Problemas farmacoterapéuticos asociados a la nutrición parenteral total detectados en el seguimiento farmacoterapéutico y su impacto económico / Drug-therapy problems associated with total parenteral nutrition detected in pharmaceutical care practice and their economic impact

Introducción: La nutrición parenteral total es la administración de los nutrientes requeridos por vía intravenosa. No es un método libre de complicaciones. El químico farmacéutico en el área asistencial por medio del seguimiento farmacoterapéutico puede aportar a la mejora de la terapia nutricional de un paciente con nutrición parenteral total.Objetivo: Detectar los problemas farmacoterapéuticos asociados a la nutrición parenteral total a través del seguimiento farmacoterapéutico en pacientes y los ahorros de las intervenciones farmacéuticas generados en una clínica de tercer nivel en Barranquilla-Colombia.Método: Se realizó un estudio evaluativo, cuasi-experimental, ambiespectivo en 109 pacientes con prescripción de nutrición parenteral total en una clínica de tercer nivel de la ciudad de Barranquilla, durante 6 meses.Resultados: Se detectaron un total de 81 problemas relacionados con los medicamentos durante la fase de estudio, de los cuales el 75,31% fueron del tipo de dosis pauta y/o duración no adecuada. 20 problemas relacionados con los medicamentos se convirtieron en resultados negativos asociados a los medicamentos, de estos, el 55% fueron del tipo inefectividad cuantitativa. Fueron realizadas 81 intervenciones, con un porcentaje de aceptación de 93,83% (76), de las intervenciones aceptadas se lograron resolver 67 problemas, 5 intervenciones no fueron aceptadas y 14 problemas no pudieron ser resueltos debido a distintos factores. En cuanto a los ahorros generados, se alcanzó la cifra de $ 12.751.595 COP en seis meses de desarrollo del estudio.Conclusión: La identificación del perfil del paciente y los riesgos asociados al soporte nutricional ayudarán a generar un impacto económico para la institución y clínico en el paciente teniendo una visión integral de los problemas farmacoterapéuticos asociados. (AU)

Introduction: Total parenteral nutrition is the administration of the nutrients that an individual requires intravenously. It is not a method free of complications. The Pharmacist in care area through pharmacotherapeutic monitoring can contribute to the improvement of the nutritional therapy of a patient with Total parenteral nutrition. Objective: To detect pharmacotherapy problems associated with total parenteral nutrition through pharmacotherapy follow-up in patients and the savings from pharmaceutical interventions generated in a third level clinic in Barranquilla-Colombia.Methodology: It was performed an evaluative study with a quasi-experimental methodological design of ambyespective type, in relation to the time of collection of the data, in 109 patients prescribed with total parenteral nutrition in a third level clinic located in Barranquilla Colombia, in the period between November-December 2018 and January-May 2019.Results: A total of 81 drug related problem were detected during study phase, of which 75,31% were dose type and/or inadequate duration. 20 drug related problem became into negative outcome medications, of these, 55% were quantitative ineffectiveness type. 81 interventions were performed, with an acceptance percentage of 93,83% (76), of these accepted interventions, 67 problems were solved, 5 interventions were not accepted and 14 problems could not be solved due to different factors. Regarding the savings generated, the figure of $12.751.595 COP was reached in six months of study development.Conclusion: The identification of the patient’s profile and the risks associated with nutritional support will help generate an economic impact for the institution and clinician on the patient by having a comprehensive view of the associated pharmacotherapeutic problems. (AU)

Behavioral changes in preterm children during nasogastric tube feeding. Comparative study of manual administration by parents versus mechanical administration via electric syringe pump.

INTRODUCTION: Manual feeding by parents using a syringe, a widespread practice in Sweden since the 1980s, favors parents' involvement in childcare tasks. This approach is used in our neonatal unity since 2007. OBJECTIVE: To study the behavioral changes of preterm children during nasogastric tube feeding: manual milk administration by parents (MAP) versus electric syringe administration (ESA) over a 30-minute period. METHOD: This is a randomized, crossover study conducted in the neonatology unit of Toulouse. Preterm children under 33 weeks of age and over 7 days of life were included. A video recording was performed to assess the children's behavioral response, using the Dsilna score. The reviewer was blinded. RESULTS: 15 preterm children with a median gestational age of 30.1 weeks and a median birth weight of 1.210 g were included from March to October 2012. The facility, environment, and state of alertness of children were similar in both groups. Signs of well-being were significantly more prevalent in the MAP group versus the ESA group (36.2 (±8.0) versus 30.7 (±9.5)), (p = 0.04), particularly "hand-to-mouth, mouth gestures, seeking suction and sucking". Although not significant, motor withdrawal signs were more apparent and fluctuating in the ESA group. Qualitative analysis of NIDCAP observations confirms this data. CONCLUSION: There are behavior changes of preterm children during nasogastric tube feeding. This pilot study showed previously undescribed results: MAP is associated with more common well-being signs and could be more widely used in neonatal units.

Sensitivity of differential time to positivity compared to pour plates for diagnosing catheter-related blood stream infection: An evaluation in patients with chronic intestinal failure.

BACKGROUND & AIMS: A retrospective evaluation was undertaken in intestinal failure (IF) patients with long term CVCs to evaluate differential time to positivity (DTP) against paired quantitative blood cultures (PP) for the diagnosis of CRBSI. METHODS: A list of patients with a diagnosis of CRBSI was obtained from the intestinal failure unit database for a five year period, 2013 to 2017. Microbiology records were reviewed to obtain further information about blood culture and pour plate examinations. Organisms and times of collection, loading and positivity were recorded. Patients with a contemporaneous set of central and peripheral PP and blood cultures were included in an analysis of the sensitivity of DTP compared to PP. RESULTS: There were 61 (45.5%) episodes in 56 patients where complete sets of central and peripheral blood cultures and PP were received. All 61 episodes had positive central blood cultures, 59 (96.7%) had positive central line PP and 17 (27.9%) had positive peripheral PP. Using PP as the gold standard, DTP sensitivity was 96.0% for 50 episodes where PP were consistent with CRBSI. Sensitivity increased to 100% for 17 episodes where there were no delays in either collection or loading of blood cultures. CONCLUSIONS: This is the first evaluation to support the use of DTP as a sensitive test in diagnosing CRBSI in patients with IF and provides confidence to IF centers where pour plate cultures are not available.

Epicutaneo-caval catheters in neonates: New insights and new suggestions from the recent literature.

Epicutaneo-caval catheters have been widely used in neonatal intensive care units since Shaw has described them in 1973. These central venous access devices are usually placed at bedside and they have the purpose of delivering parenteral nutrition and/or drugs that are not compatible with the peripheral route. Even though in the last decade there was a fast advancement in the world of vascular access devices, such changes have only marginally affected the field of neonatal venous access. The aim of this editorial is to give 10 recommendations that correspond to 10 novelties in the field of epicutaneo-caval catheter: some are already evidence-based and should be introduced in our daily practice now, while others are particularly interesting and deserve further clinical studies.

Effect of peripherally inserted central catheter (PICC) parenteral nutrition on immune function and nutritional support after radical gastrectomy for gastric cancer.

Objective of the present study was to investigate the effects of peripherally inserted central catheter (PICC) parenteral nutrition support on immune function and nutritional support in patients undergoing radical gastrectomy for gastric cancer. 140 patients who underwent radical gastrectomy for gastric cancer were selected as participants and were divided into study group and the control group by random number table, with 70 cases in each group. Patients in the two groups underwent standard gastrectomy under general anesthesia by the same group of doctors. The study group received postoperative PICC catheter parenteral nutrition, and the control group received central venous catheter (CVC) nutrition support. Comparative study was done using t test and Chi-square test. The serum levels of ALB, TFN, PA, Hb, CD4+, CD8+, CD4+/CD8+, IgA, IgG, IgM and CD3+ in the two groups were observed before and after treatment, and the postoperative complications of the two groups were compared. After treatment, the levels of ALB, TFN, PA and Hb in the two groups were significantly increased (P<0.05). Levels of CD3+, CD4+, CD4+/CD8+, IgA, IgG and IgM also amplified significantly after treatment in both the groups, while CD8+ decreased significantly (P<0.05). What's more, the improvement degree of the study group was significantly greater than that of the control group (P<0.05). The time of drawing drainage tube, recovering intestinal function, getting off bed and the length of hospital stay in the study group were significantly shorter than those in the control group (P<0.05). The incidence of postoperative complications in the study group and control group were 8.6% (6/70 cases) and 11.4% (8/70 cases) respectively, and there was no significant difference (P>0.05). PICC catheter parenteral nutrition support and improve the nutritional status of patients, it was proved a safe and effective nutritional support which improve the cellular immune function and accelerated the recovery of gastrointestinal function.

[Black precipitate in parenteral nutrition]. / Precipitado negro en nutrición parenteral.

INTRODUCTION: Introduction: a black precipitate was observed in the filter during the infusion of a parenteral nutrition without lipids. There are similar findings published in which copper and sulphur (from cysteine) were found in the composition of the precipitate. Objective: to determine if copper and cysteine are involved in the formation of the precipitate. Methods: samples of the parenteral nutrition solution were taken before and after its passage through the filter. Amino acids concentrations were analysed in both samples by ion exchange chromatography and post-column derivatization with ninhydrin in a Biochrom 30 device. Copper concentrations were measured by atomic absorption spectrometry in a PerkinElmer AAnalyst™ 200 device. Results: a decrease in cysteine concentration of 29.3% was found. The concentration of copper decreased by 75.9%. Conclusions: the decrease in the concentrations of cysteine and copper in the filtered solution suggest that both are involved in the formation of the black precipitate observed in the filter.

INTRODUCCIÓN: Introducción: durante la infusión de una nutrición parenteral sin lípidos se observó un precipitado negro en el filtro. Hay hallazgos similares publicados en los que se han detectado cobre y azufre (proveniente de la cisteína) en la composición del precipitado. Objetivo: comprobar que la cisteína y el cobre intervienen en la formación del precipitado. Métodos: se tomaron muestras de la solución de nutrición parenteral antes y después de su paso por el filtro. Se analizaron en ambas muestras las concentraciones de aminoácidos mediante cromatografía de intercambio iónico y derivatización post-columna con ninhidrina en un equipo Biochrom 30 y las de cobre mediante espectrometría de absorción atómica en un equipo PerkinElmer AAnalyst™ 200. Resultados: las concentraciones de cisteína y cobre en la solución disminuyeron en un 29,3% y 75,9%, respectivamente. Conclusiones: la disminución de las concentraciones de cisteína y cobre en la solución filtrada sugieren que ambos están involucrados en la formación del precipitado negro observado en el filtro.

Scalp Intravenous Catheter Infiltration Leading to Subdural and Intraparenchymal Fluid Collection and Severe Neurologic Sequelae: A Case Report.

INTRODUCTION: Preterm infants require intravenous (IV) access for administration of medications, IV fluids, and parenteral nutrition. The scalp is a common site for obtaining IV access, and in children with hydrocephalus or wide fontanelles and sutures, there is a high probability of penetrating the meninges and brain matter with the scalp IV needle. If this penetration occurs and remains unnoticed, the contents of the IV infusion can infiltrate into the brain and cause severe brain damage. CASE PRESENTATION: A 3-day-old female neonate, born with myelomeningocele, was receiving total parenteral nutrition through a scalp-vein IV. She experienced a sudden increase in head circumference, a bulging fontanelle, and respiratory distress. Magnetic resonance images demonstrated subdural fluid collection, and the patient underwent emergency surgery. The dura, when opened, exuded milky-white fluid consistent in color with parenteral nutrition. Postoperative imaging showed a parenchymal abnormality caused by the intracranial and intraparenchymal infusion of parenteral nutrition. Four years later, the child had a shunt and had mild cognitive impairment. DISCUSSION: In cases of accidental intracranial administration of parenteral nutrition, we recommend that aggressive therapy be pursued to minimize the risks of developing comorbidities such as meningitis and to allow for maximal functional recovery.

Endovascular extraction of entrapped long-term central feeding catheter: Case series.

Long-term tunneled central venous catheters are widely used in several clinical indications, that is, hemodialysis, chemotherapy, and total parenteral nutrition. However, central venous catheters are associated with a number of complications, including catheter occlusion and sepsis, which may necessitate earlier catheter removal. In most cases manual traction is sufficient to remove the catheter. Nevertheless, in some cases severe adhesions, formed between the catheter and the vessel wall, complicate simple catheter removal. We present four cases of entrapped long-term central venous catheters and describe methods (e.g. endoluminal balloon dilatation and wire snare) performed by experienced cardiologists at high-volume center to remove them. We claim that permanent central venous catheters removal procedures may be unpredictable and hazardous. Therefore, entrapped central venous catheters should be extracted by experienced operators in specialized high-volume centers.

Cost, Time, and Error Assessment During Preparation of Parenteral Nutrition: Multichamber Bags Versus Hospital-Compounded Bags.

BACKGROUND: Parenteral nutrition (PN) is associated with material and manpower costs and requires preparation time. The aim of this study was to evaluate the cost of PN using multichamber bags (MCBs) compared with hospital-compounded bags (COBs). The secondary aim of this study was to assess and compare preparation time and errors related to the production and preparation processes of PN bags. MATERIALS AND METHODS: A prospective, observational, cost-accounting study was conducted in 10 Spanish hospital pharmacy services. The cost assessments included components, raw materials, and hospital staff. Only PN bags with equivalent volume and nutrition value were included in the analyses. Assessment of errors related to PN was performed simultaneously with the cost and time comparison analyses. RESULTS: Among the 597 PN bags (295 MCBs, 302 COBs) evaluated, 392 PN bags (295 MCBs, 97 COBs) had an equivalent volume and nutrition value. The mean (standard deviation) total cost of the MCB was $62.11 ($12.34) per bag compared with $67.54 ($8.50) per bag for COBs, resulting in a significant cost savings of $5.71. On average, the time required to prepare an MCB was 38 minutes shorter (P < .001). Significantly fewer total number (percent) of errors was observed in the preparation of MCBs (3 [1.0%]) compared with COBs (15 [5.0%]); P < .01). CONCLUSION: The use of MCBs results in significant savings in cost and preparation time, which may have a beneficial effect on the economic burden associated with PN as well as a reduction in errors related to PN preparation.

Eficacia y seguridad del uso de oligoelementos pediátricos endovenosos que aporten zinc, cobre, iodo, manganeso y selenio a recien nacidos o lactantes que reciben nutrición parenteral / Efficacy and safety of the use of intravenous pediatric trace elements that provide zinc, copper, iodine, manganese and selenium to newborns or infants receiving parenteral nutrition

INTRODUCCIÓN: En el Hospital Nacional Edgardo Rebagliati Martins ­ ESSALUD nacen aproximadamente 7 mil niños anualmente, de los cuales el 10 % requiere de una atención especial en la unidad de cuidados intensivos neonatales y donde también el 2.5 % son bebes prematuros que nacen con pesos menores de 1500 gramos y que requieren cuidados extremos como el de recibir soporte nutricional vía parenteral. La nutrición parenteral (NP) es una técnica de soporte vital y nutricional artificial, en la que los nutrientes se administran por vía endovenosa para cubrir las necesidades energéticas y mantener un estado nutricional adecuado en aquellos pacientes donde la vía enteral es insuficiente, inadecuada o está contraindicada. Existen diversas circunstancias o condiciones clínicas que hacen que un niño no pueda alimentarse de manera normal (vía oral) y deba recibir, vía parenteral, el soporte nutricional que necesita. Los elementos claves de una óptima nutrición, según la Organización Mundial de la Salud (OMS), están conformados por los macro y micronutrientes, estos últimos representados por las vitaminas, minerales y oligoelementos. Los oligoelementos son componentes químicos conformados principalmente por zinc, cobre, iodo, selenio, manganeso, entre otros, y que cumplen diversas funciones dentro del organismo entre las que destacan su participación en diversos sistemas enzimáticos. Actualmente, en EsSalud no se cuenta con soluciones de administración endovenosa que aporten oligoelementos en la NP para pacientes pediátricos. De este modo, los especialistas manifiestan la necesidad de contar con un suplemento nutricional que brinde estos elementos de acuerdo a las necesidades de cada paciente, y que, además, éste sea específicamente de uso pediátrico. TECNOLOGÍA SANITARIA DE INTERÉS: Los oligoelementos son micronutrientes o elementos químicos que en cantidades muy pequeñas resultan indispensables para diversas funciones dentro del organismo. Estos compuestos participan principalmente como catalizadores en sistemas enzimáticos (WHO, 1996). Estos son principalmente zinc, selenio, cobre, iodo y manganeso (NCBI, 1989), importantes para el presente dictamen. METODOLOGÍA: Se llevó a cabo una búsqueda sistemática de la literatura con respecto a la eficacia y seguridad del uso de oligoelementos pediátricos endovenosos que aporten zinc, cobre, iodo, manganeso y selenio a recién nacidos o lactantes que reciben nutrición parenteral. La búsqueda se inició revisando la información sobre el uso del medicamento de acuerdo con entidades reguladoras como: Food and Drug Administration (FDA); European Medicines Agency (EMA); Dirección General de Medicamentos y Drogas (DIGEMID); Organización Mundial de la Salud (OMS). Se realizó tanto una búsqueda sistemática como una búsqueda manual en las páginas web de grupos dedicados a la investigación y educación en salud que elaboran guías de práctica clínica descritas a continuación: National Guideline Clearinghouse (NGC); National Institute for Health and Care Excellence (NICE); Canadian Agency for Drugs and Technologies in Health (CADTH); Scottish Medicines Consortium (SMC). RESULTADOS: De acuerdo con la pregunta PICO, se llevó a cabo una búsqueda de evidencia científica relacionada al uso de oligoelementos pediátricos endovenosos que aporten zinc, cobre, iodo, manganeso y selenio a recién nacidos o lactantes que reciben nutrición parenteral. En la presente sinopsis se describe la evidencia disponible según el tipo de publicación, siguiendo lo indicado en los criterios de elegibilidad (GPC, ETS, RS, MA y ECA fase III). CONCLUSIONES: El presente dictamen tuvo como objetivo evaluar la mejor evidencia científica disponible hasta setiembre del 2019 en relación a la eficacia y seguridad del uso de oligoelementos pediátricos que aporten zinc, cobre, iodo, manganeso y selenio a pacientes pediátricos que reciben nutrición parenteral. La evidencia proveniente de dos RS y dos ECA, la cual también ha sido utilizada como evidencia en las GPC identificadas, sugieren de manera conjunta que el aporte de oligoelementos en la NP en neonatos y lactantes es necesario a fin de dar el soporte nutricional adecuado, tomando en consideración las concentraciones específicas para cada etapa de la vida, así como la edad gestacional al nacimiento, el peso al nacer y las condiciones fisiológicas de fondo. El aporte de cada oligoelemento trae beneficios específicos en cuanto a la función biológica que desempeñan cada uno dentro del organismo, entre los que se encuentran, optimización de las funciones bioquímicas relacionadas al crecimiento y desarrollo, mejora del sistema inmunológico, mejora del desarrollo neurológico. No obstante, el exceso o la falta de cada uno de los oligoelementos trae consigo consecuencias biológicas asociadas a toxicidad tales como, principalmente, problemas neurológicos (exceso de manganeso), mortalidad y problemas tiroideos (deficiencia de iodo), incremento de infecciones (deficiencia de zinc), y mayor de dependencia de oxígeno (deficiencia de selenio). Es necesario brindar el aporte específico requerido de oligoelementos a los neonatos y lactantes utilizando la mejor opción disponible comercialmente, que se ajuste a las necesidades recomendadas. Por lo expuesto, el Instituto de Evaluaciones de Tecnologías en Salud e Investigación - IETSI, aprueba el uso de oligoelementos pediátricos que aporten zinc, cobre, iodo, manganeso y selenio en neonatos y lactantes que reciben nutrición parenteral, según lo establecido en el Anexo N° 1. La vigencia del presente dictamen preliminar es de dos años a partir de la fecha de publicación. Así, la continuación de dicha aprobación estará sujeta a los resultados obtenidos de los pacientes que reciban este tratamiento y de nueva evidencia que pueda surgir en el tiempo.

Tunneled central venous catheters in pediatric intestinal failure: a single-center experience.

BACKGROUND: Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients. METHODS: An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012. RESULTS: Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8). CONCLUSIONS: CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.

Effect of Delaying Replacement of Parenteral Nutrition Intravenous Administration Sets: Preclinical Experiments and a Dynamic Laboratory Model of Microbial Colonization.

BACKGROUND: Recommendations prescribe daily intravenous administration set (IVAS) replacement for parenteral nutrition (PN) comprising intravenous fat emulsions (IVFE) due to risk of micro-organism growth and resultant central-line associated bloodstream infections (CLABSIs), but system disconnection for this practice may allow contamination and CLABSIs. MATERIALS AND METHODS: Laboratory experiments and model development were used to simulate PN administration after contamination from healthcare workers' hands. This study observed the growth of micro-organisms known to cause CLABSIs in a variety of PN and other IV fluids and developed a model to investigate the effect of delaying IVAS replacement on microbial growth for up to 7 days. RESULTS: Micro-organisms grew at different rates and were affected by solution type. In static experiments, growth was supported in IVFE and all-in-one PN, but suppressed in 50% glucose. Growth patterns were consistent over time for Staphylococcus epidermidis, Staphylococcus aureus, and Candida albicans in IVFE, all-in-one PN, and 0.9% sodium chloride in both static and dynamic experiments. C. albicans grew exponentially to clinically significant numbers in all-in-one PN and IVFE IVAS after 30 hours, but negligible growth of S. epidermidis or S. aureus occurred for 7 days. CONCLUSION: All-in-one PN and IVFE support the C. albicans growth after minimal initial contamination, with micro-organisms migrating from the fluid bag to the central venous access device. Improved aseptic nontouch technique during clinical practice is vital to prevent contamination. Daily IVAS replacement of for all-in-one PN and IVFE should continue until the safety of prolonging IVAS replacement is confirmed by randomized trials.

Assessing the appropriateness of parenteral nutrition use in hospitalized patients. A comparison on parenteral nutrition bag prescription in different wards and nutritional outcomes.

PURPOSE: Our aim is to assess parenteral nutrition (PN) bag prescription in hospitalized patients and evaluate clinical outcomes linked to PN therapy. METHODS: We performed an observational longitudinal retrospective study on PN prescription in a General Public Hospital in Turin, Italy, on ninety-five patients receiving PN prescribed by the Nutrition Support Team (NST). We described patients' demography and assessed nutritional outcomes, as well as PN bag prescription in different wards. Medians were calculated for several clinical parameters before and after PN therapy. A z-test for proportions has been performed to better understand the impact of various conditions on clinical outcomes and to compare differences between administered nutrients and required amounts. RESULTS: The NST resulted responsible for only 18% of bags prescribed in the geriatrics ward and for 48% in the surgery wards. PN was not able to fulfill nutritional requirements resulting in a median lack of 3.1 calories and 0.23 g of proteins per kilogram of reference body weight per day. Despite this, PN therapy was able to improve total blood proteins and calcium blood levels in our cohort. The NST changed the prescription in 55.8% of the pre-existing PN regimens. CONCLUSIONS: More strict adherence to guidelines is needed in order to maximize effectiveness of PN and observe a positive impact on clinical parameters.

Successful exchange transfusion in extremely preterm infant after symptomatic lipid overdose.

BACKGROUND: Complications of intravenous lipid administration are relatively uncommon. However, inadvertent rapid infusion of intravenous fat emulsion (IVFE) is an inherent risk when fats are infused separately from the dextrose-amino acid solution. CASE REPORT: Extremely preterm infant, born at 25 weeks and 6 days of gestational age weighing 920 g, who inadvertently received a massive overdose of IVFE due to a device failure. He developed lethargy, apnea, metabolic acidosis and hemodynamic instability requiring mechanical ventilation and inotropic support. Despite discontinuation of IVFE and supportive care, clinical course and metabolic acidosis worsened, so a double-volume exchange transfusion was performed. The procedure was well tolerated, without complications. Serum triglyceride concentration as well as other laboratory data normalized immediately after the exchange transfusion. The patient was extubated to continuous positive airway pressure and inotropic support was discontinued 24 hours after the procedure. He was discharged home at 40 weeks of corrected age with normal magnetic resonance imaging and neurological examination. CONCLUSION: In cases of profound, symptomatic hypertriglyceridemia due to lipid overdose, double-volume exchange transfusion should be considered, even in extremely preterm infants.

Does a Dedicated Lumen for Parenteral Nutrition Administration Reduce the Risk of Catheter-Related Bloodstream Infections? A Systematic Literature Review.

Guidelines recommend using single-lumen central vascular access devices (CVADs) for the administration of parenteral nutrition (PN) or lipid-based solutions, or a dedicated lumen on a multilumen CVAD. Publications reviewed by the authors reported comparative rates of catheter-related bloodstream infection (CR-BSI) in patients with CVADs who received PN through a dedicated lumen compared with those who had PN administered through multilumen CVADs. Two studies included 650 patients with 1349 CVADs. CR-BSIs were equally distributed between the 2 groups. Both studies were poorly reported and had significant risk of bias. These results should be interpreted with caution.

Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model.

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document.