de la población anciana y, en consecuencia, la mayor presencia de enfermedades crónicas que pueden derivar en discapacidad, dependencia, mayor internación y costos para el sistema de salud. La presencia de un equipo interdisciplinario, buenas prácticas y seguimiento de las familias en el hogar es fundamental.

Stability of N-Acetylcysteine (NAC) in Standardized Pediatric Parenteral Nutrition and Evaluation of N,N-Diacetylcystine (DAC) Formation.

The ESPGHAN/ESPEN/ESPR-Guidelines on pediatric parenteral nutrition (PPN) recommend the administration of the semiessential amino acid (AA) cysteine to preterm neonates due to their biochemical immaturity resulting in an inability to sufficiently synthetize endogenous cysteine. The soluble precursor N-acetylcysteine (NAC) is easily converted into bioavailable cysteine. Its dimer N,N-diacetylcystine (DAC) is almost unconvertable to cysteine when given intravenously resulting in a diminished bioavailability of cysteine. This study aims to understand the triggers and oxidation process of NAC to DAC to evaluate possibilities of reducing DAC formation in standardized PPN. Therefore, different air volumes (21% O2) were injected into the AA compartment of a standardized dual-chamber PPN. O2 concentrations were measured in the AA solution and the headspaces of the primary and secondary packaging. NAC and DAC concentrations were analyzed simultaneously. The analysis showed that O2 is principally delivered from the primary headspace. NAC oxidation exclusively delivers DAC, depending on the O2 amount in the solution and the headspaces. The reaction of NAC to DAC being containable by limiting the O2 concentration, the primary headspace must be minimized during manufacturing, and oxygen absorbers must be added into the secondary packaging for a long-term storage of semipermeable containers.

[Standardised parenteral nutrition in low birth weight preterm newborns: a case report.] / La nutrizione parenterale standardizzata nei neonati pretermine di basso peso: descrizione di un caso.

The aim of this study is to evaluate the possibility of increasing the use of standardised parenteral nutrition (PN) as a replacement of individualized parenteral nutrition in the neonatal intensive care unit (NICU). The standardisation of the PN formulations has the potential to improve nutrient intakes, quality control, cost effectiveness and reduce prescription errors. In our hospital the individualized PN solutions are made by Chemists for premature babies born during the working days. We have been using standardised PN formulations for about two years for the preterm infants born during the weekend. The use of SPN is currently limited to the weekend, until our Chemists can prepare the IPN.In this study we describe the case of a sick low birth weight baby for whom we used for the first time the bags of a standardised PN "ready to use" since the sixth day of life for thirteen consecutive days. The baby was not a very low birth weight, but he needed parenteral nutrition because he was relatively unstable and he had a poor feeding tolerance. As result of the study, the baby growth was regular and the SPN were well tolerated. No adverse effects were reported.

Physicochemical Compatibility of Dexmedetomidine With Parenteral Nutrition.

BACKGROUND: Dexmedetomidine is an α2-agonist used as a sedative agent in the intensive care setting. Simultaneous administration of dexmedetomidine and parenteral nutrition (PN) may be required. The aim of this study was to evaluate the physicochemical compatibility of dexmedetomidine Y-site administered with PN. METHODS: Three PN and 3 dexmedetomidine solutions were compounded. The tested infusion rate for PN was 66 mL/h. For dexmedetomidine, we considered the initial and maximum infusion rates (0.7 and 1.4 µg/kg/h) detailed in the data sheet. Taking this into account and considering a weight range of 55-95 kg, we tested 2 dexmedetomidine infusion rates (10 and 36 mL/h). The samples obtained were examined visually against light. pH was analyzed with a pH meter. Mean fat droplet diameter was determined by dynamic light scattering. Quantification of dexmedetomidine concentration was carried out by ultraperformance liquid chromatography-high-resolution mass spectrometry. For each PN-dexmedetomidine admixture, tests were performed in triplicate. RESULTS: No alterations were observed by visual inspection. Average pH was 6.25 ± 0.01. Droplet diameter remained below 500 nm (298 ± 10 nm for 10-mL/h rate and 303 ± 5 nm for 36-mL/h rate). Dexmedetomidine concentrations at t = 0 were 519 ± 31 ng/mL and 1391 ± 90 ng/mL for 10- and 36-mL/h infusion rates, respectively. At t = 24 hours, the concentrations obtained were 494 ± 22 and 1332 ± 102 ng/mL, which translates into ≥90% of the initial concentrations. CONCLUSION: Dexmedetomidine is physicochemically compatible with PN during simulated Y-site administration at the tested infusion rates.

Low caloric intake and high fluid intake during the first week of life are associated with the severity of bronchopulmonary dysplasia in extremely low birth weight infants.

OBJECTIVE: To study whether there is an association between nutritional intake during the first week of life and severity of bronchopulmonary dysplasia (BPD) in extremely low birth weight (ELBW) infants. METHODS: In a retrospective cohort study, medical records of all ELBW infants admitted to our Neonatal Intensive Care Unit (2010-2017) were reviewed for infants' demographics, clinical characteristics, nutritional intake during their first week of life, and BPD risk factors. RESULTS: During the study period 226 infants were identified of whom 67% (151/226) had moderate-severe BPD and the rest served as controls. Overall infants with moderate-severe BPD were younger, smaller, and spent more time on mechanical ventilation than their controls [(mean±standard deviation) 24.7±1.7 vs. 26.8±2.0 weeks gestational age (p < 0.001); 678±154 vs. 837±129 grams (p < 0.001); and 37.9±23.6 vs. 13.7±15.3 days (p < 0.001) respectively]. During the first week of life, the average caloric, carbohydrate, protein and lipid intakes were significantly lower, and the average fluid intake was significantly higher in the moderate-severe BPD than the control group. After adjustment for confounders, fluid intake, and days on mechanical ventilation were significantly associated with moderate-severe BPD with an odds ratio [OR (95% confidence interval)] of 1.03 (1.01-1.04), and 1.05 (1.03-1.07) respectively. Daily caloric intake was associated with an increased risk for moderate-severe BPD [OR: 0.94 (0.91-0.97)]. CONCLUSION: Low caloric intake, and high fluid intake during the first week of life are associated with the severity of BPD in ELBW infants.

Stability of high-dose thiamine in parenteral nutrition for treatment of patients with Wernicke's encephalopathy.

BACKGROUND & AIMS: Wernicke's encephalopathy is associated mainly with malnourishment in alcohol-dependent patients but can be caused also by cancer, Crohn's disease, gastrointestinal surgery or prolonged parenteral nutrition (PN) without adequate supplementation of vitamins. The disorder, with a significant mortality rate of up to 20%, is often associated with the underlying disease and intensifies after administration of non-supplemented PN. Thus, it seems justified to add thiamine to PN admixtures prepared for parenterally fed patients. Due to the lack of data on the stability of thiamine in PN admixtures at concentrations exceeding 60 mg/L, we decided to determine the possibility of adding a high dose of thiamine (800 mg per bag, 320 mg/L) to PN admixtures in order to treat Wernicke's encephalopathy in malnourished patients. METHODS: The study aimed to assess the stability of the physical properties of PN admixtures (pH, zeta potential, particle size) and to determine thiamine content using an HPLC method. RESULTS: Thiamine was found to degrade regardless of the PN admixture composition and storage conditions. The highest decrease in thiamine content was observed at room temperature without light protection whereas the lowest at a temperature of 4 ± 1 °C with light protection. CONCLUSIONS: The treatment of Wernicke's encephalopathy in parenterally fed patients is possible with the use of high thiamine doses (800 mg) added to PN admixtures without a decrease in the drug content above 10% within the first 24 h. It should be emphasized that thiamine as a photosensitive drug must be stored and administered under conditions ensuring light protection.

Influence of the type of amino acids in the formation of precipitates of copper and sulphur in parenteral nutrition.

INTRODUCTION: Objective: we found a black precipitate during the infusion of a parenteral nutrition without lipids. The objective of this study is to check the composition of the precipitate and the influence of the type of amino acids in its formation. Methods: four PN bags were prepared with the following composition: 1 l of amino acids solution, 150 g glucose, 60 mEq potassium, 217 mEq chloride, 105 mEq sodium, 15 mEq magnesium, 15 mEq calcium, 18.63 mmol phosphorus and trace elements (Addamel®). Each bag was prepared using a different type of amino acids solution with different amount of cysteine per litre: Tauramin® 10% (0.5 g/l), Primene® 10% (1.89 g/l), Tauramin® 12.6% (0.62 g/l) or Synthamin® 10% (0 g/l). Tauramin® 10% and Primene® 10% were packaged in glass containers whereas Tauramin® 12.6% and Synthamin® 10%, in plastic. The contents of each bag were filtered using Pall NEO96E 0.2 micron filters. A 2.25% area of each filter was observed by scanning electron microscopy at 100x magnification. The analysis by energy dispersive spectroscopy (EDS) was performed at 1,000x magnification. Results: in the Primene® 10% and Tauramin® 10% filters, a greater amount of precipitate was observed than with Tauramin® 12.6% and Synthamin® 10%. The percentage of copper and sulphur in each area of the filters studied was, respectively, 22.9% and 11.5% (Primene® 10%), 19.3% and 9.6% (Tauramin® 10%), 3.7% and 0% (Tauramin® 12.6%), 2.5% y 0% (Synthamin® 10%). Conclusions: the observed precipitate contains copper and sulphur. Precipitate formation occurs in high cysteine content amino acids solutions packaged in glass containers. It is important to use filters in the administration of PN to ensure that this type of precipitates are retained and do not pass to the patient. Key words.

INTRODUCCIÓN: Objetivo: durante la infusión de una nutrición parenteral (NP) sin lípidos se observó un precipitado negro en el filtro. El objetivo del estudio es comprobar la composición del precipitado y la influencia del tipo de aminoácidos en su formación. Métodos: se prepararon cuatro bolsas de NP con 1.000 ml de solución de aminoácidos, 150 g glucosa, 60 mEq potasio, 217 mEq cloruro, 105 mEq sodio, 15 mEq magnesio, 15 mEq calcio, 18,63 mmol fósforo y oligoelementos (Addamel®). Se utilizaron distintos tipos de aminoácidos con concentraciones de cisteína diferentes: Tauramin® 10% (0,5 g/l), Primene® 10% (1,89 g/l), Tauramin® 12,6% (0,62 g/l) o Synthamin® 17 (0 g/l). Tauramin® 10% y Primene® 10% estaban envasados en vidrio y Tauramin® 12,6% y Synthamin® 17, en plástico. El contenido de cada bolsa se filtró utilizando filtros Pall NEO96E de 0,2 micras. Se estudió un área de 2,25% de cada filtro mediante microscopía electrónica de barrido a 100 aumentos. El análisis mediante espectroscopia de dispersión de energía (EDS) se realizó a 1.000 aumentos. Resultados: en los filtros con Primene® 10% y Tauramin® 10%, se observó mayor precipitación que con Tauramin® 12,6% y Synthamin® 10%. El porcentaje de cobre y azufre en cada área de los filtros estudiados fue 22,9% y 11,5% (Primene® 10%), 19,3% y 9,6% (Tauramin® 10%), 3,7% y 0% (Tauramin 12,6%), 2,5% y 0% (Synthamin 10%). Conclusiones: el precipitado observado contiene cobre y azufre. La formación de precipitados se produce con soluciones de aminoácidos envasadas en vidrio, con gran cantidad de cisteína. Es importante usar filtros en la administración de NP para garantizar que los precipitados se retengan y no se pasen al paciente.