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Boullata JI, Salman G, Mirtallo JM, Canada TW, Monczka J, Gura KM, Kiritsy P. Parenteral nutrition compatibility and stability: Practical considerations. Nutr Clin Pract 2024. [PMID: 38994914 DOI: 10.1002/ncp.11189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/17/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
Parenteral nutrition (PN) is a complex preparation that contains multiple component products with the associated risk for incompatibilities and diminished stabilities when combined together as an admixture. Significant patient harm can result from prescribing, preparing, and administering PN without confirming compatibility and stability. Incompatibility or instability is rarely obvious to the unaided eye, so safe PN admixture relies on incorporating physicochemical properties of the included components into compatibility and stability decisions. Practices include applying active ingredient concentration limits to reduce risk for incompatibilities and instabilities. The purpose of the current article is to distill the wide-ranging information on PN compatibility and stability into a feasible blueprint that individual healthcare organizations can then use to design and implement practical initiatives. Compatibility and stability considerations can be incorporated into the routine tasks of PN prescribing, order reviewing, preparing, and administering. The focus of this review is on identifying potential physicochemical interactions that can be addressed at each step in the PN use process. Organizations should incorporate compatibility and stability considerations into the routine procedures and practices of all clinicians involved with PN therapy. Those clinicians in healthcare organizations and caregivers in the home should then be in a position to safely provide the appropriate PN admixtures in terms of compatibility and stability.
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Affiliation(s)
| | - Genene Salman
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, California, USA
| | - Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Todd W Canada
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | | | - Kathleen M Gura
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Kiritsy
- Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
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Mirtallo JM, Blackmer A, Hennessy K, Allen P, Nawaya AD. Parenteral nutrition insecurity: ASPEN survey to assess the extent and severity of parenteral nutrition access and reimbursement issues. Nutr Clin Pract 2024; 39:396-408. [PMID: 38102986 DOI: 10.1002/ncp.11110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/11/2023] [Accepted: 11/18/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Parenteral nutrition (PN) shortages and lack of qualified professional staff to manage PN impact safe, efficacious care and costs of PN. This American Society for Parenteral and Enteral Nutrition (ASPEN)-sponsored survey assessed the frequency and extent to which PN access affects PN delivery to patients. METHODS Healthcare professionals involved with PN were surveyed. Questions were developed to characterize the respondent population and determine the extent and severity of PN access issues to components, devices, and healthcare professionals, as well as their effects on discharge and transfer issues. Reimbursement issues included cost, adequacy of therapy, and healthcare professional reimbursement. Burdens were types and frequency of errors, adverse events, and nutrition problems resulting from PN access issues. Impact on professionals and organizations was determined. RESULTS Respondents (N = 350) worked in hospitals (75%) and home infusion (25%). Per day, clinicians cared for <15 patients receiving PN. All age populations were represented. Respondents reported shortages of macronutrients (72%, 233 of 324) and micronutrients (91%, 297 of 324). Issues with access to healthcare workers were observed. PN access issues contribute to increased costs of PN, and knowledge regarding the current rate of PN reimbursement is limited. Respondents (75%, 197 of 261) observed an error due to PN access issues. Adverse events (57%, 149 of 259) were observed leading to temporary or permanent harm (24%, 61 of 259) as well as near death (4%, 9 of 259) and death (1%, 2 of 259). Providers reported time away from other job responsibilities and workplace stress. CONCLUSION PN access issues result in "PN insecurity" that negatively impacts patients and healthcare providers and leads to adverse events including death in patients receiving PN.
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Affiliation(s)
- Jay M Mirtallo
- Clinical Practice, American Society for Parenteral and Enteral Nutrition and College of Pharmacy, The Ohio State University, Delaware, Ohio, USA
| | - Allison Blackmer
- Clinical Practice, Quality and Advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | | | - Penny Allen
- Nutrition Services, Optum Infusion Pharmacy, Bend, Oregon, USA
| | - Alaa D Nawaya
- Nutrition Support, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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de Antonio-Cuscó M, Pérez-Terán P, Mateu-de Antonio J, Masclans-Enviz JR. Critical patient's healing walks and photoprotecion: the dark side of the sun. Med Intensiva 2023; 47:552-553. [PMID: 37380510 DOI: 10.1016/j.medine.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 06/30/2023]
Affiliation(s)
| | - Purificación Pérez-Terán
- Intensive Care Unit, Hospital del Mar, Barcelona, Spain; Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Spain; Department of Medicine, Universitat Pompeu Fabra (UPF), Spain
| | | | - Joan Ramon Masclans-Enviz
- Intensive Care Unit, Hospital del Mar, Barcelona, Spain; Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Spain; Department of Medicine, Universitat Pompeu Fabra (UPF), Spain
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Smazal AL, Ilahi IM, Raucci J, Robinson DT. Administering Parenteral Nutrition in the Neonatal Intensive Care Unit: Logistics, Existing Challenges, and a Few Conundrums. Clin Perinatol 2023; 50:557-573. [PMID: 37536764 DOI: 10.1016/j.clp.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Use of parenteral nutrition (PN) in the neonatal intensive care unit (NICU) requires evaluating the need for central venous catheters, potential drug incompatibilities, unintentional exposures, and suboptimal energy and nutrient intake during the transition to full enteral nutrition. Risks of photooxidation reactions in PN components, refeeding syndrome, and excess early amino acid intake should prompt the reevaluation of routine practices. The goal of this paper is to review the practicalities, challenges, and conundrums of administering PN in the NICU.
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Affiliation(s)
- Anne L Smazal
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Imran M Ilahi
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Janice Raucci
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Berlana D. Parenteral Nutrition Overview. Nutrients 2022; 14:4480. [PMID: 36364743 PMCID: PMC9659055 DOI: 10.3390/nu14214480] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 09/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain;
- Pharmacology, Toxicology and Therapeutic Chemistry Department, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
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Dickerson RN, Bingham AL, Canada TW, Chan LN, Cober MP, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2021 for Pharmacy Nutrition Support Practice. Hosp Pharm 2022; 57:673-680. [PMID: 36081538 PMCID: PMC9445547 DOI: 10.1177/00185787221095765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2021 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 211 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 18 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | | | - Todd W. Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V. Cogle
- Auburn University – Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M. Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Perrier Q, Piquemal M, Leenhardt J, Choisnard L, Mazet R, Desruet MD, Durand M, Bedouch P. A quality by design approach for the qualification of automating compounding device for parenteral nutrition. Eur J Pharm Sci 2022; 179:106275. [PMID: 35987326 DOI: 10.1016/j.ejps.2022.106275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/16/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
Automated compounding device (ACD) are increasingly used for parenteral nutrition (PN) bag production, and their acquisition must be sufficiently thought. The law requires the qualification of these ACD, but did not specify the tests to be performed. The quality by design (QbD) risk based approach allowed to define the quality target product profile in order to acquire the best ACD for each unit, and thanks a risk analysis permitted to define the critical quality attributes (CQA). These CQA will allowed to define tests performed during qualification. The ACD qualified was a 12 pump volumetric system. The CQA for PN bags consisted in sterile, precisely and accurately production with enough stability. During operational qualification volumetric accuracy test was performed, and during the performance qualification: flush volume, media fill, microbiological integrity of environment, sterility of control bag and production test were performed. At the end, all tests were conclusive (excepted for some results mostly due to analytical bias) and the ACD was considered to produce sterile bags in a control environment, precisely (relative standard deviation < 4%) and accurately (mean bias < 1% for weight and < 7% for other controls) with a sufficient stability. The QbD risk based approach allowed to acquire the best ACD for our need, and qualify relevant elements regarding the production process.
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Affiliation(s)
- Quentin Perrier
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, INSERM U1055, Laboratory of Fundamental and Applied Bioenergetics, Grenoble, France
| | - Marie Piquemal
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Leenhardt
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, INSERM U1039, Laboratory of Bioclinical Radiopharmaceutics, Grenoble, France
| | - Luc Choisnard
- Univ. Grenoble Alpes, CNRS 5063, DPM, Saint Martin d'Hères, France.
| | - Roseline Mazet
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, CNRS 5063, DPM, Saint Martin d'Hères, France
| | | | - Marjorie Durand
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France.
| | - Pierrick Bedouch
- Department of Pharmacy, Grenoble Alpes University Hospital, Grenoble, France; Univ. Grenoble Alpes, CNRS 5525, TIMC-IMAG, Grenoble, France
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Clauss C, Tack V, Macchiarulo M, Akerman M, El-Chaar G, Hanna N, Tiozzo C. Light protection of parenteral nutrition, cholestasis, and other prematurity-related morbidities in premature infants. Front Pediatr 2022; 10:900068. [PMID: 35989991 PMCID: PMC9381878 DOI: 10.3389/fped.2022.900068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Parenteral Nutrition (PN) can lead to intestinal failure associated liver disease (IFALD). There are no human studies to date studying specifically the benefits of light-protection on neonatal IFALD. Recently, the European Medicines Agency and the American Society for Parenteral and Enteral Nutrition (ASPEN) both recommended full light protection of PN to reduce the risk of adverse clinical outcomes. OBJECTIVE The primary objective of this study was to evaluate the impact of light-protecting PN on the incidence of cholestasis and peak direct bilirubin levels in premature infants. STUDY DESIGN Retrospective chart review of preterm infants requiring PN for a minimum of 2 weeks with or without light-protection. After light protection of the PN solution, primary outcomes (including cholestasis and direct bilirubin levels) of both groups were compared. Secondary outcomes include evaluation of bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), sepsis and mortality. RESULTS A total of 50 preterm infants <37 weeks gestation were included, 25 infants in each group. There was a statistically significant decrease in the rate of cholestasis (12 vs. 3, p = 0.005), median peak direct bilirubin levels (1.7 vs. 0.9 mg/dL, p = 0.02) and total bilirubin levels (4.1 vs. 3.4, p = 0.05) in the light-protection group compared to no light-protection group. There was a decrease in the incidence of severe BPD (with an increase of mild BPD, resulting in the same overall BPD rate) in the light-protection compared to no light-protection group (7 vs. 15, p = 0.0223). There was no difference in NEC, ROP, sepsis or mortality. CONCLUSION Our study supports that the practice of light-protecting PN may reduce the incidence of IFALD in premature infants. Moreover, there was a trend toward decreased incidence of severe BPD in the light-protection group. Further light protection studies are needed to confirm these findings.
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Affiliation(s)
- Christie Clauss
- Department of Pharmacy, NYU Langone Hospital-Long Island, Mineola, NY, United States
| | - Valentyna Tack
- Department of Neonatology, Children's National Hospital, Washington, DC, United States
| | - Maria Macchiarulo
- Department of Pharmacy, Hassenfeld Children's Hospital at NYU Langone, New York, NY, United States
| | - Meredith Akerman
- Department of Foundations of Medicine, NYU Langone Hospital-Long Island, Mineola, NY, United States
| | - Gladys El-Chaar
- Department of Pharmacy, NYU Langone Hospital-Long Island, Mineola, NY, United States.,Department of Pharmacy, St. John's University College of Pharmacy and Health Sciences, Queens, NY, United States
| | - Nazeeh Hanna
- Division of Neonatology, Department of Pediatrics, New York University Long Island School of Medicine, Mineola, NY, United States
| | - Caterina Tiozzo
- Division of Neonatology, Department of Pediatrics, New York University Long Island School of Medicine, Mineola, NY, United States
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Boullata JI, Mirtallo JM, Sacks GS, Salman G, Gura K, Canada T, Maguire A. Parenteral nutrition compatibility and stability: A comprehensive review. JPEN J Parenter Enteral Nutr 2021; 46:273-299. [PMID: 34788478 DOI: 10.1002/jpen.2306] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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 ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joseph I Boullata
- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jay M Mirtallo
- Clinical Practice Specialist, American Society for Parenteral and Enteral Nutrition, Professor Emeritus, The Ohio State University, College of Pharmacy, Columbus, OH
| | - Gordon S Sacks
- Senior Director, Medical Affairs for PN Market Unit, Fresenius Kabi USA, LLC, Lake Zurich, IL
| | - Genene Salman
- Assistant Professor of Pharmacy Practice, Marshall B. Ketchum University, College of Pharmacy, Department of Pharmacy Practice, Fullerton, CA
| | - Kathleen Gura
- Manager, Pharmacy Clinical research Program/Clinical Specialist GI/Nutrition, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA
| | - Todd Canada
- Clinical Pharmacy Services Manager & Nutrition Support Team Coordinator, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Angela Maguire
- Clinical Pharmacist, BJC HomeCare Infusions, Overland, MO
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- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
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Cober MP, Gura KM, Mirtallo JM, Ayers P, Boullata J, Anderson CR, Plogsted S. ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations. Nutr Clin Pract 2021; 36:1106-1125. [PMID: 34705289 DOI: 10.1002/ncp.10778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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Affiliation(s)
- M Petrea Cober
- Neonatal Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA.,College of Pharmacy, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kathleen M Gura
- Pharmacy Clinical Research Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA.,College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, Mississippi, USA
| | - Joseph Boullata
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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