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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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Wischmeyer PE, Klek S, Berger MM, Berlana D, Gray B, Ybarra J, Ayers P. Parenteral nutrition in clinical practice: International challenges and strategies. Am J Health Syst Pharm 2024; 81:S89-S101. [PMID: 38869257 PMCID: PMC11170506 DOI: 10.1093/ajhp/zxae079] [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 Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert medication that is susceptible to errors that may affect patient safety. Over time, considerable progress has been made to make PN practices safer. The purpose of this article is to address ongoing challenges to improve the PN use process from prescription to administration and monitoring, and to outline practical aspects fostering the safety, quality, and cost-effectiveness of PN, as discussed at the International Safety and Quality of PN Summit. SUMMARY Opportunities to improve the PN use process in clinical practice include the promotion of inter-disciplinary communication, vigilant surveillance for complications, staff education to increase competency, and more consistent use of advanced technologies that allow automated safety checks throughout the PN process. Topics covered include considerations on PN formulations, including the value of intravenous lipid emulsions (ILEs), trends in compounding PN, the current and future role of market-authorized multi-chamber PN bags containing all 3 macronutrients (amino acids, glucose/dextrose, and ILE) in the United States and in Europe, and strategies to cope with the increasing global problem of PN product shortages. CONCLUSION This review outlines potential strategies to use in clinical practice to overcome ongoing challenges throughout the PN use process, and ultimately promote PN patient safety.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland
| | - 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
| | | | | | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, MS
- University of Mississippi School of Pharmacy, Jackson, MS, USA
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Kumpf VJ, Gray B, Monczka J, Zeraschi S, Klek S. Parenteral nutrition at home/long-term parenteral nutrition. Am J Health Syst Pharm 2024; 81:S112-S120. [PMID: 38527076 PMCID: PMC11170492 DOI: 10.1093/ajhp/zxae081] [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: 03/21/2024] [Indexed: 03/27/2024] Open
Abstract
PURPOSE Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already complex therapy, posing additional risk of potential complications. This article is based on presentations and discussions held at the International Safety and Quality of PN Summit, providing insights into aspects of home PN (HPN) and examples of good HPN practice. SUMMARY One critical step in the HPN process is when patients transition from a hospital to a home setting, and vice versa. Generally, electronic PN ordering is not feasible in an HPN setting, leading to potential difficulties in communication and coordination. HPN requires that patients (or their home caregivers) administer PN, and thus their education and competency are crucial. Likewise, the choice of PN formulation is of great importance. For example, using more modern intravenous lipid emulsions containing medium-chain triglycerides, olive oil, and/or fish oil can provide benefits in terms of liver function during long-term HPN. Internationally, there are wide variations in delivery of HPN, with compounded PN dominating in some countries while others make greater use of market-authorized multichamber bags (MCBs). Patient-related factors, institutional considerations, and the availability of different MCB formulations, are also contributing factors guiding formulation and delivery system preferences. CONCLUSION Education and communication remain key components of a successful HPN process. The information shared here may help to motivate efforts to improve HPN processes and to consider the often-differing perspectives of patients and their healthcare professionals.
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Affiliation(s)
- 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
| | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland
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Bakrey H, Shivgotra R, Abdu A, Soni B, Shahtaghia NR, Jain SK, Thakur S. Use of Total Parenteral Nutrition (TPN) as a Vehicle for Drug Delivery. Curr Drug Targets 2024; 25:306-329. [PMID: 38454772 DOI: 10.2174/0113894501284598240226102943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.
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Affiliation(s)
- Hossamaldeen Bakrey
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Riya Shivgotra
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Abdulkadir Abdu
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Bindu Soni
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Navid Reza Shahtaghia
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Subheet Kumar Jain
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
- Centre for Basic and Translational Research in Health Sciences, Guru Nanak Dev University, Amritsar, 143005, India
| | - Shubham Thakur
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
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Rivas García F, Martínez RJG, Camarasa FJH, Cerdá JCM, Messeguer FL, Gallardo MLV. A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life. Pharmaceuticals (Basel) 2023; 17:65. [PMID: 38256898 PMCID: PMC10820363 DOI: 10.3390/ph17010065] [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: 11/06/2023] [Revised: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
"End of life" is a stage defined by the existence of an irreversible prognosis that ends with a person's death. One of the aspects of interest regarding end of life focuses on parenteral nutrition, which is usually administered in order to avoid malnutrition and associated complications. However, parenteral nutrition can be adapted to specific circumstances and evolve in its functionality through supplementation with certain nutrients that can have a beneficial effect. This narrative review aims to carry out a situation analysis of the role that could be adopted by supplemental parenteral nutrition in attenuating alterations typical of end of life and potential improvement in quality of life.
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Vara-Luiz F, Glória L, Mocanu I, Curado A, Medeiros I, Duarte MA, Banhudo A, Ferreira S, Vaz AM, Bastos I, Fonseca J. Clinical Nutrition in Portuguese Gastroenterology Departments: A Multicentric Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16333. [PMID: 36498411 PMCID: PMC9740062 DOI: 10.3390/ijerph192316333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Hospital nutrition is a major public health problem, as up to 50% of hospitalized patients suffer from undernutrition. Adequate nutritional support (NS) decreases morbidity/mortality, shortens the length of stay, and reduces costs. We aimed to evaluate the engagement of Portuguese gastroenterology departments in NS, especially in artificial nutrition (AN). METHODS Cross-sectional multicentric study, using an online survey sent to 31 Portuguese gastroenterology departments. RESULTS Nine centers were involved, and all departments were engaged in NS activities. The most performed nutrition technique was endoscopic gastrostomy and not all departments had the expertise to perform all nutrition procedures, namely, endoscopic jejunostomy. Two departments had an AN outpatient clinic. Five centers were involved in hospital nutrition committees. Only four performed systematic nutritional evaluation of every patient on admission. Two departments developed research in the nutrition field. An increase staff and nutrition training were pointed out as suggestions to improve NS. CONCLUSIONS This study outlines a broad picture of NS/AN in Portuguese gastroenterology departments. Medical nutritional training and increasing nutrition teams' staff may contribute to developing NS/AN. Multidisciplinary management of nutrition-related disorders is of utmost importance, and gastroenterologists are expected to be at the core of hospital nutrition.
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Affiliation(s)
- Francisco Vara-Luiz
- GENE–Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal
| | - Luísa Glória
- Gastroenterology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
| | - Irina Mocanu
- GENE–Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
| | - António Curado
- Gastroenterology Department, Centro Hospitalar do Oeste, 2500-176 Caldas da Rainha, Portugal
| | - Isabel Medeiros
- Gastroenterology Department, Hospital do Espírito Santo, 7000-811 Évora, Portugal
| | - Maria Antónia Duarte
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada, 9500-370 Ponta Delgada, Portugal
| | - António Banhudo
- Gastroenterology Department, Hospital Amato Lusitano, 6000-085 Castelo Branco, Portugal
| | - Susana Ferreira
- Gastroenterology Department, Hospital do SAMS, 1849-017 Lisboa, Portugal
| | - Ana Margarida Vaz
- Gastroenterology Department, Centro Hospitalar Universitário do Algarve, 8000-386 Faro, Portugal
| | - Isabel Bastos
- Gastroenterology Department, Centro Hospitalar do Baixo Vouga, 3810-164 Aveiro, Portugal
| | - Jorge Fonseca
- GENE–Artificial Feeding Team, Gastroenterology Department, Hospital Garcia de Orta, 2805-267 Almada, Portugal
- Grupo de Patologia Médica, Nutrição e Exercício Clínico (PaMNEC), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), 2829-511 Almada, Portugal
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Wang H, Su S, Wang C, Hu J, Dan W, Peng X. Effects of fish oil-containing nutrition supplementation in adult sepsis patients: a systematic review and meta-analysis. BURNS & TRAUMA 2022; 10:tkac012. [PMID: 35702267 PMCID: PMC9185164 DOI: 10.1093/burnst/tkac012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/26/2021] [Accepted: 03/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Although fish oil has been used as an immunonutritional preparations for the treatment of sepsis patients, there is still controversy as to whether it is beneficial to them. We systematically reviewed published clinical trial data to evaluate the effectiveness of fish oil-containing nutrition supplementation in sepsis patients. METHODS A systematic search was undertaken in PubMed, Embase, Chinese Biomedicine Database, the Cochrane Library and the China Knowledge Resource Integrated Database to obtain clinical controlled trails. RCTs on nutrition therapy containing fish oil among adult sepsis patients were selected for analysis in comparison with routine therapy. RESULTS Twenty-five published trials were included in the meta-analysis. Fish oil-containing nutrition supplementation reduced the mortality compared with the control group (relative risk (RR) 0.74, I 2 = 0%). Fish oil also shortened the ICU stay (MD -3.57 days; 95% CI -4.54, -2.59; p<0.00001; I 2 = 76%), hospital stay (MD -9.92 days; 95% CI -15.37, -4.46; p = 0.0004; I 2 = 91%) and the duration of mechanical ventilation support (MD -2.26; 95% CI -4.27, -0.26; p = 0.03; I 2 = 83%). A subgroup analysis based on the route of administration revealed that parenteral administration of fish oil could reduce mortality in septic patients (RR =0.68, I 2 = 0%), but no significant difference in mortality was observed in the fish oil group administered by enteral route (RR = 0.80, I 2 = 0%). No statistically significant publication biases were detected for the above clinical endpoints (p>0.05). CONCLUSIONS Parenteral nutrition containing fish oil could significantly decrease mortality in sepsis patients while enteral administration could not. Fish oil-containing nutrition supplementation.
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Affiliation(s)
- Hongyu Wang
- Clinical Medical Research Center, Southwest Hospital, The Third Military Medical University, Chongqing 400000, China
- Department of Burns and Plastic, PLA No.983 Hospital, Tianjin 300000, China
| | - Sen Su
- Clinical Medical Research Center, Southwest Hospital, The Third Military Medical University, Chongqing 400000, China
| | - Chao Wang
- Institute of Burn Research, Southwest Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, The Third Military Medical University, Chongqing, China
| | - Jianhong Hu
- Institute of Burn Research, Southwest Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, The Third Military Medical University, Chongqing, China
| | - Wu Dan
- Clinical Medical Research Center, Southwest Hospital, The Third Military Medical University, Chongqing 400000, China
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Schönenberger KA, Reber E, Dürig C, Baumgartner A, Efthymiou A, Huwiler VV, Laimer M, Bally L, Stanga Z. Management of Hyperglycemia in Hospitalized Patients Receiving Parenteral Nutrition. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:829412. [PMID: 36992742 PMCID: PMC10012056 DOI: 10.3389/fcdhc.2022.829412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Almost half of inpatients on parenteral nutrition experience hyperglycemia, which increases the risk of complications and mortality. The blood glucose target for hospitalized patients on parenteral nutrition is 7.8 to 10.0 mmol/L (140 to 180 mg/dL). For patients with diabetes, the same parenteral nutrition formulae as for patients without diabetes can be used, as long as blood glucose levels can be adequately controlled using insulin. Insulin can be delivered via the subcutaneous or intravenous route or, alternatively, added to parenteral nutrition admixtures. Combining parenteral with enteral and oral nutrition can improve glycemic control in patients with sufficient endogenous insulin stores. Intravenous insulin infusion is the preferred route of insulin delivery in critical care as doses can be rapidly adjusted to altered requirements. For stable patients, insulin can be added directly to the parenteral nutrition bag. If parenteral nutrition is infused continuously over 24 hours, the subcutaneous injection of a long-acting insulin combined with correctional bolus insulin may be adequate. The aim of this review is to give an overview of the management of parenteral nutrition-associated hyperglycemia in inpatients with diabetes.
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Affiliation(s)
- Katja A. Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- *Correspondence: Katja A. Schönenberger,
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Dürig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annic Baumgartner
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andriana Efthymiou
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentina V. Huwiler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Markus Laimer
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Kader R, Liminga G, Ljungman G, Paulsson M. Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals' Attitudes and Sources of Information. Pharmaceutics 2021; 13:pharmaceutics13101676. [PMID: 34683968 PMCID: PMC8538608 DOI: 10.3390/pharmaceutics13101676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/11/2021] [Indexed: 02/01/2023] Open
Abstract
Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.
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Affiliation(s)
- Rania Kader
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Gunnar Liminga
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Gustaf Ljungman
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Mattias Paulsson
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Correspondence: ; Tel.: +46-18-611-3733
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Physicochemical Stability and Compatibility Testing of Voriconazole in All-in-One Parenteral Nutrition Admixtures. Pharmaceutics 2021; 13:pharmaceutics13091447. [PMID: 34575522 PMCID: PMC8468966 DOI: 10.3390/pharmaceutics13091447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Drug compatibility with all-in-one (AiO) parenteral nutrition (PN) admixtures is a very important pharmaceutical quality issue to be answered based on appropriate laboratory testing. We assessed voriconazole (V), a poorly water-soluble (logP ≈ 1) single-daily dosed antifungal drug monitored in patients and thus candidate for AiO PN admixing for convenient and safe patient care. We evaluated V compatibility and stability in AiO PN admixtures through adapted therapeutic drug monitoring method (drug stability) and visual microscopic emulsion stability by lipid droplets analysis improved by an automated microscopic digital assessment. (2) V was added in concentrations of 0.05/0.25/0.5 mg/mL (143.1/715.7/1431.5 µM), correlating to daily therapeutic dosing, to three commercially available industrial AiO PN admixtures. Three aliquots were stored in the refrigerator (4 °C), at room temperature (24 °C) and under stress conditions in a water bath (37 °C). Samples taken at 0/24/48/72/168 h after admixing were subjected to a stability-indicating one-week analysis. Assessment included visual examination, lipid droplet measurement according to an established and validated method (bright-field microscopy using oil immersion), pH measurement (glass electrode) and V identification/quantification (LC–MS/MS). (3) After one week, all samples at 37 °C showed slight yellow discoloration. The pH values remained stable. All samples met specifications for lipid droplets according to size (upper size ≤8 µm, mean size <4.5 ± 2 µm) and number (n ≤ 9 lipid droplets >5 µm). V concentrations were within an acceptable range, calculated for every timepoint as percent of the theoretical concentration spiked into the AiO PN. The median recovery was 98.2% (min–max, 90–112%). (4) At therapeutic doses, commercial V formulations were compatible and stable within specifications over one week in commonly used volumes of commercial AiO PN admixtures at 4–37 °C.
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Kumar V, Rahim A, Choudry E, Jabbar R, Khowaja WH, Ariff S, Ali SR. A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan. Cureus 2021; 13:e15226. [PMID: 34178539 PMCID: PMC8223258 DOI: 10.7759/cureus.15226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness. Methodology A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed. Results The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied. Conclusion Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.
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Affiliation(s)
- Vikram Kumar
- Neonatology, Indus Hospital and Health Network, Karachi, PAK
| | - Anum Rahim
- Indus Hospital Research Center, Indus Hospital and Health Network, Karachi, PAK
| | - Erum Choudry
- Indus Hospital and Research Center, Indus Hospital and Health Network, Karachi, PAK
| | - Rafia Jabbar
- Pediatrics, Indus Hospital and Health Network, Karachi, PAK
| | - Waqar H Khowaja
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Shabina Ariff
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Syed Rehan Ali
- Neonatology, Indus Hospital and Health Network, Karachi, PAK
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12
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Tomczak S, Stawny M, Jelińska A. Co-Administration of Drugs and Parenteral Nutrition: In Vitro Compatibility Studies of Loop Diuretics for Safer Clinical Practice. Pharmaceutics 2020; 12:pharmaceutics12111092. [PMID: 33202945 PMCID: PMC7696202 DOI: 10.3390/pharmaceutics12111092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 12/26/2022] Open
Abstract
Parenteral nutrition (PN) admixtures are prone to interacting with drugs administered intravenously via a common catheter. This may cause a threat to a patient’s health and life. The literature that has been reported on the compatibility of loop diuretics with PN presents conflicting results. This work aimed to study the compatibility of furosemide and torsemide with PN used in clinical practice. Undiluted solutions of drugs were mixed with PN at various ratios determined by flow rates. In order to assess compatibility, visual control was followed by pH measurement, osmolality, mean emulsion droplet diameter (MDD), and zeta potential upon mixing and at 4 h of storage. No macroscopic changes that indicated lipid emulsion degradation were observed. After the addition of the drugs, the value of pH ranged from 6.37 ± 0.01 to 7.38 ± 0.01. The zeta potential was in reverse proportion to the drug concentration. The addition of the drugs did not affect the MDD. It may be suggested that the co-administration of furosemide or torsemide and PN caused no interaction. The absence of such signs of unwanted interactions allowed for the co-administration of the mentioned loop diuretics and PN at each of the studied ratios.
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13
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Tang QQ, Hong ZW, Ren HJ, Wu L, Wang GF, Gu GS, Chen J, Zheng T, Wu XW, Ren JA, Li JS. Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression. Front Nutr 2020; 7:564379. [PMID: 33123545 PMCID: PMC7573310 DOI: 10.3389/fnut.2020.564379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.
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Affiliation(s)
- Qin-Qing Tang
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China.,Department of General Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhi-Wu Hong
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Hua-Jian Ren
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Lei Wu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Ge-Fei Wang
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Guo-Sheng Gu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jun Chen
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Tao Zheng
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Xiu-Wen Wu
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jian-An Ren
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
| | - Jie-Shou Li
- Jinling Hospital Research Institute of General Surgery, Nanjing, China.,Laboratory for Trauma and Surgical Infections, Jinling Hospital, Nanjing, China
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14
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Nutritional Management and Outcomes in Malnourished Medical Inpatients in 2020: The Evidence Is Growing! J Clin Med 2019; 9:jcm9010027. [PMID: 31877661 PMCID: PMC7019932 DOI: 10.3390/jcm9010027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 12/14/2022] Open
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