Parenteral Nutrition Bags Research Articles

Complicaciones hepatobiliares asociadas a la Nutrición Parenteral Domiciliaria (NPD)

Home-based parenteral nutrition (HBPN) allows recovering or maintaining the nutritional status of patients with chronic intestinal failure that cannot afford their nutritional requirements through the digestive route. Frequently, liver function impairments develop along the treatment, which in the most severe cases, and especially in premature and low-weight infants, may lead to an irreversible liver failure. The proper composition of the parenteral nutrition bag, avoiding an excess of energy intake, together with the use of new types of lipid emulsions (with lower content in -6 fatty acids and voided of phytosterols) as well as the use, although being minimal, of the enteral route, may contribute to a decrease in the occurrence of HBPN-associated liver disease. It is necessary to perform monthly clinical and biochemical checks to early detect liver function impairments in order to perform the appropriate changes in the treatment and assess the indication of a potential bowel transplant before the liver damage becomes irreversible.

Contamination of integral protective suits in the sterile environment used for producing total parenteral nutrition bags

Manufacturing of parenteral nutrition in a cleanroom requires a strict survey of environmental microbiological contamination. In the cleanroom of our hospital's pharmacy, the staff wears integral protective suits made of polyester with an open hood, the main function of which is to protect the products and the environment from any human contamination. The objective of this study was to determine the level of microbiological contamination of the suits during the production process at several spots on the clothing and at different times; and then to evaluate the impact of the use of an additional protection, namely, sterile single-use polyethylene arm-cover sleeves. First, 160 samplings, taken with agar contact plates, were carried out on the coveralls of staff working in an A-Class (ISO 5) cleanroom at T = 0, 1, 2, 3, 4, and 5 hours of presence in the room. Then, after the introduction of additional protective sleeves, 120 samplings (60 above and 60 under the protective arm sleeves, worn over the coveralls) were carried out. The study showed that microbiological contamination increases with time, sometimes after 1 hour of stay in the cleanroom room. Forearms are the crucial site of contamination, and the use of arm covers is hence recommended. Dans le processus de fabrication de poches de nutrition parentérale en zone à atmosphère contrôlée (ZAC), la maîtrise de la contamination microbiologique de l’environnement est une priorité. Dans l’unité de nutrition parentérale de l’hôpital Armand-Trousseau, le personnel est revêtu de combinaisons intégrales stériles en polyester dont le rôle premier est de protéger l’environnement et les préparations de toute contamination d’origine humaine. L’objectif de cette étude a été de déterminer la contamination microbiologique des combinaisons en cours de fabrication, puis d’évaluer l’impact de l’utilisation d’une protection complémentaire, des protège-bras en non-tissé stériles à usage unique. Dans un premier temps, un total de 160 prélèvements sur les casaques, par géloses de type « contact », ont été réalisés sur le personnel manipulant en classe A à différents temps de présence dans l’unité. Dans un second temps, après la mise en place des protège-bras, 120 prélèvements (60 sur les protège-bras, 60 sur la combinaison sous les protège-bras) ont été effectués. Cette étude a montré que la contamination microbiologique augmente au cours du temps et les normes sont dépassées après une heure de présence dans la ZAC. Les avant-bras constituent le site le plus critique et l’utilisation de protège-bras réduit la contamination microbiologique de cette zone.

Analysis of Sodium and Potassium in Total Parenteral Nutrition Bags by ICP-MS and ICP-AES:Critical Influence of the Ingredients

The compounding of total parenteral nutrition solutions (TPN) in the hospital pharmacy is a high-risk activity for which a quality assurance programme is necessary. The complexity of parenteral nutrition solutions containing almost 50 ingredients makes it difficult to measure each of them. On the other hand, the assay of electrolytes such as sodium and potassium is accepted as a quality marker for estimating compounding errors. Thus, the aim of this study was to estimate the influence of ingredients on the accuracy of assays of electrolytes. Experiments were performed with aqueous working simulated solutions of sodium and potassium prepared by the addition of each nutrient step by step, (dextrose, amino acids, lipids, vitamins and trace elements). Sodium and potassium levels were measured by Inductively Coupled Plasma Mass Spectroscopy (ICP-MS) and Atomic Emission Spectroscopy (ICP-AES). The performance of these methods was compared using statistical evaluations (t-test and Mann–Whitney test).The study highlights the interference of amino acids, vitamins and trace elements when measuring sodium, but no interference was noted during the measurement of potassium. To reduce the risk and to improve the quality of compounding, we used an automated compounding device but, even in this case, the acceptance criterion for sodium and potassium determination was not <10%.

Influence of adherence to the national guidance on nutrition screening and dietitian referral on clinical outcomes of those requiring parenteral nutrition

National guidance in the UK on nutrition support suggests that all patients should be screened on initial admission to hospital and, where appropriate, be referred to a healthcare professional. The present study aimed to investigate whether initial nutrition screening influenced the outcome of patients who received parenteral nutrition (PN). Data were prospectively evaluated on 100 consecutive patients referred to the multidisciplinary PN team in a teaching hospital. Information was obtained from medical notes, electronic patient records, completed PN prescription charts, dietetic record cards and nursing care plans. Patients who were treatable by nutritional supplements or enteral nutrition were not included. Patients were divided into two groups: guidance compliant and guidance noncompliant, in order to compare outcome measures such as the duration of PN treatment, total number of PN bags used per patient and length of hospital stay. Comparison of data between the two groups was carried out using either the independent samples t-test or the Mann-Whitney U-test. There was no difference in outcome measures between the guidance compliant and noncompliant groups. Patients in the guidance noncompliant group were more likely to be in general (77%) than critical wards (23%). Patients who were in the guidance compliant group received nutrition support earlier. Compliance with the national guidance in the UK on screening did not improve outcomes in patients requiring parenteral nutrition in this cohort. Initial nutrition screening prior to PN administration warrants further investigation to ensure value is added to patient care.

A 4-year survey of the activity of a malnutrition task force in an Italian research hospital

Objective The proper management of nutritional support remains a challenging task in many Western hospitals. This study aimed at reporting a 4-y survey on the centralized management of nutritional support by a malnutrition task force in an Italian research hospital. Methods The requests for nutritional supports, the number of patients treated with enteral nutrition in the medical and surgical units, and the number of home artificial nutritional support activated were recorded from 2005 to 2008. Results The median number of first and follow-up visits per month significantly increased from 16 (25th–75th percentiles 13–26) in 2005 to 74 (25th–75th percentiles 69–82) in 2008 ( P < 0.001) and from 56 (25th–75th percentiles 42–82) in 2005 to 101 (25th–75th percentiles 90–120) in 2008 ( P = 0.001), respectively. This trend was observed also in the number of patients treated with enteral nutrition (from 95 in 2004 to 190 in 2008) and in those on home artificial nutritional support (from 25 in 2004 to 65 in 2008), whereas the number of parenteral nutrition bags produced remained substantially stable. Conclusion The centralized management of nutritional support is a successful strategy, which provides the appropriate prescription of artificial nutrition during hospitalization and at discharge. Multidisciplinary nutrition support teams or task forces should be created in every hospital.

Shielding Parenteral Nutrition From Light: Does the Available Evidence Support a Randomized, Controlled Trial?

Exposure of total parenteral nutrition to ambient light induces the generation of peroxides, creating oxidant stress, which potentially compounds complications of prematurity. Photograph protection of total parenteral nutrition reduces the peroxide load and has been shown to be associated with nutritional and biochemical benefits in animals and humans. It is unclear whether this reduction in peroxides from total parenteral nutrition leads to a reduction in the complications of prematurity, such as bronchopulmonary dysplasia. Our hypothesis was that shielding total parenteral nutrition from ambient light is linked to clinical benefits. The purpose of this work was to determine whether photograph protection of total parenteral nutrition (light protected), as compared with no photoprotection (light exposed), reduces the occurrence of bronchopulmonary dysplasia or death in preterm infants. The Canadian Neonatal Network provided data for infants born in 2006 at <28 weeks' gestation admitted to level 3 NICUs in Canada. A retrospective analysis was performed comparing bronchopulmonary dysplasia and death in infants who received light-exposed or light-protected parenteral nutrition. Data were analyzed by using logistic regression models. RESULTS. Thirteen NICUs offered partial light-protected (total parenteral nutrition bag only, intravenous tubing exposed) and 13 offered light-exposed parenteral nutrition; not a single NICU offered complete light-protected parenteral nutrition (total parenteral nutrition bag plus intravenous tubing). The incidence of bronchopulmonary dysplasia or death was 66% with light-protected (n = 428) vs 59% with light-exposed (n = 438) parenteral nutrition. Partial photograph protection of total parenteral nutrition was not associated with a reduction in bronchopulmonary dysplasia or death as compared with no photograph protection; this relationship is confounded by covariates with strong associations with bronchopulmonary dysplasia. Partial photograph protection of total parenteral nutrition solutions confers no clinical benefit, while consuming valuable resources. A randomized, controlled trial is justified to determine whether there is a true "cause-and-effect" relationship between complete photoprotection of total parenteral nutrition and bronchopulmonary dysplasia or death.

Evaluation of Parenteral Nutrition Management in a Hospital without a Formal Nutrition Support Team

Purpose A preliminary review of several adult inpatients receiving parenteral nutrition (PN) revealed opportunities for improvement. In response, a drug usage evaluation (DUE) was conducted to: 1) determine specific areas of adult PN management needing improvement; 2) evaluate the current PN order forms; 3) identify reasons for PN wastage; 4) establish pharmacist involvement in prescribing/monitoring of PN in a community hospital without a formal nutrition support team. Methods A prospective DUE was performed on various adults receiving PN from January through February 2005. The following data were collected and evaluated: 1) PN indication; 2) whether ordered PN formula met patients' estimated needs; 3) adequate adjustments of electrolyte or glucose imbalances; 4) appropriate ramping/tapering of PN; 5) appropriate laboratory data ordered. Additionally, a record was kept of PN solutions wasted from January through April 2005. Results Twenty-two adult patients receiving PN were prospectively reviewed. Protein and caloric needs were met in only 59% of patients (n = 13), and electrolytes were abnormal in 73% of patients (n = 16), with most physicians making minimal or no electrolyte adjustments. PN was not routinely ramped up upon initiation. Phosphorus, triglycerides, and prealbumin were not routinely monitored. An average of 14.5 PN bags was wasted per month. In response to these findings, the PN order forms were redesigned to facilitate appropriate monitoring and to facilitate physician-initiated consults for pharmacists to manage PN. One year after implementation, a 40% reduction in PN wastage was noted. Conclusions Pharmacists play an integral role in PN management, resulting in improved patient monitoring and a reduction in expensive PN wastage.

Ergonomic and economic aspects of total parenteral nutrition

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. 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. 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.

Estudio multicéntrico de prevalencia de hiperglucemia en pacientes hospitalizados con nutrición parenteral

The aim of this cross-sectional national multicentric study was to determine the prevalence of hyperglycemia in patients with parenteral nutrition and to assess other clinical factors associated with this complication. All Spanish hospital pharmacy services were invited to participate in the study. Twenty eight (28) pharmacy services agreed to participate. The study included 442 patients. The prevalence of hyperglycemia (plasma levels > 200 mg/dL) was 26.7%. Eighty four point two per cent of the patients received less than 3.5 mg/kg/minute of glucose, this infusion rate being considered as the safe threshold. In most patients, follow-up of glycemia was based on capillary blood determination with reactive strips and in 27.6% of the cases in which insulin was prescribed, it was added to the parenteral nutrition bag, in full or in part. No significant correlations were found between glycemia and the clinical factors studied (disorders, fever, medication), except for insulin. This national multicentric study of the prevalence of hyperglycemia among patients with parenteral nutrition, leaded by hospital pharmacists, was a joint effort aimed to better understand this metabolic complication. Findings are consistent with those reported by other authors and have allowed us to describe the current situation.

Standards for Specialized Nutrition Support: Home Care Patients

Standards for Specialized Nutrition Support: Home Care Patients

Assessment of Ascorbic Acid Stability in Different Multilayered Parenteral Nutrition Bags: Critical Influence of the Bag Wall Material

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. 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. 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. 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.

Parenteral nutrition practices in hospital pharmacies in Switzerland, France, and Belgium

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).

Brief-history-and-development-of-parenteral-nutrition-support

Patients who are unable to use their gastrointestinal system for feeding purposes are now usually started on parenteral nutrition. It is a therapeutic tool used in the clinical management of patients requiring special nutritional care both in the hospital, and at home (home parenteral nutrition). The idea of providing nutrients intravenously in humans was first realised when Sir Christopher Wren injected wine and ale in do gs way back in the middle of the 17 th century. The historic experiment initiated further investigation and studies on this novel approach to nutrition. Better understanding of the metabolic and pharmacological properties of the macronutrients (protein, carbohydrates, and lipid), the micronutrients (trace elements, and vitamins), and the electrolytes have made it possible to administer parenteral nutrition safely to all types of patients where it is indicated. Continuous development and improvement in the pharmaceutical presentations of these nutrients have helped to minimise the metabolic problems seen in the early days of parenteral nutrition administration. Production of the single- or multilayered parenteral nutrition bags using materials which are inert and capable of reducing oxygen permeability such as the combination of ethylenevinylacetate-polyvinylidine chloride has ensured better stability of the parenteral nutrition admixture. The multicompartmental bag has provided a much more simpler and convenient way of initiating parenteral nutrition. The increase in knowledge, development and improvement in parenteral nutrition support has made it possible to provide parenteral nutrition support at home.

Physical characteristics of total parenteral nutrition bags significantly affect the stability of vitamins C and B1: a controlled prospective study.

Vitamin degradation occurring during the storage of total parenteral nutrition (TPN) mixtures is significant and affects clinical outcome. This study aimed to assess the influence of the TPN bag material, the temperature, and the duration of storage on the stability of different vitamins. Solutions of multivitamin and trace elements at recommended doses were injected into either an ethylvinyl acetate (EVA) bag or a multilayered (ML) bag filled with 2500 mL of an identical mixture of carbohydrates (1200 kcal), fat (950 kcal), and amino acids (380 kcal). The bags were then stored at 4 degrees C, 21 degrees C, or 40 degrees C. Concentrations of vitamins A, B1, C, and E were measured up to 72 hours after compounding, using high-pressure liquid chromatography. Ten percent to 30% of vitamin C degradation occurred within the first minutes after TPN compounding. Vitamin C was more stable in ML bags (half-life: 68.6 hours at 4 degrees C, 24.4 hours at 21 degrees C, and 6.8 hours at 40 degrees C) than in EVA bags (half-life: 7.2 hours at 4 degrees C, 3.2 hours at 21 degrees C, and 1.1 hour at 40 degrees C). Moreover, appearance of dehydroascorbic acid in the TPN mixture did not compensate for vitamin C losses. Vitamin B1 was stable at 21 degrees C, but a 43% loss occurred at 40 degrees C after 72-hour storage in EVA bags. The other vitamins were stable in the TPN mixture stored in both bags at any temperature and without daylight protection. Degradations of vitamins C and B, are significantly reduced in ML bags compared with EVA bags. To prevent vitamin C deficiencies, its initial dose should be adapted to its degradation rate, which depends on the TPN bag material, the ambient temperature, and the length of time between TPN compounding and the end of infusion to the patient.

Multivitamins for the Millennium

On October 15, 2001, Baxter Healthcare Corporation (Deerfield, IL) announced that it had received approval from the Food and Drug Administration (FDA) to market a new adult parenteral multivitamin product, INFUVITE Adult. This product, manufactured by the Canadian firm Sabex, Inc (Boucherville, Quebec, Canada), is the first to meet the FDA’s amended requirements for marketing of an “effective” adult parenteral multivitamin formulation. The new requirements for increased dosages of vitamins B1, B6, and C and folic acid, as well as addition of vitamin K, are based on the recommendations from a 1985 workshop sponsored jointly by the American Medical Association’s (AMA) Division of Personal and Public Health Policy and FDA’s Division of Metabolic and Endocrine Drug Products. Specific modifications of the previous formulation include increasing the provision of ascorbic acid (vitamin C) from 100 mg/d to 200 mg/d, pyridoxine (vitamin B6) from 4 mg/d to 6 mg/d, thiamine (vitamin B1) from 3 mg/d to 6 mg/d, folic acid from 400 g/d to 600 g/d, and addition of phylloquinone (vitamin K) at 150 g/d. The implications of these changes are important for all healthcare practitioners involved in the care of patients receiving parenteral nutrition (PN). The presence of phylloquinone can interfere with the hypothrombinemic effect of anticoagulant therapy such as warfarin; thus, patients receiving this medication may need to have their prothrombin time and international normalized ratio (INR) closely monitored. The impact on vitamin compatibility and stability should also be recognized when using this product. The package insert alludes to the presence of aluminum, although the specific amount is not disclosed. Previous work has demonstrated that certain patient populations may be extremely vulnerable to aluminum toxicity. Burn patients receiving large quantities of human serum albumin and calcium gluconate, both of which are contaminated with aluminum, may be at an even greater risk for aluminum toxicity if they require PN with daily multivitamins. Alterations in bone formation, mineralization, parathyroid hormone (PTH) secretion, and urinary calcium excretion have been attributed to aluminum toxicity in long-term PN patients or patients with renal impairment. Ascorbic acid is the least stable of all multivitamins, and degradation leading to loss of biological activity has been reported. The amount of ascorbic acid degraded has been shown to directly correlate with the amount of oxygen present in the compounded bag. Degradation by direct reaction with oxygen has been identified as the primary mechanism. Sources of oxygen include infusions containing dissolved air such as glucose, introduction of air during transfer of additives from bottle to PN bag, and residual air in the compounded bag after sealing. Although one would presume that this would support the need for a higher intake of ascorbic acid, limitations to the safe provision of vitamin C in PN formulations should be carefully reviewed. Because the ascorbic acid degradation pathway results in the production of oxalic acid, the potential for calcium oxalate precipitation in a PN bag exists. Since the advent of “hyperalimentation,” practitioners have learned that more is not necessarily better. Will providing higher intakes of vitamins translate into better outcomes for our patients? Only time will provide the answer.

Quantitative determination of fat emulsion using 1,6-diphenyl-1,3,5-hexatriene as fluorescence probe: application to the compounding of all-in-one parenteral nutrition admixtures.

The potential contamination of binary bags by traces of fat emulsion stemmed from ternary bags prepared just before, led us to determine traces of lipids into the line set of the automated compounder MM23. Diphenylhexatriene (DPH) was chosen as fluorescence probe due to its strong fluorescence enhancement in a lipid environment. Optimization of experimental conditions (i.e. DPH amounts, pH of fat emulsion samples, ultrasounds use, light, temperature and contact duration) for fluorescence measurement and validation of analytical method were performed. This method was linear over 0.5-8.0 mg l(-1) (r=0.999) of fat emulsion. The intra-day and inter-day precisions were inferior to 2% for the 2.0 and 8.0 mg l(-1) standards. Under optimized conditions, the detection limit and quantitation limit were 0.10 and 0.29 mg l(-1) of lipids respectively. Compared to the colorimetric method using sodium dichromate, it is at least 100 times more sensitive. The proposed method permitted to rapidly measure fat emulsion traces in automated compounder line set for parenteral nutrition solutions and thus, to assess the risk of contamination of binary bags by lipids. At last, this method was shown to be conveniently applied to the analysis of fat emulsion in the final total parenteral nutrition bag.

The photodegradation of vitamins A and E in parenteral nutrition mixtures during infusion

Background & Aims: Vitamins A and E are the most light-sensitive vitamins. Vitamin A is degraded by photolysis, while vitamin E degrades by photo-oxidation. The composition of the parenteral nutrition mixture and the container could therefore influence degradation during daylight administration. The aim of this study was therefore to determine the influence of fat emulsion and the type of bag on the photo-degradation of vitamins A and E in Parenteral Nutrition (PN) mixtures during simulated infusion in daylight. Methods: Representative adult PN mixtures, with and without fat emulsion, were prepared. Samples for analysis were taken from infusates and each bag during simulated infusion. Degradation of vitamins A and E was determined by stability-indicating HPLC analysis. Results: Results indicated that vitamin A loss proceeded rapidly during infusion, resulting in up to 80% loss in 6 hours, even with light protection of the bag. The presence of fat emulsion did not provide significant light protection. Vitamin E degradation was substantial if mixtures were prepared in EVA bags but was largely prevented if PN mixtures were compounded and stored in multi-layered bags. Conclusions: It is recommended that all PN bags should be light-protected during infusion in daylight. The use of multi-layered bags will prevent vitamin E losses during infusion.

Les préparations pédiatriques dans les hôpitaux français

Drug formulations that are specifically intended for pediatric use have not been widely developed in France and do not adequately meet therapeutic needs, particularly as regards hospital requirements. A multicenter study was therefore carried out to evaluate the situation. A questionnaire was sent out in June 1998 to all French university hospital pharmacies and also to those public and private hospitals known to be involved in pediatric care. Of the 78 questionnaires mailed, 63 answers were received. The information requested concerned all the drug formulations prepared in 1997. Ten out of the 63 hospitals that replied stated that the questionnaire was not relevant in their particular case. Fifty-three answers were therefore evaluated, i.e., corresponding to data from 35 university hospitals, 15 public general hospitals, and three private hospitals. For 7,022 pediatric beds, 1,155,544 units were prepared consisting of 968,520 capsules prepared from 220 active substances, 33,493 liquid preparations for oral intake, 87,592 parenteral nutrition bags, 48,225 injectable antibiotic drugs, 10,663 injectable anticancer agents, and 7,051 miscellaneous sterile preparations. The most frequently prescribed active substances were, in decreasing order of importance, as follows: diphemanil, captopril, fludrocortisone, ranitidine, spironolactone, and ursodesoxycholic acid. A marked heterogeneity was displayed in galenic forms and drug dosages. In conclusion, this study has shown the most commonly prescribed drugs and the most frequently prepared dosages for pediatric use. Drug manufacturing companies may find it an useful source of information on the limited pediatric market; it may also encourage pediatricians to homogenize and optimize their therapeutic strategies, and pharmacists to establish specific quality-control procedures. The authors recommend that national guidelines be set up, and it is suggested that the health authorities could participate in organizing the means whereby drugs for pediatric use are made more readily available.

Economic investigation of the use of three-compartment total parenteral nutrition bag: prospective randomized unblinded controlled study

Optimal strategy for total parenteral nutrition (TPN) administration is essential both in terms of clinical effectiveness and economic efficiency. The aim of the present economic analysis was to provide a systematic and comprehensive cost comparison of the application of three currently available TPN systems: Separate Bottles (SB), Hospital-Compounded Bags (HCB) and Three-Compartment Bags (TCB). Sixty patients, admitted to the Geneva University Hospital and requiring TPN, were randomly assigned to one of the three systems. Three standard TPN formulas were prescribed to meet the patients' protein energy needs. TPN-related activities of medical, nursing and pharmacy staff were timed for the 24 hours of TPN administration. Manpower, nutrient solutions and medical supplies costs were calculated on the basis of mean Swiss salaries and hospital prices. TCB was the least expensive TPN system. SB and HCB systems' application costs were 120 and 150% of TCB cost, respectively. All intersystems cost comparisons were statistically significant (ANOVA p≤0.01). SB system required more items and manipulations, resulting in higher nurses manpower cost. Pharmacy overhead cost due to compounding was responsible for the higher cost of HCB system. Detailed manpower data presented in this study allow for an estimation of TPN application costs in other hospitals, using local salaries, specific product prices and compounding costs.

Light protection during parenteral nutrition infusion: is it really necessary?

Many nutrient compounds incorporated into parenteral nutrition (PN) mixtures are sensitive to light. The most light-sensitive compounds can be found in the vitamin group, in particular retinol (vitamin A),1 tocopherol (vitamin E),2 vitamin K,3 and riboflavin.4 Some amino acids are also potentially sensitive to light. One of the most common questions asked of pharmacists is whether or not PN bags should be covered in a light-protecting overwrap during administration, and, if so, should the administration set also be protected. It is clearly somewhat illogical to recommend the need to protect the bag and not the administration set from light, if there is indeed a risk of degradation when PN is exposed to light. Despite the obvious response, that light protection should be mandatory, a range of issues is ignored, in particular the desire by care staff to be able to “observe” the infusion at all times, and the practicalities, especially of covering the administration set, or the non-availability of light-protecting sets in practice. And, as in all matters scientific, answers are far from simple. Here are a few questions to illustrate the pharmaceutical complexity of the issue: Which ingredients are light sensitive, and how rapid is the photoreaction that results in loss of biological activity? What intrinsic factors affect degradation (e.g., PN composition [Does fat emulsion provide a barrier to light?], the total volume of the PN mixture, frequency of mixing during infusion, flow rate, type of bag [ethyl vinyl acetate or multilayered], the composition, length, and thickness of the administration set tubing, and exposure time)? What contribution to total loss is due to infusion? Is the source of the light important (e.g., is it dependent on particular wavelengths)? If daylight causes degradation, how are losses influenced by the time of day, the season, weather conditions, and even geographic location? Even the position of the infusion in relation to a nearby window is significant.1 Then there are the difficulties associated with accurately determining losses likely to occur in practice, especially as the light (daylight) source cannot be controlled and there is no artificial-light–source alternative available that exactly reproduces the same wavelength distribution and intensity of daylight. It can also prove difficult to measure the range of light intensity in daylight because it differs across the wavelength spectrum. This spectrum is related to the photochemical reactions caused by daylight. Is it any wonder that the literature is confusing? For example, Billion-Rey et al.3 reported a 90% degradation of vitamin A in All-in-One PN mixtures during exposure to light, but Dahl et al.5 suggested that vitamin A is unaffected under such conditions. A similar contrast can be found with tocopherol. Drott et al.2 reported an approximate 30% loss in daylight, whereas Billion-Rey et al.3 observed no losses under similar conditions.