Compounding TPN admixtures: then and now

Compounding TPN admixtures has significantly developed since the first clinical reports by Dr. Dudrick and colleagues from the University of Pennsylvania approximately 35 years ago. Today, the responsibility for the compounding of sage parenteral nutrition admixtures for patients incapable of oral or enteral nutrition primarily rests with the pharmacy department. Although others may influence the desirable components to be contained therin, no one is more qualified to deal with the physicochemical issues and aseptic technique compounding requirements than a registered pharmacist. In fact, the United States Pharmacopeia (USP) , the official drug compendium in the US since 1906, has published Chapter 797 entitled "Pharmaceutical Compounding--Sterile Preparations", enforceable by the FDA, and makes clear the role of the pharmacist in the compounding of safe parenteral admixtures. Ultimately, after careful pharmaceutical review of the final formulation, the composition of the final admixture for infusion will be determined based on the ability to safely compound the prescribed additives in the desired quantities of a specified volume of sterile fluid. There will always be instances, where, for example the patient's needs cannot be safely met through the TPN admixture, primarily because of stability, compatibility and/or sterility issues. When this occurs, suitable alternative methods of delivering the additives in question must be sought so as not to compromise the safety issues of the final TPN infusion. Although there have been many advances in the development of nutritional additives, compounding devices, and containers, significant safety issues continue to arise necessitating further modification of paretneral nutrition protocols. ASPEN, through periodic reviews of tis published guidelines, such as the 1998 Safe Practices for Parenteral Nutrition Formulations, is in a key position to keep nutrition support clinicians abreast of the central issues affecting the safety of TPN therapy.(Journal of Parenteral and Enteral Nutrition

[Recent advances in nutritional support and postnatal growth in premature infants]

Nutrition has always been described as challenging in premature infants, especially in very low birth weight (VLBW, < 1500 g) infants. Therefore, postnatal malnutrition is frequently observed in these infants and most develop a severe postnatal growth restriction with a very high incidence of hypotrophy at term corrected age. Otherwise, both insufficient nutritional intakes and postnatal growth restriction during the perinatal period have been associated with adverse developmental outcomes. In this article, an optimized nutritional policy characterized by a standardization of nutritional support is discussed. This policy implies the use of one standardized parenteral nutrition solution and a rapidly enriched feeding regimen. Recent studies in VLBW infants have demonstrated that this approach is associated with significant improvement of nutritional support, postnatal growth and biological homeostasis. Only 6% of appropriate for gestational age infants at birth were described small for gestational age at discharge. This policy has recently been reproduced by the industry that developed the first manufactured triple-chamber parenteral nutrition bags specifically designed for premature infants. It represents a great opportunity for premature infants to improve their development and long-term outcomes.

A review of the trends in the use of enteral and parenteral nutrition support

This is a review article that discusses the trends in the use of enteral and parenteral nutrition support. Although enteral nutrition has existed longer than parenteral nutrition, only recent data would suggest a clinical benefit of enteral nutrition compared with parenteral nutrition. In this article, indications for parenteral nutrition are listed. Also, data comparing bacterial translocation and complications associated with both forms of nutritional support are discussed. Clinical outcome in specific gastrointestinal diseases is also discussed.

Wandel der perioperativen Therapie bei elektiven kolorektalen Resektionen in Deutschland 1991 und 2001/2002

BACKGROUND

To assess changes in perioperative treatment of patients undergoing elective colorectal resections, surveys were sent to all German surgical departments in 1991 and 2001/2002.

METHODS

1,207 chairmen of departments for general or visceral surgery were asked to answer a survey concerning the principles of perioperative treatment of patients undergoing elective colorectal resection. The results of this questionnaire were compared to a survey that had been performed in 1991.

RESULTS

616 chairmen (51.0%) responded to the survey (1991: 76.4%). In 2001/2002 preoperative parenteral alimentation was utilized routinely in only 10.3% (1991: 40.0%) of all hospitals. Preoperative i.v.-pyelography was used only in 24.7% of the hospitals (1991: 79.7%). Intraoperative testing of colorectal anastomoses was more common in 2001/2002 (63.7%) than in 1991 (40.1%). At the same time the incidence of "single-shot"-antibiotic prophylaxis increased from 24.0% to 70.4 %. Orthograde bowel lavage, perioperative antibiotic prophylaxis and postoperative parenteral alimentation were use as often in 2001/2002 as in 1991. Intraperitoneal drains were routinely inserted in most of the surgical departments after left-sided colonic resections (2001/2002: 86.2%; 1991: 88.2%) or rectal resections (2001/2002: 90.5%; 1991: 94.4%).

CONCLUSION

During the last decade, perioperative therapy for patients undergoing elective colorectal resection has changed substantially. Most of these changes occurred in the perioperative medical treatment. However, surgical traditions like intraperitoneal drainage are still very frequently utilized.

New developments in total parenteral nutrition for children

The field of parenteral nutrition continues to evolve along two major paths: prevention of complications and refining of nutritional needs. Parenteral nutrition-associated liver disease remains a vexing problem. No single factor is to blame; rather, it requires a number of "hits." In the infant, the liver disease primarily appears to be related to prematurity of bile flow and production, infection, lack of enteral feedings, and most recently appreciated, perhaps free radicals. We are able to meet the nutritional needs of our patients, but our knowledge of actual nutritional requirements remains incomplete. Future studies need to define better appropriate intakes and to rigorously test the utility of proposed nutrients such as glutamine.

[Total parenteral nutrition. History. Present time. Future]

Total parenteral nutrition (TPN) has been available for only 30 years. However, history in this field goes back more than 350 years with the first landmark being the description of general blood circulation by William Harvey in 1628. His discovery is the anatomical basis for intravenous infusions. Many investigations were performed during the following centuries showing that solutions containing electrolytes and glucose could be given intravenously in man. The accumulated knowledge of protein metabolism formed the basis for studies on intravenous nutrition with protein hydrolysates, peptides and amino acids. The observation in the late 30-s by Robert Elman that amino acids in the form of protein hydrolysate could be safely administered intravenously in man was the first major step toward TPN. During the following years, major efforts were made to find methods to prepare infusion solutions with a high energy content and low osmotic pressure. The most realistic alternative seemed to be fat in the form of an emulsion. Many studies of a large number of various fat emulsions were made however, all of these emulsions caused severe adverse reactions in man. The first safe fat emulsion, intralipid, was made available in the early 60s. This was the second major step toward TPN. It was then no problem to include vitamins, electrolytes and trace elements in the fat emulsions and the solutions of amino acids and glucose. A few years later it was shown that a central venous catheter could be used to administer the infusion fluid intravenously. Many clinical investigations and reports have shown that the newly developed intravenous nutritional regimens are adequate alternatives to the ordinary diet. In this way it has been possible to maintain or obtain a good nutritional condition in most situations when oral or tube feeding can not be used. TPN has been shown to be of very great clinical importance to prevent and treat starvation often related to high morbidity and mortality.

Recent advances: parenteral nutrition support

Even though there is an abundance of research related to the clinical and physiologic effects of parenteral nutrition and specific nutritional substrates, few new products have been released for clinical use. This review illustrates some of the directions being taken in the future development of parenteral nutrition products and some new perspectives related to the current effects (or lack of effects) of TPN. When considering the individual effects of specific nutrient substrates (arginine, glutamine, LCTs, MCTs, SCFAs) as reviewed here, it becomes apparent that the infusion of parenteral nutrition has the potential to produce a variety of metabolic responses that could be both beneficial and harmful. These effects depend on the type and quantity of substance infused as well as the disease and clinical condition of the patient. This also is true for those substances (GH, IGF-1) being evaluated to direct the effects of TPN infusions in a manner that improves protein accretion and supports the immunologic response of the body. At best, these investigations are producing a great amount of new and more specific information about the metabolic response to illness and the effects of TPN and individual substrate on that response.

Challenge to clinical pharmacy practice in Malaysia

OBJECTIVE

To report on the current status and future trends of clinical pharmacy practice in Malaysia.

DATA SOURCES

Published conference reports and journal articles.

DATA EXTRACTION

Data on areas related to clinical pharmacy practice in Malaysian hospitals were gleaned from various publications.

DATA SYNTHESIS

Malaysia is capable of implementing clinical pharmacy services in hospitals and perhaps also in the community setting. The important factors in clinically oriented pharmacy practice include improvement of the drug-control process, development of physical and human resources, clinical pharmacy skills, and the training of practicing pharmacists. A number of Malaysian pharmacists have already developed a unit-dose drug distribution system, patient counseling, therapeutic drug monitoring, drug information, and total parenteral nutrition services.

CONCLUSIONS

The pharmacy profession in Malaysia has many challenges ahead and it is hoped that every practicing pharmacist will be highly committed to future professional needs so that clinical pharmacy practice in Malaysia becomes a reality.

Does perioperative total parenteral nutrition reduce medical care costs?

An economic analysis accompanied a multicenter Department of Veterans Affairs randomized, controlled trial of perioperative total parenteral nutrition (TPN). The cost of providing TPN for an average of 16.15 days before and after surgery was $2405, more than half of which ($1025) included costs of purchasing, preparing, and delivering the TPN solution itself; lipid solutions accounted for another $181, additional nursing care for $843, and miscellaneous costs for $356. Prolonged hospital stay added another $764 per patient to the $2405 cost of providing TPN, bringing the total to $3169. The incremental costs attributed to perioperative TPN were highest ($3921) for the patients least likely to benefit, that is, those who were less malnourished and at low risk of nutrition-related complications. Incremental costs were lowest ($3071) for high-risk patients. On the basis of the hospital-based method of administering TPN that was used in the clinical trial, perioperative TPN did not result in decreased costs for any subgroup of patients.

[Future perspectives in parenteral nutrition]

Some of the future perspectives of parenteral nutrition will most likely be related to the possibilities of improving the infusion solutions used. There are studies indicating that intravenous amino acid mixtures may produce better biochemical and clinical effects either by increasing the content of histidin, arginine, tyrosine, cysteine/cystine and branched chain amino acids or by adding glutamine, ornithin, ornithin-ketoglutaric acid, taurine and glutathion. Several possibilities of improving the intravenous fat emulsions have been studied and discussed. The use of medium chain fatty acid glycerides (MCT) instead of long chain fatty acid glycerides (LCT) may be of some value. Physical mixtures of LCT and MCT have been studied. Glycerides of both medium chain and long chain fatty acids of the same glycerol molecule ('structured lipids') have also been investigated. The omega-3-fatty acids (alfalinolenic, eicosapentaenoic and docosahexaenoic acid) have unique biochemical properties which may be beneficial in various clinical situations when parenteral nutrition is indicated. Intravenous fat emulsions containing triglycerides of these fatty acids are now being extensively investigated. The omega-3-fatty acids will change the pattern of eicosanoids formed, reduce the tendency to platelet aggregation, increase the resistance to endotoxins, and reduce the viscosity of the blood. Triglycerides of gamma linolenic acid have been considered to be of value in situations when there may be a reduced activity of delta-6-desaturase to transform linoleic acid to arachidonic acid. Many other known (carnitine, non-protein sources, vitamins and trace elements) or unknown nutrients may be found to be useful in order to improve the infusion solutions used in parenteral nutrition.(ABSTRACT TRUNCATED AT 250 WORDS)

New developments in lipid emulsions for parenteral nutrition

More than one thousand publications have demonstrated the safety and efficacy of today's lipid emulsions including long chain fatty acids under experimental and clinical conditions. This has resulted in a general acceptance of a dual energy system comprising both carbohydrates and lipids as non-protein calories in total parenteral nutrition. Non-carnitine-dependent fatty acid has been suggested as a superior energy source in clinical situations where carnitine may be in the subnormal range. A medium chain triglyceride (MCT) emulsion would provide an energy source with a more readily oxidizable substrate. The tolerance of MCT is less than that of long chain triglyceride (LCT), whereby only physical mixtures of these emulsions will be used in humans. A structured lipid (SL) is a triglyceride which includes both medium and long chained fatty acids within the same triglyceride. Emulsions including SL have demonstrated a decreased protein energy expenditure and increased serum albumin in burned animal. The SL has also been superior to LCT emulsions in stimulating muscle protein synthesis and maintaining body weight in hepatectomized animals. These positive effects on protein kinetics have been concomitant with a lower RES involvement during septicemia in burned guinea pigs. Emulsions including fatty acids with odd-number carbons give a possibility to provide a fat emulsion which also could contribute positively to the glucose homeostasis. The omega-3 family of fatty acids has demonstrated a potential pharmacologic effect with regard to their ability to decrease blood viscosity and improve survival rate in endotoxin shock in an experimental model. These observations have been ascribed to changes in thromboxin A2 levels.(ABSTRACT TRUNCATED AT 250 WORDS)

[Parenteral nutrition - present status and modern trends]

In the present paper practical references for the use of aimed balanced nutrition, particularly of parenteral nutrition, in surgery are given. The complete and total parenteral nutrition is an intervening therapeutic form for the patient. Before the beginning of the nutrition a possibly comprehensive diagnosis of the condition of the nutrition with the help of the state of nutrition is necessary, the volume of which will be depend on the existing diagnostic possibilities of an institution. Moreover, the success and the effectivity of the parenteral nutrition depend on the optimum composition of the nutrient and on a good nutritional technique as well as on an optimum control of the course of nutrition. Taking into consideration the high use for the improvement of the results of treatment a considerable expenditure must be put up with. This means a very strong indication.