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Ayers P, Berger MM, Berlana D, Cogle SV, De Cloet J, Gray B, Klek S, Kumpf VJ, Monczka J, Ybarra J, Zeraschi S, Wischmeyer PE. Expert consensus statements and summary of proceedings from the International Safety and Quality of Parenteral Nutrition Summit. Am J Health Syst Pharm 2024; 81:S75-S88. [PMID: 38869255 PMCID: PMC11170495 DOI: 10.1093/ajhp/zxae078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
PURPOSE The International Safety and Quality of Parenteral Nutrition (PN) Summit consisted of presentations, discussions, and formulation of consensus statements. The purpose here is to briefly summarize the summit and to present the consensus statements. SUMMARY There was a high degree of consensus, with all statements approved by all authors/summit experts. These consensus statements should be regarded not as formal guidelines but rather as best-practice guidance intended to complement national and international nutrition society evidence-based guidelines and position statements. This article also summarizes key discussion topics from the summit, encompassing up-to-date knowledge and practical guidance concerning PN safety and quality in various countries and clinical settings, focusing on adult patients. Clear geographical differences exist between practices in Europe and the United States, and different approaches to improve the safety, quality, and cost-effectiveness of PN vary, particularly with regard to the delivery systems used. Discussion between experts allowed for an exchange of practical experience in optimizing PN use processes, opportunities for standardization, use of electronic systems, potential improvements in PN formulations, better management during PN component shortages, and practical guidance to address patients' needs, particularly during long-term/home PN. CONCLUSION The consensus statements are the collective opinion of the panel members and form best-practice guidance. The authors intend that this guidance may help to improve the safety and quality of PN in a variety of settings by bridging the gap between published guideline recommendations and common practical issues.
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Affiliation(s)
- Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, MS
- University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Berlana
- Pharmacy Service, Vall d’Hebron Barcelona Hospital Campus and Department of Pharmacology, Toxicology and Therapeutic Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain
| | - Sarah V Cogle
- Department of Pharmacy, Clinical Programs, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joeri De Cloet
- Pharmacy Department, Ghent University Hospital, Ghent, Belgium
| | | | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland
| | - Vanessa J Kumpf
- Center for Human Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Sarah Zeraschi
- Pharmacy Department and Nutrition and Intestinal Failure Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
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2
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Cogle SV, Ayers P, Berger MM, Berlana D, Wischmeyer PE, Ybarra J, Zeraschi S, De Cloet J. Parenteral nutrition in the hospital setting/short-term parenteral nutrition. Am J Health Syst Pharm 2024; 81:S102-S111. [PMID: 38869256 PMCID: PMC11170504 DOI: 10.1093/ajhp/zxae080] [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] [Indexed: 06/14/2024] Open
Abstract
PURPOSE This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely. SUMMARY Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries. CONCLUSION The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.
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Affiliation(s)
- Sarah V Cogle
- Department of Pharmacy, Clinical Programs, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, MS, USA
| | - Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Berlana
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus and Department of Pharmacology, Toxicology and Therapeutic Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Sarah Zeraschi
- Pharmacy Department and Nutrition and Intestinal Failure Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joeri De Cloet
- Pharmacy Department, Ghent University Hospital, Ghent, Belgium
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Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, Lichota M, Mühlebach S, Van Gossum A, Wanten G, Wheatley C, Bischoff SC. ESPEN practical guideline: Home parenteral nutrition. Clin Nutr 2023; 42:411-430. [PMID: 36796121 DOI: 10.1016/j.clnu.2022.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023]
Abstract
This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion catheter and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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Affiliation(s)
- Loris Pironi
- University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS AOUBO, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy.
| | - Kurt Boeykens
- Vitaz Hospital, Nutrition Support Team, Sint-Niklaas, Belgium
| | | | - Francisca Joly
- Beaujon Hospital, APHP, University of Paris VII, Clichy, France
| | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland
| | - Simon Lal
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology and Hospital Pharmacy, University of Basel, Basel, Switzerland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), UK
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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Goh RJL, Li H, Cheah MCC, Salazar E. The use of standardized commercially available parenteral nutrition as a bridge to customized compounded bag in the acute hospital setting is safe and feasible. Clin Nutr ESPEN 2022; 47:321-324. [DOI: 10.1016/j.clnesp.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/07/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale RG, Waitzberg D, Bischoff SC, Singer P. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. [PMID: 34242915 DOI: 10.1016/j.clnu.2021.03.031] [Citation(s) in RCA: 212] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Marco Braga
- University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Franco Carli
- Department of Anesthesia of McGill University, School of Nutrition, Montreal General Hospital, Montreal, Canada
| | | | - Martin Hübner
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Lausanne, Lausanne, Switzerland
| | - Stanislaw Klek
- General Surgical Oncology Clinic, National Cancer Institute, Krakow, Poland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | | | - Dan Waitzberg
- University of Sao Paulo Medical School, Ganep, Human Nutrition, Sao Paulo, Brazil
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
| | - Pierre Singer
- Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel
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Layec S, Seynhaeve E, Trivin F, Carsin-Mahé M, Dussaulx L, Picot D. Management of entero-atmospheric fistulas by chyme reinfusion: A retrospective study. Clin Nutr 2020; 39:3695-3702. [DOI: 10.1016/j.clnu.2020.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/01/2020] [Accepted: 03/27/2020] [Indexed: 02/06/2023]
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7
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Cogle SV, Martindale RG, Ramos M, Roberti GJ, Roberts PR, Taylor K, Sacks GS. Multicenter Prospective Evaluation of Parenteral Nutrition Preparation Time and Resource Utilization: 3-Chamber Bags Compared With Hospital Pharmacy-Compounded Bags. JPEN J Parenter Enteral Nutr 2020; 45:1552-1558. [PMID: 33188572 DOI: 10.1002/jpen.2045] [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: 04/30/2020] [Revised: 10/16/2020] [Accepted: 11/06/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Sarah V Cogle
- Department of Pharmacy Practice, Auburn University, Auburn, Alabama, USA.,Department of Pharmacy, East Alabama Medical Center, Opelika, Alabama, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Gregory J Roberti
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Pamela R Roberts
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Kaci Taylor
- Department of Pharmacy, OU Medical Center, Oklahoma City, Oklahoma, USA
| | - Gordon S Sacks
- Department of Pharmacy Practice, Auburn University, Auburn, Alabama, USA.,Medical Affairs, Fresenius Kabi, LLC, Lake Zurich, Illinois, USA
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Cost-Consequences Analysis of Increased Utilization of Triple-Chamber-Bag Parenteral Nutrition in Preterm Neonates in Seven European Countries. Nutrients 2020; 12:nu12092531. [PMID: 32825528 PMCID: PMC7551227 DOI: 10.3390/nu12092531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 11/29/2022] Open
Abstract
The safety of parenteral nutrition (PN) remains a concern in preterm neonates, impacting clinical outcomes and health-care-resource use and costs. This cost-consequence analysis assessed national-level impacts of a 10-percentage point increase in use of industry-prepared three-chamber bags (3CBs) on clinical outcomes, healthcare resources, and hospital budgets across seven European countries. A ten-percentage-point 3CB use-increase model was developed for Belgium, France, Germany, Italy, Portugal, Spain, and the UK. The cost-consequence analysis estimated the impact on compounding error harm and bloodstream infection (BSI) rates, staff time, and annual hospital budget. Of 265,000 (52%) preterm neonates, 133,000 (52%) were estimated to require PN. Baseline compounding methods were estimated as 43% pharmacy manual, 16% pharmacy automated, 22% ward, 9% outsourced, 3% industry provided non-3CBs, and 7% 3CBs. A modeled increased 3CB use would change these values to 39%, 15%, 18%, 9%, 3%, and 17%, respectively. Modeled consequences included −11.6% for harm due to compounding errors and −2.7% for BSIs. Labor time saved would equate to 41 specialized nurses, 29 senior pharmacists, 26 pharmacy assistants, and 22 senior pediatricians working full time. Budget impact would be a €8,960,601 (3.4%) fall from €260,329,814 to €251,369,212. Even a small increase in the use of 3CBs in preterm neonates could substantially improve neonatal clinical outcomes, and provide notable resource and cost savings to hospitals.
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9
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Picot D, Layec S, Seynhaeve E, Dussaulx L, Trivin F, Carsin-Mahe M. Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas. Nutrients 2020; 12:nu12051376. [PMID: 32403450 PMCID: PMC7285017 DOI: 10.3390/nu12051376] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022] Open
Abstract
Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm (n = 232), and the length of distal small intestine was 117 ± 72 cm (n = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.
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10
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Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, Lichota M, Mühlebach S, Van Gossum A, Wanten G, Wheatley C, Bischoff SC. ESPEN guideline on home parenteral nutrition. Clin Nutr 2020; 39:1645-1666. [PMID: 32359933 DOI: 10.1016/j.clnu.2020.03.005] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 02/07/2023]
Abstract
This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Kurt Boeykens
- AZ Nikolaas Hospital, Nutrition Support Team, Sint-Niklaas, Belgium
| | | | - Francisca Joly
- Beaujon Hospital, APHP, Clichy, University of Paris VII, France
| | | | - Simon Lal
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology and Hospital Pharmacy, University of Basel, Basel, Switzerland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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Hellerman Itzhaki M, Singer P. Advances in Medical Nutrition Therapy: Parenteral Nutrition. Nutrients 2020; 12:E717. [PMID: 32182654 PMCID: PMC7146311 DOI: 10.3390/nu12030717] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/29/2020] [Accepted: 02/29/2020] [Indexed: 01/08/2023] Open
Abstract
Parenteral nutrition has evolved tremendously, with parenteral formulas now safer and more accessible than ever. "All-in-one" admixtures are now available, which simplify parenteral nutrition usage and decrease line infection rates alongside other methods of infectious control. Recently published data on the benefits of parenteral nutrition versus enteral nutrition together with the widespread use of indirect calorimetry solve many safety issues that have emerged over the years. All these advances, alongside a better understanding of glycemic control and lipid and protein formulation improvements, make parenteral nutrition a safe alternative to enteral nutrition.
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Affiliation(s)
| | - Pierre Singer
- Department of General Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva 49100, Israel;
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12
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Berlana D, Almendral MA, Abad MR, Fernández A, Torralba A, Cervera‐Peris M, Piñeiro G, Romero‐Jiménez R, Vázquez A, Ramírez E, Yébenes M, Muñoz Á. Cost, Time, and Error Assessment During Preparation of Parenteral Nutrition: Multichamber Bags Versus Hospital‐Compounded Bags. JPEN J Parenter Enteral Nutr 2018; 43:557-565. [DOI: 10.1002/jpen.1436] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/02/2018] [Accepted: 07/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- David Berlana
- Vall d´Hebron Barcelona Hospital Campus Barcelona Spain
| | | | | | | | | | | | | | | | - Amparo Vázquez
- La Fe University and Politechnic Hospital Valencia Spain
| | | | - María Yébenes
- Pharmacoeconomics & Outcomes‐Research‐Iberia Pozuelo de Alarcón Spain
| | - Álvaro Muñoz
- Pharmacoeconomics & Outcomes‐Research‐Iberia Pozuelo de Alarcón Spain
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13
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Parenteral nutrition in the ICU: Lessons learned over the past few years. Nutrition 2018; 59:188-194. [PMID: 30529820 DOI: 10.1016/j.nut.2018.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 08/11/2018] [Accepted: 08/11/2018] [Indexed: 02/07/2023]
Abstract
Since the early 1990s enteral nutrition (EN) has been considered the optimal route of feeding rather than parenteral nutrition (PN), which was considered harmful in critically ill patients with intense inflammation. The aim of this review was to summarize recent developments and progress in PN, which have changed the view on this feeding technique. PubMed and personal databases were searched for studies and reviews reporting historical development of PN, and for clinical trials conducted after 2010 investigating PN in critical illness, comparing it to EN or not. Trials from the past decade have explored modalities and timing of artificial feeding. Trials based on equation-estimated energy targets and applying an early full feeding strategy have generally had negative results in terms of complications (infections, prolonged ventilation, and intestinal complications with EN). The few trials that based their targets on measured energy targets have achieved reduction of complications regardless of the route. Opposing enteral and parenteral feeding is no longer rational in the critical care setting. A pragmatic and reasonable approach offers better options for the individual patient. Although PN is simpler to deliver than EN, its metabolic consequences are more complicated to handle. A combination of both techniques may be a more reasonable approach in the sickest patients.
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14
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Krueger CK, Canada TW. Determining Efficacy, Safety, and Preparation of Standardized Parenteral Nutrition. Nutr Clin Pract 2018; 33:158-159. [DOI: 10.1002/ncp.10025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Chelsea K. Krueger
- Division of Pharmacy; University of Texas MD Anderson Cancer Center; Houston Texas USA
| | - Todd W. Canada
- Division of Pharmacy; University of Texas MD Anderson Cancer Center; Houston Texas USA
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15
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De Cloet J, Van Biervliet S, Van Winckel M. Physicochemical stable standard all-in-one parenteral nutrition admixtures for infants and children in accordance with the ESPGHAN/ESPEN guidelines. Nutrition 2017; 49:41-47. [PMID: 29571608 DOI: 10.1016/j.nut.2017.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Because there are almost no standard all-in-one parenteral nutrition admixtures available for infants and children, the aim was to develop standard two-compartment parenteral nutrition bags for different weight categories based on the ESPGHAN/ESPEN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Clinical Nutrition and Metabolism) guidelines. The 1 g/kg/d lipid version for the 3 to 10 kg weight category (PED1) was assessed for short- and long-term physicochemical stability with the ability to add additional electrolytes (PED1+E). METHODS The lipid compartment A and the all-in-one admixture of A + B + vitamins + trace elements were assessed physically by visual inspection, Sudan red test, pH measurement, and lipid droplet size distribution. Chemical stability for compartment A was evaluated by quantitative analyses of non-esterified fatty acids and peroxide content. The glucose-amino acid-electrolyte compartment B was evaluated physically by visual inspection, measuring particle contamination and pH. Chemical stability was assessed by discoloration, quantitative analyses of glucose, and the amino acids L-cysteine, L-tyrosine, and L-tryptophan. RESULTS No phase separation or coalescence occurred, and the mean droplet size diameter did not exceed 0.5 µm. Peroxide content and non-esterified fatty acids concentration of compartment A remained well below the limit of acceptation. No precipitation was detected for compartment B; only a slight yellow discoloration was noted at 80 d. Concentrations of glucose, L-tyrosine, and L-tryptophan remained stable; only L-cysteine decreased significantly from its initial concentration. CONCLUSION The two-compartment PED1 and PED1+E admixtures are stable up to 80 d 2° to 8°C + 24 h room temperature (RT) with an additional 7 d 2° to 8°C + 48 h RT after mixing and addition of vitamins and trace elements.
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Affiliation(s)
- Joeri De Cloet
- Pharmacy department, University Hospital Ghent, Ghent, Belgium.
| | | | - Myriam Van Winckel
- Paediatric Gastroenterology department, University Hospital Ghent, Ghent, Belgium
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 960] [Impact Index Per Article: 137.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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Yu J, Wu G, Tang Y, Ye Y, Zhang Z. Efficacy, Safety, and Preparation of Standardized Parenteral Nutrition Regimens: Three-Chamber Bags vs Compounded Monobags-A Prospective, Multicenter, Randomized, Single-Blind Clinical Trial. Nutr Clin Pract 2017; 32:545-551. [PMID: 28537849 PMCID: PMC5542131 DOI: 10.1177/0884533617701883] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Parenteral nutrition (PN) covering the need for carbohydrates, amino acids, and lipids can either be compounded from single nutrients or purchased as an industrially manufactured ready-to-use regimen. This study compares a commercially available 3-chamber bag (study group) with a conventionally compounded monobag regarding nutrition efficacy, safety, and regimen preparation time. Materials and Methods: This prospective, randomized, single-blind study was conducted at 5 Chinese hospitals from October 2010–October 2011. Postsurgical patients requiring PN for at least 6 days were randomly assigned to receive the study or control regimen. Plasma concentrations of prealbumin and C-reactive protein (CRP), regimen preparation time, length of hospital stay (LOS), 30-day mortality, safety laboratory parameters, and adverse events (AEs) were recorded. Results: In total, 240 patients (121 vs 119 in study and control groups) participated in this study. Changes in prealbumin concentrations during nutrition support (ΔPrealb(StudyGroup) = 2.65 mg/dL, P < .001 vs ΔPrealb(ControlGroup) = 0.27 mg/dL, P = .606) and CRP values were comparable. Regimen preparation time was significantly reduced in the study group by the use of 3-chamber bags (t(StudyGroup) = 4.90 ± 4.41 minutes vs t(ControlGroup) = 12.13 ± 5.62 minutes, P < .001). No differences were detected for LOS, 30-day mortality, safety laboratory parameters, and postoperative AEs (37 vs 38 in study and control groups). Conclusion: The PN regimen provided by the 3-chamber bag was comparable to the compounded regimen and safe in use. Time savings during regimen preparation indicates that use of 3-chamber bags simplifies the process of regimen preparation.
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Affiliation(s)
- Jianchun Yu
- 1 Department of General Surgery, Peking Union Medical College Hospital, CAMS&PUMC, Beijing, China
| | - Guohao Wu
- 2 Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yun Tang
- 3 Department of General Surgery, The PLA General Hospital of China, Beijing, China
| | - Yingjiang Ye
- 4 Department of General Surgery, Peking University People's Hospital, Beijing, China
| | - Zhongtao Zhang
- 5 Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Cotogni P. Management of parenteral nutrition in critically ill patients. World J Crit Care Med 2017; 6:13-20. [PMID: 28224103 PMCID: PMC5295165 DOI: 10.5492/wjccm.v6.i1.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/10/2016] [Accepted: 12/09/2016] [Indexed: 02/06/2023] Open
Abstract
Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.
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Kochevar M, Guenter P, Holcombe B, Malone A, Mirtallo J. A.S.P.E.N. Statement on Parenteral Nutrition Standardization. JPEN J Parenter Enteral Nutr 2017; 31:441-8. [PMID: 17712154 DOI: 10.1177/0148607107031005441] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.
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Pradelli L, Graf S, Pichard C, Berger MM. Supplemental parenteral nutrition in intensive care patients: A cost saving strategy. Clin Nutr 2017; 37:573-579. [PMID: 28169021 DOI: 10.1016/j.clnu.2017.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS The Swiss supplemental parenteral nutrition (SPN) study demonstrated that optimised energy provision combining enteral nutrition (EN) and SPN reduces nosocomial infections in critically ill adults who fail to achieve targeted energy delivery with EN alone. To assess the economic impact of this strategy, we performed a cost-effectiveness analysis using data from the SPN study. METHODS Multivariable regression analyses were performed to characterise the relationships between SPN, cumulative energy deficit, nosocomial infection, and resource consumption. The results were used as inputs for a deterministic simulation model evaluating the cost-effectiveness of SPN administered on days 4-8 in patients who fail to achieve ≥60% of targeted energy delivery with EN by day 3. Cost data were derived primarily from Swiss diagnosis-related case costs and official labour statistics. RESULTS Provision of SPN on days 4-8 was associated with a mean decrease of 2320 ± 338 kcal in cumulative energy deficit compared with EN alone (p < 0.001). Logistic regression analysis showed that each 1000 kcal decrease in cumulative energy deficit was associated with a 10% reduction in the risk of nosocomial infection (odds ratio 0.90; 95% confidence interval 0.83-0.99; p < 0.05). The incremental cost per avoided infection was -63,048 CHF, indicating that the reduction in infection was achieved at a lower cost. CONCLUSION Optimisation of energy provision using SPN is a cost-saving strategy in critically ill adults for whom EN is insufficient to meet energy requirements.
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Affiliation(s)
- Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, Via Vittorio Alfieri, 17, 10121 Turin, Italy.
| | - Séverine Graf
- Service des Soins Intensifs, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; Nutrition Unit, Division of Intensive Care, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Genève Switzerland
| | - Claude Pichard
- Nutrition Unit, Division of Intensive Care, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Genève Switzerland
| | - Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne Switzerland
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Derenski K, Catlin J, Allen L. Parenteral Nutrition Basics for the Clinician Caring for the Adult Patient. Nutr Clin Pract 2016; 31:578-95. [PMID: 27440772 DOI: 10.1177/0884533616657650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Parenteral nutrition (PN) is a life-sustaining therapy providing nutrients to individuals with impaired intestinal tract function and enteral access challenges. It is one of the most complex prescriptions written routinely in the hospital and home care settings. This article is to aid the nutrition support clinician in the safe provision of PN, including selecting appropriate patients for PN, vascular access, development of a PN admixture, appropriate therapy monitoring, recognition of preparation options, and awareness of preparation and stability concerns.
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Affiliation(s)
| | | | - Livia Allen
- CoxHealth Medical Centers, Springfield, Missouri, USA
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Alfonso JE, Berlana D, Ukleja A, Boullata J. Clinical, Ergonomic, and Economic Outcomes With Multichamber Bags Compared With (Hospital) Pharmacy Compounded Bags and Multibottle Systems: A Systematic Literature Review. JPEN J Parenter Enteral Nutr 2016; 41:1162-1177. [DOI: 10.1177/0148607116657541] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Andrew Ukleja
- Gastroenterology, Cleveland Clinic, Weston, Florida, USA
| | - Joseph Boullata
- Hospital of the University of Pennsylvania, and Drexel University, Philadelphia, Pennsylvania, USA
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Chhim RF, Crill CM. Premixed Parenteral Nutrition Solution Use in Children. J Pediatr Pharmacol Ther 2015; 20:378-84. [DOI: 10.5863/1551-6776-20.5.378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES: In response to national drug shortages, our institution established criteria for the use of commercial premixed parenteral nutrition (PN) solutions in select pediatric patients. Although these solutions have been marketed for use in children, there are no data in this patient population. The objective of this study was to review our use of commercial premixed PN solutions in children.
METHODS: This was a retrospective review of patients ≤18 years of age who received a premixed PN solution from October 2010 to April 2012. All premixed PN courses were assessed for incidence of premixed PN discontinuation due to laboratory abnormalities. Estimated goal and actual protein and total caloric intake were evaluated for premixed PN courses that were continued for >48 hours.
RESULTS: Sixty-nine patients received 74 courses of premixed PN solutions for a mean duration of 5.6 ± 6.2 (range, 1–31) days. Fifteen courses (20%) required discontinuation of premixed PN as a result of mild laboratory abnormalities. No changes in clinical status were observed in patients and all abnormalities were corrected after switching to individualized PN. In patients receiving PN for >48 hours, premixed PN solutions provided goal protein in 48/49 (98%) courses and goal calories in 33/49 (67%) courses.
CONCLUSIONS: Premixed PN solutions were used in a wide range of pediatric patients and provide a potential option for PN support in pediatric patients when drug shortages limit PN product supply. Close monitoring for electrolyte abnormalities and protein and caloric intake is recommended when using premixed PN solutions in children.
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Affiliation(s)
- Rebecca F. Chhim
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Catherine M. Crill
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
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Wojda TR, Mohammed O, Evans DC. Perioperative Nutrition Support for Surgical Patients: Aspects and Commentary. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0106-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Parenteral nutrition admixtures for pediatric patients compounded with highly refined fish oil-based emulsion: Assessment of physicochemical stability - Letter to Editor. Clin Nutr 2015; 34:781-2. [PMID: 25933443 DOI: 10.1016/j.clnu.2015.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/06/2015] [Indexed: 11/21/2022]
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Berger MM, Pichard C. Development and current use of parenteral nutrition in critical care - an opinion paper. Crit Care 2014; 18:478. [PMID: 25184816 PMCID: PMC4423637 DOI: 10.1186/s13054-014-0478-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 07/24/2014] [Indexed: 02/07/2023] Open
Abstract
Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.
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Affiliation(s)
- Mette M Berger
- Service de Médecine Intensive Adulte et Brûlés, Lausanne University Hospital (CHUV), 1011, Lausanne, Switzerland.
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, 14, Switzerland.
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Berger MM. The 2013 Arvid Wretlind lecture: Evolving concepts in parenteral nutrition. Clin Nutr 2014; 33:563-70. [DOI: 10.1016/j.clnu.2014.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/02/2014] [Accepted: 03/18/2014] [Indexed: 12/12/2022]
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Magee G, Zaloga GP, Turpin RS, Sanon M. A retrospective, observational study of patient outcomes for critically ill patients receiving parenteral nutrition. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:328-333. [PMID: 24968991 DOI: 10.1016/j.jval.2014.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 01/09/2014] [Accepted: 02/18/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate health care-related utilization for critically ill patients receiving parenteral nutrition (PN) administered via a premixed multichamber bag (MCB) or compounded solutions (COM). DESIGN A retrospective database analysis of critically ill patients (intensive care unit stay ≥ 3 days) receiving PN and discharged between January 1, 2010, and June 30, 2011, using the Premier Hospital Database. Patients were identified as receiving MCB or COM on the basis of product description codes. Primary outcomes were length of stay (LOS) and total costs. Comorbidities and clinical outcomes were identified using International Classificaion of Diseases, Ninth Revision diagnosis codes. All costs reported were for inpatient services only. Patients receiving MCB and COM were matched on key patient and hospital characteristics using a propensity score methodology. Multivariate regression models for cost and LOS used generalized linear models with a log link and gamma distribution. RESULTS A total of 42,631 patients met the inclusion criteria (MCB = 5,679; COM = 36,952), and the final matched population included 3,559 patients from each cohort. Baseline patient and hospital characteristics were well matched between groups. Adjusted multivariate models demonstrated a small difference between groups for LOS (MCB = 9.40 days vs. COM = 9.65 days; P = 0.014). In addition, patients receiving MCB incurred approximately 9.1% less in total costs (MCB = $37,790 vs. COM = $41,569; P < 0.001). CONCLUSIONS Overall, patients receiving MCB and COM experienced similar LOS, though patients receiving MCB had significantly lower overall costs. Interpretation of the study findings is subject to several limitations, and additional studies that include explicit identification of the method for compounding are needed.
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Affiliation(s)
| | - Gary P Zaloga
- Global Medical Affairs, Baxter Healthcare, Deerfield, IL, USA
| | - Robin S Turpin
- Global Health Economics and Outcomes Research, Deerfield, IL, USA; Health Delivery Systems and Pharmacoeconomics, Takeda Pharmaceuticals, Deerfield, IL, USA; Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA
| | - Myrlene Sanon
- Global Health Economics and Outcomes Research, Deerfield, IL, USA.
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Bigioni F, Verlato G, De Lorenzi L, Frigo AC, Gaio P, Di Lenardo E, Bertazzo A, Chiandetti L. Assessment of standardised parenteral nutrition in paediatrics. Eur J Clin Nutr 2014; 68:535-6. [DOI: 10.1038/ejcn.2013.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bozat E, Korubuk G, Onar P, Abbasoglu O. Cost analysis of premixed multichamber bags versus compounded parenteral nutrition: breakeven point. Hosp Pharm 2014; 49:170-6. [PMID: 24623870 PMCID: PMC3940682 DOI: 10.1310/hpj4902-170] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Industrially premixed multichamber bags or hospital-manufactured compounded products can be used for parenteral nutrition. The aim of this study was to compare the cost of these 2 approaches. MATERIALS AND METHODS Costs of compounded parenteral nutrition bags in an university hospital were calculated. A total of 600 bags that were administered during 34 days between December 10, 2009 and February 17, 2010 were included in the analysis. For quality control, specific gravity evaluation of the filled bags was performed. RESULTS It was calculated that the variable cost of a hospital compounded bag was $26.15. If we take the annual fixed costs into consideration, the production cost reaches $36.09 for each unit. It was estimated that the cost for the corresponding multichamber bag was $37.79. Taking the fixed and the variable costs into account, the breakeven point of the hospital compounded and the premixed multichamber bags was seen at 5,404 units per year. In specific gravity evaluation, it was observed that the mean and interval values were inside the upper and lower control margins. CONCLUSION In this analysis, usage of hospital-compounded parenteral nutrition bags showed a cost advantage in hospitals that treat more than 15 patients per day. In small volume hospitals, premixed multichamber bags may be more beneficial.
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Affiliation(s)
- Erkut Bozat
- Institute of Social Sciences, İstanbul Bilgi University, Istanbul, Turkey
- Eczacibasi-Baxter, Istanbul, Turkey
| | - Gamze Korubuk
- Hospital Pharmacy, Hacettepe University Teaching Hospital, Ankara, Turkey
| | - Pelin Onar
- Nutrition Support Team, Hacettepe University Teaching Hospital, Ankara, Turkey
| | - Osman Abbasoglu
- Department of General Surgery, Hacettepe University Teaching Hospital, Ankara, Turkey
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Thibault R, Graf S, Clerc A, Delieuvin N, Heidegger CP, Pichard C. Diarrhoea in the ICU: respective contribution of feeding and antibiotics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R153. [PMID: 23883438 PMCID: PMC4056598 DOI: 10.1186/cc12832] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/09/2013] [Indexed: 02/08/2023]
Abstract
Introduction Diarrhoea is frequently reported in the ICU. Little is known about diarrhoea incidence and the role of the different risk factors alone or in combination. This prospective observational study aims at determining diarrhoea incidence and risk factors in the first 2 weeks of ICU stay, focusing on the respective contribution of feeding, antibiotics, and antifungal drugs. Methods Out of 422 patients consecutively admitted into a mixed medical–surgical ICU during a 2-month period, 278 patients were included according to the following criteria: ICU stay >24 hours, no admission diagnosis of gastrointestinal bleeding, and absence of enterostomy or colostomy. Diarrhoea was defined as at least three liquid stools per day. Diarrhoea episodes occurring during the first day in the ICU, related to the use of laxative drugs or Clostridium difficile infection, were not analysed. Multivariate and stratified analyses were performed to determine diarrhoea risk factors, and the impact of the combination of enteral nutrition (EN) with antibiotics or antifungal drugs. Results A total of 1,595 patient-days were analysed. Diarrhoea was observed in 38 patients (14%) and on 83 patient-days (incidence rate: 5.2 per 100 patient-days). The median day of diarrhoea onset was the sixth day, and 89% of patients had ≤4 diarrhoea days. The incidence of C. difficile infection was 0.7%. Diarrhoea risk factors were EN covering >60% of energy target (relative risk = 1.75 (1.02 to 3.01)), antibiotics (relative risk = 3.64 (1.26 to 10.51)) and antifungal drugs (relative risk = 2.79 (1.16 to 6.70)). EN delivery per se was not a diarrhoea risk factor. In patients receiving >60% of energy target by EN, diarrhoea risk was increased by the presence of antibiotics (relative risk = 4.8 (2.1 to 13.7)) or antifungal drugs (relative risk = 5.0 (2.8 to 8.7)). Conclusion Diarrhoea incidence during the first 2 weeks in a mixed population of patients in a tertiary ICU is 14%. Diarrhoea risk factors are EN covering >60% of energy target, use of antibiotics, and use of antifungal drugs. The combination of EN covering >60% of energy target with antibiotics or antifungal drugs increases the incidence of diarrhoea.
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Simmer K, Rakshasbhuvankar A, Deshpande G. Standardised parenteral nutrition. Nutrients 2013; 5:1058-70. [PMID: 23538938 PMCID: PMC3705334 DOI: 10.3390/nu5041058] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/18/2013] [Accepted: 03/19/2013] [Indexed: 11/16/2022] Open
Abstract
Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.
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Affiliation(s)
- Karen Simmer
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women and Princess Margaret Hospital for Children, Subiaco, WA 6008, Australia; E-Mail:
- Centre of Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Crawley, WA 6009, Australia
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +61-893-401-260; Fax: +61-893-401-266
| | - Abhijeet Rakshasbhuvankar
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women and Princess Margaret Hospital for Children, Subiaco, WA 6008, Australia; E-Mail:
| | - Girish Deshpande
- Department of Neonatal Paediatrics, Nepean Hospital, Kingswood, NSW 2747, Australia; E-Mail:
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW 2747, Australia
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Walter E, Liu FX, Maton P, Storme T, Perrinet M, von Delft O, Puntis J, Hartigan D, Dragosits A, Sondhi S. Cost analysis of neonatal and pediatric parenteral nutrition in Europe: a multi-country study. Eur J Clin Nutr 2012; 66:639-44. [PMID: 22252109 DOI: 10.1038/ejcn.2011.225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Parenteral nutrition (PN) is critical in neonatal and pediatric care for patients unable to tolerate enteral feeding. This study assessed the total costs of compounding PN therapy for neonates, infants and children. METHODS Face-to-face and telephone interviews were conducted in 12 hospitals across four European countries (Belgium, France, Germany and UK) to collect information on resources utilized to compound PN, including nutrients, staff time, equipment cost and supplies. A bottom-up cost model was constructed to assess total costs of PN therapy by assigning monetary values to the resource utilization using published list prices and interview data. RESULTS A total of 49,922 PN bags per year were used to treat 4295 neonatal and pediatric patients among these hospitals. The daily total costs of one compounded PN bag for neonates in the 12 hospitals across the four countries equalled euro 55.16 (Belgium euro 53.26, France euro 46.23, Germany euro 64.05, UK Ł 37.43/\[euro]42.86). Overall, nutrients accounted for 25% of total costs, supplies 18%, wages 54% and equipment 3%. Average costs per bag for infants <2 year were euro 84.52 (euro 74.65 in Belgium, euro 83.84 in France, euro 92.70 in Germany and Ł 52.63/euro 60.26 in the UK), and for children 2-18 years euro 118.02 (euro 93.85 in Belgium, euro 121.35 in France, euro 124.54 in Germany and Ł 69.49/euro 79.56 in the UK), of which 63% is attributable to nutrients and 28% to wages. CONCLUSION The data indicated that PN costs differ among countries and a major proportion was due to staff time (Ł 1=euro 1.144959).
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Affiliation(s)
- E Walter
- Institute for Pharmacoeconomic Research, Vienna, Austria.
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Abstract
Professor Pennington was an advocate for quality in all aspects of nutrition support and its delivery, ensuring that the patient remained at the centre of all decisions, and that specialist artificial nutrition support was best managed by the multidisciplinary nutrition team and the education of the wider healthcare community. Within the conference theme of ‘Quality’, this commentary aims to outline drivers for and risks to aspects of quality in parenteral nutrition (PN) services. Quality is defined as a particular property or attribute associated with excellence; in the context of the provision of PN this can be translated to quality processes and standards in the assessment, prescription, preparation, administration and monitoring of PN. Quality products and services are delivered through the timely application of knowledge, competence, procedures and standards. Quality can be so easily compromised; inattention, ignorance and arrogance all play their part. PN is a high-risk therapy; the quality of its delivery should not be entirely dependent on the skills, knowledge and competence of those delivering this care but on accepted standards, procedures, communication, resource and infrastructure. Identification of key steps in the provision of PN and a review of the relevant patient safety data reveal points where safeguards can be put in place to ensure quality is not compromised. Full evaluation of standardisation, computerisation and competency-based training as risk-reduction strategies is required.
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Mühlebach S, Franken C, Stanga Z. Practical handling of AIO admixtures - Guidelines on Parenteral Nutrition, Chapter 10. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2009; 7:Doc18. [PMID: 20049073 PMCID: PMC2795373 DOI: 10.3205/000077] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 11/30/2022]
Abstract
All-in-one admixtures (AIO-admixtures) provide safe, effective and low-risk PN (parenteral nutrition) for practically all indications and applications. Water, energy (carbohydrates and lipids), amino acids, vitamins and trace elements are infused together with PN either as industrially-manufactured AIO admixtures provided as two- or three-chamber bags (shelf life usually more than 12 months) completed with electrolytes and micronutrients where appropriate or as individually compounded ready-to-use AIO admixtures (compounding, usually prepared by a pharmacy on either a daily or weekly basis and stored at 2–8°C). Physico-chemical and microbial stability of an AIO admixture is essential for the safety and effectiveness of patient-specific PN, and its assurance requires specialist pharmaceutical knowledge. The stability should be documented for an application period of 24 (–48) hours. It is advisable to offer a limited selection of different PN regimes in each hospital. For reasons of drug and medication safety, PN admixtures prepared for individual patients must be correctly labelled and specifications for storage conditions must also be followed during transport. Monitoring is required where applicable. Micronutrients are usually administered separately to AIO admixtures. In case compatibility and stability have been well documented trace elements and/or combination preparations including water-soluble or water-soluble/fat soluble vitamin supplements can be added to PN admixtures under strict aseptic conditions. AIO admixtures are usually not used as vehicles for drugs (incompatibilities).
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Affiliation(s)
- S Mühlebach
- CSO Vifor Pharma Ltd, Villars-sur-Glâne, Switzerland University of Basel, Switzerland
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Bischoff SC, Kester L, Meier R, Radziwill R, Schwab D, Thul P. Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2009; 7:Doc20. [PMID: 20049081 PMCID: PMC2795381 DOI: 10.3205/000079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 01/05/2023]
Abstract
PN (parenteral nutrition) should be standardised to ensure quality and to reduce complications, and it should be carried out in consultation with a specialised nutrition support team whenever possible. Interdisciplinary nutrition support teams should be established in all hospitals because effectiveness and efficiency in the implementation of PN are increased. The tasks of the team include improvements of quality of care as well as enhancing the benefit to cost ratio. Therapeutic decisions must be taken by attending physicians, who should collaborate with the nutrition support team. “All-in-One” bags are generally preferred for PN in hospitals and may be industrially manufactured, industrially manufactured with the necessity to add micronutrients, or be prepared “on-demand” within or outside the hospital according to a standardised or individual composition and under consideration of sterile and aseptic conditions. A standardised procedure should be established for introduction and advancement of enteral or oral nutrition. Home PN may be indicated if the expected duration of when PN exceeds 4 weeks. Home PN is a well established method for providing long-term PN, which should be indicated by the attending physician and be reviewed by the nutrition support team. The care of home PN patients should be standardised whenever possible. The indication for home PN should be regularly reviewed during the course of PN.
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Affiliation(s)
- S C Bischoff
- Dept. Nutritional Medicine and Prevention, University Stuttgart-Hohenheim, Germany
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Miller SJ. Commercial Premixed Parenteral Nutrition: Is It Right for Your Institution? Nutr Clin Pract 2009; 24:459-69. [DOI: 10.1177/0884533609339067] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sarah J. Miller
- From the University of Montana, Saint Patrick Hospital, Skaggs School of Pharmacy, Missoula, Montana
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Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009; 28:387-400. [PMID: 19505748 DOI: 10.1016/j.clnu.2009.04.024] [Citation(s) in RCA: 680] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 04/29/2009] [Indexed: 02/07/2023]
Abstract
Nutritional support in the intensive care setting represents a challenge but it is fortunate that its delivery and monitoring can be followed closely. Enteral feeding guidelines have shown the evidence in favor of early delivery and the efficacy of use of the gastrointestinal tract. Parenteral nutrition (PN) represents an alternative or additional approach when other routes are not succeeding (not necessarily having failed completely) or when it is not possible or would be unsafe to use other routes. The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications. This nutritional approach has been a subject of debate over the past decades. PN carries the considerable risk of overfeeding which can be as deleterious as underfeeding. Therefore the authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient. Data on long-term survival (expressed as 6 month survival) will also be considered a relevant outcome measure. Since there is a wide range of interpretations regarding the content of PN and great diversity in its practice, our guidance will necessarily reflect these different views. The papers available are very heterogeneous in quality and methodology (amount of calories, nutrients, proportion of nutrients, patients, etc.) and the different meta-analyses have not always taken this into account. Use of exclusive PN or complementary PN can lead to confusion, calorie targets are rarely achieved, and different nutrients continue to be used in different proportions. The present guidelines are the result of the analysis of the available literature, and acknowledging these limitations, our recommendations are intentionally largely expressed as expert opinions.
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Affiliation(s)
- Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Tikva, Israel
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Abstract
OBJECTIVE In pediatric intensive care, two approaches to parenteral nutrition are available: individualized admixtures or commercial standard solutions. Even though individualized admixtures can be tailored to sometimes highly intricate requirements, standard solutions are able to meet the demands of the majority of pediatric patients. To address the growing importance of costs in intensive care, we investigated whether relevant differences between individualized admixtures and standard solutions in terms of costs can be found. DESIGN Retrospective analysis. SETTING University-affiliated intensive care unit. PATIENTS Fifty consecutively admitted pediatric patients requiring parenteral nutrition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Comparison of actual costs of individualized admixtures and theoretical costs of standard solutions. Mean actual costs of individualized admixtures of Euro 81.78 (+/- 16.33) per patient and day were significantly higher than the theoretical costs of standard solutions of Euro 61.21 (+/- 6.55). Cost differences increased with patients' body weights. CONCLUSIONS Parenteral nutrition with standard solutions offers the potential of a relevant cost reduction compared with individualized admixtures in critically ill children.
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Menne R, Adolph M, Brock E, Schneider H, Senkal M. Cost Analysis of Parenteral Nutrition Regimens in the Intensive Care Unit: Three-Compartment Bag System vs Multibottle System. JPEN J Parenter Enteral Nutr 2008; 32:606-12. [DOI: 10.1177/0148607108322404] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Roland Menne
- From the Department of Anaesthesiology and Intensive Care Medicine, Marien-Hospital Witten, Germany; the Department of Surgery, Marien-Hospital Witten, Germany; HealthEcon AG, Basle, Switzerland; and the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
| | - Michael Adolph
- From the Department of Anaesthesiology and Intensive Care Medicine, Marien-Hospital Witten, Germany; the Department of Surgery, Marien-Hospital Witten, Germany; HealthEcon AG, Basle, Switzerland; and the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
| | - Elisabeth Brock
- From the Department of Anaesthesiology and Intensive Care Medicine, Marien-Hospital Witten, Germany; the Department of Surgery, Marien-Hospital Witten, Germany; HealthEcon AG, Basle, Switzerland; and the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
| | - Heinz Schneider
- From the Department of Anaesthesiology and Intensive Care Medicine, Marien-Hospital Witten, Germany; the Department of Surgery, Marien-Hospital Witten, Germany; HealthEcon AG, Basle, Switzerland; and the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
| | - Metin Senkal
- From the Department of Anaesthesiology and Intensive Care Medicine, Marien-Hospital Witten, Germany; the Department of Surgery, Marien-Hospital Witten, Germany; HealthEcon AG, Basle, Switzerland; and the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
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Raper S, Milanov S, Park GR. The cost of multicompartment ‘big bag’ total parenteral nutrition in an ICU. Anaesthesia 2008. [DOI: 10.1046/j.1365-2044.2002.2412_26.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Montero Hernández M, Martínez Vázquez MJ, Martínez Olmos M, Campelo Sánchez E, Inaraja Bobo MT, Martínez López de Castro N. [Economic assessment of the implementation of a parenteral nutrition protocol for patients undergoing intestinal resection by a multidisciplinary team]. FARMACIA HOSPITALARIA 2006; 30:20-8. [PMID: 16569180 DOI: 10.1016/s1130-6343(06)73939-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE An economic assessment on the impact of total parenteral nutrition guidelines developed by the Hospital Nutrition Committee for patients undergoing intestinal resection and implemented by a nutritional support multidisciplinary team, was conducted. METHOD A comparative retrospective study of two consecutive annual periods before and after the implementation of total parenteral nutrition guidelines for patients undergoing intestinal resection developed by the Nutrition Committee was carried out. Cost-effectiveness analysis from the hospital perspective was performed with the pharmacoeconomic program Pharma-Decision Hospital. Effectiveness was assessed as nutritional gain and safety profile; as well as determination of the costs of acquisition, preparation, administration, monitoring and nutritional complications. Sensitivity analysis (+/-20%) of effectiveness and hospital stay. RESULTS Among 326 patients hospitalized for intestinal resection, 69 out of 172 (40%) received parenteral nutrition during the early period, versus 40 out of 154 (26%) after the surgery procedure (p < 0.01). In 79% of the patients with parenteral nutrition, the adequacy of the indication was assessed, being adequate in 51.7% and 56.7%, respectively (p = 0.66). Nutritional gain before and after surgery was similar (78.3 vs. 82.5%, p > 0.05), with patients having less episodes of hypophosphatemia postoperatively (60 vs. 38%). Mean total cost per patient before and after surgery was 9,180.81 and 7,871.96, respectively. The sensitivity analysis confirmed the above results. CONCLUSIONS The development of total parenteral nutrition guidelines by the Nutrition Committee for surgical patients undergoing intestinal resection and their implementation by a multidisciplinary team improved the use of parenteral nutrition and reduced associated costs, with the same nutritional evolution.
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Genton L, Mühlebach S, Dupertuis YM, Pichard C. Ergonomic and economic aspects of total parenteral nutrition. Curr Opin Clin Nutr Metab Care 2006; 9:149-54. [PMID: 16477180 DOI: 10.1097/01.mco.0000214574.82686.ac] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Ergonomics in total parenteral nutrition include the work performed in the (hospital) pharmacy and on the medical ward. This article reviews the developments in total parenteral nutrition ergonomics and the related cost-savings. RECENT FINDINGS Research focuses on the ergonomic advantages of multi-compartment total parenteral nutrition bags compared with the multi-bottle system, of multi versus single-layered total parenteral nutrition bags and of the presence of a nutritional team and training in clinical nutrition to improve regimen prescription and delivery. SUMMARY Three-compartment bags are safe, economic and ergonomic. It is important, however, to keep the knowledge of pharmacies to compound total parenteral nutrition for children and (adult) patients with specific pathologies. Research is ongoing in the development of bags with more than three compartments, to include for instance vitamins. This necessitates improvements in bag materials and wrapping. Progress can be made regarding total parenteral nutrition prescription and delivery, as well as in the incidence of related infections by promoting training in clinical nutrition and the implementation of a multidisciplinary nutritional support team.
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Affiliation(s)
- Laurence Genton
- Clinical Nutrition, University Hospital, Geneva, Switzerland
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Dupertuis YM, Ramseyer S, Fathi M, Pichard C. Assessment of ascorbic acid stability in different multilayered parenteral nutrition bags: critical influence of the bag wall material. JPEN J Parenter Enteral Nutr 2005; 29:125-30. [PMID: 15772391 DOI: 10.1177/0148607105029002125] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The recent development of multilayered bags has minimized ascorbic acid oxidation in parenteral nutrition (PN) admixtures. However, the gas-barrier property of multilayered bags depends on their plastic material. This study compared ascorbic acid stability in different multilayered bags under experimental conditions. METHODS Oxygen permeability of a newly developed 6-layered bag (6-L) was compared with a highly mechanical-resistant 3-layered bag (3-L(R)) and a highly flexible 3-layered bag (3-L(F)) using gas chromatography. Ascorbic acid stability was assessed by iodine titration in bags filled with 2.5 L H(2)O and 40 g carbohydrates after setting residual O(2) content at < or =1 or > or =5 ppm. The effect of storage at 4 degrees C, 21 degrees C, and 40 degrees C on ascorbic acid stability was assessed over 48 hours in a complete PN admixture (ie, 330 g carbohydrates, 100 g lipids, 96 g amino acids and trace elements) using high-pressure liquid chromatography. RESULTS Oxygen permeability was markedly reduced in 6-L bags (0.5 mL O(2) /m(2)/d) compared with 3-L(R) (150 mL O(2) /m(2)/d) and 3-L(R) (1500 mL O(2)/m(2)/d). Accordingly, ascorbic acid was more stable in 6-L bags (half-life [T(1/2)] = 16 days up to 40 degrees C) than in 3-L(R) (T(1/2) = 9 days at 4 degrees C, 47 hours at 21 degrees C and 29 hours at 40 degrees C) and 3-L(F) (T(1/2) = 15 hours at 4 degrees C, 10 hours at 21 degrees C, and 6 hours at 40 degrees C). During the first 6 hours after PN admixture compounding, an additive ascorbic acid loss of 4.6 +/- 0.5 mg/L/ppm O(2) occurred because of residual O(2) in the bag. CONCLUSIONS The new combination of plastic layers and careful O(2) monitoring during the filling process allowed near to complete prevention of ascorbic acid degradation in multilayered PN bags during 48 hours, regardless of the storage temperature.
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Affiliation(s)
- Yves M Dupertuis
- Clinical Nutrition and Central Laboratory of Medical Chemistry, Geneva University Hospital, CH-1211 Geneva 14, Switzerland
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Quelle place pour les prémélanges industriels en nutrition parentérale de l'adulte à l'hôpital ? Analyse des données de la littérature. NUTR CLIN METAB 2005. [DOI: 10.1016/j.nupar.2005.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pichard C, Genton L. From basic research to cost-effectiveness trials: the needed spirit to promote clinical nutrition. Curr Opin Clin Nutr Metab Care 2005; 8:373-6. [PMID: 15930960 DOI: 10.1097/01.mco.0000172575.71643.c2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Ready-to-use all-in-one admixtures are standards for short and long-term parenteral nutrition. Their limited stability does not allow storage over prolonged periods of time. Multichamber bags represent industrially manufactured near complete standard parenteral nutrition premixes with extended shelf lives. This review focuses on the characterization of multichamber bags, their influence on parenteral nutrition practice, the need for individual parenteral nutrition compounding, and the role of the pharmacist in the nutrition team. RECENT FINDINGS The all-in-one admixture concept, its correlation with parenteral nutrition effectiveness, safety, and pharmaceutical issues are reviewed. Multichamber bags, the bag material, their use and practical handling are addressed. SUMMARY Newly developed container materials are mainly responsible for the increased stability of multichamber bag parenteral nutrition premixes. Multichamber bags are used for (standard) parenteral nutrition in adults. Multichamber bags cannot eliminate individualized all-in-one parenteral nutrition compounding. Pharmaceutical assistance with expertise in compatibility and stability is mandatory for the nutrition team to implement and control good parenteral nutrition practices, e.g. to convert multichamber bags into complete ready-to-use all-in-one admixtures or to compound individualized regimens. The incorporation of additional components into parenteral nutrition admixtures (pharmaconutrients, drugs) must rely on documented compatibility with the parenteral nutrition admixtures. Multichamber bags have their advantages and limitations. Studies on the effectiveness and costs of multichamber bags are needed to meet the expectations of pharmacists, physicians, nurses, and industry for optimal parenteral nutrition in patients.
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Maisonneuve N, Raguso CA, Paoloni-Giacobino A, Mühlebach S, Corriol O, Saubion JL, Hecq JD, Bailly A, Berger M, Pichard C. Parenteral nutrition practices in hospital pharmacies in Switzerland, France, and Belgium. Nutrition 2004; 20:528-35. [PMID: 15165615 DOI: 10.1016/j.nut.2004.03.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Important changes in administering total parenteral nutrition (PN) admixtures have occurred over the past decade. This study describes hospital pharmacists' practices in France (F), Switzerland (CH), and Belgium (B). METHODS From the responses received using a standardized questionnaire, (n = 378) we determined the origin, types of container used, and choice of PN formula (standard versus tailor-made) and the type of quality control and the existence of nutrition support teams. RESULTS The mean response rates were 55.6% (CH), 30.5% (F), and 24.5% (B). Standard formulas were used mainly for adult patients (CH, 86%; F, 79%; B, 86%), whereas approximately 50% of tailor-made PN bags were used for children. Single-compartment or multicompartment bags or glass bottles contained standard formulas. Most standard formulas were provided by industry, apart from (B), where 50% of PN solutions were compounded by hospital pharmacies. Single-compartment bags contained generally tailor-made formulas produced exclusively by hospital pharmacies in (CH) and (B), whereas 33% were provided by industry in (F). Quality controls were mostly visual and occurred in 75% to 95% of hospitals. Nutrition support teams were present in 32% to 45% of hospitals. CONCLUSION The choice, origin, and type of container used for PN formulas were highly variable among countries. However, the use of standard formulas in bags was predominant in (CH) and (B). The function of nutrition support teams was similar in (F), (CH), and (B).
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Affiliation(s)
- N Maisonneuve
- Department of Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland
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Foulmann K, Charpiat B, Gadot A, Gérard-Boncompain M. Adéquation des apports en nutrition parentérale : poches à la carte ou prémélanges industriels ? NUTR CLIN METAB 2004. [DOI: 10.1016/j.nupar.2004.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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CON. Clin Nutr 2002. [DOI: 10.1016/s0261-5614(02)80041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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