Comparing Aluminum Concentrations in Adult and Pediatric Parenteral Nutrition Solutions: Multichamber-Bag versus Compounded Parenteral Nutrition

Aluminum contamination in parenteral nutrition (PN) solutions can lead to neurotoxicity, reduced bone mass, and liver toxicity, especially in pediatric patients. Ingredients commonly used in PN compounding, such as vitamins, trace elements, calcium, and phosphate salts, contain significant amounts of aluminum. This study aimed to compare aluminum concentrations in multichamber-bag (MCB) and compounded PN for adults and pediatrics. A prospective study assessed aluminum concentrations in various types of MCB and compared them with compounded PN formulations with similar compositions. The types of MCB included Lipoflex® (without electrolytes), Omegaflex®, Finomel®, Smofkabiven® (with and without electrolytes), Olimel®, Clinimix®, and Numeta®. Overall, 80 aluminum determinations were included: 36 for MCBs and 44 for compounded PN. MCBs showed significantly lower aluminum concentrations than compounded PN: 11.37 (SD 6.16) vs. 21.45 (8.08) µg/L, respectively. Similar results were observed for adult (n = 40) and pediatric (n = 40) PN formulations (12.97 (7.74) vs. 20.78 (10.28) µg/L, and 9.38 (2.23) vs. 22.01 (5.82) µg/L, respectively). Significant differences were also found between MCBs depending on the manufacturing company. These findings suggest that MCBs PN offer a safer option for reducing aluminum contamination in PN. Harmonizing regulations concerning aluminum concentrations in PN solutions could help mitigate differences between PN formulations.

Long-term effect of tocilizumab on mortality, readmissions, persistent symptoms and lung function in SARS-CoV-2 patients 1 year after hospital discharge: A matched cohort study

BACKGROUND

Tocilizumab is presumed to be an effective and safe treatment for severe SARS-Cov-2, but its usefulness has not been investigated yet for long-term outcomes. This study aimed to evaluate the influence of tocilizumab on mortality in patients with SARS-CoV-2 throughout the year following discharge.

METHODS

A retrospective observational analysis was performed on electronic medical records of patients with SARS-CoV2 who were discharged from our hospital after surviving the first wave in March-April 2020. Logistic regression was used to analyse the effect of tocilizumab on mortality, as the main outcome, and propensity-score analysis to further validate their effect. Secondary outcomes were readmissions, persistent symptoms and lung function evolution. Patients were selected by matching their individual propensity for receiving therapy with tocilizumab, conditional on their demographic and clinical variables.

RESULTS

A total of 405 patients were included in the mortality study (33.6 % were treated with tocilizumab) and 390 were included in the assessment of persistent symptoms. After propensity-score analysis, no association between tocilizumab use and 1-year overall mortality was found (HR= 2.05, 95 % CI: 0.21-19.98). No differences regarding persistent symptoms (OR= 1.01 95 %CI 0.57-1.79), nor lung function parameters (forced vital capacity: coefficient -0.16 95 %CI -0.45 to 0.14) were found throughout the year follow-up between control and tocilizumab group.

CONCLUSIONS

The administration of tocilizumab in patients with SARS-CoV-2 did not show any effect on long-term mortality. Identically, no association were found regarding readmissions, persistent symptoms or lung function evolution and tocilizumab administration in our cohort of patients after 1 year follow-up.

Aluminum blood concentration in adult patients: effect of multichamber-bag versus hospital-compounded parenteral nutrition

BACKGROUND

the administration of aluminum-contaminated parenteral nutrition (PN) leads to an accumulation of aluminum. The aim of this study was to assess blood aluminum concentrations (BACs) of inpatients receiving multichamber-bag (MCB) PN compared to those receiving compounded PN.

METHODS

available BACs were retrospectively gathered from patient charts of adult inpatients receiving PN from 2015 to 2020, and compared depending on the type of PN administered. Long-term PN patients, defined as ≥ 20 days of PN, receiving at least > 10 days of compounded PN, were compared to long-term patients receiving only MCB.

RESULTS

a total of 160 BACs were available from 110 patients. No differences were found according to type of PN (mean BAC: 3.11 ± 2.75 for MCB versus 3.58 ± 2.08 µg/L for compounded PN). Baseline total bilirubin, surgery and days with PN were related to higher BACs (coefficient: 0.30 [95 % CI, 0.18-0.42], 1.29 [95 % CI, 0.52-2.07], and 0.06 [95 % CI: 0.01-0.11], respectively). Regarding long-term PN, patients receiving only MCB (n = 21) showed lower BACs compared to the compounded PN (n = 17) [2.99 ± 1.55 versus 4.35 ± 2.17 µg/L, respectively; p < 0.05].

CONCLUSIONS

although there were no differences in BAC according to type of PN administered, in long-term PN, MCB PN was associated with lower BACs as compared to compounded PN.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

Effect of tocilizumab versus standard of care in adults hospitalized with moderate-severe COVID-19 pneumonia

INTRODUCTION AND OBJECTIVES

Tocilizumab is an interleukin-6 receptor-blocking agent proposed for the treatment of severe COVID-19; however, limited data are available on their efficacy. The aim of this study was to assess the effect of tocilizumab on the outcomes of patients with COVID-19 pneumonia by using propensity-score-matching (PSM) analysis.

METHODS

A retrospective observational analysis of hospitalized COVID-19 adult patients admitted to the Vall d'Hebron Hospital was performed between March and April 2020. We used the logistic regression to analyze the effect of tocilizumab on mortality, as main outcome, and PSM analysis to further validate their effect. Secondary outcomes were length-of-stay (LOS) and intensive-care-unit (ICU) stay. Same outcomes were also assessed for early tocilizumab administration, within 72h after admission. Patients were selected by matching their individual propensity for receiving therapy with tocilizumab, conditional on their demographic and clinical variables.

RESULTS

A total of 544 COVID-19 patients were included, 197 (36.2%) were treated with tocilizumab of whom 147 were treated within the first 72h after admission; and 347 were included in the control group. After PSM analyses, the results showed no association between tocilizumab use and overall mortality (OR=1.03, 95%CI: 0.63-1.68). However, shorter ICU-stay in the tocilizumab group was found compared to the control group (Coefficient -4.27 95%CI: -6.63 to -1.92). Similar results were found in the early tocilizumab cohort.

CONCLUSIONS

The administration of tocilizumab in patients with moderate to severe COVID-19 did not reduce the risk of mortality in our cohort of patients, regardless of the time of administration.

Effect of tocilizumab versus standard of care in adults hospitalized with moderate-severe COVID-19 pneumonia

Introduction and objectives

Tocilizumab is an interleukin-6 receptor-blocking agent proposed for the treatment of severe COVID-19; however, limited data are available on their efficacy. The aim of this study was to assess the effect of tocilizumab on the outcomes of patients with COVID-19 pneumonia by using propensity-score-matching (PSM) analysis.

Methods

A retrospective observational analysis of hospitalized COVID-19 adult patients admitted to the Vall d’Hebron Hospital was performed between March and April 2020. We used the logistic regression to analyze the effect of tocilizumab on mortality, as main outcome, and PSM analysis to further validate their effect. Secondary outcomes were length-of-stay (LOS) and intensive-care-unit (ICU) stay. Same outcomes were also assessed for early tocilizumab administration, within 72 h after admission. Patients were selected by matching their individual propensity for receiving therapy with tocilizumab, conditional on their demographic and clinical variables.

Results

A total of 544 COVID-19 patients were included, 197 (36.2%) were treated with tocilizumab of whom 147 were treated within the first 72 h after admission; and 347 were included in the control group. After PSM analyses, the results showed no association between tocilizumab use and overall mortality (OR = 1.03, 95%CI: 0.63–1.68). However, shorter ICU-stay in the tocilizumab group was found compared to the control group (Coefficient −4.27 95%CI: −6.63 to −1.92). Similar results were found in the early tocilizumab cohort.

Conclusions

The administration of tocilizumab in patients with moderate to severe COVID-19 did not reduce the risk of mortality in our cohort of patients, regardless of the time of administration.

Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.

Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition"

BACKGROUND

The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN).

METHODS

The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience.

RESULTS

The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation.

CONCLUSIONS

This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

Cohort Multicenter Study on the Role of Medications in Parenteral Nutrition-Related Alteration of Liver Function Tests in Adults

BACKGROUND

Our objective was to assess in non-critically-ill adult inpatients receiving parenteral nutrition (PN) the risk of developing liver function test (LFT) alterations when receiving concomitant possibly hepatotoxic medications or others reported to improve LFTs during PN.

METHODS

A multicenter retrospective analysis of prospectively collected data was performed on patients receiving PN. Two groups were recruited: group LALT (patients with any LFT alterations during PN), and group NOLALT (patients without such alterations). Exclusion criteria were previous sepsis, shock, renal failure, hyperglycemia, LFT alteration, or biliopancreatic surgical procedures. Medications were classified into 2 categories: medications reported to improve LFTs during PN (n = 8) and possibly hepatotoxic medications (n = 54), including a subgroup of possibly highly hepatotoxic medications (n = 30).

RESULTS

The study included 200 patients, 136 (68.0%) in the LALT group. The groups differed in the number of patients requiring surgical intervention ≤7 days before PN (LALT, 94 [69.1%]; NOLALT, 29 [45.3%]; P < .002) and those receiving possibly hepatotoxic medications (LALT, 126 [92.6%]; NOLALT, 45 [70.3%]; P < .001). Variables in the final Cox regression model were possibly hepatotoxic medications, odds ratio (OR) 3.310 (1.678-6.530); surgical intervention prior to PN, OR 1.861 (1.277-2.711); baseline triglyceridemia, OR 1.005 (1.001-1.009); and creatinine, OR 1.861 (1.043-3.323).

CONCLUSIONS

Patients who received PN and concomitantly possibly hepatotoxic medications had a 3-fold risk of developing LFT alterations. Medications reported to improve LFTs had no effect. The use of possibly hepatotoxic medications during PN was associated with LFT alterations.

Impact of parenteral nutrition standardization on costs and quality in adult patients

BACKGROUND

Parenteral nutrition (PN) is a costly therapy that can also be associated with serious complications. Therefore, efforts are focusing on reducing rate of complications, and costs related to PN.

OBJECTIVE

The aim was to analyze the effect of the implementation of PN standardization on costs and quality criteria. Secondary aim was to assess the use of individualized PN based on patient's clinical condition.

METHODS

We compare the use of PN before and after the implementation of PN standardization. Demographic, clinical and PN characteristics were collected. Costs analysis was performed to study the costs associated to the two different periods. Quality criteria included were: 1) PN administration; 2) nutrition assessment (energy intake between 20-35 kcal/kg/day; protein contribution according to nitrogen balance); 3) safety and complications (hyperglycemia, hypertriglyceridemia, hepatic complications, catheter-related infection); 4) global efficacy (as serum albumin increase). Chi-square test was used to compare percentages; logistic regression analysis was performed to evaluate the use of customized PN.

RESULTS

296 patients were included with a total of 3,167 PN compounded. During the first period standardized PN use was 47.5% vs 85.7% within the second period (p < 0.05). No differences were found in the quality criteria tested. Use of individualized PN was related to critical care patients, hypertriglyceridemia, renal damage, and long-term PN. Mean costs of the PN decreased a 19.5%. Annual costs savings would be € 86,700.

CONCLUSIONS

The use of customized or standard PN has shown to be efficient and flexible to specific demands; however customized PN was significantly more expensive.

Study of hyperglycemia in non critically-ill patients receiving parenteral nutrition: incidence and risk factors

BACKGROUND

The objectives of our study on non-critically ill patients receiving parenteral nutrition (PN) are to assess the incidence of hyperglycemia, the risk factors associated to its development and its influence in patient's evolution.

METHODS

A multicentric prospective observational study was performed in 9 hospitals. Four multivariate studies were developed to study the temporal risk in the occurrence of hyperglycemia (endpoint), intensive care unit (ICU) admission, length of stay (LOS) and death. Demographics, nutrients, drugs and clinical variables were collected. Independent variables studied as a possible risk factors were: sex, diabetes mellitus 2, baseline glycemia, albuminemia, pancreatitis, surgery in the 7 days prior to the end point, infection, insulin/somatostatin/corticoids administration during the study, glomerular filtration rate (GFR), and difference in the amount of glucose administration between the endpoint and one day before.

RESULTS

119 patients were enrolled in the study, 25 cases of hyperglycemia were detected. In the clinical factors associated with PN hyperglycemia, significant variables were: surgery in the 7 days before the end point, GFR, glucose load in the 24 hours previous to the end point insulin administration and somatostatine/octreotide administration during the study. Hyperglycemia was significantly associated with ICU admission and increased LOS.

CONCLUSIONS

Glucose administration in non-critically ill patients receiving PN should be reassessed downwards, especially in the immediate postsurgery, renal impairment and in patients treated with somatostatin analogues. It should be taken into account that an increase in glucose dose may lead to hyperglycemia in these patients and hyperglycemia correlates with longer hospital stay and increased frequency of ICU admissions.

Cost analysis of adult parenteral nutrition systems: three-compartment bag versus customized

BACKGROUND

Parenteral nutrition (PN) is a costly technology used widely to provide nutrition to patients who have an inaccessible or non-functioning intestine. Two all-in-one systems currently being used are customized formulations and three-compartment bags.

OBJECTIVE

To provide a systematic cost comparison of the two all-in-one PN systems: individualized (made from nutrient solutions) versus commercialized (made from three-compartment bag), both prepared in hospital pharmacies.

SETTING

This study was conducted in three public Spanish hospitals.

METHOD

We conducted a cost-minimization study to analyze prospectively the total cost of PN bags, accounting for all of the processes involved in preparing and delivering PN bags (cost of manpower, nutrition solutions, medical supplies and quality controls) in three different healthcare settings. To compare therapeutic alternatives of equivalent nutritional value, the study was performed for the most frequently employed formulation and similar to commercial preparations. A univariate sensitivity analysis was performed to evaluate the impact of different rates of use of three-compartment PN bag.

RESULTS

157 routine acts of PN bag preparation (65 customized and 92 three-compartment) were observed and timed over 9 days. Total costs of the 157 PN bags were included in the study. Mean costs of customized bags were higher than three-compartment bags, 51.16 ± 5.63 € versus 39.69 ± 3.00 € respectively (p < 0.01). Manpower costs were responsible for the majority of the differences found (70%). The time to complete an adult bag for the hospital compounded system was a mean of 25.9 minutes longer than the three-compartment system. In scenarios using a three-compartment system for 30%, 70% and 90% of PN provision, a cost savings of 4.3%, 10.1% and 12.9% respectively could be achieved. Greatest rates of changing from customized bags (70% and 90%), in a hospital with 1,800 PN bags/year, might reduce the annual budget by 9306 € and 11,964.8 €, respectively. Meanwhile, in a large facility the savings for 8,000 TPN days would be 64,248 € and 82,605 €, respectively.

CONCLUSIONS

Since seeking cost-reduction of effective treatments is needed, the use of three-compartment bags for standard adult PN could lead to cost savings. Our data should be helpful for health care providers to calculate their own cost of administer.

Outpatient treatment of Pseudomonas aeruginosa bronchial colonization with long-term inhaled colistin, tobramycin, or both in adults without cystic fibrosis

STUDY OBJECTIVE

To compare clinical and microbiologic outcomes in adults without cystic fibrosis who had Pseudomonas aeruginosa bronchial colonization and were receiving inhaled colistin or colistin plus tobramycin with those who were receiving inhaled tobramycin as outpatient treatment.

DESIGN

Prospective, observational cohort study.

SETTING

Referral pneumology service at a tertiary university care hospital.

PATIENTS

Eighty-one Caucasian adults without cystic fibrosis who received 97 courses of inhaled colistin alone, colistin plus tobramycin, or inhaled tobramycin alone as outpatient treatment of P. aeruginosa bronchial colonization between January 2004 and December 2008.

MEASUREMENTS AND MAIN RESULTS

The frequency and duration of hospitalizations for respiratory exacerbations were the primary outcomes compared among treatment groups. Secondary outcomes were emergence of bacterial resistance, antibiotic use during admission, emergence of other opportunistic microorganisms, achievement of sustained P. aeruginosa eradication in the airways, and mortality, as well as safety and changes in respiratory function. No significant differences between colistin and tobramycin were found in the mean number of hospital admissions, duration of hospitalizations, duration of antibiotic treatment, adverse events, mortality, or emergence of other opportunistic microorganisms. Emergence of resistance to colistin was lower than resistance to tobramycin (hazard ratio 0.09, 95% confidence interval [CI] 0.03-0.32). Patients treated with both inhaled antibiotics had fewer days of hospitalization and fewer days of antibiotic use than those treated with tobramycin alone (relative risk [RR] 0.33, 95% CI 0.10-1.12, and RR 0.27, 95% CI 0.08-0.93, respectively).

CONCLUSION

Results with colistin were similar to those with tobramycin for inhaled treatment of P. aeruginosa colonization in this population; however, combined use of colistin and tobramycin appeared to be associated with fewer days of hospitalization and shorter duration of antibiotic treatment. Prospective, double-blind, placebo-controlled trials of outpatient nebulized antibiotics, especially colistin plus tobramycin, should be performed to ascertain the efficacy of this therapy for treatment of P. aeruginosa colonization in patients without cystic fibrosis.

Changes in biochemical, hematological and immunological profiles after low-dose intravenous immunoglobulin administration in patients with hypogammaglobulinemia

We assessed the immediate effect of intravenous immunoglobulins (IVIG) on the biochemical, immunological and hematological profiles in patients with hypogammaglobulinemia. Over a period of three months, patients with antibody deficiencies, who had been established on stable IVIG treatment as replacement therapy in our hospital, were enrolled in the study. Participants underwent pre-therapy determinations of their biochemical, immunological and hematological profiles. Laboratory determinations were repeated after completion of IVIG infusions. Over the study period, fourteen patients were enrolled and a total of 34 pre- and post-IVIG infusion determinations were performed and results compared. We found that low-dose IVIG treatment in patients with hypogammaglobulinemia results in post-infusion biochemical and hematological changes, as follows: an increase in total protein concentration and a reduction in albumin, total cholesterol, sodium and alkaline phosphatase concentrations as well as lymphocyte and platelet counts. All these biochemical and cellular changes seems to be transient, since they were not observed in the subsequent pre-infusion determination. However, in other patient populations, some of these changes might differ, depending on the dose of IVIG administered and the baseline condition and immunological status of the patient.

Use of colistin in the treatment of multiple-drug-resistant gram-negative infections

PURPOSE

The use of colistin for the treatment of infections caused by multiple-drug-resistant (MDR) gram-negative microorganisms was studied.

METHODS

The efficacy of colistin for treating infections caused by MDR gram-negative microorganisms and the development of renal toxicity were studied in hospitalized adult patients in Spain. Patients treated between January 2001 and October 2001 were included.

RESULTS

Over the study period, 71 courses of inhaled colistin, 12 courses of i.v. or intramuscular (i.m.) colistin, and 2 courses of intrathecal colistin were administered to 80 patients. All were infected by MDR organisms: 69 (86%) by Acinetobacter baumannii and 11 (14%) by Pseudomonas aeruginosa. In 41 patients (51%), the episodes were caused by A. baumannii strains susceptible exclusively to colistin. The causative organisms were cleared in 92% of the patients from whom posttreatment repeat specimens were obtained. The in-hospital mortality rate was 18% (14 patients). There were no significant changes in mean serum urea or creatinine concentrations in patients receiving i.v. or i.m. therapy.

CONCLUSION

Colistin was used in 80 patients infected with A. baumannii or P. aeruginosa and appeared to be efficacious and safe.