Parenteral Nutrition Formulations Research Articles

Practice of parenteral nutrition in hospitalized adult patients in Korea: A retrospective multicenter cross-sectional study.

There have been no studies on the characteristics of parenteral nutrition (PN) supply for adult inpatients in South Korea. The aim of this retrospective multicenter cross sectional study was to investigate the current practice and characteristics of PN support in hospitalized adult patients in South Korea for the first time. This study was conducted retrospectively for the adult patients who were hospitalized and received PN in nine hospitals on August 1st, 2017 to October 30th, 2017. We evaluated the type of PN formulation, PN administration period, administration route, calories supplied, amount of protein supplied, and laboratory results. Among the 11,580 inpatient admissions on that day, 1,439 patients received PN (12.4%). The majority of enrolled patients (96.5%) used the commercial PN, of which 86.2% were multi-chamber. 71.2% of them received PN peripherally. The average in hospital PN duration was 17.8 ± 52.6 days. Patients received only 65.4 ± 25.4% calories of their target calories. The in-hospital mortality of enrolled patients was 22%. In South Korea, commercial PN was usually administered to hospitalized adult patients and in-hospital mortality in adult patients using PN was higher in South Korea compared to other countries. This study provides the characteristics and the PN support status of hospitalized adult patients receiving PN in South Korea.

Neonatal parenteral nutrition formulation: where are we?

Introduction: the introduction of parenteral nutrition in preterm infants has meant a major advance in their prognosis, being the last few years very fruitful in terms of publication of guidelines in this area. Objectives: to know the formulation and preparation procedures of neonatal parenteral nutrition (NPN) in Spanish hospitals. Methods: a multi-centre survey was conducted in Pharmacy Services on the aforementioned processes. Results: fifty-five hospitals met inclusion criteria. Electronic prescription systems were use by 51 %, 65.5 % always formulated individually, while 34.4 % had predesigned formulas. Tricameral preparations were used by 13.0 %. In 52.7 % of cases, first day nutrition was prepared on demand, starting before 8 hours of life in 88.1 % of cases. Inorganic phosphate was the first option in 10.4 %, vitamins, trace elements and zinc were added daily in 92.7 %, 90.9 % and 70.9 % of cases, respectively. NPN including lipids in the same bag was formulated by 45.4 % of the hospitals, compared to 34.5 % where it was administered separately in all cases. In 50.9 % of hospitals they never added heparin to their NPN. The 89.1 % used photoprotected bags. The stability of the admixture varied from 24 hours to 15 days. Conclusion: the elaboration of the PPN in Spain is subject to great variability. There is controversy regarding the use of heparin and ternary mixtures, which is reflected in the variability of clinical practice.

A Clinical Trial Assessing the Safety, Efficacy, and Delivery of Olive-Oil-Based Three-Chamber Bags for Parenteral Nutrition.

Limited evidence exists to precisely estimate efficacy and safety differences between parenteral nutrition (PN) prepared using olive-oil-based three-chamber bags (3CBs) and soybean-oil-based compounded bags (CoBs) in hospitalized adult patients. We designed a multicenter, randomized, prospective, open-label, noninferiority protocol to compare the efficacy, safety, and distribution of olive-oil-based 3CBs and soybean-oil-based CoB formulations in adult Chinese patients requiring PN during surgical intervention. Subjects were randomized to receive either one of the study treatments using an interactive voice or web-based recognition system in accordance with the randomization code. Randomization was further stratified based on the study site and surgical category. Both treatment groups received similar amounts of calories and protein. In addition, the two study treatments contained a similar composition of the amino-acid component. The only difference between the two PN formulations was the lipid constitution. The duration of administration of study treatments was a minimum of 5 days up to a maximum of 14 days after the surgical procedure. The primary efficacy endpoint was serum prealbumin levels on day 5 of the study. Noninferiority was proved if the anti-log of the lower bound of the 95% confidence interval (CI) of the treatment difference was at least 0.80. Other efficacy measures included treatment preparation time; duration to achieve tolerability of oral nutrition; associated infectious complications; length of hospitalization; and laboratory assessment of markers of nutrition, inflammation, metabolism, and oxidative stress. A total of 458 patients were enrolled in the study. The results showed that olive-oil-based 3CBs were non-inferior to soybean-based CoBs, besides being well tolerated. The infection rate was found to be significantly lower in the olive-oil-based 3CB group. Thus, this study may be used as a reference for future research on lipid emulsion and 3CBs.

Enteral and parenteral nutrition considerations in pediatric patients

Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed. The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients. The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.

Relationship between arginine intake in parenteral nutrition and preterm neonatal population plasma arginine concentrations: a systematic review.

ContextVery preterm neonates (VPNs) are unable to digest breast milk and therefore rely on parenteral nutrition (PN) formulations. This systematic review was prepared following PRISMA-P 2015 guidelines. For the purpose of this review, desirable mean plasma arginine concentration is defined as ≥80 micromoles/L.ObjectiveThe review was performed to answer the following research question: “In VPNs, are high amounts of arginine in PN, compared with low amounts of arginine, associated with appropriate circulating concentrations of arginine?” Therefore, the aims were to 1) quantify the relationship between parenteral arginine intakes and plasma arginine concentrations in PN-dependent VPNs; 2) identify any features of study design that affect this relationship; and 3) estimate the target parenteral arginine dose to achieve desirable preterm plasma arginine concentrations.Data SourcesThe PubMed, Scopus, Web of Science, and Cochrane databases were searched regardless of study design; review articles were not included.Data ExtractionOnly articles that discussed amino acid (AA) intake and measured plasma AA profile post PN in VPNs were included. Data were obtained using a data extraction checklist that was devised for the purpose of this review.Data AnalysisTwelve articles met the inclusion criteria. The dose–concentration relationship of arginine content (%) and absolute arginine intake (mg/(kg × d)) with plasma arginine concentrations showed a significant positive correlation (P < 0.001).ConclusionFuture studies using AA solutions with arginine content of 17%–20% and protein intakes of 3.5–4.0 g/kg per day may be needed to achieve higher plasma arginine concentrations.

Evaluation of Y-site compatibility of home total parenteral nutrition and intravenous loop diuretics.

In chronic kidney disease (CKD), the design of the parenteral nutrition (PN) regimen becomes more challenging where only individualized PN is appropriate, coupled with the increased risk of unintended interactions with diuretic therapy. In an effort to ensure safe therapy in the home, we assessed the physical stability of bespoke PN formulations intended for use in CKD in the simultaneous presence of Y-site compatibility of furosemide and torasemide. The patient's daily needs were determined based on both metabolic demands as well as the demand for fluids.Complete admixtures were subjected to physical stability analysis consisting of visual inspection, a validated light microscope method, pH measurement, zeta potential measurement, and characterization of oily globule size distribution. Y-site compatibility of furosemide and torasemide with the formulated admixtures was also performed.The total parenteral admixture was stable over 7 days at +4°C and 24 h at +25°C and compatible via the Y-line together with furosemide and torasemide over 12 h at +25°C.The stability assessment guarantees the safety and efficiency of home PN with loop diuretics therapy in CKD patients. This means that these patients do not need long hospitalization and they can be safely treated at home. Furthermore, this study proved that torasemide is the same safety diuretic as furosemide, which has a great impact on clinical practice.

Optimizing Vitamin and Trace Element Profiles in Blood after Gastrointestinal Tract Surgery by a New Parenteral Nutrition Formula

Introduction: Though micronutrient formulations for parenteral nutrition (PN) have been revised, the impacts of these changes on nutritional parameters, blood micronutrient levels, and safety have yet to be clarified. We examined the efficacy and safety of a new PN formulation with a micronutrient composition based on the Food and Drug Administration 2000 recommendation in surgical patients. Methods: This phase III clinical trial (JapicCTI-No. 142610) was a prospective, randomized, controlled, parallel-group, open-label, multicenter study. Two types of PN, OPF-108 (revised formula, n = 51) and ELN (previous formula mainly based on American Medical Association 1975 guidelines, n = 59), were given to patients from POD1 or 2 to POD7 after surgery. OPF-108 contains more vitamin B1, B6, C, and folic acid, a much lower dose of vitamin K, and less iron than ELN. Nutritional parameters and micronutrient profiles in blood and safety were evaluated. Results: Nutritional parameters on POD5 and 8 were similar between the 2 groups. Blood vitamin B1, B6, and folic acid levels on POD 5 and 8 were higher in the OPF-108 group than in the ELN group. Only OPF-108 restored vitamin C levels to within the normal range on POD5 and 8. Vitamin K levels far exceeded the upper limit of the standard range on POD5 and 8 in the ELN group, whereas OPF-108 essentially maintained these levels within the standard ranges. Serum iron levels on POD8 were nearly normal in both the OPF-108 and ELN groups. Conclusion: Beneficial effects of the new micronutrient formulation were demonstrated in surgical patients.

Calcium/Phosphate Solubility Curves for Premasol and Trophamine Pediatric Parenteral Nutrition Formulations.

Calcium and phosphate incompatibility in parenteral nutrition formulations remains a critical concern for patient safety. This study examined calcium phosphate solubility for 2-in-1 admixtures prepared using 2 commercially available pediatric amino acid solutions (Premasol, Baxter Healthcare Corp; or Trophamine, B. Braun Medical Inc), applying identical test methods, storage conditions, and acceptance criteria. Parenteral 2-in-1 admixtures included amino acid; dextrose; static concentrations of sodium, potassium, and magnesium, and varying concentrations of calcium (0-60 mEq/L), phosphate (15-50 mmol/L), and cysteine. Three replicate samples were stored for 48 hours at 40°C ± 2°C and then visually inspected for particulate matter, evaluated for subvisible particulate matter, when particulate matter was noted, microscopic examination was performed to confirm the presence of calcium phosphate crystals. Pass criteria were: all replicates free of visible particulate matter related to calcium phosphate crystals and particle counts below US Pharmacopeia <788> limits. Premasol and Trophamine generated identical calcium phosphate curves for 2% amino acid formulations containing 20% dextrose with/without cysteine, and similar curves for the 1% or 3% amino acid formulations containing 10% or 20% dextrose with/without cysteine. Calcium phosphate particles were identified in failed samples by scanning electron microscopy/energy dispersive X-ray spectroscopy. Calcium phosphate solubility was higher in formulations containing cysteine 40 mg/g amino acid vs. cysteine 20 mg/g amino acid and in cysteine 20 mg/g amino acid vs. no cysteine. Admixtures made with 1%, 2%, or 3% Premasol or Trophamine have essentially equivalent calcium phosphate solubility curves when tested with identical methods, storage conditions, and acceptance criteria.

Diseño, implementación y análisis de un sistema de cálculo de fórmulas de nutrición parenteral en neonatos con apoyo del farmacéutico

En este estudio se diseñó una hoja de cálculo para formulación de nutriciones parenterales neonatales, en base a los requerimientos sugeridos por la literatura internacional, y se comparó con los datos obtenidos de la formulación por el método manual y una calculadora online. Vale señalar que ni el método manual ni el de la calculadora online consideraban las características de cada marca comercial de los medicamentos usados en las nutriciones parenterales. Esta hoja de cálculo le permitió al farmacéutico acceder a datos relevantes tanto del paciente como de la formulación, lo que redundó en una correcta validación. Se realizó un estudio retrospectivo de 40 nutriciones parenterales neonatales formuladas en el Hospital Luis Gabriel Dávila entre los meses de enero y noviembre de 2014, incluyéndose únicamente los pacientes que recibieron siete o más días de nutrición parenteral.

PMU65 - COST-MINIMIZATION ANALYSIS OF SMOFKABIVEN® CENTRAL FOR ADULT PATIENTS WITH IMPOSSIBLE, INSUFFICIENT OR CONTRAINDICATED ORAL OR ENTERAL NUTRITION VERSUS STANDARD ENDOVASCULAR TREATMENT IN THE MEXICAN PUBLIC HEALTHCARE SYSTEM

The primary objective of medical nutritional therapy is the maintenance of nutritional support, according to the specific requirements of each patient. Specifically, patients who require nutritional intervention are unable to meet their nutritional needs via oral or enteral channels due to gastrointestinal tract disorders. The multi-chamber bag SMOFKabiven® Central is a parenteral nutrition formulation administered via a central line. To perform a cost minimization analysis and budget impact analysis, comparing the multi-chamber bag SMOFKabiven® Central versus compounded and multi-chamber bags currently available in the Mexican public healthcare system. A systematic literature review was conducted to identify the efficacy of all comparators; no statistically significant differences were found between the different nutrition methods and as such a cost minimization analysis was developed. Direct medical costs were considered, taken from publicly available sources. For compounded bags, a micro-costing was performed according to the required concentration of each nutritional component, ie. lipids, glucose and amino-acids, considering the same formulation as SMOFKabiven® Central. The cost of SMOFKabiven® Central was provided by the Fresenius Kabi, the analysis included the presentations of 1477 mL and 1970 mL. National epidemiologic and public information were employed for the budget impact analysis. Savings associated to the introduction of SMOFKabiven® Central 1477 mL and 1970 mL were MX$788.44 and MX$840.00 respectively, in comparison with the lowest costing alternative currently available in the market. Consequently, the budget impact analysis showed savings related to the introduction of SMOFKabiven® Central in the Mexican public healthcare system. The multi-chamber bag SMOFKabiven® Central is at least equally effective than other nutrition systems available in Mexico. Additionally, SMOFKabiven® Central represents a cost-saving alternative for the Mexican public healthcare system.

PRM18 - Total Parenteral Nutrition in Asian Countries – A Systematic Literature Review of Cost-Effectiveness Studies

An ever-growing proportion of critically ill adult patients require parenteral nutrition (PN) as a lifesaving therapy when enteral nutrition is inadequate or impossible. It is estimated that PN utilization will significantly grow in Asia Pacific region in the near future. The objective of this study was to evaluate cost-effectiveness of different PN formulations in Asian countries using systematic literature review. The literature search was conducted in PubMed/Medline and Tufts registry. Cost-effectiveness studies assessing different parenteral formulations in malnourished adults in Asian countries were included. Two independent reviewers screened and evaluated studies using the 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Four articles satisfied predefined inclusion criteria. The studies evaluated addition of omega-3 fatty acids (n=2) or structured triglycerides (n=1) to standard lipid emulsions and cost-benefit of a nutritional support team for PN (n=1). The studies were performed in Chinese (n=3) and Japanese (n=1) healthcare contexts. All of the studies analyzed healthcare costs from patients’ perspective over a short time horizon, limited to the length of hospital stay. The most commonly employed model type was discrete event simulation model (n=2). All four studies demonstrated cost-effectiveness of the new technologies vs. standard PN treatment. The mean CHEERS score for the studies was 15 (SD=4.30) and studies mostly failed to justify the choice of model and time horizon. No study reported cost per quality-adjusted life year. The present study demonstrated that only few studies assessed cost-effectiveness of PN in Asian countries. All of them showed that novel PN formulations were cost-effective in comparison to standard treatment. However, a longer time horizon and focus on subgroups with homogenous prognoses are required to provide sufficient evidence and direct PN to “all patients who need it, in a cost-effective manner”, as recommended by World Health Organization.

PRM16 - Cost-Effectiveness of Parenteral Nutrition in Hospitalized Adult Patients

Management of severely malnourished adults often requires parenteral nutrition (PN) as a life-sustaining feeding mode in patients with intestinal failure. Different types of PN are commercially available. The choice of an optimal treatment should be made considering their benefits, harms and costs. This study aimed to establish cost-effectiveness of different types of PN based on a systematic review. A comprehensive literature search was performed in PubMed/Medline and Tufts registry for economic evaluations published since 2000 through 2017. Full economic evaluations that compared different parenteral fluids in malnourished adults published in English were included. Quality of the studies was assessed using 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Forty-seven potentially relevant articles were found, with 6 satisfying predefined inclusion criteria. The studies evaluated different PN formulations enriched with either omega-3 fatty-acid lipid emulsions (n=4), glutamine (n=2) or structured triglyceride (STG)-based emulsions (n=1) compared to standard PN. The studies captured patient (n=3), hospital (n=2) and healthcare provider perspective (n=1), analyzing context of European countries (n=3) or China (n=3) and most of them were cost-effectiveness analyses (n=5). Five studies were model-based economic evaluations with four of them applying discrete event simulation. None of the studies reported cost per quality-adjusted life year. Special PN formulations appeared to be cost-effective when compared to standard PN. The CHEERS assessment resulted in total score of 16.3 (SD=4.42), with none of the studies reporting discount rates or measurement and valuation of preference based outcomes and with only one study characterizing heterogeneity. Addition of omega-3 lipids, glutamines or structured triglyceride-based emulsions into parenteral fluids appear to be generally cost-effective from the study perspectives. The lack of a well-designed pharmacoeconomic analysis highlights the need for further economic evaluations, which will provide a rationale for the informed healthcare decision-making.

Short chain polyphosphates as a strategic colloidal source of phosphate for parenteral admixtures

Short chain sodium polyphosphates – (NaPO3)9 – PolyP – were added to 2-in-1 pediatric parenteral nutrition (PN) formulations as new alternative phosphate sources. Solutions of PolyP and Ca2+ in the presence of Mg2+, glucose, amino acids and trace elements were analyzed by electronic absorption and 31P NMR spectroscopies, as well as by pH measurements. Additionally, to verify the biocompatibility of short chain PolyP solutions, red blood cell (RBCs) units were evaluated by analyzing hemoglobin, hematocrit, and hemolysis. The blood clotting action of the PolyP was determined through Prothrombin time. We observed that the short chain PolyP anions did not interfere in the quality control parameters for RBCs units or in the blood extrinsic coagulation pathway. The spectral changes observed in the 31P NMR confirm the association of Mg2+ and Ca2+ with PolyP in the admixtures. Compatibility diagrams showed that the PolyP-Ca/Mg systems reflect a gel behavior based on the PolyP chains interaction with the incoming cations maintaining a supramolecular equilibrium until a limiting concentration. We observed that the greater the PolyP concentration, the greater the amount of Ca2+ that could be added to the admixture without phase separation and that the increased complexity of species (glucose, amino acid, trace elements and Mg2+) in the admixture favored a still higher final Ca2+ concentration. The overall colloidal behavior of short chain PolyPs shows that these polyanions function not only as alternative and safe phosphate sources in PN formulations but also as polyanions that increase the admixture stability against phase separation by efficiently sequestering metal cations present.

An assessment of exposure to rare earth elements among patients receiving long-term parenteral nutrition

Patients receiving long-term parenteral nutrition (PN) are exposed to potentially toxic elements, which may accumulate in bone. Bone samples collected from seven PN patients (average = 14 years) and eighteen hip/knee samples were analyzed for Al as part of a previous investigation. Yttrium was serendipitously detected in the PN bone samples, leading to the present investigation of rare earth elements (REEs). A method for quantitating fifteen REEs in digested bone was developed based on tandem ICP-MS (ICP-MS/MS) to resolve spectral interferences. The method was validated against nine biological reference materials (RMs) for which assigned values were available for most REEs. Values found in two NIST bone SRMs (1400 Bone Ash and 1486 Bone Meal) compared favorably to those reported elsewhere. Method detection limits ranged from 0.9 ng g−1 (Tm) to 5.8 ng g−1 (Y). Median REE values in the PN patient group were at least fifteen times higher than the “control” group, and exceeded all previously reported data for eleven REEs in human bones. REE content in PN bones normalized to the Earth’s upper crust revealed anomalies for Gd in two patients, likely from exposure to Gd-containing contrast agents used in MRI studies. A retrospective review of the medical record for one patient revealed an almost certain case of nephrogenic systemic fibrosis, associated with Gd exposure. Analysis of two current PN formulations showed traces of REEs with relative abundances similar to those found in the PN bones, providing convincing evidence that PN solutions were the primary source of REEs in this population.

Compatibility of intravenous ibuprofen with lipids and parenteral nutrition, for use as a continuous infusion.

There is increasing interest to administer ibuprofen as a continuous infusion instead of a traditional bolus for treating Patent Ductus Arteriosus (PDA). However, its compatibility data with commonly used drugs in the neonatal period, including parenteral nutrition (PN) and lipids is unavailable. The aim is to determine the compatibility of intravenous ibuprofen lysine with various ANZNN parenteral nutrition consensus group standard neonatal PN formulations and lipids. The PN and lipid solutions used in a tertiary neonatal unit were obtained. These included a Starter, Standard Preterm and low carbohydrate PN, and IV SMOF lipid admixture (SMOFLipid 20% 15 mL; Vitalipid N infant 4 mL, Soluvit N 1 mL) plus vitamin mixtures. 10% glucose was used as a control. 1:1 mixtures of different concentrations (1.25 to 5mg/mL) of ibuprofen lysine and each of the PN/glucose/lipid formulations were made. Samples were taken at hourly intervals for a total of 4 hours and tested for both physical (visual assessment, pH and microscopy) and chemical compatibility (High Performance Liquid Chromatography analysis). Zeta potential and particle diameter were measured for SMOF lipid admixture and ibuprofen combination to assess emulsion stability. 24 hour stability of ibuprofen dilution in 5 mL BD Luer-lok polypropylene syringes at 25°C was also assessed. Most PN formed opaque solutions when mixed with ibuprofen 2.5 and 5mg/mL solutions. However, ibuprofen dilution of 1.25mg/mL produced clear, colourless solutions with no microscopic particles when mixed with all PN/glucose/lipid formulations tested. Ibuprofen was chemically stable with all PN and SMOF lipid admixture, for a period of 4 hours. The zeta potential and particle diameter were within acceptable limits. Ibuprofen lysine was stable over 24 hours in Luer-lok polypropylene syringes. Ibuprofen 1.25mg/mL is physically and chemically compatible with 10% glucose, starter PN, standard preterm and low carbohydrate PN, and SMOF lipid admixture plus vitamins for a period of four hours, which is the maximum time they could be in an admixture during a continuous infusion.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study.

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective. In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests. Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002). A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

Iodine Content of Enteral and Parenteral Nutrition Solutions

Iodine is essential for thyroid hormone synthesis, and iodine deficiency may result in thyroid disorders including goiter and hypothyroidism. Patients on long-term enteral nutrition (EN) or parenteral nutrition (PN) may be at risk for micronutrient deficiencies. The recommended daily allowance for iodine intake is 150 μg for nonpregnant adults. However, there is no current consensus among scientific societies regarding the quantity of iodine to be added in adult EN and PN formulations. The objective of this study was to determine the iodine content of U.S. adult enteral and parenteral nutrition solutions. This study also aimed to determine whether adult patients in the United States who are receiving long-term artificial nutrition may be at risk for iodine deficiency. Ten enteral nutrition solutions and 4 parenteral nutrition solutions were evaluated. The iodine contents of these solutions were measured spectrophotometrically and compared to the labeled contents. Measured and labeled EN iodine contents were similar (range 131-176 μg/L and 106-160 μg/L, respectively). In contrast, PN formulas were found to contain small, unlabeled amounts of iodine, averaging 27 μg/L. Typical fluid requirements are 30 to 40 mL/kg/day for adults receiving either total EN (TEN) or total PN (TPN). Adults on long-term TEN likely consume enough servings to meet their daily iodine requirements. However, patients on long-term TPN would require on average 5.6 L PN/day to meet the recommended daily allowance of iodine. This volume of PN is far in excess of typical consumption. Thus, U.S. patients requiring long-term TPN may be at risk for iodine deficiency. EN = enteral nutrition; PN = parenteral nutrition; TEN = total enteral nutrition; TPN = total parenteral nutrition; UIC = urinary iodine concentration.

Severe hypercalcaemia and hypophosphataemia with an optimised preterm parenteral nutrition formulation in two epochs of differing phosphate supplementation

ObjectiveTo compare in two epochs of differing phosphate provision serum calcium, phosphate, potassium, and sodium concentrations and the frequency of abnormality of these electrolytes and of sepsis in preterm infants...

Safety of parenteral nutrition in newborns: Results from a nationwide prospective cohort study

Limited or delayed availability of parenteral nutrition (PN) solutions, as well as difficulties in ordering are often identified as reasons for non-compliance with international guidelines in newborns. This study aims at assessing the modality of use and safety of premixed standardized PN solutions in a nationwide prospective cohort of newborns treated in clinical practice. Two premixed fixed formulations with respective osmolarity of 715 and 790mOsm/L specifically designed for neonates were made available throughout the country for clinical use from birth onwards. Descriptive data and modality of use were prospectively collected in a case report form, whereas all related and unrelated adverse events were recorded on a separate adverse event form. A total of 14,167 infants were prospectively included and 16,640 parenteral nutrition periods were analyzed. Mean age was 33 weeks of gestation, and mean weight was 2086g. The majority of infants (81%) started the parenteral nutrition the first day of life or the day after. The route of parenteral nutrition delivery was peripheral in 47% of the parenteral nutrition periods. During the whole study, a total of 72 adverse events occurring in 68 infants were reported. Of these adverse events, 59 (0.37% of the nutrition periods), among which 19 serious adverse events, were reported as related to the parenteral nutrition solutions. The events related to parenteral nutrition solutions were general disorders and administration site conditions (n=42 including 9 cases of cutaneous necrosis), and nutrition and metabolism disorders (n=17). There was no case of thrombophlebitis. Six of the 19 serious events related to the parenteral nutrition solutions (32%) were due to the misuse of the infusion bag. These data support the concept that ready-to-use parenteral nutrition formulations can safely provide parenteral nutrition from birth onwards. They further support that parenteral solutions with an osmolarity up to 800mOsm/L are well-tolerated when infused on a peripheral vein. Considering the potential risk of errors and misuses, this study also highlights the need for nutrition practice care guidelines for neonates and for regular campaigns providing information and strategies for a safe use of parenteral nutrition solutions.

PARENTERAL NUTRITION IN NEONATUS AND COMPATIBILITY ISSUES: A REVIEW ARTICLE

Intravenous drug administration in Neonatal Intensive Care Unit is critical because of poor venous access, polymedication, fluid restriction, and lowinfusion rate. Since parenteral nutrition (PN) is infused intravenously, it is often considered as a vehicle for medication administration. Medicationsmay be added to PN formulations in an effort to decrease fluid requirements, reduce the need for Y-site injections, reduce the possibility of line contamination due to manipulation, and decrease labor time required for drug administration. Risk is further increased by inadequate information on the physicochemical compatibility of drugs.Keywords: Parenteral nutrition, Neonatus, Compatibility.