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(1) Background: parenteral nutrition (PN) is indispensable for patients unable to receive oral or enteral feeding. However, the complexity of PN solutions presents challenges regarding stability and compatibility. Precipitation reactions may occur. The most frequent is the formation of calcium phosphate (Ca-P). The different factors influencing these reactions must be considered to ensure patient safety. (2) Methods: eight paediatric PN solutions were prepared, following standard protocols. Samples were stored at room temperature and in a refrigerator. Electron microscopy, coupled with energy dispersive X-ray spectroscopy (EDS), was employed. Precipitates were analysed for composition and morphology. (3) Results: precipitates were observed in all samples, even at day 0. Crystalline structures, predominantly composed of calcium or magnesium, sometimes associated with chlorine or phosphorus, were detected. Additionally, amorphous precipitates, contained heterogeneous compositions, including unexpected elements, were identified. (4) Conclusions: various precipitates, primarily calcium- or magnesium-based, can form in PN solutions, although it is not expected that they can form under the real conditions of use. Calcium oxalate precipitation has been characterised, but the use of organic calcium and phosphate salts appears to mitigate calcium phosphate precipitation. Electron microscopy provides interesting results on NP precipitation, but sample preparation may present technical limitations that affect the interpretation of the results.
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Fosfatos de Calcio , Precipitación Química , Estabilidad de Medicamentos , Soluciones para Nutrición Parenteral , Soluciones para Nutrición Parenteral/química , Fosfatos de Calcio/química , Humanos , Nutrición Parenteral , Espectrometría por Rayos X , Microscopía Electrónica , Magnesio/química , Calcio/química , Calcio/análisisRESUMEN
(1) Background: Parenteral nutrition (PN) is a technique used for the administration of nutrients to patients for whom traditional routes cannot be used. It is performed using solutions with extremely complex compositions, which can give rise to a large number of interactions. These interactions can impact their stability and put the patient's life at risk. The aim of this study is to determine how changes in composition and storage protocol affect the stability of NP solutions. (2) Methods: Twenty-three samples were prepared according to routine clinical practice, with modifications to the concentration of some components. The samples were stored at room temperature (RT) and refrigerated (4 °C). Measurements of the droplet diameter, pH, density and viscosity were performed for both storage protocols on days 1, 3, 10 and 14. (3) Results: The samples with the lowest concentration of lipids (PN13-17) and proteins (PN18-22) showed a larger droplet diameter than the rest of the samples throughout the experiments. The USP limits were exceeded for some of the measurements of these sample groups. The pH density and viscosity remained relatively constant under the conditions studied. (4) Conclusions: The PN samples were considered stable and safe for administration under real-world conditions, but the samples with the lowest concentrations of lipids and proteins showed a tendency towards emulsion instability.
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(1) Background: parenteral nutrition (PN) solutions are an extremely complex mixture. It is composed of a multitude of chemical elements that can give rise to a large number of interactions that condition its stability and safety. The aim of this study was to evaluate the stability of PN solutions for preterm infants. (2) Methods: eight samples were prepared according to the protocol for prescribing PN in preterm infants. Samples PN1-PN7 had the normal progression of macronutrients and standard amounts of micronutrients for a 1 kg preterm infant. The PN8 sample had a high concentration of electrolytes, with the idea of forcing stability limits. Samples were stored both at room temperature and under refrigeration. Measurements of globule size, pH, density, and viscosity were performed in both storage protocols on different days after processing. (3) Results: the changes in the composition of the samples did not affect the evolution of the stability at the different measurement times and temperatures. Viscosity was affected by the compositional changes made in the PN samples, but no alterations due to time or temperature were observed. Density and pH remained stable, without significant changes due to time, storage temperature, or different composition. (4) Conclusion: all samples remained stable during the study period and did not undergo significant alterations due to compositional changes or different experimental conditions.
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INTRODUCTION: Institutionalized patients who require nutrition support regularly visit the Unit of Nutrition Support of the Hospital Pharmacy Service. During these visits, prior to establishing a nutrition regime and followup scheme, an initial nutritional status assessment is performed. Telemedicine and Telepharmacy have expanded in recent years for remote monitoring of institutionalized persons. OBJECTIVE: To evaluate the implementation of a Telemedicine informatics application for nutritional support surveillance of instutionalized persons in nursing homes from a hospital pharmacy service. Method: A multidisciplinary team led by the Hospital Pharmacy Service was created. Data of institutionalized persons in nursing homes needing artificial nutritional support was extracted from the SILICON prescription system and the internal ecords of the hospital pharmacy service. Nursing homes were selected on the basis of their previous experience using the Telemedicine informatics application TELEA. The following nutritional support variables were assessed: score on Mini-Nutritional Assessment questionnaire; a 24-h food record; pressure ulcer control; and laboratory parameters. The existing information flow between nursing homes and hospital specialists was analyzed. The functionalities available on TELEA were considered. RESULTS: In 2021, over 300 institutionalized persons from 28 nursing homes were incluided for nutritional support surveillance program of the hospital pharmacy service. The project was implemented in two nursing homes serving 38 patients, although only 13 were involved in the nutrition surveillance program of the Nutrition Support Unit. Nutritional status assessment and nutritional support surveillance reports were adapted to the Telemedicine informatics application. Paper reports were replaced with electronic data or online questionnaires available on the informatics application. An information flow protocol was established. An instantaneous messaging and alert system was activated, which allowed continuous communication. Some Telepharmacy requests were categorized as preferential when the clinical status of the patient so required. All the information generated during the nutritional status assessment and nutritional support surveillance process was integrated into the electronic medical history of each patient. CONCLUSIONS: TELEA-based nutritional support surveillance facilitates the continuum of care by enabling direct communication between nursing homes and secondary care for institutionalized persons. This model makes it possible to record nutrition-related data on the electronic medical history of patients through a Telepharmacy process. This model also eliminates paper prescriptions and medical reports, and unnecessary travels. A nutritional status profile should also be made available to facilitate nutrition surveillance in institutionalized persons with chronic diseases. That would be the first step for a new integrated healthcare informatics application for frail/polymorbid elderly patients.
Introducción: Los pacientes institucionalizados que requieren soporte nutricional artificial acuden de forma periódica a las consultas de la Unidad de Soporte Nutricional del Servicio de Farmacia. En ellas se realiza una valoración nutricional inicial, a partir de la cual se establece la pauta nutricional y el plan de seguimiento. La Telemedicina y la Telefarmacia se han expandido en los últimos años para la monitorización remota de personas institucionalizadas. OBJETIVO: Evaluar la implementación de una aplicación informática de Telemedicina para la vigilancia del soporte nutricional de personas nstitucionalizadas en residencias de ancianos desde un servicio de farmacia hospitalaria.Método: Se formó un equipo multidisciplinar liderado por el Servicio de Farmacia. Los datos de pacientes institucionalizados que requieren soporte nutricional artificial se obtuvieron del programa SILICON y de los registros internos del Servicio de Farmacia. Se eligieron las primeras residencias candidatas según la experiencia previa en el manejo de la aplicación informática de asistencia domiciliaria. Se analizaron llas variables de soporte nutricional necesarias para el seguimiento nutricional: Mini Nutritional Assessment, recordatorio de ingestas de las últimas 24 horas, control de úlceras por presión y parámetros analíticos. Se analizó el flujo de información existente entre las residencias sociosanitarias y la atención hospitalaria y se valoraron las opciones disponibles a través de la plataforma tecnológica de asistencia domiciliaria. RESULTADOS: El Servicio de Farmacia realizó seguimiento nutricional a más de 300 pacientes institucionalizados en 28 residencias sociosanitarias en el año 2021. El proyecto se implantó en dos residencias sociosanitarias que cuentan con 38 pacientes institucionalizados, aunque solo 13 pacientes estaban en seguimiento por la Unidad de Soporte Nutricional. Todos los registros generados en la valoración y seguimiento nutricional se adecuaron a la aplicación informática de asistencia domiciliaria, se cambiaron los registros en papel por información incluida en la plataforma o cuestionarios online facilitados a través de la misma. Además, se protocolizó el flujo de información generada y se activó un sistema de mensajería con alertas que permite una comunicación continua. En caso de que la situación clínica del paciente lo requiera se puede programar una teleconsulta preferente.Toda la información generada en el proceso de valoración y seguimientonutricional de cada paciente se integró en la historia clínica electrónica. CONCLUSIONES: El seguimiento nutricional a través de la aplicación informática de asistencia domiciliaria facilita la continuidad asistencial por el establecimiento de una comunicación directa entre las residencias sociosanitarias y la atención hospitalaria, permitiendo la integración de la información nutricional de los pacientes en la historia clínica electrónica mediante un proceso de Telefarmacia. Se han eliminado las prescripciones en papel, informes clínicos impresos y los desplazamientos innecesarios. El desarrollo de este perfil podría ser extensible al seguimiento nutricional de pacientes con patologías crónicas, y ser el precedente de un nuevo programa de cuidado integral del paciente anciano frágil o pluripatológico.
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Servicio de Farmacia en Hospital , Telemedicina , Humanos , Anciano , Casas de Salud , Apoyo Nutricional , InformáticaRESUMEN
BACKGOUND AND AIMS: Total parenteral nutrition (TPN) is an extremely complex mixture. The multitude of chemical compounds involved can give rise to numerous reactions that condition its stability. We set out to review the existing literature on different issues related to stability, and which are still of concern in the hospital environment; such as the stability of the lipid emulsion. In addition, we analyse other related factors and parameters that allow us to predict the stability of TPN based on the composition. MATERIAL AND METHODS: we searched PubMed and Google Scholar, over the date range 1995-2019 for relevant studies about TPN stability. We included experimental studies where the physical stability of the lipid emulsion in TPN had been analysed. We applied specific exclusion criteria. RESULTS: we included 20 papers in this review of TPN stability. The studies combined different analytical techniques to assess the stability. In all the studies, the mean droplet diameter (MDD) is measured and the stability analysis is completed with other measurements. Temperature and components concentration are also considered. CONCLUSIONS: studies on the stability of TPN used differing components with different chemical characteristics and their results can be difficult to extrapolate. There is no clear consensus about the composition of the mixtures and there is also great variety in the analytical techniques that were used to analyse stability. It is necessary to conduct new studies to update information on TPN stability.
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Lípidos , Nutrición Parenteral Total , Emulsiones , HumanosRESUMEN
Hospital Pharmacy Service (HPS) in Spain have been impacted by the health crisis caused by the COVID-19 pandemic. Thus, the outbreak has forced HPSs to adapt their outpatient consultation services to Telepharmacy to optimize clinical outcomes and reduce the risk of contagion. The purpose of this article is to describe and analyze the experience of HPSs with outpatient Telepharmacy during the COVID-19 pandemic and expose the lessons learned. Measures have been adopted in on-site outpatient pharmacy clinics to prevent exposure of patients and professionals to the virus. These measures are based on national and international recommendations on social distancing and hygiene. With regard to remote outpatient pharmacy services, teleconsultation with drug dispensing has been promoted based on five basic procedures, each with its advantages and limitations: home drug delivery from HPSs, with the advantage of universal access and the limitation of entailing a substantial investment in resources; HPS coordination with primary care pharmacists, which requires no investments but with limited access to some geographic areas; HPS coordination with community pharmacists based on a large network of pharmacies, which requires the patient to go to the pharmacy, without confidentiality being guaranteed for any patient; geolocation and hospital-based medication dispensing, which provides universal access and direct traceability, but entails investment in human resources; and HPS coordination with associations of patients, which does not entail any additional cost but limits the information available on the diseases of society members. Three main lessons have been learned during the pandemic: the satisfactory capacity of HPS to provide outpatient pharmacy consultation services in the setting of a public health crisis; the usefulness of Telepharmacy for the clinical follow-up, healthcare coordination, outpatient counseling, and informed dispensing and delivery of medication (with a high level of satisfaction among patients); and the need to foster Telepharmacy as a complementary tool through a mixed model of outpatient pharmacy consultation service that incorporates the advantages of each procedure and adapts to the individual needs of each patient in a context of humanized healthcare.
Los servicios de farmacia hospitalaria (SFH) en España se han visto afectados por la crisis sanitaria provocada por SARS-CoV-2 y han tenido que adoptar sus procedimientos de atención farmacéutica (AF) al paciente externo (PE) mediante estrategias de Telefarmacia, con los objetivos de maximizar los resultados en salud y reducir el riesgo de contagio. El objetivo de ese artículo es describir y analizar los procedimientos AFPE durante la pandemia SARS-CoV-2 y comunicar las lecciones aprendidas en los SFH. En relación con las consultas externas de AF presenciales, se han adoptado medidas para minimizar el contagio viral de pacientes y profesionales, siguiendo las recomendaciones nacionales e internacionales de referencia de distanciamiento temporal, espacial y recomendaciones higiénicas. En cuanto a las consultas externas de AF no presenciales, se han potenciado las teleconsultas con dispensación del tratamiento en base a cinco procedimientos básicos, cada uno de ellos con sus ventajas y limitaciones: dispensación domiciliaria desde SFH que presenta las ventajas de la universalidad de acceso, pero requiere una elevada inversión en recursos; coordinación del SHF con farmacéuticos de atención primaria, que conlleva una nula inversión en recursos, pero limita el acceso a determinadas zonas geográficas; coordinación del SFH con farmacéuticos comunitarios, que utiliza una amplia red de oficinas de farmacia, pero exige el desplazamiento del paciente sin garantías de confidencialidad para todos los casos; geolocalización y dispensación hospitalaria, que permite un acceso universal y trazabilidad directa, pero requiere un incremento en recursos humanos; y coordinación del SFH con asociaciones de pacientes, que no requiere inversión económica, pero limita el acceso a las patologías de los asociados. Destacamos finalmente tres lecciones aprendidas: la capacidad de AFPE de SFH españoles ante una crisis sanitaria; la utilidad de la Telefarmacia para el seguimiento clínico, la coordinación asistencial, información al PE, dispensación y entrega informada (con elevada satisfacción de los pacientes); y la necesidad de potenciar la Telefarmacia como herramienta complementaria, en un modelo mixto de AFPE que incorpore las ventajas de cada uno de los procedimientos adaptándose a las necesidades individuales de los pacientes en un entorno de humanización de la asistencia sanitaria.