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 American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Update on the Use of Filters for Parenteral Nutrition: An ASPEN Position Paper.

Intravenous in-line filters play a critical role in promoting patient safety during parenteral nutrition (PN) administration. Guidelines for using filters for PN have been issued by a number of professional organizations and manufacturers of PN components. Yet despite this guidance, filter use remains controversial. Recent changes in recommendations for filtering lipid injectable emulsions have added to confusion and created considerable variation in practice. This Position Paper aims to review past guidance regarding the filtration of PN, examine the clinical consequences of infusing particulate matter, discuss the challenges and issues related to filtration, and clarify the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations for the use of filters for PN administration. This paper was approved by the ASPEN Board of Directors.

Recommendations for photoprotection of parenteral nutrition for premature infants: An ASPEN position paper.

Although crucial in improving health outcomes in the preterm infants, parenteral nutrition (PN) is not without risk, especially if handled improperly. A growing body of evidence suggests that components of PN admixtures, including lipid injectable emulsions (ILEs), are susceptible to degradation, including oxidation when exposed to light (ie, photo-oxidation), resulting in the production of reactive oxygen species. Infants, especially those born preterm, are considered more susceptible to consequences of oxidative stress than children and adults. Oxidative stress is associated with bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and intestinal failure-associated liver disease. The American Society for Parenteral and Enteral Nutrition (ASPEN) assembled a working group to provide recommendations on clinical practice surrounding photoprotection of PN.This Position Paper reviews the scientific literature on the formation of quantifiable peroxides and other degradation products when PN admixtures and ILEs are exposed to light and reports adverse clinical outcomes in premature infants exposed to PN. Recommendations for photoprotection of PN admixtures and ILEs are provided, as well as the challenges in achieving complete photoprotection with the equipment, supplies, and materials currently available in the US. ASPEN and the authors understand that the full implementation of complete photoprotection may not currently be feasible given current product availability; recommendations provided in this paper serve to represent the goal to which to strive as well as to highlight the importance of product availability to achieve these practices. This paper has been approved by the ASPEN Board of Directors.

Multicenter Prospective Evaluation of Parenteral Nutrition Preparation Time and Resource Utilization: 3-Chamber Bags Compared With Hospital Pharmacy-Compounded Bags.

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.

Importance of public-private partnerships for nutrition support research: An ASPEN Position Paper.

Parenteral and enteral nutrition support are key components of care for various medical and physiological conditions in infants, children, and adults. Nutrition support practices have advanced over time, driven by the goals of safe and sufficient delivery of needed nutrients and improved patient outcomes. These advances have been, and continue to be, dependent on research and development studies. Such studies address aspects of enteral and parenteral nutrition support: formulations, delivery devices, health outcomes, cost-effectiveness, and related metabolism. The studies are supported by public funding from the government and by private funding from foundations and from the nutrition support industry. To build public trust in nutrition support research findings, it is important to underscore ethical research conduct and reporting of results for all studies, including those with industry sponsors. In 2019, American Society for Parenteral and Enteral Nutrition's (ASPEN's) Board of Directors established a task force to ensure integrity in nutrition support research that is done as collaborative partnerships between the public (government and individuals) and private groups (foundations, academia, and industry). In this ASPEN Position Paper, the Task Force presents principles of ethical research to guide administrators, researchers, and funders. The Task Force identifies ways to curtail bias and to minimize actual or perceived conflict of interests, as related to funding sources and research conduct. Notably, this paper includes a Position Statement to describe the Task Force's guidance on Public-Private Partnerships for research and funding. This paper has been approved by the ASPEN Board of Directors.

Parenteral Nutrition Prescribing and Order Review Safety Study: The Need for Pharmacist Intervention.

INTRODUCTION: Errors have been reported in the literature to occur at each step of the parenteral nutrition (PN) use process, necessitating standardized processes, clinician competence, and open communication for those involved. This study was performed at Central Admixture Pharmacy Services (CAPS®) in collaboration with the American Society for Parenteral and Enteral Nutrition (ASPEN) with the purpose to study the need for and success of PN pharmacist interventions. METHODS: A survey was developed and sent to all CAPS customers for study enrollment and to identify their demographic and practice characteristics. For those enrolled, CAPS pharmacists reviewed every PN order in a 1-month period using an error/intervention tool to capture data on prescription elements requiring intervention, along with acceptance of that intervention. RESULTS: Two hundred thirty-two unique CAPS customers (23% response rate) participated in the study, representing 37,634 unique PN prescriptions. Two hundred forty-eight PN prescriptions (0.66%) from 59 customers required ≥1 intervention. The top 3 intervention types were electrolyte dose clarification, calcium/phosphorus incompatibility, and amino acid dose clarification. A greater number and percentage of interventions were required for neonatal prescriptions, as compared with adult and pediatric prescriptions. No significant difference was found in many of the other customer characteristics. CONCLUSION: This study supports the need for institutions to develop systems to comply with published PN safety recommendations, including knowledgeable and skilled pharmacists to complete the order review and verification steps for this high-alert medication.

ASPEN Consensus Recommendations for Refeeding Syndrome.

INTRODUCTION: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. METHODS: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. FINDINGS/RECOMMENDATIONS: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. CONCLUSIONS: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.

Compounding parenteral nutrition: reducing the risks.

Compounding parenteral nutrition, either manually or with an automated compounding device, requires aseptic conditions and trained personnel. The revised version of United States Pharmacopeia Chapter <797> is a comprehensive document that describes standards and procedures to minimize the risk of contamination of compounded parenteral products. The chapter includes evidence-based instructions for pharmacy design, washing, garbing, cleaning, quality assurance, and personnel training and evaluation designed to improve compounding practices in all pharmacies that compound parenteral products. Because parenteral nutrition is a compounded product mixed from multiple additives, it is important to maintain these standards, especially when using an automated compounding device. This article is an overview of United States Pharmacopeia Chapter <797>, with special emphasis on parenteral nutrition.

Use of parenteral nutrition in patients receiving isolated kidney or simultaneous pancreas/kidney transplantation.

BACKGROUND: There is little information available on the use of parenteral nutrition (PN) in patients after a kidney (KID) or simultaneous pancreas-kidney (SPK) transplantation. This study examined the indications and use of PN in these patients. METHODS: Retrospective study of 25 patients (12M/13F; mean age: 51 +/- 11 years old) receiving PN after KID or SPK transplantation. Patients were divided in 2 groups according to the number of PN days (group A = <7 days and group B = >7 days). RESULTS: Overall mortality was 16% (group A: 0/7; group B: 4/18). Postoperative ileus (n = 7), intestinal fistula (n = 5), and nausea/vomiting (n = 4) were the most common indications for PN. Functional disorders accounted for 56% (14/25) of the indications for PN. Factors differentiating group A (7/25; median = 5 [4-6] days) from group B (18/25; median =9 [7-31] days) included a significantly higher preoperative serum albumin, SPK transplantation for the first time, and diagnosis of ileus as the indication for PN initiation. CONCLUSIONS: Functional disorders of the digestive tract are the primary reason for initiation of PN in isolated KID and SPK transplantation patients. Well-nourished patients undergoing their first SPK transplantation who develop postoperative ileus usually do not need nutrition intervention.

The Shrinking of Formalized Nutrition Education in Health Professions Curricula and Postgraduate Training.

The quantity of formalized nutrition education is shrinking in curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized nutrition therapies. In U.S. schools of pharmacy, parenteral nutrition is considered a highly specialized and advanced practice so little time is devoted to this area and more attention is focused on chronic disease state management (ie, hypertension, diabetes mellitus, and congestive heart failure). Nutrition support fellowships for physicians and nutrition support residency programs for pharmacists have dwindled in number over the years so that only a handful of these healthcare professionals are produced each year from the remaining formalized programs. Physicians, nurses, pharmacists, and dietitians can positively affect patient care, but each profession must first determine how best to integrate basic and applied nutrition concepts into their professional curricula and training programs. There must also be consensus among the healthcare professions as to the depth of nutrition education and the stage of training at which these integrations should occur. Only by having these crucial conversations among all disciplines will we be able to develop new strategies to expand nutrition education in the training of future medical practitioners.

Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years.

Parenteral nutrition (PN) is a complex, high-alert medication, and errors associated with the use of this therapy may lead to significant harm to patients. This document reviews error reports from the Institute for Safe Medication Practices' Medication Errors Reporting Program that are associated with the PN use process over the past 10 years. Actual PN-related errors are outlined, with most occurring in the PN-compounding/dispensing and PN administration steps. Clinicians involved in any phase of the PN use process should review their institutional or homecare company's processes for reporting of PN errors and collaborate with their medical safety officer and/or committees involved with medication error reporting.

Lipid Injectable Emulsion Survey With Gap Analysis.

BACKGROUND: Lipid injectable emulsion (ILE) is an integral part of parenteral nutrition (PN), providing energy and essential fatty acids. With recent consensus recommendations for PN, clinical guidelines for ordering and preparation of PN, the U.S. Food and Drug Administration approval of new ILE products, and revised ILE labeling to include a 1.2-micron filter, a gap in current practice knowledge was apparent. MATERIALS AND METHODS: The American Society for Parenteral and Enteral Nutrition PN Safety Committee surveyed clinicians on how ILE products are prescribed, prepared, and administered to patients from neonates to adults. RESULTS: The results of this survey conducted in late 2016 found a wide variation in practice, particularly across patient age groups. CONCLUSION: These findings demonstrate the need for ongoing dissemination and education on standardized safe practices for ILE use.

Parenteral nutrition safe practices: results of the 2003 American Society for Parenteral and Enteral Nutrition survey.

BACKGROUND: The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its "Safe Practices for Parenteral Nutrition" guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines. METHODS: A web-based survey consisting of 45 questions was conducted (n = 651) June 1-30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN. RESULTS: There were 651 survey responses, 90% of which were from hospital-based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders, but dietitians and pharmacists had significant involvement. PN base components were most often ordered as percentage final concentration after admixture (eg, 20% dextrose), which is inconsistent with safe practice guidelines of ordering by total amount per day (eg, 200 g/day). There was no consistent method for ordering PN electrolytes. Approximately 45% of responders reported adverse events directly related to PN that required intervention. Of these events, 25% caused temporary or permanent harm, and 4.8% resulted in a near-death event or death. CONCLUSIONS: Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.

Treatment of electrolyte disorders in adult patients in the intensive care unit.

PURPOSE: The treatment of electrolyte disorders in adult patients in the intensive care unit (ICU), including guidelines for correcting specific electrolyte disorders, is reviewed. SUMMARY: Electrolytes are involved in many metabolic and homeostatic functions. Electrolyte disorders are common in adult patients in the ICU and have been associated with increased morbidity and mortality, as has the improper treatment of electrolyte disorders. A limited number of prospective, randomized, controlled studies have been conducted evaluating the optimal treatment of electrolyte disorders. Recommendations for treatment of electrolyte disorders in adult patients in the ICU are provided based on these studies, as well as case reports, expert opinion, and clinical experience. The etiologies of and treatments for hyponatremia hypotonic and hypernatremia (hypovolemic, isovolemic, and hypervolemic), hypokalemia and hyperkalemia, hypophosphatemia and hyperphosphatemia, hypocalcemia and hypercalcemia, and hypomagnesemia and hypermagnesemia are discussed, and equations for determining the proper dosages for adult patients in the ICU are provided. Treatment is often empirical, based on published literature, expert recommendations, and the patient's response to the initial treatment. Actual electrolyte correction requires individual adjustment based on the patient's clinical condition and response to therapy. Clinicians should be knowledgeable about electrolyte homeostasis and the underlying pathophysiology of electrolyte disorders in order to provide the optimal therapy to patients. CONCLUSION: Treatment of electrolyte disorders is often empirical, based on published literature, expert opinion and recommendations, and patient's response to the initial treatment. Clinicians should be knowledgeable about electrolyte homeostasis and the underlying pathophysiology of electrolyte disorders to provide optimal therapy for patients.

Review of the refeeding syndrome.

Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.

Water, water everywhere: dehydration in the elderly.

Dehydration is a common disorder in the frail elderly patient. Understanding the mechanisms by which fluid and electrolyte abnormalities occur, as well as the implications of specific laboratory values, is key to providing optimal diagnosis and treatment. Management of fluid abnormalities relies on gradual rehydration with the proper fluids to restore both fluid and electrolytes.

Uncertainty about the safety of supplemental glutamine: an editorial on "A randomized trial of glutamine and antioxidants in critically ill patients".

Previously small randomized clinical trials and several meta-analyses have suggested improved patient outcomes from parenteral glutamine supplementation. A recent large multi-center randomized trial conducted in critically ill patients with documented multiple organ failure at enrollment demonstrated an increase in mortality among those receiving supplemental glutamine. This article discusses the discrepancies in trial outcomes and the risks associated with glutamine administration during critical illness.

Joint Commission for Accreditation of Health Care Organizations guidelines: too late to intervene for nutritionally at-risk surgical patients.

BACKGROUND: Joint Commission for Accreditation of Health Care Organizations (JCAHO) guidelines recommend nutritional screening within 24 hours of hospital admission, with full nutrition assessment if at-risk. This study examines whether these guidelines detect surgical patients who may benefit from preoperative nutrition support. METHODS: A retrospective chart review was conducted for patients undergoing nonemergent esophageal, gastric, pancreatic, or colon surgery between 1996 and 2001 to determine dates of admission, day of surgery, and timing of documented nutrition screening and assessment. RESULTS: Most patients undergo surgery within 24 hours of admission, and undergo initial screening or full assessment after surgery. Twenty percent of patients are admitted for diagnostic testing, preoperative cardiovascular workup, or medical management preoperatively and are assessed 5 to 6 days before surgery, but these are the minority. CONCLUSION: Because of the high incidence of nonemergent surgeries that occur within 24 hours of admission, screening and assessment by JCAHO guidelines cannot detect patients who may benefit from preoperative nutrition support. Systems to identify these patients must be implemented earlier in nutrition screening and assessment.